Left Lateral Section Graft Research Articles

Incidence of superficial left hepatic vein and its usability for graft hepatic vein venoplasty in pediatric liver transplantation.

The anatomy of the left hepatic vein (LHV) is variable; thus, it should be considered for graft hepatic vein (GHV) venoplasty for left lateral section (LLS) and left liver grafts. This study assessed the incidence of superficial LHV (sLHV) branches according to LHV anatomy and its usability for GHV venoplasty in pediatric liver transplantation (LT). This study consisted of three parts: (1) anatomical classification of LHV variations and the incidence of sLHV branches; (2) morphometric simulative analysis of GHV reconstruction and (3) clinical application based on LHV anatomy. The LHV anatomy of 248 potential LLS graft donors was classified into four types according to the number and location of GHV openings: one single opening (type 1; n= 186 [75.0%]), two large openings (type 2; n= 35 [14.1%]), one large and one small adjacent opening (type 3; n= 14 [5.6%]), and two large widely-separated openings (type 4; n= 13 [5.2%]). An sLHV branch was identified in 87 of 248 (35.1%) donor livers. Morphometric analysis of simulative GHV venoplasty with an sLHV branch increased GHV diameters by 30% in type 1 LLS grafts and 20% in type 2/3 LLS grafts. An analysis of 50 consecutive patients who underwent pediatric LT showed that the 2-year rates of GHV obstruction were 2.0% with LLS grafts and 0% with left liver grafts. The GHV orifice can be enlarged through LHV anatomy-based unification venoplasty. Unification venoplasty with an sLHV branch provided sufficient enlargement of the GHV orifice.

Dextroplantation of a reduced left lateral section graft in an infant undergoing living donor liver transplantation

Dextroplantation of a reduced left lateral section graft in an infant undergoing living donor liver transplantation

Dextroplantation of a reduced left lateral section graft in an infant undergoing living donor liver transplantation

Graft size matching is essential for successful liver transplantation in infant recipients. We present our technique of graft dextroplantation used in an infant who underwent living donor liver transplantation (LDLT) using a reduced left lateral section (LLS) graft. The patient was an 11-month-old 7.8 kg-weighing female infant with hepatoblastoma. She was partially responsive to systemic chemotherapy, thus LDLT was performed to treat the tumor. The living donor was a 34-year-old mother of the patient. After non-anatomical size reduction, the weight of the reduced LLS graft was 235 g, which was 3.0% of the graft-recipient weight ratio. Recipient hepatectomy was performed according to the standard procedures of pediatric LDLT. At the beginning of graft implantation, the graft was temporarily placed at the abdomen to determine the implantation location. The graft portal vein was anastomosed with an interposed external iliac vein homograft. As the liver graft was not too large and it was partially accommodated in the right subphrenic fossa, the abdominal wall wound was primarily closed. The patient recovered uneventfully. An imaging study revealed deep accommodation of the graft within the right subphrenic fossa. The patient has been doing well for 3 months without any vascular complications. Dextroplantation of a reduced LLS graft can be a useful technical option for LDLT in infant patients.

Third retransplantation using a whole liver graft for late graft failure from hepatic vein stent stenosis in a pediatric patient who underwent split liver retransplantation

We present a case of third retransplantation using a whole liver graft in a 13-year-old girl who suffered graft failure and hepatopulmonary syndrome following split liver retransplantation with endovascular stenting of the hepatic and portal veins as an infant. She was diagnosed with biliary atresia-polysplenia syndrome, and thus underwent living donor liver transplantation from her mother at 9 months of age. The first liver graft failed due to stenosis of the portal vein. She underwent the second liver transplantation with a split left lateral section graft. Endovascular stenting was performed to the portal vein stenosis 2 months and hepatic vein stenosis 9 months after transplantation. During the next 9 years, 11 sessions of balloon angioplasty for hepatic vein stent stenosis were performed. Ten years after the second transplantation, she underwent third transplantation using a whole liver graft recovered from a 12-year-old-girl. The double inferior vena cava technique was used for outflow vein reconstruction. The graft portal vein was anastomosed with the stent-containing portal vein stump because it was not possible to remove the stent and the inner diameter of the portal vein stent was large enough. An aorto-hepatic jump graft was used for arterial reconstruction. The patient recovered slowly and is doing well for 6 months posttransplant. In conclusion, because stenting of the hepatic vein or portal vein can induce graft failure leading to late retransplantation, we emphasize secure vascular reconstruction to prevent endovascular stenting during liver transplantation in infants.

