Morphometric and simulation analyses of right hepatic vein reconstruction in adult living donor liver transplantation using right lobe grafts

Abstract

The incidence of clinically significant right hepatic vein (RHV) stenosis after adult living donor liver transplantation has been higher than expected. In this study, an assessment of the risk factors for the development of RHV stenosis in this context was undertaken. Hepatic anatomy, surgical techniques, and the incidence of RHV stenosis 1 year after transplantation were evaluated retrospectively in 225 recipients of right lobe grafts. These patients underwent independent RHV reconstruction, which was facilitated by the application of computed tomography morphometry and computational simulation analyses. Three types of preparation of the orifice of the graft RHV and 7 types of preparation for venoplasty of the recipient RHV were used. The frequency of high, middle, and low sites of RHV insertion into the inferior vena cava (IVC) was 56.0%, 36.4%, and 7.6%, respectively, for donors, and 26.7%, 58.7%, and 14.7%, respectively, for recipients. Nine patients (4%) developed RHV stenosis of early onset that required stent insertion during the first 2 postoperative weeks; in 12 patients (5.3%), RHV stenosis of delayed onset occurred. Inappropriate matching of RHV sites of insertion correlated with the incidence of stenosis of early onset (P ¼ 0.039). Technical refinements to avoid adverse consequences of inappropriate ventrodorsal matching of RHV sites of insertion include making the recipient RHV orifice wide and enlarging the recipient IVC by a customized incision and patch venoplasty after anatomical assessment of the RHV and IVC of the graft and recipient. Liver Transpl 16:639-648, 2010. V C 2010 AASLD. Received July 22, 2009; accepted January 24, 2010.A graft of the right lobe (RL) of the liver allows satisfactory matching of the sizes of the graft and the recipient liver. Such partial liver grafts are used most commonly in adult living donor liver transplantation (LDLT). Successful implantation of an RL graft requires effective reconstruction of sufficiently large outflow veins, including the right hepatic vein (RHV), the middle hepatic vein (MHV), and the inferior RHV.Reconstruction of the RHV is an important procedure during RL graft implantation with respect to both surgical technique and recovery of graft function. The surgical techniques that have been used for RHV reconstruction are direct anastomosis, incision/excision venoplasty, and patch venoplasty. 1-11 Although these techniques have been described in detail, relatively little is known about the outcomes for each of

Anomalous hepatic vein anatomy of left lateral section grafts and customized unification venoplasty for pediatric living donor liver transplantation

“…For these 300 donors, a computational simulation of virtual LLS graft harvesting was performed with dynamic computed tomography images and commercial 3-dimensional reconstruction software (Lucion, Infinitt Co., Seoul, Korea). 4 The surgical feasibility was simulated for a single LHV opening and for 2 adjacent LHV openings, which enabled surgical unification by LHV transection in the virtual 3-dimensional environment. The anatomical variations of LHV were classified into 4 types according to the number, size, and location of the graft hepatic vein openings (Fig.…”

Doppler Sonography of Patients With and Without Acute Cellular Rejection After Right-Lobe Living Donor Liver Transplantation

“…Because the histopathologic features of these diseases are also characterized by venulitis and perivenulitis around the central vein and perivenular hepatocytes, respectively, these features may affect the compliance of the hepatic parenchyma, thereby affecting the VPI. In addition, hepatic vein stenosis is relatively common after right‐lobe living donor liver transplantation, with an approximate incidence of 10%, 20 making it important to radiologically differentiate between acute cellular rejection and hepatic vein stenosis, but this study does not suggest a solution for this kind of dilemma. We think that a further study should be followed for this scheme.…”

Hepatofugal Portal Venous Flow on Doppler Sonography After Liver Transplantation

“…Its incidence has been reported to be 4% to 6% of living donor liver transplantations using right-lobe grafts. 28,29 In such cases, stent placement in the stenotic portion is very effective. In our series of patients with hepatofugal portal venous flow and hepatic vein stenosis, the flow disappeared after stent placement.…”