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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 3  |  Page : 140-145

Our experiences on microsurgical anastomosis of hepatic arteries, without thrombosis, in living donor liver transplantations


1 Department of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, Ataturk University, Erzurum, Turkey
2 From Private Practice, Istanbul, Turkey
3 Department of General Surgery, Faculty of Medicine, Ataturk University, Erzurum, Turkey
4 Department of General Surgery, Faculty of Medicine, Akdeniz University, Antalya, Turkey

Date of Submission09-Sep-2019
Date of Acceptance20-Oct-2019
Date of Web Publication26-May-2020

Correspondence Address:
Dr. Ensar Zafer Barin
Departments of Plastic, Reconstructive and Aesthetic Surgery, Ataturk University, Erzurum 25240
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_74_19

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  Abstract 


Background/Aims: Liver transplant is the ultimate and exclusive treatment of liver failure. Since the transfer of hepatic lobe takes place along with its own hepatic artery, the anastomosis process requires the utilization of microsurgical techniques and equipment in the living donor liver transplantations (LDLT). The success of the anastomosis directly affects the result of the surgery and thereby effects patient survival. Otherwise, in the case of failure, it can lead to mortality of the patient. The aim of this study is to retrospectively evaluate the hepatic artery anastomosis in terms of vascular characteristics, arterial diameters, operation time, complications, and thrombosis rates and also to achieve more successful results with lower complication rates. Furthermore, the study aims to share the accumulated knowledge and the experience to develop the technique further and to learn how to make the transfer more easily in the future. Materials and Methods: From 2010 to 2017, 85 LDLTs were performed in Ataturk University Organ Transplantation and Research Center. The hepatic artery anastomosis was performed by the same microsurgeon. Results: We have not encountered any hepatic arterial thrombosis. The success of 100% anastomosis in our series is compatible with the literature, and it was found to have a higher success rate. However, the fact that our current series is small should not be overlooked. Conclusion: The collaboration between microsurgeons and transplant surgeons to reduce technical complications can play an important role in obtaining long-term and permanent transplantation outcomes.

Keywords: Anastomosis, hepatic artery, living donor liver transplantation, microsurgery


How to cite this article:
Barin EZ, Tan O, Cinal H, Kara M, Ozturk G, Aydinli B. Our experiences on microsurgical anastomosis of hepatic arteries, without thrombosis, in living donor liver transplantations. Turk J Plast Surg 2020;28:140-5

How to cite this URL:
Barin EZ, Tan O, Cinal H, Kara M, Ozturk G, Aydinli B. Our experiences on microsurgical anastomosis of hepatic arteries, without thrombosis, in living donor liver transplantations. Turk J Plast Surg [serial online] 2020 [cited 2020 Jul 10];28:140-5. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/3/140/284967




  Introduction Top


After applying the supportive treatment to the patient, the ultimate and exclusive treatment is to perform liver transplantation in the cases of acute or chronic liver failure. The two indications for liver transplantation, which are commonly accepted by the medical community, are shorter survival time (which is considered as less than a year) and unacceptable life quality due to liver disease. The first successful liver transplantation was performed in 1967 by Starzl.[1] Nowadays, liver transplantations are being performed in two categories as either cadaveric donor liver transplantation (CDLT) or as living donor liver transplantation (LDLT), where its importance and popularity are increasing day by day.[2],[3] Insufficient organ donations and inadequate liver procurement as well as strong kinship bonds have helped to raise the LDLT rates as compared to CDLT. Thousands of LDLT have been performed in many centers around the world since it was first reported in 1989.[4],[5]

In CDLT, the hepatic artery system is taken from the aortic level, and anastomosis is performed at this level to the recipient. Thus, this is a gross vascular process which does not require any microsurgical techniques. However, in LDLT, hepatic lobule is transferred along with its own hepatic artery. This process requires microsurgical anastomosis technique and equipment due to its small diameter.

