Original Paper Eur Surg Res 1992;24:155-159
First Department of Surgery, Kobe University School of Medicine, Kobe, Japan
Keywords Upper caval anastomosis Canine liver transplantation Hemodynamic evaluation
Suprahepatic Vena cava Anastomosis of the Donor Liver to the Recipient Retrohepatic Vena cava in Canine Liver Transplantation
Abstract A revised method of the upper caval anastomosis in canine orthotopic liver transplantation is described. It uses the recipi ent retrohepatic inferior vena cava below the suprahepatic veins for vascular suturing. Ten consecutive operations were performed to assess the feasibility of this method, with special reference to the outflow obstruction at the level of the suprahe patic inferior vena cava. Seven of 10 dogs survived more than 6 days. The cause of death was not related to the outflow obstruction in any instance. Regardless of the duration of sur vival, free hepatic vein pressures as well as portal vein pres sures of all dogs remained in the physiological range even after the skin closures. Based on these observations, we conclude that this approach is safe and reproducible in experimental transplantation of the canine liver.
Introduction Although numerous reports have appeared describing various technical modifications for orthotopic liver transplantation (OLT) in dogs [1-6], the upper caval anastomosis is still a crucial step for the ultimate success of the operation. The recipient hepatectomy, in cluding the caval cuff formation, therefore
Received: August 21, 1991 Accepted: November 18, 1991
represents the key to a more secure anastomo sis [7], This is especially the case with experi mental liver transplantation in dogs having deep and narrow subdiaphragmatic space. In most previous studies reporting detailed pro cedures for both dogs and humans, the supra hepatic inferior vena cava was generally oc cluded above the liver with vascular clamps and was subsequently divided on the hepatic
Dr. Yonsori Ku, MD First Department of Surgery Kobe U niversity School of Medicine 7-5-2. Kustnoki-cho Chuo-ku, Kobe 650 (Japan)
© 1992 S. Karger AG, Basel 0014-312X/92/ 0243-0155S2.75/0
Downloaded by: King's College London 137.73.144.138 - 1/23/2019 11:49:49 PM
Y. Ku Y. Maekawa M. Tominaga T. Iwasaki H. Shiki T. Fukumoto M. Samido Y. Fujino A. Morita Y. Kuroda H. Ohyanagi Yo Saitoh
Materials and Methods Mongrel dogs of both sexes weighing between 10 and 15 kg were used for 10 consecutive OLT. The donors and the recipients were matched by body weight so that the ratio was about 1:1.2. During opera tions, all animals were anesthetized with sodium pen tobarbital. and parenteral fluid support with lactated Ringer’s solution was provided at a rate of 150 ml/h. Antibiotics were given daily through a intravenous route in the postoperative course. Immunosuppressive drugs were not given.
156
Donor Operation
A midline abdominal incision was made from xyphoid to pubis. The portal vein was cleared of fat and lymphatic tissue exposing the junction of the coronary, splenic and superior mesenteric veins. At this point, a 5-french cannula was placed in the portal vein via the coronary vein for pressure monitoring. The common bile duct was transected close to the duodenum and a 5-french cannula placed in the proximal duct to estab lish external drainage of bile. The other harvesting pro cedures were essentially the same as those described by Jamieson et al. [5], Flushout solutions consisted of 500 ml of ice-cold Ringer’s lactate with 6,000 U heparin and 1,000 ml of University of Wisconsin solution. During the final dissection on the back table, the suprahepatic inferior vena cava was cleaned and cut. leaving its length about 10 mm above the hepatic edge with all tributaries ligated. Recipient Operation
Total hepatectomy was performed under a centrif ugal pump assisted venovenous bypass. During the final stage of the recipient hepatectomy. the hepatic parenchyma was peeled off the retrohepatic vena cava to attain 10-15 mm of its free length below the supra hepatic veins with sharp and blunt technique. In the process, all tributaries from the hepatic parenchyma were ligated meticulously except for the right hepatic vein. This was used for placement of a 5-french can nula (medical grade silicone) in the hepatic vein of the graft. Subsequently, the upper caval cuff was formed with sharp dissection at the level of the retrohepatic inferior vena cava approximately 10 mm below the ostium of the left hepatic vein (fig. 1). Prior to implan tation of the