Impact of left hepatic vein classification on hepatic vein reconstruction and prognosis after pediatric living-donor liver transplantation using left lateral liver segments / 中华肝胆外科杂志

Objective:To study the impact of donor left hepatic vein classification and the reconstruction methods on hepatic venous outflow obstruction (HVOO) after pediatric living-donor liver transplantation using left lateral liver segments.Methods:A retrospective study was performed on the clinical data of 653 children recipients who underwent living-donor liver transplantation with left lateral liver segments from January 2014 to December 2020 at Tianjin First Central Hospital. There were 309 males and 344 females, aged 7.0 (6.0, 10.0) months, with an age range of 3-121 months. Based on the left hepatic vein on preoperative donor enhancement CT as well as the intraoperative reconstruction methods, the recipients were divided into 3 groups: type Ⅰ group ( n=514), anastomosis using a single opening was performed directly between the donor and the recipient; type Ⅱ group ( n=118), angioplasty was performed on two adjacent recipient venous orifices before anastomosis, and type Ⅲ group ( n=21), an interposition vessel was anastomosed to two widely spaced openings or the two veins were anastomosed separately. The preoperative general status of the patient, postoperative HVOO incidences, and graft and recipient survival rates were compared among the three groups. The patients were followed up by outpatient reexamination or telephone. Results:Graft to recipient weight ratio in the type Ⅲ group was smaller than that in the type Ⅰ group and the type Ⅱ group ( P<0.05). For all the 653 patients, the incidence of postoperative HVOO was 4.59% (30/653), with the incidences of HVOO in the 3 groups of patients were 4.1% for the type Ⅰ group (21/514), 5.1% for the type Ⅱ group (6/118), and 14.3% for the type Ⅲ group (3/21), respectively. There was no significant difference among the groups ( P>0.05). The recipient cumulative survival rates at 1 and 3 years after surgery in the type I group were 97.8% and 97.0%, and the corresponding rates in the type Ⅱ group were 96.5% and 94.2%, and in the type Ⅲ group were 94.1% and 86.9%, respectively. There was a significant difference between the type Ⅰ and type Ⅲ groups ( P=0.048). The graft cumulative survival rates at 1 and 3 years in the type Ⅰ group were 97.4% and 96.9%, and the corresponding rates in the type Ⅱ group were 94.9% and 92.5%, and in the type Ⅲ group were 94.1% and 86.9%, respectively. The difference in the postoperative graft cumulative survival rates between the type Ⅰ group and type Ⅱ group was significant ( P=0.044). Conclusions:The anatomy of the left hepatic vein supplying the left lateral liver segment was highly variable, and the majority of the variations could be reconstructed. A reasonable reconstructive method could reduce the incidence of postoperative HVOO and improved the outcomes of the graft.

Outflow reconstruction in right lobe graft adult-adult living donor liver transplantation: a report of 21 cases / 中华器官移植杂志

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.

Reconstruction of the Middle Hepatic Vein in Right Lobe Living Donor Liver Transplantation: The Experience at Ajou University Hospital

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.

Outflow Reconstruction using Cryopreserved Aortic Patch in Right Lobe Living Donor Liver Transplantation

METHODS: Living donor liver transplantation (LDLT) using a right lobe graft has been widely used to compensate for the cadaveric organ shortage. Successful reconstruction of the middle hepatic vein (MHV) is required to provide an adequate functional volume in LDLT with using the right lobe. We describe herein a new technique using a cryo-preserved aortic patch for outflow reconstruction of the right lobe graft with or without MHV. METHODS: From November 2005 through March 2006, 20 adult patients who received a right lobe graft (n=10) or an extended right lobe graft (n=10) for LDLT were included. During the bench procedure of the right lobe graft, we reconstructed the new MHV with using cryopreserved veins just like the MHV of the extended right lobe graft, and we then made a venous pouch to form a common trunk between the MHV (or new MHV) and the RHV of the right lobe graft with using a cryopreserved aortic patch. During graft implantation, anastomosis of an outflow tract was made between the venous pouch of the graft and the common trunk of recipient's RHV-MHV-LHV. One week following the transplantation, measurement of the pressure gradient between the MHV and IVC was done, as well as performing regular follow-up 3D-CT scans and liver function tests. RESULTS: The mean pressure gradient between the reconstructed MHV and the recipient's IVC was 2.3+/-1.2mmHg, and in all cases, the serial liver function tests showed gradual improvement as the days progressed post-operatively. There was no evidence of hepatic venous congestion of the graft and/or obstruction of the reconstructed MHVs according to the serial postoperative follow-up images of the Doppler US and MD-CT. CONCLUSION: We suggest that reconstructing the outflow tract with a cryopreserved aortic patch is a good alternative technique for preventing anterior segment congestion in LDLT with using a right lobe graft with or without MHV.

Technical Evolution in Living Donor Liver Transplantation / 대한이식학회지

During the last 15 years, much progress has been made in the technical aspect of living donor liver transplantation (LDLT). In fact, LDLT has contributed to understanding of the detailed anatomy of the liver and performing more precise hepatectomy. Recently, more complex cases which were relative contraindications for liver transplantation such as Budd-Chiari syndrome and portal vein thrombosis have been challenged in LDLT area. This review focuses on donor hepatectomy and hanging maneuver in the donor, and hilar dissection and venous reconstruction in the recipient. In addition, recent technical advances in complex cases were also introduced. Biliary complication has been the most common, intractable complication to disturb the quality of life of the long-term survivors. Reduction of its complication rate is a pending question of the transplant surgeon. In LDLT, donor safety is paramount. Technical innovations should be balanced with any unexpected harm to the donors.