Impact of Right Lobe with Middle Hepatic Vein Graft in Living-Donor Liver Transplantation

Technical improvements in adult-to-adult living-donor liver transplantation (LDLT) have led to the use of right-lobe grafts to overcome the problems encountered with 'small-for-size grafts'. The major controversy remains that the venous drainage from anterior segment substantially depends on tributaries of the middle hepatic vein (MHV), and deprivation of such tributaries may critically influence the postoperative graft function. Right-lobe grafts with MHV could resolve the potential problem of congestion in anterior segment. From December 2000 to January 2004, we performed 217 right-lobe LDLTs for adult patients. Of these, 40 patients received a right lobe with MHV graft (18.4%). The overall cumulative 3-year graft survival rate of a right lobe with (n = 40) and without MHV (n = 177) was 86.2% and 74.8% (p = NS). The proximal side of the MHV and the drainage vein of segment IV to the MHV (the left medial superior vein) were preserved in 24 patients. All of them needed venous interposition graft for anastomosis. All patients had a patent right hepatic vein (RHV) and MHV anastomosis during the follow-up period. We adopted the right lobe with MHV graft in 40 LDLT cases. Vein graft is essential for safe MHV anastomosis in cases which preserve proximal side of the MHV.     

Donor graft outflow venoplasty in living donor liver transplantation.

Hepatic venous outflow reconstruction is a key to successful living donor liver transplantation (LDLT) because its obstruction leads to graft dysfunction and eventual loss. Inclusion or reconstruction of most draining veins is ideal to ensure graft venous drainage and avoids acute congestion in the donor graft. We developed donor graft hepatic venoplasty techniques for multiple hepatic veins that can be used in either right- or left-lobe liver transplantation. In left-lobe grafts, venoplasty consisting of the left hepatic vein and adjacent veins such as the left superior vein, middle hepatic vein, or segment 3 vein is performed to create a single, wide orifice without compromising outflow for anastomosis with the recipient's vena cava. In right lobe graft where a right hepatic vein (RHV) is adjacent with a significantly-sized segment 8 vein, accessory RHV, and/or inferior RHV, venoplasty of the RHV with the accessory RHV, inferior RHV, and/or segment 8 vein is performed to create a single orifice for single outflow reconstruction with the recipient's RHV or vena cava. Of 35 venoplasties, 2 developed hepatic venous stenoses which were promptly managed with percutaneous interventional radiologic procedures. No graft was lost due to hepatic venous stenosis. In conclusion, these techniques avoid interposition grafts, are easily performed at the back table, simplify graft-to-recipient cava anastomosis, and avoid venous outflow narrowing.     

Usefulness of three-dimensional computed tomography in a living-donor extended right lobe liver transplantation

Although living-donor liver transplantation (LDLT) of right lobe graft is becoming a popular option for adult patients, management of venous outflow remains controversial. We report a successful extended-right lobe liver transplantation using a recipient's left portal vein as a graft from the middle hepatic vein. Preoperative three-dimensional computed tomography (3D-CT) of the donor revealed a small right hepatic vein (RHV) without inferior RHV and a large middle hepatic vein (MHV) draining segments 5 and 8. During the donor operation, right lobe graft was harvested with the MHV, preserving the drainage vein from segment 4. The donor recovered uneventfully except for mild transient hyperbilirubinemia. The recipient's condition rapidly improved, and was discharged from hospital 49 days postoperation. A 3D-CT after LDLT also clearly revealed successful vascular anastomosis. Preoperative and postoperative 3D-CT was useful for determination of the vascular anatomy and the decision about the line of transection in the donor hepatectomy, as well as for evaluation of the vascular anastomoses after transplantation. (Liver Transpl 2002;8:1076-1079.)     

