Relation Between the Middle Hepatic Vein Drainage Area Volume and Alanine Aminotransferease After Left Liver Harvesting

Influence of outflow-obstructed liver volume and venous communication development: A three-dimensional volume study in living donors

Living donor liver transplantation using the left liver graft with the middle hepatic vein (MHV) is a well-established procedure. Following such procedures, outflow obstruction occurs in remnant livers. However, the effects of the outflow-obstructed liver volume (LV_Out-Ob ), with or without venous communication development, remain unclear. The aim of the study is to investigate effects of outflow-obstructed regions by focusing on short-term outcomes and remnant liver hypertrophy in left liver procurement donors. Of 532 donors, we collected data from 119 undergoing left liver procurement with the MHV. Postoperative hepatic parameters, venous communication development, and liver hypertrophy were evaluated in 2 donor groups based on LV_Out-Ob . The left liver was procured with the MHV in 119 donors, who formed 2 more groups based on the median LV_Out-Ob : large-outflow-obstruction group (n = 60; LV_Out-Ob  ≥ 263 mL) and small-outflow-obstruction (n = 59; LV_Out-Ob  < 263 mL) group. Postoperative liver function parameters were significantly impaired in the large-outflow-obstruction group compared with the small-outflow-obstruction group. Postoperative venous communication developed in 52 (66.7%) of 78 donors analyzed. Hypertrophy ratios in remnant right livers and right paramedian sectors were significantly higher in the small-outflow-obstruction group than in the large-outflow-obstruction group (P = 0.01 and P = 0.02, respectively). The liver hypertrophy ratio of outflow-obstructed regions was better, especially in small regions developing venous communication (P =  0.001). The postoperative morbidity rate did not differ significantly (P = 0.66). In conclusion, the procurement of the left liver graft with the MHV was safely performed with minimal morbidity by assessing the donor remnant right liver volume with and without outflow obstruction. Attention should be paid that postoperative hepatic parameters and remnant liver hypertrophy were impaired in the remnant livers with large outflow-obstructed regions compared with those with small outflow-obstructed regions. Liver Transplantation 23 1531-1540 2017 AASLD.

Total resection of the right hepatic vein drainage area with the aid of three-dimensional computed tomography

PURPOSE

We analyzed the feasibility and safety of our preliminary surgical approach for total hepatic resection of the right hepatic vein drainage area (THR-RHV) with the aid of three-dimensional computed tomography (3D-CT) guidance.

METHODS

Clinical findings and 3D-CT volumetry results were investigated in five patients who underwent THR-RHV for a hepatic malignant tumor close to the right hepatic vein (RHV).

RESULTS

The mean estimated remnant liver volume after a conventional right lobectomy was 474 ml, whereas that after THR-RHV was 614 ml, indicating that 140 ml (13.8%) of additional liver volume had been preserved by performing THR-RHV. The median operative time, mean ischemic time, and mean blood loss during surgery were 406 min, 51 min, and 587 ml, respectively. Histological examinations confirmed a negative surgical margin in all five patients. The mean liver volume estimated by 3D-CT was 458 ml, whereas the mean actual resected liver volume was 468 g, resulting in a mean error ratio of 3.1%.

CONCLUSIONS

THR-RHV allowed for a higher remnant liver volume than that after conventional right lobectomy of the liver, and proved feasible with acceptable perioperative results. This technique thus promotes both safety and curability for patients with a tumor close to the RHV.

Venous reconstruction based on virtual liver resection to avoid congestion in the liver remnant

BACKGROUND

Hepatic vein (HV) reconstruction may prevent venous congestion following resection of liver tumours that encroach on major HVs. This study aimed to identify criteria for venous reconstruction based on preoperative evaluation of venous congestion.

METHODS

A volumetric analysis using image-processing software was performed in selected patients with liver tumours suspected on preoperative imaging of major HV invasion. The size of the non-congested liver remnant (NCLR) was calculated by subtracting the congested area from the liver remnant. Venous reconstruction was scheduled in patients who met the following criteria: normal liver function (indocyanine green retention rate at 15 min (ICGR(15) ) of less than 10 per cent) with a NCLR smaller than 40 per cent of total liver volume (TLV), or liver dysfunction (ICGR(15) 10-20 per cent) with a NCLR smaller than 50 per cent of TLV. Surgical outcomes and liver regeneration were investigated.

RESULTS

A total of 55 patients with suspected HV invasion were enrolled. Sacrifice of one or more HVs was deemed possible in 37 patients. Venous reconstruction was scheduled in 18 patients. At operation, there was seen to be no venous involvement in 11 patients. The HV was sacrificed in 29 patients, and preserved or reconstructed in 24. Volume restoration ratios at 3 months were similar in the sacrifice (88 per cent) and preserve (87 per cent) groups. Operating time was shorter (465 min) and blood loss was lower (580 ml) in the sacrifice than in the preserve group (523 min and 815 ml respectively).

CONCLUSION

The HV can be sacrificed safely according to the proposed criteria, reducing surgical invasiveness without influencing the postoperative course.