Ann Liver Transplant.  2021 Nov;1(2):146-152. 10.52604/alt.21.0024.

Application of a tissue expander to stabilize graft position in liver transplantation

• Kang WH
• Hwang S
• Ahn CS
• Moon DB
• Ha TY
• Song GW
• Jung DH
• Park GC
• Namgoong JM
• Yoon YI
• Lee SG

• KMID: 2560865
• DOI: http://doi.org/10.52604/alt.21.0024

Abstract

A small-sized left liver graft may fall into the large right subphrenic fossa, in which such a size mismatch can result in graft hepatic vein outflow obstruction as well as excessive stretching of the reconstructed portal vein. A tissue expander (TE) was used to prevent detrimental dextro-rotation of the liver graft through obliteration of the dead space at the right subphrenic fossa. We herein present our experience regarding TE application in liver transplantation (LT). TEs of various sizes and shapes are commercially available, and the dome-shape TEs with an external connecting tube and an injection port are the most frequently used. The indications for TE application can be classified into four categories: pediatric LT cases using a living-donor or split deceased-donor left-sided liver graft, adult LT cases using a living-donor left liver graft, LT with dual-graft implantation, and unusual conditions such as a recipient with situs inversus. The underlying cause of TE application is basically identical in all four categories, but the technical details of TE application differ from each other. The timing of TE removal depends on the degree of graft regeneration and the amount of water within the TE, which is usually 1 to 3 weeks after LT. We experienced no serious adverse TE-associated complications in more than 100 cases. In conclusion, TE application is simple, safe, and effective to provide mechanical support for the liver graft, and therefore performed readily if indicated.

Keyword

Living donor liver transplantation; Small-for-size graft; Dual-graft; Size mismatch; Graft outflow vein obstruction

Figure

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  Figure 1 A pediatric case of tissue expander application. (A) The patient was an 8-year-old boy weighing 28 kg suffering from large multiple hepatoblastomas invading the retrohepatic inferior vena cava. A 250 g-weighing left liver graft with a graft-to-recipient weight ratio of 0.89% was implanted with vein homograft interposition of the inferior vena cava. (B) The liver graft was relatively small compared with the native 2,064 g-weighing tumor-bearing liver and its corresponding right subphrenic fossa. (C) A tissue expander was placed to prevent collapse toward the right subphrenic fossa. (D) The water within the tissue expander was gradually aspirated after 7 days, and the tissue expander was removed in 2 weeks.

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  Figure 2 Gross photograph of a dome-shaped tissue expander with an external connecting tube and an injection port.

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  Figure 3 An adult sample case of tissue expander application. (A) A small-for-size left liver graft is implanted. (B, C) A tissue expander is inserted to place the liver graft in the right position to prevent twisting of the hepatic and portal vein anastomoses. (D) The desirable configuration of the outflow graft hepatic veins is illustrated.

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  Figure 4 An adult case showing progressive regeneration of the left liver with caudate lobe graft. (A) A dotted line in the donor liver computed tomography indicates the hepatic transection line. (B–D) The water within the tissue expander was gradually evacuated along the graft regeneration. The tissue expander was removed on day 22 after transplantation.

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  Figure 5 An adult case of dual-graft implantation with tissue expander application. (A, B) A tissue expander is placed under the right-sided left liver graft. (C) The tissue expander was decompressed along the graft regeneration. (D) Uneventful full generation of both left-liver grafts is visible.

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  Figure 6 An adult case of situs inversus with tissue expander application. (A) A 42-year-old man weighing 95 kg with situs inversus totalis underwent deceased-donor whole-liver transplantation. The deceased donor weighed 58 kg, thus donor-recipient body weight ratio was 0.61 and the graft-to-recipient weight ratio was 1.43%. (B) A large tissue expander was inserted into the left subphrenic space for mechanical support of the liver graft. (C, D) The tissue expander was decompressed along the graft regeneration.

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  Figure 7 Intraoperative photographs showing removal of a tissue expander. (A) Water within the tissue expander is completely aspirated. (B–D) The abdominal wound is reopened and the connecting tube is gently extracted to deliver the tissue expander.

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