Portal vein reconstruction in pediatric liver transplantation from living donors.

OBJECTIVE: The authors analyze the surgical pattern and the underlying rationale for the use of different types of portal vein reconstruction in 110 pediatric patients who underwent partial liver transplantation from living parental donors. SUMMARY BACKGROUND DATA: In partial liver transplantation, standard end-to-end portal vein anastomosis is often difficult because of either size mismatch between the graft and the recipient portal vein or impaired vein quality of the recipient. Alternative surgical anastomosis techniques are necessary. METHODS: In 110 patients age 3 months to 17 years, four different types of portal vein reconstruction were performed. The portal vein of the liver graft was anastomosed end to end (type I); to the branch patch of the left and right portal vein of the recipient (type II); to the confluence of the recipient superior mesenteric vein and the splenic vein (type III); and to a vein graft interposed between the confluence and the liver graft (type IV). Reconstruction patterns were evaluated by their frequency of use among different age groups of recipients, postoperative portal vein blood flow, and postoperative complication rate. RESULTS: The portal vein of the liver graft was anastomosed by reconstruction type I in 32%, II in 24%, III in 14%, and IV 29% of the cases. In children <1 year of age, type I could be performed in only 17% of the cases, whereas 37% received type IV reconstruction. Postoperative Doppler ultrasound (mL/min/100 g liver) showed significantly (p < 0.05) lower portal blood flow after type II (76.6 +/- 8.4) versus type I (110 +/- 14.3), type III (88 +/- 18), and type IV (105 +/- 19.5). Portal vein thrombosis occurred in two cases after type II and in one case after type IV anastomosis. Portal stenosis was encountered in one case after type I reconstruction. Pathologic changes of the recipient native portal vein were found in 27 of 35 investigated cases. CONCLUSION: In living related partial liver transplantation, portal vein anastomosis to the confluence with or without the use of vein grafts is the optimal alternative to end-to-end reconstruction, especially in small children.     

Could the use of interposition grafts for arterial reconstruction be avoided by more caudate graft placement in living donor liver transplantation?

One of the major challenges in living donor liver transplantation (LDLT) is short and small vessels (particularly the hepatic artery), particularly in segmental liver grafts from living donors. In the present study we report an alternative surgical technique that avoids interpositional vessel grafts or tension on the connection by anastomizing the allograft hepatic vein to the recipient inferior vena cava in a more caudate location. From March 2000 to January 2003, 28 patients (11 women/17 men) underwent 28 LDLT. Until June 2001, the preferred technique for hepatic vein anastomosis was end-to-end anastomosis between the allograft hepatic vein and the recipient hepatic vein (HV-HV) (n = 10). Thereafter an end-to-side anastomosis was performed between allograft hepatic vein and recipient inferior vena cava (HV-IVC) (n = 18). The level of venotomy on the recipient vena cava was decided according to the pre-anastomotic placement of the allograft in the recipient hepatectomy site with sufficient width to have an hepatic artery anastomosis without tension or need for an interposition graft during hepatic artery and portal vein anastomoses. Except the right lobe allograft with anterior and posterior portal branches, all portal and hepatic artery anastomoses were constructed without an interposition graft or tension in the HV-IVC group. Only one hepatic artery thrombosis developed in the HV-IVC group. As a result, this technique may avoid both hepatic artery thrombosis and the use of interposition grafts in living donor liver transplantation.     

Vascular closure staples for portal vein reconstruction in living-donor liver transplantation

BACKGROUND: Portal vein reconstruction is still a crucial problem in living-donor liver transplantation. Vascular closure staples (VCS) have been applied for small peripheral and large vessels because of the technical ease with which they can be employed. We describe here our experience with portal vein reconstruction in living donor-liver transplantation and compare VCS with conventional sutures in portal vein reconstruction. METHODS: The anastomosis between the donor portal vein and recipient portal vein or the right external iliac vein graft was created using either VCS or conventional sutures. RESULTS: The stenotic ratios were .51 +/- .15 and .79 +/- .25 for the conventional sutures and VCS, respectively. The stenotic ratio was significantly lower in VCS compared with conventional sutures. CONCLUSIONS: VCS compared with conventional sutures has the advantage of low risk of anastomotic stenosis.     

Portal vein reconstruction in adult living donor liver transplantation using cryopreserved vein grafts.

