Surg Gynecol Obstet 1993 Jan;176(1):11-7

Reconstruction of the hepatic vein in reduced size hepatic transplantation

Emond JC, Heffron TG, Whitington PF, Broelsch CE

University of Chicago Pritzker School of Medicine, Department of Surgery,
Illinois.

Abstract

Reconstruction of the hepatic vein (HV) is not required in size-matched
orthotopic liver transplantation (OLT) because the vena cava (VC) is replaced.
In reduced size OLT, used for providing small livers for children, the HV is
often implanted directly. Grafts obtained from a split liver in which the right
lobe is used for a second recipient or from a live donor must be implanted
without the VC. To evaluate the occurrence of outflow complications and their
prevention, we have reviewed our experience with 72 left sided reduced grafts in
children. Between July 1985 and November 1990, 93 reduced grafts were performed.
Twenty-one were right lobe grafts with orthotopic replacement of the VC.
Seventy-two were left grafts comprising 28 full left lobes and 44 lateral
segments. Grafts were obtained from reduction of a cadaver liver in 39, from the
left lobe of a split liver in 21 and from a live donor in 12. Of the left
grafts, 47 were implanted with preservation of the recipient VC. Overall, HV
obstruction occurred in 12 patients. Obstruction occurred acutely in three
patients, causing graft failure and death in two and was repaired successfully
in one patient. Chronic HV obstruction was documented in three patients with
ascites and graft enlargement requiring retransplantation. This complication
occurred in five of 25 patients with VC, six of 18 with end to end HV
anastomosis, one of 18 with end to side implantation of HV and zero of 15 using
a triangular anastomosis (p = 0.05). Outflow obstruction has not received
adequate attention in descriptions of reduced-size OLT. Marked hepatic swelling
and fluid retention that occur after reduced size hepatic transplantation may be
the result of incomplete HV obstruction. In this series, end to end anastomosis
of the HV resulted in a high frequency of outflow obstruction. This was
prevented when anastomoses were designed to allow the graft to rest comfortably
in the hepatic fossa after abdominal closure.