The liver has a dual blood supply from the hepatic artery as well as from the portal vein. Hence, the parenchyma gets blood through both of them; but the biliary tract has no correlation with the portal circulation. For this reason, the success of the anastomosis directly affects the operation result and the patient survival. Otherwise, the situation results in mortality.[6] While hepatic artery anastomosis has been performed by miscellaneous medical branches which have microsurgical experience, it is common practice for it to be performed by plastic surgeons in many centers all across the world.[7]


  Materials and Methods Top


Patients population

We were involved in 85 LDLT operations, which were performed at the Ataturk University Organ Transplantation and Research Center. Fifty-five of the patients were male and 30 of them were female. The patients' ages ranged between 6 months and 68 years of age. The median age of the patients was 40.2 years. The indications for these LDLTs were; Hepatitis B virus related cirrhosis (n = 27), cryptogenic cirrhosis (n = 15), fulminant hepatic failure (n = 8), Wilson's disease-related cirrhosis (n = 8), autoimmune hepatic failure (n = 6), Budd–Chiari syndrome-related hepatic failure (n = 3), portal vein thrombosis-related cirrhosis (n = 2), and others.

Surgical technique

Hepatic artery reconstructions were performed under surgical microscope by the same plastic surgeon in all of the patients. Microsurgical procedure had three stages, where the first stage was the dissection of recipient and donor arteries, second stage was the mutual positioning of tips and the final stage was the anastomosis of arteries. The right hepatic artery (RHA) was preferred primarily because of its adequate calibration and high flow rate. Furthermore, pulsation and flow intensity were controlled by palpation. In case the RHA has short length, or if it has a small diameter, inadequate flow, or if it is damaged, then the other vessels such as left hepatic artery (LHA), the replaced hepatic artery (rHA), proper hepatic artery, gastroduodenal artery, and segment 4 artery can be used. There was no intervention to the arteries in the case of diameter discrepancy, in which the rate was 1/1.5. However, when the rate was found to be >1.5, oblique resection was applied to the small vessel. Anastomosis was performed using a micro approximator and in addition plastic transparent material was used under the anastomosis line. Single dose of low-molecular-weight heparin was applied subcutaneously and prophylactic dose was applied before anastomosis in the case where INR and PTT values were found to be normal. Any other antiaggregant agent was not used. Before the anastomosis, the diameters of the recipient and donor arteries were measured under microscope with sterilized paper ruler. Hepatic arteries were classified into two groups according to their diameters [Table 1].
Table 1: Diameters of hepatic arteries

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8-0 nylon was preferred in microsutures used in anastomosis if the diameter of arteries were under 2 mm, and 9-0 nylon was preferred if it was larger than 2 mm. In case of spasm after anastomosis, topical papaverine was used. Adequate flow was controlled by pulsation of arteries and patency test was not recommended due to the fragile structure of arteries. Furthermore, arterial perfusion was corrected by peribiliary bleeding in the periphery of the anastomosis site. Intraoperative color Doppler ultrasonography (USG) was used for corroboration of hepatic artery flow in suspicious cases. Color Doppler USG and liver enzymes levels were tracked for hepatic artery perfusion for 7 days.


  Discussion Top


The first liver transplantation was performed by Thomas Earl Starzl in 1963. However, there was no significant increase in the number of transplantations in the following two decades. Factors, such as innovations in surgery and anesthesia, development of better drugs, and change of intensive care conditions, have led to an increase in the number of transplantation operations in the world since the 1990's.

Owing to inadequate organ donations, LDLT came to mind in the late 1980s.[8],[9] LDLT series have been reported both in Asia and America.[10],[11],[12],[13] The first pediatric and adult LDLT operations were performed by Haberal in 1990 in Turkey.[14],[15] Since that time, LDLT surgeries have been performed successfully in many centers around Turkey.

One of the most important steps of LDLT is hepatic artery anastomosis, which directly affects patient survival. Failure of anastomosis results with 80% mortality.[16],[17],[18] Therefore, this process must be done meticulously. It is possible to distinguish two factors affecting it as internal and external factors which play a role in the success of anastomosis.

Age, etiology of hepatic failure, the structure and diameter of vessels, accompanying vascular pathologies such as atherosclerosis, diabetes, intimal damage, and finally diameter discrepancy are the internal factors, and they cannot be changed. The experience and the skill of surgeon, surgical equipment, and technique, as well as the selection of recipient's vessel are the external factors, and they can be changed.

