Original Paper Received: January 20, 2014 Accepted: May 5, 2014 Published online: September 10, 2014
Dig Surg 2014;31:210–218 DOI: 10.1159/000363416
Reconstructing Middle Hepatic Vein Tributaries in Right-Lobe Living Donor Liver Transplantation Peixian Chen Wentao Wang Lunan Yan Tianfu Wen Bo Li Jichun Zhao Department of Liver and Vascular Surgery, West China Hospital of Sichuan University, Chengdu, PR China
Key Words Living donor liver transplantation · Right lobe · Middle hepatic vein · Reconstruction · Venoplasty
Abstract Aims: To investigate the effectiveness of our technique and policy in reconstructing middle hepatic vein (MHV) tributaries of patients undergoing right-lobe living donor liver transplantation (LDLT). Methods: From January 2001 to December 2010, 186 adult patients underwent right-lobe LDLT without the MHV. Patients were divided into two groups: group A (n = 71) and group B (n = 115) without or with the MHV tributaries reconstruction. We evaluated the serum liver function markers after transplantation and monitored vascular flow in the graft and interpositional vein by Doppler ultrasonography. Results: The cumulative 1-, 3-, 5-year graft and patient survival rates were not significant between group A and group B (p = 0.287 and p = 0.258). Biliary complications appeared to be more frequent in group A than in group B (16.9 vs. 5.2%, p = 0.009). Liver function impairment was found in patients without MHV reconstruction and those with occluded interpositional vessels early after transplantation. The cumulative 1-, 3-, 6and 12-month patency rate of the interpositional veins was 81.51, 79.60, 74.69 and 72.68%, respectively. Conclusion: The reconstruction technique based on our policy ensures
© 2014 S. Karger AG, Basel 0253–4886/14/0313–0210$39.50/0 E-Mail [email protected] www.karger.com/dsu
excellent outflow drainage and favorable recipient outcome, while better criteria for MHV reconstruction should be established. © 2014 S. Karger AG, Basel
Introduction
Adult-to-adult living donor liver transplantation (LDLT) offers a valuable opportunity to expand the donor pool for adult recipients. Compared with left hemiliver graft, right hemi-liver graft in an adult can provide a larger volume liver and hence satisfy the demands of the recipient’s metabolism as well as minimize the risk of small-for-size syndrome (SFSS). Early studies showed right-lobe LDLT without the middle hepatic vein (MHV) or MHV tributaries reconstruction caused severe congestion of the right anterior segment and early graft dysfunction [1]. A right liver graft with MHV trunk has been proven to provide an adequate graft volume for recipients and facilitate early graft regeneration [2–7]; however, it also extends the donor operation and hence raises concern as to donor safety. Under such circumstances, reconstruction of the MHV tributaries with venous grafts was recommended to prevent the potential congestion in the right anterior segment [1] and to guarantee donor safety. Also, evidence has shown that right-lobe LDLTs with the Lunan Yan, PhD 37# Guoxuexiang, Wuhou District Chengdu, Sichuan 610041 (PR China) E-Mail cpxcsugreat @ gmail.com
MHV tributaries reconstruction (modified right lobe) could provide a functioning liver mass comparable to right-lobe LDLTs with MHV trunk (extended right lobe) [8]. For a modified right lobe there would be technical difficulty as to the additional reconstruction of the MHV tributaries. Firstly, the source of optimal venous grafts for the procedure remains a concern, whether it is cryopreserved or autologous or prosthetic vein grafts [3, 8–30]. Secondly, an appropriate reconstruction policy also remains a concern, which could obviate additional procedures and possible outflow problems. Another issue concerns a wide outflow orifice for sufficient venous drainage. As a result, it is highly contentious referring to the complicated procedures and the necessity of the MHV reconstruction. Herein, we presented the surgical indications, techniques, as well as short- and long-term results for hepatic vein reconstruction in LDLTs with modified right lobes at our center. Methods From January 2001 to December 2010, 262 patients underwent LDLTs at West China Hospital, Sichuan