Impact of venous drainage on regeneration of the anterior segment of right living-related liver grafts

The effect of additional venous reconstruction on morphologic and functional regeneration of the anterior segment of right-lobe liver grafts was compared among three groups according to graft type: right liver graft without the middle hepatic vein (MHV) or MHV tributaries (n=7), with MHV tributaries (n=25) and with the MHV (n=10). Whole graft volume (GV) and anterior segment volume (ASV) were estimated from CT scans and post-operative laboratory data and daily ascitic fluid volume were examined. Peak GV in each group was reached two or three wk after surgery. The ASV/GV ratios of the grafts with the MHV or MHV tributaries were higher than those of grafts without additional venous reconstruction. However, the asparate aminotransferase and ascitic fluid volume values in the group that received grafts with MHV tributaries were higher than in the group that received grafts with the MHV in the same period. Although rapid enlargement of the anterior segment of right-lobe grafts with MHV tributaries occurred in the early post-operative period, complete functional liver regeneration may not occur even after additional tributary reconstruction. These results suggest that the selection of right-lobe grafts with the MHV is more beneficial for recipients, as long as donor safety is protected and that as many MHV tributaries as possible should be reconstructed in right-lobe grafts without MHV.     

Adult-to-adult live-donor liver transplantation: the current status

Adult-to-adult live-donor liver transplantation (ALDLT) has emerged successfully to partially relieve the refractory shortage of deceased donor grafts caused by the increasing demands of patients with endstage liver diseases. Following the first successful live-donor liver transplantation (LDLT) for a child with biliary atresia in 1989, further extension of the technique, using left-lobe liver grafts for LDLT for large adolescents and adults, has resulted in satisfactory graft and patient survival outcomes. However, small-for-size syndrome may occur in some patients with large body size, and in those with acute-on-chronic liver failure or severe portal hypertension. To overcome the problem of graft-to-body-size mismatch, ALDLT, using a right-lobe liver graft was developed. Although routine inclusion of the middle hepatic vein (MHV) in the right-lobe liver graft is still controversial, the importance of providing good venous drainage for the right anterior sector to ensure better early graft function has gained wide recognition. Preservation of the MHV in the donor is intuitively considered important in reducing the donor risk. However, there are scarce data supporting the contention that postoperative complication is related to the absence of the MHV in the left-liver remnant. Duct-to-duct biliary reconstruction has potential advantages over hepaticojejunostomy, and has become the preferred technique in ALDLT. However, biliary complications, especially biliary strictures on long-term follow-up, occur in about 30% of the recipients. The potential beneficial effect of internal or external biliary drainage in reducing the biliary complication rate after duct-to-duct biliary reconstruction in ALDLT also remains controversial. Dual-liver grafts and right-posterior sector grafts have been used in ALDLT, and are reported to result in satisfactory survival outcomes at selected transplant centers. There is no strong evidence supporting the postulate that patients with hepatitis C infection have an inferior survival outcome after ALDLT when compared with recipients of a deceased-donor liver transplant. ALDLT has contributed to satisfactory survival outcomes in patients with hepatocellular carcinoma (HCC). It allows early surgery for the patients and eliminates the uncertainty of prolonged waiting for a deceased-donor liver graft, and the risks of dropout related to disease progression. The exact selection criteria of patients with HCC for ALDLT have yet to be defined.     

成人活体肝移植的早期经验

目的 总结成人活体肝移植的早期经验,提高活体肝移植效果.方法 回顾性分析解放军总医院肝移植中心2006年6月至2008年2月31例成人活体肝移植资料.结果 31例中慢性乙型肝炎肝硬化失代偿期8例,急性肝功能衰竭7例,肝细胞肝癌12例,肝脏紫癜病2例,肝门部胆管癌1例和Wilson 病1例.含肝中静脉(middle hepatic vein,MHV)的右半肝移植25例,不含MHV的右半肝移植3例,双供肝为含MHV的右半肝+左外叶和含MHV的右半肝+左半肝各1例,左半肝辅助性原位肝移植1例.33例供者中5例发生并发症6例次.9例受者发生并发症11例次,其中胆道并发症4例,血管并发症3例,感染性并发症3例,切口延迟愈合1例.2例肺部感染和1例全身多处曲霉菌感染者死亡.结论 活体肝移植已成为拓展供肝来源的有效途径,合理的供、受者评估,手术方式和术后处理是关键.     