No data are available for the management of venous jump or interposition conduits for portal vein (PV) reconstruction in adult living donor liver transplantation (LDLT). The feasibility of using cryopreserved vein grafts as PV conduits was examined. Cryopreserved vein (n = 23) was used as a patch, interposition, or jump graft. The patency results were compared with those of anastomosis without vein patch (n = 217) or those with vein autografts (n = 10). The 5-yr primary and secondary patency rates of the cryopreserved vein grafts were 58% and 79%, respectively. In conclusion, our data indicate that the use of cryopreserved vein grafts should be limited as conduits in PV reconstruction in adult LDLT.     

Isolated adult intestinal transplantation using portal venous drainage

There is some evidence that portal venous drainage may offer immunologic and metabolic advantages in small bowel transplantation. Isolated small bowel transplantation was performed in 14 adult patients. In all cases, the donor pancreas was transplanted into another patient. During the donor procedure, the superior mesenteric artery and vein were separated below the division of the inferior pancreaticoduodenal artery and below the veins of the pancreatic head. An arterial interposition graft was used in all cases. One donor mesenteric artery was reconstructed in 6 patients; two arteries in 5 patients; and three arteries in 3 patients. Proximal arteries of the graft were ligated and the upper part of the jejunum resected. In 10 patients, a direct anastomosis was performed in an end-to side fashion between donor superior mesenteric vein (SMV) and recipient inferior mesenteric vein (IMV). In 2 patients, a branch of the superior mesenteric vein was used and 2 patients required a venous interposition graft to confluence using the donor iliac vein. Patency of the venous anastomosis was documented by magnetic resonance imaging (MRI) angiography after 6 months. No vascular complications have been observed to date. Portal venous drainage is technically feasible in most cases. An anastomosis to the recipient IMV offers the advantage of being direct despite the short donor vein segment. Furthermore, donor and recipient vessels are well matched for size. Using microsurgical techniques, vascular complications may be avoided.     

A selective approach to preexisting portal vein thrombosis in patients undergoing liver transplantation.

Splanchnic venous inflow is considered mandatory to ensure graft survival after liver transplantation. Over a 68-month period, we performed 570 liver transplants in 495 patients. Portal vein thrombosis was present in 16 patients. At transplant, the extent of the occlusion included portal vein alone (n = 4), portal including confluence of the splenic and superior mesenteric veins (n = 8), portal, splenic, and distal superior mesenteric veins (n = 2), and the entire portal vein, splenic vein, and superior mesenteric vein (n = 2). The operative approach included thrombectomy alone (n = 5), anastomosis at the confluence of the splenic and superior mesenteric splenic veins (n = 8), and extra-anatomic venous reconstruction (n = 3). The mean operative blood loss was 22 +/- 22 units, and the mean operative time was 9.7 +/- 4.8 hours. The 1-year actuarial survival rate was 81%, with a mean follow-up of 12.5 months. In summary, with a selective approach and the use of innovative forms of splanchnic venous inflow, portal vein thrombosis is no longer a contraindication to liver transplantation.     

Portal vein reconstruction in pediatric living donor liver transplantation for patients younger than 1 year with biliary atresia

Background/PurposeInfants with biliary atresia undergoing living donor liver transplantation (LDLT) are at increased risk of portal vein (PV) complications because of their smaller vascular caliber and sclerosis because of previous Kasai portoenterostomy and recurrent cholangitis.MethodOf 154 children who underwent transplantation between November 2005 and January 2011, 34 with biliary atresia received a transplant while younger than 1 year. Six patients underwent PV reconstruction with an interposition vein graft, and the others underwent the branch patch technique. The clinical characteristics of those who underwent the interposition reconstruction or the branch patch technique were compared, and the PV complications were assessed.ResultsPortal vein complications occurred in 5 patients (14.7%) in the branch patch group. There were 4 patient deaths, and all of them had received branch patch reconstruction. The branch patch reconstruction cases with a sclerotic small caliber (<4 mm) determined by using preoperative ultrasonography showed a significantly high mortality rate (44.4%). All patients with interposition vein graft reconstruction are still alive with excellent graft function without anticoagulation therapy.ConclusionThe interposition vein graft appears to be a feasible option with better graft survival and less PV complications when performing LDLT for biliary atresia in infants younger than 1.     

