Middle Hepatic Vein Reconstruction Research Articles

Validity of preoperative volumetric analysis of congestion volume in living donor liver transplantation using three-dimensional computed tomography

Reconstruction of middle hepatic vein (MHV) tributaries is controversial in right-lobe living donor liver transplantation (LDLT). This study aimed to evaluate the appropriateness of reconstructing MHV tributaries by volumetry using 3-dimensional computed tomography (3D-CT). Between November 2003 and January 2005, 42 donor livers (right-lobe graft, n = 25; left-lobe graft, n = 17) were evaluated using this software. The total congestion volume (CV) associated with the MHV tributaries and the inferior right hepatic vein (IRHV), and graft volume (GV) were calculated. In recipients with right-lobe grafts, CV/(right liver volume [RLV]) and (GV - CV)/(standard liver volume [SLV]) were compared between 2 groups: with reconstruction (n = 16) and without reconstruction (n = 9). To evaluate the influence of CV on the remnant right lobe in donors, total bilirubin was compared between 2 groups: high CV (CV > 20%, n = 13) or low CV (CV < or = 20%, n = 4). The mean CV/RLV ratio was 32.3 +/- 17.1% (V5, 15.2 +/- 9.9%; V8, 9.2 +/- 4.1%; and IRHV, 8.5 +/- 11.4%) and the maximum ratio was as high as 80.8%. The mean (GV - CV)/SLV ratio before reconstruction in patients with or without reconstruction resulted in 33.5 +/- 12.8% and 55.4 +/- 12.9%, respectively (P < 0.01). In donors, total bilirubin was significantly high in the high CV group on postoperative day 1 compared with the low CV group (P < 0.05). In conclusion, calculation of CV using 3D-CT software proved to be very useful. We concluded that this evaluation should be an integral part of procedure planning, especially for right-lobe LDLT.

Composite clustered reconstruction of multiple middle hepatic vein branches in right lobe graft

Composite clustered reconstruction of multiple middle hepatic vein branches in right lobe graft

Preoperative detection of hepatic venous collaterals in right liver graft

A 51-year-old woman underwent right liver donation for her husband, who had a history of hepatitis C, liver cirrhosis, and hepatocellular carcinoma. Her preoperative dynamic computed tomography (CT) revealed that segment VIII was predominantly drained by a tributary of the right hepatic vein (RHV) and segment V by three tributaries (V5) of the middle hepatic vein (MHV). Three-dimensional graphic images created from the CT (Liver Segmentation Simulator, Hitachi Medico Inc., Chiba, Japan) revealed two anastomoses between V5 and the RHV tributaries (Fig. 1). Based on volumetric estimation, the right liver graft corresponded to 52% of the standard liver volume of the recipient. Right oblique view of the middle hepatic vein (blue) and right hepatic vein (red). This 3D graphic was rendered by Liver Segmentation Simulator, using 3 mm-thick CT images. Note the two anastomoses between V5 and right hepatic vein (arrowheads). RHV, right hepatic vein; MHV, middle hepatic vein; V5, tributary of middle hepatic vein in segment V. CT, computed tomography; RHV, right hepatic vein; MHV, middle hepatic vein. As predicted preoperatively, after transection of the liver parenchyma, congestion of the right paramedian sector was not observed by temporary clamping of the right hepatic artery. Intraoperative Doppler ultrasonography demonstrated regurgitation of venous flow in V5, which drained into the RHV tributary through the anastomosis (Fig. 2). A right liver graft was harvested with the distal portion of the MHV including V5, which communicated with the RHV. No reconstruction of MHV tributraies was performed in the recipient. Hepatic venous anastomosis (arrow) demonstrated by intraoperative Doppler ultrasonography after liver transection. Note V5 flow, which pours into the RHV tributaries. The postoperative course of the donor and the recipient was uneventful. Doppler ultrasonography consistently revealed hepatopetal portal flow of P5 in the recipient. The V5 was patent on CT 1 and 3 months after transplantation. Kaneko and colleagues1 reported postoperative formation of hepatic venous anastomosis. Sano et al.2 reported that intraoperative Doppler ultrasonography revealed anastomosis of hepatic veins in 24% of living donors. The indication for MHV reconstruction in a right liver graft depends on the anatomy of the MHV tributaries.3 If it is preoperatively known that the MHV tributaries are anastomosed with the RHV, vascular conduits for reconstruction of the MHV tributaries do not need to be prepared.4 Preoperative information regarding communication between the RHV and MHV is important for planning right liver transplantation, and it was provided by thin-sliced liver CT and 3-dimensional graphic images of hepatic vein anatomy in this particular case. We would like to thank Drs. Norio Nakao and Koui Miura (Department of Radiology, Hyogo College of Medicine, Hyogo, Japan), as well as Mr. Tomohiro Nagao (Hitachi Medico Inc., Chiba, Japan) for use of the Liver Segmentation Simulator.

