ABSTRACT
Introduction: The size and shape of the thyroid gland may alter remarkably with age, gender, physiologicalcondition, race, and geographical location. Thus the knowledge of the various parameters and position ofthyroid gland are important while doing surgeries on thyroid gland as well as during tracheostomy in emergencycondition.Materials and methods: The study was structured to investigate the morphometric as well as topographicalfeatures of the thyroid gland in 100 cadavers (58 males and 42 females) from Maharashtrian populationResult: The right lobe of the thyroid gland was found to be larger than the left lobe. An average length and widthof isthmus were 1.38 cm and 1.02 cm. An average weight of thyroid gland was 14.5grams. The P value was 0.00it shows that gender wise difference in different parameters was highly significant. Most commonly the isthmuswas lying opposite to 1st 2nd and 3rd tracheal rings. Gender wise difference in position of isthmus was statisticallyinsignificant.Conclusion: This study highlights the various parameters of thyroid gland as well as shows the gender wisedifference in it.
ABSTRACT
Objective@#To assess application of reconstruction of retrohepatic inferior vena cava using artificial blood vessel in right lobe living donor liver transplantation (LDLT) in the treatment of hepatocellular carcinoma (HCC) beyond Milan Criteria.@*Methods@#The clinical data of 9 HCC patients who underwent right lobe liver transplantation after reconstruction of retrohepatic inferior vena cava using artificial blood vessel between June 2015 and Nov 2016 at Liver Transplantation Center of the First Affiliated Hospital of Nanjing Medical University were retrospectively analyzed. The liver of the patients was removed with retrohepatic inferior vena cava, and then the right donor graft was implanted by conventional orthotopic liver transplantation.@*Results@#All 9 liver transplantations were performed successfully. The time of reconstruction of hepatic venous outflow of the donor graft was (22.6±3.0) min, anhepatic time was (45.0±7.1) min, and total operation time was (321.9±52.5) min. All patients recovered uneventfully, ICU and hospital stay day were (1.2±0.4) days and (18.4±3.0) days. 2 patients suffered from thrombosis of artificial blood vessel, one recovered after conservative treatment and another was treated by placement of vein stent. No abdominal/pulmonary infection and non-artificial blood vascular complications were found, and none died in perioperative period. Postoperative pathological results showed that all patients were hepatocellular carcinomas and vascular tumor thrombosis was found in 5 cases. All patients were follow up, 1 patient died of pulmonary and brain metastasis 10 months after operation. One patient survived with local recurrence of tumor in liver. The other patients had no tumor recurrence and metastasis.@*Conclusion@#Replacement of retrohepatic inferior vena cava using artificial blood vessel in right lobe living donor liver transplantation is safe and feasible in the treatment of HCC beyond Milan Criteria, and might improve the resection rate of diseased liver and the prognosis of HCC patients after living donor liver transplantation.
ABSTRACT
After having experienced more than 2,000 cases of adult living donor liver transplantation (LDLT), we established the concepts of right liver graft standardization. Right liver graft standardization intends to provide hemodynamics-based and regeneration-compliant reconstruction of vascular inflow and outflow. Right liver graft standardization consists of the following components: Right hepatic vein reconstruction includes a combination of caudal-side deep incision and patch venoplasty of the graft right hepatic vein to remove the acute angle between the graft right hepatic vein and the inferior vena cava; middle hepatic vein reconstruction includes interposition of a uniform-shaped conduit with large-sized homologous or prosthetic grafts; if the inferior right hepatic vein is present, its reconstruction includes funneling and unification venoplasty for multiple short hepatic veins; if donor portal vein anomaly is present, its reconstruction includes conjoined unification venoplasty for two or more portal vein orifices. This video clip that shows the surgical technique from bench to reperfusion was a case presentation of adult LDLT using a modified right liver graft from the patient's son. Our intention behind proposing the concept of right liver graft standardization is that it can be universally applicable and may guarantee nearly the same outcomes regardless of the surgeon's experience. We believe that this reconstruction model would be primarily applied to a majority of adult LDLT cases.
Subject(s)
Adult , Humans , Hepatic Veins , Intention , Liver Transplantation , Liver , Living Donors , Portal Vein , Reperfusion , Tissue Donors , Transplants , Vena Cava, InferiorABSTRACT
Background: Liver abscess is a major health problem in tropical and subtropical regions. Aim: The present study aimed to evaluate the clinical profile, management of amoebic liver abscess patients. Materials and methods: A cross-sectional study was conducted in Department of Surgery MNR Medical College Hospital, Sangareddy over a period of 2 years from June 2014 to July 2016. A total of 100 patients with liver abscess were included in this study. Clinical examination, detail case history, ultrasonography reports, case management and outcome were recorded during study. Results: Among 100 patients, 88 were males and 12 were females. Majority of cases were belongs to the age group of 30 -40 years (45%). Most common clinical features of amoebic liver abscess was fever (89%), abdominal pain (78%) and diarrhoea (37%). The major signs were hepatomegaly (87%), right lobe abscess (68%), left lobe abscess (36%) and pleural effusion (18%). Mortality rate was 3% out of 100 patients.
