Optimizing venous outflow reconstruction for V5 & V8 in right-lobe living-donor liver transplantation: “half-circumferential anastomosis” using autologous vein grafts

Background: Living donor liver transplantation (LDLT) is the predominant transplantation technique in regions with low rates of deceased donation. Right-lobe grafting is adopted in most clinical and radiological donor/recipient scenarios. Due to the considerable variations in right-lobe hepatic venous anatomy, many techniques have been used over the years for the purpose of appropriate venous outflow reconstruction during the recipient procedure. In this paper, we present the technical details and consequences of a complex venous outflow reconstruction model (CORM) based on experience, and the long-term patency results obtained using the model. Methods: Data of patients with end-stage liver disease who underwent LDLT between 21 December 2017 and 29 November 2022 were prospectively collected and retrospectively reviewed. The nomenclature of CORM was assigned when three or more hepatic vein anastomoses were performed. Patients with CORM (CORM group; n = 69) were compared with non-CORM patients (non-CORM group; n = 130) in terms of demographic, pre- and postoperative clinical, and follow-up features. Results: Sixty-nine recipients had three or more separate outflow reconstructions (RHV, RIHV, and one or more anterior sectoral veins); these constituted the CORM group. The estimated graft volume of the CORM group was significantly lower than that of the non-CORM group (833 vs. 898; p = 0.022), and the mean GRWR was also significantly lower (1.1 vs. 1.2; p = 0.004). CORM cases showed longer anhepatic phases, as well as longer times for cold and warm ischemia, than non-CORM cases (63 vs. 51 min, 46 vs. 38 min, and 48 vs. 33 min, p < 0.001), though no difference was found with respect to total operative duration. There were no statistical differences between the two groups with respect to rates of in-hospital re-exploration, length of ICU stay, or length of total hospital stay. Graft survival rates at 1 year, 3 years, and 5 years were 88.1%, 83.3%, and 83.3%, respectively, in the CORM group, and 82.9%, 80.2%, and 70.6%, respectively, in the non-CORM group (p = 0.167). Conclusions: Performing three or more CORMs in right-lobe LDLT is not associated with inferior outcomes, either with regard to perioperative variables or to patient and graft outcomes. Right-lobe graft with complex venous anatomy from a living donor should not be a determinant factor for donor exclusion.

O300 Aims: Current data suggest that right lobe live donor liver transplantation (RLDLT) has an inferior graft survival outcome when compared with cadaveric whole-graft liver transplantation (CWLT). Detailed comparison of the operative outcomes between these two groups of patients in a single center has not been reported. The aim of the present study was to evaluate the operative and survival outcomes of patients who underwent RLDLT and to compare the results with those of CWLT recipients in a single institution. Methods: A prospective study was performed on 180 consecutive adult patients who underwent primary liver transplantation from January 2000 to February 2004. They were given the options of LDLT and CWLT after being listed for transplantation. Detailed counseling was provided to patients and their relatives who opted for RLDLT. The middle hepatic vein was included in the graft in all except one patient. The operative and survival outcomes of 124 patients undergoing RLDLT were compared with those of 56 CWLT recipients during the same study period. Results: Fifty-eight (47%) patients were on high-urgency list and 23 (19%) of them were on life-support before operation in the RLDLT group. The corresponding figures in the CWLT group were 17 (30%) and 5 (9%). The preoperative Model for End-stage Liver Disease scores in patients with chronic liver diseases were comparable in both groups (median, 21 vs. 19, p = 0.396). The waiting time for liver transplantation was significantly shorter in the RLDLT group (median, 13.5 vs. 237 days, p <0.001). The graft weight to estimated standard liver weight ratio was lower in the RLDLT group (median, 0.489 vs. 0.982, p <0.001). The cold ischemic time of liver graft was much shorter (median, 113 vs. 362 minutes, p < 0.001), but the time required for graft implantation was longer in the RLDLT group (median, 273 vs. 244 minutes, p = 0.017). Twenty-two (18%) patients in the RLDLT group and 9 (16%) patients in the CWLT group did not require blood transfusion. The postoperative hospital stay was comparable (median, 19 vs. 17 days). The hospital mortality rate in the RLDLT group was 1.6%, and was not different from that in the CWLT group (5.4%). Hospital mortality did not occur in the last 105 consecutive patients in the RLDLT group. There was no donor mortality. Thirty-one (25%) patients in the RLDLT group developed biliary stricture on follow-up, while 3 (5%) patients in the CWLT group developed the complication (p = 0.002). At a median follow-up of 22 months, the actuarial graft and patient survival rates were 89% and 90%, respectively, in the RLDLT group, and both were 88% in the CWLT group. Conclusions: Despite a more complex operation and smaller graft volume, RLDLT results in favorable operative outcomes comparable to those of CWLT. However, there is a significantly higher incidence of biliary stricture associated with RLDLT. Further refinement in biliary reconstruction technique is required before RLDLT becomes a standard operation.

