Mücahit ÖZBİLGİN, Tarkan ÜNEK, Cihan AĞALAR, Tufan EGELİ, Serhan DERİCİ, Canan ALTAY, Mesut AKARSU, Sevda ÖZKARDEŞLER, İbrahim ASTARCIOĞLU

Canlı Vericili Karaciğer Transplantasyonlarındaki Arteryel Çalma Sendromunda Gastroduodenal Arter Ligasyonu, Duct-To-Duct Safra Anastomozlarında Komplikasyonlara Yol Açar mı?

Amaç: Canlı vericili karaciğer transplantasyonlarında (CVKT) hepatik arter rekonstrüksiyonu esnasında tanı konulan arteryel çalma sendromu’nun tedavisinde yapılan gastroduodenal arter ligasyonunun, “duct-to-duct” safra anastomozlarında komplikasyonlara olan etkisinin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: Bu çalışma retrospektif bir kohort çalışmadır. Dokuz Eylül Üniversitesi Hastanesi Genel Cerrahi Karaciğer Nakli Biriminde Haziran 2000-2017 yıllarında CVKT yapılan 18 yaşından büyük ve en az 6 ay sağ kalımı olan hastalar çalışmaya dahil edildi. Hastaların demografik verileri, greft ağırlığı, soğuk iskemi süreleri, Child ve MELD skorları, kullandıkları immünossüpresif ajanlar ve duct-to-duct safra anastomozu yapılan olgularda gastroduodenal arter ligasyonu sonrası postoperatif biliyer komplikasyonların ortaya çıkıp çıkmadığı incelendi. Bulgular: CVKT yapılan 240 hastanın hepatik arter rekonstrüksiyonu esnasında intraoperatif olarak 11’inde (%4,5) Doppler Ultrasonografi ile gastroduodenal arter çalma sendromu tanısı konuldu. Hastaların safra yolu anastomozları; 8(%72,7)’inde duct-to-duct anastomoz ve 3(%27,3)’ünde Roux-en-Y Hepatikojejunostomi şeklindeydi. Ortalama izlem süresi 3260 (371-4357) gündü. Takiplerinde duct-to-duct safra yolu anastomozu yapılan 8 olgunun hiç birisinde safra yolu komplikasyonu gelişmediği görüldü (p<0,001). Sonuç: CVKT’larında safra yolu devamlılığı “duct-to-duct” şeklinde olan hastalarda arteriyel çalma sendromu’nun tedavisinde gastroduodenal arter ligasyonu güvenle yapılabilir.

Anahtar Kelimeler:

Karaciğer nakli, Gastroduodenal arter ligasyonu, safra yolu komplikasyonu

DOES THE LIGATION OF GASTRODUODENAL ARTERY PERFORMED AT ARTERIAL STEAL SYNDROME IN LIVING DONOR LIVER TRANSPLANTATION CAUSE COMPLICATIONS IN DUCT-TO-DUCT BILIARY ANASTOMOSIS?

Objective: It was aimed to evaluate whether the ligation of gastroduodenal artery performed for the treatment of arterial steal syndrome diagnosed during hepatic artery reconstruction in living donor liver transplantation (LDLT) cause complications in duct-to-duct bile anastomoses.Material and Method: This retrospective cohort study included patients older than 18 years of age who underwent LDLT and survived for at least 6 months at the Liver Transplantation Unit of General Surgery Department in Medical Hospital of Dokuz Eylul University between June 2000 and July 2017. The patients' demographic data, graft weight, duration of cold ischemia, Child and MELD scores, immunosuppressive agents they used and the presence of postoperative biliary complications after the gastroduodenal artery ligation were investigated.Results: Gastroduodenal artery steal syndrome was diagnosed through Doppler ultrasonography in 11 (4.5%) of 240 patients with LDLT intraoperatively during hepatic artery reconstruction. Of the biliary anastomoses, 8 (72.7%) were indent duct-to-duct anastomosis and 3 (27.3%) were Roux-en-Y Hepaticojejunostomy. The average follow-up time was 3260 (371-4357) days. None of the 8 patients who underwent duct-to-duct biliary anastomosis developed biliary tract complication (p <0.001). Conclusion: Gastroduodenal artery ligation can be performed safely in the treatment of arterial steal syndrome in patients with duct-to-duct biliary anastomosis in LDLT.

Keywords:

Liver transplantation, ligation of gastroduodenal artery, bile tract complication,