ABSTRACT
Agenesis of right lobe of liver is a rare finding and was defined as the absence of liver tissue on the right side with preservation of the middle hepatic vein without previous disease or surgery. Congenital agenesis of right hepatic lobe is a rare anomaly which is found incidentally in radiologic examination. Here we present a case of 22 year old female who came with abdominal distension suspecting liver cirrhosis she was investigated and on imaging studies incidentally it was revealed that there is absence of right lobe of liver.
ABSTRACT
Objectives: The aim of the study was to know the intrahepatic ramification pattern of portal vein in right lobe of liver & its variations. Methods: 25 human fresh livers were obtained after autopsy and studied by corrosion cast method. Polymeric granules of butyl butyrate were dissolved in acetone and 20% homogenous solution was made. Solution was injected into portal vein and the injected liver was placed in 10 %formal saline for 24 hours at room temperature (20°C) for polymerization of infused butyl butyrate solution. Maceration of liver tissue achieved by wholeorgan immersion in 1.8 N KOH solution at 68°C for 24 hrs. Each cast thus obtained was preserved in glycerin and details were studied. Results: The length of the right portal vein varies 0.5 to 1.8 cm (1.2 cm). The right portal vein bifurcated into second order branches - right anterior portal vein (RAPV) & right posterior portal vein (RPPV) in 87 % of the cases, while trifurcated in rest of 13 % of cases. The angle between the anterior and posterior division ranged from 58°-95 °. Anterio-superior (P8) branch shown three type of ramification - Bifurcation type (72 %), P8- one pedicle type (8 %) and P8- trifurcation type (20%). Anterio-inferior (P5max ) branch shown the three type of ramification pattern - P5 -common type (72 %), P5 – P8 anterior type (28 %) but P5 – P8 posterior type was not observed. Right Posterior Portal Vein has shown three types of ramification pattern - Type I-Fan shaped (64%),Type II (28 %) & Type III-Trifurcation type (8%). Conclusions: The findings of present study on hepatic vasculature have immense importance in the field of hepato-biliary surgeries like hepatic resection, segmentectomy and liver transplantation.
ABSTRACT
Objective To review the techniques used in biliary reconstruction for adult-adult living donor liver transplantation using a right lobe graft. Methods The clinical data of 21 pairs of donor and recipient who underwent right lobe living donor liver transplantation from April 2007 to May 2009 at Beijing Youan Hospital were analyzed retrospectively. Biliary anastomoses consisted of 10 single right hepatic duct to common hepatic duct anastomoses, 5 donor double branched ducts to recipient double branched ducts anastomoses, 5 single anastomoses between a donor double branched duct which had been converted to a single duct by ductoplasty to a single recipient bile duct, and 1 hepaticojejunostomy. A T-tube was inserted through the anterior wall of the common hepatic duct and splinted across the anastomosis in 2 recipients and a Y-tube was used in 1 recipient. Results 4 recipients died during the first post-transplant month. Another recipient received a retransplantation for acute liver necrosis. The remaining recipients were alive. The 1-year survival rate of the recipients was 77.65 %.5 patients developed biliary leakage and 2 patients developed biliary stricture. The 7 biliary complications were treated and cured by further surgical procedures. There was no significant difference in the biliary complications among the three different types of biliary anastomotic groups (x2 = 0. 659,P=0. 719). Conclusion The different types of biliary anastomoses can be used in living donor liver transplantation depending on the situations found in the donors and recipients. Continuous suturing on the posterior wall of the bile duct, interrupted suturing on the anterior wall and microsurgical techniques in biliary reconstruction are effective modalities to minimize biliary complications.
