Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients

Gavara, Concepcion Gomez; Bhangui, Prashant; Salloum, Chady; Osseis, Michael; Esposito, Francesco; Moussallem, Toufic; Lahat, Eylon; Fuentes, Liliana; Compagnon, Philippe; Ngongang, Norbert; Lim, Chetana; Azoulay, Daniel

doi:10.1002/lt.24999

Cited by 42 publications

(42 citation statements)

References 38 publications

(80 reference statements)

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“…Unlike ICG clearance, which is performed postoperatively, intraoperative ICG fluorescence quantification can lead to an intraoperative modification of the surgical strategy (modulation of the portal flow and so on). ( 27 )…”

Section: Discussionmentioning

confidence: 99%

Indocyanine Green Fluorescence Imaging to Predict Graft Survival After Orthotopic Liver Transplantation: A Pilot Study

et al. 2020

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The incidence of primary nonfunction (PNF) after liver transplantation (LT) remains a major concern with the increasing use of marginal grafts. Indocyanine green (ICG) fluorescence is an imaging technique used in hepatobiliary surgery and LT. Because few early predictors are available, we aimed to quantify in real time the fluorescence of grafts during LT to predict 3‐month survival. After graft revascularization, ICG was intravenously injected, and then the fluorescence of the graft was captured with a near infrared camera and postoperatively quantified. A multiparametric modeling of the parenchymal fluorescence intensity (FI) curve was proposed, and a predictive model of graft survival was tested. Between July 2017 and May 2019, 76 LTs were performed, among which 6 recipients underwent retransplantation. No adverse effects of ICG injection were observed. The parameter a150 (temporal course of FI) was significantly higher in the re‐LT group (0.022 seconds−1 (0.0011‐0.059) versus 0.012 seconds−1 (0.0001‐0.054); P = 0.01). This parameter was the only independent predictive factor of graft survival at 3 months (OR, 2.4; 95% CI, 1.05‐5.50; P = 0.04). The best cutoff for the parameter a150 (0.0155 seconds−1) predicted the graft survival at 3 months with a sensitivity (Se) of 83.3% and a specificity (Spe) of 78.6% (area under the curve, 0.82; 95% CI, 0.67‐0.98; P = 0.01). Quantitative assessment of intraoperative ICG fluorescence on the graft was feasible to predict graft survival at 3 months with a good Se and Spe. Further prospective studies should be undertaken to validate these results over larger cohorts and evaluate the clinical impact of this tool.

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Section: Discussionmentioning

confidence: 99%

Indocyanine Green Fluorescence Imaging to Predict Graft Survival After Orthotopic Liver Transplantation: A Pilot Study

et al. 2020

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“…Clinical data prior to LT included date of birth; sex; race; ethnicity; body mass index (BMI); MELD‐Na score prior to LT; cytomegalovirus (CMV) status; presence of comorbidities, such as coronary artery disease (CAD), hypertension, diabetes mellitus (DM), and chronic kidney disease (CKD); etiology for chronic liver disease; presence of clinical decompensations, such as variceal bleeding; acute kidney injury with hepatorenal physiology; spontaneous bacterial peritonitis (SBP); ascites (worst documented episode according to the International Ascites Club proposed classification); hepatic encephalopathy (worst documented episode, according to the West Haven classification); or hepatocellular carcinoma (HCC). We also reviewed operative reports to determine how many SPSSs were ligated and to find the explant pathology to evaluate for the presence of malignancies, such as HCC or cholangiocarcinoma, that were not previously found. The latest endoscopic data prior to LT (within 6 months from LT) as well as the data from donors were also extracted, including the graft status of either a deceased or living graft, DCD or a donation after brain death (DBD) donor, donor sex, age, BMI, donor comorbidities (such as the presence or not of DM, hypertension, hepatitis B, and hepatitis C), and CMV status.…”

