ContentslistsavailableatScienceDirect
International
Journal
of
Surgery
Case
Reports
j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m
“U-shaped”
mesoportal
jump
graft
to
manage
portal
vein
thrombosis
during
liver
transplantation:
A
case
report
Damiano
Patrono
a,
Sara
Salomone
a,
Carla
Guarnaccia
b,
Francesco
Tandoi
a,
Francesco
Lupo
a,
Paolo
Fonio
b,
Renato
Romagnoli
a,∗aGeneralSurgery2U–LiverTransplantUnit,A.O.U.CittàdellaSaluteedellaScienzadiTorino,UniversityofTorino,Torino,Italy bRadiologyDepartment,A.O.U.CittàdellaSaluteedellaScienzadiTorino,UniversityofTorino,Torino,Italy
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received19February2020 Receivedinrevisedform9April2020 Accepted28April2020
Availableonline15May2020
Keywords:
Portalveinthrombosis Yerdelclassification Jumpgraft Iliacbifurcation Casereport
a
b
s
t
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INTRODUCTION:Onceconsideredacontraindicationtolivertransplantation,portalveinthrombosisstill
representsasignificantchallengetothelivertransplantsurgeon.Yerdelgrade3thrombosisis
usu-allymanagedbyinterposingadonoriliacveinjumpgraftbetweengraftportalveinanddistalsuperior
mesentericvein.Venouspatchisnormallyplacedinaretrogastricpositiontoavoiditskinking.
PRESENTATIONOFCASE:Wereportanewtechnicalvariantofstandardmesoportaljumpgraft,inwhich
aU-shapedgraftwasobtainedusingiliacbifurcation.Thistechniquewasusedtomanageacaseofgrade
3portalveinthrombosisinwhichportalveinwasunsuitableduetoseverepylephlebitisandpylorus
dissectionhadtobeabandonedduetoinflammatorychangesissueofchronicpancreatitis.Thevenous
patchwasofsufficientlengthandshapetobypasspancreaticheadandfirstduodenum,avoidingthe
needforitsretrogastricplacementandpylorusdissection.
DISCUSSION:Thiscaseisafurtherdemonstrationthattechnicalapproachtoportalveinthrombosismust
betailoredaccordingtoitsextentandsurgicalscenario.Inselectedcases,useofacurvedU-shapedjump
graftmayrepresentavaluableoption.
CONCLUSION:Thistechnicaloptionshouldbeincludedamongoptionsforthemanagementofportalvein
thrombosisandbepartofthearmamentariumoflivertransplantsurgeon.
©2020TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen
accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
1. Introduction
Non-tumoral portal vein thrombosis (PVT) is observed in 5%–26%ofpatientscandidatetolivertransplantation(LT),with2% ofthempresentingcomplexPVT[1].Portalveinthrombosishas longbeenconsideredasacontraindicationforLTduetoincreased technicaldifficulty andinferior outcomes,but severaltechnical optionsforitsmanagementduringLThavebeendeveloped,ranging fromlowdissectionoftheportalvein+/−thrombectomyto cavo-portalhemitransposition[2,3].TechnicalapproachtoPVTmainly dependsonPVTextension,availabilityoflargeportalvein collater-alsandpresenceofspontaneousorsurgicalportosystemicshunt, assessedduringpre-LTwork-upandintraopearatively[4].Several
Abbreviations:PVT,portalveinthrombosis;LT,livertransplantation;SMV, supe-riormesentericvein;D1,firstduodenum;MELD,modelforend-stageliverdisease; CT,computedtomography;IVC,inferiorvenacava;TIPS,transjugularportosystemic shunt.
∗ Correspondingauthorat:UniversityofTurin,GeneralSurgery2U-Liver Trans-plantCenter,CorsoBramante88-90,10126,Turin,Italy.
E-mailaddress:renato.romagnoli@unito.it(R.Romagnoli).
