Objectives: Hepatic vein outflow obstruction in liver transplantation can lead to graft or patient loss.
We used an intrauterine balloon to overcome this complication in 13 liver transplant recipients. Here, we report the results of these cases; our report, as far as we know, involves the highest number of patients on this issue.
Materials and Methods: Positional hepatic vein outflow obstruction was diagnosed in 13 of 651 liver trans-plant recipients between January 2014 and December 2016. The grafts were repositioned by intrauterine balloon placed to the right subdiap-hragmatic area. Data of donors, recipients, and grafts and posto-perative courses were analyzed.
Results: Of the 13 patients, 9 were men, with age range of patients of 22 to 70 years. The amount of saline used to inflate the balloon was variable (200-450 cm3), and hepatic vein outflow obstruction was relieved after balloon implantation in all patients. There were no balloon-related complications. Removal was done at bedside, without any additional sedation or any additional skin incision on days 2 to 15. Doppler ultrasonography scans were performed before and after the balloon removal. There were no vascular complications after removal.
Conclusions: Intrauterine balloon can be safely and efficiently used for hepatic vein outflow obstruction during liver transplant when needed.
Key words : Hypotension, Intrauterine balloon, Liver graft dysfunction
Hepatic vein outflow obstruction (HVOO), which can lead to serious acute Budd-Chiari syndrome in liver transplant, may cause graft dysfunction and eventually graft loss if not diagnosed and then corrected immediately. It is generally related to surgical technical problems and/or a recipient graft size mismatch and has been classified as early or late. Early HVOO is suspected intraoperatively by the surgeon during inspection and palpitation of the implanted graft after reperfusion and then diagnosed by intraoperative Doppler ultrasonography. Early HVOO could also be suspected and diagnosed by the presence of immediate and repeated hypotension attacks in the transplant recipient, which are resistant to fluid resuscitation by the anesthesia team.1
Other reasons related to the development of HVOO include the wrong hepatic vein anastomosis technique, kinking of the hepatic veins, compression of the vena cava by an oversized graft, and the malpo-sitioning of the liver in the recipient’s abdomen.2,3 Clinical characteristics can mimic acute Budd-Chiari syndrome, and this vascular complication has been shown to account for about 3% of liver transplants.4,5 The incidence increases to 5% to 13% in living-donor liver transplant and in pediatric split liver transplants due to greater range of mobility of smaller grafts in the recipient’s abdomen.6,7 This form of obstruction should be recognized early and promptly relieved to prevent complications and subsequent graft failure.
Here, we describe our new technique and also report our series of use of an intrauterine balloon (Bakri balloon, Cook Medical Inc., Bloomington, IN, USA), which we have been placing in our HVOO-complicated liver transplant cases effectively and safely for over 4 years. This balloon has been widely used by gynecologists for many years to overcome the lethal complication of postpartum intrauterine bleeding. As far as we know, our study is the first to describe use of this intrauterine balloon in liver transplant recipients and includes the largest number of cases with this device in the literature to overcome HVOO complications.
Materials and Methods
The intrauterine balloon was used in 13 adult patients who developed HVOO while undergoing liver transplant at the Inonu University Liver Transplant Institute between January 2014 and December 2016. During implantation of the liver graft, if there was a sign of HVOO during intra-operative ultrasonography or any suspicion of HVOO by the surgeon, the balloon was placed under the graft. Ultrasonography was performed again, and the volume of saline needed to inflate the balloon was decided according to the optimal positioning and the sufficient hepatic venous drainage of the congested graft.
The balloon is a sterile packed balloon designed to be able to be used in any surgical field. It has a length of 54 cm, a diameter of 24F, and a maximum saline inflation volume of 500 cm3. Because it has been widely used by obstetricians for postpartum hemorrhage, we confidently and safely used this device during liver transplant surgery in the operating room when needed. The balloon also functions as a drain and allows monitoring of blood loss and other secretions through its large lumen. It can be easily removed any time at bedside or an outpatient clinic after the deflation of the saline-filled part without causing any pain or difficulty in patients. If there is any drainage through the lumen and the surgeon decides to keep the drain in place, after deflation, it can be left in place to be used as an abdominal drain. There is no need for any sedation, local anesthesia, or any additional incision during deflation and/or removal of this balloon.
Between January 2014 and December 2016, our center performed 651 liver transplant procedures, with 19% being pediatric patients. Of 651 cases, 533 (81.9%) were living-donor liver transplants, with 89 (16.7 %) conducted in patients younger than 18 years old and 444 (83.3%) conducted in patients over 18 years old. Regarding deceased-donor liver trans-plants (n = 118; 18.1%), 35 (29.7%) were conducted in patients younger than 18 years old and 83 (70.3%) were conducted in patients over 18 years old.
We clinically suspected and diagnosed HVOO with Doppler ultrasonography after portal reper-fusion intraoperatively in 12 patients. The grafts seemed to be congested. A balloon was then placed, and inflow and outflow of the transplanted grafts were measured again by Doppler ultrasonography after congestion was revealed. Another Doppler ultra-sonography examination was done at the end of the operation before closure of the abdomen to confirm the patency of all of the vascular anastomoses. After patients were taken to the intensive care unit, routine Doppler ultrasonography examinations were perfor-med daily by radiologists.