Pediatric split liver transplantation for congenital factor X deficiency: first 10-year follow-up of a case with portal vein stenting

Congenital factor X (FX) deficiency is a rare autosomal-recessive disease that induces bleeding disorder. Herein, we present the 10-year posttransplant course of a pediatric patient who underwent liver transplantation (LT) with portal vein (PV) stenting for correction of severe congenital FX deficiency, with focus on long-term maintenance of coagulation function and patency of PV stenting. A 17-month-old infant with recurrent hemorrhagic episodes due to FX deficiency underwent split LT using a left lateral section graft. The graft-recipient weight ratio was 2.2%. The graft implantation procedures were performed by following the standard pediatric split LT procedure. Nevertheless, a wall stent was inserted due to PV anastomotic stenosis on posttransplant day 1. Graft function recovered slowly because of partial parenchyma infarct, and the patient was discharged at 46 days after LT operation. The FX activity started to increase soon after LT and gradually normalized; the coagulation profiles have been maintained well for the past 10 years. The patient has been doing well for the past 10 years after LT without any episodes of abnormal bleeding. Due to the risk of vascular complications owed to PV stenting, life-long follow-up is mandatory with special attention until attainment of complete physical growth to adolescent and adulthood.

Outflow vein venoplasty of left lateral section graft for living donor liver transplantation in infant recipients

Outflow vein venoplasty of left lateral section graft for living donor liver transplantation in infant recipients

Graft outflow vein venoplasty for a laparoscopically harvested left lateral section graft in pediatric living donor liver transplantation

Laparoscopically harvested left lateral section (LLS) grafts have drawbacks regarding the size of the graft left hepatic vein (LHV) orifice although they have the merit of cosmetics concerning the donor’s wound. We present a case of pediatric living donor liver transplantation (LDLT) using a laparoscopically harvested LLS graft and describe the refined surgical techniques for graft LHV venoplasty with a circumferential vein patch. The patient was a 46-month-old boy with marked growth retardation who was diagnosed with progressive familial intrahepatic cholestasis type 2. The donor was his 25-year-old mother. The LLS graft weighed 285 g. A circumferential patch of external iliac vein homograft was attached to the graft LHV orifice after incisions were made at the medial wall of the LHV trunk and superficial LHV branch, which made the graft LHV orifice much larger. The recipient’s hepatic vein orifice was also enlarged by unifying the three hepatic vein orifices. Other surgical procedures followed the standard LDLT operation. This patient recovered uneventfully and has been doing well for 1 year. In conclusion, our incision-and-patch venoplasty to enlarge the graft outflow vein orifice was beneficial for reducing the risk of hepatic vein outflow obstruction in LDLT using a laparoscopically harvested LLS graft.

Living liver donor surgical complication : single center experience with 512 cases

Introduction: Korea is the one of the most common country to do living donor liver transplantation. But almost big liver transplantation center is in Seoul which is capital of Korea. Beside Seoul, There are no big living donor liver transplantation center except Dague catholic university medical center. We were reached to 500th living donor liver transplantation in 2017. We review our donor complication and find way to reduce the rate of morbidity. Method: Institutional LT database was searched from 2005.05.08. to 2017.12.31. Their medical records and imaging studies were reviewed. Result: From 2005.05.08 we did first living donor hepatectomy, we did 512 living donor hepatectomy until 2017.12.31. Among them, 324 were male and 188 were female. Graft types were Right liver graft in 457 (89.3%), Left liver graft in 47 (9.2%), Left lateral section graft in 2 (0.4%) and Right posterior section graft in 6 (1.2%). Mean age of total donor was 30 years and Mean BMI was 22. Mean hospital days was 10days. All of the donors, surgical complication occurred in 32donors.(6.3%) Minor complication was 10 cases(1.9%). Major complication was 24case.(4.7%) Between major complication, the most common complication was biliary complication (n=17) and the Other complications were small bowel obstruction operation(2), , bleeding control(n=2), pleural effusion drainage(n=2), portal vein stent insertion(n=1). There are no mortality. The most common complication was biliary complication which were 20cases (3.8%). Among them intra-op T-tube insertion were 9 case and 3 case were PTBD insertion and 3case did ERCP. There are re-operation case was just one case, which was immediate right hepatic artery bleeding. Conclusion: Our center’s complication was very low. But still biliary complication is the most common complication. When we meet abnormal biliary anatomy we must be careful and we try to reduced biliary complication.

