- Email: [email protected]
Adult Living Donor Liver Transplantation With Right Lobe Graft: The Venous Outflow Management in the Milan-Niguarda Experience
Adult Living Donor Liver Transplantation With Right Lobe Graft: The Venous Outflow Management in the Milan-Niguarda Experience L. De Carlis, A. Lauterio, A. Giacomoni, A.O. Slim, V. Pirotta, J. Mangoni, and P. Mihaylov ABSTRACT 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.
T
O FACE THE LIMITED SUPPLY of organs available for transplantation, adult living donor liver transplantation (ALDLT) using right lobe grafts is an established treatment option for selected patients with end-stage liver disease.1– 4 One of the most important technical aspects is the hepatic venous outflow management concerning the middle hepatic vein (MHV) and the right lobe.5,6 In right lobe ALDLT without the MHV, reconstruction of MHV tributaries draining the right paramedian sector (corresponding to segments 5 and 8, V5 and V8) is often necessary to avoid severe graft congestion, but the various technical options have not been well understood.7,8 Herein we have briefly reported our surgical experience in the venous outflow management by hepatic vein reconstruction in ALDLT. PATIENTS AND METHODS From March 2001 through October 2007, we performed 36 right lobe ALDLT and one pediatric transplant (segments 2 and 3). The donors were 16 men and 10 women of median age of 36.8 years (range ⫽ 25– 64 years). Liver size and the anatomy of the hepatic
vessels, including hepatic veins; number and size of MHV tributaries or short inferior right hepatic veins (IRHV); portal vein; and arteries were assessed by multislice computed tomography scan with vascular reconstruction. Biliary anatomy was investigated using intraoperative cholangiography only in the first five cases. For the remaining 31 donors, the biliary tree was studied with magnetic resonance imaging (MRI) using a paramagnetic contrast agent with delayed biliary excretion. The MRI was also used to determine the percentage of liver steatosis. Our donor evaluation protocol has been previously described in detail.3,9,10 Right lobe transplantation was performed only when the calculated graft-to-recipient weight ratio (GRWR) was above 0.8% (range ⫽ 0.81%–1.12%). The volume of the donor liver was measured by computed tomography (CT) scan. The recipients were 21 men and 15 women of median age of 54.7 years (range ⫽ 27– 63 years). The recipients were on the From the Hepato-biliary Surgery and Liver Transplantation Unit, Azienda Ospedaliera Niguarda Cà Granda, Milan, Italy. Address reprint requests to Luciano De Carlis, Hepato-biliary Surgery and Liver Transplantation Unit, Azienda Ospedaliera Niguarda Cà Granda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy. E-mail: [email protected]
0041-1345/08/$–see front matter doi:10.1016/j.transproceed.2008.05.051
© 2008 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1944
Transplantation Proceedings, 40, 1944 –1946 (2008)
VENOUS OUTFLOW WITH RIGHT LOBE GRAFT waiting list for cadaveric donor liver transplantation as status UNOS 2B or 3. Donor and recipient blood groups were identical or compatible in all cases. The transplant was performed by grafting the right donor hemiliver (segments 5, 6, 7, and 8) to the recipient. The resection line was defined either by parenchymal demarcation obtained by clamping the right hilum or via intraoperative ultrasonography mapping MHV. The resection line was set a few millimeters from the right side of the MHV. In all cases, the MHV was retained with the left hemiliver to guarantee the greatest safety to the donor. The parenchymal transection was performed using the cavitron ultrasonic surgical aspirator. The other details of donor surgery have been described previously.3,9,10 The major IRHV, V5 or V8, if presented as greater than 5 mm, was isolated and preserved. In the presence of MHV tributaries larger than 5 mm, we evaluated liver surface congestion intraoperatively after parenchymal transection with simultaneous clamping of the MHV tributaries and the right hepatic artery. If the clamping test showed parenchyma discoloration, we proceeded with reconstruction of the MHV branches. While undertaking surgery on the recipient, we never used a venous-venous bypass or temporary portocaval shunt. Particular attention was devoted to achieve the best possible outflow. We always performed a caval slitting or cavoplasty to assure the largest outflow in the anastomosis between the right hepatic vein and the vena cava. The portal and the arterial anastomoses were end-to-end between the right elements of the graft and the right or common vessels of the recipient. Whenever possible, our first choice was to perform a direct biliary anastomosis between the right hepatic duct of the graft and the common or the right hepatic duct of the recipient. Vascular flow in the transplanted graft (right hepatic artery, portal vein, right hepatic vein, IRHV, and reconstructed MHV tributaries) was checked by Doppler ultrasound every day to postoperative day 5 and twice a week until hospital discharge. The immunosuppression was induced via administration of rabbit-antithymocyte globulin, calcineurin inhibitors (cyclosporine or tacrolimus), azathioprine, or mycophenolate mofetil and steroids. The immunosuppressive regimen was maintained with cyclosporine or tacrolimus alone starting at 1 month after the transplant.