Intrahepatic venous collaterals formation following outflow block in adult-to-adult living donor liver transplantation

A right liver graft without the middle hepatic vein (MHV) trunk is now commonly used in adult-to-adult living donor liver transplantation (LDLT), but it is unclear whether hepatic venous collaterals would develop in clinical patient just after occlusion of hepatic veins. Between January 2005 and October 2006, 56 consecutive adult patients underwent LDLT using right lobe grafts without MHV in our center. Twenty-four patients (42.9%) had MHV tributaries reconstruction. Vascular flow in the graft and interposition vein graft patency was checked by Doppler ultrasonography (US) daily during hospital stay and monthly follow-up after discharge for 2 y. Among 24 cases with MHV reconstruction, interpositional graft block occurred in one case within 7 d after transplantation. A reversed flow in MHV tributaries and collaterals between MHV and right hepatic vein (RHV) was detected by Doppler US. Vessel graft blocks were found in 10 of 22 cases of MHV tributaries reconstruction between 4 to 9 mo after transplantation. Collaterals formation between MHV and RHV developed in 4 of 10 cases of vessel graft block, and their graft function did not deteriorate. In conclusion, nearly half of the patients needed reconstruction of MHV tributaries when a right lobe graft without MHV was used in LDLT. The authors thought that the reconstruction of MHV tributaries should be established when the congested area was dominant by the clamping test or when the diameter of the tributaries was >5 mm. It was found that there may not be any problems if reconstructed vessel graft obstruction was found 3 mo after transplantation, as intrahepatic venous collaterals between MHV and RHV could develop.     

Safety and necessity of including the middle hepatic vein in the right lobe graft in adult-to-adult live donor liver transplantation

OBJECTIVE: To evaluate the safety of donors who have donated the middle hepatic vein in right lobe live donor liver transplantation (LDLT) and to determine whether such inclusion is necessary for optimum graft function. SUMMARY BACKGROUND DATA: The necessity to include the middle hepatic vein in a right lobe graft in adult-to-adult LDLT is controversial. Inclusion of the middle hepatic vein in the graft provides uniform hepatic venous drainage but may lead to congestion of segment IV in the donor. METHODS: From 1996 to 2002, 93 right-lobe LDLTs were performed. All right-lobe grafts except 1 contained the middle hepatic vein. In the donor operation, attention was paid to preserve the segment IV hepatic artery and to avoid prolonged rotation of the right lobe. The middle hepatic vein was transected proximal to a major segment IVb hepatic vein whereas possible to preserve the venous drainage in the liver remnant. RESULTS: There was no donor death. Two donors had intraoperative complications (accidental left hepatic vein occlusion and portal vein thrombosis) and were well after immediate rectification. Twenty-four donors (26%) had postoperative complications, mostly minor wound infection. The postoperative international normalized ratio on day 1 was better in the donors with preservation of segment IVb hepatic vein than those without the preservation, but, in all donors, the liver function was largely normal by postoperative day 7. The first recipient had severe graft congestion as the middle hepatic vein was not reconstructed before reperfusion. In 7 other recipients, the middle hepatic vein was found occluded intraoperatively owing to technical errors. The postoperative hepatic and renal function of the recipients with an occluded or absent middle hepatic vein was worse than those with a patent middle hepatic vein. The hospital mortality rate was also higher in those with an occluded middle hepatic vein (3/9 vs. 5/84, P = 0.028). CONCLUSIONS: Inclusion of the middle hepatic vein in right-lobe LDLT is safe and is essential for optimum graft function and patient survival.     

