title: Presentation, diagnosis, and management of early hepatic venous outflow complications in whole cadaveric liver transplant.
abstract: Early hepatic venous outflow obstruction (HVOO) can be a devastating complication leading to graft loss after liver transplantation (LT). A retrospective study on 777 adult LT recipients over a 5-year period (August 2007 to August 2012) was undertaken to determine the incidence of early HVOO presenting within 3 months of transplant, its clinical features and management, and potential technical risk factors related to the implanting technique. Cases of early HVOO were screened for by identifying recipients with problematic ascites within 3 months of transplant. Definitive diagnosis for HVOO was based on a wedge pressure of >12 mm Hg. Considering only whole livers, the incidence of early problematic ascites was 3% (20/695) of which more than one-third (35%, 7/20) were then confirmed to have HVOO. Overall, the incidence of early HVOO was 1% (7/695). Two hepatic veins (HVs) with extension piggybacks (PBs; n = 423) were the dominant implanting technique in the time period of study rather than the 3 HV PB (n = 182) and caval replacement techniques (n = 82). Considering the implantation technique, all cases of HVOO occurred after 2 HVs when extension PBs had been used with an incidence of 1.7% (7/423). Institutionally, early HVOO was mainly managed surgically by either cavoplasty within a month of transplant (n = 4) or retransplant (n = 1), and the remainder (n = 2) were medically managed with diuretics. In conclusion, early HVOO is rare, and there is no evidence from this study that a given implantation technique is at a higher risk of developing HVOO (2 HV with extension versus 3 HV and caval replacement; P = 0.11). However, early revisional surgery for HVOO can preserve graft function with retransplantation being reserved for when surgical cavoplasty or radiological stenting is technically not possible.
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, United Kingdom.
authors.forename: Shirin Elizabeth
authors.initials: SE
authors.lastname: Khorsandi
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, United Kingdom.
authors.forename: Anuja
authors.initials: A
authors.lastname: Athale
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, United Kingdom.
authors.forename: Hector
authors.initials: H
authors.lastname: Vilca-Melendez
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, United Kingdom.
authors.forename: Wayel
authors.initials: W
authors.lastname: Jassem
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, United Kingdom.
authors.forename: Andreas
authors.initials: A
authors.lastname: Prachalias
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, United Kingdom.
authors.forename: Parthi
authors.initials: P
authors.lastname: Srinivasan
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, United Kingdom.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Rela
authors.affiliation: Institute of Liver Studies, King's College Hospital, London, United Kingdom.
authors.forename: Nigel
authors.initials: N
authors.lastname: Heaton
mesh_terms: D000328:Adult; D000368:Aged; D001201:Ascites / Q000175:diagnosis; D001706:Biopsy; D006502:Budd-Chiari Syndrome / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D005260:Female; D006085:Graft Survival; D006503:Hepatic Veins / Q000601:surgery*; D006801:Humans; D015994:Incidence; D008099:Liver / Q000098:blood supply / Q000601:surgery; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome