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Preservation of Recipient Middle Hepatic Vein for Drainage of Anterior Sector Veins in Adult-to-Adult Living-Donor Liver Transplantation
Preservation of Recipient Middle Hepatic Vein for Drainage of Anterior Sector Veins in Adult-to-Adult Living-Donor Liver Transplantation M.E. Facciuto, M.I. Rodriguez-Davalos, S. Nagarajan, M.K. Singh, J.P. Rocca, and P.A. Sheiner
The inclusion of donor middle hepatic vein (MHV) in right-lobe living-donor grafts and the need for reconstruction of the MHV tributaries have long been controversial areas in living-donor liver transplantation. We report technical details in restoration of venous drainage of the anterior sector (segments V and VIII) of the right lobe of the liver graft using a preserved MHV from the recipient liver, and address the issue of reconstruction of donor MHV tributaries without use of an interposition graft. We review clinical situations in which restoration of outflow drainage of the anterior segment of the liver graft should be considered. HETHER THE DONOR middle hepatic vein (MHV) should be included in right-lobe graft in adult-toadult living-donor liver transplantation (LDLT) is controversial.1 Congestion of the poorly drained anterior sector of the graft, which includes segments V and VIII, has been described, and addressing the outflow of the MHV tributaries may lead to better regeneration and larger volume of the liver graft.2,3 Numerous methods of reconstructing the outflow MHV tributaries are described in the literature.4 –11 Herein, we report our experience using the recipient MHV as a vascular conduit to restore blood outflow to the MHV tributaries from the anterior sector of right-lobe liver grafts.
W
PATIENTS AND METHODS Between August 2002 and November 2007, a total of 15 LDLTs were performed at our institution. We describe the use of recipient MHV as an interposition graft to drain the MHV tributaries in 3 patients undergoing adult-to-adult right-lobe LDLT. Preoperative donor evaluation included specific assessment of donor liver MHV tributaries draining the right anterior segments using preoperative computed tomography (CT). When the anterior segments of the donor liver (segments V or VIII) were found to drain exclusively to the MHV (independent from the right hepatic vein) and the diameter of the MHV tributaries was greater than 5 mm, restoration of the venous drainage of segments V or VIII was considered. The operative procedure for the donor surgery has been described in detail by Malago et al.12 The resection line was kept along the margin of the MHV, which was left with the donor. The major tributaries of the MHV were identified, resected at the junction with the MHV, and preserved for possible anastomosis. Venous congestion in the anterior segments of the right lobe was investigated after transection of the liver parenchyma as previously described by Sano et al.13 In brief, by temporary clamping of the
right hepatic artery, the liver surface of the veno-occlusive area becomes discolored compared with other sectors of the right lobe of the donor liver. In all 3 patients, the discolored area was consistent with the areas exclusively drained by MHV tributaries described at preoperative CT. Thus, reconstruction of the MHV tributaries was indicated. During the recipient operation, the inferior vena cava was preserved in all cases, and the liver was dissected from surrounding structures and left attached only by the major hepatic veins and the portal vein. After vascular clamps were applied, the recipient MHV was exposed from its junction to the inferior vena cava by careful blunt dissection of the liver parenchyma in a bloodless field, leaving a long (5–10 cm) venous conduit for drainage of donor MHV tributaries. After vascular division and total hepatectomy was accomplished, the stump of the left hepatic vein (LHV) was left open for flushing of preservation solution after graft reperfusion. The donor right lobe was brought to the operative field after back table flush. The recipient caval opening was anastomosed to the donor right hepatic vein orifice. The donor segment V or VIII hepatic vein was anastomosed end to end to the recipient MHV with 6-0 polypropylene running suture (Fig 1). Small branches of the recipients MHV were over sewn with 7-0 polypropylene. After portal vein anastomosis was completed, the liver was reperfused. Through the LHV stump, the graft was flushed and preservation solution and blood were vented. After venting was completed, the From the Liver Transplant and Hepatobiliary Surgery/Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York. Address reprint requests to Marcelo E. Facciuto, MD, Assosiate Professor, Department of Surgery, Liver Transplant and Hepatobiliary Surgery, Westchester Medical Center, Transplant Center, BHC-A Wing, 95 Grasslands Road, Valhalla, NY 10595. E-mail: [email protected]
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.02.088
Transplantation Proceedings, 41, 1687–1690 (2009)
1687
1688
FACCIUTO, RODRIGUEZ-DAVALOS, NAGARAJAN ET AL
Fig 1. Diagram shows the dissected middle hepatic vein in the recipient anastomosed to the segment V vein of the donor in right-lobe living-donor liver transplantation. LHV stump was closed. No congestion of the right-lobe graft was noted. The hepatic artery and biliary anastomoses were subsequently performed. Intraoperative color Doppler ultrasonography confirmed excellent flow in MHV tributaries.