Branching Patterns and Drainage Territories of the Middle Hepatic Vein in Computer-Simulated Right Living-Donor Hepatectomies

Full right hepatic grafts are most frequently used for adult-to-adult living donor liver transplantation (LDLT). One of the major problems is venous drainage of segments 5 and 8. Thus, this study was designed to provide information on venous drainage of right liver lobes for operation-planning. Fifty-six CT data sets from routine clinical imaging were evaluated retrospectively using a liver operation-planning system. We defined and analyzed venous drainage segments and the impact of anatomic variations of the middle hepatic vein (MHV) on venous outflow from segments 5 and 8. MHV variations led to significant shifts of segment 5 drainage between the middle and right hepatic vein. In cases with the most frequent MHV branching pattern (n = 33), a virtual hepatectomy closely right to the MHV intersected drainage vessels that provided drainage for 30% of the potential graft, not taking into account potential veno-venous shunts. In individuals with inferior MHV branches that extend far into segments 5 and 6 (n = 10), the overall graft volume at risk of impaired venous drainage increased by 5% (p < 0.001). If this is confirmed in clinical trials and correlated with intraoperative findings, the use of liver operation-planning systems would be beneficial to improve overall outcome after right lobe LDLT.     

Outflow reconstruction in right hepatic live donor liver transplantation

BACKGROUND: Inconstant venous anatomy increases the risk of outflow complications in right hepatic live donor liver transplantation (RH-LDT), but no consensus has emerged guiding optimal reconstruction for venous outflow. METHODS: We retrospectively analyzed surgical venous reconstruction using a flexible approach to anterior accessory veins in 48 RH-LDTs performed between April, 1998 and July, 2002. RESULTS: Actuarial recipient graft and patient survival was 79% and 85%, respectively. Single hepatic venous anastomosis was performed in 74% of the patients. Twelve patients underwent reconstruction of 20 accessory veins, including 7 posterior segment veins and 13 anterior segment veins. Anterior vein reconstruction techniques included end-to-end anastomosis to the middle hepatic vein, interposition conduit, venoplasty, or a combination of techniques. Documented complications related to the venous anastomosis occurred in only 1 patient (2%), with no patient having a documented venous thrombosis of either the main RHV or a reconstructed accessory vein. There were no differences in outcome based on single versus multiple venous reconstruction. Anteromedial congestion was noted in 3 patients in the absence of anatomic venous anastomotic complication, but the clinical significance of this finding is unclear. CONCLUSIONS: Despite variations in segmental venous drainage and a propensity for anteromedial congestion in right hepatic grafts, RH-LDT can be performed without outflow obstruction with close attention to a wide RHV anastomosis. In addition, anterior accessory vein reconstruction can be reserved for grafts of marginal size or quality where early postoperative venous congestion may impair early graft function. Routine extended hepatectomy incorporating the MHV with the graft is unnecessary.     

活体右半肝移植的流出道重建21例

目的 探讨活体右半肝移植中的流出道重建技术,预防肝静脉淤血的发生.方法 回顾分析21例成人活体右半肝移植的临床资料.供者标准肝体积为1150.1～1629.8 cm3,供肝重量为585～920 g,与受者标准肝体积比为43%～67%,与受者重量比为0.82%～1.59%,供者残肝体积百分比为32%～55%,供肝大泡脂肪变性均＜10%.对于含肝中静脉的供肝,将肝中静脉和肝右静脉开口修整成尽可能大的三角形开口,供肝植入时,与受者肝右静脉扩大的三角形开口行端侧吻合.不含肝中静脉的供肝,如存在粗大的肝中静脉属支(直径超过5 mm),则用自体或异体血管搭桥(无粗大的肝中静脉属支者采用肝右静脉)与受者腔静脉直接吻合.供肝门静脉右支直接与受者门静脉主干吻合,供肝动脉与受者肝动脉行端端吻合,供肝右肝管与受者肝管行端端吻合.结果 21例供肝中,4例含肝中静脉,17例不含肝中静脉,其中有2例采用自体大隐静脉搭桥,5例采用冷冻的异体髂动脉搭桥,10例采用肝右静脉直接与受者腔静脉吻合.术后1个月,重建肝中静脉属支的7例受者流出道均通畅.含肝中静脉者、不含肝中静脉的血管搭桥者及不含肝中静脉且未使用血管搭桥者术后1年存活率分别为75%、85.7%和70%,三者间比较,差异均无统计学意义(P＞0.05).术后受者发生胆道并发症7例;发生小肝综合征1例,经脾动脉栓塞治疗后痊愈.术后供者未发生严重并发症,随访6～31个月,均恢复正常工作生活,无一例死亡.结论 含肝中静脉与不含肝中静脉的右半供肝植入后均可取得良好的临床效果.如果右半供肝不含肝中静脉,采用自体或异体血管重建肝中静脉属支是预防肝淤血和保证移植肝功能的有效方法.     