Left Lobe Living Donor Liver Transplantation in Adults

To compare early patency and outcomes of single outflow [single outflow technique (SOT)] and double outflow [double outflow technique (DOT)] reconstruction in right lobe living donor liver transplantation (RtLDLT) in a multicenter open-labeled randomized controlled trial. Optimum graft venous outflow is a key factor in determining outcomes of RtLDLT. There are no data directly comparing SOT and DOT techniques of graft outflow reconstruction. Adult patients undergoing RtLDLT needing anterior sector vein reconstruction were enrolled. A prosthetic graft was used to create a neo-middle hepatic vein (neoMHV). Web-based permuted block randomization was used to allocate patients to SOT or DOT (1:1) before graft implantation. The primary endpoint was neoMHV patency for up to 6 weeks. Secondary endpoints were postoperative morbidity and survival. Intention-to-treat and as-treated analyses are reported. Five centers randomized 219 patients to SOT (n = 110) or DOT (n = 109). Both groups were similar in baseline characteristics. SOT had better neoMHV patency at 2 weeks (92.5% vs 82.9%, P = 0.032), 4 weeks (84% vs 69%, P = 0.011) but not at 6 weeks (69.5% vs 59.2%, P = 0.124). Cox proportional hazards analysis revealed DOT [hazard ratio: 1.56 (95% CI = 1.02, 2.4); P = 0.041] and use of Dacron graft [hazard ratio: 2.83 (95% CI = 1.16, 6.94), P = 0.023] as independent risk factors for neoMHV thrombosis. SOT was associated with better in-hospital survival (97.3% vs 90.8%; P = 0.044) but similar 1-year survival (89% vs 85%, P = 0.340). SOT was associated with improved survival in patients who developed early allograft dysfunction or needed reoperation. SOT has better early neoMHV patency than DOT and may be associated with better early survival.

Objective To explore the application of autologous portal vein graft in the in vitro hepatectomy and liver autotransplantation. Methods Clinical data of a patient with cholangiocarcinoma who underwent in vitro hepatectomy and liver autotransplantation in the Southwest Hospital of the Third Military Medical University on July 2009 were analyzed retrospectively. The patient was male, 61 years old and was admitted in the hospital for one month of upper abdominal pain and discomfort, hypodynamia, loss of appetite, yellow skin and sclera for half a month and 6 days of shallowing stool color. Occupying lesions in the left medial lobe and right anterior lobe, infiltrated middle, left hepatic vein and infiltrated root of the right hepatic vein were observed by computed tomography(CT). The magnetic resonance cholangiopancreatography(MRCP) showed the left hepatic duct was infiltrated and intrahepatic bile duct dialated. The informed consent of the patient was obtained and the ethical committee approval was received. The patient received in vitro hepatectomy and liver autotransplantation. The liver was removed out of the body and the tumor was resected completely. The branch of the right hepatic vein on the cut of liver underwent plasty to be a jointly entry. The liver venous outflow was rebuilt using autologous portal vein graft and the remanent liver was transplanted in situ. The intraoperative and postoperative condition of the patient were observed. Results The operation was successful. The anhepatic phase was 200 min. The time spend of in vitro hepatectomy and reconstruction of venous outflow using autologous portal vein graft was 130 min The patient recovered well and the liver function indexes regained normal 15 d after the operation. The blood flow of the hepatic vein, portal vein and hepatic artery were good by repeated CT scan. The patient were discharged healthy. The postoperative pathological examination showed cholangiocarcinoma. Conclusions For the in vitro hepatectomy and liver autotransplantation, there are advantages of using the autologous portal vein graft to rebulid the liver venous outflow. To select a suitable patient can achieve good clinical efficacy. Key words: Portal vein; Hepatectomy; Liver transplantation; Liver neoplasms