Advances in adult living donor liver transplantation: a review based on reports from the 10th anniversary of the adult-to-adult living donor liver transplantation meeting in Tokyo.

In 1993, the Shinshu Group performed the first successful adult-to-adult living donor liver transplantation (LDLT). During the first 10 years of LDLT, many technical innovations have been reported. The major limitation of LDLT for adult recipients is the size of the graft. To overcome the problem, several graft types were designed, including left liver graft with caudate lobe, right liver, modified right liver, and right lateral sector and dual grafts. The necessity and criteria of reconstruction of middle hepatic vein is still on debate in right liver graft without trunk of middle hepatic vein. Biliary reconstruction remains a significant source of morbidity in LDLT. Donor safety must always be the primary consideration in LDLT and the selection criteria and management of the living donor must continue to be refined. On February 21, 2004, the 10(th) anniversary of the adult-to-adult LDLT meeting was held in Tokyo to review the accumulated experience and the presented information is summarized.

Background and clinical impact of tissue congestion in right-lobe living-donor liver grafts: a magnetic resonance imaging study.

Although right-lobe liver grafts from living donors have been widely accepted as an option for adult patients, impact of middle hepatic vein (MHV) deprivation is a recent controversy. Fifty recipients of right-lobe living-donor liver grafts without MHV or drainage reconstruction in anterior segment were evaluated for posttransplant tissue congestion with T2-weighted magnetic resonance imagings. Age of recipients and donors ranged from 19 to 69 (median 50) and 19 to 64 (46) years, respectively. Graft-to-recipient weight ratio ranged from 0.74% to 1.66% (1.06%). Cavoplasty was provided during right hepatic vein reconstruction to avoid anastomotic stricture. Congestion was observed in 88% of segments V and 85% of segments VIII in the first month. Congestion positively correlated with anatomic dependency on MHV. Also, donors were significantly older in age in grafts with more congestion. However, congestion improved within several months in most grafts. Graft congestion was associated neither with morbidities nor with graft loss except for temporary correlation with ascites production in the third and fourth posttransplant weeks. A significant proportion of right-lobe liver grafts without MHV experience morphologic congestion of the anterior segment in the early phase after transplantation, which is dependent on venous anatomy and donor age. However, the congestion spontaneously resolves in most cases. These results suggest that reconstruction of drainage vein(s) from the anterior segment is not necessary for all grafts provided good outflow through compensatory routes is secured. Additional reconstruction may be indicated in grafts with marginal size, anatomy, and quality.

Right anterior sector drainage in right-lobe live-donor liver transplantation.

The necessity of providing venous drainage for the right anterior sector of a right-lobe graft in adult-to-adult right-lobe live-donor liver transplantation has been controversial. Inclusion of the middle hepatic vein in the right-lobe graft to ensure better early graft function is also under debate. This report summarizes the views of five Asian centers on the necessity of providing venous drainage to the right anterior sector in a right-lobe graft as presented at the Asian Living Donor Transplantation Symposium 2002. All five centers recognize the importance of adequate drainage of the right anterior sector, but they adopt different approaches in including the middle hepatic vein in the graft. Tokyo University uses an occlusion test of the right hepatic artery and middle hepatic vein to define whether the right anterior sector is dusky or regurgitation of blood flow is present in the right anterior portal vein before the decision is made for middle hepatic vein reconstruction. The Asan Medical Center uses hydrostatically dilated saphenous venous graft to anastomose prominent segment V and VIII hepatic vein branches to the inferior vena cava. The University of Hong Kong Medical Centre includes the middle hepatic vein in every graft and anastomoses it to the recipient's middle or left hepatic vein. Kyoto University uses venous jump graft for anastomosing prominent middle hepatic vein branches to the inferior vena cava for recipients receiving a small-for-size graft or graft with dominant middle hepatic vein drainage. The Chang Gung Memorial Hospital adopts a flexible approach in inclusion of the middle hepatic vein in the graft depending on the donor size and the hepatic venous configuration of the right-lobe graft. In summary, the criteria for inclusion and reconstruction of the middle hepatic vein vary. Further analysis is needed to confirm the importance of adequate drainage of the right anterior sector in right-lobe live-donor liver transplantation.

