Living-Donor Right Hepatectomy with or without Inclusion of Middle Hepatic Vein: Comparison of Morbidity and Outcome in 56 Patients

Abstract

Venous congestion of segments V and VIII is observed frequently in living-donor right lobe liver transplants without middle hepatic vein (MHV) drainage, and can be a cause of graft dysfunction and failure. Inclusion of the MHV with the graft is controversial, however, because of the perceived potential for increased donor morbidity.We compared the outcome of living liver donors in whom the MHV was either left intact in the donor (group 1; n = 28) or was removed with the graft (group 2; n = 28). All prospective donors completed an extensive multidisciplinary evaluation to determine suitability for surgery and to ensure that the MHV could be removed safely without compromising venous outflow from the remaining liver. Patient demographics including age, weight, body-mass index, and liver volumetry as determined by computerized tomography were similar in both groups. Operative time in group 2 was significantly shorter than in group 1. There was no difference in estimated blood loss, transfusion requirements, peak serum liver tests, time interval from surgery to complete normalization of liver tests, complications, and length of hospitalization. We conclude that including the MHV with livingdonor right lobe grafts can be performed safely in most donors. Key words: Liver transplantation, living donor Received 30 October 2003, revised and accepted for publication 18 December 2003Over the past 5 years, living-donor liver transplantation (LDLT) of right lobe grafts has become increasingly common, with further growth anticipated as the gap between the need and availability of cadaver livers expands (1). A critical determinant of recipient outcome after LDLT is the quantity of functional liver mass transplanted. In addition to the actual size of the graft, apparent functional mass can be affected by several factors including venous congestion, portal hypertension, and recipient clinical status (2,3). Venous congestion of Couinaud's segments V and VIII of right lobe grafts is observed frequently when middle hepatic vein (MHV) tributaries from these segments are ligated. Although venous congestion usually resolves as intrahepatic venous collaterals to the right hepatic vein enlarge, it may persist and contribute to the development of graft dysfunction and failure. Reported solutions to mitigate this problem include revascularization of large segment V and VIII veins, revascularization of the entire MHV, retention of a segment of the MHV with the graft to promote development of venous collaterals, and splenic artery ligation or splenectomy to reduce portal venous inflow (4-11). Currently there is no consensus as to which approach is optimal.Since the inception of our right lobe LDLT program, the surgical management of venous drainage from segments V and VIII has evolved from routine ligation to selective revascularization of MHV tributaries from segments V and VIII, and most recently to routine MHV revascularization. Inclusion of the MHV with the graft is controversial, however, because of the perceived potential of increasin...

Initial Poor Graft Dysfunction and Primary Graft Non-Function After Orthotopic Liver Transplantation

“…In the pediatric population, the recipient receives an adult lateral left segment or left lobe. In adult-to-adult LDLT, an extended right lobe graft with or without middle hepatic vein can increase graft volume though the donor is relatively small (Lo et al, 2004;Cattral et al, 2004). Finally, ischemic preconditioning may also be of benefit in partial liver transplantation to protect SFSS grafts, as it has been shown to maintain the hepatic microcirculation and decrease the activation of Kupffer cells (Franco-Gou et al, 2004;Vajdová et al, 2004).…”

Branching Patterns and Drainage Territories of the Middle Hepatic Vein in Computer-Simulated Right Living-Donor Hepatectomies

“…Right lobe grafts (segments [5][6][7][8] are most frequently used for adult-to-adult LDLT (1,2). The extent of venous reconstruction required to prevent congestion of the graft is still a main focus of clinical discussion.…”

“…The extent of venous reconstruction required to prevent congestion of the graft is still a main focus of clinical discussion. The fate of the MHV and its branches is an important aspect of an ongoing debate (3)(4)(5)(6)(7). Especially the segments 5 and 8 of right hepatic grafts are prone to venous congestion (8,9), which may lead to a loss of functional liver tissue and, as a consequence, possible dysfunction or failure of the graft (10).…”

Analysis and Outcomes of Right Lobe Hepatectomy in 101 Consecutive Living Donors

“…Living donor liver transplantation (LDLT) has become an accepted therapy for patients with end-stage liver failure in many transplant centers worldwide, and further growth is expected as the gap between the need and availability of deceased donor liver transplants increases (1)(2)(3). An ongoing concern about LDLT, however, is donor risk.…”