Safety and necessity of including the middle hepatic vein in the right lobe graft in adult-to-adult live donor liver transplantation

Abstract

Objective: To evaluate the safety of donors who have donated the middle hepatic vein in right lobe live donor liver transplantation (LDLT) and to determine whether such inclusion is necessary for optimum graft function.

Summary background data: The necessity to include the middle hepatic vein in a right lobe graft in adult-to-adult LDLT is controversial. Inclusion of the middle hepatic vein in the graft provides uniform hepatic venous drainage but may lead to congestion of segment IV in the donor.

Methods: From 1996 to 2002, 93 right-lobe LDLTs were performed. All right-lobe grafts except 1 contained the middle hepatic vein. In the donor operation, attention was paid to preserve the segment IV hepatic artery and to avoid prolonged rotation of the right lobe. The middle hepatic vein was transected proximal to a major segment IVb hepatic vein whereas possible to preserve the venous drainage in the liver remnant.

Results: There was no donor death. Two donors had intraoperative complications (accidental left hepatic vein occlusion and portal vein thrombosis) and were well after immediate rectification. Twenty-four donors (26%) had postoperative complications, mostly minor wound infection. The postoperative international normalized ratio on day 1 was better in the donors with preservation of segment IVb hepatic vein than those without the preservation, but, in all donors, the liver function was largely normal by postoperative day 7. The first recipient had severe graft congestion as the middle hepatic vein was not reconstructed before reperfusion. In 7 other recipients, the middle hepatic vein was found occluded intraoperatively owing to technical errors. The postoperative hepatic and renal function of the recipients with an occluded or absent middle hepatic vein was worse than those with a patent middle hepatic vein. The hospital mortality rate was also higher in those with an occluded middle hepatic vein (3/9 vs. 5/84, P = 0.028).

Conclusions: Inclusion of the middle hepatic vein in right-lobe LDLT is safe and is essential for optimum graft function and patient survival.

Figures

FIGURE 1. CT scan showing a large branch of hepatic vein draining segment VIII into the right hepatic vein.

FIGURE 2. CT scans showing a segment VIII hepatic vein draining into the middle hepatic vein. Segment III hepatic vein (receiving a branch of segment IVb) drained into the middle hepatic vein more proximal than the segment VIII hepatic vein. In this donor, only the segment VIII hepatic vein was harvested with the graft.

FIGURE 3. CT scan showing the middle hepatic vein receiving a large trunk draining segment IV and part of segment III. The middle hepatic vein was transected proximal to this large trunk (black line). A segment VIII branch (*) was also included in the transection line.

FIGURE 4. Graph showing the median values of postoperative (a) hemoglobin, (b) platelet counts, and (c) international normalized ratio (INR) in the donors.

FIGURE 5. Graph showing the median values of postoperative (a) serum total bilirubin and (b) alanine aminotransferase (ALT) levels in the donors.

FIGURE 6. Graph showing the median values of (a) serum urea and (b) creatinine levels in the donors.

FIGURE 7. Graph showing the median values of postoperative (a) international normalized ratio (INR), (b) alanine aminotransferase (ALT), and (c) bilirubin of the donors with and without sacrifice of segment IVb hepatic veins.

FIGURE 8. (a) Picture showing the dusky segment V and part of segment VIII in a patient who received a graft with segment VIII hepatic vein but without the middle hepatic vein. (b) The dusky area disappeared after the right hepatic artery blood flow was restored. The graft appeared swollen.