The impact of portal vein reconstruction on portal vein complications after pediatric living-donor liver transplantation with left lobe graft

BackgroundThis study aimed to determine whether the different methods of portal vein reconstruction have an impact on the occurrence of portal vein complications after pediatric living-donor liver transplantation with left lobe graft.MethodsA total of 567 recipients were eligible for enrollment in this study and were divided into the following 2 groups according to the type of portal vein reconstruction: group 1 underwent anastomosis of the left and right bifurcations of the recipient portal vein to the donor portal vein (type 1), whereas group 2 underwent anastomosis of the bevel formed by the main trunk and right branch of the recipient portal vein to the donor portal vein (type 2). Postoperative portal vein complications and recipient and graft survival rates were compared between the 2 groups before and after propensity score matching.ResultsPortal vein complications occurred in 53 (9.3%) patients, including 46 recipients with portal vein stenosis and 7 with portal vein thrombosis. After propensity score matching, the incidence of portal vein stenosis in group 2 was lower than that in group 1 (P = .035). The first diagnosis time of portal vein stenosis in group 2 was later than that in group 1 (P = .033), and the incidence of early portal vein stenosis was lower than that in group 1 (P = .009). There were no statistically significant differences in the incidence of portal vein thrombosis and recipient and graft survival rates between the 2 groups.ConclusionsType 2 portal vein reconstruction appears to be a viable technique in pediatric living-donor liver transplantation with left lobe graft that can effectively reduce the incidence of portal vein stenosis.     

Portal venoplasty for recipients in living-related liver transplantation.

BACKGROUND: In living-related liver transplantation (LRLT) in small children, standard end-to-end portal vein (PV) anastomosis is usually difficult because of a inadequate total PV length, or because of a size mismatch between the graft and the recipient PV. In this report, we present our new portal venoplasty technique for the recipient PV. METHODS: After dissection of the recipient PV, the wall between the right and left branches of the PV is severed longitudinally as in the branch patch technique. The anterior and posterior edges of both branches are joined using running sutures, to form a longer and wider PV for anastomosis. RESULTS: This new portal venoplasty technique was used in 7 of 28 child cases, and gave good results without thrombosis or other complications. CONCLUSIONS: Our new portal venoplasty technique is useful in LRLT in small children when the recipient or graft PV is not long enough.     

Surgical techniques for vascular reconstruction of the portal vein and hepatic artery in living-donor liver transplantation]

To decide how to reconstruct the portal vein and hepatic artery for liver transplantation, anatomical variation, diameter, length, and injury to vessels during surgery, and the quality of recipient vessels should be considered. Hence, it is of key importance for donor and recipient surgeries to prepare adequate vessels for reconstruction. For reconstruction of the portal vein, anastomosis with as large a diameter as possible is required to obtain good portal flow. In cases with sclerosing stenosis and old thrombus, technical innovations such as branch-patch, a conduit using a vein graft, and venoplasty using a venous patch are necessary. For reconstruction of the hepatic artery, selecting a satisfactory recipient artery, overcoming size mismatch, and gentle handling of a recipient artery with pathological changes are important. Arteries smaller than 3 mm are anastomosed with a surgical microscope using the united suture technique. The fishmouth technique or funnelization technique can be used for anastomoses with a significant size mismatch, and an autoarterial graft is used when arteries do not reach each other.     

Living-related liver transplantation with renoportal anastomosis for a patient with large spontaneous splenorenal collateral

BACKGROUND: A large splenorenal collateral must be interrupted during liver transplantation to secure adequate portal perfusion. However, this process increases the complexity of the operative procedure and may cause hazardous bleeding. Recently, renoportal anastomosis in portal reconstruction was reported in cadaveric liver transplantation for patients with surgically created splenorenal shunts. We used this technique in a living-related liver transplantation. METHODS: A 29-year-old female with a large spontaneous splenorenal collateral and a portal venous thrombus underwent a living-related liver transplantation. At surgery, the left renal vein was divided and the distal stump was anastomosed to the portal vein of the graft without interrupting collaterals. RESULTS: Adequate portal venous blood flow was maintained throughout the postoperative course. The patient was discharged 9 weeks after transplantation and remains well. CONCLUSION: The renoportal anastomosis could be used for portal reconstruction in living-related liver transplantation for patients with a large splenorenal collateral. It provides adequate portal perfusion without interrupting collateral circulation.     

