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Chen CY, Lin NC, Liu C, Hsia CY, Loong CC. Single-Center Experience in Managing Right Liver Grafts From Trifurcation or Independent Right Posterior Portal Vein in Adult Living Donor Liver Transplantation. Transplant Proc 2023:S0041-1345(23)00221-X. [PMID: 37150659 DOI: 10.1016/j.transproceed.2023.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 03/27/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND The right liver graft has sometimes been from the trifurcation portal vein (TPV) or independent right posterior portal vein (IRPPV). Managing these PV anatomies to increase the recipient's survival rate remains challenging. Many published techniques could overcome this problem, such as simple unification venoplasty (SUV), autologous portal Y-graft interposition, conjoined unification venoplasty (CUV) with a baseball-like conduit, and SUV plus circumferential fence-like vein extension. This study reviewed our strategy for managing the right liver grafts from TPV or IRPPV in adult living donor liver transplantation (aLDLT). METHODS We enrolled the study population who underwent aLDLT using the grafts with TPV or IRPPV at our institute from October 2004 to October 2022. We analyzed the reconstruction methods for these grafts and postoperative PV complications in donors and recipients. RESULTS During the study period, of 528 aLDLT recipients, we identified 26 donors with TPV (n = 10) or IRPPV (n = 16). Eight grafts from TPV had a single PV orifice. The other 18 grafts had dual right PVs that underwent initial PV management, including SUV (n = 13), recipient's right and left portal veins to graft's dual PVs (n = 2), Y-graft interposition (n = 1), CUV (n = 1) and SUV with fence-like vein extension (n = 1). One SUV graft changed to fence venoplasty due to significant tension for PV anastomosis. The acute right posterior PV thrombus and anterior PV stenosis happened in 2 cases with Y-graft interposition and native PVs direct anastomosis. One donor with TPV had portal vein thrombosis and needed thrombectomy with vein patch repair. CONCLUSIONS The graft from TPV should be carefully planned. A single PV orifice may be feasible but not always possible. An SUV could cover most IRPPVs, but if the distance between the right anterior and posterior PVs is a problem, CUV would be an alternative method. In addition, SUVs with fence venoplasty could relieve PV anastomosis tension.
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Affiliation(s)
- Cheng-Yen Chen
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Niang-Cheng Lin
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chinsu Liu
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yuan Hsia
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Che-Chuan Loong
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Yoo SY, Hwang S, Ha TY, Song GW, Jung DH, Park GC, Ahn CS, Moon DB, Kim KH, Yoon YI, Park YH, Cho HD, Chung YK, Kang SH, Choi JU, Lee SG. Long-term results of conjoined unification venoplasty for multiple portal vein branches of the right liver graft in living donor liver transplantations. KOREAN JOURNAL OF TRANSPLANTATION 2019; 33:106-111. [PMID: 35769974 PMCID: PMC9188932 DOI: 10.4285/jkstn.2019.33.4.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 11/06/2022] Open
Abstract
Background Autologous portal vein Y-graft (PYG) interposition has been the standard procedure for reconstruction of double portal vein (PV) orifices of right liver grafts during living donor liver transplantations. However, it has the disadvantage of being vulnerable to anastomotic stenosis. A refined technique of conjoined unification venoplasty (CUV) was developed to secure PV reconstruction. Methods We reviewed the surgical outcomes in PV reconstructions using CUVs in 21 cases which were followed up for >3 years. Results The mean age of recipients was 51.7±4.9 years. The model for end-stage liver disease score was 15.3±6.4. The graft-recipient weight ratio was 1.12±0.21. Recipient PYGs were harvested in all cases. All living donors were blood relatives or relatives through marriage with type III PV anomalies. The number of right liver graft PV orifices was two in 19 cases and three in two cases. For the central intervening vein patch, a PV segment was used in six cases, and an autologous greater saphenous vein patch was used in the remaining 15 cases. The 21 patient cohort displayed a 100% 4-year patient survival rate. None of them underwent any PV interventions including interventional stenting. Serial follow-up computed tomography scans revealed that the reconstructed PV showed early reshaping with a stable streamlined configuration for over 3 years. Conclusions PV reconstruction using the CUV technique appears to be significantly more effective in preventing PV complications. We believe that CUV is a useful technique to reconstruct right liver grafts with multiple PV orifices.