University Medical School, Chengdu, China. They included 57 pediatric recipients, 10 receiving dual grafts, 9 undergoing adult-to-adult LDLTs with MHV trunk, and 186 undergoing adult-to-adult right-lobe LDLTs without MHV who were the subjects in the present study. Clinical data of the recipients and donors were collected from the Chinese Liver Transplantation Registration (CLTR). These patients consisted of 160 men and 26 women, aged from 18 to 69 years (mean 42.8). The indication for LDLT included liver cancer in 86 (46.2%) recipients, cirrhosis in 70 (37.6%) recipients, cholestatic diseases in 12 (6.5%) recipients, and acute liver failure in 12 (6.5%) recipients. Recipients were divided into two groups: group A without MHV tributaries reconstruction (n = 71) and group B with MHV tributaries reconstruction (n = 115). Demographic data of the patients are listed in table 1. The donors were 117 males and 69 females, aged from 19 to 65 years (mean 34.9). They consisted of 44 offspring, 43 siblings, 20 parents, 44 spouses, 2 in-law relationships, 5 altruistic volunteers, and 20 of other kinship. ABO incompatibility occurred in 29 donations. All cases were approved by the local ethics committee. The number and size of thick MHV tributaries draining the right paramedian sector were evaluated by CT scan before hepatectomy. Throughout donor hepatectomy, the major short hepatic veins (inferior right hepatic veins, IRHV), V5 or V8, if present and >5 mm, were isolated and preserved for reconstruction. According to the policy of our center, if the congested area was dominant as determined by the clamping test [31] or the diameter of the tributaries was ≥5 mm, we would proceed with bench reconstruction of the MHV tributaries. Whether the IRHV reconstruction is required was also based on the above criteria. The harvested liver graft was flushed with 2 liters of University of Wisconsin solution (UW) or histidine-tryptophan-ketoglutarate (HTK) through the right portal vein.
MHV Reconstruction in RL-LDLT
Either great saphenous vein grafts from the recipients or cryopreserved iliac artery (CIA) grafts were used for interposition. 33 recipients had reconstructed MHV tributaries with GVS grafts and 82 recipients utilized CIA grafts. Anastomosis between V5 or V8 and vessel grafts was carried out using a continuous 6-0 prolene suture. The innovative method of hepatic vein reconstruction has been carefully described in our previous studies [30, 32, 33]. A wide anastomotic stoma and short reconstructive veins were required to guarantee adequate outflow and to obviate liver graft compression and interpositional vessels kinking after reperfusion. When both V5 and V8 were needed to be reconstructed, they would be anastomosed separately to the IVC (multi-opening vertical anastomosis) (fig. 1a) or a Y-shaped venous patch (fig. 1b) would be used. Alternatively, V5/V8 branches were anastomosed to a longitudinal venous patch lying in the MHV groove, and then anastomosing the common trunk of graft right hepatic vein and venous patch to the recipient single caval opening, in this way the modified right lobe was reconstructed into the shape of an extended right lobe (fig. 1c). If the IRHV were preserved in the harvested graft, it was anastomosed end-to-side to the recipient’s retrohepatic vena cava. Inflow vascular and biliary reconstruction was carried out after hepatic vein reconstruction. Vascular flow in the graft or interposition vein patency was checked by Doppler ultrasonography (DUS) daily during hospital stay, and once a week thereafter until discharge. After discharge, it was evaluated by DUS every month, and then every 2 months for 2 years. Serum liver function markers such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), international normalized ratio (INR) and total bilirubin (TB) were measured daily for 2 weeks after LDLT, and twice a week until discharge. Statistical Analysis The significance of difference between the two groups was determined by Student’s t test, Mann-Whitney U test and the χ2 test. The Kaplan-Meier method was used to calculate graft survival probabilities after LDLT. Intergroup differences in graft survival rates were compared using the log-rank test. Statistical significance was accepted for a p value
