Technical Aspects of Orthotopic Liver Transplantation—a Survey-Based Study Within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplantation Society Networks
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Orthotopic liver transplantation (OLT) has emerged as the mainstay of treatment for end-stage liver disease. However, technical aspects of OLT are still subject of ongoing debate and are widely based on personal experience and local institutional protocols.
An international online survey was sent out to all liver transplant centers (n = 52) within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplant Society networks. The survey sought information on center-specific OLT caseload, vascular and biliary reconstruction, graft reperfusion, intraoperative control of hemodynamics, and drain policies.
Forty-two centers gave a valid response (81%). Out of these, 50% reported piggy-back and 40.5% total caval replacement as their standard technique. While 48% of all centers generally do not apply veno-venous bypass (vvBP) or temporary portocaval shunt (PCS) during OLT, vvBP/PCS are routinely used in six centers (14%). Portal vein first reperfusion is used in 64%, followed by simultaneous (17%), and retrograde reperfusion (12%). End-to-end duct-to-duct anastomosis without biliary drain (67%) is the most frequently performed method of biliary reconstruction. No significant associations were found between the center caseload and the surgical approach used. The predominant part of the centers (88%) stated that techniques of OLT are not evidence-based and 98% would participate in multicenter clinical trials on these topics.
Technical aspects of OLT vary widely among European centers. The extent to which center-specific variation of techniques affect transplant outcomes in Europe should be elucidated further in prospective multicenter trials.
KeywordsSurvey Liver transplantation Piggy-back Reperfusion Abdominal drain
Artery first reperfusion
British Transplant Society
Donation following cardiac death
Extended criteria donors
End-to-end duct-to-duct anastomosis
Model for End-stage Liver Disease
Orthotopic liver transplantation
Portal vein first reperfusion
Randomized controlled trial
Side-to-side duct-to-duct anastomosis
Total caval replacement
Warm ischemia time
The authors would like to thank the responsible boards of the ET, BTS, ST, and ScaT for their support and Dr. Marieke van Rosmalen (ET) for her kind assistance.
The study was designed and the survey was distributed by the initiating study team (ZC, UPN, JB, GL). Data collection and analysis was performed by ZC, UPN, JB, and GL. Initial manuscript was drafted by ZC, GL, JB, UPN, and MNS. Further authors (JP, MG, SN, AM, GB, XR, JP, JL, ZM, PD, BE, MM, NH, WS) have substantially contributed to the final version of the manuscript. All authors have read and approved the final version of the manuscript.
This research project is supported by the START-Program (No. 136/17) of the Faculty of Medicine, RWTH Aachen, and funded by the Excellence Initiative of the German federal and state governments (G:(DE-82) ZUK2-SF-OPSF443).
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
- 2.Czigany Z, Schoning W, Ulmer TF, Bednarsch J, Amygdalos I, Cramer T, Rogiers X, Popescu I, Botea F, Fronek J, Kroy D, Koch A, Tacke F, Trautwein C, Tolba RH, Hein M, Koek GH, Dejong CHC, Neumann UP, Lurje G. Hypothermic oxygenated machine perfusion (HOPE) for orthotopic liver transplantation of human liver allografts from extended criteria donors (ECD) in donation after brain death (DBD): a prospective multicentre randomised controlled trial (HOPE ECD-DBD). BMJ Open. 2017;7(10):e017558.CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Gurusamy KS, Koti R, Pamecha V, Davidson BR. Veno-venous bypass versus none for liver transplantation. The Cochrane database of systematic reviews. 2011;(3):Cd007712.Google Scholar
- 4.Gurusamy KS, Naik P, Abu-Amara M, Fuller B, Davidson BR. Techniques of flushing and reperfusion for liver transplantation. The Cochrane database of systematic reviews. 2012;(3):Cd007512.Google Scholar
- 5.Gurusamy KS, Pamecha V, Davidson BR. Piggy-back graft for liver transplantation. The Cochrane database of systematic reviews. 2011;(1):Cd008258.Google Scholar
- 8.Starzl TE, Marchioro TL, Porter KA, Brettschneider L. Homotransplantation of the liver. Transplantation. 1967;5(4):Suppl:790–803.Google Scholar
- 9.Gurusamy KS, Naik P, Davidson BR. Routine drainage for orthotopic liver transplantation. The Cochrane database of systematic reviews. 2011;(6):Cd008399.Google Scholar
- 10.Manzini G, Kremer M, Houben P, Gondan M, Bechstein WO, Becker T, Berlakovich GA, Friess H, Guba M, Hohenberger W, Ijzermans JN, Jonas S, Kalff JC, Klar E, Klempnauer J, Lerut J, Lippert H, Lorf T, Nadalin S, Nashan B, Otto G, Paul A, Pirenne J, Pratschke J, Ringers J, Rogiers X, Schilling MK, Seehofer D, Senninger N, Settmacher U, Stippel DL, Tscheliessnigg K, Ysebaert D, Binder H, Schemmer P. Reperfusion of liver graft during transplantation: techniques used in transplant centres within Eurotransplant and meta-analysis of the literature. Transplant international : official journal of the European Society for Organ Transplantation. 2013;26(5):508–16.Google Scholar