RESULTS
Three women, aged 59, 56, and 64 years, were the recipients of these procedures. End-stage liver disease was due to primary sclerosing cholangitis in 1 patient and hepatitis C in the other 2. Right-lobe grafts from 3 men, aged 26, 34, and 47 years, respectively, were transplanted successfully. The MHV was anastomosed to the segment V vein in 2 patients and to the segment VIII vein in 1 patient. Routine color Doppler ultrasonography was performed in all 3 patients on the first postoperative day and showed adequate outflow through the MHV. The patients were discharged from the hospital on postoperative days 9, 12, and 10, respectively. There were no postoperative complications except for wound dehiscence in 1 patient, which was surgically repaired during a second admission within a month. All 3 patients were doing well at 6, 22, and 23 months of follow-up. The patency of the MHV outflow has been good
in all 3 patients as demonstrated at contrast-enhanced CT in 1 patient at 22 months of follow-up (Fig 2). DISCUSSION
The importance of obtaining effective drainage of the anterior segments of right-lobe grafts has been increasingly recognized. There is clear evidence that including the MHV in the donor right lobe improves the drainage of the right anterior segments and improves the ratio of anterior segment volume to graft volume.3,14 Reconstruction of MHV tributaries remains a good alternative option to including the MHV in the graft. Ghobrial et al15 found drainage of the right lobe of the liver predominantly by MHV tributaries in one-fourth of their patients. To determine the need for reconstruction of MHV tributaries, the proportion of the congestive area and the diameter of the tributaries are critical elements.16 Sano et al13 assessed the need for venous reconstruction of the MHV tributaries by clamping the right hepatic artery after parenchymal transection at the donor hepatectomy. If the discolored area was large, then the reconstruction of MHV tributaries was indicated. Recipient variables have an im-
BLOOD FLOW TO MIDDLE HEPATIC VEIN
1689
duits such as great saphenous vein, superficial femoral vein, umbilical vein, and collateral omental vein. Other alternatives include cryopreserved cadaveric vascular conduits such as iliac artery and vein, and prosthetic interposition grafts.4,7–10 Preserving the recipient MHV is a simple and efficient method of outflow reconstruction in right-lobe grafts. Takatsuki et al11 initially described dissecting the recipient MHV and closing the LHV during the final step of the hepatectomy before cross-clamping. In our series, dissection of the MHV is made safer and faster under total vascular isolation in a bloodless liver parenchyma. In addition, the LHV stump is left patent for flushing blood and preservation solution after reperfusion. We believe that preservation of recipient MHV is ideal for reconstruction of donor MHV tributaries larger than 5 mm that drain the anterior segments of the right lobe exclusively. However, this may not be feasible in patients with hepatocellular carcinoma or patients who have undergone previous liver resection in close proximity to the MHV.
REFERENCES
Fig 2. Sagittal contrast-enhanced computed tomographic scan obtained at 22-month follow-up shows the patent segment V vein draining into the recipient middle hepatic vein.
