Ann Hepatobiliary Pancreat Surg.  2019 May;23(2):178-182. 10.14701/ahbps.2019.23.2.178.

Pediatric living donor liver transplantation with homograft replacement of retrohepatic inferior vena cava for advanced hepatoblastoma

• Namgoong J
• Choi JU
• Hwang S
• Oh SH
• Park GC

• KMID: 2448773
• DOI: http://doi.org/10.14701/ahbps.2019.23.2.178

Abstract

Replacement of the retrohepatic inferior vena cava (IVC) after concurrent resection of IVC and hepatocellular carcinoma-containing liver is settled as a feasible living donor liver transplantation (LDLT) technique to cope with tumors around the IVC. This technique makes LDLT comparable to deceased-donor liver transplantation (DDLT). In the current Korean setting, the common substitute for IVC is a Dacron graft for adult recipients. In contrast, such a synthetic graft cannot be used for pediatric patients because of ongoing growth. We present one pediatric LDLT case with IVC homograft replacement for advanced hepatoblastoma. The patient was a 8 year-old boy suffering from large multiple hepatoblastomas. The tumors encroached the retrohepatic IVC. Thus there was high risk of residual tumor cells at the IVC, if it was preserved. Thus, we decided to replace IVC at the time of LDLT. After waiting for >1 month, we finally obtained cold-stored IVC homograft and LDLT was performed with the mother's left liver. A 4 cm-long IVC allograft was anastomosed at the back table. The left liver graft with IVC interposition was implanted along standard procedure similar to DDLT. The patient recovered uneventfully and is undergoing scheduled adjuvant chemotherapy. We have performed >20 cases of IVC replacement in adult recipients with hepatocellular carcinoma or Budd-Chiari syndrome, but all vessel substitutes were synthetic, because sizable IVC homograft is unavailable. In pediatric recipients, various vein homografts such as iliac vein, IVC and other large-sized veins, can be used depending on body size of recipient and availability of vessel grafts.

Keyword

Interposition; Venoplasty; Pediatric transplantation

MeSH Terms

Adult
Allografts*
Body Size
Budd-Chiari Syndrome
Carcinoma, Hepatocellular
Chemotherapy, Adjuvant
Hepatoblastoma*
Humans
Iliac Vein
Liver Transplantation*
Liver*
Living Donors*
Male
Neoplasm, Residual
Polyethylene Terephthalates
Transplants
Veins
Vena Cava, Inferior*
Polyethylene Terephthalates

Figure

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  Fig. 1 Pretransplant computed tomography finding (A) and intraoperative photograph (B) of the recipient. Huge multiple tumors occupied the whole liver and the inferior vena cava is also invaded.

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  Fig. 2 Intraoperative photographs of the recipient shows tumor invasion of the cephalic (A) and caudal (B) parts of the inferior vena cava.

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  Fig. 3 Intraoperative photographs of the bench work. (A) The middle and left hepatic vein orifices are unified. (B) A 4 cmlong cold-preserved vena cava homograft is placed to assess matching in size and length. (C, D) Since the vena cava homograft appears short, another iliac vein homograft was attached to elongate its length. (E, F) Vena cava homograft is attached to the left liver graft.

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  Fig. 4 Intraoperative photographs of the left liver graft combined with a vena cava homograft. The outflow orifice of the conjoined graft hepatic veins is visible.

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  Fig. 5 Intraoperative photographs of the recipient hepatectomy. (A–D) The retrohepatic vena cava was excised after clamping. (E) The native liver is removed completely.

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  Fig. 6 Intraoperative photographs of the graft implantation. (A, B) The cephalic and caudal ends of the vena cava homograft were anastomosed using 5-0 PDS. (C) The liver graft is reperfused after portal vein reconstruction.

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  Fig. 7 Intraoperative photographs of the diaphragm excision. The tumor-invaded diaphragm was excised (A) and repaired directly (B).

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  Fig. 8 Posttransplant computed tomography finding showing tissue expander support at day 4 and its decompression at day 12 after transplantation.

Reference

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