Outflow tract reconstruction in living donor liver transplantation

BACKGROUND: Hepatic venous reconstruction is critical in living donor liver transplantation because outflow obstruction may lead to graft dysfunction or loss. We describe our experience and analyze outcomes with a technique of creating a single outflow tract using venoplasties of the graft and recipient hepatic veins. PATIENTS AND METHODS: A retrospective study was done on 38 consecutive living donor liver transplants performed from June 1994 to March 2000. The grafts included 36 left-side grafts and 2 right-side grafts. Nine grafts had multiple hepatic veins and required a venoplasty of two or three hepatic veins to create a single outflow orifice. Triple recipient hepatic venoplasty was performed in 32 patients, double venoplasty in 5 and none in 1. RESULTS: There were four cases of outflow obstruction, three occurring in patients with a double recipient venoplasty. Two of the problems were remedied intraoperatively by adjusting the position of the graft although two were structural in nature and required the insertion of expandable metallic vascular stents. All donors and recipients with their original grafts are alive at a mean follow-up period of 27 months. CONCLUSION: A triple recipient venoplasty with a matching venoplasty of multiple graft hepatic veins to create a single wide outflow orifice is recommended in living donor liver transplantation using left side grafts.     

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。     

Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation

Shirouzu Y, Ohya Y, Hayashida S, Asonuma K, Inomata Y. Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation.
Clin Transplant 2011: 25: 625–632. © 2010 John Wiley & Sons A/S. Abstract: Background: Hepatic outflow block is one of the major complications leading to severe graft dysfunction after left lobe living donor liver transplantation (LDLT). Methods: Medical records of 46 recipients of a left lobe LDLT were reviewed. The method of outflow reconstruction and post‐transplant morphological changes of hepatic veins were investigated. The subjects were followed up until September 2008, with a median follow‐up period of 2.0 yr (range: 0.5–5.9 yr). Results: There were no multiple outflow tracts to be reconstructed, and the median caliber of the single orifices with or without venoplasty was 32.0 mm. The difference between the angle of hepatic veins to the sagittal plane measured on computed tomography was calculated for pre‐operative donors and post‐operative recipients a month after LDLT. Both left and middle hepatic veins showed a significantly greater change in angle than the right hepatic vein. Both left and middle hepatic veins more frequently showed a nearly flat wave form on Doppler study one month after LDLT. In the 46 recipients of left lobe grafts, three developed outflow block (6.5%). Conclusions: The middle and left hepatic veins tend to distort and stretch during graft regeneration. These characteristics seem to be associated with outflow disturbances.     

成人间活体肝移植的手术技术改进(附13例报告)

目的探讨成人间活体肝移植的手术技术改进.方法2005年3-6月,施行了13例成人间右半肝活体肝移植,其中1例接受了2个左半肝,另1例接受了1个活体右半肝,1个尸体左半肝,术中采用了改良的手术技术,包括右肝静脉的重建,肝中静脉分支的搭桥,肝动脉搭桥及胆道吻合的改进.结果全组供体无严重并发症及死亡,受体发生并发症4例,包括肝动脉栓塞,胆漏,右膈下脓肿及肺部感染各1例,1例再移植因术后肺部感染,导致多器官衰竭（MOF）死亡.13例中除右肝静脉与下腔静脉（IVC）直接吻合,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.移植物与受体重量比（GRWR）为0.72%至1.24%,其中9例＜1.0%,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避免小肝综合征,从而使活体右半肝移植成为相当安全的手术.     

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.     

Complex outflow anatomy in left lateral lobe graft and modified venous reconstruction in pediatric living donor liver transplantation

Hepatic venous outflow reconstruction is of critical significance in pediatric patients undergoing living donor liver transplantation. Accurate knowledge of the anatomical variations is important to obtain appropriate size segmental grafts. The diameter of the hepatic veins and the potential risk of complications at the level of the anastomosis require an adequate primary vascular reconstruction. We describe a venous outflow reconstruction technique, in a living related left lateral lobe graft, with unfavorable hepatic venous anatomy.     

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.     

