Transplantation bench surgery of the abdominal organs

Liver bench surgery: carefully dissect the donor inferior vena cava, especially in the suprahepatic region, where the adventitia is firmly adherent to the surrounding diaphragm, and on the posterior side to avoid uncontrollable posterior bleeding during implantation. Recognize hepatic artery variations (Michel\u2019s classification) when examining the superior mesenteric artery. Dissect the hepatic artery from the aortic patch to the level of bifurcation of the gastroduodenal artery, cleaning off the celiac plexus and fibrofatty tissue enveloping the vessels. Do not ligate the small collaterals too near to the vascular ostia, especially in atheromasic arteries. Kidney bench surgery: carefully remove the perinephric fat without skeletonizing the ureters; avoid extensive opening and massive cleaning of perinephric fat in kidneys from older donors. Mark and subtend both the ureters with light mosquito forceps to avoid their accidental shortening and injury. Cut the left renal vein along the left margin of the vena cava. Choose the right renal vein elongation technique that is most appropriate according to the shape of the vein. Pay special attention to the inferior polar arteries, which often originate far from the main renal artery, from the inferior abdominal aorta, or from the iliac axis. Pancreas bench surgery: manipulate the pancreas parenchyma very carefully to minimize edema, injuries, and bleeding, all factors which increase the risk of acute pancreatitis of the graft

Residual right portal branch flow after first-step ALPPS: Artifact or homeostatic response?

Background/Aims: Mutual interactions between portal vein and hepatic artery can be documented during hepatobiliary surgery. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a recently introduced surgical technique which can also represent a unique living human model to investigate intrahepatic blood circulation. We report three consecutive cases in which a residual right portal branch flow was clearly detectable after first-step ALPPS, and try to further investigate this unexpected finding with intraoperative clamping tests. Methodology: Every patient was evaluated with CT scan 7 days after first-step ALPPS and Intraoperative Doppler Ultrasonography (IOUS) at both steps of the procedure. Results: In every patient, CT scan and second-step IOUS demonstrated a clear hepatopetal flow distally to the divided right portal branch. The flow was present after right biliary duct clamping and stopped after right total hilar clamping as well as after right hepatic artery occlusion. Conclusions: Neither cross-portal circulation between the two hemilivers nor trans-sinusoidal backflow from the hepatic veins can explain these findings, which are rather consistent with a refilling of the occluded portal branch through the opening of intrahepatic arterioportal shunts (APS). APS could represent the simplest homeostatic mechanism that regulate intrahepatic blood flow

Massive Haematochezia due to Splenic Artery Bleeding into the Colon: Unusual Manifestation of Advanced Pancreatic Cancer

We describe a case of an uncommon early pancreatic cancer presentation in a patient in his 60s who had haemorrhagic shock from extensive haematochezia and required blood transfusions as well as surveillance in an intensive care unit. A splenic artery pseudoaneurysm that had been effectively embolized by angiography was seen to be actively bleeding into the colon lumen on a computerized tomography (CT) scan along with a necrotic mass of the pancreatic tail. A pancreatic mucinous adenocarcinoma was diagnosed by a transgastric biopsy. A pancreatico-colic fistula was discovered by CT scan after a colic contrast enema. A transabdominal drainage of the necrotic collection and targeted antibiotic treatment had been performed with a satisfying patient outcome. In order to assess a potential secondary surgical resection, systemic chemotherapy was planned. In conclusion, haematochezia with hemodynamic instability originated from a splenic artery pseudoaneurysm fistulising into the colon (arterio-colic fistula) and sepsis originating from a tumoral pancreatic abscess fistulising into the colon (tumoral pancreatico-colic fistula)