1945
segment 8 (V8). Inferior hepatic veins draining segment 6 were presented in 11 cases. In 10 cases, we performed an end-to-side anastomosis between the IRHV and the side of the recipient vena cava using 6-0 running suture, while in one case we decided to ligate the vein. In three cases, the MHV tributaries were end-to-end anastomosed to the stump of the recipient MHV, which was preserved as long as possible during the recipient surgery. In one of these cases (V5), an interposition vein graft was necessary. In another case, the tributary vein was joined to the RHV after back table plasty. In all other cases (five V8, one V5, and one V6) the vein tributaries were not reconstructed. A CT scan performed from 1 to 3 months after surgery did not show any congested area in the liver parenchyma. DISCUSSION
ALDLT is a well-accepted option to successfully treat selected patients who cannot easily obtain a cadaveric organs while on the waiting list for liver transplantation. The management of hepatic vein outflow is a crucial, important issue in living donor liver transplantation.7,11,12 Inclusion of the MHV in the graft or reconstruction of tributaries greater than 5 mm from the right lobe to the MHV is recommended by most authors.2,12 In our experience, the reconstruction of these veins is not always necessary when GRWR is ⬎0.8. Intrahepatic rearrangement of venous flow was evident by control CT examinations. Pre- and intraoperative evaluations of the segmental branches of the hepatic vein are crucial for decisions to reconstruct these collaterals. Anastomosis of V5 or V8 to the stump of the recipient MHV reduces the number of vascular anastomoses and maintains a physiological angle between these collaterals and the caval vein.
RESULTS
REFERENCES
With 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. Causes of death were: massive pulmonary bleeding in a subject with RendùOsler syndrome, systemic aspergillosis, sepsis, and cardiac arythmias. Two recipients underwent retransplantation with a whole liver as a consequence of arterial thrombosis or small-for-size-syndrome. The recipient complications were: three hemorrhages, four biliary leaks from the cut surface, five anastomotic leaks, nine late anastomotic strictures, and one early kinking of the choledochus. Three of these patients developed two biliary complications. None of the donors experienced intraoperative complications. The donor complications were: four bile leaks, seven pleural effusions, and one pulmonary embolism. Four donors developed two complications. All complications were successfully only treated by medical management. All donors are alive and well. Large MHV tributaries (⬎5 mm) were present in 10 cases: two draining segment 5 (V5) and eight draining
1. Marcos A, Fisher RA, Ham JM, et al: Right lobe living donor liver transplantation. Transplantation 68:798, 1999 2. Marcos A: Right lobe living donor liver transplantation: a review. Liver Transpl 6:3, 2000 3. Giacomoni A, De Carlis L, Lauterio A, et al: Right hemiliver transplant: results from living and cadaveric donors. Transplant Proc 37:1167, 2005 4. Lo CM, Fan ST, Liu CL, et al: Lesson learned from one hundred right lobe living donor liver transplants. Ann Surg 240: 151, 2004 5. Liu CL, Lo CM, Fan ST: What is the best technique for right hemiliver living donor liver transplantation? With or without the middle hepatic vein? Duct-to-duct biliary anastomosis or Rouxen-Y hepaticojejunostomy? J Hepatol 43:17, 2005 6. de Villa VH, Chen CL, Chen YS, et al: Right hepatic lobe living donor liver transplantation addressing the middle hepatic vein controversy. Ann Surg 238:27, 2003 7. Akoad ME, Pomposelli JJ, Pomfret EA, et al: Venous outflow reconstruction without venovenous bypass or cavoplasty in live donor adult liver transplantation (LDALT) using right lobe graft (RLG). Am J Transplant 4(suppl 8):172, 2004 8. Sano K, Makuuchi M, Miki K, et al: Evaluation of hepatic venous congestion: proposed indication criteria for hepatic vein reconstruction. Ann Surg 236:241, 2002
1946 9. De Carlis L, Giacomoni A, Sammartino C, et al: Right lobe living-related liver transplantat: experience at Niguarda Hospital. Transplant Proc 35:516, 2003 10. Giacomoni A, Lauterio A, Slim AO, et al: Biliary complication after living donor liver transplantation. Transpl Int 19:466, 2006
DE CARLIS, LAUTERIO, GIACOMONI ET AL 11. Egawa H, Inomata Y, Uemoto S, et al: Hepatic vein reconstruction in 152 living related donor liver transplantation patients. Surgery 121:250, 1997 12. Sugawara Y, Makuuchi M, Sano K, et al: Vein reconstruction modified right liver graft for living donor liver transplantation. Ann Surg 237:180, 200
T
