Ann Hepatobiliary Pancreat Surg.  2019 May;23(2):183-186. 10.14701/ahbps.2019.23.2.183.

Wedged-patch venoplasty of the left liver graft portal vein for size matching in pediatric living donor liver transplantation

• Kang SH
• Namgoong J
• Hwang S
• Jung DH
• Kim KM

• KMID: 2448774
• DOI: http://doi.org/10.14701/ahbps.2019.23.2.183

Abstract

Portal vein (PV) size matching between recipient and liver graft is important in preventing anastomotic stenosis in living donor liver transplantation (LDLT). In right liver grafts, the diameter of graft PV is usually >10 mm. Thus, PV size matching does not become critical in adult recipients. If the recipient PV is very large, funneling fence can be attached to graft PV. However, if the diameter of graft PV is <8 mm, it can induce anastomotic stenosis. We experienced a few cases of PV anastomotic stenosis due to small-sized graft PV in >5000 LDLT cases, but graft PV widening was not performed because graft PV is considered as being a no-touch area. In thinking out of the box, we performed wedged-patch venoplasty to exceptionally narrow graft PV. A 4 year-old female patient underwent second LDLT due to progressive deterioration of graft function after 3 years. At first LDLT operation for biliary stresia, an iliac vein conduit was interposed for PV reconstruction. At second LDLT operation, the diameter of interposed PV was 10 mm, but the left liver graft PV was only 6 mm-sized. Uniquely, the left PV was waist only at first-order PV. To resolve this PV waist, a longitudinal incision was made to release the waist. A cold-preserved fresh iliac vein patch was inserted to widen the PV orifice. The patch size was adjusted to match the size of the recipient PV. The patient recovered uneventfully. This wedged-patch venoplasty technique can be applied to small-sized graft PV, to cope with PV size mismatching in LDLT.

Keyword

Portal vein stenosis; Venoplasty; Pediatric transplantation

MeSH Terms

Adult
Constriction, Pathologic
Female
Humans
Iliac Vein
Liver Transplantation*
Liver*
Living Donors*
Portal Vein*
Thinking
Transplants*

Figure

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  Fig. 1 Pretransplant computed tomography findings of the recipient. The first liver graft was severely damaged (A), but the interposed portal vein was well maintained (B).

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  Fig. 2 Computed tomography findings of the donor. The left liver was small (A) and a waist is present at the first-order left portal vein (B, arrow).

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  Fig. 3 Operative photographs of portal vein (PV) venoplasty. The ventral wall of the graft PV is incised and a large-sized patch is attached (A). A vein patch is anastomosed (B). The final shape of enlarged graft PV is visible (C), and its diameter is more than 15 mm (D).

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  Fig. 4 Operative photographs of hepatic vein (HV) venoplasty. The middle and left HVs are unified (A and B). An incision is applied at the middle HV trunk and a vein patch is attached (C). The size of conjoined outflow orifice was measured to be approximately 30 mm (D).

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  Fig. 5 Operative photograph taken after all reconstructions. An arrow indicates the vein patch at the portal vein anastomosis.

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  Fig. 6 Computed tomography finding of the recipient taken 2 weeks after transplantation. The reconstructed portal vein appears streamlined without noticeable stenosis.

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