Reconstruction of the middle hepatic vein tributary in adult right lobe living donor liver transplantation

Middle hepatic vein reconstruction in adult right lobe living donor liver transplantation improves recipient survival

BACKGROUND

The efficacy and necessity of middle hepatic vein (MHV) reconstruction in adult-to-adult right lobe living donor liver transplantation (LDLT) remain controversial. The present study aimed to evaluate the survival beneficiary of MHV reconstructions in LDLT.

METHODS

We compared the clinical outcomes of liver recipients with MHV reconstruction (n = 101) and without MHV reconstruction (n = 43) who underwent LDLT using right lobe grafts at our institution from January 2006 to May 2017.

RESULTS

The overall survival (OS) rate of recipients with MHV reconstruction was significantly higher than that of those without MHV reconstruction in liver transplantation (P = 0.022; 5-yr OS: 76.2% vs 58.1%). The survival of two segments (segments 5 and 8) hepatic vein reconstruction was better than that of the only one segment (segment 5 or segment 8) hepatic vein reconstruction (P = 0.034; 5-yr OS: 83.6% vs 67.4%). The survival of using two straight vascular reconstructions was better than that using Y-shaped vascular reconstruction in liver transplantation with two segments hepatic vein reconstruction (P = 0.020; 5-yr OS: 100% vs 75.0%). The multivariate analysis demonstrated that MHV tributary reconstructions were an independent beneficiary prognostic factor for OS (hazard ratio=0.519, 95% CI: 0.282-0.954, P = 0.035). Biliary complications were significantly increased in recipients with MHV reconstruction (28.7% vs 11.6%, P = 0.027).

CONCLUSIONS

MHV reconstruction ensured excellent outflow drainage and favored recipient outcome. The MHV tributaries (segments 5 and 8) should be reconstructed as much as possible to enlarge the hepatic vein anastomosis and reduce congestion.

Explant portal vein for reconstructing middle hepatic vein in right lobe living donor liver transplantation-outcome analysis

BACKGROUND

The aim of the study was to study the four week patency rates of the reconstructed neo middle hepatic vein specifically using the explant portal vein (PV) in right hemiliver live donor liver transplantation (LDLT). We hypothesized that short term patency of the neo-MHV should result in good graft and patient outcomes.

METHODS

Pre, intra and post operative variables were prospectively collected for 88 consecutive patients undergoing right hemiliver LDLT from January 2014 to October 2015.

RESULTS

Explant PV was used to reconstruct neo-MHV in 76 (86.4%, 76/88) patients. Neo MHV patency rate at 28 days with explant PV was 89.4% (59/66) and with other conduit (PTFE) was 90.9% (10/11). All occlusions were detected after 7 days. There was no impact of the patency of the neo-MHV on the incidence of early allograft dysfunction, sepsis, rejection, morbidity or mortality, despite the contribution of the anterior sector to the graft volume being more than 50% in close to two-thirds of patients.

CONCLUSION

The reconstructed neo-MHV has excellent short term patency rates at 4 weeks. Perhaps due to the absence of early occlusions, there was no impact on graft or patient outcomes in the study population.

Pancreaticoduodenectomy with venous reconstruction using cold-stored vein allografts: long-term results of a single center experience

BACKGROUND

The use of cadaveric vein allografts was first described by our group as a feasible option for venous reconstruction. The aim of this study was to report long-term results of this innovative technique.

METHODS

Cold-stored veins harvested from donor cadavers were used as homologous grafts for venous reconstruction after vascular resection during pancreaticoduodenectomy. Surgical technique included patch closure or segmental interposition. Graft patency was assessed by computed tomography postoperatively and during follow-up. Postoperative morbidity and mortality were also analyzed.

RESULTS

Eleven patients underwent venous resection and reconstruction by using fresh vein allografts for patch closure in four cases, conduit interposition in six cases and a Y-shaped graft interposition in one case. Median clamping time, operative time and estimated blood loss were 30 min, 6.6 h, and 337 ml, respectively. One patient, who had preoperative SMV thrombus, developed early portal vein thrombosis and died. Among the remaining 10 patients, there were no cases of graft thrombosis or stenosis during active follow-up (median 9, range 1-23, months).

CONCLUSIONS

Our experience with cold-stored vein allografts suggests that this technique is a useful option for treating major vascular resections during pancreaticoduodenectomy with good results on follow-up.

