Optimal line of hepatotomy for left lateral living donor liver transplantation according to the anatomical variations of left hepatic duct system

Bile duct anatomical variations: Relevance for liver division and preparing left split liver grafts for pediatric transplantation: Cohort study

BACKGROUND

liver lateral section graft is the most common graft type used for transplantation in children worldwide. Compared to whole liver grafts, a higher rate of biliary complications has been described. Historically, 2 techniques have been described for transection of liver - trans-hilar or trans-umbilical parenchymal transection. Though these techniques allow dividing the biliary system at two distinct positions, the usual surgical strategies do not take advantage of this advantage.

MATERIAL AND METHODS

A retrospective study was conducted on 40 candidates who volunteered for donation of their left lateral liver section for transplantation, between October 2017 and April 2019. Preoperative imaging was analyzed to depict the arterial and biliary anatomy of the liver and their variations, with a dedicated attention to the left liver (segments 2, 3 and 4). Anatomy of the biliary system was taken into account for defining the optimal surgical strategy - either through a trans-hilar or a trans-umbilical parenchymal transection.

RESULTS

In 26/40 patients, arterial or biliary variations were much relevant for decision-making on the optimal plane of liver division (trans-umbilical (N = 14) and trans-hilar (N = 26)). This resulted in 23 grafts with a single artery and bile duct, 6 grafts with double arteries and a single bile duct, and 9 grafts with double bile ducts and a single artery; only two grafts had complex anatomy. There was no arterial complication and the overall incidence of biliary problems was 14.7%. All grafts are functioning well at a mean follow-up of 19.6 ± 8.5 months.

CONCLUSIONS

Anatomical variations are frequent and their knowledge is relevant for procurement of lateral section liver graft. Knowledge of these variation, or -better- preoperative biliary imaging is helpful in guiding parenchymal transection at procurement and preparing optimal liver grafts.

Individualized biliary reconstruction techniques in autotransplantation for end-stage hepatic alveolar echinococcosis

BACKGROUND

Biliary reconstruction in ex vivo liver resection followed by autotransplantation (ERAT) for end-stage hepatic alveolar echinococcosis (HAE) remains the most challenging step, we present our experience with this complex procedure.

METHODS

A retrospective data analysis of 55 patients with end-stage HAE underwent ERAT, the biliary reconstruction techniques and short- and long-term outcomes were discussed.

RESULTS

All autografts were derived from the left lateral section after extensive ex vivo liver resection, multiple bile ducts were observed in 52 (94.5%) patients, and forty-four (80.0%) cases required ductoplasty. Biliary reconstruction was achieved with duct-to-duct anastomosis in 32 (58.2%) patients, Roux-en-Y hepaticojejunostomy (RYHJ) in 14 (25.5%) patients, and a combination of the two methods in 9 (16.4%) patients. Twenty (36.4%) patients had multiple anastomoses. Biliary leakage occurred in 8 (14.5%) patients postoperatively. Three (5.5%) patients died of liver failure, cerebral hemorrhage and intraabdominal bleeding. During a median of 31 months followed-up time, 3 (5.5%) patients developed anastomotic stricture, 1 of whom was treated by repeat RYHJ, while the others were managed with stenting.

CONCLUSIONS

With a well-designed plan and precise anastomosis, complex biliary reconstruction in ERAT can be performed with few biliary complications by a professional team.

Using on-site liver 3-D reconstruction and volumetric calculations in split liver transplantation

BACKGROUND

Split liver transplantation increases the number of grafts available for transplantation. Pre-recovery assessment of liver graft volume is essential for selecting suitable recipients. The purpose of this study was to determine the ability and feasibility of constructing a 3-D model to aid in surgical planning and to predict graft weight prior to an in situ division of the donor liver.

METHODS

Over 11 months, 3-D volumetric reconstruction of 4 deceased donors was performed using Pathfinder Scout© liver volumetric software. Demographic, laboratory, operative, perioperative and survival data for these patients along with donor demographic data were collected prospectively and analyzed retrospectively.

RESULTS

The average predicted weight of the grafts from the adult donors obtained from an in situ split procedure were 1130 g (930-1458 g) for the extended right lobe donors and 312 g (222-396 g) for left lateral segment grafts. Actual adult graft weight was 92% of the predicted weight for both the extended right grafts and the left lateral segment grafts. The predicted and actual graft weights for the pediatric donors were 176 g and 210 g for the left lateral segment grafts and 308 g and 280 g for the extended right lobe grafts, respectively. All grafts were transplanted except for the right lobe from the pediatric donors due to the small graft weight.

CONCLUSIONS

On-site volumetric assessment of donors provides useful information for the planning of an in situ split and for selection of recipients. This information may expand the donor pool to recipients previously felt to be unsuitable due to donor and/or recipient weight.