Korean J Transplant.  2021 Sep;35(3):189-194. 10.4285/kjt.21.0010.

Clinical sequence of an adult recipient undergone split liver transplantation using a right liver graft with erroneous deprivation of the middle hepatic vein trunk: a case report

• Yang G
• Hwang S
• Ahn CS
• Ha TY
• Jung DH

• KMID: 2520687
• DOI: http://doi.org/10.4285/kjt.21.0010

Abstract

The anatomy of middle hepatic vein (MHV) varies widely, and some individuals have aberrant MHV anatomy, thus there is risk of iatrogenic damage to graft MHV during liver splitting. We present the clinical sequences of an adult recipient who received a split right liver graft with erroneous deprivation of the MHV trunk. This is the case was a 58-year-old male patient with hepatitis B virus-associated liver cirrhosis who suffered from hepatic encephalopathy. The split right liver graft had a graft-to-recipient weight ratio of 2.1%. Soon after graft reperfusion, large-sized hepatic venous congestion (HVC) appeared at the graft liver surface, indicating lack of MHV drainage. The amount of HVC was approximately 20% of the right liver graft mass at day 1, which had gradually reduced on follow-up computed tomography (CT) scans. Although liver function recovered progressively, the patient remained bed-ridden because of pre-existing hypoxic brain damage. The patient passed away 4 years after transplantation because of pneumonia and multi-organ failure. The present case implies that there is some possibility of unrecognized damage to the graft MHV during liver splitting, suggesting the necessity of preoperative donor abdomen CT scan and preparation of intraoperative ultrasonography for easy evaluation of graft liver MHV anatomy

Keyword

Middle hepatic vein; Donor shortage; Extended right liver graft; Hepatic venous congestion; Hepatic encephalopathy; Case report

Figure

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  Fig. 1 Pretransplant computed tomography findings. (A) There is a cirrhotic liver with massive ascites. (B) Transjugular intrahepatic portosystemic shunt is located between the suprahepatic inferior vena cava and the main portal vein.

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  Fig. 2 Pretransplant brain computed tomography (CT) findings. (A) CT taken 2 days prior to transplantation shows diffuse brain swelling with poor differentiation at the grey matter and white matter junction involving bilateral cerebral hemispheres. (B) CT taken 3 days following transplantation shows resolution of brain swelling with improvement of brain perfusion.

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  Fig. 3 Gross photographs of graft at bench work. (A) The hemihepatic discoloration line is marked at the liver surface. (B) A 1.5-cm-sized wall defect (arrow) is identified at the suprahepatic inferior vena cava (IVC) of the right liver graft. The wall defect corresponds to the graft hepatic vein orifice of the split left lateral section graft. (C) The internal lumens of the suprahepatic IVC are visible. (D) The wall defect at the suprahepatic IVC is closed with primary sutures.

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  Fig. 4 Intraoperative photograph of the liver graft. A large-sized hepatic venous congestion occurred at the right anterior section of the right liver graft soon after graft reperfusion with the portal blood flow.

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  Fig. 5 Gross photograph of the explanted liver. Hepatitis B virus-associated mixed macronodular and micronodular cirrhosis is visible.

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  Fig. 6 Posttransplant follow-up computed tomography (CT) scans. (A) CT taken at day 1 shows a large-sized perfusion defect at the right anterior section of the liver graft. (B) CT taken at day 7 shows a reduction of the perfusion defect and the development of intrahepatic venous collaterals. (C) CT taken after 6 months shows nearly complete resolution of hepatic venous congestion-associated perfusion defect. (D) CT taken after 1 year shows disappearance of perfusion defect at the liver graft.

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