Reconstructing middle hepatic vein tributaries in right-lobe living donor liver transplantation

AIMS

To investigate the effectiveness of our technique and policy in reconstructing middle hepatic vein (MHV) tributaries of patients undergoing right-lobe living donor liver transplantation (LDLT).

METHODS

From January 2001 to December 2010, 186 adult patients underwent right-lobe LDLT without the MHV. Patients were divided into two groups: group A (n = 71) and group B (n = 115) without or with the MHV tributaries reconstruction. We evaluated the serum liver function markers after transplantation and monitored vascular flow in the graft and interpositional vein by Doppler ultrasonography.

RESULTS

The cumulative 1-, 3-, 5-year graft and patient survival rates were not significant between group A and group B (p = 0.287 and p = 0.258). Biliary complications appeared to be more frequent in group A than in group B (16.9 vs. 5.2%, p = 0.009). Liver function impairment was found in patients without MHV reconstruction and those with occluded interpositional vessels early after transplantation. The cumulative 1-, 3-, 6- and 12-month patency rate of the interpositional veins was 81.51, 79.60, 74.69 and 72.68%, respectively.

CONCLUSION

The reconstruction technique based on our policy ensures excellent outflow drainage and favorable recipient outcome, while better criteria for MHV reconstruction should be established.

[Specific considerations in living-donor liver transplantation]

INTRODUCTION

Due to the limited number of cadaver donors, adult living liver donor transplantation became an alternative for liver transplantation. During living liver donor transplantation, the safety and uncomplicated recovery of the donor are as important as the appropriate volume and weight of the donated graft. The middle hepatic vein causes a significant dilemma, due to the special anatomical position. The reconstruction of the middle hepatic vein branches supplying S5, S8 is suggested when the anatomically right liver lobe is transplanted.

AIM

The aim of the present study was to investigate the requirements of the reconstruction of middle hepatic vein and to give an accurate description about the discrepancy between the portal vein in- and outflow.

METHOD

The authors analyzed the liver anatomic characteristics of 130 donors undergoing living liver donor transplantation with the use of MeVis software. The so-called porto-hepatic disparity index (shift) was introduced.

RESULTS

The right hepatic vein was dominant in 64.6% of all cases, while the left hepatic vein was never observed to be dominant. The territories of V5 and V8 were responsible for the 33.2±8.9% of the right hepatic lobe area. The correlation between portal venous territory and vein dominancy were as follows: R2 = 0.7811 in the left liver lobe; R² = 0.5463 in the area of middle hepatic vein and R² = 0.5843 in the case of the right hepatic vein. The average value of the shift was 28.2%.

CONCLUSIONS

The differences among the pattern of portal in- and hepatic outflow is an important issue that should be taken into consideration when deciding the necessity for reconstruction of the middle hepatic vein.

Use of cold-stored vein allografts for venous reconstruction during pancreaticoduodenectomy

INTRODUCTION

Venous resections and reconstructions of portal vein and/or superior mesenteric vein in course of pancreaticoduodenectomy are becoming a common practice and many surgical options have been described, from simple tangential resection and venorrhaphy to large segmental resections followed by interposition grafting. The aim of this study was to report the first experience of using fresh cadaveric vein allografts for venous reconstruction during pancreaticoduodenectomy focusing on technical feasibility and postoperative outcomes.

METHODS

From January 2001 to October 2012, out of 151 patients undergoing pancreaticoduodenectomy for pancreatic head tumor, 22 (14.5 %) received a vascular resection of the mesentericoportal axis. In five of these patients, vascular reconstruction was accomplished by using cold-stored venous allografts of iliac and femoral veins from donor cadaver. Patients' data, surgical techniques, and clinical outcomes were analyzed.

RESULTS

Five patients undergoing pancreaticoduodenectomy were selected to receive a vascular reconstruction using a fresh venous allograft for patch closure in three cases, conduit interposition in one case and a Y-shaped graft in the last case. No graft thrombosis or stenosis occurred postoperatively and at long-term follow-up. Mortality rate was zero.

CONCLUSION

The use of fresh vein allografts is a feasible and effective technique for venous reconstruction during pancreaticoduodenectomy. However, prospective surveys including large cohorts of patients are necessary to confirm these results.