Portal and arterial reperfusion during liver transplant: A comparison between the simultaneous and sequential techniques
Gustavo Ferreira1,2,3, Andre L. Watanabe1, Natalia C. Trevizoli1, Fernando M. Jorge1, Ana V. Figueira1, Carolina F. Couto1.
1Liver Transplantation Division, Instituto de Cardiologia do Distrito Federal, Brasilia, Brazil; 2Department of Sciences Applied to Surgery and Ophtalmology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; 3Surgery Division, Hospital Metropolitano Doutor Celio de Castro, Belo Horizonte, Brazil
Introduction: A critical step in the liver transplantation procedure is the reperfusion of the liver graft after being connected to the circulatory system of the receptor. There are two possible techniques for the reperfusion: it may occur immediately after the portal vein anastomosis has been completed, with revascularization of the graft with blood from the portal system first, and then with arterial blood after the completion of the arterial anastomosis, in what is usually referred to as the sequential technique; or the reperfusion can occur only after both portal and arterial anastomosis have been completed, in what is referred to as the simultaneous technique. There is significant debate in the literature on whether one of these techniques offer advantages over the other, with studies pointing to a reduction of biliary complications with use of the simultaneous technique, while other studies failed to show any improvement. We present an analysis of 100 liver transplants performed using each technique, consisting in the largest single-center study on this subject performed so far.
Materials and Methods: We analyzed 200 liver transplants performed on a tertiary Brazilian hospital during the 2014 to 2017 period, with 100 transplants using the sequential technique being performed immediately before 100 transplants using the simultaneous technique. All procedures used whole liver grafts procured from cadaveric donors. Statistical analysis was performed using Yates corrected Pearson's chi-square for qualitative parameters and t test for quantitative parameters.
Results: There was a significant difference in blood products transfusion between the two groups, with a mean of 1.11 units in the sequential perfusion (SeP) group, as opposed to 0.59 in the simultaneous perfusion (SiP) group (p=0.02). There was also a statistically significant difference in total procedure time, with an average of 398 minutes in the SeP group vs. 368 in the SiP group (p=0.0001); total ischemia time, with an average of 421 minutes in the SeP group vs. 472 minutes in the SiP group (p=0.002); and receptor age, with a mean of 51.1 years in the SeP group vs. 54.3 in the SiP group (p=0.03). No difference was found in mortality or biliary stenosis between the two groups.
Discussion: While there was an increase in total ischemia time associated with SiP, due to the additional time in completing the arterial anastomosis before reperfusion, there was no negative impact in patient mortality or morbidity. Reduction in total operative time and intraoperative transfusion may be associated with quicker hemostasis and liver function in SiP.
Conclusion: The use of the simultaneous reperfusion technique in liver transplant, while having no direct impact on patient mortality, may decrease total procedure time and need for intraoperative blood transfusion. The expected increase in total ischemia time with the use of the simultaneous technique does not appear to increase patient morbidity or mortality.
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