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Right Lobe Living Related Liver Transplantation in Adults Without Venous Drainage of the Paramedian Sector
Right Lobe Living Related Liver Transplantation in Adults Without Venous Drainage of the Paramedian Sector O. Detry, A. De Roover, C. Coimbra, J. Delwaide, M.F. Hans, J. Monard, A. Kaba, J. Joris, P. Honoré, and M. Meurisse ABSTRACT Introduction. There is some controversy on the necessity of venous reconstruction of the right paramedian sector (segments V and VIII) during right lobe living related liver transplantation. In this report we describe the evolution of posttransplant graft function in five consecutive right lobe recipients without specific drainage of the right paramedian sector. Material and methods. The technique of common right hepatectomy for right lobe graft harvesting and transplantation did not include the middle hepatic vein in the graft. The mean total ischemic time was 51 minutes (ranges: 35 to 64 minutes). The mean graft to recipient weight ratio was 1.35% ⫾ 0.15%. No patient developed small-for-size syndrome. Results. All patients showed a rise in transaminases with a maximum at postoperative day 2 (mean aspartate aminotransferase: 1067 ⫾ 432 IU/mL). Liver function improved rapidly, with coagulation normalized at postoperative day 5. Bilirubin decreased progressively to normalize in three patients at postoperative day 14. Ultrasonography and computed tomography demonstrated that the paramedian sector of the right liver was congested, a state that was temporary with normalization of the liver tests and congestion disappeared at follow-up. No complication was linked to congestion. Discussion. This series showed that in right lobe liver transplantation with a relatively large-size graft, reconstruction of the hepatic veins of the paramedian sector may not be necessary despite the induction of some degree of venous congestion. In smaller grafts, this congestion might be avoided by reconstruction of the large veins draining segments V and VIII.
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IGHT LOBE LIVING RELATED liver transplantation (LRLT) has been recently introduced in adult recipients.1 Commonly, the right lobe graft (Couinaud’s segments V to VIII) is transplanted with anastomoses of the right hepatic artery, the right branch of the portal vein and the right hepatic vein.2 With this technique, venous drainage from the right paramedian sector of the right liver graft (segments V and VIII) depends on collateral veins to the right hepatic vein. In some cases, poor venous outflow can result in severe congestion and liver failure.3 In this report we describe the evolution of posttransplant liver function in five consecutive right lobe recipients whose grafts were transplanted without specific drainage of the right paramedian sector. PATIENTS AND METHODS Five recipients of right lobe grafts were evaluated prospectively in this study. Indications for transplantation were autoimmune hep-
atitis; hepatitis B virus cirrhosis with hepatocarcinoma (two cases); and hepatitis C cirrhosis with (one case) or without (one case) hepatocarcinoma. Before the procedure four recipients were in Child C status and one in Child B. The mean age of the donors was 34 years (range: 21 to 53 years); the mean age of the recipients, 51 years (range: 17 to 69 years). All donors were first-degree relatives of the recipient. The technique was the common right hepatectomy (segments V to VIII) for right lobe graft harvesting and transplantation without including the middle hepatic vein in the graft.2 The From the Departments of Liver Surgery and Transplantation (O.D., A.D.R., C.C., M.F.H., J.M., P.H., M.M.), Hepatology (J.D.), and Anaesthesiology and Intensive Care (A.K., J.J.), University of Liège, Liège, Belgium. Address reprint requests to Dr Olivier Detry, Department of Liver Surgery and Transplantation, University Hospital of Liège, Sart-Tilman B35, B-4000 Liège, Belgium. E-mail: Oli.Detry@chu. ulg.ac.be
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.05.013
Transplantation Proceedings, 37, 2865–2868 (2005)
2865
2866
DETRY, DE ROOVER, COIMBRA ET AL
Fig 1. Postoperative glutamate pyruvate transminase (GPT) evolution.
recipients underwent total hepatectomy and usual piggyback liver transplantation after completion of a temporary, end-to-side, portocaval shunt. The reconstruction started by the end-to-side suture of the right hepatic vein to the recipient inferior vena cava and the end-to-end anastomosis of the graft right portal vein to the recipient portal vein. No middle hepatic vein was reconstructed. The graft was then reperfused, ending the ischemia. Mean total (from clamping of the lobar hepatic artery and portal vein to reperfusion) ischemic time was 51 min (ranges: 35 to 64 minutes). The arterial perfusion of the graft was assured by an end-to-end anastomosis between the graft right hepatic artery and the recipient main hepatic artery after selective ligation of the splenic artery. Bile duct reconstruction was performed by
Fig 2. Postoperative evolution of the coagulation function expressed as Quick level.