Dig Surg 2014;31:210–218 DOI: 10.1159/000363416
Reconstructing Middle Hepatic Vein Tributaries in Right-Lobe Living Donor Liver Transplantation Peixian Chen Wentao Wang Lunan Yan Tianfu Wen Bo Li Jichun Zhao Department of Liver and Vascular Surgery, West China Hospital of Sichuan University, Chengdu, PR China
Key Words Living donor liver transplantation · Right lobe · Middle hepatic vein · Reconstruction · Venoplasty
Abstract Aims: To investigate the effectiveness of our technique and policy in reconstructing middle hepatic vein (MHV) tributaries of patients undergoing right-lobe living donor liver transplantation (LDLT). Methods: From January 2001 to December 2010, 186 adult patients underwent right-lobe LDLT without the MHV. Patients were divided into two groups: group A (n = 71) and group B (n = 115) without or with the MHV tributaries reconstruction. We evaluated the serum liver function markers after transplantation and monitored vascular flow in the graft and interpositional vein by Doppler ultrasonography. Results: The cumulative 1-, 3-, 5-year graft and patient survival rates were not significant between group A and group B (p = 0.287 and p = 0.258). Biliary complications appeared to be more frequent in group A than in group B (16.9 vs. 5.2%, p = 0.009). Liver function impairment was found in patients without MHV reconstruction and those with occluded interpositional vessels early after transplantation. The cumulative 1-, 3-, 6and 12-month patency rate of the interpositional veins was 81.51, 79.60, 74.69 and 72.68%, respectively. Conclusion: The reconstruction technique based on our policy ensures
© 2014 S. Karger AG, Basel 0253–4886/14/0313–0210$39.50/0 E-Mail [email protected] www.karger.com/dsu
excellent outflow drainage and favorable recipient outcome, while better criteria for MHV reconstruction should be established. © 2014 S. Karger AG, Basel
Introduction
Adult-to-adult living donor liver transplantation (LDLT) offers a valuable opportunity to expand the donor pool for adult recipients. Compared with left hemiliver graft, right hemi-liver graft in an adult can provide a larger volume liver and hence satisfy the demands of the recipient’s metabolism as well as minimize the risk of small-for-size syndrome (SFSS). Early studies showed right-lobe LDLT without the middle hepatic vein (MHV) or MHV tributaries reconstruction caused severe congestion of the right anterior segment and early graft dysfunction [1]. A right liver graft with MHV trunk has been proven to provide an adequate graft volume for recipients and facilitate early graft regeneration [2–7]; however, it also extends the donor operation and hence raises concern as to donor safety. Under such circumstances, reconstruction of the MHV tributaries with venous grafts was recommended to prevent the potential congestion in the right anterior segment [1] and to guarantee donor safety. Also, evidence has shown that right-lobe LDLTs with the Lunan Yan, PhD 37# Guoxuexiang, Wuhou District Chengdu, Sichuan 610041 (PR China) E-Mail cpxcsugreat @ gmail.com
MHV tributaries reconstruction (modified right lobe) could provide a functioning liver mass comparable to right-lobe LDLTs with MHV trunk (extended right lobe) [8]. For a modified right lobe there would be technical difficulty as to the additional reconstruction of the MHV tributaries. Firstly, the source of optimal venous grafts for the procedure remains a concern, whether it is cryopreserved or autologous or prosthetic vein grafts [3, 8–30]. Secondly, an appropriate reconstruction policy also remains a concern, which could obviate additional procedures and possible outflow problems. Another issue concerns a wide outflow orifice for sufficient venous drainage. As a result, it is highly contentious referring to the complicated procedures and the necessity of the MHV reconstruction. Herein, we presented the surgical indications, techniques, as well as short- and long-term results for hepatic vein reconstruction in LDLTs with modified right lobes at our center. Methods From January 2001 to December 2010, 262 patients underwent LDLTs at West China Hospital, Sichuan University Medical School, Chengdu, China. They