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

Abstract

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...

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

“…A direct comparison of the operative times with and without TPCS was available in 3 studies. 9,10,14 There was no difference in 2 studies, 9,14 and 1 study found that the operative time was shorter in patients undergoing TPCS. 10 The intraoperative blood product transfusion requirement was described in 6 articles.…”

“…10 The intraoperative blood product transfusion requirement was described in 6 articles. 1,3,8,10,13,14 The number of red blood cell units transfused into patients with a TPCS ranged from 1.1 Ϯ 2.3 to 98.4 Ϯ4.3 units. A comparison of patients with a TPCS and patients without one was reported in 3 articles.…”

“…10,13,14 Two of 3 studies found that a TPCS was associated with less red blood cell requirement. 13,14 The amount of fresh frozen plasma transfused into patients with a TPCS ranged from 1.4 Ϯ2.7 to 19 Ϯ14.7 units. Two of 3 studies found that TPCS was associated with less fresh frozen plasma transfusion.…”

“…Two of 3 studies found that TPCS was associated with less fresh frozen plasma transfusion. 13,14 Platelet transfusion was described in 3 studies and ranged from 5 to 17 units. 8,10,14 One of 2 studies found that TPCS was associated with less platelet transfusion.…”

“…13,14 Platelet transfusion was described in 3 studies and ranged from 5 to 17 units. 8,10,14 One of 2 studies found that TPCS was associated with less platelet transfusion. 10 Intraoperative hemodynamic variables were reported in 5 articles.…”