One Orifice Vein Reconstruction in Left Liver Plus Caudate Lobe Grafts

Abstract

We read the recent article by Hashimoto et al. (1) (Tokyo group) with interest. It described the use of a tricky back-table venous reconstruction in a left lobe liver graft with the caudate lobe (1). They recommended making a large venous reservoir by gathering the left, middle, and short hepatic veins using conduit and patch vein grafts (1). They have also proposed similar but modified techniques using patch grafts during the last few years (1–3). In contrast, we have been performing simple venous reconstructions with “cavoplasty” to increase the width of the anastomosis as shown in Figure 1.FIGURE 1.: A schematic view of the venoplasty for a hepatic venous reconstruction. The stumps of the middle and left hepatic vein were co-clamped with the anterior wall of the vena cava, thus making a simple cavoplasty to increase the size of the anastomosis. LHV, left hepatic vein, MHV, right hepatic vein, RHV, right hepatic vein.From January 2003 to March 2007, 80 living donor liver transplants using an extended left lobe with caudate lobe grafts were performed at Kyushu University Hospital. All the venous reconstruction was performed as described previously (4). Briefly, the venous septations in the left lobe grafts were spatulated to create a wide single orifice. In the recipient, the stumps of the middle and left hepatic vein were co-clamped with the anterior wall of the vena cava, making a simple cavoplasty to increase the size of the anastomosis. The anastomosis was performed with simple intraluminal mattress sutures using 5-0 continuous PDS (Ethicone Inc., Somerville, NJ). No short hepatic veins were reconstructed at all. The mean graft volume was 425g (250–600 g), corresponding to 38.4% (23.7 to 56.8%) of graft volume/standard liver volume. The mean diameter of the anastomosis was 37 mm (28 to 50 mm). Our operative, cold preservation, and warm preservation time was 724 min (437 to 1100 min), 52 min (25 to 119 min), and 32 min (25 to 41 min), in comparison to those of the Tokyo groups: 925 min, 130 min, and 74 min. Our warm and cold preservation time was less than half of that reported by Tokyo group. Our graft survival was 89.7% at 1-year and 82.8% at 3-years. We had no venous outflow complications associated with this technique. The volume of the caudate lobes in the Tokyo group increased from 22 cm3 to 35 cm3, which was consistent with our series showing the change form 24 cm3 to 37 cm3 without reconstruction of the caudate lobe veins (1, 5). Moreover, the caudate lobe / total graft volume ratio was 5.7% before and 4% after regeneration in the Tokyo series and 2% and 4% in our series (1, 5). Hwang et al. (6) reported that a poor regeneration of the caudate lobe was observed in only one of six (16.6%) in their series without short hepatic venous reconstruction, thus suggesting the formation of direct drainage pathway through major hepatic veins. The question remains whether the techniques described by the Tokyo group would result in an actual improvement in the graft outcomes. We think that our simple and refined surgical techniques have so far yielded excellent operative and survival data. Toru Ikegami Yuji Soejima Akinobu Taketomi Yoshihiko Maehara Department of Surgery and Science Graduate School of Medical Sciences Kyushu University Fukuoka, Japan