Skip to main content
SpringerLink
Log in

Temporary Intraoperative Porto-Caval Shunts in Piggy-Back Liver Transplantation Reduce Intraoperative Blood Loss and Improve Postoperative Transaminases and Renal Function: A Meta-Analysis

  • Original Scientific Report
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

The value of temporary intraoperative porto-caval shunts (TPCS) in cava-sparing liver transplantation is discussed controversially. Aim of this meta-analysis was to analyze the impact of temporary intraoperative porto-caval shunts on liver injury, primary non-function, time of surgery, transfusion of blood products and length of hospital stay in cava-sparing liver transplantation.

Methods

A systematic search of MEDLINE/PubMed, EMBASE and PsycINFO retrieved a total of 909 articles, of which six articles were included. The combined effect size and 95 % confidence interval were calculated for each outcome by applying the inverse variance weighting method. Tests for heterogeneity (I 2) were also utilized.

Results

Usage of a TPCS was associated with significantly decreased AST values, significantly fewer transfusions of packed red blood cells and improved postoperative renal function. There were no statistically significant differences in primary graft non-function, length of hospital stay or duration of surgery.

Conclusion

This meta-analysis found that temporary intraoperative porto-caval shunts in cava-sparing liver transplantation reduce blood loss as well as hepatic injury and enhance postoperative renal function without prolonging operative time. Randomized controlled trials investigating the use of temporary intraoperative porto-caval shunts are needed to confirm these findings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

Abbreviations

ALT:

Alanine aminotransferase

AST:

Aspartate aminotransferase

CI:

Confidence interval

DCD:

Donation after cardiac death

DRI:

Donor risk index

FFP:

Fresh frozen plasma

ICU:

Intensive care unit

IV:

Inverse variance

LOS:

Length of hospital stay

MELD:

Model for end stage liver disease

PNF:

Primary non-function

PRBC:

Packed red blood cells

RCT:

Randomized controlled trial

TPCS:

Temporary intraoperative porto-caval shunt

References

  1. Calne RY, Williams R (1968) Liver transplantation in man. I. Observations on technique and organization in five cases. Br Med J 4(5630):535–540

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Tzakis A, Todo S, Starzl TE (1989) Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 210(5):649–652

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Belghiti J, Panis Y, Sauvanet A, Gayet B, Fekete F (1992) A new technique of side to side caval anastomosis during orthotopic hepatic transplantation without inferior vena caval occlusion. Surg Gynecol Obstet 175(3):270–272

    CAS  PubMed  Google Scholar 

  4. Figueras J, Llado L, Ramos E et al (2001) Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc 7(10):904–911. doi:10.1053/jlts.2001.27870

    CAS  Google Scholar 

  5. Pratschke S, Meimarakis G, Bruns CJ et al (2013) Temporary intraoperative porto-caval shunt: useless or beneficial in piggy back liver transplantation? Transpl Int 26(1):90–98

    Article  PubMed  Google Scholar 

  6. Maluf DG, Edwards EB, Kauffman HM (2006) Utilization of extended donor criteria liver allograft: is the elevated risk of failure independent of the model for end-stage liver disease score of the recipient? Transplantation 82(12):1653–1657. doi:10.1097/01.tp.0000250571.41361.21

    Article  PubMed  Google Scholar 

  7. Arai M, Mochida S, Ohno A, Arai S, Fujiwara K (1998) Selective bowel decontamination of recipients for prevention against liver injury following orthotopic liver transplantation: evaluation with rat models. Hepatology 27(1):123–127. doi:10.1002/hep.510270120

    Article  CAS  PubMed  Google Scholar 

  8. Moreno-Gonzalez E, Meneu-Diaz JG, Fundora Y et al (2003) Advantages of the piggy back technique on intraoperative transfusion, fluid compsumption, and vasoactive drugs requirements in liver transplantation: a comparative study. Transplant Proc 35(5):1918–1919

    Article  CAS  PubMed  Google Scholar 

  9. Moher D, Shamseer L, Clarke M et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 4:1. doi:10.1186/2046-4053-4-1

    Article  PubMed  PubMed Central  Google Scholar 

  10. Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52(6):377–384

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR (2009) Introduction to meta-analysis, 1st edn. Wiley, New York