The hepatic artery reconstruction is the most critical step of the LDLT operation, and thus that part requires the most attention. Shifting at this stage of operation, from tired and distracted transplant surgeons to new microsurgical crew, which commonly consists of plastic surgeons, is a reasonable choice. Sharing the operation load and stress by two surgical teams and providing a breathing space to the transplant surgeons during the hepatic artery anastomosis probably reduces complication rate and increases the success levels.

Adequate light and magnification are the most essential and indispensable prerequisites for microsurgery. Either surgical (operating) microscope or surgical loupe is used for this purpose. It is a controversial subject to use a surgical loupe or microscope in LDLT. After many years following Starlz's report, which had underlined the importance of microsurgery in liver transplantation,[19] Mori et al. initially reported microsurgical hepatic artery reconstruction in LDLT.[20] In this study, they performed 14 hepatic artery anastomoses, where 7 of them were conducted with microsurgical magnification and remaining with loupe. Any complication was not encountered in the group under the microscope, and two complications were seen in the loupe group. Guarrera et al. studied the differences between using loupe or microscope. They argued that if the hepatic artery diameter is not too small, using loupe is more suitable, and it is easier to use in respiratory and heartbeat movements; and furthermore, they also reported that they achieved better results with loupe magnification in terms of survival.[21] Ohdan et al. performed anastomosis with a head-mounted binocular system called varioscope and claimed that they overcame the problems experienced with microscopes such as positioning and tilting.[22] Although studies related to using surgical loupe reported some successful results and while the studies argue that the surgeon can move more flexible and can take advantage of the deep planning of intra-abdominal surgical site with this mobility; the latest technology microscopes have three-dimensional movement potential in addition to their electromagnetic motion property. These make it possible for the surgeon and assistant to work with much more organized and synchronized movements under microscope compared to the loupe. Therefore, the concentration on the surgery itself increases, and this also positively affects both the duration and result of the operation.

The type and the size of used microsutures are also important for surgical success. Nylon sutures are used as the first choice with its better knot ability, and it has softer and more flexible structure than the polyproline sutures. We preferred 9-0 nylon sutures under 2 mm diameter and used 8-0 nylon sutures over the diameter of 2 mm.

In contrast to free flap, replantation and peripheral nerve surgery, hepatic artery anastomosis in LDLT has some extra difficulties. Unlike the others, hepatic artery anastomosis is performed in much deeper plane, which provides a very limited field of view and manipulation. Another challenge for hepatic artery anastomosis is bloody field which causes escape from hepatic or portal vein anastomosis. In addition, the bile fluid from the open gall duct mouths in the graft is also leaked to the surgical field. All of these negativities affect the vision. Another problem specific to hepatic artery anastomosis is the necessity to work in a moving field. From one side, the respiratory movement of the lungs takes place, and the cardiac beat from the other side makes the hepatic artery anastomosis to become much more difficult.

Anastomosis technique used in hepatic artery micro-anastomosis is another external factor playing a role in success. Even though the technique varies with the structure of arteries, as well as the size and the area of operation; the microsurgeon's personal habit and preference are also critical determinants. Several methods have been reported in the literature in this regard. Classical method which has been reported in 1981,[23] is the application with individual sutures using microvascular clamps. In our study, we performed all the anastomosis without any problems using this conventional method. Wei et al. reported a series of 152 cases of LDLT in 2004 by also using a conventional anastomosis technique and declared anastomosis-related complications rate of 2%.[24] Yamamoto et al. reported a new anastomosis technique called the “back wall technique”. This technique eliminates the using of micro-clamps due to inadequate space for their placement in deep abdominal cavity. Furthermore, the study also argues that it eliminates intimal damage without turning microclamps.[25] Alper et al. reported their outcomes of 150 patients who underwent hepatic arterial reconstruction. They used surgical loupes in four patients and surgical (operating) microscopes in the remaining 146 patients. Approximately 79% of the anastomoses were performed with the posterior wall technique. There was no significant difference in the complications due to the surgical technique used.[26] Ulusal et al. performed hepatic artery reconstruction in series of LDLT both with conventional method using microclamps and with back wall technique without using clamps. They proclaimed that there was no difference between the two techniques for anastomosis outcome.[27] Haberal et al. have described two new techniques for hepatic artery reconstruction in LDLT. The first of these is the modified parachute technique which was used in a series consisting of 104 cases. However, after anastomosis, high rate of hepatic artery stenosis was observed and thus they have designed a new technique which was a modification of posterior wall technique. They reported the complications rates at similar rates to those reported in the literature. Okazaki et al. also developed a new technique to overcome this compulsive artery reconstruction, called the double-needle microsuture technique. When they evaluated their results from this new technique, they found hepatic artery thrombosis (HAT) incidence as equivalent to the literature.