graft, the ostium of a drainage vein from the caudate lobe, usually encountered at the posterior wall of the retrohepatic inferior vena cava, was intraluminally identified and oversewn. The extra length of the upper caval cuff thus obtained greatly facilitated the anastomosis (fig. 2). We attempted to take firm, wide and full thickness bites of both vessels using the continuous everting technique (8]. The remaining vas cular reconstruction was made according to the stan dard technique described in detail elsewhere [9], All cannulas for pressure monitoring were subcutaneously guided to the back of the animal. Also, a cannula placed in the common bile duct was treated in the same way to monitor bile output of the graft. Hemodynamic Studies
Portal vein pressure (PVP) of the recipient was measured using a simple water column manometer for hemodynamic evaluation of this technique at two dif-
Ku/Maekawa/Tominaga/Iwasaki/Shiki/ Fukumoto/Samido/Fujino/Morita/ Kuroda/Ohyanagi/Saitoh
A Revised Method of the Upper Caval Anastomosis
Downloaded by: King's College London 137.73.144.138 - 1/23/2019 11:49:49 PM
edge during total hepatectomy [3, 5, 6]. Ac cording to our experience, this frequently re sults in a caval cuff that is too short or dam aged for the subsequent anastomosis. In re sponse to these technical difficulties, other investigators currently propose a modifica tion consisting of preservation of the retrohepatic inferior vena cava during the final part of the recipient hepatectomy [7], The advan tage of this technique includes the ease in con trolling the right adrenal vein as well as the preparation of the caval cuffs in a leisurely and secure manner. However, in spite of the ease of this technique, the upper caval anasto mosis of the donor liver to the recipient retrohepatic inferior vena cava below the suprahepatic veins has been considered unadvisable because of the possible kinking of the vessel [3.7], In this regard, we evaluated the feasibil ity of a revised method for the upper caval anastomosis at the level of the recipient retrohepatic inferior vena cava below the suprahepatic veins. With this method, we have trans planted 10 consecutive canine livers with un expectedly excellent results, that is, no dog died because of technical reasons associated with bleeding or outflow obstruction at the upper caval anastomosis. In this paper, we report a revised technique of reconstruction of the suprahepatic inferior vena cava, using the recipient retrohepatic inferior vena cava, and its transplant results.
ferent time points: (l) prior to hepatectomy, and (2) after the skin closure. In addition, free hepatic vein pressure (FHVP) was measured after the skin closure to evaluate outflow obstruction at the upper caval anastomosis. Graft function was evaluated by the vol ume of bile excreted. Statistics
Paired Student’s t test was used for statistical anal ysis. Values are expressed as means ± SD.
Results Survivals and causes of death are summa rized in table l . Seven out of 10 animals lived between 6 and 39 days. In most of these ani mals. there was histological evidence of rejec tion. which consisted of focal necrosis of hé patocytes and mononuclear cell infiltration of the portal triad. The other 3 animals died within the first 48 h. One of these died sud denly because of massive bleeding from the stump of the coronary vein caused by acci-
Fig. 2. The upper caval anastomosis using the re cipient rctrohepatic inferior vena cava below the suprahepatic veins. After completion of intraluminal everting suture of the posterior wall, a 5-french cannula is placed in the left hepatic vein (LHV) of the graft through the recipient right hepatic vein (RHV) for pressure monitoring.
Table 1. Survival time and cause of death Dog No. I 2 3 4
Survival time Cause of death 7 days 8 days 7 days 2 days
5
24 h
6 7 8
24 h 7 days 39 days
9 10
7 days 6 days
Rejection Rejection Rejection Bleeding from the portal vein anastomosis Bleeding due to dislocation of the portal vein cannula Liver failure Rejection Bile peritonitis due to dislocation of a cannula in the common bile duct Rejection Intestinal obstruction
157
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Fig. 1. The preparation of the upper caval cuff. At the final part of the recipient hepatectomy, the inferior vena cava (I VC) is cut approximately 10 mm below the ostium of the left hepatic vein (LHV). All of the hepatic veins arc ligated and cut. except for the right hepatic vein (RHV). MHV = Middle hepatic vein.
Dog No.