portant role in the decision to reconstruct MHV tributaries. The functional recovery and graft regeneration has been significantly better in small-for-size grafts when the reconstructed venous outflow was patent2 and in the presence of severe portal hypertension.17 Numerous methods have been reported for successful reconstruction of MHV tributaries with autologous con-
1. de Villa VH, Chen CL, Chen YS, et al: Right lobe living donor liver transplantation: addressing the middle hepatic vein controversy. Ann Surg 238:275, 2003 2. Kim DG, Moon IS, Kim SJ, et al: Effect of middle hepatic vein reconstruction in living donor liver transplantation using right lobe. Transplant Proc 38:2099, 2006 3. Mizuno S, Iida T, Yagi S, et al: Impact of venous drainage on the regeneration of the anterior segment of right living-related liver grafts. Clin Transplant 20:509, 2006 4. Yi NJ, Suh KS, Lee HW, et al: An artificial vascular graft is a useful interposition material for the drainage of the right anterior section in living donor liver transplantation. Liver Transpl 13:1075, 2007 5. Hong WU, Yan LN, Li B, et al: Hepatic venous outflow in right lobe graft without middle hepatic vein. Hepatol Res 37:1044, 2007 6. Eguchi S, Takatsuki M, Soyama A, et al: A modified triangular venoplasty for reconstruction of middle hepatic vein tributaries in living donor liver transplantation. Surgery 141:829, 2007 7. Kilic M, Avdin U, Sozbilen M, et al: Comparison between allogenic and autologous vascular conduits in the drainage of anterior sector in right living donor liver transplantation. Transpl Int 20:697, 2007 8. Hwang S, Lee SG, Ha TY, et al: Tailoring transection of segment V vein for optimal sharing of middle hepatic vein in right lobe living donor liver transplantation. Hepatogastroenterology 53:904, 2006 9. Kinkhabwala MM, Guarrera JV, Leno R, et al: Outflow reconstruction in right hepatic live donor liver transplantation. Surgery 133:243, 2003 10. Sato K, Sekiguchi S, Fukumori T, et al: Experience with recipient’s superficial femoral vein as conduit for middle hepatic vein reconstruction in a right-lobe living donor liver transplant procedure. Transplant Proc 37:4343, 2005 11. Takatsuki M, Miyamoto S, Kamohara Y, et al: Simplified technique for middle hepatic vein tributary reconstruction of a right hepatic graft in adult living donor liver transplantation. Am J Surg 192:393, 2006
1690 12. Malago M, Testa G, Frilling A, et al: Right living donor liver transplantation, an option for adult patients: single institution experience with 74 patients. Ann Surg 238:853, 2003 13. 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 14. Cho EH, Suh KS, Lee HW, et al: Safety of modified extended right hepatectomy in living liver donors. Transpl Int 20:779, 2007
FACCIUTO, RODRIGUEZ-DAVALOS, NAGARAJAN ET AL 15. Ghobrial RM, Hsieh CB, Lerner S, et al: Technical challenges of hepatic venous outflow reconstruction in right lobe adult living donor liver transplantation. Liver Transpl 7:551, 2001 16. Yu PF, Wu J, Zheng SS: Management of the middle hepatic vein and its tributaries in right lobe living donor liver transplantation. Hepatobiliary Pancreat Dis Int 6:358, 2007 17. Gyu Lee S, Min Park K, Hwang S, et al: Modified right liver graft from a living donor to prevent congestion. Transplantation 15;74:54, 2002
The inclusion of donor middle hepatic vein (MHV) in right-lobe living-donor grafts and the need for reconstruction of the MHV tributaries have long been controversial areas in living-donor liver transplantation. We report technical details in restoration of venous drainage of the anterior sector (segments V and VIII) of the right lobe of the liver graft using a preserved MHV from the recipient liver, and address the issue of reconstruction of donor MHV tributaries without use of an interposition graft. We review clinical situations in which restoration of outflow drainage of the anterior segment of the liver graft should be considered. HETHER THE DONOR middle hepatic vein (MHV) should be included in right-lobe graft in adult-toadult living-donor liver transplantation (LDLT) is controversial.1 Congestion of the poorly drained anterior sector of the graft, which includes segments V and VIII, has been described, and addressing the outflow of the MHV tributaries may lead to better regeneration and larger volume of the liver graft.2,3 Numerous methods of reconstructing the outflow MHV tributaries are described in the literature.4 –11 Herein, we report our experience using the recipient MHV as a vascular conduit to restore blood outflow to the MHV tributaries from the anterior sector of right-lobe liver grafts.