The preference of the recipient artery is one of the major factors that affect the success of the operation in LDLT, such as replantation and free flap surgery. Hepatic artery has very frequent and various variations. This makes the choice of the recipient artery quite complex. We claim that the right hepatic artery should be preferred because of sufficient calibration, high flow, and close position to the donor artery. Alternative arteries (LHA, segment 4 artery, replaced right or LHA, accessory right or LHA, hepatica propria and gastroduodenal artery) can also be used in cases where the right hepatic artery is absent, short, or if it has a small diameter, low-flow or if it is damaged. In our series, the right hepatic artery was used predominantly as a recipient (54 patients, 63.5%). In 13 patients, LHA was preferred as the recipient (15.2%), and in 8 patients, the right hepatic artery from the superior mesenteric artery was chosen as the recipient (9.4%). Remaining options were used decreasingly. Likewise, the right hepatic artery was used much more commonly as the donor artery.

The diameters of both recipient and donor hepatic arteries are one of the internal factors that play a role in the success of the anastomosis. Arterial diameters can vary widely with each individual due to their age and race or due to their structural differences. In our series, recipient arterial diameters were recorded on a patient basis and mean was 2.85 and donor mean was 2.46 mm. In the cirrhotic liver, intraparenchymal fibrosis increases pressure on both the portal vein and the hepatic artery. This results in the thickening of the arterial wall, intimal dissection, increased fragility and enlargement of the diameter of hepatic artery.[28] It is evident that recipient artery diameters are larger than the normal-sized donor artery diameters in our series. In incompatibility situations, where the diameter difference ration between the recipient and donor arteries does not exceed 50% or more than 1 mm, the problem can be solved with proper suturing. Otherwise on larger diameter differences, extension of the diameter with oblique incision on the narrow side is the most commonly used, which is a simple and effective method.[29] In the case of serious diameter discrepancies, the diameter can be narrowed by extracting a triangular piece from the large artery. However, this method may increase the risk of thrombosis due to the deterioration of endothelial integrity. In 19 cases (22.3%) there were significant differences found between the arteries, and all were equalized with oblique cuts. None of these patients had early or late thrombus. We think that oblique cut can be a definite and practical solution with no need to apply triangular resection, which may increase the thrombosis risk, and which also may extend operation time.

Another internal factor which plays an important role in the success of the anastomosis is hepatic artery spasm which occurs intraoperatively. Spasm is a physiological response to external factors such as surgical manipulation, irrigation, and heat exchange. When viewed from this angle, using highly sensitive microsurgical instruments, manipulating as atraumatic as possible on the arteries walls, avoiding patency test to control flow after anastomosis, and verifying blood flow either manually or with color Doppler USG is necessary for preventing and monitoring hepatic artery spasm. When the spasm develops, warm saline application or local anesthetics and papaverine can be safely used topically. In our study, 5 (5.8%) patients developed spasm after anastomosis, and these spasms were removed by topical papaverine and hot saline application.

Intimal dissection, which is an undesirable intraoperative complication, may also be observed. However, as long as this entity is affected by hepatic arterial stasis and hypertension-related cirrhosis, the transplant surgeon may have the role of traumatic interruption of the hepatic artery in resection of the recipient liver. Therefore, it is important that the recipient arteries must be properly cut with special atraumatic scissors to minimize the intimal dissection risk. If there is no structural problem or angiopathic disease in the donor artery, the intimal dissection is almost never encountered. In case of intimal dissection of the recipient artery, it is advisable to resect the artery until the dissection is lost and intact artery structure is found. It is considered as extremely risky and it is an avoidable option in hepatic artery anastomosis. First of all, it is not known how far the dissection extends and with this resection all valuable recipient artery system can be fed. Furthermore, if dissection ends, a critical distance (gap) that makes primarily repair impossible will most likely occur between the donor and the recipient arteries. This will necessitate the use of vascular grafts and double anastomosis, which means a two-fold thrombosis risk. Moreover, since the intimal dissection is a process that moves in the opposite direction to the blood flow, contrarily dissected intima is reposed to the muscular layer with the blood flow. Thus, our preferred option is meticulous approach to dissected artery and suturing two layers both as adventitia-muscular and intimal, instead of resection. Despite intimal dissection in recipient arteries encountered in 7 cases (8.2%) anastomoses were successfully completed as described above and the recipient artery was not shortened or unchanged.

