Ann Liver Transplant.  2021 May;1(1):71-78. 10.52604/alt.21.0007.

Tailored standardization of portal vein reconstruction for pediatric liver transplantation at Asan Medical Center

• Hwang S
• Namgoong JM

• KMID: 2560854
• DOI: http://doi.org/10.52604/alt.21.0007

Abstract

Pediatric recipients, especially infants, are vulnerable to vascular complications because recipient vessels are smaller than those in adult liver transplantation (LT). Once portal vein (PV) stenosis occurs, it is often difficult to treat it through radiological angioplasty. Endovascular stenting is regarded as the final life-saving procedure, with a likelihood of needing retransplantation later. We have established standardized customization of surgical techniques for pediatric LT. Here, we present our tailored standardization of PV reconstruction for pediatric LT with the following 5 topics. 1) tadpole vein homograft conduit interposition for hypoplastic PV in infant patients undergoing split or living donor LT; 2) side-to-side anastomosis for hypoplastic PV in infant patients undergoing infant-to-infant whole liver LT; 3) PV branch patch venoplasty for size-matching in pediatric patients undergoing split or living donor liver transplantation; 4) PV conduit interposition in pediatric patients with congenital absence of PV; 5) wedged patch venoplasty for small-sized graft left PV. There are two features in our techniques for PV reconstruction: 1) frequent use of vein homograft; and 2) funneling of the recipient PV to match with the graft PV. In conclusion, secure PV reconstruction is important for successful pediatric LT. Thus, every effort should be made to ensure obtainment of sufficient portal blood inflow. From the viewpoint of hemodynamics principles, a funnel-shaped PV conduit is the most desirable configuration to ensure effective flow from the splanchnic system in infant patients with PV hypoplasia.

Keyword

Portal vein stenosis; Endovascular stenting; Vascular insufficiency; Portal vein hypoplasia; Vein homograft

Figure

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  Figure 1 The technique of tadpole anastomosis for portal vein reconstruction using vein homograft interposition. (A) Illustration of the technique to achieve optimal combination of the recipient portal vein stump and vein homograft end. A longitudinal slit at the vein homograft is automatically widely opened by suture-induced tension and portal vein blood pressure. (B) An operative field photograph is taken after portal reperfusion. An arrow indicates the anastomosis line. The longitudinal axis of the interposed vein homograft is marked to facilitate anastomosis without twisting. (C) Follow-up computed tomography scan taken at 1 week after transplantation shows smooth stenosis-free transition from the recipient-side superior mesenteric vein-splenic vein confluence to the interposed vein homograft (arrow).

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  Figure 2 The technique of side-to-side unification of the portal vein in infant-to-infant whole liver transplantation. (A) Illustration of the technique: a deep longitudinal incision is made at the 6 o’clock direction of the graft portal vein (PV) and the 12 o’clock direction of the recipient PV. Running sutures are then used to unify these two PVs. This technique creates an enlarged conduit from the superior mesenteric vein–splenic vein confluence to the hilar PV confluence. (B) An operative field photograph is taken after portal reperfusion, in which PV anastomosis appears to be enlarged (arrow). (C) Follow-up computed tomography scan taken at 1 year after transplantation shows normal configuration of the PV system. Arrow indicates the site of PV anastomosis.

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  Figure 3 The technique of branch patch venoplasty in pediatric recipients. (A) Two first-order portal vein (PV) branches are transected and their central line is incised to make long PV branch patches. The branch patch can be anastomosed to the graft PV directly or after making a funnel through unification venoplasty. (B) An operative field photograph is taken after portal reperfusion, in which the PV anastomosis site is smoothly expanded (arrow). (C) Follow-up computed tomography scan taken at 4 days after transplantation shows a slight anastomotic stenosis (arrow) of the PV probably due to tension at the anastomosis site.

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  Figure 4 Intraoperative photographs for portal vein (PV) interposition graft in a pediatric patient with congenital absence of the PV. (A) The confluence portion of the superior mesenteric vein-splenic vein is meticulously dissected. (B) The vein branches at the confluence portion are securely clamped and a longitudinal incision is made at the confluence portion. (C–E) A cold-stored fresh iliac vein conduit is anastomosed to the confluence portion in an end-to-side fashion. (F, G) The PV conduit is anastomosed with the graft PV. (H) The PV conduit is expanded after portal reperfusion.

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  Figure 5 Wedged-patch venoplasty of the waisted left portal vein of a left liver graft. (A) Computed tomography of the donor liver shows a waist at the first-order left portal vein (PV) (arrow). (B, C) The ventral wall of the graft PV is longitudinally incised and a vein patch is attached. (D) The diameter of the graft PV is markedly enlarged. (E) The interposed patch (arrow) is visible at the PV anastomosis. (F) Computed tomography taken at 2 weeks after transplantation shows that the reconstructed PV appears (arrow) smoothly streamlined without stenosis.

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  Figure 6 Spiral winding suture to make a sizable conduit using a greater saphenous vein homograft patch.

Reference

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