Allograft Inflow - Concern in Liver Transplantation after Intraoperative Radiotherapy for Cholangiocarcinoma
C. Lupascu, J. LerutClinical case, no. 6, 2014
Patients who underwent local radiotherapy during surgicalresection for cholangiocarcinoma are at increased risk ofdeveloping extensive thrombosis of splanchnic vessels andsecondary biliary cirrhosis on the remnant liver; hence theybecome liver transplantation candidates. In these recipients,adequate graft inflow cannot be provided by conventional livertransplantation procedures. Cavoportal hemitransposition andrenoportal anastomosis alongside complex arterial reconstructionsare innovative techniques to restore allograft inflow insuch cases. We report two cases of hilar cholangiocarcinomaformerly treated by left hepatectomy-Whipple en Bloc andintraoperative radiotherapy that developed late secondarybiliary cirrhosis requiring liver transplantation. During transplantprocedure, concern has been raised by the previousradiation-induced peritoneal injury with extended splanchnicthrombosis. Cavoportal hemitransposition and renoportalanastomosis were performed respectively, beside arterial graftreconstructions. Patients survived 57 and 18 days respectively, after transplantation. Cavoportal hemitransposition and renoportalanastomosis likewise complex arterial reconstructions arelife-saving procedures to secure allograft inflow in the setting ofradiation-induced extensive splanchnic thrombosis. However,this condition adversely affects patient and graft survival owingto high rates of early vascular and biliary complications, sothese patients are not good liver transplantation candidates.Abbreviations: CCA - cholangiocarcinoma, CPHT - cavoportalhemitransposition, Ct - celiac trunk, DSVT - diffusesplanchnic vein thrombosis, HA - hepatic artery, IVC - inferiorvena cava, LRV - left renal vein, LT - liver transplantation, PV- portal vein, PVT - portal vein thrombosis, RISC -radiation induced sclerosing cholangitis, RISC-BC - radiationinduced sclerosing with biliary cirrhosis, RPA - renoportalanastomosis
