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

Abstract

The goals of this study were to evaluate the incidence of hepatic venous outflow obstruction (HVOO) in pediatric patients after living donor liver transplantation (LDLT) using left-sided lobe grafts and to assess the therapeutic modalities used for the treatment of this complication at a single center. Four hundred thirteen primary LDLT procedures were performed with left-sided lobe grafts between 1996 and 2006. All transplants identified with HVOO from a cohort of 380 grafts with survival greater than 90 days were evaluated with respect to the patient demographics, therapeutic intervention, recurrence, and outcome. Seventeen cases (4.5%) were identified with HVOO. Eight patients experienced recurrence after the initial balloon venoplasty. Two patients finally required stent placement after they experienced recurrence shortly after the initial balloon venoplasty. A univariate analysis revealed that a smaller recipient-to-donor body weight ratio and the use of reduced grafts were statistically significant risk factors. The cases with grafts with multiple hepatic veins had a higher incidence of HVOO. In conclusion, the necessity of repeated balloon venoplasty and stent placement was related to poor graft survival. Therefore, the prevention of HVOO should be a high priority in LDLT. When grafts with multiple hepatic veins and/or significant donor-recipient size mismatching are encountered, the use of a patch graft is recommended. Stent placement should be carefully considered because of the absence of data on the long-term patency of stents and stent-related complications. New stenting devices, such as drug-eluting and biodegradable stents, may be promising for the management of HVOO. Liver Transpl 16:1207-1214, 2010. V C 2010 AASLD.Received April 5, 2010; accepted July 2, 2010.Techniques for reduced size liver transplantation, split liver transplantation, and living donor liver transplantation (LDLT) have been developed to address the shortage of organs and the size discrepancy between donors and recipients. 1,2 These types of liver transplantation are technically demanding because of the use of short vascular pedicles, which are more likely to cause postoperative vascular complications. Hepatic venous outflow obstruction (HVOO) is a rare vascular complication; however, it may lead to graft dysfunction without appropriate management. 3,4 The causes of HVOO include technical problems, subsequent fibrosis with inflammatory processes, and compression or twisting of the anastomosis caused by Abbreviations: BA, biliary atresia; GRWR, graft-to-recipient weight ratio; HVOO, hepatic venous outflow obstruction; IVC, inferior vena cava; LDLT, living donor liver transplantation; LL, left lobe; LLS, left lateral segment; r-LLS, reduced left lateral segment; SD, standard deviation; WD, Wilson's disease.

Remnant Left Lobe Torsion Causing Hepatic Venous Outflow Obstruction After Hepatic Right Lobectomy for Giant Hepatocellular Carcinoma: Report of a Case

“…HVOO is recognized as one of the lethal complications after liver transplantation because it deteriorates liver function and results in graft loss 1,2) . HVOO is caused by stenosis or occlusion of the hepatic vein, leading to hepatic congestion and liver failure 5) .…”

“…Hepatic venous outflow obstruction (HVOO) is recognized as a potentially lethal complication after living donor liver transplantation (LDLT) 1,2) . It has not been well -known that this condition can occur after hepatic resection.…”

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

“…The reported incidence is as high as 4.5%. To maximize venous outflow, particularly when grafts with multiple hepatic veins and/or significant donor‐recipient size mismatching are encountered, Sakamoto et al14 suggested a venous graft patch on the anterior side of the anastomosis for left‐sided grafts. In this study, we experienced 1 case of early hepatic vein stenosis, which resolved spontaneously.…”

Current Issues in Pediatric Liver Transplantation

“…Hepatic vein outflow obstruction remains a particular concern for the pediatric liver recipient with incidence increasing in younger age and lower weight patients as well as in those with size mismatch as described above. 37,38 Postoperative liver transplant bleeding is usually surgical in nature and requires reexploration. The incidence of biliary tract complications (stenosis, stricture, obstruction, or leak) can be as high as 15% in the first 30 days after transplant and often require surgical interventions (ie, stent placement, percutaneous drainage, surgical reconstruction).…”