Novel technique for pediatric living donor liver transplantation in patients with portal vein obstruction: The “pullout technique”

Abstract

PV hypoplasia may increase the risk of posttransplant complications, especially when it extends to near the SMV and SpV junction. We described our experience of 10 pediatric cases of PV hypoplasia/thrombus in which the pullout technique was required for PV reconstruction. There were five male and five female patients. The median age was 9 months, and the median weight was 8.1 kg. The indications for the pullout technique were PV hypoplasia in seven patients and PV thrombus in 3. The inflow sites of the enlarged LGV were as follows: the main PV trunk (n = 2), the SMV and SpV junction (n = 4), and the SpV (n = 4). The posterior face of the pancreas was tunneled along the PV, and the PV was returned to its original position with or without the use of an interposed vein graft. The pullout technique created a good operative field, which allowed for the complete removal of the hypoplastic PV or thrombectomy with the safe use of various interposed vein grafts.

Efficacy of intraoperative cine‐portogram for complicated portal vein reconstruction in pediatric living donor liver transplantation

“…However, not only the modification of the portal flow but also the assessment of the quality of the PV wall is imperative for maximizing the portal flow in pediatric LDLT. In a previous report, we underscored the importance of an intraoperative evaluation of the PV and several techniques for obtaining a sufficient portal flow 4,6,7,11 …”

“…Portosystemic collateral pathways appearing on the preoperative images were ligated before implantation to ensure sufficient PV flow, regardless of their size. The LGV and SRS were interrupted by direct ligation while the RPS were occluded by cautery as described previously 4,6,7 . Since May 2016, the PVP has been measured at three different time points: after laparotomy, at collateral interruption, and before abdominal closure 4 .…”

“…IOUS was performed after PV reconstruction to determine whether a sufficient PV flow had been achieved. The pullout technique was applied in one case requiring improvement of the operative view and allowed for the complete removal of the phlebosclerotic PV and safe use of interposed vein grafts that was first reported by Shaw et al in 1985 7,8 . In cases with complications, a mobile C‐arm for IOCP was applied when frequent re‐anastomosis was required due to an insufficient PV flow (flow volume less than 10 mL/kg body weight/minute) despite visible collateral interruption or recurrent PVT after primary PV reconstruction 9,10 .…”

Extensive Thrombectomy as a Legitimate Strategy in Living Donor Liver Transplantation With Advanced Portal Vein Thrombosis

“…The most significant obstacle in advanced PVT is the difficulty in safely approaching the SMV thrombus to be removed. Kasahara et al pulled out the thrombosed PV caudally from the pancreas for direct manipulation and thrombectomy. The main advantage of these direct techniques is complete clearance of the PVT under direct inspection, whereas the disadvantage is huge amounts of bleeding due to vigorous collateral vessels with portal hypertension.…”

Post‐transplant metabolic syndrome in children: Know better to cure better

“…Liver transplantation is one of the most consequential achievements of modern medicine. Advances in surgical, anesthesia and intensive‐care techniques, as well as early and long‐term care result in excellent patient survival …”