COMMENTARY ON TECHNIQUE/CASE REPORT patients with portal hypertension requiring Lastly, one must applaud the excellent Commentary on transjugular intrahepatic portosystemic collaboration between the operating sur- Intraoperative Portal Vein shunts and was demonstrated to be of value geons and the interventional radiologists. in pediatric patients in a 12-patient series Successful liver transplantation must be Evaluation and Stenting 2 with excellent results in 1998. Portal vein predicated on a multidisciplinary approach, stenosis and thrombosis was identified as a and this collaboration is the type of medical major contributor to graft loss during the advancement needed for the success in he manuscript ‘‘P4 Stump Approach for earliest series of adult to pediatric living extremely complex patients such as PLDLT T Intraoperative Portal Vein Stenting in donor liver transplantation and this problem recipients. Pediatric LDLT: An innovative technique is still in the process of being addressed as for a challenging problem’’ explores a difficult 1,3,4 this manuscript demonstrates. Poor angu- dilemma and offers a potential solution for Adam S. Bodzin, MD impending portal vein complications in pedi- lation, or compression at the root of mesen- James Michael Millis, MD tery or anywhere along the course of the vein, atric liver transplantation. While living donor Department of Surgery may cause a catastrophic complication lead- pediatric liver transplant has evolved over University of Chicago ing to graft loss and death. The algorithm of decades, the portal vein remains a potential Chicago, IL flow dynamics used in this study appears to calamity for young recipients of live donor firstname.lastname@example.org produce reliable outcomes in both the inter- livers. Portal vein complications arise both vention and the control groups warranting early and as late as 5 years out and may lead other’s consideration for similar approaches to both graft loss and ultimately, mortality. to avoid potential for problems. Moreover, surgical revisions of portal vein REFERENCES One legitimate concern with regards to stenosis can be quite challenging, as appropri- 1. Millis JM, Seaman DS, Piper JB, et al. Portal the use of portal vein stenting in children is ate-sized conduits are often unavailable. This vein thrombosis and stenosis in pediatric liver transplantation. Transplantation. 1996;62: the potential inability for the stent to expand group defined an innovative operative protocol 748–754. with the growth of the pediatric recipient. that investigates portal flow in the setting of 2. Hackworth CA, Leef JA, Rosenblum JD, et al. This group uses relatively large stents with augmenting maneuvers and preemptively Transjugular intrahepatic portosystemic shunt diameters of 7 to 10 mm with self-expanding intervenes with excellent collaborative work creation in children: initial clinical experience. properties that theoretically have potential to Radiology. 1998;206:109–114. with their interventional radiology colleagues. expand to an appropriate size with normal 3. Millis JM, Cronin DC, Brady LM, et al. Primary Their results compare favorably with other living-donor liver transplantation at the University adult portal veins being approximately 10 to methods such as delayed stenting, using con- of Chicago: technical aspects of the first 104 15 mm in diameter. Although long-term duits from the superior mesenteric vein, or recipients. Ann Surg. 2000;232:104–111. results are not yet available, mean 27.7- from the confluence of the splenic and supe- 4. Chen CL, Cheng YF, Huang V, et al. P4 stump month patency of 100% shows great promise. rior mesenteric veins. The technique described approach for intraoperative portal vein stenting in Our group has been using portal vein stenting pediatric LDLT: an innovative technique for a in this manuscript may be preferable to the challenging problem. Ann Surg. 2017 [Epub ahead for several decades in the pediatric popula- other more standard methods if the operating of print]. tion (<2 y of age) and have not identified room is suitable for interventional radiology to 5. Buell JF, Funaki B, Cronin DC, et al. Long-term problems as the children grow into adult age perform complex procedures. venous complications after full-size and segmental and sizes; one would expect their results to The use of metal stents in the portal pediatric liver transplantation. Ann Surg. 2002;236: circulation is most commonly seen in mirror ours. 658–666. The authors report no conflicts of interest. Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/17/26703-0e45 DOI: 10.1097/SLA.0000000000002605 Annals of Surgery Volume 267, Number 3, March 2018 www.annalsofsurgery.com | e45 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery – Wolters Kluwer Health
Published: Mar 1, 2018
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