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Outflow reconstruction in domino liver transplantation with interposition of autologous portal vein...
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IMAGES IN LIVER TRANSPLANTATION Outflow Reconstruction in Domino Liver Transplantation With Interposition of Autologous Portal Vein Graft. A New Technical Option in Living Donor Domino Liver Transplant Scenario Alexandre Cerqueira, 1 Lucio Pacheco-Moreira, 2 Marcelo Enne, 1 Jefferson Alves, 1 Rodrigo Amil, 1 Elizabeth Balbi, 1 and Jose ´ Manoel Martinho 1 1 Transplant Unit and 2 Clinical and Surgical Hepatology Program, Bonsucesso General Hospital, Rio de Janeiro, Brazil Received March 30, 2006; accepted May 19, 2006. In 1997, a new modality of liver transplantation was introduced: the sequential, or domino, liver transplan- tation. 1 The Achilles heel of domino transplantation re- mains the inferior vena cava length of both the familial amyloidotic polyneuropathy (FAP) patient and the dom- ino recipient. Some investigators have reported that the pericardium may be sectioned to lengthen the vena cava stumps, 2 and serious complications of inferior vena cava anastomosis in domino liver transplantation have been reported. 3 Recently, Pena et al. 4 and Pacheco-Moreira et al. 5 described the new technique for domino liver trans- plantation in which vascular outflow anastomosis in the domino recipient were performed with an iliac/ca- val vein graft from cadaveric donor. For this reason, some technical difficulties such as short vena cava stump, pericardial effusion, and bad outflow in both patients are avoided. This technique also avoids the necessity of the venovenous bypass or the hemody- namic changes after caval clamping in FAP patients. In this case we describe the success of using a recip- ient’s inverted portal vein bifurcation as an interposi- tion graft to drain the outflow in the domino recipient also in a living donor liver transplantation scenario. Lately, techniques for reconstruction of hepatic vessels including the portal vein have been reported in living donor liver transplantation. 6,7 A 37-year-old man (a FAP patient’s husband) donated a right liver. The living donor liver transplantation recipient, a 36-year-old woman with FAP, agreed to also be a dom- ino donor. The native hepatectomy in the FAP patient was performed with inferior vena cava preservation, and veno- venous bypass was not required. The living donor right graft was implanted in the FAP patient as usual. The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day. The FAP liver as a domino graft was harvested with- out the vena cava (Fig. 1) and perfused on the back- table with Belzer solution (Viaspan, DuPont Pharma, Wilmington, DE). The middle and left hepatic veins were joined together (Fig. 2). The autologous portal vein bi- furcation (domino recipient) was used as vascular graft according to inverted Y-graft technique (Fig. 3). The venous graft of the right portal vein was anastomosed with right hepatic vein, and the left portal vein was anastomosed with the new common trunk of the middle and left hepatic veins using a 5-0 polypropylene run- ning suture. A 49-year-old man with end-stage liver disease sec- ondary to hepatitis C agreed to accept the FAP liver. The recipient’s hepatectomy was performed with preserva- tion of the inferior vena cava, and the liver was im- planted in the standard piggyback fashion using the portal stump of the venous graft as the outflow from the Abbreviation: FAP, familial amyloidotic polyneuropathy. Address reprint requests to Alexandre Cerqueira, Rua Londres 616, Pre ´ dio 03 2° andar, Rio de Janeiro, Brazil 21041030. Telephone: 0552139779811; Fax: 0552139779811; E-mail: [email protected] DOI 10.1002/lt.20878 Published online in Wiley InterScience (www.interscience.wiley.com). LIVER TRANSPLANTATION 12:1298-1300, 2006 © 2006 American Association for the Study of Liver Diseases.
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Transcript of Outflow reconstruction in domino liver transplantation with interposition of autologous portal vein...
IMAGES IN LIVER TRANSPLANTATION
Outflow Reconstruction in Domino LiverTransplantation With Interposition of AutologousPortal Vein Graft. A New Technical Option inLiving Donor Domino Liver Transplant Scenario
Alexandre Cerqueira,1 Lucio Pacheco-Moreira,2 Marcelo Enne,1 Jefferson Alves,1 Rodrigo Amil,1
Elizabeth Balbi,1 and Jose Manoel Martinho1
1Transplant Unit and 2Clinical and Surgical Hepatology Program, Bonsucesso General Hospital, Rio deJaneiro, Brazil
Received March 30, 2006; accepted May 19, 2006.
In 1997, a new modality of liver transplantation wasintroduced: the sequential, or domino, liver transplan-tation.
1The Achilles heel of domino transplantation re-
mains the inferior vena cava length of both the familialamyloidotic polyneuropathy (FAP) patient and the dom-ino recipient. Some investigators have reported that thepericardium may be sectioned to lengthen the venacava stumps,2 and serious complications of inferiorvena cava anastomosis in domino liver transplantationhave been reported.3
Recently, Pena et al.4 and Pacheco-Moreira et al.5
described the new technique for domino liver trans-plantation in which vascular outflow anastomosis inthe domino recipient were performed with an iliac/ca-val vein graft from cadaveric donor. For this reason,some technical difficulties such as short vena cavastump, pericardial effusion, and bad outflow in bothpatients are avoided. This technique also avoids thenecessity of the venovenous bypass or the hemody-namic changes after caval clamping in FAP patients.