Early and late HAT have been reported as another complication of hepatic artery reconstruction. The major series of one of the most common complications, HAT, is presented in [Table 2].[26]
Table 2: Hepatic artery thrombosis

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Hepatic artery thrombosis is classified as early and late. Despite the fact that there is not a complete consensus on this issue, thrombosis that occurs during the first 1 week to 10 days is called early thrombosis and any period after that is classified as late. Risk factors are defined in relation to early HAT.[30] These can be sorted as; long ischemic time, arterial variations, prolonged operation time, low body weight, especially in pediatric recipients, the use of arterial conduits and cytomegalovirus positive donors. With or without these risk factors, surgery-related effects (twisting and stenosis) can cause thrombosis in the same way. In early hepatic arterial thrombosis, abnormal laboratory values and symptoms may not occur at baseline; therefore, routine Doppler ultrasound examination is vital. It is recommended that anastomosis must be followed with a 12 h with Doppler USG for 14 days postoperatively in the literature.[31] The approach in the treatment of hepatic artery thrombosis is basically three-fold. These are replantation, revascularization, and observation. Revascularization can be provided with thrombolysis, thrombectomy, or anastomosis renewal. Late HAT is especially used to describe thrombosis, occurring after 1 month in cadaveric liver transplants. In the late period, emerging of HAT after collateral development causes the treatment approach to be performed according to the degree of clinical findings.

Hepatic artery stenosis is also an important complication that may occur after hepatic artery anastomosis. Stenosis may progress to complete obstruction and thus cause mortality. The causes of hepatic artery stenosis may be listed as poor surgical equipment, clamp injury, or rejection. The incidence of hepatic artery stenosis is between 3.2% and 4.8%.[31] The treatment approach in stenosis detected by Doppler ultrasound varies according to stenosis location and length of stenotic segment. The diagnostic and therapeutic percutaneous transluminal angioplasty (PTA) is sufficient for the treatment of short stenotic segments. If the intervention with PTA is not sufficient, surgical revision is required.

Another complication after hepatic artery anastomosis is aneurysm or pseudoaneurysm which is a rare complication. These occur late. This complication may be seen either due to the surgical technique used or as the result of bacterial and fungal infections. An acute intraabdominal or gastrointestinal hemorrhage occurring late after liver transplantation suggests aneurysm or pseudoaneurysm. The angiography is more valuable than the Doppler ultrasound. Hepatic artery ligation is performed after pseudoaneurysm excision in the treatment. Collaterals may be sufficient to provide vascularization if aneurysm occurs late. Otherwise, revascularization or retransplantation may be needed.

We suggest that it is possible that these and similar complications arising in hepatic artery reconstruction can be coped with early intervention.

The success of hepatic artery anastomosis is a major factor that directly determines the success of the operation and the survival of the patient. In fact, this phase of the operation is so important that it should be conducted with zero errors and possibly without any complications.

The success of 100% anastomosis in our series as well as not encountering early or late hepatic arterial thrombosis is compatible with the existing literature, and in our case, it is found to be even more successful. However, the fact that our present series is small should not be overlooked.


  Conclusion Top


Making hepatic artery anastomosis, under a microscope, using special microtools and sutures, with a rigorous and precise technique and by a strong, concentrated, separate team which has microsurgical experience, reduces the complication rate and also increases the success of anastomosis, thereby the success of the operation.

In addition, this teamwork enables the increase in the number of cadaveric partial (split) liver transplantation due to the technical superiority of the single team. Moreover, this may allow for more recipients to benefit from limited donors, which can be important, especially in the case of children.

Collaboration between microsurgeons and transplant surgeons (to reduce technical complications) can play an important role in obtaining long-term and permanent transplantation outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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