ABSTRACT
Objective To investigate some improvements in the surgical techniques of adult-to-adult living donor liver transplantation( A-A LDLT) without the middle hepatic vein(MHV) for hepat-ic vein reconstruction. Methods The retrospective analysis was made on the clinical data of 11 recipi-ents who underwent the operation in A-A LDLT including the hepatic vein reconstructed in right liver lobe without MHV from June 2007 to January 2008. The key techniques included reconstructing out-flow of graft on shaping the tips of vena cava and right hepatic veins, cadaveric vein allografts stored in 4℃ UW solution within 7d being used for significant-sized hepatic vein reconstruction such as tributa-ries of the middle hepatic vein from V5, V8 and right inferior hepatic vein. Results 10 cases success-fully underwent reconstruction of outflow of graft on shaping the tips of vena cava and right hepatic veins and the outflow reconstruction ratio of V5, V8 and right inferior hepatic vein was 81. 8% (9/11), 7 one-vein reconstruction, 1 two-vein reconstruction and 1 three-vein reconstruction. 1 recipient died of renal failure and pulmonary infection 14 days after operation without venous outflow obstruc-tion. Doppler ultrasonography showed no thrombosis and the blood flowed smoothly in the right he-patic vein of other 8 recipients during the 9th to 15th mouth of follow-up. The cumulative patency rates of these 8 survivals for interposition vein grafts were 100% (11/11), 72. 7 %(8/11), 54. 5%(6/11) and 36. 5%(4/11) in 1, 3, 6 and 9 mouths, respectively. The regeneration of paramedian sectors was equivalent. Conclusion Shaping the tips of vena cava and right hepatic veins and using cadaveric vein allografts in adult-to-adult right lobe living donor liver transplantation for hepatic vein reconstruc-tion are both safe,simple and effective methods.This approach can be recommended.
ABSTRACT
Objective To investigate technical skills on outflow reconstruction in right lobe graft adult-adult living donor liver transplantation for avoiding of venous congestion. Methods The clinical data of 21 donors and recipients who underwent right lobe living donor liver transplantation were analyzed retrospectively. Donor's standard liver volume was between 1150. 1 and 1629. 8 cm3,graft weight was between 585 and 920 g, the ratio of graft volume to recipient's estimated standard liver volume (GV/ESLV) was between 43 % and 67 %, graft-recipient weight ratio (GRWR) was between 0. 82 % and 1.59 %, the ratio of remnant liver volume to donor's standard liver volume(RLV/SLV) was between 32 % and 55 %, all graft macrosteatosis was less than 10 %. For graftwith middle hepatic vein (MHV), a triangle large orifice was made by joining MHV to right hepatic vein (RHV), then anastomosed to recipient' s enlarged orifice of RHV. For graft without MHV, if tributary of MHV＞5 mm, autologous or allogenic blood vessel was used as interposition graft to connect to IVC, and if no large MHV tributary, graft RHV was anastomosed to IVC directly. Graft's right portal vein was anastomosed to main trunk of recipient's portal vein, graft's right hepatic artery to recipient's hepatic artery, and graft's right hepatic duct to recipient's right hepatic duct. Results Among the 21 right lobe grafts, 4 right lobe grafts had MHV, 17 right lobe grafts had no MHV.Autologous greater saphenous veins were adopted in 2 cases, cryopreserved iliac arteries were adopted in 5 cases, and RHV was anastomosed directly to IVC in 10 cases. Outflow was all patent in 7 cases having reconstruction of MHV tributaries one month after operation. One-year survival rate was 75 %, 85. 7 % and 70 % respectively in MHV group, MHV tributaries reconstructed group and RHV directly anastomosed to IVC group with the difference being not significance among these three groups (P＞0. 05). Biliary complications occurred in 7 cases during the follow-up period. One case developed small-for-size syndrome, which was cured by splenic artery embolization. No severe complication occurred in donors. All donors returned to normal life during a follow-up period of 6 to 31 months. Conclusion If outflow tract was reconstructed properly, right lobe graft without MHV has equivalent clinical outcomes to right lobe graft with MHV. Using of autologous or allogenic blood vessel as interposition vessel graft for right lobe graft without MHV is an effective modality to prevent hepatic congestion and secure functional graft volume to meet recipients metabolic demand.
ABSTRACT
Reconstruction of the middle hepatic vein (MHV) tributaries, in modified right lobe grafts, appears to be effective for solving the congestion problem of the right paramedian sector (segment V, VIII). Various methods have been proposed to maintain efficient graft outflow for right lobe grafts without the middle MHV by centers with a high volume of procedures. Since December 2005, we adopted the bench procedure for reconstruction of a modified right lobe graft into the shape of an extended right lobe graft with a venous pouch to form a common trunk between the MHV (or newly reconstructed MVH) and right hepatic vein (RHV) using a cryoperserved aortic patch or bovine pericardium. Before December 2005, the graft RHV and MVH were anastomosed to the recipients' RHV and MHV/left hepatic vein. In this study, we compared the results of these two different methods (23 recipients of the direct and separate anastomosis, group A; 40 recipients of formation of a common outflow trunk, group B). The two groups were comparable in terms of preoperative parameters. Compared with group A, the middle hepatic vein patency length in group B was much better (p = 0.000). The necessity of metallic stenting due to early occlusion of the hepatic vein was significantly decreased in Group B (Group A; 5/21 vs. Group B; 2/40, p = 0.042). However, 1-year patient and graft survival was not different between the two groups (p = 1.000). Our procedure for constructing a modified right lobe graft into an anatomical figure with the extension of the right lobe graft and reconstruction of a wider outflow tract might provide an effective functioning liver mass and help to improve the outcomes in these patients.