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Affiliation(s)
- Sung Yeon Yoo
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-In Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yo-Han Park
- Department of Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hui-Dong Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Kyu Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Hyun Kang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Uk Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kang SH, Namgoong JM, Hwang S, Jung DH, Kim KM. Wedged-patch venoplasty of the left liver graft portal vein for size matching in pediatric living donor liver transplantation. Ann Hepatobiliary Pancreat Surg 2019; 23:183-186. [PMID: 31225422 PMCID: PMC6558123 DOI: 10.14701/ahbps.2019.23.2.183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 04/12/2019] [Accepted: 04/13/2019] [Indexed: 01/01/2023] Open
Abstract
Portal vein (PV) size matching between recipient and liver graft is important in preventing anastomotic stenosis in living donor liver transplantation (LDLT). In right liver grafts, the diameter of graft PV is usually >10 mm. Thus, PV size matching does not become critical in adult recipients. If the recipient PV is very large, funneling fence can be attached to graft PV. However, if the diameter of graft PV is <8 mm, it can induce anastomotic stenosis. We experienced a few cases of PV anastomotic stenosis due to small-sized graft PV in >5000 LDLT cases, but graft PV widening was not performed because graft PV is considered as being a no-touch area. In thinking out of the box, we performed wedged-patch venoplasty to exceptionally narrow graft PV. A 4 year-old female patient underwent second LDLT due to progressive deterioration of graft function after 3 years. At first LDLT operation for biliary stresia, an iliac vein conduit was interposed for PV reconstruction. At second LDLT operation, the diameter of interposed PV was 10 mm, but the left liver graft PV was only 6 mm-sized. Uniquely, the left PV was waist only at first-order PV. To resolve this PV waist, a longitudinal incision was made to release the waist. A cold-preserved fresh iliac vein patch was inserted to widen the PV orifice. The patch size was adjusted to match the size of the recipient PV. The patient recovered uneventfully. This wedged-patch venoplasty technique can be applied to small-sized graft PV, to cope with PV size mismatching in LDLT.
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Affiliation(s)
- Sang-Hyun Kang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Man Namgoong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung-Mo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kim TY, Kim JD, Choi DL. Simplified Unification Patch Venoplasty for Anomalous Portal Vein Branching in Living Donor Liver Transplantation With Right Lobe Graft. Transplant Proc 2018; 50:2664-2667. [PMID: 30401373 DOI: 10.1016/j.transproceed.2018.03.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/02/2018] [Indexed: 11/26/2022]
Abstract
Double portal vein (PV) branches during living donor liver transplantation (LDLT) with right lobe grafts have been considered challenging both in terms of donor safety and the complexity of vascular reconstruction in the recipient. Herein, we describe our experience with 24 adult LDLT recipients during which we employed unification patch venoplasty to reconstruct right lobe grafts with double PV orifices. We retrospectively reviewed the outcomes of 195 adult LDLT recipients receiving right lobe grafts, including 24 cases of adult LDLT recipients in which unification patch venoplasty was used to treat double PVs from January 2010 to June 2015. The anomalous portal vein branches of the donors were of type II in 7 cases (29.2%), type III in 15 cases (62.5%), and type IV in 2 cases (8.3%). We used propensity score matching analysis to compare the clinical outcomes of these recipients with those of 59 recipients who underwent adult LDLT using right lobe grafts with normal PVs in the same period. Intraoperative PV stenting was necessary in 2 (8.3%) of the 24 recipients undergoing unification patch venoplasty. During the follow-up period, all PVs remained patent until death or censoring. No significant difference in terms of postoperative vascular complications was evident between the 2 groups. Moreover, no major complications requiring reoperation or endoscopic and/or radiologic intervention developed in any of the 24 living donors with double PVs. In conclusion, our simplified unification patch venoplasty could be safe and feasible when used to reconstruct double PV orifices in right lobe LDLT from donors with complex PV anomalies.
