Simplifying Hepatic Venous Outflow Reconstruction in Sequential Living Donor Liver Transplantation

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1 LIVER TRANSPLANTATION 15: , 2009 ORIGINAL ARTICLE Simplifying Hepatic Venous Outflow Reconstruction in Sequential Living Donor Liver Transplantation See Ching Chan, Chung Mau Lo, Kelvin K. Ng, Kenneth S. Chok, and Sheung Tat Fan Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong, China The native liver of a familial amyloidotic polyneuropathy recipient who undergoes living donor liver transplantation used as a graft for sequential liver transplantation does not include the inferior vena cava. Implantation of this whole liver graft to a second recipient could be simplified by borrowing the experience from right liver living donor liver transplantation. With careful release of the hepatic vein from its surrounding adventitia mainly by sharp dissections, adequate lengths of these veins could be attained without compromising the native inferior vena cava. Following venoplasty of the right and middle/left hepatic vein stumps, the single cuff of the hepatic veins is anastomosed to the inferior vena cava without interpositional venous graft or patch. Satisfactory venous outflow is reliably achieved because this is the most direct outflow tract. Liver Transpl 15: , AASLD. Received February 18, 2009; accepted July 15, Sequential liver transplantation using a deceased donor liver graft for familial amyloidotic polyneuropathy (FAP) is well described. 1 Classically, the liver explanted from a patient with FAP, or an amyloid hepatic allograft (AHA), is transplanted to a second recipient (AHA recipient). The latter is usually greater than 60 years old, because the AHA will continue to produce variant transthyretin, resulting in neuropathy years later. In deceased donor sequential liver transplantation, the inferior vena cava (IVC) is included in the deceased donor liver graft and also in the AHA. Therefore, graft implantation is by end-to-end IVC anastomosis for both recipients. Total hepatectomy of the patient with FAP is similar to standard deceased donor liver transplantation, except that the suprahepatic and infrahepatic IVC of a just adequate length are included in the AHA for implantation in the AHA recipient. It is important to note that the FAP patient should not be considered at a disadvantage for being a living liver donor in the recipient total hepatectomy. A way to maintain the IVC flow during the anhepatic phase and without venovenous bypass is application of the piggyback technique. 2 This has been applied to patients with FAP who had side-toside cava-caval anastomosis and closure of the suprahepatic and infrahepatic cava. 3 In the case of living donor sequential liver transplantation, however, the IVC of the FAP patient has to be preserved in all cases and is not included in the AHA explanted from the FAP patient. This AHA, which is a whole graft and devoid of the IVC for implantation to the AHA recipient, also requires unimpeded venous outflow. The procedure, though akin to the piggyback technique, is different because the length of the hepatic veins in the AHA graft is limited. FIRST RECIPIENT The patient with FAP was 42 years old. Her main symptoms were peripheral, and autonomic polyneuropathy manifested as numbness of the limbs and constipation. She also had weight loss of 7 kg over a 1-year period. Antral biopsy by upper endoscopy revealed Congo red stained amyloid deposits in the muscularis mucosae. Electrocardiogram showed low voltage with poor R wave progression. Echocardiogram demonstrated hypertrophy of the right and left ventricles. This was typical of Abbreviations: AHA, amyloid hepatic allograft; FAP, familial amyloidotic polyneuropathy; IVC, inferior vena cava; LDLT, living donor liver transplantation; MHV/LHV, middle hepatic vein/left hepatic vein; RHV, right hepatic vein. Address reprints requests to Prof. Chung Mau Lo, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China. Telephone:(852) ; Fax: (852) ; chungmlo@hkucc.hku.hk. DOI /lt Published online in Wiley InterScience ( American Association for the Study of Liver Diseases.

