Liver transplantation by preservation of the caval flow with temporary porto-caval shunt or veno-venous bypass

Hesse, U.; Berrevoet, F.; Troisi, Roberto; Mortier, Éric; Pattyn, Piet; Hemptinne, Bernard de

doi:10.1016/s0041-1345(97)01044-0

Cited by 14 publications

(16 citation statements)

References 7 publications

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“…9,[20][21][22] Finally, normal venous return to the heart is possible during the anhepatic stage, making venovenous bypass unnecessary. 2,3,[10][11][12][13]15,16,18,19 However, the vena cava preservation technique does not avoid splanchnic congestion and portal hypertension secondary to vena porta clamping. This study shows that adding a temporary PCS to the piggyback technique can minimize hemodynamic instability and preserve renal function during the anhepatic stage.…”

Section: Discussionmentioning

confidence: 99%

“…15 Previous studies have shown that preservation of both portal and caval blood flows throughout the procedure maintains hemodynamic stability and renal perfusion pressure. [16][17][18][19] This technique is particularly useful for patients with fulminant hepatitis who lack adequate portosystemic collaterals in the splachnic area. 17 However, benefits of adding a temporary PCS to the piggyback technique during the anhepatic phase in patients with cirrhosis have not been shown.…”

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confidence: 99%

“…17 However, benefits of adding a temporary PCS to the piggyback technique during the anhepatic phase in patients with cirrhosis have not been shown. 16,18,19 To verify the feasibility and real advantages of adding a temporary PCS to the piggyback technique, we began a prospective randomized study of patients with cirrhosis. A secondary objective is to elucidate whether benefits could be obtained in all patients or only in a selected group.…”

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confidence: 99%

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Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study

Figueras

2001

Liver Transplantation

107

114

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This study aims to determine whether the use of a temporary portocaval shunt (PCS) improves hemodynamic and metabolic evolution during orthotopic liver transplantation (OLT). Preservation of the vena cava during OLT has gained wide acceptance. However, benefits of adding a temporary PCS to the piggyback technique during the anhepatic phase in patients with cirrhosis have not been shown. Eighty patients with cirrhosis were studied prospectively. They were randomly distributed into two groups: patients with a temporary PCS (n ‫؍‬ 40) and those without a PCS (n ‫؍‬ 40). In all cases, the piggyback technique was used. Hemodynamic profiles and biochemical data during OLT and clinical evolution after OLT were evaluated. Preoperative data were similar in both groups. Surgical time also was similar (403 ؎ 77 v 387 ؎ 56 minutes; P ‫؍‬ .3). Red blood cell requirements were lower in the PCS group (2.3 ؎ 2.5 v 3.3 ؎ 2.9 units), although differences were not significant. In the PCS group, 45% of patients did not need red blood cell transfusion, whereas in the other group, only 22% were not administered a transfusion (P ‫؍‬ .03). During the anhepatic phase, the decrease in cardiac output was lower in the PCS group (-9.6% v -19%; P ‫؍‬ .05), whereas diuresis during the anhepatic phase was greater in the PCS group (3.6 ؎ 2.97 v 2.1 ؎ 1.38 mL/kg/h; P ‫؍‬ .005). There were no differences in liver biochemical parameters during the first 3 postoperative days. Nevertheless, creatinine levels increased significantly during this period only in the no-PCS group. The use of a temporary PCS during OLT improves hemodynamic status, reduces intraoperative transfusion requirements, and preserves renal function during and after OLT. T he classic surgical technique for orthotopic liver transplantation (OLT) involves recipient hepatectomy with resection of the retrohepatic vena cava and cross-clamping of the portal vein. 1 Interruption of caval flow during the anhepatic phase results in a reduction in venous return to the heart 2 and a decrease in renal perfusion, 3 as well as splanchnic hyperemia secondary to portal clamping. Venovenous bypass improves hemodynamic stability and allows decompression of the occluded splanchnic venous system. 4 However, the use of venous bypass is associated with other complications, such as hypothermia and pulmonary thromboembolism. 5,6 In 1968, Calne and Williams 7 described preservation of the vena cava. This technique, known as piggyback, 8 was further developed in pediatric OLT, 9 but has gained wide acceptance in adults, mainly in Europe. [10][11][12][13] Nevertheless, it does not avoid splanchnic hyperemia secondary to portal clamping.The use of a temporary portocaval shunt (PCS) with the piggyback technique was first described by Tzakis et al,14 then by Belghiti at al. 15 Previous studies have shown that preservation of both portal and caval blood flows throughout the procedure maintains hemodynamic stability and renal perfusion pressure. [16][17][18][19] This technique is particularly useful for patient...

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study

Figueras

2001

Liver Transplantation

107

114

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“…After the exclusion of duplicates, 4386 titles were obtained; 19 articles met all the criteria, but only in 11 of those articles was the experience with patients reported. Three articles were excluded as they were written by the same group of authors [5][6][7][8] in the same hospital during a similar time period, and although it was not specified, it was assumed that they described the results from the same cohort of patients who were more fully reported in other publications that were included in our analysis. Results from the 8 included articles are summarized in Tables 1 and 2, including a total of 2073 patients.…”

Section: Resultsmentioning

confidence: 99%

Temporary portocaval shunt in orthotopic liver transplantation: Need for a standardized approach?