W
PATIENTS AND METHODS Between August 2002 and November 2007, a total of 15 LDLTs were performed at our institution. We describe the use of recipient MHV as an interposition graft to drain the MHV tributaries in 3 patients undergoing adult-to-adult right-lobe LDLT. Preoperative donor evaluation included specific assessment of donor liver MHV tributaries draining the right anterior segments using preoperative computed tomography (CT). When the anterior segments of the donor liver (segments V or VIII) were found to drain exclusively to the MHV (independent from the right hepatic vein) and the diameter of the MHV tributaries was greater than 5 mm, restoration of the venous drainage of segments V or VIII was considered. The operative procedure for the donor surgery has been described in detail by Malago et al.12 The resection line was kept along the margin of the MHV, which was left with the donor. The major tributaries of the MHV were identified, resected at the junction with the MHV, and preserved for possible anastomosis. Venous congestion in the anterior segments of the right lobe was investigated after transection of the liver parenchyma as previously described by Sano et al.13 In brief, by temporary clamping of the
right hepatic artery, the liver surface of the veno-occlusive area becomes discolored compared with other sectors of the right lobe of the donor liver. In all 3 patients, the discolored area was consistent with the areas exclusively drained by MHV tributaries described at preoperative CT. Thus, reconstruction of the MHV tributaries was indicated. During the recipient operation, the inferior vena cava was preserved in all cases, and the liver was dissected from surrounding structures and left attached only by the major hepatic veins and the portal vein. After vascular clamps were applied, the recipient MHV was exposed from its junction to the inferior vena cava by careful blunt dissection of the liver parenchyma in a bloodless field, leaving a long (5–10 cm) venous conduit for drainage of donor MHV tributaries. After vascular division and total hepatectomy was accomplished, the stump of the left hepatic vein (LHV) was left open for flushing of preservation solution after graft reperfusion. The donor right lobe was brought to the operative field after back table flush. The recipient caval opening was anastomosed to the donor right hepatic vein orifice. The donor segment V or VIII hepatic vein was anastomosed end to end to the recipient MHV with 6-0 polypropylene running suture (Fig 1). Small branches of the recipients MHV were over sewn with 7-0 polypropylene. After portal vein anastomosis was completed, the liver was reperfused. Through the LHV stump, the graft was flushed and preservation solution and blood were vented. After venting was completed, the From the Liver Transplant and Hepatobiliary Surgery/Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York. Address reprint requests to Marcelo E. Facciuto, MD, Assosiate Professor, Department of Surgery, Liver Transplant and Hepatobiliary Surgery, Westchester Medical Center, Transplant Center, BHC-A Wing, 95 Grasslands Road, Valhalla, NY 10595. E-mail: [email protected]
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.02.088
Transplantation Proceedings, 41, 1687–1690 (2009)
1687
1688
FACCIUTO, RODRIGUEZ-DAVALOS, NAGARAJAN ET AL
Fig 1. Diagram shows the dissected middle hepatic vein in the recipient anastomosed to the segment V vein of the donor in right-lobe living-donor liver transplantation. LHV stump was closed. No congestion of the right-lobe graft was noted. The hepatic artery and biliary anastomoses were subsequently performed. Intraoperative color Doppler ultrasonography confirmed excellent flow in MHV tributaries.
RESULTS
Three women, aged 59, 56, and 64 years, were the recipients of these procedures. End-stage liver disease was due to primary sclerosing cholangitis in 1 patient and hepatitis C in the other 2. Right-lobe grafts from 3 men, aged 26, 34, and 47 years, respectively, were transplanted successfully. The MHV was anastomosed to the segment V vein in 2 patients and to the segment VIII vein in 1 patient. Routine color Doppler ultrasonography was performed in all 3 patients on the first postoperative day and showed adequate outflow through the MHV. The patients were discharged from the hospital on postoperative days 9, 12, and 10, respectively. There were no postoperative complications except for wound dehiscence in 1 patient, which was surgically repaired during a second admission within a month. All 3 patients were doing well at 6, 22, and 23 months of follow-up. The patency of the MHV outflow has been good
in all 3 patients as demonstrated at contrast-enhanced CT in 1 patient at 22 months of follow-up (Fig 2). DISCUSSION
The importance of obtaining effective drainage of the anterior segments of right-lobe grafts has been increasingly recognized. There is clear evidence that including the MHV in the donor right lobe improves the drainage of the right anterior segments and improves the ratio of anterior segment volume to graft volume.3,14 Reconstruction of MHV tributaries remains a good alternative option to including the MHV in the graft. Ghobrial et al15 found drainage of the right lobe of the liver predominantly by MHV tributaries in one-fourth of their patients. To determine the need for reconstruction of MHV tributaries, the proportion of the congestive area and the diameter of the tributaries are critical elements.16 Sano et al13 assessed the need for venous reconstruction of the MHV tributaries by clamping the right hepatic artery after parenchymal transection at the donor hepatectomy. If the discolored area was large, then the reconstruction of MHV tributaries was indicated. Recipient variables have an im-
BLOOD FLOW TO MIDDLE HEPATIC VEIN
1689
duits such as great saphenous vein, superficial femoral vein, umbilical vein, and collateral omental vein. Other alternatives include cryopreserved cadaveric vascular conduits such as iliac artery and vein, and prosthetic interposition grafts.4,7–10 Preserving the recipient MHV is a simple and efficient method of outflow reconstruction in right-lobe grafts. Takatsuki et al11 initially described dissecting the recipient MHV and closing the LHV during the final step of the hepatectomy before cross-clamping. In our series, dissection of the MHV is made safer and faster under total vascular isolation in a bloodless liver parenchyma. In addition, the LHV stump is left patent for flushing blood and preservation solution after reperfusion. We believe that preservation of recipient MHV is ideal for reconstruction of donor MHV tributaries larger than 5 mm that drain the anterior segments of the right lobe exclusively. However, this may not be feasible in patients with hepatocellular carcinoma or patients who have undergone previous liver resection in close proximity to the MHV.