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。     

Hepatic venoplasty in living-donor liver transplantation using right lobe graft with middle hepatic vein

Inclusion of the middle hepatic vein in a right lobe graft from a living-donor may improve venous drainage and avoid graft dysfunction, but reconstruction of the middle hepatic vein is technically difficult. We developed a hepatic venoplasty technique, which was applied in eight consecutive right lobe liver transplantations. The right and middle hepatic veins of the graft were joined together to form a triangular cuff for a single anastomosis to the recipient's inferior vena cava. Hepatic venoplasty was successful in all cases, and no interposition graft was required. Venovenous bypass was not used. All grafts showed immediate function, and no hepatic venous outflow obstruction was observed. There was no reoperation and the graft survival rate was 100%. This hepatic venoplasty technique can be applied systemically as a standard one in right lobe liver graft with the middle hepatic vein to simplify the recipient hepatectomy and to obviate venous outflow obstruction.     

Reconstruction of three right hepatic veins using cadaveric iliac vein in right lobe living donor liver transplantation: case report

In various right hepatic vein anatomies, reconstruction is a surgically challenging technique in right lobe living donor liver transplantation. The right inferior hepatic vein is the most common hepatic vein abnormality in right lobe living-donor liver transplantation. Three accessory right hepatic veins is a rare right hepatic vein variation. We experienced one case of three right hepatic vein reconstruction among 300 partial liver transplantations using the right lobe in our center over 10 years. The donor right lobe had one main right hepatic vein and three accessory hepatic veins at the lower border of the liver. Restoration of accessory hepatic veins to the inferior vena cava was performed after construction of one conduit from the three accessory hepatic veins using a cadaveric donor iliac vein.     

活体右半供肝Ⅴ和Ⅷ段静脉回流的重建方法

目的 总结活体右半供肝移植中,不含肝中静脉的右半供肝Ⅴ、Ⅷ段静脉回流的重建方法.方法 回顾性分析55例活体右半供肝移植中,不含肝中静脉的右半供肝Ⅴ、Ⅷ段静脉回流重建的临床资料.所有供者均通过了受者标准肝体积、供肝与受者体重比(GRWR)、供肝与受者标准肝体积比及供肝内血管解剖等指标的综合评估.供肝在切取、灌注及修整后,51例采用尸体髂静脉作为重建材料,其他4例分别采用受者的大隐静脉、曲张的脐静脉、肝内门静脉和肝静脉作为重建材料,以串联的方式重建供肝断面Ⅴ、Ⅷ段静脉回流.肝移植时,供肝肝右静脉与受者肝右静脉开口吻合,重建的Ⅴ、Ⅷ段静脉与受者肝中、肝左静脉汇合部吻合,供肝门静脉与受者门静脉右支或主干吻合.门静脉开放血流后依次重建肝动脉及胆道.术后对供、受者进行常规监测.结果 1例受者术后发生流出道梗阻,术后第43天死亡;1例受者术后第7天出现不明原因的急性重型肝组织坏死,行尸体供肝肝移植后痊愈.其余53例受者恢复顺利,术后4周时腹部CT检查显示重建的移植肝Ⅴ、Ⅷ段静脉回流通畅.55例供者术后均恢复顺利,术后2周出院.结论 不含肝中静脉的活体右半供肝Ⅴ、Ⅷ段静脉回流的重建在活体肝移植中是可行的,应选择合适的重建材料及手术方式.受者肝移植后临床效果良好.     

Techniques of reconstruction of hepatic veins in living-donor liver transplantation, especially for right hepatic vein and major short hepatic veins of right-lobe graft

