Transplant International ISSN 0934-0874
ORIGINAL ARTICLE
Anatomical variations of donor portal vein in right lobe living donor liver transplantation: the safe use of variant portal veins Necdet Guler,1 Murat Dayangac,1 Onur Yaprak,1 Murat Akyildiz,1,2 Yusuf Gunay,1 Fatih Taskesen,1 Babek Tabandeh,3 Fisun Bulutcu,1,4 Yildiray Yuzer1 and Yaman Tokat1 1 2 3 4
Center for Organ Transplantation, Florence Nightingale Hospital, Istanbul, Turkey Department of Gastroenterology, Istanbul Bilim University, Istanbul, Turkey Department of General Surgery, Medical Park Goztepe Hospital, Istanbul, Turkey Department of Anesthesiology, Istanbul Bilim University, Istanbul, Turkey
Keywords cryopreserved vein graft, hilar variations, live donor surgery, living donor liver transplantation, portal vein reconstruction, right lobe graft. Correspondence Murat Dayangac MD, Florence Nightingale Hospital, Center for Organ Transplantation, Abide-i Hurriyet Cad. No: 164, Sisli 34381, Istanbul, Turkey. Tel.: 90 212 225 83 98; fax: 90 212 224 03 56; e-mail: [email protected] Conflict of interest The authors have declared no conflict of interests. Received: 9 May 2013 Revision requested: 10 June 2013 Accepted: 30 August 2013 Published online: 15 October 2013
Abstract 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.
doi:10.1111/tri.12190
Introduction Living donor liver transplantation (LDLT) has gained worldwide acceptance for the treatment of end-stage liver disease. The experience and the technical advances achieved in the last decade in this field made it possible to steadily improve the post-transplant results [1]. In adult LDLT, right lobe (RL) is generally preferred with the purpose of providing a larger size liver graft; however, a higher incidence of vascular and biliary variations has been reported with the RL grafts as compared with the left lobes [2–6]. © 2013 Steunstichting ESOT. Published by John Wiley & Sons Ltd 26 (2013) 1191–1197
Portal vein (PV) variations constitute a significant proportion of vascular variations in RL grafts, and their incidence has been reported as high as 22% in previous publications [2,6–10]. Anatomical variations of the PV are also associated with higher rates of biliary variations [2,8]. The clinical implications of PV variations include technically challenging operations with complex reconstructions, as well as the rejection of potential donors. In addition, PV variations can jeopardize donor safety. Inadvertent narrowing during the closure of the PV orifices in the remnant liver has been reported to cause PV thrombosis in the donor [6]. 1191
Guler et al.
The safe use of RL grafts with variant PV in DLT
Currently, clinical data on the use of RL grafts with PV variation, as well as the outcome of both the donors and the recipients of such grafts are limited. In this paper, in a large series of LDLTs in which RL grafts with variant PV anatomy were used, we report our experience in PV reconstruction techniques in LDLT. We retrospectively evaluated the different reconstruction techniques, the impact of accompanying biliary variations on the recipient outcomes, and the results of right hepatectomy in donors with PV variations. Patients and methods From July 2004 to July 2012, 418 LDLTs were performed at Florence Nightingale Hospital, Istanbul. Donor evaluation started with the assessment of the voluntary intent of the donor and blood group compatibility. Only donors within the fourth degree of consanguinity were accepted. After the serological and thrombophilia testing, a thorough clinical evaluation was performed. Donor candidates who had diabetes, hypertension, or any other significant medical diseases were excluded. Assessment of the vascular anatomy and the liver parenchyma and liver volumetry was performed by computed tomography (CT; 16-detector, Sensation 16-Siemens, Erlangen, Germany), and the evaluation of biliary anatomy was performed by magnetic resonance
cholangiography (MRC; 1,5-T scanner, Magnetom Sonata, Siemens, Erlangen, Germany). Donors whose future liver remnant volume was 28) body mass index, those with mild steatosis on the precontrast CT scan, and those who test positive for anti-HBc underwent liver biopsy selectively. The anatomical variations of the PV and the bile ducts were described according to Cheng [9] (Fig. 1) and Huang [11] classifications, respectively. In a total of 386 RL donors, 52 (12.6%) donors were identified to have portal vein variations. The clinical data for these 52 donors and their recipients were retrospectively analyzed in this study. All postoperative complications in donors and recipients were graded according to Clavien classification [12]. All numerical data are reported as median and interquartile range. Incidence rates were compared with the chi-square test. A P-value
