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Simplified technique for one-orifice vein reconstruction in left-lobe liver transplantation

2008; Lippincott Williams & Wilkins; Volume: 15; Issue: 1 Linguagem: Inglês

10.1002/lt.21580

1527-6473

Shintaro Yamazaki, Tadatoshi Takayama, Kazuto Inoue, Tokio Higaki, Masatoshi Makuuchi,

Liver Disease and Transplantation

Direct anastomosis of the hepatic veins to a thin inferior vena cava (IVC) can sometimes cause a bend at the anastomotic site, which results in outflow occlusion. The deformation of the outflow anastomosis caused by graft regeneration can lead to hepatic vein stenosis and graft congestion. This phenomenon is common when the outflow tract is narrow and the distance from the IVC is short. To overcome these problems, techniques for reconstructing hepatic vessels have been reported.1, 2 We therefore believe that the key to successful outflow vessel reconstruction is the realization of a sufficient drainage area between the liver graft and the IVC. IVC, inferior vena cava; SHV, short hepatic vein The basic concept behind creating a wide orifice has been described previously.3 To enlarge the outflow channel of the IVC, an autologous vein, a cryopreserved vein, or both are used as a vein patch at the cavotomy site (Fig. 1A).3, 4 (A) Venoplasty of the recipient's inferior vena cava. To make a wide outflow channel from the left liver graft, an autologous vein graft from the extracted liver (portal vein or hepatic vein) or a cryopreserved graft was used as a vein patch. (B) Dorsal side view of the reconstructed left liver with the caudate lobe graft. A long vein graft was cut horizontally into 2 pieces. One piece was trimmed to function as a conduit with a small vein flap; this was then sutured between the short hepatic vein from the caudate lobe and the other hepatic veins. The other piece was cut longitudinally to create a wide vein flap sheet; this was sutured around the outflow channel of the liver graft to act as a circular-cuff vein patch. (C) Dorsal side view of the reconstructed left liver with the caudate lobe graft. A pantaloon-shaped iliac vein graft was used to reconstruct the outflow channel. The smaller orifice of the iliac vein was sutured to the short hepatic vein from the caudate lobe. The other orifice was cut longitudinally to create a wide vein flap sheet; this was sutured around the outflow channel of the liver graft to act as a circular-cuff vein patch. In most cases of left liver grafts, the left hepatic vein, middle hepatic vein, and superficial left hepatic vein were originally connected, whereas the short hepatic vein (SHV) branched independently from the lower side. In the conventional method, the SHV of the caudate lobe can be resected with part of the recipient's IVC (Fig. 1B). The venoplasty of the liver graft was performed at the back table. The cryopreserved vein graft was divided into 2 pieces. One piece was anastomosed around the outflow vessel of the liver graft to act as a large circular cuff, whereas the other was anastomosed to the SHV to act as a conduit and a part of the side wall of the cuff. However, this method was too intricate to be used as a standard procedure, so we simplified the technique by using a cryopreserved iliac vein graft. The cryopreserved graft from the iliac vein was originally branched to inner and outer tracts. The smaller orifice of the iliac vein graft was joined to the caudate lobe, while the other was cut longitudinally to make a wide flap. The latter was attached around the outflow route of the liver graft to act as a circular cuff (Fig. 1C). The cryopreserved iliac vein graft thus functioned as a ready-made circular cuff with a conduit from the SHV at a time. At the recipient site, vena cavotomy was performed according to Fig. 1A. The single large circular cuff created from the hepatic graft was simply attached to the cavotomy site. The favorable vascular patency and blood flow achieved with this approach have been confirmed by Doppler ultrasonography and enhanced computed tomography. Excellent triphasic waveforms and velocities have been demonstrated. Our simplified venoplasty technique is an effective method of overcoming both technical difficulties and outflow stenosis. This technique can be suitable when the distance between the hepatic vein and the caudate vein is large. It reduces the complexity of left liver plus caudate lobe grafts in comparison with previous methods. The operation time and the liver graft cold-preservation time for the simplified technique are shorter than those for the previous methods. It also guarantees a sufficient distance from the liver graft to the recipient IVC and minimal deformation of the outflow channel. The application of this technique in the presence of a suitable SHV may facilitate graft function.