Hanging of the Hepatic Veins Septa: A Safe Control Prior and During Outflow Anastomosis in Liver Transplantation

Inferior vena cava (IVC) preservation during orthotopic liver transplantation (OLT) is known as the “piggyback” technique. The end-to-side anastomosis is constructed between the graft's IVC and recipient's hepatic veins using a Satinsky side clamp applied in a transverse position. To stabilize the large Satinsky clamp and preserve a sufficient vascular stump after hepatectomy and before graft implantation, we propose a technical innovation consisting of hanging the septa between the left and middle hepatic vein and between the middle and right hepatic vein using 2 tapes. This technique showed some advantages when performing the caval outflow anastomosis, representing a further technical refinement of the piggyback end-to-side technique for the implantation on the 3 hepatic veins. From November 2001 to September 2012, we performed 272 consecutive OLT at our institution with the piggyback technique using the hanging of the hepatic veins septa in all cases. In conclusion, the hanging of the 3 hepatic veins septa presented in this study represents a simple, safe and reproducible technique for the outflow anastomosis using the piggyback technique.     

Hepatic Venous Outflow Obstruction in Adult Deceased Donor Liver Transplantation: Classic Piggyback Implantation Versus a Modified Technique that Widens the Ostium of the Recipient's Left and Middle Hepatic Veins

BackgroundThe classic piggyback technique uses the union of the 3 hepatic veins to perform the cavo-caval anastomosis. However, due to the lateral localization of the right hepatic vein, the partial clamping of the vena cava in this technique significantly reduces the venous return to the right atrium. To avoid this, we adopted in 2015 a modified piggyback technique, in which we use the common trunk of the middle and left hepatic veins and also perform a lateral incision toward the right in the anterior wall of the vena cava in order to widen the final ostium of the cavo-caval anastomosis. The aim of the study was to analyze the incidence of hepatic venous outflow obstruction between those 2 techniques.MethodsRetrospective study of liver transplant recipients undergoing venography for suspected hepatic venous outflow obstruction from January 2009 to June 2021. Patients undergoing transplantation with living donors or split grafts and pediatric cases were excluded from the study.ResultsFrom January 2009 to December 2014 and from January 2015 to June 2021, 587 (group 1) and 730 (group 2) deceased-donor liver transplants were performed with the classic and the modified piggyback techniques, respectively. The incidence of cases with suspected hepatic venous outflow obstruction in groups 1 and 2 were 1.87% (n = 11) and 0.95% (n = 7), respectively (P = 0,15). The number of confirmed patients with outflow blockage that required endovascular treatment during venography in groups 1 and 2 were 4 (0.68%) and 5 (0.68%), respectively (P = 0,31).ConclusionsThis modified piggyback technique did not increase the incidence of hepatic venous outflow obstruction at our service.     

腔静脉成型术在背驮式肝移植术中的应用

目的推荐和总结在实施背驮式肝移植术中采用腔静脉成型术，以期减少术后肝脏流出道梗阻并发症的发生。方法总结2002年1月至2003年4月所实施的23例背驮式肝移植病人，术中实施受体肝静脉成型后，在腔静脉前壁做等腰三角形成型，与供体肝后腔静脉后壁的等腰三角形成型后对口吻合，以减少肝脏流出道梗阻的经验。结果22例病人术中过程顺利，术后恢复良好，无一例发生肝脏流出道梗阻。1例由于术中切肝时误将受体肝后腔静脉横断而改行原位肝移植，术后恢复良好，未发生流出道梗阻。结论在背驮式肝移植术中采用腔静脉成型技术，可以明显降低肝脏流出道梗阻并发症的发生。同时具有简化切肝过程，降低吻合难度，强化移植肝的稳定性，无肝期短的优点。当供受体之间大小存在明显差异时，或实施儿童的减体积性肝移植时该技术具有明显优势。强调用此法切肝时切忌误伤受体肝后腔静脉。     

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.     

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.)     

Suprahepatic venacavaplasty (cavaplasty) with retrohepatic cava extension in liver transplantation: experience with first 115 cases.