included 57 pediatric recipients, 10 receiving dual grafts, 9 undergoing adult-to-adult LDLTs with MHV trunk, and 186 undergoing adult-to-adult right-lobe LDLTs without MHV who were the subjects in the present study. Clinical data of the recipients and donors were collected from the Chinese Liver Transplantation Registration (CLTR). These patients consisted of 160 men and 26 women, aged from 18 to 69 years (mean 42.8). The indication for LDLT included liver cancer in 86 (46.2%) recipients, cirrhosis in 70 (37.6%) recipients, cholestatic diseases in 12 (6.5%) recipients, and acute liver failure in 12 (6.5%) recipients. Recipients were divided into two groups: group A without MHV tributaries reconstruction (n = 71) and group B with MHV tributaries reconstruction (n = 115). Demographic data of the patients are listed in table 1. The donors were 117 males and 69 females, aged from 19 to 65 years (mean 34.9). They consisted of 44 offspring, 43 siblings, 20 parents, 44 spouses, 2 in-law relationships, 5 altruistic volunteers, and 20 of other kinship. ABO incompatibility occurred in 29 donations. All cases were approved by the local ethics committee. The number and size of thick MHV tributaries draining the right paramedian sector were evaluated by CT scan before hepatectomy. Throughout donor hepatectomy, the major short hepatic veins (inferior right hepatic veins, IRHV), V5 or V8, if present and >5 mm, were isolated and preserved for reconstruction. According to the policy of our center, if the congested area was dominant as determined by the clamping test [31] or the diameter of the tributaries was ≥5 mm, we would proceed with bench reconstruction of the MHV tributaries. Whether the IRHV reconstruction is required was also based on the above criteria. The harvested liver graft was flushed with 2 liters of University of Wisconsin solution (UW) or histidine-tryptophan-ketoglutarate (HTK) through the right portal vein.
MHV Reconstruction in RL-LDLT
Either great saphenous vein grafts from the recipients or cryopreserved iliac artery (CIA) grafts were used for interposition. 33 recipients had reconstructed MHV tributaries with GVS grafts and 82 recipients utilized CIA grafts. Anastomosis between V5 or V8 and vessel grafts was carried out using a continuous 6-0 prolene suture. The innovative method of hepatic vein reconstruction has been carefully described in our previous studies [30, 32, 33]. A wide anastomotic stoma and short reconstructive veins were required to guarantee adequate outflow and to obviate liver graft compression and interpositional vessels kinking after reperfusion. When both V5 and V8 were needed to be reconstructed, they would be anastomosed separately to the IVC (multi-opening vertical anastomosis) (fig. 1a) or a Y-shaped venous patch (fig. 1b) would be used. Alternatively, V5/V8 branches were anastomosed to a longitudinal venous patch lying in the MHV groove, and then anastomosing the common trunk of graft right hepatic vein and venous patch to the recipient single caval opening, in this way the modified right lobe was reconstructed into the shape of an extended right lobe (fig. 1c). If the IRHV were preserved in the harvested graft, it was anastomosed end-to-side to the recipient’s retrohepatic vena cava. Inflow vascular and biliary reconstruction was carried out after hepatic vein reconstruction. Vascular flow in the graft or interposition vein patency was checked by Doppler ultrasonography (DUS) daily during hospital stay, and once a week thereafter until discharge. After discharge, it was evaluated by DUS every month, and then every 2 months for 2 years. Serum liver function markers such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), international normalized ratio (INR) and total bilirubin (TB) were measured daily for 2 weeks after LDLT, and twice a week until discharge. Statistical Analysis The significance of difference between the two groups was determined by Student’s t test, Mann-Whitney U test and the χ2 test. The Kaplan-Meier method was used to calculate graft survival probabilities after LDLT. Intergroup differences in graft survival rates were compared using the log-rank test. Statistical significance was accepted for a p value