Simplified one‐orifice venoplasty for middle hepatic vein reconstruction in adult living donor liver transplantation using right lobe grafts

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). The aim of this report was to introduce evolution of our MHV reconstruction technique and excellent outcomes of simplified one‐orifice venoplasty. We compared clinical outcomes with two reconstruction techniques through retrospective review of 95 recipients who underwent LDLT using right lobe grafts at our institution from January 2008 to April 2012; group 1 received separate outflow reconstruction and group 2 received new one‐orifice technique. The early patency rates of MHV in group 2 were higher than those in group 1; 98.4% vs. 88.2% on postoperative day 7 (p = 0.054) and 96.7% vs. 82.4% on postoperative day 14, respectively (p = 0.023). Right hepatic vein (RHV) stenosis developed in three cases in group 1, but no RHV stenosis developed because we adopted one‐orifice technique (p = 0.043). The levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in group 2 were significantly lower than those in group 1 during the early post‐transplant period. In conclusion, our simplified one‐orifice venoplasty technique could secure venous outflow and improve graft function during right lobe LDLT.     

Living donor right hepatectomy with inclusion of the middle hepatic vein: outcome in 200 donors

Venous congestion of segments V and VIII of the graft is observed frequently in right-lobe living donor liver transplants (LDLT) without middle hepatic vein (MHV) drainage. It can cause graft dysfunction and failure. Inclusion of the MHV in the right lobe graft allows optimal venous drainage but can pose adverse effects for the donor. From May 2005 to April 2011, we performed 202 right-lobe LDLTs using grafts that all (except two) contained the MHV. The mean duration of donor surgery was 558 ± 132 minutes (median 540, range 332-1100), and estimated blood loss 441 ± 309 mL (median 350, range 35-3200). No donor was admitted to the intensive care unit postoperatively. The mean hospital stay was 8.7 ± 2.1 days (median 8, range 6-22). Postoperatively, 39 donors (19.5%) experienced Clavien grade I and II complications, mostly minor wound infections or massive ascites necessitating diuretic therapy. Seven (3.5%) donors displayed Clavien grade III complications, including five bile leakages requiring endoscopic retrograde biliary drainage and two abdominal wound dehiscences requiring repair under general anesthesia. There was no donor death. In conclusion, inclusion of the MHV in a right-lobe LDLT was safe for most donors.     