2 SEQUENTIAL LIVING DONOR LIVER TRANSPLANTATION 1515 Figure 1. (A) Amyloid hepatic allograft (AHA) on back-table after right hepatic vein (RHV) and middle hepatic vein (MHV)/left hepatic vein (LHV) venoplasty (trapezoid). (B) Preoperative computed tomography of the familial amyloidotic polyneuropathy patient s RHV, which is similar in size to the MHV. mutation of the transthyretin gene involving a substitution of valine by alanine in codon 30 (V30A). 4 After she had been listed for deceased donor liver transplantation for half a year, her Model for End-Stage Liver Disease (MELD) score remained low, despite the fact that 2 points were added every 3 months arbitrarily by an allocation system. Her husband volunteered and donated the left liver including the middle hepatic vein (MHV) for living donor liver transplantation (LDLT). The ratio of graft volume to standard liver volume was 47%. Total hepatectomy of the AHA was similar to LDLT with preservation of the IVC. Delivery of the AHA started with application of a bulldog vascular clamp to the middle portion of the common hepatic artery. The common hepatic artery matched satisfactorily in size with the left hepatic artery of the left liver graft from the living donor, and was severed with scissors. This was followed by application of a Blalock clamp (Blalock Pulmonary Artery Clamp; Pilling Weck, Research Triangle Park, NC) to the proximal main portal vein. The latter was then divided with scissors at the bifurcation and thus a single portal vein cuff was maintained. Sufficient lengths of the right hepatic vein (RHV) and MHV/left hepatic vein (LHV) common trunks were ensured. This was made possible by taking down the adventitial tissue embracing the hepatic veins by careful sharp dissection with scissors and coagulating diathermy. Picking up of the tissue before cutting prevented inadvertent injury to the hepatic veins. A TA30 vascular stapler (TA30, V3 [2.5 mm]; United States Surgical, Norwalk, CT) was applied to the RHV at a right angle to the IVC which was flush with the RHV, followed by division of the RHV just above the staples. This provided a short but definite stump of the RHV. A Satinsky clamp was then applied to the MHV/LHV stump also at a right angle to the IVC, which was flush with the stump. The common trunk was then severed with scissors, again providing a venous stump. Implantation of the left liver graft with the MHV was routine. She recovered uneventfully from this LDLT. The AHA after explantation from the FAP patient was immediately brought to the back-table and was flushed with three times of its volume of histidine-tryptophanketoglutarate solution via the portal vein similar to LDLT. 5 The common hepatic artery and common hepatic duct were flushed in the same fashion. The RHV was merged with the common trunk of the MHV and LHV to a single cuff using 6-0 prolene. Because the LHV was comparable to the MHV in size, a trapezoid venoplasty was fashioned with the RHV as the base (base 26 mm, height 23 mm, apical width 16 mm) (Fig. 1A). SECOND RECIPIENT The AHA recipient was a 60-year-old female hepatitis B carrier with a 4-cm hepatocellular carcinoma and Child-Pugh C cirrhosis. Liver functional reserve was compromised (serum total bilirubin level 48 mol/l, prothrombin time 18 seconds, and platelet count /L). The AHA, which did not include the IVC, underwent hepatic venoplasty. Total hepatectomy of the AHA recipient was the same as that for LDLT and the IVC was preserved. Delivery of the native liver was started with application of a Blalock clamp to the main portal vein. After ligation of the right and left portal veins, these two veins were severed 1 cm distal to the portal vein bifurcation. The RHV was divided with ATW35 (Ethicon Endo-Surgery Inc., Cincinnati, OH) followed by the common trunk of the MHV and RHV, also with ATW35. Control of the infrahepatic and suprahepatic IVC was by the Rummel tourniquet and Ulrich-Swiss clamp (Ulrich AG, St. Gallen, Switzerland), respectively. The staple lines on the MHV and LHV were excised. A venotomy trapezoid in shape and of the same size as the AHA hepatic venoplasty was made on the IVC by excising the MHV/LHV common

