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Artigo Acesso aberto Produção Nacional Revisado por pares

BIBTEX RIS

Outflow reconstruction in domino liver transplantation with interposition of autologous portal vein graft. A new technical option in living donor domino liver transplant scenario

2006; Lippincott Williams & Wilkins; Volume: 12; Issue: 8 Linguagem: Inglês

10.1002/lt.20878

1527-6473

Alexandre Cerqueira, L.F. Pacheco-Moreira, Marcelo Enne, Jefferson Alves, Rodrigo Amil, E. Balbi, José Manoel Martinho,

Renal Transplantation Outcomes and Treatments

In 1997, a new modality of liver transplantation was introduced: the sequential, or domino, liver transplantation.1 The Achilles heel of domino transplantation remains the inferior vena cava length of both the familial amyloidotic polyneuropathy (FAP) patient and the domino recipient. Some investigators have reported that the pericardium may be sectioned to lengthen the vena cava stumps,2 and serious complications of inferior vena cava anastomosis in domino liver transplantation have been reported.3 FAP, familial amyloidotic polyneuropathy. Recently, Pena et al.4 and Pacheco-Moreira et al.5 described the new technique for domino liver transplantation in which vascular outflow anastomosis in the domino recipient were performed with an iliac/caval vein graft from cadaveric donor. For this reason, some technical difficulties such as short vena cava stump, pericardial effusion, and bad outflow in both patients are avoided. This technique also avoids the necessity of the venovenous bypass or the hemodynamic changes after caval clamping in FAP patients. In this case we describe the success of using a recipient's inverted portal vein bifurcation as an interposition graft to drain the outflow in the domino recipient also in a living donor liver transplantation scenario. Lately, techniques for reconstruction of hepatic vessels including the portal vein have been reported in living donor liver transplantation.6, 7 A 37-year-old man (a FAP patient's husband) donated a right liver. The living donor liver transplantation recipient, a 36-year-old woman with FAP, agreed to also be a domino donor. The native hepatectomy in the FAP patient was performed with inferior vena cava preservation, and venovenous bypass was not required. The living donor right graft was implanted in the FAP patient as usual. The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day. The FAP liver as a domino graft was harvested without the vena cava (Fig. 1) and perfused on the back-table with Belzer solution (Viaspan, DuPont Pharma, Wilmington, DE). The middle and left hepatic veins were joined together (Fig. 2). The autologous portal vein bifurcation (domino recipient) was used as vascular graft according to inverted Y-graft technique (Fig. 3). The venous graft of the right portal vein was anastomosed with right hepatic vein, and the left portal vein was anastomosed with the new common trunk of the middle and left hepatic veins using a 5-0 polypropylene running suture. LHV, left portal vein; RHV, right hepatic vein; MHV, middle hepatic vein. The middle and left hepatic veins were joined together. Y-graft technique—PV, portal vein; LPV, left portal vein; RPV, right portal vein. A 49-year-old man with end-stage liver disease secondary to hepatitis C agreed to accept the FAP liver. The recipient's hepatectomy was performed with preservation of the inferior vena cava, and the liver was implanted in the standard piggyback fashion using the portal stump of the venous graft as the outflow from the FAP liver. The postoperative course was uneventful, and the patient was discharged on the 17th postoperative day. Angio computed tomography scan at the second postoperative month showed good outflow (Fig. 4). Arrows denote sites of anastomosis. MHV, middle hepatic vein; LHV, left portal vein; LPV, left portal vein; RHV, right hepatic vein; RPV, right portal vein; PV, portal vein. The size of the vein diameter is the more important factor in this technique. The portal vein that was used in this case was 22 mm in diameter (Fig. 5). This approach would be feasible only with portal vein diameters of 20 mm or more. This would not be a problem with iliac/vena caval grafts. Arrow denotes site of anastomosis. IVC, inferior vena cava; PV, portal vein; SV, splenic vein; SMV, superior mesenteric vein. In summary, this technique is especially useful when the donor for the FAP is a living donor instead of a deceased donor. The technique may be considered as a strategy for avoiding the complications described in the domino scenario, especially in the FAP patient, and it is in accordance with domino transplant philosophy.