LAPAROSCOPIC LEFT LATERAL SECTIONECTOMY IN LIVING LIVER DONOR

Introduction.Living donor liver transplantation has proved to be an effective, safe and radical treatment modality for patients with end-stage liver diseases. Left lateral section (LLS) of donor’s liver is used in pediatric recipients. Laparoscopic LLS procurement was fi rst described by D. Cherqui in 2002. At present, this technique is routinely used only by 5 hospitals in the world. However, up to date, some authors consider it to be a new standard to perform such a surgery in living donors.Aim.To analyze the fi rst Russian experience in laparoscopic left lateral sectionectomy (LapLLS) in living related donor.Materials and methods.From May to September 2016 fi ve LapLLS were performed in living donors. In all cases donors were women (mothers in 4 cases and aunt in 1 case). Recipients were children aged from 6 months through 3 years with body mass from 5.6 to 12.5 kg. Liver transection was carried out under conditions of maintained blood supply. Parenchymal transection was performed using a harmonic scalpel, bipolar coagulation and ultrasound dissection.Results. Average donor age was 32 ± 5 years. Average operation time was 287 ± 16 min. Average LLS graft weight was 220 ± 16 g. Intraoperative blood loss did not exceed 100 ml (95 ± 5 ml). Donors were discharged on the 3rd–4th post-op day. There were no postoperative complications in donors. Recipients were also characterized by a standard course of the postoperative period.Conclusion.LapLLS is an effective and safe method with several advantages. Primarily, these are early rehabilitation of the donors and shortening of the hospital stay, which are important for the quick return to normal way of live. Excellent visualization of anatomical structures, including vascular and biliary ones, allows performing precise selection. In addition, good cosmetic effect is also an important aspect.

Living Donor Liver Transplantation for Biliary Atresia With Severe Preduodenal Portal Vein Stricture: Success and Pitfall of Portal Vein Reconstruction

BackgroundWe report a rare case of 10-month-old female who underwent living donor liver transplantation (LDLT) for syndromic biliary atresia with preduodenal portal vein (PV) and its severe stricture owing to the previous Kasai portoenterostomy. Because we successfully performed “left at right liver transplantation (LAR-LT) and graft rerotation” in this case, we are present tips and pitfalls for this operation. MethodsPreoperative computed tomography scan showed that her preduodenal PV was stenotic from the confluence of the superior mesenteric vein and splenic vein to hepatic hilum, which made us consider the necessity of ≥3 cm interposition vein graft to complete a safe PV anastomosis. To reduce a gap between donor and recipient's PV, we decided to put a left lateral section graft at the right subphrenic space called left-at-right liver transplantation. Thus, LDLT was performed with an identical lateral sectional graft from her father. After total hepatectomy, we implanted a graft in her right subphrenic space, and anastomosed the donor left hepatic vein to her inferior vena cava. Then, we anastomosed an interposition graft harvested from her left internal carotid vein to her PV. ResultsEven after reflowing PV flow, because the duodenum compressed the interposition vein graft, PV flows were totally insufficient. Therefore, we flipped a liver graft 180° from right to left upper abdominal cavity, which could reduce the gap between PVs and acceptable PV flow was obtained. ConclusionsIn the present case, LAR-LT could reduce the distance of PVs. In addition, our rerotation method could be useful to alleviate tension on the PV anastomosis caused by preduodenal PV.