BACKGROUND: We first introduced the orthotopic liver transplantation utilizing cavaplasty technique in 1994. This paper describes the surgical technique and assesses the outcome of the cavaplasty OLT. METHODS: The cavaplasty procedure was used in 115 consecutive orthotopic liver transplantations, including six left lateral and two right lobe transplantations, between November 1994 and September 2000. Fifty-three (66.3%) transplantations required femoro-axillary veno-venous bypass in the initial 4 years, whereas only eight (22.9%) needed VB in the subsequent 2 years. Conversion to piggyback or standard technique was not necessary in any patient. RESULTS: Median results are as follows: operative time 4.5 hr, warm ischemia time 25 min, and blood transfused (packed red blood cells) 6 units. These findings did not differ between first transplantation and retransplantation. There were no perioperative deaths related to the cavaplasty technique. No hepatic venous outflow obstruction was observed, including living-related OLTs. No patient required postoperative hemodialysis for acute renal failure. The median intensive care and hospital stays were 2 days and 10 days, respectively. CONCLUSIONS: The cavaplasty technique requires no retrocaval, hepatic vein, or short hepatic vein dissection, and the inferior vena cava can be preserved, which provides advantages for hepatectomy and easy hemostasis, especially during retransplantation. The wide-open triangular caval anastomosis is easy to perform, allowing short implantation time and size matching and avoiding outflow obstruction. The short implantation time reduces the need for veno-venous bypass. Our experience indicates that the cavaplasty technique can be applied to all patients and is justified by minimal technical complications.     

Vascular Complications Following Adult Piggyback Liver Transplantation With End-to-Side Cavo-Cavostomy: A Single-Center Experience

Background

Vascular complications remain a significant cause of morbidity, graft loss, and mortality following orthotopic liver transplantation (OLT). These problems predominantly include hepatic artery and portal vein thrombosis or stenosis. Venous outflow obstruction may be specifically related to the technique of piggyback OLT.

Materials and Methods

Between February 2002 and February 2009, we performed 200 piggyback OLT in 190 recipients. A temporary portacaval shunt was created in 44 (22%) cases, whereas end-to-side cavo-cavostomy was routinely performed for graft implantation. Pre-existent partial portal or superior mesenteric vein thrombosis was present in 17 (12%) cirrhotics in whom we successfully performed eversion thrombectomy, which was followed by a typical end-to-end portal anastomosis. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft in 31 (16%) patients.

Results

The 14 (7%) vascular complications included hepatic artery thrombosis (n = 5), hepatic artery stenosis (n = 3), aortic/celiac trunk rupture (n = 2), portal vein stenosis (n = 2), and isolated left and middle hepatic venous outflow obstruction (n = 1). There was also 1 case of arterial steal syndrome via the splenic artery. No patient experienced portal or mesenteric vein thrombosis. Therapeutic modalities included re-OLT, arterial/aortic reconstruction and splenic artery ligation. Vascular complications resulted in death of 5 (36%) patients.

Conclusion

Our experience indicated that piggyback OLT with an end-to-side cavo-cavostomy showed a low risk of venous outflow obstruction. Partial portal or mesenteric vein thrombosis is no longer an obstacle to OLT; it can be successfully managed with the eversion thrombectomy technique.     

Reconstruction of venous outflow of domino liver graft using deceased donor iliac/cava veins

The double piggyback technique has been proposed for domino liver transplantation. To make this possible, it is necessary to reconstruct the venous outflow of the domino liver graft on the back table. The authors describe the technical details of this procedure in three consecutive cases. A deceased donor cava-iliac bifurcation segment was used. The iliac veins were anastomosed to the ostia of the right and middle-left hepatic veins, and the graft cava vein was anastomosed to the ostium of the three hepatic veins of the recipient. In all cases anatomic compatibility was observed; the outcome of the patients was satisfactory.     

Outflow block secondary to stenosis of the inferior vena cava following living-donor liver transplantation?