The aim of this study was to evaluate the effects of portal hemodynamics on indices of liver function and graft regeneration in patients after adult right lobe living donor liver transplantation (R-LDLT). Sixty-four patients who underwent R-LDLT and had an uneventful postoperative course were enrolled in this study. The contribution of portal flow was greater to the recipient grafts versus the donor livers (90.74% versus 69.12%, P < 0.0001). Portal flow variations decreased significantly during the first 10 days after R-LDLT (P < 0.0001); variations in the hepatic arterial flow were more constant during this period (P = 0.812). The mean portal venous pressure (PVP) before recipient hepatectomy (the initial PVP) was 23.1 ± 4.0 mm Hg; the mean PVP after reperfusion (the final PVP) was 15.0 ± 4.3 mm Hg (P < 0.0001). Furthermore, the mean hepatic portal venous gradient (ie, PVP - central venous pressure) before recipient hepatectomy was 17.1 ± 4.3 mm Hg; it decreased to 10.6 ± 4.5 mm Hg after reperfusion (P < 0.0001). These findings suggest that after graft reperfusion, the vascular resistance of the hepatic parenchyma decreased, and there was an associated mild decrease in the portal hypertension. Multiple regression analysis indicated that PVPs correlated significantly with indices of liver function after living donor liver transplantation (P < 0.05). Patients were separated into 4 groups according to their PVP values: group A (initial PVP ≥ 23 mm Hg, final PVP ≥ 15 mm Hg), group B (initial PVP < 23 mm Hg, final PVP ≥ 15 mm Hg), group C (initial PVP ≥ 23 mm Hg, final PVP < 15 mm Hg), and group D (initial PVP < 23 mm Hg, final PVP < 15 mm Hg). Immediately after R-LDLT, the peak values for aspartate aminotransferase, alanine aminotransferase, the international normalized ratio and the average ascites production varied appreciably in these groups. The regeneration rate of the liver graft 3 months after R-LDLT was significantly greater in group A versus the other groups. In conclusion, PVP is a significant hemodynamic factor that influences the functional status of the liver and graft regeneration after R-LDLT.

Introduction: Acute liver failure (ALF), a life-threatening clinical syndrome of sudden and severe liver dysfunction, is associated with a coagulation abnormality and hepatic encephalopathy in patients without previous clinically liver disease. Therefore, ALF is very complicated status and the chance of spontaneous healing is poor. Liver transplantation (LT) is the only definitive treatment modality with well demonstrated efficacy for ALF patients. Right lobe living donor liver transplantation (RLDLT) is an excellent option for adult patients with ALF in cadeveric donor shortage. We analyzed the etiologies and our experiences in adult patients who underwent emergency RLDLT for ALF. Methods: We evaluated the charts of adult patients with ALF underwent RLDLT at Turgut Ozal Medical Center (Malatya, Turkey) between January, 2007 and September, 2011. All of the ALF patients were identified by retrospective review of a prospectively acquired liver database that contained recipient and donor demographics, perioperative findings, and postoperative outcomes. Continuous variables are reported as means ± standard deviations, and categorical variables as numbers and percentages. Results: We performed 643 liver transplants including cadaveric and live donors, and of thirty adult patients 30 (4.7%) with ALF underwent RLDLT during this study period. The median age was 32,2±13.05 years. The etiologies of ALF in the RLDLT patients were acute hepatitis B in 11 (36.6%) patients, hepatitis A in 4 (13.3%), drug intoxication in 4 (13.3%), pregnancy in 2 (6.7%), hepatitis B with pregnancy in 1 and mushroom intoxication in one (3.3%), and 7 (23.3%) unknown etiologies. The mean of hepatic coma grade (Model for End-Stage Liver Disease scores) was 34.13± 8.72. Mean graft-to-recipient weight percentage was 1.3 ± 0.3%. Mean interval between indication for transplant and LT procedure was 19.7 ± 23.6 h. Mean cold ischemia time was 154.35 ± 59.6 min. Mean recipient operation time was 605 ± 120 min. The RLDLT patients had a higher biliary and vascular complication rate (40%, 20% respectively). Survival rate of RLDLT patients was 70%, nine deaths occurred due to pulmonary (n=2), cardiac (n=1), sepsis (n=2), encephalopathy (n=4) complications. The mean intensive care unit stay was 3.2 ± 2.3 days and the mean postoperative hospital stay was 29.5 ± 23 days for RLDLT patients. The mean follow-up times were 305 days (1-1582). All of the donors remained alive and well with normal liver function at the time of the final follow-up examination. Conclusions: Liver transplantation is potentially the only curative modality and has markedly improved the prognosis of ALF patients. The interval between onset of ALF and death is short and crucial because of progressive multi-organ failure at a rapid rate in addition to the liver. Therefore, RLDLT should be considered a life-saving procedure, characterized by quicker access to liver grafts and very short ischemia time, for adult patients with ALF in shortage of deceased donor. Declaration of Interest: The authors report no conflict of interest and no funding from any company.

