Modified Dual Hepatic Vein Anastomosis in Pediatric Living-Donor Liver Transplantation Using Left Lateral Segment Grafts With Two Wide Orifices

Abstract

Background: The anatomic variation of hepatic vein in the left lateral segment (LLS) increases the risk of outflow complication in pediatric living liver transplantation (LDLT). Here, we share a modified method for dual hepatic vein reconstruction in pediatric LDLT using LLS with two wide orifices.Methods: From Sep 2018 to Dec 2019, 434 pediatric LDLTs using LLS were performed in our center. Hepatic veins of grafts were classified into three types with emphasis on the number, size, and location of orifices at the cut surface: a single opening (type I, n = 341, 78.57%); two adjacent orifices (type II, n = 66, 15.21%); two wide orifices with orifices distances <20 mm (type IIIa, n = 15, 3.46%); and two wide orifices with orifices distances >20 mm (type IIIb, n = 12, 2.76%). Rv was defined as the ratio of diameter of V2 and V3 (refer to hepatic vein drained segments II and III). We developed a modified dual hepatic vein anastomosis to reconstruct outflow for type IIIb grafts with Rv ≤1. Briefly, the hepatic vein of segment II was anastomosed to the common stump of middle hepatic vein (MHV) and left hepatic vein (LHV), followed by unification of V3 and the longitudinal incision orifice in inferior venous cave (IVC).Results: During median follow-up of 15.6 months (7.5–22.9 months), no hepatic vein complications occurred.Conclusion: This novel modified dual hepatic vein anastomosis could serve as a feasible surgical option for type IIIb LLS grafts with Rv ≤1 in pediatric LDLT.

Hepatic venous reconstruction of the left lateral segment with emphasis on anomalous hepatic vein in pediatric liver transplantation

“…The published study does not refer to a comparative analysis of the WIT, as well as the need and clamping time of IVC, with the other types of LLS grafts (control group) used. [26] In the current study, the HVG interposition technique showed no difference in WIT or the need for IVC clamping when compared with the other types of LLS grafts used. Another aspect of this discussion is the presence of a V3 in an extremely inferior location in the LLS graft, making it difficult or even impossible to directly anastomose this vein in the retrohepatic IVC, especially in small infants.…”

“…[27] The large caliber formed by venoplasty between the HVG conduit and V2 allows a wide anastomosis; despite this, the higher GHV/RHV correlation in type IIIB LLS grafts did not determine the need for IVC clamping during implantation, as shown in Table 1. In the situation of extreme mismatching, this can be solved by communicating the 3 recipient's HV, with triangulation and enlargement of the common ostium toward the IVC, thus enabling the compatibility of the very small recipient Dar et al [28] HAG interposition a 3 HV venoplasty Case report 6 mo Patent graft HV Sakamoto et al [12] No BTVR−Dual HV anastomosis in recipient V2G: LHV + V3G: MHV or V2G: LHV/MHV + V3G: RHV 10 Median 7.9 y 1 HVOO (10%)-BV Hwang et al [8] HVG interposition b 3 HV venoplasty Case report 6 mo Patent graft HV Veerankutty et al [29] QVP anchored to V2G ± V3G Anteromedial IVC venotomy Case report 3 mo Patent graft HV Hou et al [26] No BTVR−Dual HV anastomosis in recipient V2G: LHV ± MHV V3G: Anteromedial IVC venotomy 08 Mean 15.6 mo…”

“…The literature related to outflow reconstruction of LLS grafts with AHV is scarce, and the published studies, [8,12,[25][26][27][28][29] represented with small samples or case reports, generally describe the use of different surgical strategies (Table 3) and miscellaneous outcomes. In short, the techniques are summarized in the use of conduits and dual independent anastomosis.…”

Venous outflow obstruction in pediatric left lateral segment split liver transplantation

“…14 Since then, different surgical venous anastomoses have been described. [15][16][17][18] A number of factors are known to affect the incidence of VOO after LLS graft transplantation including vessel size and length, number and anatomy of graft segmental veins, and graft positioning. 19 Of note, in the early postoperative period, VOO may be caused by technical problems; at a later stage, parenchyma growth, fibrosis, organized thrombus, and intimal hyperplasia play an important role.…”

“…One such technique, initially described in 1991, involves the creation of a triangular anastomosis along the anterior surface of the inferior vena cava 14 . Since then, different surgical venous anastomoses have been described 15–18 …”