1 2 3 4 5 6 7 8 9 10 Mean±SD
PVP. cm H20 before after hepatectomy skin closure 8.9 10.5 8.0 li.O 8.9 10.5 8.0 6.1 8.5 7.6 8.8+ 1.5
11.0 8.0 8.3 9.5 10.5 8.0 8.5 8.8 9.5 10.0 9.2+1.1
FHVP cm H20
6.7 7.4 5.0 7.5 5.8 7.4 3.1 5.4 5.5 5.3 5.9 ±1.4
dental removal of a cannula in the portal vein. One of the remaining 2 dogs had clot around the anastomosis of the portal vein. In the oth er, the cause of death was not determined, but was presumed hepatic failure because of the lack of bile output. Regardless of the survival time, none had thrombosis of the upper caval anastomosis at the time of death. Mean bile excretion in the first 5 days was 36 ± 10 ml/ day in the 7 dogs which survived longer than 6 days. The hemodynamic data are given in ta ble 2. Although mean PVP in the recipient after the skin closure (9.2 ± 1.1 cm H20 ) tended to be slightly higher than those ob tained prior to hcpatectomy (8.8 ± 1.5 cm H20), there was no statistically significant dif ference. On the other hand, FHVP levels of all dogs after the skin closures were in the phys iological range, the mean value being 5.9 ± 1.4 cm H20 .
158
Discussion As far as we could ascertain in the litera ture, the upper caval anastomosis of the do nor liver to the recipient retrohepatic inferior vena cava below the hepatic veins has not been previously described. In most previous studies [3, 5, 6], the suprahepatic vena cava is clamped above the liver including the dia phragm during the final phase of recipient hepatectomy and divided close to the hepatic parenchyma. However, in this setting, subse quent vascular suturing is technically quite demanding especially in dogs. To make the anastomosis easier, it is tempting to prepare the recipient upper caval cuff in sufficient length leaving the retrohepatic inferior vena cava below the hepatic veins. However, a too long cuff has been considered a possible cause of twisting or telescoping of the anastomosed suprahepatic inferior vena cava with conse quent outflow obstruction in dogs [3] as well as humans [7], As described by others [3], 510 mm of the recipient upper caval cuff is available for anastomosis after transection of the suprahepatic inferior vena cava on the hepatic edge in dogs. In this regard, the length of the upper caval cuff, if transected 10 mm below the ostium of the left hepatic vein, is about 16-18 mm from the vascular clamp. According to our experience, the extra length thus obtained greatly improved access to the vessel and resulted in more secure anastomo sis of the suprahepatic inferior vena cava. We have used this method in 10 consecu tive operations. Although the preparation of the upper caval cuff seems to add consider able time, the duration of the anhepatic phase in this method is lengthened (an average of 12 min) as compared to our previous series using the standard technique. The 5-day survival rate with this method was 70%. None of the 10 dogs died because of technical reasons associated with bleeding from the upper caval
Ku/Maekawa/Tominaga/lwasaki/Shiki/ Fukumolo/Samido/Fujino/Morita/ Kuroda/Ohyanagi/Saitoh
A Revised Method of the Upper Caval Anastomosis
Downloaded by: King's College London 137.73.144.138 - 1/23/2019 11:49:49 PM
Table 2. PVP and FHVP before and after revascu larization in 10 dogs
anastomosis. In addition, none of the dogs showed macroscopic evidence of congestion of the transplanted liver not only after reper fusion, but also at autopsy. During previous experiments in our laboratory, it has been observed that the upper caval anastomosis using the standard technique frequently re sulted in intractable bleeding from this site and consequently affected survival. We performed manomctric studies includ ing measurements of PVP and FHVP to eval uate hemodynamically the feasibility of this method in view of the outflow obstruction at the level of the upper caval anastomosis. The observations were made in each animal im mediately after the laparotomy and the skin closure. Although PVP tended to be slightly higher in most dogs after the skin closure as compared to those obtained at the time of lap arotomy, there was no statistically significant difference between them. Free hepatic vein pressure measured after the skin closure also remained in the physiological range. Although
it may be tempting to speculate that kinking was just prevented by the catheter introduced into the left hepatic vein of the graft, we have obtained the same rate of success even with out the catheter in our recent series. There fore, we believe this flexible catheter is not acting as a stent to prevent outflow obstruc tion at the anastomotic site. Furthermore, irrespective of the duration of survival, bile output remained constant during the initial 5 days in all dogs which survived longer than 6 days. The mean bile output was 36 ml/day in our series, which is comparable to the value reported precisely by Goodrich et al. [2] and indicates the functioning grafts in these ani mals. These results altogether indicate the ab sence of the outflow obstruction at the level of the upper caval anastomosis with this meth od. Although this method has been previously considered unadvisable, wc conclude that it is safe and reproducible and is of particular value for other laboratories currently inter ested in canine OLT.
