Identification of veno-occlusive regions in a right liver graft after reconstruction of vein segments 5 and 8: Application of indocyanine green fluorescence imaging

Authors

  • Yoshikuni Kawaguchi M.D.,

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Yasuhiko Sugawara M.D., Ph.D.,

    Corresponding author
    • Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Takeaki Ishizawa M.D., Ph.D.,

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Shouichi Satou M.D.,

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Junichi Kaneko M.D.,

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Sumihito Tamura M.D.,

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Taku Aoki M.D.,

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Yoshihiro Sakamoto M.D.,

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Kiyoshi Hasegawa M.D.,

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • Norihiro Kokudo M.D.

    1. Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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  • This work was supported by a Grant-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, Sports, Science, and Technology and Grants-in-Aid for Research on Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome and Research on Measures for Intractable Diseases from the Japanese Ministry of Health, Labor, and Welfare.This study was conducted with the approval of the Institutional Ethics Review Board of Tokyo University and registered in the UMIN-CTR (UMIN000003656, https://center.umin.ac.jp/ctr/index.htm). Informed consent was obtained from all the patients.

Address reprint requests to Yasuhiko Sugawara, M.D., Ph.D., Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo 113-8655, Japan. Telephone: +81-3-5800-8841; FAX: +81-3-5800-8843; E-mail: yasusuga-tky@umin.ac.jp

To The Editors:

In living donor liver transplantation using a right liver graft (RLG) without the middle hepatic vein, the stumps of vein segment 5 (V5), vein segment 8 (V8), or both are considered for reconstruction to prevent postoperative liver dysfunction due to venous occlusion.[1, 2] Recent advances in imaging studies allow accurate estimations of regional liver volumes with postoperative venous occlusion after liver resection.[3] Methods to confirm such regions intraoperatively, however, have not yet been established. Here we describe the identification of a large veno-occlusive region in an RLG after reconstruction of V5 and V8 with an indocyanine green (ICG) fluorescence imaging technique.

A 52-year-old male underwent living donor liver transplantation for alcoholic liver cirrhosis. The donor was his 50-year-old wife. The parenchymal volumes of the portal segments and hepatic regions drained by the hepatic vein tributaries in the candidate graft were calculated on the basis of computed tomography with region-growing software (Organ Volume Analysis, Hitachi Medico, Chiba, Japan).[4] The sum of the liver volumes of the regions drained by the right hepatic veins [380 mL or 30.7% of the recipient standard liver volume (RSLV): 1238 mL], V5 (83 mL or 6.7% of RSLV), and V8 (71 mL or 5.7% of RSLV) was 534 mL (43.1% of RSLV). In contrast, the liver volume of the RLG was 637 mL (51.4% of RSLV), and this suggested the presence of a tributary draining the regions between the right and left liver (an intersegmental vein; see the arrowhead in the right panel of Fig. 1).

Figure 1.

A preoperative volumetric analysis revealed the border between the right and the left liver (the white dotted line) and the liver volume of the regions drained by each tributaries of the hepatic veins (left). The right panel shows an intersegmental vein (arrowhead).

The procurement of the graft was scheduled to harvest the regions fed by the right portal vein (see the white, dotted line in the left panel of Fig. 1). Because of its narrow diameter and our ability to secure a sufficient graft volume without reconstruction, we planned to sacrifice the intersegmental vein.[5] The RLG was harvested along the demarcation line, which was demonstrated by the clamping of the right portal vein (see the left panel of Fig. 2). The right hepatic vein, V5, V8, portal vein, and hepatic artery were reconstructed (see the right panel of Fig. 2). ICG (1.65 mg or 2.5 μg/mL of the graft liver volume) was then administered intravenously to identify the veno-occlusive regions.[6] After 300 seconds, a clear demarcation was indicated between the veno-occlusive regions [corresponding to 103 mL (637 mL − 534 mL) or 8.3% of RSLV] and the non–veno-occlusive regions (Fig. 3). Despite the identification of large veno-occlusive regions, further reconstruction was not performed as preoperatively planned.[5] The postoperative course was uneventful, and the patient was discharged on postoperative day 40.

Figure 2.

Demarcation line between the right and left liver demonstrated by clamping of the right portal vein (left) and reconstruction of V5 and V8 with cryopreserved vein grafts in the RLG (right).

Figure 3.

Fluorescence imaging revealed a clear demarcation between the veno-occlusive regions and the non–veno-occlusive regions. The left panel shows the gross appearance, and the right panel shows a fluorescence image 300 seconds after the injection of ICG.

Regions with venous occlusion are considered to have poor function.[6] An RLG with reconstruction of the tributaries of the middle hepatic vein (a so-called modified RLG), therefore, will not have the same function as an RLG with the trunk of the middle hepatic vein (a so-called extended RLG).[7] In the present case, ICG fluorescence imaging allowed us to identify veno-occlusive regions which had been drained by the intersegmental vein. In an RLG without V5 and V8 reconstruction in a different case, the regions which had been drained by V5, V8, and the intersegmental vein were visualized as veno-occlusive regions (Fig. 4). The major advantage of this technique is that it provides real-time visualization of regions with venous occlusion and serves as a guide for determining the need for venous reconstruction. One of the drawbacks of this technique is that it cannot be applied to estimate postoperative venous occlusion without laparotomy because of the need for observing the liver surface directly.

Figure 4.

A preoperative volumetric analysis demonstrated the border between the right and the left liver (the white dotted line), and revealed that the liver volume of the regions drained by the right hepatic vein was 858 mL (73.1% of RSLV; left). After reconstruction of the trunk of the right hepatic vein (and the sacrifice of V5 and V8), fluorescence imaging 300 seconds after the injection of ICG revealed the veno-occlusive regions which had been drained by V5, V8, and the intersegmental vein (right).

In conclusion, preoperative and intraoperative evaluations of veno-occlusive regions are important for determining whether the metabolic demands of recipients and donors are satisfied and enhance the safety of living donor liver transplantation.

  • Yoshikuni Kawaguchi, M.D.

  • Yasuhiko Sugawara, M.D., Ph.D.

  • Takeaki Ishizawa, M.D., Ph.D.

  • Shouichi Satou, M.D.

  • Junichi Kaneko, M.D.

  • Sumihito Tamura, M.D.

  • Taku Aoki, M.D.

  • Yoshihiro Sakamoto, M.D.

  • Kiyoshi Hasegawa, M.D.

  • Norihiro Kokudo, M.D.

  • Artificial Organ and Transplantation Surgery DivisionDepartment of SurgeryGraduate School of MedicineUniversity of Tokyo, Tokyo, Japan

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