ORIGINAL ARTICLE
Anatomical variations of donor portal vein in right lobe living donor liver transplantation: the safe use of variant portal veins Necdet Guler,1 Murat Dayangac,1 Onur Yaprak,1 Murat Akyildiz,1,2 Yusuf Gunay,1 Fatih Taskesen,1 Babek Tabandeh,3 Fisun Bulutcu,1,4 Yildiray Yuzer1 and Yaman Tokat1 1 2 3 4
Center for Organ Transplantation, Florence Nightingale Hospital, Istanbul, Turkey Department of Gastroenterology, Istanbul Bilim University, Istanbul, Turkey Department of General Surgery, Medical Park Goztepe Hospital, Istanbul, Turkey Department of Anesthesiology, Istanbul Bilim University, Istanbul, Turkey
Keywords cryopreserved vein graft, hilar variations, live donor surgery, living donor liver transplantation, portal vein reconstruction, right lobe graft. Correspondence Murat Dayangac MD, Florence Nightingale Hospital, Center for Organ Transplantation, Abide-i Hurriyet Cad. No: 164, Sisli 34381, Istanbul, Turkey. Tel.: 90 212 225 83 98; fax: 90 212 224 03 56; e-mail: [email protected] Conflict of interest The authors have declared no conflict of interests. Received: 9 May 2013 Revision requested: 10 June 2013 Accepted: 30 August 2013 Published online: 15 October 2013
Abstract 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.
doi:10.1111/tri.12190
Introduction Living donor liver transplantation (LDLT) has gained worldwide acceptance for the treatment of end-stage liver disease. The experience and the technical advances achieved in the last decade in this field made it possible to steadily improve the post-transplant results [1]. In adult LDLT, right lobe (RL) is generally preferred with the purpose of providing a larger size liver graft; however, a higher incidence of vascular and biliary variations has been reported with the RL grafts as compared with the left lobes [2–6]. © 2013 Steunstichting ESOT. Published by John Wiley & Sons Ltd 26 (2013) 1191–1197
Portal vein (PV) variations constitute a significant proportion of vascular variations in RL grafts, and their incidence has been reported as high as 22% in previous publications [2,6–10]. Anatomical variations of the PV are also associated with higher rates of biliary variations [2,8]. The clinical implications of PV variations include technically challenging operations with complex reconstructions, as well as the rejection of potential donors. In addition, PV variations can jeopardize donor safety. Inadvertent narrowing during the closure of the PV orifices in the remnant liver has been reported to cause PV thrombosis in the donor [6]. 1191
Guler et al.
The safe use of RL grafts with variant PV in DLT
Currently, clinical data on the use of RL grafts with PV variation, as well as the outcome of both the donors and the recipients of such grafts are limited. In this paper, in a large series of LDLTs in which RL grafts with variant PV anatomy were used, we report our experience in PV reconstruction techniques in LDLT. We retrospectively evaluated the different reconstruction techniques, the impact of accompanying biliary variations on the recipient outcomes, and the results of right hepatectomy in donors with PV variations. Patients and methods From July 2004 to July 2012, 418 LDLTs were performed at Florence Nightingale Hospital, Istanbul. Donor evaluation started with the assessment of the voluntary intent of the donor and blood group compatibility. Only donors within the fourth degree of consanguinity were accepted. After the serological and thrombophilia testing, a thorough clinical evaluation was performed. Donor candidates who had diabetes, hypertension, or any other significant medical diseases were excluded. Assessment of the vascular anatomy and the liver parenchyma and liver volumetry was performed by computed tomography (CT; 16-detector, Sensation 16-Siemens, Erlangen, Germany), and the evaluation of biliary anatomy was performed by magnetic resonance
cholangiography (MRC; 1,5-T scanner, Magnetom Sonata, Siemens, Erlangen, Germany). Donors whose future liver remnant volume was 28) body mass index, those with mild steatosis on the precontrast CT scan, and those who test positive for anti-HBc underwent liver biopsy selectively. The anatomical variations of the PV and the bile ducts were described according to Cheng [9] (Fig. 1) and Huang [11] classifications, respectively. In a total of 386 RL donors, 52 (12.6%) donors were identified to have portal vein variations. The clinical data for these 52 donors and their recipients were retrospectively analyzed in this study. All postoperative complications in donors and recipients were graded according to Clavien classification [12]. All numerical data are reported as median and interquartile range. Incidence rates were compared with the chi-square test. A P-value