Living-donor liver transplantation (LDLT) is now widely accepted as a therapeutic option for adult patients with acute and chronic end-stage liver disease. In the early period, the left lobe was the major liver graft used in adult LDLT to ensure donor safety, especially in Eastern countries. However, the frequent extremes of graft-size insufficiency in left-lobe LDLT represented a greater risk of small-for-size graft syndrome in the recipient, which has focused attention on transplantation of the right lobe from a living donor. The major concern of right-lobe LDLT has focused on its safety for the donor and the necessity for including the middle hepatic vein (MHV) in the graft to avoid congestion of the right anterior segment. The MHV carries out important venous drainage for the right anterior segment and is essential for perfect graft function. The decision of whether to take the MHV with the liver graft (extended right lobe graft) or whether to retain it in the donor, with reconstruction of the MHV tributaries in the liver graft (modified right lobe graft) has been extensively discussed in numerous studies. However, adequate right hepatic vein and major short hepatic vein (middle and inferior right hepatic vein [RHV]) drainage of the liver graft is perhaps equally important as MHV outflow drainage for the integrity of right-lobe graft function. Herein, the author describes various techniques of venoplasty of the right hepatic vein (RHV) and the major short hepatic veins to obviate venous outflow obstruction in these veins.     

150例活体肝移植供肝的后台修整

目的 总结150例活体供肝的后台修整经验.方法 回顾性分析2007年2月至2008年5月间完成的150例活体供肝的修整资料.结果 150例供肝中,包含肝中静脉及尾状叶的左半肝3例,肝左静脉与肝中静脉成形;左外侧叶2例;带肝中静脉右半肝67例,肝右静脉与肝中静脉成形;不带肝中静脉右半肝78例.78例不带肝中静脉右半肝中23例未进行S_5、S_8静脉的重建,供肝血流恢复后S_5、S_8肝组织均有不同程度的淤血.其余55例用不同材料重建S_5、S_8静脉:新鲜尸体髂静51例,受体大隐静脉1例,受体曲张脐静脉1例,受体肝内门静脉1例,受体肝静脉1例.145例右半肝供肝中门静脉为C型的7例,均成形为一个开口.结论 HTK是活体供肝的最佳灌注、保存液,供肝流出道恰当的成形、重建不但可简化供肝植入的操作步骤,还可最大限度的保护有功能的肝组织,是受体术后顺利恢复的关键.     

Review of the surgical approach to prevent small-for-size syndrome in recipients after left lobe adult LDLT

Left lobe liver grafts increase the donor safety in adult-to-adult living-donor liver transplantation (ALDLT). However, the left lobe graft provides about 30–50 % of the required liver volume to adult recipients, which is insufficient to sustain their metabolic demands, which can lead to small-for-size syndrome (SFSS). Transient portal hypertension and microcirculatory hemodynamic derangement, apart from outflow obstruction, during the first week after reperfusion are the critical events associated with small-for-size graft transplantation. The incidence of SFSS in left lobe ALDLT can be decreased by increasing the left lobe graft volume by effective utilization of the caudate lobe with preserved vascular supply, by modulating the portal pressure with splenectomy or a porto-systemic shunt or by hepatic venous outflow reconstruction to prevent the development of venous congestion. In this review, we discuss the pathophysiology of SFSS and the various surgical strategies that can be performed to prevent SFSS in an effort to enhance the donor safety during living-donor liver transplantation.     

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.     

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.     

Technical refinement in adult-to-adult living donor liver transplantation using right lobe graft

OBJECTIVE: To report the authors' experience with living donor liver transplantation in adults using right lobe liver grafts, performed by a modified technique. SUMMARY BACKGROUND DATA: The initial results of seven living donor liver transplants in adults using extended right lobe grafts were satisfactory, but serious complications occurred in two donors, and six recipients required repeat laparotomy. Another 11 similar operations were performed. Further evaluation was made with the aim of improving the postoperative outcome. METHODS: From December 1996 to August 1998, 11 patients underwent living donor liver transplantation using right lobe grafts. The first four patients underwent surgery using methods previously designed and the next seven underwent a modification designed to minimize devitalized tissues on the liver transection surface, improve hepatic venous drainage, and reduce the number of hepatic duct orifices. RESULTS: There were no donor deaths. Donor complications included cholestasis (n = 1) and minor wound infection (n = 1). All the first four recipients required a repeat laparotomy for infected necrotic liver transection surface (n = 1), acute pancreatitis (n = 1), hepatic vein thrombosis (n = 1), and leakage from one of the two bilioenteric anastomoses (n = 1). The patient with hepatic vein thrombosis died. In the last seven recipients, all of whom survived the operation, one required a repeat laparotomy with the discovery of a methicillin-resistant Staphylococcus aureus culture of fibrinous exudate at the left subphrenic peritoneum, and another had right hepatic duct stump necrosis. The latter was likely related to hypovolemic shock secondary to bleeding from the right saphenous vein on removal of a hemofiltration catheter. Comparison of the incidence of repeat laparotomy between the first four and the remaining seven recipients showed a significant trend of improvement. Combining the result of the seven patients reported previously, the improvement in terms of relaparotomy rate is significant. CONCLUSION: With modification of surgical technique, living donor liver transplantation in adults using right lobe liver grafts can become a relatively safe procedure.     