Although it is well known that outflow block is caused by stenosis or occlusion of hepatic vein anastomoses following living donor liver transplantation (LDLT), there have been few reports on inferior vena cava (IVC) stenosis following LDLT. In this paper, we report two cases of IVC stenosis and hepatic vein outflow block following right hepatic LDLT in the absence of stenosis of any of the anastomoses. Both patients presented with liver dysfunction, an ascitic fluid volume of approximately 2000 mL, and congestion in their biopsy specimens, and venocavography demonstrated IVC stenosis with gradients of more than 10 mmHg in patients with a dominant inferior right hepatic vein (IRHV) anastomosis. After a Gianturco expandable metallic stent successfully implanted in the IVC, the patient's liver function recovered and the volume of ascitic fluid decreased. The pathogenesis of hepatic vein outflow block secondary to IVC stenosis following LDLT may involve the anastomosis with the IRHV, which is the dominant draining vein of the graft and larger than the RHV, caudal to the IVC stenosis and a significant IVC pressure gradient that results in increased IRHV pressure. In conclusion, it is important to include hepatic vein outflow block in the differential diagnosis when patients who have undergone right hepatic LDLT in which anastomosis of the large IRHV has been performed develop manifestations of liver dysfunction.     

Hepatic venous outflow reconstruction in right live donor liver transplantation.

The increasing experience with live donor liver transplantation has allowed for the identification of potential morbidities associated with technical considerations. Technical graft failure can be associated with both inflow and outflow vascular compromise. Although the latter has not always been given the relevance of the former, evidence pointing to its pivotal role continues to mount. We believe that impaired venous outflow was a cause of previously unexplained graft failures during our initial experience. Based on this observation, we developed a technique to prevent the "choking" of the graft at the outflow anastomosis with the inferior vena cava (IVC). The enhanced outflow via a cloaca maximum is achieved by reconstructing the graft vessels with preserved veins or arteries (usually iliac vessels are used) from a blood-group-identical or blood-group-compatible deceased organ donor. Alternatively, hepatic vein or portal vein obtained from the resected native liver can be used. The reconstructed common outflow is anastomosed to a triangular opening of the IVC. Such enhanced outflow provides optimal venous drainage, especially during the early phase of growth of the graft.     

New hepatic vein reconstruction in left liver graft.

The incidence of hepatic venous stenosis is higher in partial liver transplantation. New methods for hepatic venous reconstruction in left liver transplantation, which secure wide anastomosis, were devised and are reported here. In the graft, the right side of the middle hepatic vein or the left side of the left hepatic vein was cut longitudinally and a rectangular-shaped vein patch was attached for venoplasty. In the recipient, after the left and middle hepatic veins were joined, the right side of the middle hepatic vein was cut toward the closed right hepatic vein, making a horizontal cavotomy for anastomosis. Of 92 patients who underwent conventional hepatic vein reconstruction, 3 were complicated by hepatic venous stenosis (median follow-up 43 months). By contrast, there were no hepatic vein complications in the 20 patients who underwent the new technique (7 months). The current method appears to be technically feasible for outflow reconstruction in left liver graft transplantation.     

改良背驮式同种异体肝移植:附14例报告

摘要：目的 总结分析改良背驮式肝移植供肝修整与手术后并发症的关系。方法 回顾性分析我院17例原位背驮式同种异体肝移植中14例改良背驮式肝移植并发症的发生与供肝修整中的关系。14例中行动脉血管变异整形2例，门静脉搭桥吻合1例；14例各韧带修剪后缝合10例，未缝合4例。结果 全组改良背驮式肝移植14例围手术期无死亡；手术成功100％。术后腹腔内出血3例，与供肝修整有关2例。手术后无动脉及门静脉血管并发症，无胆道并发症，无肝脏流出道梗阻。结论 修肝是肝移植中一个重要的环节，修肝质量的好坏，直接关系到术中植肝时手术操作的难度及术后供肝存活的质量；关系到术后并发症的发生。而对于改良背驮式肝移植供肝修整中,肝后下腔静脉的成形至关重要,成形口与供肝静脉出口必相对应,可以有效防止血液涡流的产生,确保流出道通畅,并有效防止血栓的形成。     