- 11.Jesse MT, Abouljoud M, Eshelman A. Determinants of burnout among transplant surgeons: a national survey in the United States. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2015;15(3):772–8.CrossRefGoogle Scholar
- 12.Levitsky J, Singh N, Wagener MM, Stosor V, Abecassis M, Ison MG. A survey of CMV prevention strategies after liver transplantation. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2008;8(1):158–61.Google Scholar
- 13.Nadim MK, Davis CL, Sung R, Kellum JA, Genyk YS. Simultaneous liver-kidney transplantation: a survey of US transplant centers. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2012;12(11):3119–27.CrossRefGoogle Scholar
- 14.Kluger MD, Memeo R, Laurent A, Tayar C, Cherqui D. Survey of adult liver transplantation techniques (SALT): an international study of current practices in deceased donor liver transplantation. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2011;13(10):692–8.CrossRefGoogle Scholar
- 15.Mehrabi A, Mood ZA, Fonouni H, Kashfi A, Hillebrand N, Muller SA, Encke J, Buchler MW, Schmidt J. A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2009;15(5):466–74.CrossRefGoogle Scholar
- 16.Pratschke S, Rauch A, Albertsmeier M, Rentsch M, Kirschneck M, Andrassy J, Thomas M, Hartwig W, Figueras J, Del Rio Martin J, De Ruvo N, Werner J, Guba M, Weniger M, Angele MK. Temporary Intraoperative Porto-Caval Shunts in Piggy-Back Liver Transplantation Reduce Intraoperative Blood Loss and Improve Postoperative Transaminases and Renal Function: A Meta-Analysis. World journal of surgery. 2016;40(12):2988–98.CrossRefPubMedGoogle Scholar
- 19.Jovine E, Mazziotti A, Grazi GL, Ercolani G, Masetti M, Morganti M, Pierangeli F, Begliomini B, Mazzetti PG, Rossi R, Paladini R, Cavallari A. Piggy-back versus conventional technique in liver transplantation: report of a randomized trial. Transplant international : official journal of the European Society for Organ Transplantation. 1997;10(2):109–12.CrossRefGoogle Scholar
- 21.Hesse UJ, Berrevoet F, Troisi R, Pattyn P, Mortier E, Decruyenaere J, de Hemptinne B. Hepato-venous reconstruction in orthotopic liver transplantation with preservation of the recipients’ inferior vena cava and veno-venous bypass. Langenbeck’s archives of surgery / Deutsche Gesellschaft fur Chirurgie. 2000;385(5):350–6.CrossRefGoogle Scholar
- 22.Belghiti J, Panis Y, Sauvanet A, Gayet B, Fekete F. A new technique of side to side caval anastomosis during orthotopic hepatic transplantation without inferior vena caval occlusion. Surgery, gynecology & obstetrics. 1992;175(3):270–2.Google Scholar
- 23.Cescon M, Grazi GL, Varotti G, Ravaioli M, Ercolani G, Gardini A, Cavallari A. Venous outflow reconstructions with the piggyback technique in liver transplantation: a single-center experience of 431 cases. Transplant international : official journal of the European Society for Organ Transplantation. 2005;18(3):318–25.CrossRefGoogle Scholar
- 24.Polak WG, Porte RJ. The sequence of revascularization in liver transplantation: it does make a difference. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2006;12(11):1566–70.CrossRefGoogle Scholar
- 25.Heidenhain C, Heise M, Jonas S, Ben-Asseur M, Puhl G, Mittler J, Thelen A, Schmidt S, Langrehr J, Neuhaus P. Retrograde reperfusion via vena cava lowers the risk of initial nonfunction but increases the risk of ischemic-type biliary lesions in liver transplantation—a randomized clinical trial. Transplant international : official journal of the European Society for Organ Transplantation. 2006;19(9):738–48.CrossRefGoogle Scholar
- 26.Weniger M, Andrassy J, Weig T, Grabein B, Crispin A, Rentsch M, Siebers C, Bazhin A, D'Haese JG, Hartwig W, Werner J, Guba M, Faist E, Pratschke S, Angele MK. Temporary Intra-Operative Portocaval Shunts, Post-Operative Infections, and Mid-Term Survival after Cava-Sparing Liver Transplantation. Surgical infections. 2017;18(7):803–9.CrossRefPubMedGoogle Scholar
- 27.van Rijn R, Karimian N, Matton APM, Burlage LC, Westerkamp AC, van den Berg AP, de Kleine RHJ, de Boer MT, Lisman T, Porte RJ. Dual hypothermic oxygenated machine perfusion in liver transplants donated after circulatory death. The British journal of surgery. 2017;104(7):907–17.CrossRefPubMedPubMedCentralGoogle Scholar
- 29.Weiss S, Messner F, Huth M, Weissenbacher A, Denecke C, Aigner F, Brandl A, Dziodzio T, Sucher R, Boesmueller C, Oellinger R, Schneeberger S, Oefner D, Pratschke J, Biebl M. Impact of abdominal drainage systems on postoperative complication rates following liver transplantation. European journal of medical research. 2015;20:66.CrossRefPubMedPubMedCentralGoogle Scholar
- 30.Fernandez-Aguilar JL, Suarez Munoz MA, Santoyo Santoyo J, Sanchez-Perez B, Perez-Daga JA, Aranda Narvaez JM, Ramirez Plaza C, Becerra Ortiz R, Titos Garcia A, Gonzalez Sanchez A, Montiel Casado C. Is liver transplantation without abdominal drainage safe? Transplantation proceedings. 2010;42(2):647–8.CrossRefPubMedGoogle Scholar
- 31.Paes-Barbosa FC, Massarollo PC, Bernardo WM, Ferreira FG, Barbosa FK, Raslan M, Szutan LA. Systematic review and meta-analysis of biliary reconstruction techniques in orthotopic deceased donor liver transplantation. Journal of hepato-biliary-pancreatic sciences. 2011;18(4):525–36.CrossRefPubMedGoogle Scholar