suture of the bile ducts to a Roux-in-Y loop or a duct-to-duct anastomosis, without bile duct drainage. Mean graft-to-recipient weight ratio (GRWR) was 1.35% ⫾ 0.15% (ranges: 0.97% to 1.9%). No patient developed small-for-size syndrome or refractory ascitis. All recipients were prospectively followed during the first 2 weeks by daily liver laboratory tests and Doppler ultrasonography, and protocol computed tomography after 10 days and 6 months. Recipient postoperative immunosuppression included tacrolimus, mycophenolate mofetil, and low-dose steroids for the first 3 months, and with a steroid-free regimen after the third month. One recipient died on postoperative day 11 from multiple organ failure due to invasive aspergillosis.
LIVER TRANSPLANTATION WITHOUT VENOUS DRAINAGE
2867
Fig 3. Postoperative evolution of the bilirubin level.
RESULTS Laboratory Tests
The results are expressed as mean values and standard errors of the mean. All patients developed a rise in transaminases (Fig 1), reaching a maximum at postoperative day 2 (mean: 1067 ⫾ 432 IU/mL). In two patients aspartate aminotransferase peaked over 1,500 IU/mL. Liver function improved rapidly, with coagulation normalized at postoperative day 5 (Fig 2). Bilirubin decreased progressively to normalize in three patients at postoperative day 14 (Fig 3). Ultrasonography and Computed Tomography
All patients developed congestion of the paramedian sector. At ultrasonography this part of the liver was hyperechogenic. The congestion was confirmed by computed tomography (Fig 4). The congestion was temporary with normalization of liver tests and disappearance by computed tomography at 6 months’ follow-up. No complication was linked to this congestion in the follow-up of the four surviving patients. One patient developed stenosis of a duct-to-duct bile duct anastomosis. DISCUSSION
In the common technique of right lobe LRLT, the venous hepatic branches draining segments V and VIII are ligated.2 Among patients undergoing hepatectomy, this ligation usually does not pose problems, because collateral circulation develops via the sinusoids and short hepatic veins, and occasionally via the portal vein.4 However, it was reported that in LRLT, a right liver graft without a middle hepatic vein might be complicated with severe congestion of the paramedian sector. Some cases of right liver graft failure due to venous congestion were published.3
Fig 4. Hepatic computed tomography of patient 3, showing congestion during the early posttransplant period (a), which disappeared at 6 months’ follow-up (b).
DETRY, DE ROOVER, COIMBRA ET AL
2868
Several means of reconstruction of the middle hepatic vein tributaries have been described, mainly by teams in the Eastern world.5,6 In this report we described the postoperative evolution of five recipients of right lobe LRLT. These recipients suffered from congestion of the paramedian sector, as assessed by imaging and liver laboratory tests demonstrating cytolysis. However, no complication due to this partial graft congestion was encountered. Liver function improved gradually, with normalization of the coagulation within 5 days, and of bilirubinemia within 2 weeks. No patients developed graft dysfunction related to smallfor-size syndrome or graft failure due to congestion. They did not develop refractory ascitis. This congestion was temporary as assessed by control computed tomography at 6 months’ follow-up. These good results of right lobe LRLT without reconstruction of hepatic veins of the paramedian sector might be due to the relatively large size of the grafts in this series (⬎1% GWRWR). It is likely that this congestion of the paramedian sector induced some liver tissue destruction or dysfunction, as demonstrated by the posttransplant cytolysis that was not attributable to graft ischemia or liver damage during harvesting. In a smaller graft it is likely that function of the whole right lobe would be necessary to achieve good posttransplant recovery.