O FACE THE LIMITED SUPPLY of organs available for transplantation, adult living donor liver transplantation (ALDLT) using right lobe grafts is an established treatment option for selected patients with end-stage liver disease.1– 4 One of the most important technical aspects is the hepatic venous outflow management concerning the middle hepatic vein (MHV) and the right lobe.5,6 In right lobe ALDLT without the MHV, reconstruction of MHV tributaries draining the right paramedian sector (corresponding to segments 5 and 8, V5 and V8) is often necessary to avoid severe graft congestion, but the various technical options have not been well understood.7,8 Herein we have briefly reported our surgical experience in the venous outflow management by hepatic vein reconstruction in ALDLT. PATIENTS AND METHODS From March 2001 through October 2007, we performed 36 right lobe ALDLT and one pediatric transplant (segments 2 and 3). The donors were 16 men and 10 women of median age of 36.8 years (range ⫽ 25– 64 years). Liver size and the anatomy of the hepatic
vessels, including hepatic veins; number and size of MHV tributaries or short inferior right hepatic veins (IRHV); portal vein; and arteries were assessed by multislice computed tomography scan with vascular reconstruction. Biliary anatomy was investigated using intraoperative cholangiography only in the first five cases. For the remaining 31 donors, the biliary tree was studied with magnetic resonance imaging (MRI) using a paramagnetic contrast agent with delayed biliary excretion. The MRI was also used to determine the percentage of liver steatosis. Our donor evaluation protocol has been previously described in detail.3,9,10 Right lobe transplantation was performed only when the calculated graft-to-recipient weight ratio (GRWR) was above 0.8% (range ⫽ 0.81%–1.12%). The volume of the donor liver was measured by computed tomography (CT) scan. The recipients were 21 men and 15 women of median age of 54.7 years (range ⫽ 27– 63 years). The recipients were on the From the Hepato-biliary Surgery and Liver Transplantation Unit, Azienda Ospedaliera Niguarda Cà Granda, Milan, Italy. Address reprint requests to Luciano De Carlis, Hepato-biliary Surgery and Liver Transplantation Unit, Azienda Ospedaliera Niguarda Cà Granda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy. E-mail: [email protected]
0041-1345/08/$–see front matter doi:10.1016/j.transproceed.2008.05.051
© 2008 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1944
Transplantation Proceedings, 40, 1944 –1946 (2008)
VENOUS OUTFLOW WITH RIGHT LOBE GRAFT waiting list for cadaveric donor liver transplantation as status UNOS 2B or 3. Donor and recipient blood groups were identical or compatible in all cases. The transplant was performed by grafting the right donor hemiliver (segments 5, 6, 7, and 8) to the recipient. The resection line was defined either by parenchymal demarcation obtained by clamping the right hilum or via intraoperative ultrasonography mapping MHV. The resection line was set a few millimeters from the right side of the MHV. In all cases, the MHV was retained with the left hemiliver to guarantee the greatest safety to the donor. The parenchymal transection was performed using the cavitron ultrasonic surgical aspirator. The other details of donor surgery have been described previously.3,9,10 The major IRHV, V5 or V8, if presented as greater than 5 mm, was isolated and preserved. In the presence of MHV tributaries larger than 5 mm, we evaluated liver surface congestion intraoperatively after parenchymal transection with simultaneous clamping of the MHV tributaries and the right hepatic artery. If the clamping test showed parenchyma discoloration, we proceeded with reconstruction of the MHV branches. While undertaking surgery on the recipient, we never used a venous-venous bypass or temporary portocaval shunt. Particular attention was devoted to achieve the best possible outflow. We always performed a caval slitting or cavoplasty to assure the largest outflow in the anastomosis between the right hepatic vein and the vena cava. The portal and the arterial anastomoses were end-to-end between the right elements of the graft and the right or common vessels of the recipient. Whenever possible, our first choice was to perform a direct biliary anastomosis between the right hepatic duct of the graft and the common or the right hepatic duct of the recipient. Vascular flow in the transplanted graft (right hepatic artery, portal vein, right hepatic vein, IRHV, and reconstructed MHV tributaries) was checked by Doppler ultrasound every day to postoperative day 5 and twice a week until hospital discharge. The immunosuppression was induced via administration of rabbit-antithymocyte globulin, calcineurin inhibitors (cyclosporine or tacrolimus), azathioprine, or mycophenolate mofetil and steroids. The immunosuppressive regimen was maintained with cyclosporine or tacrolimus alone starting at 1 month after the transplant.