References
2
3
Fonkalsrud EW. Ono H. ShafTev O. Longmire W: Orthotopic canine liver homotransplantation without vena caval interruption. Surg Gyne col Obstet 1967:125:319-327. Goodrich EO Jr. Welch HE. Nelson JA. Beecher TS. Welch CS: Homo transplantation of the canine liver. Surgery 1956:39:244-251. Pienaar BH. Lindcll SL. Van Gulik T. Southard JH, Beizer FO: Revised method of orthotopic hepatic trans plantation in canines. Surg Gynecol Obstet 1989:169:341-346.
4
5
6
Monden M. Matters R. Fortner J: A simple method of orthotopic liver transplantation in dogs. Ann Surg 1982;195:110-113. Jamieson NV. Sundberg R. Lindcll S. Kalayoglu M. Southhard JH. Bclzcr FO: A simplified technique for transplantation of the canine liv er. Acta Chir Scand 1988:154:511515. Starzl TE, Kaupp HA. Brock DR. I^i/arus RE, Johnson RV: Recon structive problems in canine liver homotransplantation with special reference to the postoperative role of hepatic venous flow. Surg Gyne col Obstet 1960; 111:733-743.
7
8
9
Sticbcr AG. Marsh JW. Starzl TE: Preservation of the retrohepatic vena cava during recipient hepatcctomy for orthotopic transplantation of the liver. Surg Gynecol Obstet 1989:168:543-544. Starzl TE. Grotlt CG. Brettschneider l.: An everting technique for in traluminal vascular suturing. Surg Gynecol Obstet 1968; 127:125. Terblanche J. Peacock JH. Bowes J. Hobbs KEF: The technique of or thotopic liver homotransplantation in the pig. J Surg Res 1968:8:151— 160.
159
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1
First Department of Surgery, Kobe University School of Medicine, Kobe, Japan
Keywords Upper caval anastomosis Canine liver transplantation Hemodynamic evaluation
Suprahepatic Vena cava Anastomosis of the Donor Liver to the Recipient Retrohepatic Vena cava in Canine Liver Transplantation
Abstract A revised method of the upper caval anastomosis in canine orthotopic liver transplantation is described. It uses the recipi ent retrohepatic inferior vena cava below the suprahepatic veins for vascular suturing. Ten consecutive operations were performed to assess the feasibility of this method, with special reference to the outflow obstruction at the level of the suprahe patic inferior vena cava. Seven of 10 dogs survived more than 6 days. The cause of death was not related to the outflow obstruction in any instance. Regardless of the duration of sur vival, free hepatic vein pressures as well as portal vein pres sures of all dogs remained in the physiological range even after the skin closures. Based on these observations, we conclude that this approach is safe and reproducible in experimental transplantation of the canine liver.
Introduction Although numerous reports have appeared describing various technical modifications for orthotopic liver transplantation (OLT) in dogs [1-6], the upper caval anastomosis is still a crucial step for the ultimate success of the operation. The recipient hepatectomy, in cluding the caval cuff formation, therefore
Received: August 21, 1991 Accepted: November 18, 1991
represents the key to a more secure anastomo sis [7], This is especially the case with experi mental liver transplantation in dogs having deep and narrow subdiaphragmatic space. In most previous studies reporting detailed pro cedures for both dogs and humans, the supra hepatic inferior vena cava was generally oc cluded above the liver with vascular clamps and was subsequently divided on the hepatic
Dr. Yonsori Ku, MD First Department of Surgery Kobe U niversity School of Medicine 7-5-2. Kustnoki-cho Chuo-ku, Kobe 650 (Japan)
© 1992 S. Karger AG, Basel 0014-312X/92/ 0243-0155S2.75/0
Downloaded by: King's College London 137.73.144.138 - 1/23/2019 11:49:49 PM
Y. Ku Y. Maekawa M. Tominaga T. Iwasaki H. Shiki T. Fukumoto M. Samido Y. Fujino A. Morita Y. Kuroda H. Ohyanagi Yo Saitoh
Materials and Methods Mongrel dogs of both sexes weighing between 10 and 15 kg were used for 10 consecutive OLT. The donors and the recipients were matched by body weight so that the ratio was about 1:1.2. During opera tions, all animals were anesthetized with sodium pen tobarbital. and parenteral fluid support with lactated Ringer’s solution was provided at a rate of 150 ml/h. Antibiotics were given daily through a intravenous route in the postoperative course. Immunosuppressive drugs were not given.