In conclusion, this series showed that in right lobe LRLT with relatively large-size grafts, reconstruction of hepatic veins of the paramedian sector may not be necessary despite the induction of some degree of venous congestion. In smaller grafts (⬍1%), congestion should be avoided by reconstruction of the large veins draining segments V and VIII. REFERENCES 1. Detry O, De Roover A, Delwaide J, et al: Living related liver transplantation in adults: first year experience at the University of Liege. Acta Chir Belg 104:166, 2004 2. Trotter JF, Wachs M, Everson GT, et al: Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 346:1074, 2002 3. Lee S, Park K, Hwang S, et al: Congestion of right liver graft in living donor liver transplantation. Transplantation 71:812, 2001 4. Ou QJ, Hermann RE: Hepatic vein ligation and preservation of liver segments in major resections. Arch Surg 122:1198, 1987 5. Lee S, Park K, Hwang S, et al: Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion. J Hepatobiliary Pancreat Surg 10:16, 2003 6. Sugawara Y, Makuuchi M, Sano K, et al: Vein reconstruction in modified right liver graft for living donor liver transplantation. Ann Surg 237:180, 2003
R
IGHT LOBE LIVING RELATED liver transplantation (LRLT) has been recently introduced in adult recipients.1 Commonly, the right lobe graft (Couinaud’s segments V to VIII) is transplanted with anastomoses of the right hepatic artery, the right branch of the portal vein and the right hepatic vein.2 With this technique, venous drainage from the right paramedian sector of the right liver graft (segments V and VIII) depends on collateral veins to the right hepatic vein. In some cases, poor venous outflow can result in severe congestion and liver failure.3 In this report we describe the evolution of posttransplant liver function in five consecutive right lobe recipients whose grafts were transplanted without specific drainage of the right paramedian sector. PATIENTS AND METHODS Five recipients of right lobe grafts were evaluated prospectively in this study. Indications for transplantation were autoimmune hep-
atitis; hepatitis B virus cirrhosis with hepatocarcinoma (two cases); and hepatitis C cirrhosis with (one case) or without (one case) hepatocarcinoma. Before the procedure four recipients were in Child C status and one in Child B. The mean age of the donors was 34 years (range: 21 to 53 years); the mean age of the recipients, 51 years (range: 17 to 69 years). All donors were first-degree relatives of the recipient. The technique was the common right hepatectomy (segments V to VIII) for right lobe graft harvesting and transplantation without including the middle hepatic vein in the graft.2 The From the Departments of Liver Surgery and Transplantation (O.D., A.D.R., C.C., M.F.H., J.M., P.H., M.M.), Hepatology (J.D.), and Anaesthesiology and Intensive Care (A.K., J.J.), University of Liège, Liège, Belgium. Address reprint requests to Dr Olivier Detry, Department of Liver Surgery and Transplantation, University Hospital of Liège, Sart-Tilman B35, B-4000 Liège, Belgium. E-mail: Oli.Detry@chu. ulg.ac.be
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.05.013
Transplantation Proceedings, 37, 2865–2868 (2005)
2865
2866
DETRY, DE ROOVER, COIMBRA ET AL
Fig 1. Postoperative glutamate pyruvate transminase (GPT) evolution.
recipients underwent total hepatectomy and usual piggyback liver transplantation after completion of a temporary, end-to-side, portocaval shunt. The reconstruction started by the end-to-side suture of the right hepatic vein to the recipient inferior vena cava and the end-to-end anastomosis of the graft right portal vein to the recipient portal vein. No middle hepatic vein was reconstructed. The graft was then reperfused, ending the ischemia. Mean total (from clamping of the lobar hepatic artery and portal vein to reperfusion) ischemic time was 51 min (ranges: 35 to 64 minutes). The arterial perfusion of the graft was assured by an end-to-end anastomosis between the graft right hepatic artery and the recipient main hepatic artery after selective ligation of the splenic artery. Bile duct reconstruction was performed by
Fig 2. Postoperative evolution of the coagulation function expressed as Quick level.
suture of the bile ducts to a Roux-in-Y loop or a duct-to-duct anastomosis, without bile duct drainage. Mean graft-to-recipient weight ratio (GRWR) was 1.35% ⫾ 0.15% (ranges: 0.97% to 1.9%). No patient developed small-for-size syndrome or refractory ascitis. All recipients were prospectively followed during the first 2 weeks by daily liver laboratory tests and Doppler ultrasonography, and protocol computed tomography after 10 days and 6 months. Recipient postoperative immunosuppression included tacrolimus, mycophenolate mofetil, and low-dose steroids for the first 3 months, and with a steroid-free regimen after the third month. One recipient died on postoperative day 11 from multiple organ failure due to invasive aspergillosis.