PVTclassificationshavebeenproposed,withtheoneproposedby Yerdelelal.[5]beingoneofthemostintuitiveandwidelyadopted. InYerdelgrade3PVT,i.e.completethrombosisoftheportalvein andproximalsuperiormesentericvein(SMV),onetechnicaloption isdistaldissectionoftheSMVandmesoportalanastomosisusing aninterpositionjumpgraft.Toavoidkinking,thegraftnormally placedthroughthetransversemesocolonandposteriortothefirst duodenum(D1)andthepylorus[2,5–7].InpatientswithPVTand presumablysevereportalhypertension,D1dissectionorKocher maneuvermaybeparticularlychallengingduetothepresenceof largeandfragilevarices.
Wepresenthereanoveltechniqueofmesoportaljumpgraftto manageYerdel3PVTduringLT.Inthecasereportedherein,a “U-shaped”donoriliacveinjumpgraftincludingiliacbifurcationand theproximalsegmentofiliacveinswasusedtogetoverthe pan-creaticheadandD1,avoidingtheneedforD1dissectionorKocher maneuver.ThecaseisreportedinlinewiththeSCAREcriteria[8]. 2. Presentationofcase
Patientwasa49-year-oldmalewithend-stagealcohol-related liver disease and a history of several hospital admissions due
https://doi.org/10.1016/j.ijscr.2020.04.098
2210-2612/©2020TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.
Fig.1.Multiplanarcontrast-enhancedcomputedtomography(CT)3Dreconstructions.A:pretransplantCTshowinggrade3portalveinthrombosis,withproximal involve-mentofthesuperiormesentericvein(thinarrow).Athinportalveincollateralisidentifiedatthehepatoduodenalligament(thickarrow),aswellasalargeportosystemic shunt(asterisk)arisingfromdistalsuperiormesentericveinanddrainingintotheinferiorvenacava,belowtheoutletofrightrenalvein.B:post-transplantCTshowing patencyandpositionofthemesoportaljumpgraft.
todecompensatedascites and hepatic encephalopathy.Hewas referredforLTinMay2019withcreatinine0.93mg/dl,total biliru-bin11.2mg/dlandINR2.28andamodelofend-stageliverdisease (MELD)scoreof25.Pre-LTcomputedtomography(CT)highlighted thepresenceof a largethrombusin theportal veinand proxi-malSMV, sparingthesplenicveinandthedistalSMV (Fig.1A). CT alsoshowed largea thin portal vein collateral, not suitable forportalveinanastomosis,and alargespontaneousmesocaval shuntdrainingintotheinferiorvena cava(IVC)below the out-letoftherightrenalvein.Treatmentwithlowmolecularweight heparinwasstarted(enoxaparin6000IUb.i.d.)butitwasnot tol-erated.
Transjugular intrahepatic portosystemic shunt was deemed unfeasibleduetothelowextensionofPVT.BasedonPVT exten-sion,LTwasdeemedfeasiblebyusingamesoportal jumpgraft interposedbetweenSMVandgraftportalvein,theback-upoptions beingrenoportalanastomosisorcavoportalhemitransposition.At waitlisting,hisMELDscorewas29(creatinine1.12mg/dl;total bilirubin13.0mg/dl;INR2.77).
Duringorganretrieval,iliacarteriesandveins,includingaortic and IVC bifurcations, were procured. At liver transplant, long-standingPVTandpresenceoflargeportosystemiccollateralswere confirmed.Asshownbypre-LTimaging,alargemesocavalshunt originatedatthelevelofthegastrocolictrunkofHenleanddrained intoinfrarenalIVC.Therewasapictureofseverechronic pancreati-tis,withperipancreaticinflammatorychanges.Afterdissectionof thehepatoduodenalligament,portalveinappearedtobeinvolved byseverepylephlebitis,withthickenedandinflammatory walls andminimal residuallumen.A low dissectionof splenomesen-tericconfluenceandaneversionthrombectomywerecarriedout, whichwere partiallysuccessfulin re-establishinga satisfactory flowintothepreviouslyobstructedvessel.However,due tothe extremelynarrowedresiduallumenandthethickeningofthe ves-selwall, portalveinwasjudgedunsuitablefor anastomosisand abandoned.Asoriginallyplanned,wedecidedtoperformportal veinanastomosisusingan interpositiongraftbetweentheSMV and graft portal vein. To avoid prolongingcold ischemia time, arteryanastomosiswasperformedfirst. Aftergraft reperfusion, SMVwasdissecteddistallytothegastrocolictrunkofHenlefor
Fig.2. DrawingoftheU-shapedmesoportaljumpgraft.
