Ann Hepatobiliary Pancreat Surg.  2020 May;24(2):144-149. 10.14701/ahbps.2020.24.2.144.

Technical refinement of prosthetic vascular graft anastomosis to recipient inferior vena cava for secure middle hepatic vein reconstruction in living donor liver transplantation

• Jeong IJ
• Hwang S
• Ha TY
• Song GW
• Jung DH
• Park GC
• Ahn CS
• Moon DB
• Kim KH
• Yoon YI
• Lee SG

• KMID: 2500774
• DOI: http://doi.org/10.14701/ahbps.2020.24.2.144

Abstract

Backgrounds/Aims
Hemashield vascular grafts has been used for middle hepatic vein (MHV) reconstruction during living donor liver transplantation (LDLT). We occasionally encounter outflow disturbance of MHV conduit at the anastomotic stump of the middle-left hepatic vein (MLHV) trunk. To mitigate the disturbance, we carried out a series of studies regarding hemodynamics-compliant MHV reconstruction.
Methods
This study comprised of three parts: Part 1: Determining the causes of outflow disturbance; Part 2: Computational simulative analysis; and, Part 3: Clinical application of our refined technique. The types of Hemashield conduit-MLHV stump reconstruction were end-to-end anastomosis (type 1), side-toend anastomosis (type 2), and oblique cutting of the conduit end and patch plasty (type 3).
Results
In Part 1 study, the reconstruction types were type 1 in 23, type 2 in 25, and type 3 in 2. Significant anastomotic stenosis was identified in 7 (30.4%) in type 1, 6 (24.0%) in type 2, and none (0%) in type 3. The size of MLHV stump was the most important factor for anastomotic stenosis. Through Part 2 study, technical knacks were developed as follows: the conduit end was cut in a dumb-bell shape and a vessel patch attached; and then sutured bidirectionally from the 9 o’clock direction. In Part 3 study, these knacks were applied to 5 patients and none of them experienced noticeable anastomotic stenosis.
Conclusions
Our refined technique to perform conduit-MLHV stump anastomosis appears to reduce the risk of anastomotic outflow disturbance for relatively small MLHV stump.

Keyword

Prosthetic vascular graft; Middle hepatic vein; Anastomosis; Hepatic venous congestion; Living donor liver transplantation

Figure

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  Fig. 1 Intraoperative photographs and computed tomography images taken 1 week after liver transplantation. The reconstruction techniques were type 1 (A and C) and type 2 (B and D). Dotted circles indicate the outlines of the anastomosis.

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  Fig. 2 Comparison of dynamic computed tomography images taken 2-3 weeks after liver transplantation. In type 1 reconstruction technique, the anastomosis is wide (A) and narrow (C). In type 2 reconstruction technique, the anastomosis is wide (B) and narrow (D).

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  Fig. 3 Schematic illustration of the reconstruction techniques for anastomosis of a Hemashield conduit and the left-middle hepatic vein trunk stump. A colored rectangular patch indicates a vein homograft.

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  Fig. 4 Schematic illustration of the refined reconstruction techniques of type 3. A rectangular patch indicates a vein homograft.

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  Fig. 5 Dynamic computed tomography images taken 1 week after liver transplantation after application of refined type 3 reconstruction technique. (A) A 3-dimensional reconstruction image shows a neck portion at the left-middle hepatic vein trunk stump (arrow). (B-D) Detailed serial cross-sectional images of the luminal transition from a Hemashield conduit to the left-middle hepatic vein trunk stump (arrows).

Reference

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