REFERENCES
Fig 2. Sagittal contrast-enhanced computed tomographic scan obtained at 22-month follow-up shows the patent segment V vein draining into the recipient middle hepatic vein.
portant role in the decision to reconstruct MHV tributaries. The functional recovery and graft regeneration has been significantly better in small-for-size grafts when the reconstructed venous outflow was patent2 and in the presence of severe portal hypertension.17 Numerous methods have been reported for successful reconstruction of MHV tributaries with autologous con-
1. de Villa VH, Chen CL, Chen YS, et al: Right lobe living donor liver transplantation: addressing the middle hepatic vein controversy. Ann Surg 238:275, 2003 2. Kim DG, Moon IS, Kim SJ, et al: Effect of middle hepatic vein reconstruction in living donor liver transplantation using right lobe. Transplant Proc 38:2099, 2006 3. Mizuno S, Iida T, Yagi S, et al: Impact of venous drainage on the regeneration of the anterior segment of right living-related liver grafts. Clin Transplant 20:509, 2006 4. Yi NJ, Suh KS, Lee HW, et al: An artificial vascular graft is a useful interposition material for the drainage of the right anterior section in living donor liver transplantation. Liver Transpl 13:1075, 2007 5. Hong WU, Yan LN, Li B, et al: Hepatic venous outflow in right lobe graft without middle hepatic vein. Hepatol Res 37:1044, 2007 6. Eguchi S, Takatsuki M, Soyama A, et al: A modified triangular venoplasty for reconstruction of middle hepatic vein tributaries in living donor liver transplantation. Surgery 141:829, 2007 7. Kilic M, Avdin U, Sozbilen M, et al: Comparison between allogenic and autologous vascular conduits in the drainage of anterior sector in right living donor liver transplantation. Transpl Int 20:697, 2007 8. Hwang S, Lee SG, Ha TY, et al: Tailoring transection of segment V vein for optimal sharing of middle hepatic vein in right lobe living donor liver transplantation. Hepatogastroenterology 53:904, 2006 9. Kinkhabwala MM, Guarrera JV, Leno R, et al: Outflow reconstruction in right hepatic live donor liver transplantation. Surgery 133:243, 2003 10. Sato K, Sekiguchi S, Fukumori T, et al: Experience with recipient’s superficial femoral vein as conduit for middle hepatic vein reconstruction in a right-lobe living donor liver transplant procedure. Transplant Proc 37:4343, 2005 11. Takatsuki M, Miyamoto S, Kamohara Y, et al: Simplified technique for middle hepatic vein tributary reconstruction of a right hepatic graft in adult living donor liver transplantation. Am J Surg 192:393, 2006
1690 12. Malago M, Testa G, Frilling A, et al: Right living donor liver transplantation, an option for adult patients: single institution experience with 74 patients. Ann Surg 238:853, 2003 13. 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 14. Cho EH, Suh KS, Lee HW, et al: Safety of modified extended right hepatectomy in living liver donors. Transpl Int 20:779, 2007
FACCIUTO, RODRIGUEZ-DAVALOS, NAGARAJAN ET AL 15. Ghobrial RM, Hsieh CB, Lerner S, et al: Technical challenges of hepatic venous outflow reconstruction in right lobe adult living donor liver transplantation. Liver Transpl 7:551, 2001 16. Yu PF, Wu J, Zheng SS: Management of the middle hepatic vein and its tributaries in right lobe living donor liver transplantation. Hepatobiliary Pancreat Dis Int 6:358, 2007 17. Gyu Lee S, Min Park K, Hwang S, et al: Modified right liver graft from a living donor to prevent congestion. Transplantation 15;74:54, 2002