approximately4cm,preservingthelargemesocavalshunt. Prepa-rationoftheretrogastrictunnelwasabandonedduetothesevere inflammatoryreactionissueofchronicpancreatitis.AU-shaped donoriliacinterpositionpatchwasthenpreparedbysuturingIVC about2 cm above theiliacbifurcation using a vascular stapler (EndopathETS-Flex45mm,EthiconEndo-surgery,Cincinnati,OH) andbystitchingsmallcollateralsoriginatingfromcommoniliac veins.SMV was tangentially clampedand an end-to-side
anas-Fig.3.Intraoperativepicturesatlower(A)andhigher(B)magnification,showingthepositionofmesoportaljumpgraftinrelationtothepancreaticheadandfirstduodenum.
Fig.4.Postoperativetrendoftransaminases,bilirubin,INRandplatelets.
tomosisbetweenthevenouspatchandtheSMVwasperformed usinga5/0polypropylenesuture,followedbyanend-to-end anas-tomosis betweenthe venous patchand graft portal veinusing thesamematerial(Fig.2).Afterclampsremoval,thejumpgraft appearedasoptimallybypassingtheduodenumandthe pancre-atic head, in theabsence of any tension on the reconstructed vascularaxis(Fig.3).Portalflowassessedbytransittimeflow mea-surement(MiraQVascular,Medistim®,Oslo,Norway)was1500
mL/min(107mL/min/100gofgraftweight).IntraoperativeDoppler ultrasoundexaminationconfirmedregulargraftperfusion.Finally, biliaryreconstructionbyanend-to-endhepatico-choledocostomy wasperformed.
Postoperative course was characterized by immediate graft functionandnosurgicalcomplications.Duetolowplateletcount,
anticoagulanttreatmentwithenoxaparin6000IUwasstartedon the7thpostoperativedayandreplacedbyacetylsalicylicacid200 mgo.d.onemonthafterLT.RepeatedDopplerultrasound exam-inations and a CT scan performed in the postoperative period demonstratedpatencyofthereconstructedvenousaxisand other-wiseregulargraftperfusion(Fig.1B).Patientmadeagoodrecovery andwasdischargedhomeon19thpostoperativeday.At6-month follow-upheisingoodhealth,withnormalhepaticfunctionand regulargraftperfusion(Fig.4).
3. Discussion
OnceconsideredacontraindicationtoLT,complexPVTstill rep-resentsatechnicalchallengeduringLTanditsincidenceislikely
underestimatedinLT series,inwhich patientswhoarerefused aprioribased onPVT extent are not takeninto account. Since thevery early experiences with PVT management, it appeared that surgical technique has to be tailored to the anatomy of PVT, including its extension below the splenomesenteric con-fluence,availabilityof largeportalveincollateralsand presence of spontaneous or surgical portosystemic shunts [7]. Whereas grade1–2PVTcasesaremosteasilymanagedbylowdissection oftheportalveintowardsthesplenomesenteric confluenceand thrombectomy[2,9],grade4PVTcasesaremorelikelytorequire non-physiologicalreconstructions,i.e.thoseinwhichportalflow isnotdrainedintothegraftandafterwhichportalhypertension persists.
AtourInstitution,whichisapproaching3500LTperformedata singlecenter,allcandidatestoLTarescreenedforPVTbya contrast-enhancedcomputedtomographywith3Dreconstructions.Inlast 10years,PVTwasdiagnosedin126candidatestoLT,classifiedas grade1,2or3in58(46%),46(36.5%)and22(17.5%),respectively. Incasegrade1–2PVTisdetected,lowmolecularweightheparinis startedand,inpatientswhoaresuitablefor,earlyTIPSisconsidered topreserveorreestablishportalveinpatency[10,11].