Section: Methodsmentioning

confidence: 99%

Clinical Outcomes of Portosystemic Shunts on the Outcome of Liver Transplantation

et al. 2020

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Spontaneous portosystemic shunts (SPSSs) have been associated with worse clinical outcomes in the pre-liver transplantation (LT) setting, but little is known about their post-LT impacts. Our aim was to compare LT candidates with and withoutSPSSs and assess the impact of SPSSs on patient mortality and graft survival in the post-LT setting. Patients 18 years or older with abdominal imaging done prior to LT were included. Exclusion criteria were the presence of pre-LT surgical shunts, LT indications other than cirrhosis, and combined solid organ transplantations. SPSSs were classified as absent, small, or large according to their maximum diameter (8 mm). Multiple variables that could influence the post-LT course were extracted for analysis. Patient and graft survival were estimated using the Kaplan-Meier method and were compared between groups using a log-rank test. The project received institutional review board approval. We extracted data from 326 patients. After comparing patients without SPSS or with small or large SPSSs, no statistical difference was found for overall patient survival: no SPSS (n = 8/63), reference; small SPSS (n = 18/150), hazard ratio (HR), 1.05 (95% confidence interval [CI], 0.45-2.46); and large SPSS (n = 6/113), HR, 0.60 (95% CI, 0.20-1.78); P = 0.20. Also, no difference was found for graft survival: no SPSS (n = 11/63), reference; small SPSS (n = 21/150), HR, 0.80 (95% CI, 0.38-1.70); large SPSS (n = 11/113), HR, 0.59 (95% CI, 0.25-1.40); P = 0.48. Similarly, no statistical significance was found for these variables when comparing if the graft used was procured from a donation after circulatory death donor versus a donation after brain death donor. In conclusion, the previously described association between SPSSs and worse clinical outcomes in pre-LT patients seems not to persist once patients undergo LT. This study suggests that no steps to correct SPSS intraoperatively are necessary. Liver Transplantation 26 693-701 2020 AASLD.Portal hypertension is defined by a hepatic venous pressure gradient of 6 mmHg or more, and in the clinical scenario of cirrhosis, it is characterized by complications, such as ascites, variceal bleeding, and hepatic encephalopathy in advanced cases. (1) In cirrhosis, portal hypertension results from the increased collagen deposition and formation of regenerative nodules, which eventually lead to an increase in portal pressure. (2) These changes are followed by compensatory splanchnic vasodilation, which will further increase portal flow and continue to worsen portal pressure (as predicted by Ohm's law). The presence of these complications leads to clinical deterioration, with some series describing up to 80% 5-year mortality if 2 complications were present concomitantly, (3) which also results in cost increases due to frequent hospital admissions. (4) A complication in the setting of portal hypertension is the formation of spontaneous portosystemic shunts (SPSSs). These are channels that form as the portal rOdriguez et al.

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“…If portal flow improves after clamping of the SPSS, ligation of the shunt is advised. A study by Gomez Gavara et al showed that large SPSS ligation was associated with lower postoperative morbidity, a decreased rate of encephalopathy, and a trend toward a lower rate of PVT. In the long term, patient and graft survival rates were also better in the ligated shunt group compared with the nonligated shunt group.…”

Section: Discussionmentioning

confidence: 99%

“…PVT is a common complication in patients waiting for a LT with a prevalence ranging from 6% to 12% of patients . Its presence can make LT more difficult, especially with higher grades of PVT where elaborate reconstruction techniques to restore portal flow may be necessary .…”

Section: Discussionmentioning

confidence: 99%

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Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients

Cited by 42 publications

References 38 publications

Indocyanine Green Fluorescence Imaging to Predict Graft Survival After Orthotopic Liver Transplantation: A Pilot Study

Indocyanine Green Fluorescence Imaging to Predict Graft Survival After Orthotopic Liver Transplantation: A Pilot Study

Clinical Outcomes of Portosystemic Shunts on the Outcome of Liver Transplantation

Intraoperative Balloon Angioplasty for Chronic Portal Vein Thrombosis in Liver Transplantation

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