Classification of Donor's Hepatic Veins and Venous Outflow Reconstruction at Liver Left Lateral Section Transplantation

Aims: To create anatomy-based strategy of HV reconstruction in LLS living donor liver transplantation (LDLT) Methods: Venous anatomy and clinical data of 53 pediatric recipients and their related living donors where evaluated. Recipient aged from 6 to 36 month with end stage liver decease underwent LDLT from 2004 to 2014 were included. Results: We divide all LHV and MHV variants into 4 groups: Type A - normal anatomy with common LHV trunk, longer 5 mm; Type B - common LHV trunk, less then 5 mm length; Type C - separate inflow of Sg 2 and 3 HV with distance between them less then 5 mm; Type D - separate inflow of Sg 2 and 3 HV with distance between them more then 5 mm. Type A anatomy is acceptable for standard HV plastic due to presence of enough length common graft HV trunk, for type B, C and D we purpose non-standard HV reconstruction methods. From 53 donors 37(69,8%) had normal type A anatomy, 5 (9,4%) had type B, 5 (9,4%) had type C and 6 (11,3%) had type D anatomy. Thus in 69,8% transplantations standard HV plastic was made. For other 30,1% we used one of HV reconstruction methods: 1) Circular plastic of common Sg 2-3 hepatic veins orifice by autovenouse patch from recipient portal vein confluence, which was performed in 5 cases with type B anatomy; 2) Forming of common Sg 2-3 graft hepatic veins orifice from separate Sg 2 and Sg 3 veins. Used in 5 cases with type C anatomy; 3) Harvesting of left lateral section graft with common orifice of donor left and middle hepatic veins. Performed in 6 cases with type D anatomy. Conclusions: Purposed HV reconstruction methods expand anatomical indication and makes 100% of relative donors eligible for LLS donation.

Anomalous hepatic vein anatomy of left lateral section grafts and customized unification venoplasty for pediatric living donor liver transplantation

In liver transplantation, a left lateral section (LLS) graft may have an unusual variant left hepatic vein (LHV) anatomy. This study was designed to analyze the incidence of unusual LHV variants and to determine technical methods for effective reconstruction in infant recipients weighing approximately 10 kg or less. The study comprised 3 parts: an LHV variation analysis, a simulation-based design for the technical modification of graft LHV venoplasty, and its clinical application. The LHV anatomy of 300 potential LLS graft donors was classified into 4 types according to the number and location of the hepatic vein openings: (1) a single opening (n = 218 or 72.7%); (2) 2 large adjacent openings (n = 29 or 9.7%); (3) 2 adjacent openings, 1 large and 1 small (n = 34 or 11.3%); and (4) 2 widely spaced openings (n = 19 or 6.3%). Types 2 and 3 required wedged unification venoplasty, and type 4 required additional vein interposition. In a series of 49 cases using LLS grafts, the graft hepatic vein complication rate was 4.5% at 3 years; stenting was necessary for 1 of the 36 type 1 LHV grafts (2.8%) and for 1 of the 13 type 2-4 LHV grafts (7.7%, P = 0.46). A customized interposition-wedged unification venoplasty technique for coping with type 4 vein variations was developed with a simulation-based approach, and it was successfully applied to a 10-month-old male infant receiving an LLS graft with a type 4 LHV. In conclusion, nearly all LHV variations can be effectively managed with customized unification venoplasty. These venoplasty techniques represent beneficial surgical options as part of graft standardization for hepatic vein reconstruction in pediatric living donor liver transplantation.