    Book  Google Scholar 

  12. Ghinolfi D, Marti J, Rodriguez-Laiz G et al (2011) The beneficial impact of temporary porto-caval shunt in orthotopic liver transplantation: a single center analysis. Transpl Int Off J Eur Soc Organ Transplant 24(3):243–250. doi:10.1111/j.1432-2277.2010.01168.x

    Article  Google Scholar 

  13. Figueras J, Llado L, Ramos E et al (2001) Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study. Liver Transplant 7(10):904–911

    Article  CAS  Google Scholar 

  14. Hesse UJ, Berrevoet F, Troisi R et al (1999) Preservation of caval flow during orthotopic liver transplantation with a temporary portocaval shunt. Chirurg 70:174–178

    Article  CAS  PubMed  Google Scholar 

  15. Arzu GD, De Ruvo N, Montalti R et al (2008) Temporary porto-caval shunt utility during orthotopic liver transplantation. Transplant Proc 40(6):1937–1940. doi:10.1016/j.transproceed.2008.06.001

    Article  CAS  PubMed  Google Scholar 

  16. de Cenarruzabeitia IL, Lazaro JL, Bilbao I, Balsells J (2007) Portocaval shunt throughout anhepatic phase in orthotopic liver transplantation for cirrhotic patients. Transplant Proc 39(7):2280–2284

    Article  PubMed  Google Scholar 

  17. Bilzer M, Roggel F, Gerbes AL (2006) Role of Kupffer cells in host defense and liver disease. Liver Int Off J Int Assoc Study Liver 26(10):1175–1186. doi:10.1111/j.1478-3231.2006.01342.x

    Article  CAS  Google Scholar 

  18. Oltean M, Zhu C, Mera S et al (2009) Reduced liver injury and cytokine release after transplantation of preconditioned intestines. J Surg Res 154(1):30–37. doi:10.1016/j.jss.2008.05.015

    Article  CAS  PubMed  Google Scholar 

  19. Fiorini RN, Shafizadeh SF, Polito C et al (2004) Anti-endotoxin monoclonal antibodies are protective against hepatic ischemia/reperfusion injury in steatotic mice. Am J Transplant Off J Am Soc Transplant Am SocTransplant Surg 4(10):1567–1573. doi:10.1111/j.1600-6143.2004.00549.x

    Article  CAS  Google Scholar 

  20. Tzakis AG, Reyes J, Nour B, Marino IR, Todo S, Starzl TE (1993) Temporary end to side portacaval shunt in orthotopic hepatic transplantation in humans. Surg Gynecol Obstet 176(2):180–182

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Belghiti J, Noun R, Sauvanet A (1995) Temporary portocaval anastomosis with preservation of caval flow during orthotopic liver transplantation. Am J Surg 169(2):277–279. doi:10.1016/S0002-9610(99)80151-2

    Article  CAS  PubMed  Google Scholar 

  22. Pratschke S, Angele M (2013) Response to gastaca. Transpl Int Off J Eur Soc Organ Transplant 26(9):e83. doi:10.1111/tri.12158

    Article  Google Scholar 

  23. Hoffmann K, Weigand MA, Hillebrand N, Buchler MW, Schmidt J, Schemmer P (2009) Is veno-venous bypass still needed during liver transplantation? A review of the literature. Clin Transplant 23(1):1–8. doi:10.1111/j.1399-0012.2008.00897.x

    Article  PubMed  Google Scholar 

  24. Gastaca M (2013) Temporary intraoperative porto-caval shunt: a more complete set of data is needed. Transpl Int Off J Eur Soc Organ Transplant 26(9):e81–e82. doi:10.1111/tri.12128

    Article  Google Scholar 

  25. Margarit C, de Cenarruzabeitia IL, Lazaro JL et al (2005) Portacaval shunt and inferior vena cava preservation in orthotopic liver transplantation. Transplant Proc 37(9):3896–3898. doi:10.1016/j.transproceed.2005.10.062

    Article  CAS  PubMed  Google Scholar 

  26. Olthoff KM, Kulik L, Samstein B et al (2010) Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc 16(8):943–949. doi:10.1002/lt.22091

    Google Scholar 

  27. Puhl G, Schaser KD, Pust D et al (2005) Initial hepatic microcirculation correlates with early graft function in human orthotopic liver transplantation. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc 11(5):555–563. doi:10.1002/lt.20394