In this case we describe the success of using a recip-ient’s inverted portal vein bifurcation as an interposi-tion graft to drain the outflow in the domino recipientalso in a living donor liver transplantation scenario.Lately, techniques for reconstruction of hepatic vesselsincluding the portal vein have been reported in livingdonor liver transplantation.6,7
A 37-year-old man (a FAP patient’s husband) donated aright liver. The living donor liver transplantation recipient,a 36-year-old woman with FAP, agreed to also be a dom-ino donor. The native hepatectomy in the FAP patient wasperformed with inferior vena cava preservation, and veno-venous bypass was not required. The living donor rightgraft was implanted in the FAP patient as usual. Thepostoperative course was uneventful, and the patient wasdischarged on the 14th postoperative day.
The FAP liver as a domino graft was harvested with-out the vena cava (Fig. 1) and perfused on the back-table with Belzer solution (Viaspan, DuPont Pharma,Wilmington, DE). The middle and left hepatic veins werejoined together (Fig. 2). The autologous portal vein bi-furcation (domino recipient) was used as vascular graftaccording to inverted Y-graft technique (Fig. 3). Thevenous graft of the right portal vein was anastomosedwith right hepatic vein, and the left portal vein wasanastomosed with the new common trunk of the middleand left hepatic veins using a 5-0 polypropylene run-ning suture.
A 49-year-old man with end-stage liver disease sec-ondary to hepatitis C agreed to accept the FAP liver. Therecipient’s hepatectomy was performed with preserva-tion of the inferior vena cava, and the liver was im-planted in the standard piggyback fashion using theportal stump of the venous graft as the outflow from the
Abbreviation: FAP, familial amyloidotic polyneuropathy.Address reprint requests to Alexandre Cerqueira, Rua Londres 616, Predio 03 2° andar, Rio de Janeiro, Brazil 21041030. Telephone:0552139779811; Fax: 0552139779811; E-mail: [email protected]
DOI 10.1002/lt.20878Published online in Wiley InterScience (www.interscience.wiley.com).
LIVER TRANSPLANTATION 12:1298-1300, 2006
© 2006 American Association for the Study of Liver Diseases.
FAP liver. The postoperative course was uneventful,and the patient was discharged on the 17th postoper-ative day. Angio computed tomography scan at the sec-ond postoperative month showed good outflow (Fig. 4).
The size of the vein diameter is the more importantfactor in this technique. The portal vein that was usedin this case was 22 mm in diameter (Fig. 5). This ap-proach would be feasible only with portal vein diame-ters of 20 mm or more. This would not be a problemwith iliac/vena caval grafts.
In summary, this technique is especially useful whenthe donor for the FAP is a living donor instead of adeceased donor. The technique may be considered as astrategy for avoiding the complications described in thedomino scenario, especially in the FAP patient, and it isin accordance with domino transplant philosophy.
REFERENCES
1. Furtado A, Tome L, Oliveira FJ, Furtado E, Viana J, Per-digoto R. Sequential liver transplantation. Transplant Proc1997;29:467-468.
Figure 1. LHV, left portal vein; RHV, right hepatic vein; MHV,middle hepatic vein.
Figure 2. The middle and left hepatic veins were joinedtogether.
Figure 3. Y-graft technique—PV, portal vein; LPV, left portalvein; RPV, right portal vein.
Figure 4. Arrows denote sites of anastomosis. MHV, middlehepatic vein; LHV, left portal vein; LPV, left portal vein; RHV,right hepatic vein; RPV, right portal vein; PV, portal vein.
Figure 5. Arrow denotes site of anastomosis. IVC, inferiorvena cava; PV, portal vein; SV, splenic vein; SMV, superiormesenteric vein.
IMAGES IN LIVER TRANSPLANTATION 1299
LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
2. Azoulay D, Samuel D, Castaing D, Adam R, Adams D, SaidG, et al. Domino liver transplantation for metabolic disor-ders: experience with familial amyloidotic polyneuropathy.J Am Coll Surg 1999;189:584-593.
3. Nicoluzzi JE, Massault PP, Matmar M, Dousset B, CalmusY, Houssin D, et al. Pitfalls of domino transplant. Trans-plantation 2001;72:751.
4. Pena JR, Barroso E, Martins A, Andrade JR, Pereira JP.Sequential whole liver transplant resected as piggy-backfrom FAP patients [abstract]. Liver Transpl 2002;8:C-24.
5. Pacheco-Moreira LF, Oliveira ME, Balbi E, Silva AC, Miec-znikowski R, Faria LJA, et al. A new technical option fordomino liver transplantation. Liver Transpl 2003;9:632-633.
6. Kokudo N, Sugawara Y, Kaneko J, Imamura H, Sano K,Makuuchi M. Reconstruction of isolated caudate portalvein in left liver graft. Liver Transpl 2004;10:1163-1165.
7. Yamazaki S, Takayama T, Inoue K, Higaki T, Makuuchi M.Interposition of autologous portal vein graft in left livertransplantation. Liver Transpl 2005;11:1615-1616.
1300 CERQUEIRA ET AL.
LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