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Wozney P, Zajko AB, Bron KM, Point S, Strazl TE. Vascular complications after liver transplantation: A 5-year experience. AJR Am J Roentgenol 1986;147:657-663.
Settmacher U, Stange B, Haase R, Heise M, Steinmu ¨ller TH, Bechstein WO, Neuhaus P. Arterial complications after liver transplantation. Transpl Int 2000;13:372-378.
Karatzas T, Lykaki-Karatzas E, Webb M, Nery J, Tsaroucha A, Demirbas A, et al. Vascular complications, treatment, and outcome following orthotopic liver transplantation. Transplant Proc 1997;29:2853-2855.
Manner M, Otto G, Senninger N, Kraus T, Goerich J, Herfarth C. Arterial steal: An usual cause for hepatic hypoperfusion after liver transplantation. Transplant Int 1991;4:122-124.
Rasmussen A, Hjortrup A, Kirkegaard P. Intraoperative measurement of graft blood ﬂow—a necessity in liver transplantation. Transpl Int 1997; 10: 74.
Langer R, Langer M, Scholz A, Felix R, Neuhaus P, Keck H. The splenic steal syndrome and the gastroduodenal steal syndrome in patients before and after liver transplantation. Aktuelle Radiol 1992; 2: 55-58.
Vogl TJ, Pegios W, Balzer JO, Lobo M, Neuhaus P. Arterial steal syndrome in patients after liver transplantation: transarterial embolization of the splenic and gastroduodenal arteries. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2001; 173: 908.
Geissler I, Lamesch P, Witzigmann H, Jost U, Hauss J, Fangmann J. Splenohepatic arterial steal syndrome in liver transplantation: clinical features and management. Transpl Int 2002; 15: 139-141.
De Carlis L, Sansalone CV, Rondinara GF, et al. Splenic artery steal syndrome after orthotopic liver transplantation: diagnosis and treatment. Transplant Proc 1993; 25: 2594-96.
Nussler NC, Settmacher U, Haase R, Stange B, Heise M, Neuhaus P. Diagnosis and treatment of arterial steal syndromes in liver transplant recipients. Liver Transpl 2003; 9: 596.
Rogers J, Chavin KD, Kratz JM, et al. Use of autologous radial artery for revascularization of hepatic artery thrombosis after orthotopic liver transplantation: case report and review of indications and options for urgent hepatic artery reconstruction. Liver Transpl 2001; 7: 913.
Reivich M, Holling HE, Roberts P, Toole JF. Reversal of blood ﬂow through the vertebral artery and its effect on cerebral circulation. N Engl J Med 1961;265:878-885.
Alvarez D, Gerona S, Waisburg Z, Ciardullo M, deSantibanes E, Mastai R. Splanchnic hyperemia after liver transplantation in patients with end-stage liver disease. Liver Transpl Surg 1998;4: 300-303.
Richter S, Mu ¨cke I, Menger MD, Vollmar B. Impactofintrinsic blood ﬂow regulation in cirrhosis: Maintenance of hepatic arterial buffer response. Am J Physiol Gastrointest Liver Physiol 2000;279:G454-4G62.
Piscaglia F, Zironi G, Gaiani S, Mazziotti A, Cavallari A, Gramantieri L, et al. Systemic and splanchnichemodynamic changes after liver transplantation for cirrhosis: A long-term prospective study. Hepatology 1999;30:58-64.
Farges O, Belghiti J. Editorial on ‘‘diagnosis and treatment of arterial steal syndromes in liver transplantation recipients’’. Liver Transpl 2003; 9: 603.
Nishida S, Kadono J, DeFaria W, Levi DM, Moon JI, Tzakis AG, Madariaga JR. ‘’Gastroduodenal artery steal syndrome during liver transplantation: intraoperative diagnosis with Doppler ultrasound and management’’.Transpl Int. 2005 Mar;18(3):350-3.
Uﬂacker R, Selby JB, Chavin K, Rogers J, Baliga P. Transcatheter splenic artery occlusion for treatment of splenic artery steal syndrome after orthotopic liver transplantation. Cardiovasc Intervent Radiol 2002; 25: 300.
Nishida S, Kato T, Levi D, et al. Effect of protocol Doppler ultrasonography and urgent revascularization on early hepatic artery thrombosis after pediatric liver transplantation. Arch Surg 2002; 137: 1279.
Nüssler NC, Settmacher U, Haase R, Stange B, Heise M, Neuhaus P.Diagnosis and treatment of arterial steal syndromes in liver transplant recipients. Liver Transpl. 2003 Jun;9(6):596-602.
Dai J, Wu XF, Yang C, Li HJ, Chen YL, Liu GZ, Song YZ, Wu HH, Ding JL, Li N. Study of relationship between the blood supply of the extrahepatic bile duct and duct supply branches from gastroduodenal artery on imaging and anatomy.Chin Med J (Engl). 2015; 128:322-6.
Kobayashi S, Nakanuma Y, Matsui O. Intrahepatic peribiliary vascular plexus in various hepatobiliary disease: a histological survey. Hum Pathol 1994;25:940‑6.
Stange BJ, Glanemann M, Nuessler NC, Settmacher U, Steinmüller T, Neuhaus P. Hepatic artery thrombosis after adult liver transplantation. Liver Transpl 2003;9:612‑20.
Stapleton GN, Hickman R, Terblanche J. Blood supply of the right and left hepatic ducts. Br J Surg 1998;85:202‑7.
Donato P, Coelho P, Rodrigues H, Vigia E, Fernandes J, Caseiro‑Alves F, et al. Normal vascular and biliary hepatic anatomy: 3D demonstration by multidetector CT. Surg Radiol Anat 2007;29:575‑82.
Blakolmer K, Jain A, Ruppert K, Gray E, Duquesnoy R, Murase N, et al. Chronic liver allograft rejection in a population treated primarily with tacrolimus as baseline immunosuppression: long‑term follow‑up and evaluation of features for histopathological staging. Transplantation 2000;69:2330‑6.
S. Sevmış, F. Boymat, C. Aytekin, C.K. Görür, G. Moray ve M. Haberal : Arteryel steal syndrome after orthotopıc liver transplantation. Transplant Proc 2006; 38: 3651-3655.