Hepatic venous reconstruction in pediatric living‐related donor liver transplantation – Experience of a single center

Abstract

In pediatric patients submitted to living related liver transplantation, hepatic venous reconstruction is critical because of the diameter of the hepatic veins and the potential risk of twisting of the graft over the line of the anastomosis. The aim of the present study is to present our experience in hepatic venous reconstruction performed in pediatric living related donor liver transplantation. Fifty-four consecutive transplants were performed and two methods were utilized for the reconstruction of the hepatic vein: direct anastomosis of the orifice of the donor left or left and middle hepatic veins and the common orifice of the recipient left and middle hepatic veins (group 1-26 cases), and wide triangular anastomosis after creating a wide triangular orifice in the recipient inferior vena cava at the confluence of all the hepatic veins with an additional longitudinal incision in the inferior angle of the orifice (group 2-28 cases). In group 1, eight patients were excluded because of graft problems in the early postoperative period and five among the remaining 18 patients (27.7%) presented stricture at the site of the hepatic vein anastomosis. All these patients had to be submitted to two or three sessions of balloon dilatations of the anastomoses and in four of them a metal stent had to be placed. The liver histopathological changes were completely reversed by the placement of the stent. Among the 28 patients of the group 2, none of them presented hepatic vein stenosis (p = 0.01). The results of the present series lead to the conclusion that hepatic venous reconstruction in pediatric living donor liver transplantation must be preferentially performed by using a wide triangulation on the recipient inferior vena cava, including the orifices of the three hepatic veins. In cases of stenosis, the endovascular dilatation is the treatment of choice followed by stent placement in cases of recurrence.

Hepatic venous outflow obstruction in pediatric living donor liver transplantation using left-sided lobe grafts: Kyoto university experience

“…One of the causes of HVOO, especially in late-onset pediatric cases, is the dislocation of the graft due to the regeneration of the liver parenchyma or the accommodation of the graft in the abdominal cavity. 6,8,23 An end-to-end anastomosis might be affected to a greater extent than an end-to-side anastomosis by the dislocation of the regenerated graft. Thus, the technique proposed by the Tokyo group may be more appropriate in larger children with leftsided lobe grafts.…”

Percutaneous transluminal venoplasty after venous pressure measurement in patients with hepatic venous outflow obstruction after living donor liver transplantation

“…15 Also, the incidence of venous outfl ow obstruction after LDLT is higher when left-lobe, rather than right-lobe, grafts are used (5.8% vs. 0.8%), 15 possibly due to a higher degree of anatomical variations in the left hepatic vein and to technical challenges attributable to the angle and size of the reconstruction. 9,15,16,17 A diagnosis of venous outfl ow obstruction is based on anomalous clinical and laboratory fi ndings and is confi rmed by Doppler US and liver biopsy fi ndings. 15 Histopathological fi ndings are moderate fi brosis in zone 3 as a result of sinusoidal dilation and areas of necrosis around the central lobular vein.…”

“…16,26,27 To address hepatic venous outfl ow obstruction after LDLT, balloon venoplasty with or without EMS placement has been used. 7,8 Ko et al, 8 who treated 27 patients who had undergone percutaneous interventional treatment for hepatic venous outfl ow obstruction, recommended the introduction of EMS.…”

Current concept of small-for-size grafts in living donor liver transplantation

“…Other techniques with wide outfl ow include the triangular technique and the triplerecipient hepatic vein reconstruction technique. [80][81][82] Avoiding rotation is the other tactic in venous reconstruction for left lobe LDLT, despite the huge free right subphrenic space. Egawa et al 78 reported four cases of outfl ow obstruction caused by graft rotation into the right subphrenic space.…”