Reconstruction of Middle Hepatic Vein Tributaries With Artificial Vascular Grafts in Living Donor Liver Transplant Using Right Lobe Grafts: A Case Series

BackgroundCongestion of the anterior section of the grafted liver might be a problem when performing living donor liver transplant using a right lobe graft without middle hepatic vein (MHV). This can be prevented by MHV tributary reconstruction. We report our procedure and results of reconstructing MHV tributaries using artificial vascular grafts (AVGs).MethodsWe consider venous reconstruction when the estimated territory of each MHV tributary of the transplanted liver is more than 100 mL. For tributaries distant from the stump of the right hepatic vein of the graft, we use heparin-bonded AVGs made of expanded polytetrafluoroethylene with circular rings as the interposition graft between the MHV tributary and the inferior vena cava. During donor surgery, the suturing margin of the MHV tributary is secured before cutting, and it is anastomosed to the AVG during back-bench surgery. After restoration of portal flow in the recipient, we anastomose the AVG at a new position on the inferior vena cava.ResultsThe above procedure was performed for 4 cases. The estimated drainage territory of the vein that was reconstructed using the AVG ranged from 104 to 180 mL. The AVG patency was achieved for about 2 months in all cases. In terms of morbidity, biloma and pancreatic fistula were observed in 2 cases, although removal of the AVG was not required postoperatively in any of the cases.ConclusionThe heparin-bonded expanded polytetrafluoroethylene AVG with circular rings is a feasible option for MHV tributary reconstruction in living donor liver transplant using right liver lobe grafts without MHVs.     

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.     

Vein reconstruction in modified right liver graft for living donor liver transplantation

OBJECTIVE: To report the authors' experience with hepatic vein reconstruction and plasty in living donor liver transplantation for adult patients. SUMMARY BACKGROUND DATA: A right liver graft without the middle hepatic vein (MHV) trunk (modified right liver graft) can cause severe congestion of the right paramedian sector. However, the need for MHV reconstruction has not been fully recognized. METHODS: From June 2000 to December 2001, 30 adult patients received a modified right liver graft. Major MHV tributaries were preserved and reconstructed under the authors' criteria. Plasty of recipient hepatic veins for a wide outflow orifice was performed when necessitated. The regeneration of paramedian and lateral sectors of the grafts was examined by computed tomography 1 and 3 months after the operation. RESULTS: MHV tributaries were reconstructed in 18 grafts. Plasty of recipient hepatic veins was performed in 15 patients. All patients survived the operation. The regeneration of paramedian and lateral sectors was equivalent. CONCLUSIONS: A modified right liver graft can provide satisfactory surgical results if hepatic vein reconstruction and plasty are performed using the present techniques.     

Near-Infrared Spectroscopic Analysis of Hemodynamics and Mitochondrial Redox in Right Lobe Grafts in Living-Donor Liver Transplantation

Near-infrared spectroscopy (NIRS), which enables non-destructive evaluation of hemoglobin (Hb) oxygenation and the redox state of cytochromeoxidase (Cyt.aa3) in living tissues, has been employed during surgery to detect possible impairment of hemodynamics and mitochondrial respiration in the anterior segment of a right lobe liver graft in living-donor liver transplantation (LDLT). Thirty-six patients undergoing LDLT using a right lobe graft without the middle hepatic vein (MHV) were enrolled in this study. During the course of harvesting and implantation, NIRS measurements were performed on the anterior segments of the liver grafts. In two recipients of liver grafts with Hb residue over 70% in the anterior segment after ex vivo flushing, the MHV tributary was reconstructed, while it was not reconstructed in the other 34 recipients. Of those 34 recipients, 16 recipients of liver graft with 40-70% Hb residue showed transient increase of transaminase levels after LDLT. Of those 16 recipients, six recipients who showed reduction in oxidized Cyt.aa3 in the anterior segment suffered from persistent hyperbilirubinemia after LDLT. In patients showing impairment of mitochondrial redox associated with congestion caused by deprivation of the MHV tributaries, reconstruction of the MHV tributaries might have a beneficial effect.     