Evolution of anterior segment reconstruction after live donor adult liver transplantation: a single-center experience

Controversy exists regarding the best method for venous outflow reconstruction after live donor liver transplantation using right lobe grafts. Some authors advocate routine inclusion of the middle hepatic vein with the graft, whereas others favor a more selective approach. In this report, we examine the evolution of our decision making and technique of selective anterior venous segment reconstruction during live donor adult liver transplantation performed in 226 recipients. We have developed a simplified back-bench procedure using sequential-composite anastomosis using various vascular conduits with syndactylization to the right hepatic vein creating a single large-outflow anastomosis in the recipient. Conduits used include iliac artery or vein allograft, recanalized umbilical vein, cryopreserved iliac artery allograft, and 6-mm synthetic expanded polytetrafluoroethylene vascular graft. This technique can be performed quickly, safely, and under cold storage conditions and results in excellent outcome while minimizing donor risk.     

活体肝移植中变异供肝动脉的修整及重建

目的 总结活体肝移植中变异供肝动脉的修整和重建经验。方法 回顾分析自2006年9月至2010年5月间73例成人活体肝移植的临床资料,术前对供肝进行了充分的影像学评估,其中涉及供肝动脉较复杂变异者13例(17.8％),包括9例异位或副肝右动脉起自肠系膜上动脉(SMA),2例副肝右动脉发自腹腔干及2例肝动脉存在交通支。术中对这13例变异供肝动脉采用显微外科技术进行了修整和重建。结果 9例异位或副肝右动脉起自SMA者中,3例采用副肝右动脉与胆囊动脉行端侧吻合的方式成形,然后与受者的肝固有动脉或肝右动脉行端端吻合,另6例异位肝右动脉与受者肝右动脉或肝固有动脉行端端吻合;2例副肝右动脉起自腹腔干者,将供肝右动脉和副肝右动脉分别与受者肝右动脉和肝左动脉吻合重建;2例供肝动脉存在交通支者及1例双供肝移植者均予以双支动脉重建。另外,供、受者肝动脉内径不匹配者,采用供肝副肝右动脉与受者肝固有动脉行端侧吻合。所有血管均一次吻合成功,围手术期经密切监测动脉血流及给予相应抗凝治疗,术后长期随访中,所有受者均未发生肝动脉血栓形成及动脉狭窄等并发症。结论 根据动脉变异的不同,采用显微外科技术进行不同方式的修整,效果良好,其对预防活体肝移植后动脉血栓形成等并发症以及扩大活体供者范围具有重要意义。     

成人间右半肝活体肝移植肝中静脉的处理

目的 总结成人间右半肝活体肝移植肝中静脉的处理经验。方法 回顾性分析两例成人间右半肝活体肝移植肝中静脉的处理方法，1例采取含肝中静脉的右半肝活体肝移植，肝中静脉移植供肝和剩余肝脏各保留一半，既有利于保证供体左肝内叶静脉回流，同时供肝右前叶静脉回流也不受到影响；另1例则采取不含肝中静脉的右半肝活体肝移植，术中重建供肝右前叶肝静脉回流通道，使供肝前叶淤血明显改善。结果 两例供体均存活，术后顺利出院，无并发症；受体1例存活，1例术后20d死于急性重度排斥反应。结论 成人间右半肝活体肝移植肝中静脉的处理十分关键，要注意保持供受体肝流出道的通畅，既要保证供体的绝对安全，又要尽量为受体提供足够的肝容量。