Interpostion vein graft in living donor liver transplantation

In adult-to-adult living donor liver transplantation (LDLT), right lobe grafts without a middle hepatic vein can cause hepatic congestion and disturbance of venous drainage. To solve this problem, various types of interposition vein graft have been used. OBJECTIVES: We used various types of interposition vein grafts for drainage of the paramedian portion of the right lobe in living donor liver transplantation. METHODS: From June 1996 to June 2003, 37 of 176 patients (128 adults, 48 pediatric) who underwent LDLT received vein grafts for drainage of segments V, VIII, or the inferior portion of the right lobe. RESULTS: In 36 adult cases the reconstruction included the inferior mesenteric vein of the donor (n = 14); cadaveric iliac vein stored at cold (4 degrees C) temperature (n = 5); cryopreserved (-180 degrees C) cadaveric iliac vein (n = 10); cryopreserved cadaveric iliac artery (n = 1 case); donor ovarian vein (n = 1); recipient umbilical vein (n = 3); recipient saphenous vein (n = 1); recipient left portal vein (n = 1); recipient left hepatic vein (n = 1). In a pediatric case with malignant hemangioendothelioma that encased and compressed the inferior vena cava, we used an interposition vein graft to replace the inferior vena cava. CONCLUSION: Various types of interposition vein grafts can be used in living donor liver transplantation. Cryopreserved cadaveric iliac vein and artery are useful to solve these drainage problems.     

Interposition graft with polytetrafluoroethylene for mesenteric and portal vein reconstruction after pancreaticoduodenectomy

Background:

Portal vein–superior mesenteric vein resection is frequently required after surgical resection of tumours of the pancreas head. The ideal graft for portal vein reconstruction (PVR) remains undefined.

Methods:

Between May 2000 and July 2007, 28 patients had portal vein–superior mesenteric vein resection and PVR during pancreaticoduodenectomy. Their clinical reports were reviewed retrospectively with specific attention to the methods of PVR and outcomes.

Results:

Ten patients had PVR with primary anastomosis, seven had PVR with autologous vein, one had a polytetrafluoroethylene (PTFE) patch, one did not have PVR and nine had PVR with a PTFE interposition graft. There was no infection after PTFE grafting. Six patients had PVR thrombosis after surgery: four after primary anastomosis, one after interposition PTFE and one after vein repair.

Conclusion:

PTFE appeared to be an effective and safe option as an interposition graft for portomesenteric venous reconstruction after pancreaticoduodenectomy. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

The Use of Recipient Superficial Femoral Vein as a Venous Graft for Portal Vein Reconstruction in Right Lobe Living Donor Liver Transplantation

In living donor liver transplantation (LDLT), portal vein thrombosis (PVT) in the recipient is frequently regarded as a contraindication. To reconstruct the PV of a right-lobe liver graft (RLG) using an interposition or jump graft from the splenomesenteric junction, various vein grafts and technical modifications have been introduced. The internal jugular, external iliac, or great saphenous veins have been utilized in such reconstructive procedures. However, the superficial femoral vein (SFV) is preferable to the autologous vein grafts in terms of caliber, wall thickness, and length. We employed the recipient SFV to reconstruct PVT among 40 adult LDLT using RLG. Thirty-three were reconstructed by single end-to-end anastomosis with the right or left recipient PV. Three patients were transplanted with a RLG using 2 separated PVs reconstructed by double anastomoses with both the right and left PVs of the recipient. The remaining 4 patients required venous grafting for portal reconstruction. We used the recipient SFV as an interposition or jump graft from the splenomesenteric junction to the graft PV. There were 2 cases of anastomotic PV stenosis; 1 in portal reconstruction without a venous graft and the other with a SFV graft. Both were treated successfully by balloon angioplasty. The recipient SFV is an excellent size match for the PV reconstruction as a long interposition or jump conduit when the venous system from the deceased donor is not available. The indication for LDLT in patients with complete PVT should be carefully decided before transplantation in terms of portal reconstruction.     

Surgical procedures for management of right portal venous branching in right lobe living donor liver transplantation