2008

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Maintenance of portal and systemic venous return during the anhepatic phase of liver transplantation (LT) improves hemodynamic stability. With the piggyback technique, caval return is maintained; however, temporary clamping of the portal vein is still necessary. The use of a temporary portocaval shunt (TPCS) has been proposed to minimize the effect of portal venous interruption. The aim of this study was to perform a systematic review of the literature to determine whether there is evidence to support the routine use of a TPCS in LT. An electronic search of the literature from 1963 to 2007 was performed. A total of 4386 articles were identified, of which 8 met all the criteria and were included in the study. Because of the variability in reporting and the small number of studies, statistical comparison was not possible; however, a trend toward a shorter operative time, less blood product transfusion, and maintenance of higher mean arterial pressures during portal vein clamping was seen in patients with a TPCS. In conclusion, the available evidence, albeit scarce, supports the use of a TPCS in patients undergoing LT. A prospective randomized study of patients most likely to benefit from a TPCS is necessary to substantiate these findings.

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“…Essa técnica não evita a ocorrência de congestão do sistema porta. Pacientes com circulação colateral insuficiente podem apresentar aumento do sangramento e edema visceral, que dificultam a implantação do enxerto (Hesse et al, 1997). Nessa situação, um shunt temporário pode ser usado para manutenção de estabilidade hemodinâmica e adequada pressão de perfusão renal.…”

Section: Introdução E Literaturaunclassified

Transplante hepático

Soeiro¹

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convivência proveitosa para o meu aprendizado e pelo grande auxílio no meu crescimento científico. Á Profa. Dra. Lídia Raquel de Carvalho do Departamento de Estatística do Instituto de Biociências de Botucatu -UNESP, meu agradecimento pelo auxílio na análise estatística e ensinamentos.Ao Dr. Cássio Neves Ferreira, sócio e amigo, que sempre colaborou, possibilitando minha frequência no programa de pós-graduação. Aos funcionários do Departamento de Anestesiologia daFaculdade de Medicina de Botucatu -UNESP, Sra. Joana, Sra. Sônia e Sra.Neli, pela amizade e atenção que sempre me dispensaram.Á diretoria da Unimed de Sorocaba e do Hospital Unimed de Sorocaba, pela anuência para a realização dos transplantes.. LISTA DE FIGURAS RESUMOO objetivo do estudo foi analisar a experiência de um único centro com duas técnicas de transplante de fígado (TOF), convencional (C) e piggyback (PB), e comparar o intra e pós-operatórios, o custo financeiro e a sobrevivência do receptor e enxerto. Uma série consecutiva (2003)(2004)(2005)(2006) de 60 TOF em adultos foi analisada, sendo 29 no grupo PB e 31 no grupo C. Não houve diferença entre o perfil dos doadores dos grupos C e PB, mas 73% dos enxertos foram provenientes de doadores com fígados "marginais". Todos os pacientes foram submetidos à anestesia venosa total com propofol, remifentanil e cisatracúrio. A sobrevivência dos enxertos foi semelhante nos grupos em um, três e cinco anos (p > 0.05). No grupo C, foram realizados 4 retransplantes e nenhum no grupo PB. A evolução da função renal e hepática no pós-operatório foi semelhante, exceto no 1º e 5º dia do pós-operatório, quando os valores da creatinina plasmática foram maiores no grupo C (p < 0,05). A partir da fase anepática até o término da cirurgia, a pressão venosa central foi menor e a frequência cardíaca maior no grupo C (p < 0,05). A pressão de artéria pulmonar foi menor na fase anepática no grupo C ( p< 0,05). Não houve diferença de débito cardíaco e pressão de artéria pulmonar ocluída entre os grupos (p > 0,05). O tempo de cirurgia, anestesia e fase anepática foi maior no grupo PB (p < 0,05), mas não o tempo de isquemia fria e quente (p > 0,05). Houve maior utilização de concentrado de hemácias no grupo PB durante o intraoperatório (p < 0,05). A maioria dos pacientes, nos dois grupos, teve desintubação traqueal na sala de operação. Não houve diferença entre os grupos no tempo de permanência no hospital e na UTI e nos custos (p >0,05). Concluímos que, no período intraoperatório, a técnica piggyback, em relação à técnica convencional, tem menor alteração hemodinâmica, maior duração e utiliza mais concentrados de hemácias e, no período pós-operatório, a evolução clínica, a sobrevida dos pacientes e enxertos e os custos financeiros dos transplantes são semelhantes. ABSTRACT

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Liver transplantation by preservation of the caval flow with temporary porto-caval shunt or veno-venous bypass

Cited by 14 publications

References 7 publications

Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study

Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study

Temporary portocaval shunt in orthotopic liver transplantation: Need for a standardized approach?

Transplante hepático

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