156
Donor Operation
A midline abdominal incision was made from xyphoid to pubis. The portal vein was cleared of fat and lymphatic tissue exposing the junction of the coronary, splenic and superior mesenteric veins. At this point, a 5-french cannula was placed in the portal vein via the coronary vein for pressure monitoring. The common bile duct was transected close to the duodenum and a 5-french cannula placed in the proximal duct to estab lish external drainage of bile. The other harvesting pro cedures were essentially the same as those described by Jamieson et al. [5], Flushout solutions consisted of 500 ml of ice-cold Ringer’s lactate with 6,000 U heparin and 1,000 ml of University of Wisconsin solution. During the final dissection on the back table, the suprahepatic inferior vena cava was cleaned and cut. leaving its length about 10 mm above the hepatic edge with all tributaries ligated. Recipient Operation
Total hepatectomy was performed under a centrif ugal pump assisted venovenous bypass. During the final stage of the recipient hepatectomy. the hepatic parenchyma was peeled off the retrohepatic vena cava to attain 10-15 mm of its free length below the supra hepatic veins with sharp and blunt technique. In the process, all tributaries from the hepatic parenchyma were ligated meticulously except for the right hepatic vein. This was used for placement of a 5-french can nula (medical grade silicone) in the hepatic vein of the graft. Subsequently, the upper caval cuff was formed with sharp dissection at the level of the retrohepatic inferior vena cava approximately 10 mm below the ostium of the left hepatic vein (fig. 1). Prior to implan tation of the graft, the ostium of a drainage vein from the caudate lobe, usually encountered at the posterior wall of the retrohepatic inferior vena cava, was intraluminally identified and oversewn. The extra length of the upper caval cuff thus obtained greatly facilitated the anastomosis (fig. 2). We attempted to take firm, wide and full thickness bites of both vessels using the continuous everting technique (8]. The remaining vas cular reconstruction was made according to the stan dard technique described in detail elsewhere [9], All cannulas for pressure monitoring were subcutaneously guided to the back of the animal. Also, a cannula placed in the common bile duct was treated in the same way to monitor bile output of the graft. Hemodynamic Studies
Portal vein pressure (PVP) of the recipient was measured using a simple water column manometer for hemodynamic evaluation of this technique at two dif-
Ku/Maekawa/Tominaga/Iwasaki/Shiki/ Fukumoto/Samido/Fujino/Morita/ Kuroda/Ohyanagi/Saitoh
A Revised Method of the Upper Caval Anastomosis
Downloaded by: King's College London 137.73.144.138 - 1/23/2019 11:49:49 PM
edge during total hepatectomy [3, 5, 6]. Ac cording to our experience, this frequently re sults in a caval cuff that is too short or dam aged for the subsequent anastomosis. In re sponse to these technical difficulties, other investigators currently propose a modifica tion consisting of preservation of the retrohepatic inferior vena cava during the final part of the recipient hepatectomy [7], The advan tage of this technique includes the ease in con trolling the right adrenal vein as well as the preparation of the caval cuffs in a leisurely and secure manner. However, in spite of the ease of this technique, the upper caval anasto mosis of the donor liver to the recipient retrohepatic inferior vena cava below the suprahepatic veins has been considered unadvisable because of the possible kinking of the vessel [3.7], In this regard, we evaluated the feasibil ity of a revised method for the upper caval anastomosis at the level of the recipient retrohepatic inferior vena cava below the suprahepatic veins. With this method, we have trans planted 10 consecutive canine livers with un expectedly excellent results, that is, no dog died because of technical reasons associated with bleeding or outflow obstruction at the upper caval anastomosis. In this paper, we report a revised technique of reconstruction of the suprahepatic inferior vena cava, using the recipient retrohepatic inferior vena cava, and its transplant results.
ferent time points: (l) prior to hepatectomy, and (2) after the skin closure. In addition, free hepatic vein pressure (FHVP) was measured after the skin closure to evaluate outflow obstruction at the upper caval anastomosis. Graft function was evaluated by the vol ume of bile excreted. Statistics
Paired Student’s t test was used for statistical anal ysis. Values are expressed as means ± SD.