1945
segment 8 (V8). Inferior hepatic veins draining segment 6 were presented in 11 cases. In 10 cases, we performed an end-to-side anastomosis between the IRHV and the side of the recipient vena cava using 6-0 running suture, while in one case we decided to ligate the vein. In three cases, the MHV tributaries were end-to-end anastomosed to the stump of the recipient MHV, which was preserved as long as possible during the recipient surgery. In one of these cases (V5), an interposition vein graft was necessary. In another case, the tributary vein was joined to the RHV after back table plasty. In all other cases (five V8, one V5, and one V6) the vein tributaries were not reconstructed. A CT scan performed from 1 to 3 months after surgery did not show any congested area in the liver parenchyma. DISCUSSION
ALDLT is a well-accepted option to successfully treat selected patients who cannot easily obtain a cadaveric organs while on the waiting list for liver transplantation. The management of hepatic vein outflow is a crucial, important issue in living donor liver transplantation.7,11,12 Inclusion of the MHV in the graft or reconstruction of tributaries greater than 5 mm from the right lobe to the MHV is recommended by most authors.2,12 In our experience, the reconstruction of these veins is not always necessary when GRWR is ⬎0.8. Intrahepatic rearrangement of venous flow was evident by control CT examinations. Pre- and intraoperative evaluations of the segmental branches of the hepatic vein are crucial for decisions to reconstruct these collaterals. Anastomosis of V5 or V8 to the stump of the recipient MHV reduces the number of vascular anastomoses and maintains a physiological angle between these collaterals and the caval vein.
RESULTS
REFERENCES
With 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. Causes of death were: massive pulmonary bleeding in a subject with RendùOsler syndrome, systemic aspergillosis, sepsis, and cardiac arythmias. Two recipients underwent retransplantation with a whole liver as a consequence of arterial thrombosis or small-for-size-syndrome. The recipient complications were: three hemorrhages, four biliary leaks from the cut surface, five anastomotic leaks, nine late anastomotic strictures, and one early kinking of the choledochus. Three of these patients developed two biliary complications. None of the donors experienced intraoperative complications. The donor complications were: four bile leaks, seven pleural effusions, and one pulmonary embolism. Four donors developed two complications. All complications were successfully only treated by medical management. All donors are alive and well. Large MHV tributaries (⬎5 mm) were present in 10 cases: two draining segment 5 (V5) and eight draining
1. Marcos A, Fisher RA, Ham JM, et al: Right lobe living donor liver transplantation. Transplantation 68:798, 1999 2. Marcos A: Right lobe living donor liver transplantation: a review. Liver Transpl 6:3, 2000 3. Giacomoni A, De Carlis L, Lauterio A, et al: Right hemiliver transplant: results from living and cadaveric donors. Transplant Proc 37:1167, 2005 4. Lo CM, Fan ST, Liu CL, et al: Lesson learned from one hundred right lobe living donor liver transplants. Ann Surg 240: 151, 2004 5. Liu CL, Lo CM, Fan ST: What is the best technique for right hemiliver living donor liver transplantation? With or without the middle hepatic vein? Duct-to-duct biliary anastomosis or Rouxen-Y hepaticojejunostomy? J Hepatol 43:17, 2005 6. de Villa VH, Chen CL, Chen YS, et al: Right hepatic lobe living donor liver transplantation addressing the middle hepatic vein controversy. Ann Surg 238:27, 2003 7. Akoad ME, Pomposelli JJ, Pomfret EA, et al: Venous outflow reconstruction without venovenous bypass or cavoplasty in live donor adult liver transplantation (LDALT) using right lobe graft (RLG). Am J Transplant 4(suppl 8):172, 2004 8. Sano K, Makuuchi M, Miki K, et al: Evaluation of hepatic venous congestion: proposed indication criteria for hepatic vein reconstruction. Ann Surg 236:241, 2002
1946 9. De Carlis L, Giacomoni A, Sammartino C, et al: Right lobe living-related liver transplantat: experience at Niguarda Hospital. Transplant Proc 35:516, 2003 10. Giacomoni A, Lauterio A, Slim AO, et al: Biliary complication after living donor liver transplantation. Transpl Int 19:466, 2006
DE CARLIS, LAUTERIO, GIACOMONI ET AL 11. Egawa H, Inomata Y, Uemoto S, et al: Hepatic vein reconstruction in 152 living related donor liver transplantation patients. Surgery 121:250, 1997 12. Sugawara Y, Makuuchi M, Sano K, et al: Vein reconstruction modified right liver graft for living donor liver transplantation. Ann Surg 237:180, 200