Surgical techniques and longterm outcome of living donor liver transplantation for BuddChiari syndro

1
Surgical techniques and long-term outcome of
living donor liver transplantation for
Budd-Chiari syndrome

• Takako Yamada Koichi Tanaka Yasutsugu Takada
  Yasuhiro Ogura Fumitake Oike Saiho Koh
  Shosuke Nakajima
• Kyoto University Hospital Department of
  transplantation Nara Prefectural Medical
  College Department of Surgery

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Budd-Chiari syndrome (BCS)

• A clinical condition characterized by hepatic
  venous outflow obstruction secondary to an
  underlying systemic coagulative disease

Selection of treatment the degree of hepatic
injury liver biopsy results pressure
measurment
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Criteria of liver transplantation

• Fulminant form
• Liver cirrhosis
• Hepatic metabolic defects
• (Protein CProtein S deficiency )

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Aim

• To evaluate the surgical techniques of living
  donor liver transplantation (LDLT) for BCS and
  to assess determinants of long-term outcome

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Difference of surgical thechniquesDDLT vs LDLT
DDLT recurrence rate 0-10 patient
survival 45-76 (3 years)
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Patient charasteristics

• case gender age(y) underlying disease preLTx
  treatment
• 1 M 3 unknown (-)
• 2 M 10 unknown (-)
• 3 M 11 unknown splenectomyIVR
• 4 M 11 Lupus anticoagulant thrombectomyIVR
• 5 M 26 unknown TIPSIVR
• 6 M 27 unknown IVR
• 7 M 39 unknown (acute) (-)
• 8 F 32 Myeloproliferative disorders (-)
• 9 M 17 hypereosinophilic syndrome (-)

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Hepatic veins (HV) and inferior vena cava
(IVC)Pattern of stenosis
HV stenosis alone (n1)
Stenosis of HV and IVC
(n7) HV stenosis and IVC complete
obstruction (n1)
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Surgical techniques
Thrombosis and fibrotic tissue
Dissection of diaphragmatic crus Exposure of
intact IVC in posterior meiastinum
IVC cross clamp and removal of thrombotic IVC
wall
A
B
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Implantation of left-sided grafts (2 4)
Venous patch
HV reconstruction
IVC plasty with venous patch
10
Implantation of right-sided grafts (5 6 8)
B
C
D
right side of IVC wall
left side
HV reconstruction
Cavo plasty with venous patch
A
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Surgical techniques in case of IVC complete
obstruction (1 3 9)
End-to-end anastomosis between hepatic vein and
suprahepatic IVC
Closure of suprarenal IVC
End-to-end 1 End-to-side2
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Surgical procedures

• case graft IVC plasty vein graft
• Without cavoplasry
• 1 lateral end-to-side (-)
• 3 left end-to-side (-)
• 7 right end-to-side (-)
• 9 left end-to-end (-)
• With cavoplasty
• 2 left patch plasty donor IMV
• 4 left patch plasty donor IMV
• 5 right patch plasty iliac vein
• 6 right patch plasty auto portal vein
• 8 right patch plasty ovarian vein

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Results

• follow up recurrence treatment after relapse
• 1 alive 456(month) (-)
• 6 alive 7 (-)
• 7 alive 56 (-)
• 8 alive 46 (-)
• 9 alive 1 (-)
• 2 alive 78 () Baloon dilatation
• thrombectomy/cavoplasty
• metalic stent
• 4 alive 72 () cavoplasty
• metalic stent
• 3 dead (1) (-) multiple organ failure
• 5 dead (17) () pulmonary embolism

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Treatment with metalic stent for recurrence of BCS
Metalic stent
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Anticagulant therapy
POD
PT 15-20sec ACT 150-200sec
INR1.5-2.5 (Lupus anticoagulant INR 2.5-3.5)
Myeloproliferative disorder 0POD14POD
heparin sodium 50000U/body 14POD
APTT50-55sec (Plt50000 hydroxycarbamide
500mg/day)
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Conclusion

• Surgical procedure of LDLT for BCS is determined
  based on the site and extension of IVC stenosis
• In a case of IVC stenosis the patch plasty of
  IVC using a vein graft is required
• IVR is effective to treat the recurrence