Liver Graft Regeneration in Right Lobe Adult Living Donor Liver Transplantation

Optimal portal flow is one of the essentials in adequate liver function, graft regeneration and outcome of the graft after right lobe adult living donor liver transplantation (ALDLT). The relations among factors that cause sufficient liver graft regeneration are still unclear. The aim of this study is to evaluate the potential predisposing factors that encourage liver graft regeneration after ALDLT. The study population consisted of right lobe ALDLT recipients from Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan. The records, preoperative images, postoperative Doppler ultrasound evaluation and computed tomography studies performed 6 months after transplant were reviewed. The volume of the graft 6 months after transplant divided by the standard liver volume was calculated as the regeneration ratio. The predisposing risk factors were compiled from statistical analyses and included age, recipient body weight, native liver disease, spleen size before transplant, patency of the hepatic venous graft, graft weight-to-recipient weight ratio (GRWR), posttransplant portal flow, vascular and biliary complications and rejection. One hundred forty-five recipients were enrolled in this study. The liver graft regeneration ratio was 91.2 ± 12.6% (range, 58–151). The size of the spleen (p = 0.00015), total portal flow and GRWR (p = 0.005) were linearly correlated with the regeneration rate. Patency of the hepatic venous tributary reconstructed was positively correlated to graft regeneration and was statistically significant (p = 0.017). Splenic artery ligation was advantageous to promote liver regeneration in specific cases but splenectomy did not show any positive advantage. Spleen size is a major factor contributing to portal flow and may directly trigger regeneration after transplant. Control of sufficient portal flow and adequate hepatic outflow are important factors in graft regeneration.     

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.     

Adult living donor liver transplantation with right lobe graft: the venous outflow management in the Milan-Niguarda experience

In right lobe living donor liver transplantation (ALDLT), reconstruction of middle hepatic vein (MHV) tributaries is often necessary to avoid severe graft congestion. From March 2001, we performed 36 right lobe ALDLT (segments 5, 6, 7, and 8) without MHV and one pediatric transplant (segments 2 and 3). In the presence of MHV tributaries larger than 5 mm, we intraoperatively evaluated the need for reconstruction. At a mean follow-up of 848 days (range=8-2412), 33/37 transplanted patients are alive with overall patient and graft survivals of 89.2% and 83.8%, respectively. Large MHV tributaries (>5 mm) were present in 10 cases, and inferior right hepatic veins (IRHV) draining segment 6 in 11 cases. In 10 cases, we performed an end-to-side anastomosis between the IRHV and the side of the recipient vena cava. In three cases, the MHV tributaries were end-to-end anastomosed to the stump of the recipient MHV. In all other cases, the vein tributaries were not reconstructed. A computed tomography scan performed from 1 to 3 months after surgery did not show any congested area in the liver parenchyma. In our experience, reconstruction of the MHV tributaries was not always necessary when graft-to-recipient weight ratio is >0.8. Pre- and intraoperative evaluation of the segmental branches of the hepatic vein is crucial to decide about reconstructing these collaterals. Anastomosis of V5 or V8 to the stump of the recipient MHV reduces the number of vascular anastomosis and maintains a physiological angle between these collaterals and the caval vein.     