Subject(s)
Humans , Estrogens, Conjugated (USP) , Graft Survival , Hepatic Veins , Liver Transplantation , Liver , Living Donors , Pericardium , Stents , TransplantsABSTRACT
Between February 1997 and December 2003, 580 adult-to- adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (309), chronic hepatitis C (18), hepatocellular carcinoma (144), alcoholic cirrhosis (20), Wilson's disease (4), autoimmune hepatitis (4), hepatic tuberculosis (1), cholangiocarcinoma (2), cryptogenic cirrhosis (5), secondary biliary cirrhosis (7), primary biliary cirrhosis (2), fulminant hepatic failure (18), primary sclerosing cholangitis (2), vanishing bile duct syndrome (1) and re-transplantation (4). Of 580 A-A LDLTs, 119 were of high medical urgency, 96 were for acute on chronic liver failure, 18 were for acute and subacute hepatic failure, 1 was for Wilson's disease, and 4 were for re-transplantation. Recipient age ranged from 20 to 69 years. The age of the donors ranged from 16 to 63 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 307 modified right lobes (MRL), 85 left lobes, 44 left lobe plus caudate lobes, 41 right lobes, 93 dual grafts, 5 extended right lobes, 4 posterior segments, and 1 extended left lateral segment. In the MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and seventeen of 93 were emergency cases. As a right-sided graft, 47 received left lobes; 31 received a extended left lateral segment or a lateral segment; 13 received a right lobe with or without the reconstruction of middle hepatic vein tributaries; and 2 received a posterior segment. Graft volume ranged from 26.5% to 83% of the standard liver volume of the recipients. There were 46 (8.0%) one year mortalities among the 576 patients after 580 A-A LDLTs. Of the 119 patients who received emergency transplants, 108 (90.8%) survived. These encouraging results justify the expansion of A-A LDLT to adjust to increasing demands, even in urgent situations. We have aimed establish the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome the small-for-size graft syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.
Subject(s)
Adolescent , Adult , Humans , Middle Aged , Korea , Liver Transplantation/methods , Living Donors , Retrospective Studies , Survival AnalysisABSTRACT
Agenesis of the right lobe of the liver is an extremely rare anomaly of the liver, and few cases are reported in the literature. Most of the patients with this anomaly are accompanied by additional anormalies such as retrohepatic or suprahepatic gallbladder and other biliary tract diseases, including cholelithiasis, carcinoma of the gallbladder and portal hypertension. The diagnosis of this rare anatomical variant was established by ultrasonography and computed tomography. The radiological findings, clinical presentation, and differential diagnosis are reviewed.
Subject(s)
Humans , Biliary Tract Diseases , Cholelithiasis , Diagnosis , Diagnosis, Differential , Gallbladder , Hypertension, Portal , Liver , UltrasonographyABSTRACT
PURPOSE: A left lobe graft from a small donor will not meet the metabolic demands of a larger recipient in adult-to-adult living donor liver transplantation (LDLT). One solution to this problem is to use a right lobe graft. However, the necessity of the middle hepatic vein (MHV) drainage from the anterior segment of a right lobe graft was not yet clearly described in the literatures. METHODS: From July 1997 to February 1998, five right lobe grafts without having a MHV drainage were implanted in 5 recipients with 2 HBV-cirrhosis, 2 fulminant hepatic failure and 1 secondary biliary cirrhosis. The graft weight ranged from 650 gm to 1000 gm, and their volume ranged from 48% to 83% of the ideal liver mass of the recipients. RESULTS: Two grafts showed severe congestion of the anterior segment immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction in each patient postoperatively. Eventually, one patient died of sepsis on posttransplant 20th day demonstrating progressive hepatic dysfunction. CONCLUSION: A right lobe graft without having MHV drainage might result in severe congestion of the anterior segment, which was able to lead to the patient's death in an extreme situation. Preservation of the anterior segment venous drainage in the right lobe graft is possible by two harvesting method: an extended right lobe (ERL) graft in which MHV is included in the graft and a modified right lobe (MRL) graft in which venous tributaries of the anterior sement were reconstructed via interposition vein grafts into the recipient's hepatic venous system. Theoretically, in a view point of donor safety, a MRL graft is more advantageous than an ERL graft because MHV is left in the donor liver. Here, we report our experiences of 27 MRL grafts in adult-to-adult LDLTs.