LIVER TRANSPLANTATION WITHOUT VENOUS DRAINAGE
2867
Fig 3. Postoperative evolution of the bilirubin level.
RESULTS Laboratory Tests
The results are expressed as mean values and standard errors of the mean. All patients developed a rise in transaminases (Fig 1), reaching a maximum at postoperative day 2 (mean: 1067 ⫾ 432 IU/mL). In two patients aspartate aminotransferase peaked over 1,500 IU/mL. Liver function improved rapidly, with coagulation normalized at postoperative day 5 (Fig 2). Bilirubin decreased progressively to normalize in three patients at postoperative day 14 (Fig 3). Ultrasonography and Computed Tomography
All patients developed congestion of the paramedian sector. At ultrasonography this part of the liver was hyperechogenic. The congestion was confirmed by computed tomography (Fig 4). The congestion was temporary with normalization of liver tests and disappearance by computed tomography at 6 months’ follow-up. No complication was linked to this congestion in the follow-up of the four surviving patients. One patient developed stenosis of a duct-to-duct bile duct anastomosis. DISCUSSION
In the common technique of right lobe LRLT, the venous hepatic branches draining segments V and VIII are ligated.2 Among patients undergoing hepatectomy, this ligation usually does not pose problems, because collateral circulation develops via the sinusoids and short hepatic veins, and occasionally via the portal vein.4 However, it was reported that in LRLT, a right liver graft without a middle hepatic vein might be complicated with severe congestion of the paramedian sector. Some cases of right liver graft failure due to venous congestion were published.3
Fig 4. Hepatic computed tomography of patient 3, showing congestion during the early posttransplant period (a), which disappeared at 6 months’ follow-up (b).
DETRY, DE ROOVER, COIMBRA ET AL
2868
Several means of reconstruction of the middle hepatic vein tributaries have been described, mainly by teams in the Eastern world.5,6 In this report we described the postoperative evolution of five recipients of right lobe LRLT. These recipients suffered from congestion of the paramedian sector, as assessed by imaging and liver laboratory tests demonstrating cytolysis. However, no complication due to this partial graft congestion was encountered. Liver function improved gradually, with normalization of the coagulation within 5 days, and of bilirubinemia within 2 weeks. No patients developed graft dysfunction related to smallfor-size syndrome or graft failure due to congestion. They did not develop refractory ascitis. This congestion was temporary as assessed by control computed tomography at 6 months’ follow-up. These good results of right lobe LRLT without reconstruction of hepatic veins of the paramedian sector might be due to the relatively large size of the grafts in this series (⬎1% GWRWR). It is likely that this congestion of the paramedian sector induced some liver tissue destruction or dysfunction, as demonstrated by the posttransplant cytolysis that was not attributable to graft ischemia or liver damage during harvesting. In a smaller graft it is likely that function of the whole right lobe would be necessary to achieve good posttransplant recovery.
In conclusion, this series showed that in right lobe LRLT with relatively large-size grafts, reconstruction of hepatic veins of the paramedian sector may not be necessary despite the induction of some degree of venous congestion. In smaller grafts (⬍1%), congestion should be avoided by reconstruction of the large veins draining segments V and VIII. REFERENCES 1. Detry O, De Roover A, Delwaide J, et al: Living related liver transplantation in adults: first year experience at the University of Liege. Acta Chir Belg 104:166, 2004 2. Trotter JF, Wachs M, Everson GT, et al: Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 346:1074, 2002 3. Lee S, Park K, Hwang S, et al: Congestion of right liver graft in living donor liver transplantation. Transplantation 71:812, 2001 4. Ou QJ, Hermann RE: Hepatic vein ligation and preservation of liver segments in major resections. Arch Surg 122:1198, 1987 5. Lee S, Park K, Hwang S, et al: Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion. J Hepatobiliary Pancreat Surg 10:16, 2003 6. Sugawara Y, Makuuchi M, Sano K, et al: Vein reconstruction in modified right liver graft for living donor liver transplantation. Ann Surg 237:180, 2003