Effect of middle hepatic vein reconstruction in living donor liver transplantation using right lobe

BACKGROUND: This study reviewed the impact of middle hepatic vein (MHV) reconstruction on right lobe graft with regard to functional recovery and graft regeneration at 1 week after transplantation. MATERIALS AND METHODS: From January 1999 to September 2005. 211 adult living donor liver transplantations were performed using the right lobe. The reconstruction of hepatic venous tributaries from segment 5 or segment 8 or both was performed in every cases of sufficient size. The patency of graft vessels was evaluated with computed tomography (CT) angiography on postoperative day 7. We analyzed liver enzymes (aspartate transferase [AST], alanine transferase [ALT] and bilirubin) at 1 week postoperatively and evaluated regeneration activity by CT volumetry at 1 week postoperatively. RESULTS: Among 211 cases, 182 (86.3%) were reconstructed with interpositional MHV grafts. Among them, 51 cases (51.9%) were patent at 1 week postoperatively. The levels of AST and ALT in patent cases of all patients and small-for-size grafts were lower than among the occlusion cases, albeit not significantly. The mean graft regeneration at 1 week postoperatively among patent cases was 1.75 +/- 0.39 versus 1.64 +/- 0.24 in the occluded cases (P = .111), but among small-for-size grafts, there was a significant difference in graft regeneration between patent versus occluded cases (2.05 +/- 0.50 vs 1.66 +/- 0.17, P = .037). CONCLUSION: Functional recovery and graft regeneration in small-for-size grafts showed a beneficial effect in patent cases, compared with occluded cases. Our selection criteria for MHV reconstruction must include cases of small-for-size grafts not all cases.     

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 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.     

An artificial vascular graft is a useful interpositional material for drainage of the right anterior section in living donor liver transplantation.

Congestion in the anterior section in a right liver (RL) without a middle hepatic vein (MHV) may lead to graft dysfunction. To solve this problem, an RL draining MHV branches with autologous or cryopreserved vessels can be introduced. However, these vessels are often unavailable, and their preparation is time-consuming. An expanded polytetrafluoroethylene (ePTFE) graft may be used for anterior section drainage. Between February and November 2005, 26 recipients underwent RL liver transplantation draining MHV branches with an ePTFE graft (group P). Twenty-six ePTFE grafts (6 or 7 mm in internal diameter) drained 35 MHV branches on the back table to the graft right hepatic vein or to the recipient's inferior vena cava. The patency of the ePTFE graft was checked with computed tomography scans of the liver. The outcome of group P was compared with those of an RL group with MHV (group M, n=17) and an RL group without reconstruction of MHV or its tributaries (group R, n=85). The 1-month and 4-month patency rates (PRs) of the ePTFE grafts were 80.8% (21/26) and 38.5% (10/26). All showing early obstruction of the ePTFE graft had congestion in the anterior section, but all showing late obstruction were asymptomatic. The 1-month PRs of group P were comparable to, but the 4-month PRs were lower than, those of group M (both 94.1%; P<0.05). However, 1-year patient and graft survival rates of group P (both 100%) were comparable to those of group M (94.1% and 100%) and better than those of group R (83.5% and 88.2%; P<0.05). In conclusion, the early PR of group P was good, and late obstruction of the ePTFE graft had no impact on congestion in the anterior section or patient survival. Therefore, an ePTFE graft may be a useful interposition material for anterior section drainage in RL transplantation without serious complications.     

Hepatic venous reconstruction of anterior sector using three-dimensional helical computed tomography in living donor liver transplantation

In right lobe living donor liver transplantation (RL-LDLT), venous reconstruction of large middle hepatic vein (MHV) tributaries is often necessary. However the standard for reconstruction is unclear. In two recent RL-LDLT cases, we reconstructed a MHV tributary after estimating the donor's liver volume by three-dimensional images using helical computed tomography (3D-CT). 3D-CT demonstrated that the expected donor right lobe volume was 437 ml, which represented 46.2% of graft volume/recipient's standard volume ratio (GV/SV ratio) in case 1, and 600 ml (46.4%) in case 2. Moreover, 3D-CT revealed a large MHV tributary, 8 mm in diameter, drained 190 ml in volume of segment 8 in case 1, and, 7 mm in diameter, drained 138 ml in case 2. In these cases, when the area drained by the MHV tributary was excluded, GV/SV ratio were 26.1% and 35.7%, respectively. Based on this data, we reconstructed a large MHV tributary in both cases.     