成人间不含肝中静脉右半肝活体肝移植静脉流出道重建技术的改进

目的 探讨不含肝中静脉(middle hepatic vein,MHV)的成人间右半肝活体肝移植(living donor liver transplantation,LDLT)静脉流出道重建技术的改进方法.方法 通过长征医院器官移植研究所2007年6月至2008年1月完成的11例次成人间不含肝中静脉的右半肝活体肝移植病例的回顾性分析,对成人间不含肝中静脉的右半肝活体肝移植静脉流出道重建技术的改进进行总结.主要技术改进包括:采用供肝右肝静脉、受体腔静脉联合扩大成形吻合技术重建流出道;采用在4℃UW液中保存7 d以内的尸体同种异体静脉移植血管重建供肝Ⅴ、Ⅷ段肝静脉粗大属支以及右肝下静脉.结果 11例次成人间不含肝中静脉右半肝活体肝移植中10例次采用了右肝静脉、腔静脉联合扩大成形吻合技术;利用尸体同种异体静脉移植血管架桥重建肝Ⅴ、Ⅷ段肝静脉以及右肝下静脉流出道的例数占同期实施的成人间活体肝移植总例数的81.8%(9/11),其中架桥重建1支肝静脉7例,架桥重建2支肝静脉1例,架桥重建3支肝静脉1例,11例病人中,1例病人术后14 d死于肾功能衰竭和肺部感染,超声检查血流通畅,未发现架桥静脉血栓,余10例病人术后随访9～15个月,右肝静脉均通畅,未发现静脉血栓,架桥肝静脉累计通畅率为:1个月100%(11/11)、3个月72.7%(8/11)、6个月54.5%(6/11)和9个月36.5%(4/11),移植肝脏再生均衡,右肝端面Ⅴ或Ⅷ段无明显充血和肝萎缩坏死,肝功能正常.超声检查未发现血栓,血流通畅,移植肝脏再生均衡,右肝端面Ⅴ或Ⅷ段无明显充血和肝萎缩坏死,肝功能正常.结论 采用右肝静脉、腔静脉联合扩大成形吻合技术和在4℃UW液中保存7 d以内的尸体同种异体静脉移植血管重建肝Ⅴ、Ⅷ段肝静脉粗大属支以及右肝下静脉是一种简单、安全和有效的成人间不含肝中静脉右半肝活体肝移植肝静脉重建方法.     

Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion

Background/Purpose. A left lobe graft from a small donor will not usually fulfill the metabolic demands of a larger recipient in adult-to-adult living-donor liver transplantation (LDLT). One solution to this problem is to use a right lobe graft. However, the necessity of middle hepatic vein (MHV) outflow drainage from the anterior segment (AS) of a right lobe graft has not yet been clearly described in the literature. From July 1997 to February 1998, five right lobe grafts without MHV outflow drainage were implanted in five adult recipients. The graft weights ranged from 650 to 1000 g, and their volumes ranged from 48% to 83% of the ideal liver mass of the recipients. Two grafts showed severe congestion of the AS immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction in each patient postoperatively. Eventually, one patient died of sepsis, on posttransplant day 20, demonstrating progressive hepatic dysfunction. Methods. Subsequently, since March 1998, 176 of 208 adult recipients who received a right lobe graft, while demonstrating sizable (greater than 5-mm diameter) MHV tributaries underwent reconstruction of MHV outflow drainage, using the recipient's own autogenous or cryopreserved cadaveric interposition vein grafts. Results. In 170 of the 176 recipients, AS congestion was not demonstrated on enhanced liver computerized tomography (CT) or Doppler ultrasonography (USG) postoperatively, and the patency rate of interposition vein grafts was 96.6% on day 30 posttransplant. Conclusions. A right lobe graft without MHV outflow drainage might result in severe congestion of the AS, which could lead to the patient's death in an extreme situation. Preservation of MHV outflow drainage in a right lobe graft is possible by two harvesting methods: an extended right lobe (ERL) graft, in which the MHV trunk is included in the graft, and a modified right lobe (MRL) graft, in which venous tributaries of the MHV are reconstructed via interposition vein grafts into the recipient's hepatic venous system. From the viewpoint of donor safety, the ERL graft increases the donor's risk more than the MRL graft, because the remaining left liver lobe of the donor does not possess an MHV. Here, we introduce our experiences of MRL grafts in adult-to-adult LDLTs. Received: July 18, 2002 / Accepted: July 25, 2002 RID="*" ID="*" Offprint requests to: S.G. Lee     

Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation: observation by Doppler ultrasonography

