Graft rotation and late portal vein complications in pediatric living donor liver transplantation using left-sided grafts: Long-term computed tomography observations

Abstract

Right-side rotation of the graft is an uncommon event after pediatric living donor liver transplantation (LDLT) with a left-sided graft. However, graft rotation might lead to gradual portal vein (PV) stretching and late portal vein complications (PVCs). The goal of this study was to quantify the degree of graft rotation (R) by computed tomography (CT) and to determine the effect of graft rotation on the development of late PVCs. One hundred ten patients underwent LDLT with left-sided grafts between 1996 and 2009; CT images were available and were reviewed for 66 of these patients. To quantify R, the following variables were measured with CT: the longest distance between the midline and the extrahepatic PV at the level of the hepatic hilum (A), the distance between the midline and the center of the superior mesenteric vein at the level of the confluence of the splenic vein and superior mesenteric vein (B), and the inner transverse diameter of the body cavity at the level at which A was measured (C). R was calculated as (A À B)/C. In patients with a patent PV (n ¼ 59) and in patients with late PVCs (n ¼ 7), the median R values were 0.16 (range ¼ 0.03-0.38) and 0.25 (range ¼ 0.13-0.39), respectively; there was a significant difference between the 2 groups (P ¼ 0.003). Multivariate analysis showed that R ! 0.2 was the only independent risk factor for the development of late PVCs (P ¼ 0.021). In conclusion, the gradual stretching of the PV after rightside rotation of left-sided grafts might play an important role in the development of late PVCs. PV patency should be closely monitored when graft rotation is noted during clinical follow-up. Liver Transpl 17:717-722, 2011. V C 2011 AASLD.Received October 27, 2010; accepted December 25, 2010.Portal vein complications (PVCs) after pediatric living donor liver transplantation (LDLT) are uncommon. However, they may cause graft loss if left untreated. 1 Left-sided partial grafts for LDLT in children are widely accepted. The smaller diameters and shorter pedicles of the graft vessels have been implicated as causes of venous complications. 2 Well-documented risk factors for PVCs include small, hypoplastic, or sclerotic portal veins (PVs), which are usually associated with a younger age or a low recipient body weight; this is commonly observed in patients with biliary atresia and other coexisting vascular anomalies. 3,4 However, PV stretching as a cause of PVCs has not been reported. A left-sided graft could rotate gradually to the right upper quadrant fossa, and this could be followed by PV stretching. In a previous study, 5 a PV size less than 5 mm was a significant risk factor for PVCs after pediatric LDLT with a leftAbbreviations: A, longest distance between the midline and the extrahepatic portal vein at the level of the hepatic hilum; B, distance between the midline and the center of the superior mesenteric vein at the level of the confluence of the splenic vein and superior mesenteric vein; C, inner transverse diameter of the body cavity at the level at which the longest...

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