Ingrade3PVTanticoagulantsaremorefrequentlyineffective andTIPS maybeunfeasibleduetotheimpossibility toidentify asafe“landingpoint”intheportalvenoussystem.Forma surgi-calstandpoint,severaloptionsareavailable,ofwhichmesoportal anastomosisusinganinterpositionjumpgrafthasbeenmost fre-quentlydescribed.
Instandardtechnique,themesoportalinterpositionjumpgraft isplacedinatransmesocolic,prepancreaticandretrogastric posi-tion [2,5–7]. The retrogastric passage is normally required to maintainthereconstructedvenousaxisstraight,avoidingits kink-ingover pylorusandD1.Albeittheretrogastricpassagemaybe omittedinparticularcases,thisrequirestheavailabilityofa vascu-larpatchofappropriatelength,possiblyobtainedbyusingadouble elongationpatch.Surgicaltechnique,however,hastobetailoredto patientanatomyandsurgicalscenario.
Inourcase,wewereforcedtorecurtoamesoportal interpo-sitiongraftbytheimpossibilityofusingnativeportalveindueto itsseverethickeningandinflammatorychanges.Thejumpgraft wasmanufacturedbyusingthe iliacbifurcation and the proxi-maltractofcommoniliacveins,obtainingagraftofappropriate lengthandshapetogetalongthepancreaticheadandD1,while avoidinganyD1orpylorusdissectionortheneedforadouble elon-gationpatch.Inourpractice,iliacvessels,ifsuitable,arealways procuredtoallowpossiblevascularreconstructionsinthe recipi-ent.Incasepancreasisretrievedfortransplantation,iliacvessels aresharedwiththepancreasteam,accordingtoeachteam neces-sities.
Asfeasibilityof thistechniquedependsupon theavailability ofIVCbifurcation, itcouldnot befeasible whenthis hastobe sharedwithothertransplantteams,orinlivingdonorLT. Further-more,appropriatemanagementofcomplexPVTisdrivenbycareful evaluationofvascularanatomyandofthedegreeofportal hyper-tension. Thus, no“one-fits-all” approach can be recommended and our technique may not be appropriate in all grade 3 PVT cases.
4. Conclusion
Inconclusion, we describe the“U-shaped”mesoportal jump graft,atechnicalvariantofmesoportaljumpgrafttobeemployed incaseofgrade3PVT,whenuseofnativeportalveinisnot possi-ble.Bythiseasyandreproducibletechnique,agraftofgoodlength andappropriateshapecanbeobtained,possiblyavoidingtheneed foritsplacement ina retrogastricposition.Althoughlong-term
follow-upofourcaseisreassuring,furtherexperienceisnecessary toconfirmthevalueoftheproposedtechniqueinsimilarcases. Funding
Authorsdeclaretheyreceivednofundingforthispaper. Ethicalapproval
ThestudyisexemptfromethicalapprovalatourInstitution. Consent
Thepatienthasgiveninformedconsenttotheprocessingof per-sonaldata,includingconsenttotheuseofhealthdataandimages forscientificpurposes.
Registrationofresearchstudies
Noregistrationwasrequiredforthisstudy. Guarantor
Dott.DamianoPatrono. Provenanceandpeerreview
Notcommissioned,externallypeer-reviewed. CRediTauthorshipcontributionstatement
DamianoPatrono:Conceptualization,Datacuration,Writing -review&editing.SaraSalomone:Writing-originaldraft.Carla Guarnaccia:Datacuration,Visualization.FrancescoTandoi: Writ-ing-review&editing.FrancescoLupo:Writing-review&editing. Paolo Fonio: Writing - review & editing, Supervision. Renato Romagnoli:Writing-review&editing,Supervision.
DeclarationofCompetingInterest
Authorsdeclaretheyhavenoconflictofinterest. References
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