Results Survivals and causes of death are summa rized in table l . Seven out of 10 animals lived between 6 and 39 days. In most of these ani mals. there was histological evidence of rejec tion. which consisted of focal necrosis of hé patocytes and mononuclear cell infiltration of the portal triad. The other 3 animals died within the first 48 h. One of these died sud denly because of massive bleeding from the stump of the coronary vein caused by acci-
Fig. 2. The upper caval anastomosis using the re cipient rctrohepatic inferior vena cava below the suprahepatic veins. After completion of intraluminal everting suture of the posterior wall, a 5-french cannula is placed in the left hepatic vein (LHV) of the graft through the recipient right hepatic vein (RHV) for pressure monitoring.
Table 1. Survival time and cause of death Dog No. I 2 3 4
Survival time Cause of death 7 days 8 days 7 days 2 days
5
24 h
6 7 8
24 h 7 days 39 days
9 10
7 days 6 days
Rejection Rejection Rejection Bleeding from the portal vein anastomosis Bleeding due to dislocation of the portal vein cannula Liver failure Rejection Bile peritonitis due to dislocation of a cannula in the common bile duct Rejection Intestinal obstruction
157
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Fig. 1. The preparation of the upper caval cuff. At the final part of the recipient hepatectomy, the inferior vena cava (I VC) is cut approximately 10 mm below the ostium of the left hepatic vein (LHV). All of the hepatic veins arc ligated and cut. except for the right hepatic vein (RHV). MHV = Middle hepatic vein.
Dog No.
1 2 3 4 5 6 7 8 9 10 Mean±SD
PVP. cm H20 before after hepatectomy skin closure 8.9 10.5 8.0 li.O 8.9 10.5 8.0 6.1 8.5 7.6 8.8+ 1.5
11.0 8.0 8.3 9.5 10.5 8.0 8.5 8.8 9.5 10.0 9.2+1.1
FHVP cm H20
6.7 7.4 5.0 7.5 5.8 7.4 3.1 5.4 5.5 5.3 5.9 ±1.4
dental removal of a cannula in the portal vein. One of the remaining 2 dogs had clot around the anastomosis of the portal vein. In the oth er, the cause of death was not determined, but was presumed hepatic failure because of the lack of bile output. Regardless of the survival time, none had thrombosis of the upper caval anastomosis at the time of death. Mean bile excretion in the first 5 days was 36 ± 10 ml/ day in the 7 dogs which survived longer than 6 days. The hemodynamic data are given in ta ble 2. Although mean PVP in the recipient after the skin closure (9.2 ± 1.1 cm H20 ) tended to be slightly higher than those ob tained prior to hcpatectomy (8.8 ± 1.5 cm H20), there was no statistically significant dif ference. On the other hand, FHVP levels of all dogs after the skin closures were in the phys iological range, the mean value being 5.9 ± 1.4 cm H20 .