3 1516 CHAN ET AL. Figure 2. An amyloid hepatic allograft recipient after total hepatectomy. Dashed line indicates the trazepoid venotomy made on the inferior vena cava for anastomosis with the graft hepatic veins. RHV, right hepatic vein; MHV/LHV, middle hepatic vein/left hepatic vein. cuff and with extension toward the right side (Fig. 2). The IVC was then flushed with heparinized saline. Anastomosis was performed using 5-0 prolene, first of the inferior wall, followed by the base and apex, and then the superior wall. After application of a bulldog clamp on the graft main portal vein, the IVC clamp and tourniquet were released and the circulation through the IVC was restored. The bifurcation of the native portal vein was then divided to create a cuff just distal to the bifurcation. This cuff was anastomosed with the AHA with 6-0 prolene. The AHA common hepatic artery was anastomosed to the native right hepatic artery using 9-0 nylon under the operating microscope. This was followed by a duct-to-duct anastomosis. Patency and satisfactory pulsatility of all three hepatic venous outflows were verified by intraoperative Doppler ultrasonography (Fig. 3). DISCUSSION The piggyback technique was first described by Calne and Williams 6 to overcome the hepatic vein and IVC size discrepancy in grafting a 5-year-old liver to an adult recipient. Caval return occlusion through compression by the graft is particularly likely in a voluminous graft. A wide side-to-side anastomosis by inclusion of a cavotomy into the hepatic venotomy also lowers the chance of occlusion. 7 Unlike the piggyback technique, the AHA does not have an IVC that may compress onto the native IVC of the AHA recipient. This AHA in fact has a trough that houses the IVC of the AHA recipient. The main advantage of the piggyback technique is the use of a side clamp on the IVC, which allows partial venous return. Theoretically, maintenance of the hemodynamic stability also avoids venovenous bypass from attending complications. In fact, some centers prefer preservation of the IVC in FAP patients during native liver hepatectomy for hemodynamic stability while obviating venovenous bypass. 8 We have nevertheless developed implantation of the liver graft in LDLT with cross-clamp of the IVC while still obviating venovenous bypass. 9 This is coupled with flushing of the graft with histidine-tryptophan-ketoglutarate solution and with early release of IVC clamps prior to portal vein anastomosis. This solution with low potassium does not require flushing of the liver graft with plasma solution vented through the IVC before graft reperfusion. 5 The technical challenge of implantation of an AHA obtained from a patient with FAP who is involved in LDLT is the absence of the IVC. Various techniques have been described. The MHV/LHV common trunk is implanted to the common trunk of the AHA recipient followed by the RHV to its corresponding RHV stump or in the opposite order. Technical difficulties in these anastomoses were noted by Inomata et al. 10 The MHV/ LHV common trunk and the RHV were joined to each limb of a deceased donor s iliac venous graft, which contained a portion of the IVC. This provided more length to work with and a single caval cuff for anastomosis. 11 This cuff was also used even after merging of the hepatic veins to a single cuff first. 12 The AHA recipient s inverted portal vein bifurcation was also used by the same group as in the interposition graft. 13 In this case, the AHA MHV/LHV and the RHV, though widely separated as shown on the computed tomography image (Fig. 1B), were merged into a single cuff. Our experience in venoplasty of the right liver graft including the MHV 14,15 was borrowed in this situation. In fact, there