OBJECTIVE: This study sought to describe the surgical management of right portal venous (PV) branches encountered among 104 cases of right lobe living donor liver transplantation (LDLT). METHODS: From January 2002 to September 2007, we performed 104 cases of right-lobe LDLT including 11-donors who had anomalous right portal venous branches (APVB). One recipient had PV sponginess hemangioma. The donor right PV branches were type I in 93 cases, type II (trifurcation) in nine cases, and type III in two cases. Except one narrow bridge of tissue excision, the PV branches were transected on the principal of donor priority: PV branches were excised approximately 2 to 3 mm from the confluence while leaving the donor's main portal vein and confluence intact. In type II APVB, donor PV branches were obtained with two separate openings in six cases; with two separate openings joined as a common orifice at the back table in two cases, with one common opening with a narrow bridge of tissue in one case. In type III APVB, the donor right anterior and posterior PV branches were obtained with separate openings. The donor right PV branches with one common opening in 92 cases of type I PV branches and a joined common orifice in three cases of type II APVB were anastomosed to the recipient's main portal vein or to right branching. As the unavailable recipient PV for sponginess hemangioma, one case of type I right PV branches was end-to-end anastomosed to one of the variceal lateral veins of about 1 cm diameter in a pediatric patient. The PV were reconstructed as double anastomoses in six type II APVB and in one type III APVB obtained with two separate PV openings. In the another type III APVB reconstruction, we successfully utilized a novel U-shaped vein graft interposition. RESULTS: The type II APVB donor receiving a narrow bridge of portal vein tissue excision developed portal vein thrombosis on the third postoperative day and underwent reexploration for thrombectomy. There were no vascular complications, such as portal vein thrombosis or stricture among other donors or all recipients. The velocity of blood flow in the U-graft was normal. The anastomosis between the type I donor right portal vein and recipient variceal lateral vein was unobstructed. CONCLUSION: Right PV branches should be excised on the principal of donor priority while leaving the donor's main portal vein and confluence intact. Single anastomoses was the fundamental procedure of right branch reconstruction. Double anastomoses could be used as the main management for type II and type III APVB reconstruction. U-graft interposition may be a potential procedure for type III APVB reconstruction. Single anastomoses between the donor right portal vein and the recipient variceal lateral vein may be performed when recipient portal vein is unavailable. These innovations for excision and reconstruction of right PV branches were feasible, safe, and had good outcomes.     

Combined portal vein and liver resection for biliary cancer]

Portal vein resection has become common in hepatobiliary resection for biliary cancer with curative intent. When cancer invasion of the portal vein is very limited, wedge resection followed by transverse closure is indicated. Longitudinal closure is contraindicated, as this procedure causes stenosis of the portal vein. In the case of right hepatectomy, segmental resection is feasible before liver transection. Reconstruction is completed with end-to-end anastomosis, in which an intraluminal technique is used for posterior anastomosis and an over-and-over suture for anterior anastomosis. More than 5-cm resection of the portal vein often requires reconstruction with an autovein graft. In the case of left hepatectomy, portal vein resection after liver transection is preferable. The resection and reconstruction method should be determined based on both the extent of cancer invasion of the right portal vein and the length of the right portal trunk. So far, we have aggressively carried out combined portal vein and liver resection in 106 patients with advanced biliary cancer (62 cholangiocarcinoma and 44 gallbladder carcinoma). Twenty-nine patients underwent wedge resections and 77 segmental resections (66 end-to-end anastomosis and 11 autovein grafting using an external iliac vein). In patients with hilar cholangiocarcinoma (n = 58), 3- and 5-year survival rates were 23% and 8%, respectively. Three patients survived for more than 5 years after resection. In contrast, the prognosis of patients with gallbladder cancer (n = 44) was dismal. All of the patients died within 3 years after surgery, although they survived statistically longer than unresected patients. These data suggest that portal vein resection has survival benefit for patients with cholangiocarcinoma. However, the indications for this procedure in gallbladder cancer should be reevaluated.     

Retransplantation of the liver in the rat

A successful technique of liver retransplantation in the rat is described. Heterotopic nonauxiliary liver engraftment of a whole liver using cuffed anastomoses is the primary transplant procedure. The graft is implanted in the right hypochondrium and is revascularized by a portal end-to-end anastomosis. Venous drainage is via an end-to-side anastomosis between the donor infrahepatic vena cava and recipient right renal vein. The graft suprahepatic vena cava is ligated. Biliary drainage is achieved by a double stent anastomosis of the biliary ducts. Total parenchymectomy of the recipient's liver is completed leaving intact the intrahepatic and suprahepatic vena cava. Retransplantation in the orthotopic position can thus be attempted, after removal of the first graft, by cuffed anastomoses between the donor and recipient portal veins, infrahepatic vena cava and a double stent anastomosis of the common bile ducts. Anastomosis between the donor and recipient suprahepatic vena cava is completed with a 7/0 Prolene running suture. In the first group of operations (n = 6), a three week survival rate of 50% after retransplantation was obtained. Using the technical lessons of these preliminary cases, 80% of the second group of operations (n = 5), were successful in the long term. Utilization of this new technique may allow further investigations in different fields of research dealing with liver surgery and transplantation. © 1993 Wiley-Liss Inc.     