Venose Reconstruction of Left Lateral Section Graft

Background: Liver transplantation is the only one radical treatment for end stage liver diseases in children. For children with body weight below 15 kg we used left lateral section liver graft. Liver function in living donor liver transplantation (LDLT) depends on adequate blood inflow and outflow. For this reason vascular reconstruction is important part of LDLT. Vascular anatomy of donor and recipient may vary and define type of venous reconstruction. Goal of study is to evaluate anatomical variants of donor and recipient venous systemand to define anatomical indications for vascular reconstruction. Materials and methods: Results of 31 LDLT were analysed. Evaluated size mismatch ratio between donor left portal vein (PV) branches and recipient PV trunk was 1,5-2,5. Initial thrombosis of recipient PV was observed in 3,2%(1 case). Result: Left and middle hepatic vein anatomy in living donors was estimated according Nakamura and Tsuzuki classification. We divide all anatomy types of donor's left hepatic veins on four groups: 1) one common orifice of Sg2-3 hepatic veins with length over 5 mm (61,3%) 2) one common orifice of Sg2-3 hepatic veins with length less then 5 mm (9,7%) 3) two separate orifices of Sg2 and Sg3 hepatic veins with distance less then 5 mm between them (19,4%) 4) two separate orifices of Sg2 and Sg3 hepatic veins with distance over 5 mm between them (9,7%) Single left hepatic vein, acceptable for standard reconstruction, was observed only in 61,3% (19 cases). In 51,6% (16 cases) of pediatric LDLT we perform one or more vascular reconstruction methods. Discussion: Vascular size mismatch between donor and recipient, absence of the one hepatic vein trunk in donor left lateral section (LLS), presence of initial recipient PV thrombosis are common indication for vascular reconstruction. To achieve adequate venous blood inflow we used portal reconstruction methods: portoplasty with autovenous patch, cavaportal transposition, plastic of trunk and confluence of portal vein by autovenous patch ovarian vein. For venous outflow we used autovenos plastic of LLS hepatic veins, shaping of common orifice of separately incoming Sg 2, 3 LLS hepatic veins, harvesting of LLS with MHV. Conclusion: Ours technics venous reconstruction in cases, where standard methods anatomically impossible, improve results of paediatric LDLT.

Donor Hepatectomy for Living Donor Liver Transplantation: Learning Steps and Surgical Outcome

Complications associated with live liver donor surgery should be minimized. There is little information on the impact of team experience and learning on the surgical outcome. The aim of this study was to clarify the impact of team experience in a single center on the outcome of live donor hepatectomy. Graft livers consisted of 56 right lobes, 40 left lobes with/without caudate, 36 left lateral section (LLS), and 11 right posterior section (RPS). Surgeries were divided according to the time of execution: era I (n=50), era II (n=50) and era III (n=43). No postoperative mortality was recorded. Blood loss steadily decreased and operation time decreased after era II (P<0.0001). The overall frequency of postoperative morbidities by the Clavien system was significantly less for LLS graft [P=0.009, right lobe (42.9%) vs. LLS (13.9%)]. Multivariate risk factor analysis showed that donors in recent years were at low risk of morbidity and bile leakage (P=0.025 and 0.010, respectively). There was less impact for team experience on the outcome in LLS graft than other types of grafts. Our analysis demonstrated several learning steps in live liver donor surgery and confirmed their positive impact on surgical outcome.

Dual living donor liver transplantation with ABO-incompatible and ABO-compatible grafts to overcome small-for-size graft and ABO blood group barrier

ABO blood group compatibility has been regarded as an essential prerequisite for successful adult living donor liver transplantation (LDLT). Novel strategies for overcoming the ABO blood group barrier, however, have markedly improved the results of ABO-incompatible (ABOi) LDLT. We describe our strategies for dual graft LDLT to cope with ABO-incompatibility and small-for-size graft syndrome in 3 patients who underwent dual graft LDLT with ABOi and ABO-compatible (ABOc) grafts. One patient received a modified right lobe graft from an ABOi living donor and a left lateral section graft from an ABOc deceased donor, whereas the other 2 patients received 2 left lobe or left lateral section grafts from ABOi and ABOc living donors. To overcome the ABO-blood barrier, each patient was treated with preoperative anti-CD20 antibody (rituximab 375 mg/m(2)), perioperative plasma exchange, and hepatic arterial infusion. All 3 patients were males, of mean age 47.7 years (range, 40 approximately 52 years) and mean Model for End-Stage Liver Disease score 12.3 (range, 9 approximately 15). The mean graft-to-recipient weight ratio was 0.99%. All patients remain alive after a mean follow-up period of 9.5 months (range, 8.0 approximately 10.7 months). All 6 grafts have functioned normally. There were no episodes of antibody-mediated rejection or biliary complication. Dual LDLT with ABOi and ABOc grafts can be a feasible solution for simultaneously overcoming both the ABO blood group barrier and small-for-size graft syndrome.