Restoration of portal flow using a pericholedochal varix in adult living donor liver transplantation for patients with total portosplenomesenteric thrombosis

Authors

  • Deok-Bog Moon,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Sung-Gyu Lee,

    Corresponding author
    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
    • Address reprint requests to Sung-Gyu Lee, M.D., F.A.C.S., Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-Dong, Songpa-Gu, Seoul 138-736, Korea. Telephone: 82-2-3010-3485; FAX: 82-2-474-9027; E-mail: sglee2@amc.seoul.kr

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  • Chul-Soo Ahn,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Shin Hwang,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Ki-Hun Kim,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Tae-Yong Ha,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Gi-Won Song,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Gil-Chun Park,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Dong-Hwan Jung,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Jung-Man Namkoong,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Hyung-Woo Park,

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Yo-Han Park

    1. Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • There were no grants or financial support, and there are no conflicts of interest. This study was approved by institutional review committee of Asan Medical Center.

Abstract

In total portosplenomesenteric thrombosis patients, cavoportal hemitransposition (CPHT) is indicated but rarely applicable for adult-to-adult (A-to-A) living donor liver transplantation (LDLT) because partial liver graft requires splanchno-portal inflow for liver graft regeneration. If intra- & peri-pancreatic collaterals draining into pericholedochal varix were present, pericholedochal varix may provide splanchnic blood flow to the transplanted liver and also relieve recipient's portal hypertension. To date, however, there is no successful report using pericholedochal varix in liver transplantation (LT). We successfully performed A-to-A LDLTs using pericholedochal varix for those 2 patients. The surgical strategies are followings: (a) dissection of hepatic hilum to isolate left hepatic artery using for arterial reconstruction of implanted right lobe graft, (b) en-mass clamping of the undissected remaining hilum if we can leave adequate length of stump from the clamping site, and then hilum is divided, (c) delay the donor hepatectomy until the feasibility of the recipient operation is confirmed. Portal flow was established between the sizable pericholedochal varix (caliber > 1cm) and graft portal vein, but the individually designed approaches were used for each patients. Currently, they have been enjoying normal life on posttransplant 92 and 44 months respectively. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins might be an useful inflow to restore portal flow and secure good outcome in A-to-A LDLT. Liver Transpl 20:612–615, 2014. © 2014 AASLD.

For patients with diffuse thrombosis of the splanchnic venous system, portal inflow via cavoportal hemitransposition has been proposed in deceased donor whole liver transplantation.[1-5] In living donor liver transplantation, cavoportal hemitransposition is rarely indicated because a partial liver graft cannot tolerate the high systemic blood flow through the inferior vena cava. In some patients, a large pericholedochal varix draining from pancreatic collaterals can be a useful vessel for providing splanchnic blood flow with hepatotrophic factors to the graft and for relieving portal hypertension. Two adult recipients with diffuse thrombosis were successfully treated with a large pericholedochal varix for portal inflow.

SURGICAL TECHNIQUES

Patient 1 was a 50-year-old man with hepatitis B virus–related cirrhosis, ascites controlled by diuretics, and a Model for End-Stage Liver Disease score of 21 points. A preoperative computed tomography scan revealed diffuse splanchnic thrombosis and a pericholedochal varix more than 1 cm in diameter (Fig. 1A). The following surgical strategies were considered: (1) a trial dissection of the hepatic hilum to isolate the left hepatic artery and use it for the arterial inflow of the graft, (2) trial en masse clamping of the undissected remaining hilum if there was an adequate length of the stump distal to the clamp, and (3) a delay of the donor right hepatectomy until the feasibility of the recipient operation was confirmed.

Figure 1.

Three-dimensional computed tomography scan of the abdomen and operative view of portal vein reconstruction using a pericholedochal varix in patient 1, who had an obliterated splanchnic vein due to chronic thrombosis of the portal vein, superior mesenteric vein, and splenic vein. (A) A reconstruction view shows that multiple collateral veins, including a large 10.1-mm-diameter pericholedochal vein (arrow and red line), developed at the hepatic hilum and in the peripancreatic area. (B) After the isolation of the left hepatic artery, the transected hepatic hilum under mass clamping with a vascular tourniquet revealed multiple openings at the divided end, including a pericholedochal varix and a bile duct. (C) In the schema, except for the largest pericholedochal varix (red arrowhead), the openings are closed. Then, the thin vessel wall of the largest pericholedochal varix is reinforced with an autogenous, bisected great saphenous vein (red arrows). (D) A completion view shows the reinforcement of the largest pericholedochal varix (arrowhead) with the autogenous, bisected great saphenous vein (arrows). Portal vein reconstruction was performed between the donor portal vein and the reinforced pericholedochal varix.