Living-donor liver transplantation using the left liver, with special reference to vein reconstruction.

The authors describe their techniques for hepatic vein reconstruction, devised for safe living-donor liver transplantation using a left liver graft. End-to-end anastomosis of the hepatic veins is performed to prevent an outflow occlusion. To ensure adequate hepatic venous flow, it is necessary to obtain a wide ostium and sufficient length of the hepatic vein for anastomosis, which should be secured by venoplasty of the hepatic veins of the graft and the recipient. A left liver with a caudate lobe graft is useful for overcoming the problem of a small graft. Reconstruction of the short hepatic vein of the caudate lobe may allow this portion to regenerate at the same rate as the left liver. In a left liver graft without the trunk of the middle hepatic vein, reconstruction of a tributary of this vein might be necessary to prevent graft congestion in segment IV. Color Doppler ultrasonography or a hepatic arterial clamping test should be performed in donor hepatectomy to evaluate the need for middle hepatic vein reconstruction.

Vein reconstruction in modified right liver graft for living donor liver transplantation.

To report the authors' experience with hepatic vein reconstruction and plasty in living donor liver transplantation for adult patients. A right liver graft without the middle hepatic vein (MHV) trunk (modified right liver graft) can cause severe congestion of the right paramedian sector. However, the need for MHV reconstruction has not been fully recognized. From June 2000 to December 2001, 30 adult patients received a modified right liver graft. Major MHV tributaries were preserved and reconstructed under the authors' criteria. Plasty of recipient hepatic veins for a wide outflow orifice was performed when necessitated. The regeneration of paramedian and lateral sectors of the grafts was examined by computed tomography 1 and 3 months after the operation. MHV tributaries were reconstructed in 18 grafts. Plasty of recipient hepatic veins was performed in 15 patients. All patients survived the operation. The regeneration of paramedian and lateral sectors was equivalent. A modified right liver graft can provide satisfactory surgical results if hepatic vein reconstruction and plasty are performed using the present techniques.

A CASE OF NONFUNCTIONING ISLET CELL CARCINOMA OF THE PANCREAS FOUND 3 YEARS AFTER A HEPATECTOMY FOR LIVER METASTASES

We experienced a rare case of nonfunctioning islet cell carcinoma of the pancreas found as the primary lesion 3 years after a hepatectomy for liver metastases. A 65-year-old man was admitted to the hospital for treatment of a liver tumor which was found during clinical observation for gastric ulcer. Abdominal computed tomography revealed a tumor 6cm in diameter in the right hepatic lobe. Selective subsegmentectomy with reconstruction of middle hepatic vein was performed for the tumor. With histopathological and immunohistochemical examinations, it was diagnosed as either primary or metastatic carcinoid tumor of the liver. Extrahepatic lesions were not detected prior to hepatectomy. Subsequently, this patient had a pancreas tumor and recurrence of liver tumor 3 years and 1 month after the hepatectomy, and a distal pancreatectomy with splenectomy and another hepatectomy was peformed. Immunohistochemically, those pancreas and liver tumors were positive for Grimelius and chromogranin A stains and were negative for insulin, glucagon, somatostatin, serotonin, amylase and α1-antitrypsin stains. From these results, this patient was finally diagnosed as having a nonfunctioning islet cell carcinoma of the pancreas with liver metastases. He died from systemic lymph node metastases 4 years and 4 months after the initial hepatectomy. Islet cell tumor of the pancreas histologically resembles closely carcinoid tumor. When liver tumor was diagnosed as carcinoid tumor without extrahepatic disease, attention should be paid to a possible presence of nonfunctioning islet tumor of the pancreas as the primary lesion in postoperative periodical scrutinies.