Background/Aims: Our objective is to assess donor complications in all right hepatic lobe living-donor liver transplantation (LDLT) at our center. Methods: Of a total of 352 liver transplantations performed, 60 were right-lobe LDLT. Most donors (88.3%) were related to the recipients. Results: Mean hospital stay was 5.4 8 0.6 days. No complications occurred due to preoperative evaluation. Most donors received one or two units of autologous blood transfusion. Only 5 (8.3%) needed nonautologous blood transfusion. Most complications were minor and treated conservatively. Bile leaks from the cut surface of the liver occurred in 5 donors (8.3%). Two patients had potentially fatal complications: perforated duodenal ulcer and portal vein thrombosis (PVT). The donor with perforated ulcer developed septicemia and multiple organ failure. He was discharged from the hospital with hemiparesis due to cerebral ischemia. The patient with PVT remained asymptomatic and the portal vein was recanalized by the 3rd postoperative month. One donor died in the immediate postoperative period of cardiac arrest due to cardiac arrhythmia. Conclusion: Right hepatectomy for LDLT may be associated with significant morbidity, including death and it should be performed only by surgeons with great experience.

To evaluate the short term-outcomes of venous reconstruction using a round ligament-covered prosthetic vascular graft and assess its effectiveness in the prevention of prosthetic vascular graft migration in right‑lobe living donor liver transplantation (LDLT). Thirty patients underwent reconstruction of the middle hepatic vein (MHV) tributaries during right lobe LDLT between January, 2021 and October, 2022. These patients were divided into the autologous vascular graft group (A group, n = 24) and the round ligament-covered prosthetic vascular graft group (RP group, n = 6). The computed tomography (CT) density ratio of the drainage area in the posterior segment of patent grafts was significantly higher in the RP group than in the A group (0.91 vs. 1.06, p = 0.0025). However, the patency rates of reconstructed MHV tributaries in the A and RP groups were 61% and 67%, respectively, with no significant difference between the groups (p = 0.72). Prosthetic vascular graft migration did not occur in the RP group. Venous reconstruction using round ligament-covered prosthetic vascular grafts is a feasible and simple method to prevent prosthetic vascular graft migration in right-lobe LDLT.

Endovascular Treatment for Infra-inguinal Autologous Saphenous Vein Graft Occlusion Using Self Expanding Nitinol Stents

For long-term patency of small-caliber vascular prostheses, antithrombogenicity and microporous structure are very important. We have developed a new technique to give a microporous structure to a polyurethane vascular prosthesis that has favorable antithrombogenicity. A solution of tetrahydrofuran/dimethylformamide (1 : 1) containing 13 wt% of segmented polyurethane (PTMG + MDI) and calcium carbonate (mean particle size, 8 μm) was dipcoated on a glass mandrel 3 mm in diameter and placed into distilled water. After the glass mandrel was removed, the polyurethane tube was placed into hydrochloric acid, and a microporous polyurethane vascular prosthesis was produced. Prostheses made in this fashion, and autologous jugular vein grafts were implanted into the femoral artery and the carotid artery of mongrel dogs. Patency was recognized on the arteriogram and duplex scanning (ultrasonography), and the removed grafts were inspected macroscopically and microscopically. This prosthesis was similar in elasticity to a vein graft. Patency was defined 8 weeks after implantation, and this prosthesis showed less intimal hyperplasia than the autologous vein graft. The new polyurethane prosthesis might be useful for small-caliber vascular reconstruction.