原位肝移植的常用手术方式及应用体会

目的探讨经典原位肝移植术、改良背驮式肝移植术、原位肝移植腔静脉成形术在临床应用中的利弊。方法对2001年10月至2004年5月实施的155例病人的159次肝移植术式进行回顾性分析，其中经典原位肝移植术94例，改良背驮式肝移植术48例（包括改良背驮＋术中门一腔静脉端侧吻合转流8例），原位肝移植腔静脉成形术17例；术中行血管架桥5例，其中因门静脉闭锁及栓塞行供肝门静脉与受体肠系膜上静脉间架桥2例，因动脉变异分支细小不能利用行供肝腹腔干与受体腹主动脉间架桥3例。159例次肝移植手术均未应用体外静脉转流技术。结果原位肝移植腔静脉成形术的手术时间、无肝期最短，术中失血输血量最少，其术中对循环和肾功能的影响与经典术式相仿。经典原位肝移植术与背驮式肝移植术相比流出道不畅发生率较低，总手术时间较短（平均少30min），但无肝期较长（平均长8min），术中及术后肾上腺出血发生率较高，对肾功能影响较大，三组术后ICU留置天数差异亦无显著性意义（P=0．542）。结论不同的肝脏移植术式各有其优缺点，术者的经验以及对术式的熟悉程度会影响手术方式的选择，从原则上讲，手术方式的选择应根据具体病情及术中情况而决定。     

Hepatic vein obstruction due to hypertrophy of right split-liver adult allograft

The increasing shortage of liver allografts has led to the development of split liver transplantation. More frequent applications have permitted the resolution of most of its technical complications. A hitherto unreported complication of split liver transplantation, hepatic vein obstruction caused by hypertrophy of a right split-liver adult allograft, is discussed. As surgical correction was impossible, the outflow obstruction was treated successfully with interventional radiology. Received: 17 February 2000 Revised: 23 September 2000 Accepted: 25 April 2001     

改进成人间活体供肝移植的手术技术

目的研究并改进成人间活体供肝移植的手术技术。方法自2002年1月至2005年8月,施行了16例成人间活体右半供肝移植。手术中改进了技术,包括右肝静脉重建、肝中静脉分支搭桥、肝动脉搭桥及胆道吻合等。结果所有供者均无严重并发症及死亡。移植肝与受者重量比（GRWR）为0．72％～1．24％,其中9例〈1．0％,2例〈0．8％。手术除了采用移植肝的右肝静脉与受者下腔静脉（IVC）直接吻合外,5例加行右肝下静脉重建、5例取自体大隐静脉行肝中静脉分支与IVC间搭桥,保证了右肝流出道通畅。最早手术的2例受者中,1例发生肝静脉吻合口狭窄,另1例发生小肝综合征,最终导致死亡。后阶段手术的14例受者均未发生小肝综合征;发生并发症5例,分别为急性排斥反应、肝动脉栓塞、胆漏、左膈下脓肿及肺部感染;1例再次肝移植后因肺部感染,多器官功能衰竭（MOF）死亡。结论活体供肝移植中采用改进的手术技术,特别是肝静脉流出道重建的方法,可有效避免发生小肝综合征。     

����ʽ����ֲ���������ĸĽ�

目的 总结背驮式肝移植时病肝切除及肝流出道重建的经验。方法 回顾性分析1999年1月至2002年10月行67例背驮式肝移植时病肝切除及肝流出道重建的方法改进及效果。结果 肝移植病例围手术期死亡7例，手术死亡率为10.45％。2例存活超过3年，8例存活超过2年，19例存活超过1年。结论 病肝切除及肝流出道重建方法的改进有利于提高背驮式肝移植的成功率、减少技术性并发症。     

采用不含肝中静脉的右半肝行成人间活体肝移植

目的探讨采用不含肝中静脉的右半肝行成人间活体肝移植的可行性及安全性。方法2002年1月至2005年8月,我院施行了16例成人间右半肝活体肝移植,术中采用了不含肝中静脉的右半肝移植物,同时进行了一系列改良的手术技术包括肝右静脉的重建,右肝下静脉的重建,肝中静脉分支的搭桥等改进。结果全组供者无严重并发症及死亡。前2例受者中,1例发生肝静脉吻合口狭窄,1例因发生小肝综合征,死于肝功进行性恶化。后14例受者中发生并发症5例:急性排斥反应,肝动脉栓塞,胆漏,左膈下脓肿及肺部感染各1例;1例再移植术后肺部感染死于MODS。14例中除肝右静脉与下腔静脉(IVC)直接吻合外,其中5例加行右肝下静脉重建,另5例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建,保证了右肝的流出道通畅。移植物与受者重量比(GRWR)为0.72%~1.15%,11例<1.0%,其中2例<0.8%,无小肝综合征发生。结论采用了改进的手术技术,特别是肝静脉流出道的充分重建可有效的避免小肝综合征,从而使采用不含肝中静脉的活体右半肝移植成为安全可靠的手术方式。     

