Korean J Hepatobiliary Pancreat Surg.  2016 May;20(2):61-65. 10.14701/kjhbps.2016.20.2.61.

Conjoined unification venoplasty for triple portal vein branches of right liver graft: a case report and technical refinement

• Kwon JH
• Hwang S
• Song GW
• Moon DB
• Park GC
• Kim SH
• Lee SG

• KMID: 2243016
• DOI: http://doi.org/10.14701/kjhbps.2016.20.2.61

Abstract

Anomalous portal vein (PV) branching of the donor liver is uncommon and usually makes two, or rarely, more separate PV branches at the right liver graft. Autologous PV Y-graft interposition has long been regarded as the standard procedure, but is currently replaced with the newly developed technique of conjoined unification venoplasty (CUV) due to its superior results. Herein, we presented a case of CUV application to three PV openings of a right liver graft. The recipient was a 32-year-old male patient with hepatitis B virus-associated liver cirrhosis. The living liver donor was his 33-year-old sister who had a type III PV anomaly, but the right posterior PV branch was bifurcated early into separate branches of the segments VI and VII, thus three right liver PV branches were cut separately. We used the CUV technique consisting of placement of a small vein unification patch between three PV orifices, followed by overlying coverage with a crotch-opened autologous portal Y-graft. The portal Y-graft was excised and its crotches were incised to make a wide common orifice. Three bidirectional running sutures were required to attach the crotch-opened autologous portal Y-graft. After portal reperfusion, the conjoined PV portion bulged like a tennis ball, providing a wide range of alignment tolerance. The patient recovered uneventfully from the liver transplantation operation. The CUV technique enabled uneventful reconstruction of triple donor PV orifices. Thus, CUV can be a useful and effective technical option for reconstruction of right liver grafts with various anomalous PVs.

Keyword

Living donor liver transplantation; Y-graft; Portal vein anomaly; Anastomotic stenosis

MeSH Terms

Adult
Hepatitis B
Humans
Liver Cirrhosis
Liver Transplantation
Liver*
Male
Portal Vein*
Reperfusion
Running
Siblings
Sutures
Tennis
Tissue Donors
Transplants*
Veins

Figure

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  Fig. 1 Computed tomography portogram images showing triple branching of the right portal vein. P5+8 indicates the right anterior section (segments V and VIII) branch; P6 and P7 indicate the branches to the segments VI and VII.

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  Fig. 2 Operative photographs to unify the portal vein (PV) branches. Three PV orifices (A) were unified using a Y-shaped central patch of recipient's greater saphenous vein (B-F). A small niche was made at each PV orifice to elongate the suture lines (E). Arrows indicate PV orifices. An arrow head indicates the greater saphenous vein patch.

• 

  Fig. 3 Operative photographs to attach the recipient portal vein (PV) graft. Recipient's autologous portal Y-graft (arrow head) was excised (A). PV crotches were incised to make a wide common orifice and the V-shaped wall defects (arrows) were sutured (B, C). This PV patch was attached with three bidirectional running sutures (D, E). The graft PV was anastomosed with the recipient PV stump (F).

• 

  Fig. 4 Intraoperative direct portogram showing smooth streamlined portal vein lumen.

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  Fig. 5 Recipient computed tomography at 1 week showing smooth streamlined branching of the portal vein.

Reference

1. Hwang S, Lee SG, Lee YJ, Sung KB, Park KM, Kim KH, et al. Lessons learned from 1,000 living donor liver transplantations in a single center: how to make living donations safe. Liver Transpl. 2006; 12:920–927. PMID: 16721780.

2. Marcos A, Orloff M, Mieles L, Olzinski A, Sitzmann J. Reconstruction of double hepatic arterial and portal venous branches for right-lobe living donor liver transplantation. Liver Transpl. 2001; 7:673–679. PMID: 11510010.

3. Thayer WP, Claridge JA, Pelletier SJ, Oh CK, Sanfey HA, Sawyer RG, et al. Portal vein reconstruction in right lobe living-donor liver transplantation. J Am Coll Surg. 2002; 194:96–98. PMID: 11800348.

4. Lee SG, Hwang S, Kim KH, Ahn CS, Park KM, Lee YJ, et al. Approach to anatomic variations of the graft portal vein in right lobe living-donor liver transplantation. Transplantation. 2003; 75(3 Suppl):S28–S32. PMID: 12589136.

5. Hwang S, Lee SG, Ahn CS, Kim KH, Moon DB, Ha TY, et al. Technique and outcome of autologous portal Y-graft interposition for anomalous right portal veins in living donor liver transplantation. Liver Transpl. 2009; 15:427–434. PMID: 19326410.

6. Lee HJ, Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, et al. Long-term outcomes of portal Y-graft interposition for anomalous right portal veins in living donor liver transplantation. Transplant Proc. 2012; 44:454–456. PMID: 22410042.

7. Ha TY, Hwang S, Moon DB, Ahn CS, Kim KH, Song GW, et al. Conjoined unification venoplasty for graft double portal vein branches as a modification of autologous Y-graft interposition. Liver Transpl. 2015; 21:707–710. PMID: 25762169.

8. Hwang S, Ha TY, Song GW, Jung DH, Moon DB, Ahn CS, et al. Conjoined unification venoplasty for double portal vein branches of right liver graft: 1-year experience at a high-volume living donor liver transplantation center. J Gastrointest Surg. 2016; 20:199–205. PMID: 26497191.

9. Song GW, Lee SG, Hwang S, Kim KH, Ahn CS, Moon DB, et al. ABO-incompatible adult living donor liver transplantation under the desensitization protocol with rituximab. Am J Transplant. 2016; 16:157–170. PMID: 26372830.

10. Hwang S, Ha TY, Ahn CS, Moon DB, Song GW, Kim KH, et al. Hemodynamics-compliant reconstruction of the right hepatic vein for adult living donor liver transplantation with a right liver graft. Liver Transpl. 2012; 18:858–866. PMID: 22422708.

11. Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, Song GW, et al. Standardization of modified right lobe grafts to minimize vascular outflow complications for adult living donor liver transplantation. Transplant Proc. 2012; 44:457–459. PMID: 22410043.

12. Lee SY, Ko GY, Gwon DI, Song HY, Lee SG, Yoon HK, et al. Living donor liver transplantation: complications in donors and interventional management. Radiology. 2004; 230:443–449. PMID: 14699180.