    Google Scholar 

  28. de Graaf EL, Kench J, Dilworth P et al (2012) Grade of deceased donor liver macrovesicular steatosis impacts graft and recipient outcomes more than the Donor Risk Index. J Gastroenterol Hepatol 27(3):540–546. doi:10.1111/j.1440-1746.2011.06844.x

    Article  PubMed  Google Scholar 

  29. Pratschke S, Meimarakis G, Mayr S et al (2011) Arterial blood flow predicts graft survival in liver transplant patients. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc 17(4):436–445. doi:10.1002/lt.22248

    Google Scholar 

  30. Paugam-Burtz C, Kavafyan J, Merckx P et al (2009) Postreperfusion syndrome during liver transplantation for cirrhosis: outcome and predictors. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc 15(5):522–529. doi:10.1002/lt.21730

    Google Scholar 

Download references

Acknowledgments

The authors thank Dr. Amanda Tufman for proofreading this paper.

Authors’ contributions

S Pratschke designed the study and wrote the manuscript. A. Rauch and M. Kirschneck performed the statistical analysis and provided important advice on writing the manuscript. M. Albertsmeier, M. Rentsch, J. Werner and M. Guba substantially contributed to the design of the study and critically revised the manuscript. J. Andrassy and M. Thomas designed the study and critically revised the manuscript. J. Figueras, N. De Ruvo and J del Rio Martin provided important data and critically revised the manuscript. M. Weniger and M. K. Angele conceived the idea of the study, majorly contributed to its design and critically revised the manuscript. All authors read and approved the submitted version of the manuscript.

Author information

Author notes

    Authors and Affiliations

    1. Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Campus Grosshadern, Ludwig Maximilians-University, Marchioninistraße 15, 81377, Munich, Germany

      Sebastian Pratschke, Markus Albertsmeier, Markus Rentsch, Joachim Andrassy, Michael Thomas, Werner Hartwig, Jens Werner, Markus Guba, Maximilian Weniger & Martin K. Angele

    2. Chair for Public Health and Health Care Research, Research Unit for Biopsychosocial Health, Department of Medical Informatics, Biometry and Epidemiology – IBE, Ludwig Maximilians-University, Munich, Germany

      Alexandra Rauch & Michaela Kirschneck

    3. Hepato-Biliary and Pancreatic Surgery Unit, Department of Surgery, Dr Josep Trueta Hospital, Institut d’Investigació Biomèdica (IDIBGi), Girona, Spain

      Joan Figueras

    4. Auxilio Centro de Transplante, Hospital Español Auxilio Mutuo, San Juan, PR, USA

      Juan Del Rio Martin

    5. Liver Transplantation Center, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy

      Nicola De Ruvo

    Authors
    1. Sebastian Pratschke
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Alexandra Rauch
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Markus Albertsmeier
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Markus Rentsch
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Michaela Kirschneck
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Joachim Andrassy
      View author publications

      You can also search for this author in PubMed Google Scholar

    7. Michael Thomas
      View author publications

      You can also search for this author in PubMed Google Scholar

    8. Werner Hartwig
      View author publications

      You can also search for this author in PubMed Google Scholar

    9. Joan Figueras
      View author publications

      You can also search for this author in PubMed Google Scholar

    10. Juan Del Rio Martin
      View author publications

      You can also search for this author in PubMed Google Scholar

    11. Nicola De Ruvo
      View author publications

      You can also search for this author in PubMed Google Scholar

    12. Jens Werner
      View author publications

      You can also search for this author in PubMed Google Scholar

    13. Markus Guba
      View author publications

      You can also search for this author in PubMed Google Scholar

    14. Maximilian Weniger
      View author publications

      You can also search for this author in PubMed Google Scholar

    15. Martin K. Angele
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding author

    Correspondence to Martin K. Angele.

    Ethics declarations

    Conflict of interest

    The authors declare that they have no competing interests.

    Additional information

    M. Weniger and M. K. Angele have contributed equally to this work.

    Rights and permissions

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Pratschke, S., Rauch, A., Albertsmeier, M. et al. 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 J Surg 40, 2988–2998 (2016). https://doi.org/10.1007/s00268-016-3656-1

    Download citation

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s00268-016-3656-1

    Keywords

    Search

    Navigation