Anatomical variations of donor portal vein in right lobe living donor liver transplantation: the safe use of variant portal veins

In right lobe (RL) living donor liver transplantation (LDLT), portal vein (PV) variations are of immense clinical significance. In this study, we describe in detail our PV reconstruction techniques in RL grafts with variant PV anatomy and evaluate the impact of accompanying biliary variations on the recipient outcomes. In a total of 386 RL LDLTs performed between July 2004 and July 2012, the clinical data on 52 (13%) transplants using RL grafts with variant PV anatomy were retrospectively analyzed. Portal vein anatomy was classified as type 2 in 20 patients, type 3 in 24 patients, and type 4 in eight patients. The PV reconstruction techniques utilized included back‐wall plasty (n = 21), back‐wall plasty with saphenous vein graft interposition (n = 6), saphenous vein graft interposition (n = 5), cryopreserved iliac vein Y‐graft interposition (n = 6), and quiltplasty (n = 3). There was no donor mortality. In a median follow‐up of 29 months, none of the recipients had vascular complications. Anomalous PV anatomy was associated with a high (54%) incidence of biliary variations; however, these variations did not result in increased biliary complication rate. Overall, the 1‐ and 3‐year patient survival rates of recipients were 91% and 81%, respectively. Vascular and biliary variations in RL grafts render LDLT technically more challenging. By employing appropriate reconstruction techniques, it is possible to successfully use RL grafts with PV variations without endangering recipient and donor safety.     

Modified right liver graft from a living donor to prevent congestion

BACKGROUND: Right liver grafts without middle hepatic vein (MHV) drainage reconstruction resulted in severe congestion of the anterior segment (AS) in our early experience of adult-to-adult living donor liver transplantation (LDLT). However, a detailed strategy for preventing such congestion or the necessity of MHV reconstruction has not been discussed in LDLT using a right lobe graft. METHODS: From July 1997 to February 1998, two of five right lobe grafts without MHV drainage reconstruction were complicated with severe congestion of the AS. Thereafter, 42 adult recipients who received right liver grafts with sizable MHV tributaries underwent the reconstruction of MHV drainage. All sizable (>5 mm in diameter) MHV tributaries were preserved during donor hepatectomy and were reconstructed with the recipient's autogenous interposition vein grafts at the bench surgery. The reconstructed vein grafts of this modified right lobe graft were anastomosed to the stump of the MHV and/or left hepatic vein of the recipient after graft revascularization. RESULTS: Serial Doppler ultrasonography, which was regularly checked until 30 days posttransplant, revealed the patent interposition vein graft in 38 of 42 recipients (patency rate 90.5%). In these 38 recipients, no evidence of congestion in the AS was recognized on enhanced computed tomography, while providing enough functioning liver mass comparable to an extended right lobe graft. Also, congestion-related graft injury, such as an infarct of the AS, was not observed in these recipients. CONCLUSIONS: Our early experience indicated the necessity of MHV drainage reconstruction in right lobe grafts, which do not have MHV trunk in certain instances. However, preoperatively, it is difficult to predict the degree of AS congestion of the right liver graft without MHV drainage reconstruction. We suggest aggressive reconstruction of MHV drainage tributaries of the AS, under the circumstances that sizable MHV tributaries are encountered, to prevent possible congestion-related complications.     

Innovative Technique Avoiding Bleeding After Reperfusion in Living Donor Liver Transplant Using a Modified Right Lobe Graft

BackgroundLiving donor liver transplant (LDLT) is a valuable therapeutic option for overcoming the deceased donor shortage. Modified right lobe graft (MRLG) keeps the middle hepatic vein (MHV) trunk with the remnant liver to improve donor safety. Hemostasis in the MHV tributary reconstruction can be tricky; surgical stitches and energy coagulation are ineffective. Fibrin glues are excellent vascular sealants but are poor in maintaining hemostasis in an active hemorrhage or preventing resection surface-related complications after liver resection. We propose applying fibrin sealant during back table graft preparation to seal the hepatic edge and MHV reconstruction to avoid bleeding after graft revascularization.MethodsOur retrospective cohort study included all adult patients undergoing LDLT between August 2017 and December 2021. During the back table procedure, we performed the reconstruction of the inferior right hepatic vein and/or MHV tributaries from segment 5 (V5) and segment 8 (V8) using a vein harvested from a nonrelated deceased donor. Before initiating the hepatic graft implantation, we applied fibrin sealant in the resected parenchyma, especially in the V5 and V8 anastomosis, to seal the hepatic edge and hepatic vein reconstruction.ResultsNo bleeding was identified in the hepatic edge, and blood product transfusion was unnecessary for any recipients after reperfusion.ConclusionIn LDLT using MRLG with MHV reconstruction, the fibrin sealant, when applied on the raw hepatic surface, and vascular reconstruction during back table graft preparation avoided bleeding after graft revascularization.     