In living related liver transplantation, the right lobe has come to be used as a graft to meet the metabolic demands of adult or adolescent recipients. In harvesting the right lobe as a graft, however, there is controversy as to whether or not the middle hepatic vein (MHV) should be included and reconstructed. Anatomical intrahepatic anastomosis between the right hepatic vein (RHV) and MHV is considered to exist, but the formation process of this functional anastomosis has not been demonstrated by Doppler ultrasonography (US). In our case, a right lobe including a right branch of the MHV was used as a graft. In implanting, the RHV was anastomosed to the inferior vena cava and the right branch of the MHV was ligated. Using Doppler US, we checked the blood flow in the hepatic vein after transplantation. Within 3 days of surgery, no flow was detected in the right branch of the MHV. A flow around the right branch of the MHV was observed at postoperative day 6. At postoperative day 9, a reverse flow was detected in which the right branch of the MHV drained into the RHV via the anastomosis between them. Based on our results, it appears that a functional intrahepatic anastomosis between hepatic veins formed gradually within 10 days of ligation of an afferent branch, during which time the graft function did not deteriorate.     

Beneficial effects of 3-dimensional visualization on hepatic vein reconstruction in living donor liver transplantation using right lobe graft.

BACKGROUND: Recently, virtual operation planning and navigation systems have been introduced in the field of neurosurgery and orthopedic surgery. We report here the beneficial effects of 3-dimensional (3D) visualization on hepatic venous reconstruction in living donor liver transplantation (LDLT) using right lobe graft. METHODS: 3D-image reconstruction of the liver was rendered with 3-mm slices of helical computed tomography (CT) data using zioM900 (Zio Software Inc., Tokyo, Japan). To understand the anatomy of the donor's vessels and design an operation plan, a picture of the vessels in and around the liver was reconstructed. RESULTS: The 3D image demonstrated two short hepatic veins next to the inferior right hepatic vein (IRHV) as well as a large IRHV. The 3D image showed a more precise diameter of the right hepatic vein (RHV) and the IRHV and a more accurate distance between the two hepatic veins than did images measured by 2-dimensional CT. This preoperative information allowed the donor surgeon to dissect the inferior vena cava (IVC) and hepatic veins with reduced blood loss because of reduced risk of injury to the blood vessels. The 3D image revealed that both the RHV and the IRHV branched off at the same angle from the cylindrical IVC. Preoperative planning based on this information secured smooth anastomosis. CONCLUSIONS: 3D visualization is useful for hepatic venous reconstruction of the recipient as well as for donor surgery in LDLT using right lobe graft.     

Significant role of middle hepatic vein in remnant liver regeneration of right-lobe living donors

For adult patients with end-stage liver disease, living-donor liver transplantation (LDLT) of right-lobe grafts with or without the middle hepatic vein (MHV) has been increasingly used in recent years. We investigated the role of the MHV in donor remnant liver regeneration after right-lobe LDLT, which has not been described in previous studies. A total of eight living donors were included in this study of right-lobe LDLT. Four donors underwent right lobectomy (without MHV), and the remaining four underwent extended right lobectomy (with MHV). Regeneration of the donor remnant liver was assessed by volumetric computed tomography studies before and 90 days after LDLT. Comparison between the right-lobe and extended right-lobe donors did not show a clear-cut difference in the net increase of remnant liver volume at 3 months. However, the mean volume increase of the medial segment at the 90th postoperative day was 7% in the extended right-lobe donors and 61% in the right-lobe donors, showing a lower value in the remnant livers without MHV. The MHV plays a specific role in remnant liver regeneration of right-lobe living donors. We expect that this knowledge will contribute to securing a margin of safety in right-lobe LDLT.     

Experience with recipient's superficial femoral vein as conduit for middle hepatic vein reconstruction in a right-lobe living donor liver transplant procedure

Middle hepatic vein reconstruction during the right-lobe living donor liver transplant procedure has been recognized to be a significant factor. We initially reconstructed only a single middle hepatic vein orifice draining into segment 8. In cases where the right-lobe liver graft has several major middle hepatic vein tributaries, including veins draining segment 5 that are remote from the right hepatic vein orifice, a long and thick interposition conduit is necessary for reconstruction. Among 11 consecutive adult patients who received a right-lobe liver graft without a middle hepatic vein at our institution, 8 underwent reconstruction of all major middle hepatic vein tributaries using a vein graft from the recipient's superficial femoral vein. The remaining 3 patients had no major middle hepatic vein tributaries. Posttransplant-computed tomography imagings showed increased liver mass with a patent superficial femoral vein graft in 8 patients. In the absence of a venous system from a deceased donor, a recipient superficial femoral vein offers an excellent size match to maintain the venous outflow of middle hepatic vein tributaries. Reconstruction with recipient superficial femoral vein plays an important role in maximizing liver function and minimizing morbidity in the early posttransplant period.     