Outcome of extra-anatomic vascular reconstruction in orthotopic liver transplantation

BACKGROUND: Portal venous and hepatic arterial reconstruction are critical to successful outcomes in orthotopic liver transplantation (OLT). With portal vein thrombosis or inadequate hepatic arterial inflow, extra-anatomic vascular reconstruction is required. However, the clinical outcomes following extra-anatomic vascular reconstruction are largely unknown. METHODS: To determine the outcomes associated with extra-anatomic vascular reconstruction, we performed a retrospective review of 205 OLT recipients transplanted between 1995 and 2000. RESULTS: Extra-anatomic portal venous inflow was based upon the recipient superior mesenteric vein using donor iliac vein graft in a retrogastric position (n = 12). Extra-anatomic arterial inflow was based on recipient infrarenal aorta using donor iliac artery graft through the transverse mesocolon (n = 25). OLT with routine anatomic vascular construction served as control (n = 168). Extra-anatomic vascular reconstruction was not associated with increased morbidity, mortality, operating room time, length of stay, or thrombosis. CONCLUSION: We conclude that extra-anatomic vascular conduits are associated with excellent long-term outcomes and provide acceptable alternatives for vascular reconstruction in OLT.     

Vascular anastomosis and two-stage reconstruction of the gut in a living-related small bowel transplant recipient: a case report

AIM: We sought to discuss vascular anastomosis and gut reconstruction in a living-related small bowel transplantation recipient. METHODS: Living-related small bowel transplantation was performed successfully on a boy with short gut syndrome in two stages. In the first stage, 120 cm, of his mother's ileum was implanted into the recipient with the artery and vein anastomosed to the recipient's sigmoid artery and inferior mesenteric vein, respectively. The two ends of the implanted intestine were constructed as stomas. In the second stage, reconstruction of the continuity of the digestive tract was performed at 188 days after the initial transplantation. The residual small bowel was transected and both ends were anastomosed to the proximal and distal end of the graft in end-to-side fashion. The stomas were closed 30 and 43 days later. RESULTS: Both procedures were successful. Postoperative cytomegalovirus infection and acute rejection occurred successively and were controlled. No leakage of the reconstructed gut or other complications developed after the second procedure. The recipient is alive at 15 months with 8 kg an increase in weight. He is caring for himself independently and has a half-liquid diet, sometimes supplied with auxiliary enteral nutrition. A d-xylose test increased from 4.25% to 25% after the small bowel transplantation. CONCLUSIONS: Vascular anastomoses should be performed according to the state of graft and the recipient. The portal route is the first choice when possible. A two-stage gut reconstruction could decrease the incidence of complications, and offer a useful method in living-related small bowel transplantation.     

Successful Treatment of a Patient With Diffuse Portosplenomesenteric Thrombosis Using a Pericholedochal Varix for Portal Flow Reconstruction During Deceased Donor Liver Transplantation: A Case Report

Portal vein thrombosis remains a challenging issue in liver transplantation. When thrombectomy is not feasible due to diffuse portosplenomesenteric thrombosis, other modalities are adapted such as the use of a jump graft or portal tributaries or even multivisceral transplantation. For patients with diffuse thrombosis of the splanchnic venous system, a large pericholedochal varix can be a useful vessel for providing splanchnic blood flow to the graft and for relieving portal hypertension. We report our experience of successfully treating a patient with diffuse portosplenomesenteric thrombosis using a pericholedochal varix for portal flow reconstruction during deceased donor liver transplantation and eventually preventing unnecessary multivisceral transplantation. A 56-year-old man diagnosed with liver cirrhosis due to hepatitis B underwent deceased donor liver transplantation due to refractory ascites. Preoperative imaging revealed diffuse portosplenomesenteric thrombosis with large amount of ascites. During the operation, dissection of the main portal vein was not possible due to the development of multiple large pericholedochal varices and cavernous change of the main portal vein. After outflow reconstruction, portal inflow was restored by anastomosing the graft portal vein to a large pericholedochal varix. Postoperatively, although abdominal computed tomography scan showed stenosis of portal vein anastomosis site, liver function tests improved, and Doppler sonogram revealed no flow disturbance. During follow-up, the patient repeatedly developed hydrothorax and ascites. In addition, stenosis of the portal vein anastomosis and thrombosis of the portomesenteric system still remained. The patient underwent transhepatic portal vein stent insertion. After portal vein stent insertion, hydrothorax and ascites improved and the extent of thrombosis of the portomesenteric system decreased without anticoagulation therapy. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins can be a source of useful inflow to restore portal flow and decrease the extent of thrombosis, thereby preventing unnecessary multivisceral transplantation.