Hepatic venous outflow obstruction after right lateral sector living-donor liver transplantation, treated by insertion of an expandable metallic stent

Hepatic venous outflow obstruction is a relatively uncommon but important and devastating complication occurring after liver transplantation. Recently, right lateral sector liver grafts have sometimes been used in living-donor liver transplantation (LDLT), but, to our knowledge, early hepatic venous outflow obstruction has never been reported in right lateral sector LDLT. A 58-year-old woman was diagnosed with liver cirrhosis and hepatocellular carcinoma and underwent right lateral sector LDLT. Postoperatively, she developed liver dysfunction. Doppler ultrasound examination revealed flat waveforms and low-flow velocity in the right hepatic vein (RHV). A computed tomography (CT) scan revealed a ventrally distorted RHV due to hypertrophy of the liver graft. Hepatic venous obstruction was suspected and a hepatic venogram was performed. The venogram revealed stenosis of the RHV due to the distortion of the vein. We performed percutaneous transfemoral balloon dilatation, but this was not effective. We then inserted an expandable metallic stent (EMS) into the RHV. After the EMS placement, the condition of the patient improved. Venogram and CT data suggested that the obstruction of the RHV developed because of distortion of the RHV to the ventral side during liver regeneration.     

Venous outflow obstruction after orthotopic liver transplantation: use of a breast implant to maintain graft position

Hepatic venous outflow obstruction (HVOO) is a rare complication after orthotopic liver transplantation (OLT) usually related to technical issues or to malposition or kinking of the hepatic graft. When HVOO is diagnosed during the early post-transplant period, surgical options are technically very demanding and outcomes discouraging. Therefore, angioplasty and stent placement have been indicated to avoid a chronic lesion of the graft. Three cases of HVOO after OLT are reported. HVOO was diagnosed during the early post-transplant period and was due to graft malposition in two patients and kinking of the vena cava anastomosis in one. All patients were successfully treated with a 300-cc gel-filled breast implant surgically placed in the right hepatic fossa with the liver graft resting on it. Massive ascites in all three patients disappeared and renal impairment resolved within two wk post-implant placement. No prosthesis-related complications have been observed after a follow-up ranging from 30 to 58 months. We describe a simple and effective method of maintaining the liver graft in an adequate position to achieve prolonged relief of the outflow obstruction for the whole graft and discuss the advantages of a breast implant over stent placement or the use of different balloon catheters.     

Standard hepatic vein reconstruction with patch plasty using the native portal vein in adult living donor liver transplantation

An outflow obstruction of the hepatic vein is a critical complication after living donor liver transplantation (LDLT) and occasionally leads to hepatic failure. Here we introduce a simple method for preventing outflow obstructions by patch plasty in adult LDLT. Between September 2001 and May 2010, 468 adult LDLT procedures were performed at Kyoto University Hospital. We harvested each recipient's portal vein (PV) from the extirpated liver for a patch. We intended to re-form several orifices of the hepatic veins into a single, large orifice. The patch was attached to the anterior wall of the re-formed orifice on the bench. After we put in the liver graft, the procedure for the hepatic vein anastomosis to the inferior vena cava was simple enough that the warm ischemia time was reduced. Three of the 468 cases were diagnosed with an outflow obstruction. All 3 cases underwent hepatic vein reconstruction without patch plasty. In contrast, none of the 159 cases that underwent LDLT with patch plasty suffered from an outflow obstruction, regardless of the liver graft type. The procedure for hepatic vein plasty using a patch from the native PV is simple and elegant and results in excellent outcomes. We propose this as the standard procedure for hepatic vein reconstruction in adult LDLT.