Congestion of Right Liver Graft in Living Donor Liver Transplantation

Abstract

AIM: To investigate middle hepatic vein (MHV) management in adult living donor liver transplantation and safer remnant volumes (RV). METHODS: There were 59 grafts with and 12 grafts without MHV (including 4 with MHV-5/8 reconstructions). All donors underwent our five-step protocol evaluation containing a preoperative protocol liver biopsy Congestive vs non-congestive RV, remnant-volume-bodyweight ratios (RVBWR) and postoperative outcomes were evaluated in 71 right graft living donors. Dominant vs non-dominant MHV anatomy in total liver volume (d-MHV/TLV vs nd-MHV/TLV) was constellated with large/small congestion volumes (CV-index). Small for size (SFS) and non-SFS remnant considerations were based on standard cutoff -RVBWR and RV/TLV. Non-congestive RVBWR was based on non-congestive RV. RESULTS: MHV and non-MHV remnants showed no significant differences in RV, RV/TLV, RVBWR, total bilirubin, or INR. SFS-remnants with RV/TLV < 30% and non-SFS-remnants with RV/TLV ≥ 30% showed Prospective Study Radtke A et al. Liver failure in live donors of right grafts 6009 May 21, 2015|Volume 21|Issue 19| WJG|www.wjgnet.com no significant differences either. RV and RVBWR for non-MHV (n = 59) and MHV-containing (n = 12) remnants were 550 ± 95 mL and 0.79 ± 0.1 mL vs 568 ± 97 mL and 0.79 ± 0.13, respectively (P = 0.423 and P = 0.919. Mean left RV/TLV was 35.8% ± 3.9%. Non-MHV (n = 59) and MHV-containing (n = 12) remnants (34.1% ± 3% vs 36% ± 4% respectively, P = 0.148. Eight SFS-remnants with RVBWR < 0.65 had a significantly smaller RV/TLV than 63 non-SFS-remnants with RVBWR ≥ 0.65 [SFS: RV/TLV 32.4% (range: 28%-35.7%) vs non-SFS: RV/TLV 36.2% (range: 26.1%-45.5%), P < 0.009. Six SFS-remnants with RV/TLV < 30% had significantly smaller RVBWR than 65 non-SFS-remnants with RV/TLV ≥ 30% (0.65 (range: 0.6-0.7) vs 0.8 (range: 0.6-1.27), P < 0.01. Two (2.8%) donors developed reversible liver failure. RVBWR and RV/TLV were concordant in 25%-33% of SFS and in 92%-94% of non-SFS remnants. MHV management options including complete MHV vs MHV-4A selective retention were necessary in n = 12 vs n = 2 remnants based on particularly risky congestive and non-congestive volume constellations. CONCLUSION: MHV procurement should consider individual remnant congestive-and non-congestive volume components and anatomy characteristics, RVBWR-RV/TLV constellation enables the identification of marginally small remnants.

Early posttransplant hepatic venous outflow obstruction: Long-term efficacy of primary stent placement

“…1,2 Balloon angioplasty has been accepted as a safe and effective initial treatment for managing hepatic venous outflow abnormalities following liver transplantation. [3][4][5] However, balloon angioplasty may induce rupture of the fresh anastomosis and also may be ineffective in eliminating various etiologies of venous outflow abnormalities in the early posttransplant period.…”

Raising-flap technique for outflow reconstruction in living donor liver transplantation

“…Severe congestion in the anterior segment has been reported to occur in right lobe grafts without the MHV, and this leads to massive ascites and graft dysfunction. 4,7,8 To prevent congestion in the anterior segments, some institutions have preferred the inclusion of the MHV in the graft. Liu et al 9 even chose an extended right lobe graft with the MHV.…”

History and Evolution of Liver Transplantation

“…[120] Lee, aggressively reconstructed the MHV tributaries in right liver grafts without the MHV trunk and named this type of graft a modified right lobe graft. [121] Ghobrial, also recommended reconstruction of the MHV tributary veins when the RHV in the graft was <1.5 cm in diameter. [90] All MHV tributaries with a size >5 mm should be preserved during donor hepatectomy and reconstructed with autogenous interposition vein grafts.…”