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Affiliation(s)
- T Y Kim
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea
| | - J D Kim
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea.
| | - D L Choi
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea
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Yilmaz S, Kayaalp C, Isik B, Ersan V, Otan E, Akbulut S, Dirican A, Kutlu R, Kahraman AS, Ara C, Yilmaz M, Unal B, Aydin C, Piskin T, Ozgor D, Ates M, Ozdemir F, Ince V, Koc C, Baskiran A, Dogan SM, Barut B, Sumer F, Karakas S, Kutluturk K, Yologlu S, Gozukara H. Reconstruction of Anomalous Portal Venous Branching in Right Lobe Living Donor Liver Transplantation: Malatya Approach. Liver Transpl 2017; 23:751-761. [PMID: 28240812 DOI: 10.1002/lt.24753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 02/14/2017] [Indexed: 02/05/2023]
Abstract
Reconstruction of anomalous portal vein branching (APVB) during right lobe living donor liver transplantation (LDLT) can be challenging. The goal of this article is to describe our surgical technique, named the Malatya Approach, in case of APVB during right lobe LDLT. The technique unifies the APVB and obtains a funnel-shaped common extension with a circumferential fence by a saphenous vein conduit. In total, 126 (10.6%) of 1192 right lobe grafts had APVB that were divided into 2 groups according to the adopted surgical techniques: the Malatya Approach group (n = 91) and the previously defined other techniques group (n = 35). Both groups were compared regarding portal vein thrombosis (PVT), postoperative 90-day mortality and survival. PVT developed in 3 patients (3.3%) in the Malatya Approach group and developed in 10 (28.6%) patients for the other group (P < 0.001). There were 8 (8.8%) 90-day mortalities in the Malatya Approach group (1 PVT related) and 15 patients (9 PVT related) died in the other techniques group (P < 0.001). Mean follow-up time for both groups was similar (999.1 days for the Malatya Approach group versus 1024.7 days for the other group; P = 0.47), but longterm survival in the Malatya Approach group was better than in the other group (84.6% versus 40%; P < 0.001). Multivariate analysis revealed that the Malatya Approach group showed less PVT development and longer survival (P < 0.001). This technique is promising to avoid PVT and mortalities in cases of APVB during right lobe LDLT. Liver Transplantation 23 751-761 2017 AASLD.
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Affiliation(s)
- Sezai Yilmaz
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Cuneyt Kayaalp
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Burak Isik
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Veysel Ersan
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Emrah Otan
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Sami Akbulut
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Abuzer Dirican
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Ramazan Kutlu
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | | | - Cengiz Ara
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Mehmet Yilmaz
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Bulent Unal
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Cemalettin Aydin
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Turgut Piskin
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Dincer Ozgor
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Mustafa Ates
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Fatih Ozdemir
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Volkan Ince
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Cemalettin Koc
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Adil Baskiran
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Sait Murat Dogan
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Bora Barut
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Fatih Sumer
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Serdar Karakas
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Koray Kutluturk
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Saim Yologlu
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
| | - Harika Gozukara
- Liver Transplantation Institute, Inonu University, Malatya, Turkey
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Hwang S, Ha TY, Ahn CS, Moon DB, Kim KH, Song GW, Jung DH, Park GC, Lee SG. Standardized surgical techniques for adult living donor liver transplantation using a modified right lobe graft: a video presentation from bench to reperfusion. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:97-101. [PMID: 27621745 PMCID: PMC5018955 DOI: 10.14701/kjhbps.2016.20.3.97] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 05/30/2016] [Accepted: 06/05/2016] [Indexed: 12/11/2022]
Abstract
After having experienced more than 2,000 cases of adult living donor liver transplantation (LDLT), we established the concepts of right liver graft standardization. Right liver graft standardization intends to provide hemodynamics-based and regeneration-compliant reconstruction of vascular inflow and outflow. Right liver graft standardization consists of the following components: Right hepatic vein reconstruction includes a combination of caudal-side deep incision and patch venoplasty of the graft right hepatic vein to remove the acute angle between the graft right hepatic vein and the inferior vena cava; middle hepatic vein reconstruction includes interposition of a uniform-shaped conduit with large-sized homologous or prosthetic grafts; if the inferior right hepatic vein is present, its reconstruction includes funneling and unification venoplasty for multiple short hepatic veins; if donor portal vein anomaly is present, its reconstruction includes conjoined unification venoplasty for two or more portal vein orifices. This video clip that shows the surgical technique from bench to reperfusion was a case presentation of adult LDLT using a modified right liver graft from the patient's son. Our intention behind proposing the concept of right liver graft standardization is that it can be universally applicable and may guarantee nearly the same outcomes regardless of the surgeon's experience. We believe that this reconstruction model would be primarily applied to a majority of adult LDLT cases.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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