Background:The quality of healing of peripheral nerve injuries remains a common challenge causing pain and poor quality of life for millions of people and animals annually.Aims:The objectives of this study were to evaluate the healing quality of facial nerve injury in a dog model following local treatment using an autologous injection of platelet-rich plasma (PRP) or bone marrow-derived mesenchymal stem cells (BM-MSCs) at the injury site in combination with the application of an autologous saphenous vein graft as a conduit. Methods:20 apparently healthy adult Mongrel dogs were randomly divided into 4 equal groups. Dogs in groups 1, 2, and 3 were subjected to facial nerve neurectomy and saphenous vein conduit graft implantation at the site of facial nerve injury. Dogs in groups 2 and 3 received 1 ml of autologous PRP and BM-MSCs, respectively. Injections were administered directly in the vein conduit immediately after nerve injury. Dogs in group 1 (grafted but not treated; control) received only an autologous vein graft, and those in group 4 (normal control) received no graft and no PRP or BM-MSCs treatment. The dogs were monitored daily for 8 weeks after surgery. Clinical evaluation of the facial nerve, including lower eyelid, ear drooping, upper lip, and tongue functions, was carried out once per week using a numerical scoring system of 0–3. At the end of the study period (week 8), the facial nerve injury site was evaluated grossly for the presence of adhesions using a numerical scoring system of 0–3. The facial nerve injury site was histopathologically assessed for the existence of perivascular mononuclear cell infiltration, fibrous tissue deposition, and axonal injury using H&E-stained tissue sections. Results:Clinically, BM-MSCs treated dogs experienced significant (p < 0.05) improvement in the lower eyelid, ear, lip, and tongue functions 4 weeks postoperatively compared to other groups. Grossly, the facial nerve graft site in the BM-MSCs treated group showed significantly (p < 0.05) lesser adhesion scores than the other groups. Histopathologically, there was significantly (p < 0.05) less perivascular mononuclear cell infiltration, less collagen deposition, and more normal axons at the facial nerve injury site in the BM-MSCs treated group compared to the other groups. Conclusion:This study showed clinically significant enhancement of nerve regeneration by applying autologous BM-MSCs and autologous vein grafting at the site of facial nerve injury. However, further clinical trials are warranted before this application can be recommended to treat traumatic nerve injuries in the field.

To evaluate and compare the operative and survival outcomes of patients who underwent right lobe live donor liver transplantation (RLDLT) and cadaveric whole-graft liver transplant (CWLT) recipients in a single institution. Current data suggest that RLDLT has an inferior graft survival outcome when compared with CWLT. A prospective study was performed on 180 consecutive adult patients who underwent primary liver transplantation from January 2000 to February 2004. The operative and survival outcomes of RLDLT (n = 124) were compared with those of CWLT (n = 56). Fifty-five (44%) and 16 (29%) patients were on high-urgency list in the RLDLT group and the CWLT group, respectively (P = 0.045). The preoperative Model for End-Stage Liver Disease scores were comparable in both groups. The waiting time for liver transplantation was significantly shorter in the RLDLT group. The graft weight to estimated standard liver weight ratio was significantly lower in the RLDLT group. The postoperative hospital stay and hospital mortality were comparable in the RLDLT group (1.6%) and the CWLT group (5.4%). Thirty-one (25%) patients in the RLDLT group and 3 (5%) patients in the CWLT group developed biliary stricture on follow-up (P = 0.002). At a median follow-up of 27 months, the actuarial graft and patient survival rates were 88% and 90%, respectively, in the RLDLT group, and both were 84% in the CWLT group. RLDLT results in favorable operative outcomes comparable with those of CWLT. However, there is a significantly higher incidence of biliary stricture associated with RLDLT.

Durability of Portal Venous Reconstruction Following Resection During Pancreaticoduodenectomy

The purpose of this study was to determine the range of portal blood flow velocity at Doppler sonography of recipients without major complications after right-lobe living donor liver transplantation and to explore factors affecting portal blood flow velocity. Seventy-one patients (59 men, 12 women; mean age, 48.1 +/- 8.8 [SD] years; range 19-69 years) who underwent right-lobe living donor liver transplantation were enrolled. At preoperative Doppler sonography, peak portal blood flow velocity was measured at the main portal vein. On CT scans, varix score was calculated by subcategorization and grading of varices, and splenic volume was measured. The recipient's body weight and the graft weight were measured, and the graft-to-body weight ratio was calculated. Postoperatively, peak portal blood flow velocity of the recipient portal vein was measured at Doppler sonography on the first three postoperative days. The correlations between preoperative peak portal blood flow velocity, varix score, splenic volume, recipient body weight, graft weight, graft-to-body weight ratio, and recipient portal blood flow velocity were evaluated with Pearson's and Spearman's tests. Multiple regression analysis was performed to determine the factors independently correlated with recipient portal blood flow velocity. The mean peak recipient portal blood flow velocity was 47 +/- 14 cm/s (range, 23-86 cm/s). Portal blood flow velocity increased significantly as varix score increased (r = 0.463, p < 0.001). Weak positive correlations were found between portal blood flow velocity and graft weight (r = 0.255, p = 0.032) and graft-to-body weight ratio (r = 0.242, p = 0.042). Multiple regression analysis showed varix score and graft-to-body weight ratio independently correlated with portal blood flow velocity (beta = 2.496, p < 0.001; beta = 19.791, p = 0.014). Depending on the severity of preoperative portal hypertension and graft size, recipient portal blood flow velocity has a wide range in the days immediately after right-lobe living donor liver transplantation.