Preservation of Recipient Middle Hepatic Vein for Drainage of Anterior Sector Veins in Adult-to-Adult Livina-Donor Liver Transplantation
Liver Transplant and Hepatobiliary Surgery/Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York 10595 , USA.Transplantation Proceedings (Impact Factor: 0.98). 07/2009; 41(5):1687-90. DOI: 10.1016/j.transproceed.2009.02.088
The inclusion of donor middle hepatic vein (MHV) in right-lobe living-donor grafts and the need for reconstruction of the MHV tributaries have long been controversial areas in living-donor liver transplantation. We report technical details in restoration of venous drainage of the anterior sector (segments V and VIII) of the right lobe of the liver graft using a preserved MHV from the recipient liver, and address the issue of reconstruction of donor MHV tributaries without use of an interposition graft. We review clinical situations in which restoration of outflow drainage of the anterior segment of the liver graft should be considered.
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ABSTRACT: Pomposelli JJ, Akoad M, Khwaja K, Lewis WD, Cheah YL, Verbesey J, Jenkins RL, Pomfret EA. Evolution of anterior segment reconstruction after live donor adult liver transplantation: a single-center experience. Clin Transplant 2011 DOI: 10.1111/j.1399-0012.2011.01529.x. © 2011 John Wiley & Sons A/S. Abstract: Controversy exists regarding the best method for venous outflow reconstruction after live donor liver transplantation using right lobe grafts. Some authors advocate routine inclusion of the middle hepatic vein with the graft, whereas others favor a more selective approach. In this report, we examine the evolution of our decision making and technique of selective anterior venous segment reconstruction during live donor adult liver transplantation performed in 226 recipients. We have developed a simplified back-bench procedure using sequential-composite anastomosis using various vascular conduits with syndactylization to the right hepatic vein creating a single large-outflow anastomosis in the recipient. Conduits used include iliac artery or vein allograft, recanalized umbilical vein, cryopreserved iliac artery allograft, and 6-mm synthetic expanded polytetrafluoroethylene vascular graft. This technique can be performed quickly, safely, and under cold storage conditions and results in excellent outcome while minimizing donor risk.
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ABSTRACT: IMPORTANCE The use of technically variant segmental grafts are key in offering transplantation to increase organ availability. OBJECTIVE To describe the use of segmental allograft in the current era of donor scarcity, minimizing vascular complications using innovative surgical techniques. DESIGN, SETTING, AND PARTICIPANTS Retrospective study from August 2007 to August 2012 at a university hospital. A total of 218 consecutive liver transplant patients were reviewed, and 69 patients (31.6%; 38 males and 31 females; mean age, 22.5 years) received segmental grafts from living donors or split/reduced-size grafts from deceased donors. MAIN OUTCOMES AND MEASURES Graft type, vascular and biliary complications, and patient and graft survival. RESULTS Of 69 segmental transplants, 47 were living donor liver transplants: 13 grafts (27.7%) were right lobes, 22 (46.8%) were left lobes, and 12 (25.5%) were left lateral segments. Twenty-two patients received deceased donor segmental grafts; of these, 11 (50.0%) were extended right lobes, 9 (40.9%) were left lateral segments, 1 (4.5%) was a right lobe, and 1 (4.5%) was a left lobe. Arterial anastomoses were done using 8-0 monofilament sutures in an interrupted fashion for living donor graft recipients and for pediatric patients. Most patients received a prophylactic dose of low-molecular-weight heparin for a week and aspirin indefinitely. There was no incidence of hepatic artery or portal vein thrombosis. Two patients developed hepatic artery stenosis and were treated with balloon angioplasty by radiology. Graft and patient survivals were 96% and 98%, respectively. CONCLUSIONS AND RELEVANCE Use of segmental allografts is essential to offer timely transplantation and decrease waiting list mortality. Living donor liver transplants and segmental grafts from deceased donors are complementary. It is possible to have excellent outcomes combining a multidisciplinary team approach, technical expertise, routine use of anticoagulation, and strict patient and donor selection.
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ABSTRACT: In middle hepatic vein dominant livers, the anterior segment of the right lobe of the liver (segments V and VIII) drains mainly into the middle hepatic vein. In these donors, when right lobe grafts are procured without the middle hepatic vein, the graft may harbor large segment V and/or VIII veins that need reconstruction to avoid graft congestion and subsequent graft dysfunction. Draining these middle hepatic vein tributaries using autologous or cryopreserved vessels is a solution, despite the possible difficulties of their preparation. However, these vessels are not always available. Our objective was to evaluate the effectiveness and safety of using a synthetic vascular graft. Between January 2012 and October 2013, eighteen adult recipients underwent living-donor liver transplant using right lobe grafts without the middle hepatic vein at Dar Al Fouad Hospital, 6th of October City, Egypt. All grafts had a large tributary of the middle hepatic vein. Eight-mm ringed expanded polytetrafluoroethylene vascular grafts were used to drain 15 segment V vein tributaries and 3 segment VIII vein tributaries directly to the inferior vena cava. Follow-up was done using duplex ultrasound to evaluate the patency of the vascular graft and the liver congestion and the liver function tests including liver enzymes. Intraoperative Duplex ultrasound confirmed patency and absent segmental congestion in all 18 recipients. The vascular graft patency was 17/18 at 1 week (94.4%) and 15/18 at 1 month (83.3%). No recipients developed graft infection at 1 month. Synthetic vascular expanded polytetrafluoroethylene grafts could be used effectively and safely in middle hepatic vein tributary reconstruction to overcome the unavailability of autologous or cryopreserved vessel grafts or just to avoid the additional burden of recovering autologous grafts thus simplifying the procedure.
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