Microvascular Reconstruction of the Hepatic Artery: Personal Experience with 200 Cases
Makaleler > Tam Makale · 2006
Yazarlar: Mehmet Alper
Journal of Reconstructive Microsurgery, Uluslararası, Wos, 2006, cilt 22
Özet
In patients with end–stage liver disease, living donor–related liver transplantation (LDLT) has become the treatment of choice, especially in countries where organ donation is limited and viral hepatic infection rates are high. Although more than 2500 LDLTs have been performed worldwide, many important aspects specific to this procedure, including microsurgical reconstruction of the hepatic artery, are still inadequately documented. This is one of the most important parts of LDLT because hepatic arterial thrombosis (HAT) may cause complications such as delayed biliary leak, relapsing bacteremia, and fulminant liver failure, necessitating retransplantation or even resulting in death. A liver graft with a hepatic artery less than 2 mm in diameter has been accepted as a contraindication for LDLT because of the high risk of HAT. Today, microsurgical technique has minimized the risks of HAT. The aim of this presentation was to share the experiences gained in 200 cases of microvascular hepatic artery reconstructions and demonstrate the difficulties of the operation. From June 1999 to April 2005, 200 LDLTs (41 children, 159 adults) were performed at Ege University Organ Transplantation and Research Center. Except for 4 cases (2%), the anastomoses were performed with the operating microscope. A surgical loop was used for the 4 cases mentioned. Anastomoses were completed with interrupted sutures with 9–0 or 10–0 polyamide. The diameters of both recipient and graft arteries were measured. Seventy–three percent of graft arteries and 55% of recipient arteries were equal to or less than 2 mm. in diameter. Mean anastomosis time was about 50 min. The backwall–first anastomosis technique was used in almost all cases. HAT was encountered in 3 cases in this series (1.5%). Two thromboses occured in the first five transplantations. However, these failures were not the result of technical error but were related to severe hypotension following completion of anastomosis, complicated by esophageal varices bleeding in one case and hemo–pneumothorax in the other case. The third HAT occurred from a branch that was near the anastomosis and that had not been ligated proximally. The graft artery should be anastomosed to the recipient artery with delicate manipulation of these vessels facilitated by microsurgical methods, with the best position under a surgical microscope to overcome the high risk of HAT and arterial complications during LDLT.