158
Discussion As far as we could ascertain in the litera ture, the upper caval anastomosis of the do nor liver to the recipient retrohepatic inferior vena cava below the hepatic veins has not been previously described. In most previous studies [3, 5, 6], the suprahepatic vena cava is clamped above the liver including the dia phragm during the final phase of recipient hepatectomy and divided close to the hepatic parenchyma. However, in this setting, subse quent vascular suturing is technically quite demanding especially in dogs. To make the anastomosis easier, it is tempting to prepare the recipient upper caval cuff in sufficient length leaving the retrohepatic inferior vena cava below the hepatic veins. However, a too long cuff has been considered a possible cause of twisting or telescoping of the anastomosed suprahepatic inferior vena cava with conse quent outflow obstruction in dogs [3] as well as humans [7], As described by others [3], 510 mm of the recipient upper caval cuff is available for anastomosis after transection of the suprahepatic inferior vena cava on the hepatic edge in dogs. In this regard, the length of the upper caval cuff, if transected 10 mm below the ostium of the left hepatic vein, is about 16-18 mm from the vascular clamp. According to our experience, the extra length thus obtained greatly improved access to the vessel and resulted in more secure anastomo sis of the suprahepatic inferior vena cava. We have used this method in 10 consecu tive operations. Although the preparation of the upper caval cuff seems to add consider able time, the duration of the anhepatic phase in this method is lengthened (an average of 12 min) as compared to our previous series using the standard technique. The 5-day survival rate with this method was 70%. None of the 10 dogs died because of technical reasons associated with bleeding from the upper caval
Ku/Maekawa/Tominaga/lwasaki/Shiki/ Fukumolo/Samido/Fujino/Morita/ Kuroda/Ohyanagi/Saitoh
A Revised Method of the Upper Caval Anastomosis
Downloaded by: King's College London 137.73.144.138 - 1/23/2019 11:49:49 PM
Table 2. PVP and FHVP before and after revascu larization in 10 dogs
anastomosis. In addition, none of the dogs showed macroscopic evidence of congestion of the transplanted liver not only after reper fusion, but also at autopsy. During previous experiments in our laboratory, it has been observed that the upper caval anastomosis using the standard technique frequently re sulted in intractable bleeding from this site and consequently affected survival. We performed manomctric studies includ ing measurements of PVP and FHVP to eval uate hemodynamically the feasibility of this method in view of the outflow obstruction at the level of the upper caval anastomosis. The observations were made in each animal im mediately after the laparotomy and the skin closure. Although PVP tended to be slightly higher in most dogs after the skin closure as compared to those obtained at the time of lap arotomy, there was no statistically significant difference between them. Free hepatic vein pressure measured after the skin closure also remained in the physiological range. Although
it may be tempting to speculate that kinking was just prevented by the catheter introduced into the left hepatic vein of the graft, we have obtained the same rate of success even with out the catheter in our recent series. There fore, we believe this flexible catheter is not acting as a stent to prevent outflow obstruc tion at the anastomotic site. Furthermore, irrespective of the duration of survival, bile output remained constant during the initial 5 days in all dogs which survived longer than 6 days. The mean bile output was 36 ml/day in our series, which is comparable to the value reported precisely by Goodrich et al. [2] and indicates the functioning grafts in these ani mals. These results altogether indicate the ab sence of the outflow obstruction at the level of the upper caval anastomosis with this meth od. Although this method has been previously considered unadvisable, wc conclude that it is safe and reproducible and is of particular value for other laboratories currently inter ested in canine OLT.
References
2
3
Fonkalsrud EW. Ono H. ShafTev O. Longmire W: Orthotopic canine liver homotransplantation without vena caval interruption. Surg Gyne col Obstet 1967:125:319-327. Goodrich EO Jr. Welch HE. Nelson JA. Beecher TS. Welch CS: Homo transplantation of the canine liver. Surgery 1956:39:244-251. Pienaar BH. Lindcll SL. Van Gulik T. Southard JH, Beizer FO: Revised method of orthotopic hepatic trans plantation in canines. Surg Gynecol Obstet 1989:169:341-346.
4
5
6
Monden M. Matters R. Fortner J: A simple method of orthotopic liver transplantation in dogs. Ann Surg 1982;195:110-113. Jamieson NV. Sundberg R. Lindcll S. Kalayoglu M. Southhard JH. Bclzcr FO: A simplified technique for transplantation of the canine liv er. Acta Chir Scand 1988:154:511515. Starzl TE, Kaupp HA. Brock DR. I^i/arus RE, Johnson RV: Recon structive problems in canine liver homotransplantation with special reference to the postoperative role of hepatic venous flow. Surg Gyne col Obstet 1960; 111:733-743.
7
8
9
Sticbcr AG. Marsh JW. Starzl TE: Preservation of the retrohepatic vena cava during recipient hepatcctomy for orthotopic transplantation of the liver. Surg Gynecol Obstet 1989:168:543-544. Starzl TE. Grotlt CG. Brettschneider l.: An everting technique for in traluminal vascular suturing. Surg Gynecol Obstet 1968; 127:125. Terblanche J. Peacock JH. Bowes J. Hobbs KEF: The technique of or thotopic liver homotransplantation in the pig. J Surg Res 1968:8:151— 160.
159
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1
