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Graft Outflow Venoplasty on Reduced Left Lateral Segments in Living Donor Liver Transplantation for Small Babies

2011; Wolters Kluwer; Volume: 91; Issue: 6 Linguagem: Inglês

10.1097/tp.0b013e3182088bb5

1534-6080

Seisuke Sakamoto, Takanobu Shigeta, Ikumi Hamano, Akinari Fukuda, Toshihiko Kakiuchi, Naoto Matsuno, Hideaki Tanaka, Atsuko Nakagawa, Mureo Kasahara,

Organ Donation and Transplantation

Living donor liver transplantation (LDLT) is recognized as an established curative therapy for children with liver diseases, resulting in its frequent application in smaller children (1). The recent advances in infantile liver transplantation have allowed the introduction of reduced grafts to overcome the problems related to “large-for-size” grafts (2). Furthermore, meticulous surgical procedures are required in smaller children to prevent the development of vascular complications. Hepatic venous outflow obstruction (HVOO) is a critical complication, leading to graft failure without prompt management (3). The creation of a wide outflow orifice is crucial to avoid HVOO; therefore, the anatomy of the hepatic veins of the graft should be evaluated carefully. This report presents an alternative technique of hepatic vein reconstruction in LDLT using reduced left lateral segments (LLS) for smaller children. The surgical procedure of retrieving reduced LLS has been previously reported elsewhere (2). In the donor operation, after isolation of the left hepatic artery, hepatic duct, and portal branch, hepatic parenchyma was transected 5 mm to the right side of the falciform ligament without blood inflow occlusion. The lateral part and the caudal part of LLS were resected in situ, while preserving the medial tributary of the left hepatic vein. On the back table, if the graft had multiple hepatic veins, these hepatic veins were combined into one orifice in the conventional manner. The medial side of the orifice is often too short to be safely reconstructed to the recipient's inferior vena cava (IVC). A left ovarian vein or an inferior mesenteric vein, obtained from a donor, was longitudinally opened to make a sheet, which was attached around the medial side of the orifice to act as a circular cuff (Fig. 1A). The recipient's hepatectomy was performed by retaining the IVC. All the recipient's hepatic vein orifices were connected, and the newly created outflow orifice of the graft was anastomosed in an end-to-side manner using continuous 6-0 monofilament sutures.FIGURE 1.: (A) The new technique of graft outflow venoplasty. Two hepatic veins, the medial (left hepatic vein [LHV]-med) and lateral (LHV-lat) tributaries, were combined into one orifice on the back table. A donor's vein, a left ovarian vein or an inferior mesenteric vein, was longitudinally opened to make a sheet and attached around the medial side of the orifice to act as a circular cuff. (B) The transection line of reduced left lateral segments (LLS) on preoperative computed tomography. Dotted arrows indicate the medial and lateral lines of transaction. It was technically inevitable to retrieve two hepatic veins in this case. The medial tributary of the left hepatic vein (LHV-med) is more crucial than the other (LHV-lat) to maintain adequate venous drainage in reduced LLS.Twenty-six LDLTs using reduced LLS grafts were performed at our institute from November 2005 to August 2010. The recipient profiles are shown in Table 1. All the hepatic venous reconstruction was performed in an end-to-side direct anastomosis between the recipient's IVC and the graft's hepatic veins without a patch venous graft, and a case of HVOO during an operation occurred in the previous series (4); however, the three recent cases demonstrated a good recovery without any signs of HVOO.TABLE 1: The recipient profiles and the details of hepatic vein reconstructionThe Kyoto group analyzed their technique of hepatic vein reconstruction in pediatric LDLT using left-sided lobe grafts (3). They clearly showed that grafts with multiple hepatic veins were significant risk factors of HVOO, and they recommended the use of a patch graft to make a wide outflow orifice in addition to the conventional venoplasty. The concept of a new technique of hepatic vein reconstruction in LDLT using reduced LLS is based on two factors. First, the anastomosis at the medial side of the outflow orifice is an important part to avoid HVOO. The number and shape of the hepatic veins of the graft depends on the surgical procedure and the anatomical variations of hepatic venous system. The precise placing of a vascular clamp near the IVC is important to make an extrahepatic part of the left hepatic veins longer if the tributary of the graft's hepatic veins is close to the cutting line (5). The patterns of the tributaries of the left hepatic veins, such as the case presented in Figure 1(B) (MeVis Medical Solutions AG, Bremen, Germany), require the retrieval of multiple hepatic veins to ensure donor's safety. The medial tributary of the left hepatic vein is of greater risk of becoming the short length of the extrahepatic part of the vein. Second, reduced LLS is made by the reduction of the lateral part of LLS. This suggests that the medial tributary of the left hepatic vein is more crucial than the other to maintain adequate venous drainage. An LDLT using left-sided hepatic lobes without the middle hepatic vein may have inadequate venous drainage causing postoperative atrophic changes, and the authors suggested that the corresponding drainage veins into the middle hepatic vein must be preserved (6). It is important to evaluate the anatomic factors of venous drainage to affect the functional graft volume rather than the apparent graft volume when determining whether a donor can provide adequate liver volume at acceptable risks. In conclusion, the alternative technique of hepatic vein reconstruction is recommended in LDLT using reduced LLS for small babies, especially when the graft has multiple hepatic veins. Seisuke Sakamoto1 Takanobu Shigeta1 Ikumi Hamano1 Akinari Fukuda1 Toshihiko Kakiuchi1 Naoto Matsuno1 Hideaki Tanaka2 Atsuko Nakagawa3 Mureo Kasahara1 1 Division of Transplant Surgery National Center for Child Health and Development Tokyo, Japan 2 Division of Pediatric Surgery National Center for Child Health and Development Tokyo, Japan 3 Division of Pathology National Center for Child Health and Development Tokyo, Japan