Which is the best technique for hepatic venous reconstruction in pediatric living-donor liver transplantation? Experience from a single center

In liver transplantation, a left lateral section (LLS) graft may have an unusual variant left hepatic vein (LHV) anatomy. This study was designed to analyze the incidence of unusual LHV variants and to determine technical methods for effective reconstruction in infant recipients weighing approximately 10 kg or less. The study comprised 3 parts: an LHV variation analysis, a simulation-based design for the technical modification of graft LHV venoplasty, and its clinical application. The LHV anatomy of 300 potential LLS graft donors was classified into 4 types according to the number and location of the hepatic vein openings: (1) a single opening (n ¼ 218 or 72.7%); (2) 2 large adjacent openings (n ¼ 29 or 9.7%); (3) 2 adjacent openings, 1 large and 1 small (n ¼ 34 or 11.3%); and (4) 2 widely spaced openings (n ¼ 19 or 6.3%). Types 2 and 3 required wedged unification venoplasty, and type 4 required additional vein interposition. In a series of 49 cases using LLS grafts, the graft hepatic vein complication rate was 4.5% at 3 years; stenting was necessary for 1 of the 36 type 1 LHV grafts (2.8%) and for 1 of the 13 type 2-4 LHV grafts (7.7%, P ¼ 0.46). A customized interposition-wedged unification venoplasty technique for coping with type 4 vein variations was developed with a simulation-based approach, and it was successfully applied to a 10-month-old male infant receiving an LLS graft with a type 4 LHV. In conclusion, nearly all LHV variations can be effectively managed with customized unification venoplasty. These venoplasty techniques represent beneficial surgical options as part of graft standardization for hepatic vein reconstruction in pediatric living donor liver transplantation.

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“…16 We think that our unified graft LHV orifice is also suitable for such triangular or diamond-shaped anastomoses.…”

Section: Discussionmentioning

confidence: 95%

Anomalous hepatic vein anatomy of left lateral section grafts and customized unification venoplasty for pediatric living donor liver transplantation

Hwang

Kim

et al. 2013

Liver Transpl

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“…There is no consensus, however, regarding the optimal technique for constructing the anastomosis itself. Reported techniques include the following: a continuous running (single stitch) closure across a transverse cavotomy; creation of a triangular caval orifice closed using three sutures ; a wide longitudinal cavotomy anastomosed with a running stitch ; and cutting donor hepatic vein flush with liver parenchyma .…”

Section: Discussionmentioning

confidence: 99%

“…Tannuri et al. describe an incidence decrease from 27.7 to 5.7% when switching to a triangulated technique .…”

Section: Discussionmentioning

confidence: 99%

Hepatic venous outflow obstruction in pediatric liver transplantation: Technical considerations in prevention, diagnosis, and management

Sommovilla

Doyle

Vachharajani

et al. 2014

Pediatric Transplantation

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HVOO creates significant diagnostic and management dilemmas in pediatric liver transplant recipients, particularly with TVGs (split or reduced-size grafts). Numerous technical variations for the hepatic vein to IVC anastomosis have been described to minimize the incidence of this complication, but no consensus for an optimal anastomotic technique exists. One hundred and thirty-four liver transplants (70 TVGs) were performed in 124 patients between 1994 and 2011. These were divided into two cohorts. Group 1 (95 transplants, 41 TVGs) utilized a continuous running anastomosis. Group 2 (39 transplants, 29 TVGs) implemented a triangulated (three-stitch) anastomosis. All were reviewed for demographics, diagnostics, interventions, and outcome. The overall HVOO incidence was seven of 134 transplants (5.2%) and six of 70 transplants utilizing TVGs (8.6%). Group 1 incidence was five of 41 (12.2%) compared with one of 29 (3.4%; p = 0.20, OR 3.89) in Group 2. Liver Doppler was employed in all patients, and only three suggested HVOO. All patients with HVOO underwent venogram, at a median of 81 days post-transplant. All underwent percutaneous venoplasty and required 1-6 treatments, all resulting in HVOO resolution. Incidence of HVOO has improved since adopting the triangulated anastomosis, although not to a level of statistical significance. US is not adequately sensitive to exclude HVOO. Venogram is recommended in patients with prolonged ascites, and venoplasty has been highly successful in HVOO treatment.

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“…Emond et al suggested that a close distance between the right atrium and the anastomotic site enhances the hemodynamic qualities of the reconstruction . Tannuri et al noted that direct HV anastomosis must be performed using a wide longitudinal incision at the anterior wall of the IVC in pediatric LDLT . In this procedure, a new wide orifice was created at the lower level of the original HV orifice.…”

Section: Discussionmentioning

confidence: 99%

Optimizing hepatic venous outflow reconstruction for hepatic vein stenosis with indwelling stent in living donor liver retransplantation

Shigeta

Sakamoto

Sasaki

et al. 2017

Pediatric Transplantation

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The patient was a boy of 7 years and 5 months of age, who underwent LDLT for acute liver failure at 10 months of age. HV stent placement was performed 8 months after LDLT because of intractable HV stenosis. At 7 years of age, his liver function deteriorated due to chronic rejection. The patient therefore underwent living donor liver retransplantation from his father. The HV was transected with the stent in situ. The IVC was resected due to stenosis. The pericardial cavity was opened and detached around the IVC to elongate the IVC. The divided ends of the IVC were joined by suturing to the posterior wall of the IVC. A new triangular orifice was made by adding an incision on the anterior wall of the IVC. The graft HV was then anastomosed to the new orifice with continuous sutures in the posterior wall and interrupted sutures in the anterior wall using 5-0 non-absorbable sutures. Doppler ultrasound showed a triphasic waveform. We successfully performed HV reconstruction without a vascular graft. This is a feasible procedure for overcoming HV stenosis in LDLT patients with an indwelling stent.

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Which is the best technique for hepatic venous reconstruction in pediatric living-donor liver transplantation? Experience from a single center

Cited by 16 publications

References 16 publications

Anomalous hepatic vein anatomy of left lateral section grafts and customized unification venoplasty for pediatric living donor liver transplantation

Anomalous hepatic vein anatomy of left lateral section grafts and customized unification venoplasty for pediatric living donor liver transplantation

Hepatic venous outflow obstruction in pediatric liver transplantation: Technical considerations in prevention, diagnosis, and management

Optimizing hepatic venous outflow reconstruction for hepatic vein stenosis with indwelling stent in living donor liver retransplantation

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