During the exploration, the dissection of the left hepatic artery was relatively easy without much bleeding because the left hepatic artery was located on the medial side of the hepatoduodenal ligament at some distance from the bile duct with the pericholedochal venous plexus. Additional dissection of the hepatic hilum was not performed because of copious bleeding from the pericholedochal venous plexus; the donor hepatectomy was then started. After completion of the recipient's peri- and retrohepatic dissection, the recipient's great saphenous vein was procured for reinforcement of the large, thin-walled choledochal vein and plasty of the recipient's right hepatic vein.[6] After en masse clamping of the hepatoduodenal ligament (except for the isolated left hepatic artery), the recipient and donor hepatectomies were performed simultaneously to reduce undue anhepatic time. We isolated the choledochal varix at the stump of the undissected hepatic hilum, and the remaining structures were closed with 6-0 or 5-0 polypropylene sutures. The choledochal varix was reinforced with matrix sutures via the wrapping of the bisected great saphenous vein in preparation for reconstruction (Fig. 1B-D). The implantation of the modified graft (650 g and 1.1% graft-to-recipient weight ratio) was performed as previously described.[7] The left hepatic artery was used for arterial reconstruction, and Roux-en-Y hepaticojejunostomy was performed.

Patient 2 was a 58-year-old man with hepatitis B virus–related cirrhosis, hepatocellular carcinoma, and a Model for End-Stage Liver Disease score of 18 points. He had a small amount of ascites and esophageal varices without red wale signs. A preoperative computed tomography scan revealed an obliterated portosplenomesenteric vein and a large pericholedochal varix (Fig. 2A). The surgical procedures were similar to those previously described for patient 1. Before the division of the hepatic hilum for the total hepatectomy, however, we isolated the enlarged pericholedochal vein, which was 17 mm in diameter and 4 cm in length and had a thick wall. The weight of the modified right lobe graft was 900 g, and the graft-to-recipient weight ratio was 1.22%. The right portal vein of the graft was fenced with the funnel-shaped bisected great saphenous vein for size matching with the pericholedochal varix on the back table[6] (Fig. 2B,C). For arterial and biliary reconstruction, the left hepatic artery and the jejunal Roux limb, respectively, were used.

Figure 2.

Three-dimensional computed tomography scan of the abdomen and operative view of portal vein reconstruction using a pericholedochal varix in patient 2, who had an obliterated splanchnic vein due to chronic thrombosis of the portal vein, superior mesenteric vein, and splenic vein. (A1) In the axial view, the portal vein, superior mesenteric vein, and splenic vein were not visible, and multiple collateral veins developed in the intra- and peripancreatic area. (A2) In the reconstruction view, 2 sizable pericholedochal varices (16.5 and 12.3 mm) (arrows and red lines) were visible at the hepatic hilum, and multiple large collateral veins were present in the peripancreatic area. (B1) Under mass clamping with a vascular clamp with a Surg-I-Paw clamp cover (Scanlan, St. Paul, MN), a large dissected pericholedochal vein approximately 2 cm in diameter (black arrow) was visible at the transected hepatic hilum, and other openings, including a bile duct and another pericholedochal varix, were already closed with 6-0 or 5-0 Prolene sutures. (B2) The reconstructed portal vein was visible between the recipient's large dissected pericholedochal varix (black arrows), the funnel-shaped bisected great saphenous vein fence (arrowheads), and the graft's portal vein (white arrows). The left hepatic artery was noted on the lateral side of the hepatic hilum (yellow arrows) and served as the only available arterial inflow. (C) The schema shows how to reconstruct the portal vein between the graft's portal vein (white arrows), the funnel-shaped bisected saphenous vein fence (white arrowheads), and the recipient's dissected large pericholedochal varix (black arrows).

Both patients did well after transplantation (92 and 44 months, respectively). Patient 1, however, developed a large amount of ascites and severe stenosis of the portal vein anastomosis site at 5 months, which was successfully treated with percutaneous stent placement in both the right anterior portal vein and the posterior portal vein crossing the anastomotic site.

DISCUSSION

To the best of our knowledge, this is the first successful report of deceased donor or living donor liver transplantation using a pericholedochal varix. In our experience, first, the pericholedochal varix should be more than 1 cm in diameter. Multiple small-diameter pericholedochal varices cannot provide adequate portal inflow to the implanted graft and may result in graft failure.[8] Both patients had small amounts of ascites without large esophageal varices, and this was indirect evidence of effective decompression of portal hypertension through the enlarged pericholedochal varix. Second, the wall of the enlarged pericholedochal varix is usually very thin and densely attached to the bile duct wall because of periductal fibrosis. Even though it has a thick wall because of long-standing portal hypertension, troublesome bleeding is inevitable during dissection. Proper use of en masse clamping of the hepatic hilum[9] after isolation of the left hepatic artery, however, enabled us to perform the procedures without massive bleeding. Third, it is difficult to dissect the artery because of the enlarged pericholedochal varices, particularly around the right hepatic artery, and the use of the left hepatic artery should be considered.

In conclusion, in a patient with obliteration of the entire splanchnic venous system but without severe esophageal varices and ascites, an appropriately sized pericholedochal varix can provide portal inflow without cavoportal hemitransposition.

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