Three-dimensional computed tomography analysis of venous collaterals between the middle hepatic vein tributaries and the right hepatic vein in the donor remnant right lobe: Report of a case

We report how three-dimensional computed tomography (3D-CT) showed the development of obvious venous collaterals between the middle hepatic vein (MHV) tributaries and the right hepatic vein (RHV) in the remnant right lobe of a donor liver. The donor was a healthy 34-year-old man who donated the left lobe of his liver with the MHV. The 3D-CT calculated that the total drainage of the MHV tributaries was 413 ml, corresponding to 59% of the total remnant liver. The congestion calculated by 3D-CT decreased from 286 ml on postoperative day (POD) 7 to 28 ml on POD 35, corresponding to 36% and 3% of the total remnant liver, respectively. The donor was discharged from hospital with almost normal liver function, and 3D-CT analysis on POD 35 detected obvious venous collaterals between the MHV tributaries and the RHV. These findings suggest that reconstruction of the MHV tributaries in the donor remnant right lobe may not be necessary.     

Reconstruction of the middle hepatic vein tributaries using the recipient's recanalized umbilical vein in right-lobe living-donor liver transplantation

BACKGROUND: Right-lobe grafts without the middle hepatic vein (MHV) can cause severe congestion of the anterior segment in living-donor liver transplantation (LDLT). However, the indications and methods for reconstructing the MHV or its tributaries remain controversial. METHODS: We herein describe two cases of the successful use of the recipient's recanalized umbilical vein as an interposition graft to drain the major MHV tributaries in right-lobe LDLTs. RESULTS: After surgery, both right-lobe grafts are currently functioning well and all of the reconstructed venous tributaries have been confirmed to be patent by doppler ultrasonography. The histopathological features of the recanalized umbilical vein showed an intact intima with thickened media. CONCLUSIONS: The use of the recipient's recanalized umbilical vein is a good option for reconstructing MHV tributaries in right-lobe LDLTs.     

Cryopreserved aortic quilt plasty for one-step reconstruction of multiple hepatic venous drainage in right lobe living donor liver transplantation

Hepatic venous outflow should be maintained for the success of living right lobe liver transplantation. In cases when the right hepatic vein is not the dominant venous drainage, the anterior branch of the middle hepatic vein and the accessory hepatic veins should be adequately drained to preserve graft function. One-step reconstruction of the hepatic veins became a preferred technique to create separate outflow for each of the graft's veins. In this report, we have described a quilt plasty technique for 1-step reconstruction of living donor hepatic veins using cadaveric cryopreserved aorta and iliac vein grafts.     

Outflow reconstruction in recipients of right liver graft from living donors

Right-lobe transplantation is now a commonly used procedure in living donor liver transplantation (LDLT) to adult recipients. However, the risk for outflow obstruction is still an issue in LDLT. The right hepatic vein (RHV) was anastomosed end to end to the graft hepatic vein without unfavorable tension on the anastomosis. The anterior wall of the recipient hepatic vein was incised longitudinally, and a V-shaped vein graft was patched to form a wide and long orifice. This new hepatic venoplasty was used in 14 adult patients who received right liver grafts and gave good results without stenosis of the hepatic venous anastomosis or other complications. Our new technique may be useful in recipients of a right liver graft when the recipient or graft RHV is not long enough. (Liver Transpl 2002;8:167-168.)