Remnant liver regeneration and spleen volume changes after living liver donation: influence of the middle hepatic vein

BACKGROUND AND OBJECTIVES: Graft harvest with or without the middle hepatic vein (MHV) affects venous return and function of the remaining liver. The aims of this study are to compare the remnant liver volume and spleen changes in the donors of different types of graft harvest and to evaluate the influence of resection with or without the MHV on the remnant liver volume regeneration, spleen volume change and serum total bilirubin. PATIENTS AND METHODS: A total of 165 donors were grouped according to the type of graft harvest: 88 donors underwent left lateral segmentectomy (LLS), 10 donors underwent extend LLS or left lobectomy (LL), and 67 donors underwent right lobectomy (RL). Groups LLS and LL were later combined as group LH (left hepatectomy, n = 98). There were 68 men and 97 women. The mean age was 32.9 +/- 8.1 yr. The total liver volume (LV) and spleen volume (S1) before graft harvest, graft weight (GW), regenerated liver volume (LV(6m)) and spleen volume (S2) six months post-donation were calculated. RESULTS: There were no significant differences in the regenerated liver volume six months postoperation (LV(6m)) and recovery ratio (LV(6m)/LV x 100%) among the different groups, albeit significant smaller LV(6m) in both groups compared with the initial liver volume was noted. Postoperative spleen volume (S2), average spleen ratio (S2/S1) and spleen change ratio were significantly larger and higher in group RL than in group LH. A significant increase in spleen volume was noted in both groups six months after graft harvest. A significantly higher TB in group RL (4.1 +/- 1.7 mg/dL, range: 1.4-8.5 mg/dL) was noted compared with that of group LH (1.6 +/- 1.0 mg/dL, range: 0.7-6.2 mg/dL). CONCLUSION: There was a significant increase in the regenerated remnant liver and splenic volumes six months postoperation in all types of hepatectomy following living donor hepatectomy, and there was no difference in the mean TB levels among donors whether the MHV was included or not in the graft.     

Pure Laparoscopic Full‐Left Living Donor Hepatectomy for Calculated Small‐for‐Size LDLT in Adults: Proof of Concept

Adult‐to‐adult living donor liver transplantation (A2ALDLT) is an accepted mode of treatment for end‐stage liver disease. Right‐lobe grafts have usually been preferred in view of the higher graft volume, which lowers the risk of a small‐for‐size syndrome. However, donor left hepatectomy is associated with less morbidity than when it is compared to right hepatectomy. Laparoscopic donor hepatectomy (LDH) has been considered almost exclusively in pediatric transplantation. The results of laparoscopic left‐liver graft procurement for calculated small‐for‐size A2ALDLT in four donors are presented. The graft‐to‐recipient body weight ratio was <0.8 in all recipients. The mean portal vein flow and the pressure and hepatic artery flows were measured at 190 ± 56 mL/min/100 g, 13 ± 1.4 mm/Hg and 109 ± 19 mL/min, respectively. No early postoperative donor complications were recorded. One graft was lost due to intrahepatic abscesses. Asymptomatic stenosis of a right posterior duct was treated with a Roux‐en‐Y loop 4 months later in one donor. We show that LDH of the full‐left lobe is feasible. LDH is a very demanding operation, potentially decreasing donor morbidity. Standardization of this procedure, making it accessible to the growing number of experienced laparoscopic liver surgeons, could help renewing the interest for A2ALDLT in the Western world.