4 SEQUENTIAL LIVING DONOR LIVER TRANSPLANTATION 1517 Figure 3. Intraoperative Doppler ultrasonography of a graft after perfusion. (A) Right hepatic vein (RHV) and middle hepatic vein (MHV)/left hepatic vein (LHV) to the inferior vena cava anastomosis. V4b, segment IVb hepatic vein. (B) Venous outflow pulsatility in the RHV. (C) Venous outflow pulsatility in the MHV. (D) Venous outflow pulsatility in the LHV. was little tension on the hepatic veins following approximation of the MHV and RHV. In right liver LDLT, the right liver is housed in the right subdiaphragmatic space. Anastomosis of the MHV and RHV venoplasty to the IVC is end-to-side. For the AHA in this case, all three hepatic veins now in a single cuff were also joined to the IVC end-to-side. Unlike the piggyback technique, there was no graft IVC between the native IVC and the liver. Thus, widening of the hepatic vein in the AHA by opening into the IVC was not feasible. However, the compression of the native IVC by the graft IVC did not occur either. Also, privileged by the configuration of an AHA that contained a trough and provided ample space for the native IVC, venous occlusion was not a problem. Sequential liver transplantation could be viewed as LDLT using a whole graft obtained from the FAP patient grafted to the AHA recipient. Our experience from LDLT certainly facilitated the second operation. Venous outflow reconstruction without the use of an interposition venous graft expedited by a prior RHV to MHV venoplasty is simple and reliable. REFERENCES 1. Furtado A, Tome L, Oliveira FJ, Furtado E, Viana J, Perdigoto R. Sequential liver transplantation. Transplant Proc 1997;29: Reddy KS, Johnston TD, Putnam LA, Isley M, Ranjan D. Piggyback technique and selective use of veno-venous bypass in adult orthotopic liver transplantation. Clin Transplant 2000;14: Nishida S, Pinna A, Verzaro R, Levi D, Kato T, Nery JR, et al. Domino liver transplantation with end-to-side infrahepatic vena cavocavostomy. J Am Coll Surg 2001;192: Mak CM, Lam CW, Fan ST, Liu CL, Tam SC. Genetics of familial amyloidotic polyneuropathy in a Hong Kong Chinese kindred. Acta Neurol Scand 2003;107: Chan SC, Liu CL, Lo CM, Fan ST. Applicability of histidinetryptophan-ketoglutarate solution in right lobe adult-toadult live donor liver transplantation. Liver Transpl 2004; 10: Calne RY, Williams R. Liver transplantation in man. I. Observations on technique and organization in five cases. Br Med J 1968;4: Navarro F, Le Moine MC, Fabre JM, Belghiti J, Cherqui D, Adam R, et al. Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava: review of 1361 cases. Transplantation 1999;68: Garcia JH, de Vasconcelos JB, Costa PE, Coelho GR, Brasil IR, Barros MA, et al. Domino liver transplantation with double piggyback: is this the best technique? A case report. Transplant Proc 2006;38: Fan ST, Yong BH, Lo CM, Liu CL, Wong J. Right lobe living donor liver transplantation with or without venovenous bypass. Br J Surg 2003;90:48-56.

5 1518 CHAN ET AL. 10. Inomata Y, Zeledon ME, Asonuma K, Okajima H, Takeichi T, Ishiko T, et al. Whole-liver graft without the retrohepatic inferior vena cava for sequential (domino) living donor liver transplantation. Am J Transplant 2007;7: Pacheco-Moreira LF, de Oliveira ME, Balbi E, da Silva AC, Miecznikowski R, de Faria LJ, et al. A new technical option for domino liver transplantation. Liver Transpl 2003;9: Liu C, Loong CC, Hsia CY, Tsou MY, Tsai HL, Wei CF. Venoplasty of hepatic venous outflow with a venous patch in domino liver transplantation. Liver Transpl 2008;14: Cerqueira A, Pacheco-Moreira L, Enne M, Alves J, Amil R, Balbi E, et al. Outflow reconstruction in domino liver transplantation with interposition of autologous portal vein graft. A new technical option in living donor domino liver transplant scenario. Liver Transpl 2006;12: Lo CM, Fan ST, Liu CL, Wong J. Hepatic venoplasty in living-donor liver transplantation using right lobe graft with middle hepatic vein. Transplantation 2003;75: Chan SC, Lo CM, Liu CL, Wong Y, Fan ST. Versatility and viability of hepatic venoplasty in live donor liver transplantation using the right lobe with the middle hepatic vein. Hepatobiliary Pancreat Dis Int 2005;4: