Left lobe graft poses a potential risk of hepatic venous outflow obstruction in adult living donor liver transplantation

Abstract

Hepatic venous outflow obstruction (HVOO) is a critical complication after living donor liver transplantation (LDLT).This study aimed to evaluate the incidence of HVOO and the risk factors for HVOO in adults. From 2005 to 2015, 430 adult LDLT patients (right lobe [RL] graft, 270 patients; left lobe [LL] graft, 160 patients) were enrolled and divided into no HVOO (n 5 413) and HVOO (n 5 17) groups. Patient demographics and surgical data were compared, and risk factors for HVOO were analyzed. Furthermore, the longterm outcomes of percutaneous interventions as treatment for HVOO were assessed. HVOO occurred in 17 (4.0%) patients. The incidence of HVOO in patients receiving a LL graft was significantly higher than in those receiving a RL graft (8.1% versus 1.5%; P 5 0.001). The body weight and caliber of hepatic vein anastomosis in the HVOO group were significantly lower compared with the no HVOO group (P 5 0.02 and P 5 0.008, respectively). Multivariate analysis revealed that only LL graft was an independent risk factor for HVOO (OR, 4.782; 95% CI, 1.387-16.488; P 5 0.01). Among 17 patients with HVOO, 7 patients were treated with single balloon angioplasty, and 9 patients who developed recurrence were treated with repeated interventions. Overall, 6 patients underwent stent placement: 1 at the initial procedure, 3 at the second procedure for early recurrence, and 2 following repeated balloon angioplasty ( 3 interventions). These 6 patients experienced no recurrence. Overall graft survival was not significantly different between the HVOO and no HVOO groups (P 5 0.99). In conclusion, the use of a LL graft was associated with HVOO, and percutaneous interventions were effective for treating adult HVOO after LDLT. Liver Transplantation 22 785-795 2016 AASLD.Received October 26, 2015; accepted December 31, 2015. Hepatic venous outflow obstruction (HVOO) is one of the most critical complications leading to severe graft dysfunction or loss after living donor liver transplantation (LDLT). (1,2) Highly meticulous procedures are required in LDLT, demanding a greater degree of attention and skill than in deceased donor liver transplantation, and there is a greater likelihood of HVOO. When HVOO occurs, hepatic congestion can cause massive ascites, jaundice, coagulopathy, and occasionally hepatic failure. The cause of HVOO includes technical problems, compression or twisting of the anastomosis caused by graft regeneration, and subsequent fibrosis with inflammatory processes. (3,4) Previously, Akamatsu et al. (5) investigated 223 adult and pediatric patients and reported the incidence of HVOO to be 2.2%. Other investigators have reported a HVOO occurrence of 5.3% in a series of 152 pediatric LDLT patients and 4.5% in 380 consecutive

Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplant: Single Center Experience

“…Moreover, these reasons may explain why the incidence of HVOO was relatively higher in our hospital for the pediatric cases, in which left lobe/left lateral segment grafts were used, as well as for adult cases undergoing left lobe implantation. In agreement with this idea, Kitajima and associates 7 recently reported that left lobe implantation was an independent risk factor for post-LDLT HVOO.…”

“…3 Early-onset HVOO can result from a number of factors, such as a tense suture line, bending of a redundant hepatic vein, mismatch between the size of recipient and graft, low recipientto-donor body mass index ratio, compression of the IVC by a large graft, and thrombosis. 2,4,7 In contrast, the cause of late-onset HVOO includes intimal hyperplasia, fibrosis development secondary to inflammation (ie, abscesses or bile leaks), twisting of an anastomosis, external compression due to graft growth, and anastomosis strictures secondary to fibrotic changes in the dissection field. 2,4 After a first description of the standard end-toend cavocaval anastomosis technique for DDLT, researchers were stimulated to develop improved anastomosis techniques, such as the piggyback and the modified piggyback to minimize the rate of HVOO.…”

Emergency department visits and unanticipated readmissions after liver transplantation: A retrospective observational study

“…The relatively lower rate of complications after LT in our institution may be contributed to a few factors 8 . LTs using the left liver lobe and pre-existing hepatitis C are known as risk factors for long-term graft failure 9 , 10 . The most common indication for living donor LT in our institution was hepatitis B with most of these patients receiving LTs using the right liver lobe.…”

Efficacy of repeated balloon venoplasty for treatment of hepatic venous outflow obstruction after pediatric living‐donor liver transplantation: A single‐institution experience

“…Previous reports suggested that stent placement should be considered after two or three failed balloon venoplasties for HVOO after pediatric LDLT . Sakamoto et al reported a pediatric case with HVOO recurrence requiring stent placement, whose liver biopsy revealed severe fibrosis in zone 3 at 1 year after the last stent placement procedure.…”