Early Hepatoduodenal Ligament Occlusion Versus Classic Technique During Recipient Hepatectomy for Right Lobe Living Donor Liver Transplant.pptx

Early Hepatoduodenal Ligament Occlusion Versus Classic Technique During Recipient Hepatectomy for Right Lobe Living Donor Liver Transplant

1. Early Hepatoduodenal Ligament Occlusion Versus Classic Technique During Recipient Hepatectomy for Right Lobe Living Donor Liver Transplant By : Ahmed Elkoussy Lecturer of HPB and liver transplant surgery Assiut University

2. Living donor liver transplantation (LDLT) was adapted and later became the most successful and safe source for liver allografts as the deceased organ donation remains scarce . Hartmann et al (2016) Introduction

3. In liver transplantation, Recipient hepatectomy is considered one of the critical steps of procedure because significant bleeding usually occurs during this step. Kim et al(2021), Hackle et al(2016) Introduction…

4. Factors Increase Bleeding During Recipient Hepatectomy Anatomical Factors Pathophysiological Factors

5. How Can We Compensate???? . Non surgical modalities :

6. How Can We Compensate????.... . Surgical modalities :

7. Introduction…. . Dissection of the Hepatoduodenal Ligament (HDL) during recipient hepatectomy is critical for vascular inflow control and mobilization of the native liver. Taha et al (2021), Yoon et al (2018 ) This is more challenging and risky in LDLT because there is usually a need for longer vascular and biliary stumps for subsequent graft implantation. Rao et al (2018)

8. Introduction…. . Classically HDL ( inflow occlusion ) is occluded after the end of dissection. Inspite of good visualization of the anatomical structures during dissection , this classic technique is associated with severe blood loss. Perini et al (2021) So Early and prolonged HDL occlusion was advocated not only to produce a beneficial effect to improve patient outcome, but also to facilitate shorter operative time, less blood loss and greater satisfaction for the surgeon. Choi at al (2020), Ke et al (2019 )

9. Aim OF WORK The aim of the study was to compare two techniques, early versus classic Hepatoduodenal ligament occlusion during Recipient Hepatectomy for Right Lobe Living-Donor Liver Transplant, regarding blood loss, operative time, mortality rate and post transplantation graft function.

10. This is a prospective non-randomized clinical study performed in HPB Surgery and Liver Transplantation Unit, El-Rajhi Liver Hospital, Assiut University, Egypt. Study duration The study was conducted over the period of two years, from February 2020 To February 2022 . Patients And Methods

11. Sample Size Calculation The study group included 23 consecutive prospective patients , who had early inflow occlusion during recipient hepatectomy , compared them to 29 patients performed retrospectively by the classic technique. Ethical consideration The study gained approval from the Institutional Review Board (IRB) of the faculty of medicine, Assiut University, under code 17200430 . The study protocol was registered in " ClinicalTrials.gov " under code NCT04265157 .   Patients And Methods

12. The recipient Hepatectomy procedure The procedure started with a Hockey Stick or Mercedes incision.

13. Liver Mobilization And Hepato- caval Ligament Suturing The recipient Hepatectomy procedure…..

14. Retrohepatic veins emerging between the posterior liver surface and the IVC were sutured and ligated. In the control group, perihilar dissection was performed for isolation of portal vein, hepatic artery, and bile duct branches just below the hilar plate. The recipient Hepatectomy procedure…..

15. Occlusion of the hepatoduodenal ligament was done by individual clamping and division of hepatic arteries and portal vein after completion of HDL dissection (immediately before hepatectomy ). The Control Group:-

16. In the study group, we applied early continuous hepatic inflow occlusion, before any liver mobilization or hilar dissection, via a suitable vascular clamp as Peripheral Debakey at the caudal end of hepatoduodenal ligament The Study Group:-

17. In this group, the surgeons were instructed to notice and record any episodes of bowel congestion, serosal tear over the hepatoduodenal ligament, or any vascular injury at site of clamp application as hematoma or similar injuries. The Study Group …..

18. If any of these complications happened and it deemed unsuitable to continue clamping; de-clamping was done, and this was considered a failure of the technique. After end of dissection, bulldog clamps were applied individually over the hepatic arteries and portal vein then the a fore-mentioned ligament vascular clamp was removed. No portocaval shunts were performed in either group . The Study Group …..

19. The Study Group ….. Skin Incision Clamping Start End Hepatectomy Explantation Time In the study group, we measured both explantation and clamping times

20. In the control group, only the explantation time was measured. Intraoperative blood loss was estimated in both groups by the amount gathered in the suction device (or Cell-saver) after subtracting the washing saline, in addition to the amount lost in the used gauzes or packs . The Study Group …..

21. Every 1 gm increase in its weight was equivalent to 1 ml of blood loss . Withanathantrige et al (2018) Blood products transfusion was also calculated in each group, including packed RBCs, fresh frozen plasma, or cell saver reuse. The Study Group …..

22. During the follow up , graft dysfunction was assessed by measuring INR, AST, ALT and total bilirubin daily. If any complications were encountered, these were recorded and managed accordingly. After discharge, patients were followed up for at least 6 months after the procedure. Follow Up…..

23. We included a total of 52 patients who underwent LDLT. Group A included 23 consecutive prospective patients, who had early inflow occlusion during recipient hepatectomy compared them to 29 patients performed retrospectively by the classic technique Results

24. Demographic Data     Group A (n= 23) Group B (n= 29) P Recipient age 44.26 47.90 0.241   Gender Male 16 (69.6% 18(62.1%)   0.622 Female 7(30.4%) 11 (37.9%) BMI(Kg/m2) 24.96 25.86 0.586 Data is expressed as mean and standard deviation or as percentage and frequency. P is significant when ˂ 0.05. Results ……

25. Indications Of Transplantation Results ……

26.   Group A (n= 23) Group B (n= 29) P MELD 16.22 ± 4.12 17.72 ± 4.79 0.237 GRWR 1.12 ± 0.170 1.12 ± 0.181 0.967 MELD Scores And GRWR In The Studied Recipients Results ……

27. Blood Loss During Explant And Blood Loss During Clamping In The Studied Recipients   Group A (n= 23) Group B (n= 29) P Blood loss during explant, median (range), mL 2912.08 (797.44-8205.08) 3826.15 (1501.52-10 198.91) 0.017 `Blood loss during clamping, median (range),mL 2167 (597-7224)     Results ……

28. Blood Products Transfusion In The Studied Recipients P > .001 Results ……

29. Explant Time And Clamping Time In The Studied Recipients   Group A (n= 23) Group B (n= 29) P Explant time, mean ± SD, min 183.90 ± 29.88 207.16 ± 51.52 .060 Clamping time, mean ± SD, min 146.51 ± 29.51    

30. Results …… One patient developed bowel congestion 20 minutes after clamping. We did not encounter any patient with a peritoneal serosal tear, hematoma in the hepatoduodenal ligament, or hepatic artery dissection.

31. Results…… There is no significant difference in the marker of graft recovery (INR, AST, ALT and TB) at different time points Three patients died in our study (10%). One patient died of hepatic artery thrombosis, while two died from multiorgan failure.

32. Limitations Of The Study

33. Conclusion Early and continuous hepatic inflow occlusion during LDLT is a simple, safe, and effective maneuver to reduce intraoperative blood loss and reduce the need for blood transfusion products compared with the classic technique .

34. Thank you