At postoperative day 1, HVOO was seen in 1 patient in the intensive care unit while routine control Doppler ultrasonography was being performed. This patient was a 23-year-old man who was hospitalized because of a toxic fulminant hepatitis due to isoniazid use for tuberculosis. He had an emergency deceased-donor liver transplant. The body mass index of the patient was 25.3 kg/m2, and the graft implanted was 1000 g. After diagnosis of HVOO, the patient was immediately taken back to surgery and the balloon was placed to correct the HVOO, with intraoperative Doppler ultrasonography used for confirmation. Control ultrasonography in the intensive care unit was normal.
Of 651 liver transplant procedures, HVOO was diagnosed in 13 patients (1.99%). The most common cause of cirrhosis for transplant was viral hepatitis B and/or C (53.8%). Two patients had fulminant hepatitis: 1 due to mushroom poisoning and the other due to isoniazid intoxication. Of 13 patients with HVOO, 12 were considered early (diagnosed intraoperatively) and 1 was considered late (diag-nosed 1 day after the initial operation). Nine patients (69.2%) were men, and the median age was 46.0 years (range, 22-70 y), with no pediatric patients requiring balloon placement. Median weight was 72 kg (range, 50-90 kg) in males and 69.75 kg (range, 67-75 kg) in females. Median body mass index was 23.75 kg/m2 (range, 18-29.4 kg/m2) in males and 27.05 kg/m2 (range, 24.1-29 kg/m2) in females. The median weight of deceased grafts was 1197 g (range, 900-1485 g), and median weight of living grafts was 725.62 g (range, 560-900 g). Of these 13 patients, 5 (38.4%) received deceased-donor liver transplants and 8 (61.6%) received right lobe living-donor liver transplants.
The median amount of saline used to inflate the balloon was 292 cm3 (range, 200-450 cm3), and the median days of stay of the balloon was 11.5 days (range, 2-15 d) (Figure 1 and Figure 2). One of the patients had a primary dysfunction immediately after living-donor liver transplant and required retransplant with a deceased liver under emergency conditions. The balloon was removed at the second operation. The reason for dysfunction was due to a portal vein thrombosis problem that caused graft loss. The time of the drain removal and follow-up of this patient was excluded from our study due to early removal of the balloon.
No venous outflow obstruction was detected by Doppler ultrasonography during placement and after the removal of the balloon. No technique-related complications due to balloon placement or removal were recorded.
The incidence of HVOO is reported to be around 2% in the literature.8 Of 651 liver transplant procedures, we observed HVOO in 13 patients (1.99%). All cases of HVOO were managed successfully by our new intrauterine balloon placement technique. Early recognition and immediate correction of this complication are essential to save the graft and thus the patient.1 The presence of deep and wide recipient abdominal space with a relatively small-sized graft and/or compression of venous anastomosis by a large graft after abdominal wall closure or placement of the graft in its position are the most common causes of HVOO when technical errors in anastomotic suturing are excluded.3 The diagnosis should be made during the operation or as early as possible to prevent dysfunction of the transplanted liver graft. If it is diagnosed during the operation, HVOO can be prevented or treated by different approaches and even by revising the vena cava anastomosis. Because we are in favor of surgery, in our 1 patient who had HVOO diagnosed at postoperative day 1 (detected in the intensive care unit), we immediately took the patient to surgery to correct the venous obstruction. The HVOO in this case was successfully treated by placement of the balloon. Although there are other recommendations, including use of intravascular techniques and stenting, we believe that those interventions may cause much more severe complications in the early postoperative period at the anastomotic site.6 Incidence is reported to be higher with pediatric liver transplant (6.6%)7; however, we did not have any HVOO complications in any of our 124 pediatric patients (19%).
There are several techniques and modifications of these techniques described to prevent and overcome HVOO complications in the literature. The fixation of the round ligament to the abdominal wall to prevent the rotation of the graft, placement of the loops of bowel under the graft, and imbrication of the diaphragm to keep the graft in position are pre-viously described techniques used without any addi-tional devices to deal with this complication.2,8-10
Other techniques that have used additional ectopic devices to overcome this complication have been described. Malassagne and associates and Steinbrück and associates used the Sengstaken-Blakemore tube in their cases.11,12 Wang and as-sociates used tissue expanders and Foley catheters in their 7 patients.13 Donataccio and associates3 used surgical glove expanders in their report of 9 patients, Inomata and associates9 used tissue expanders for liver stabilization, and Wahab and associates14 used a Foley catheter in their patient to prevent and/or overcome HVOO. Here, we used an intrauterine balloon, which has been previously used by gynecologists for postpartum hemorrhage. This device both revealed the HVOO and drained the area (via the lumen of the balloon) without any need for additional drain placements.
Median removal time of the drain (1 patient was excluded due to emergency retransplant because of primary liver dysfunction and early balloon removal) was 11.5 days (range, 2-15 d). In some patients, the balloon was gradually deflated over time; others had balloon directly deflated and removed at once or left in place to function as a drain. There were no complications recorded during or after the removal of these balloons.
As far as we know, our series of 13 cases is the largest number of cases in the literature in which this device has been used to overcome HVOO com-plications successfully. This intrauterine balloon is still being used in our liver transplant center without any complications if HVOO is detected.
In conclusion, the intrauterine balloon can be safely and efficiently used in HVOO cases when there is no sign of suturing-related technical errors at the cava anastomosis site.
DOI : 10.6002/ect.2018.0125
From Inonu University Liver Transplantation Instıtute, Malatya, Turkey
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare.
Corresponding author: Hüseyin Kerem Tolan, Inonu University Liver Transplantation Institute, Malatya, Turkey
Phone: +90 532 598 1810
Figure 1. Computerized Tomography of a Placed Balloon
Figure 2. Intraoperative Image of a Placed Balloon