Evaluation of hepatic venous congestion: proposed indication criteria for hepatic vein reconstruction

Abstract

Objective: To establish criteria for venous reconstruction of middle hepatic vein (MHV) tributaries of the right liver graft in adult-to-adult living donor liver transplantation (LDLT).

Summary background data: In adult LDLT using the right hemiliver, the MHV is usually separated from the graft, which results in potential venous congestion in the major part of the right paramedian sector (segments 5 and 8). It is controversial whether MHV tributaries should be reconstructed.

Methods: Thirty-nine donors for LDLT were enrolled in the study. After liver transection, temporary arterial clamping was carried out to visualize congestion in the right paramedian sector by occlusion of MHV tributaries. Intra- and postoperative (on postoperative days 3 and 7) Doppler ultrasonography was performed to check the hepatic venous and portal flow in the veno-occlusive area.

Results: In 29 of 37 donors (78%), the liver surface of the veno-occlusive area was discolored with temporary arterial clamping. The discolored area was calculated to represent approximately two thirds of the right paramedian sector on computed tomography volumetry. All of the cases with discoloration exhibited absent venous flow and regurgitated portal flow in the discolored area by intraoperative Doppler ultrasonography. These ultrasonographic findings resolved by postoperative day 7 in 6 of 14 cases (43%).

Conclusions: The state of venous congestion in the right liver graft can be correctly assessed by the temporary arterial clamping method and intraoperative Doppler ultrasonography. If the venocongestive area is demonstrated to be so large that the graft volume excluding this area is thought to be insufficient for postoperative metabolic demand, venous reconstruction is recommended.

Figures

Figure 1. After liver transection for left hepatectomy with the middle hepatic vein, discoloration of the congested area in the right paramedian sector was revealed with temporary arterial occlusion. (Left) Before arterial occlusion. (Right) After arterial occlusion.

Figure 2. Color flow mapping of intraoperative Doppler ultrasonography after liver transection in extended right hemihepatectomy. Portal flow was hepatofugal in the veno-occlusive area. A; artery, PV; portal vein. Arrows indicate the direction of portal blood flow.

Figure 3. Color flow mapping of intraoperative Doppler ultrasonography after liver transection in extended left hepatectomy. Arrows indicate the direction of portal blood flow. Venous flow was regurgitated in the middle hepatic vein tributaries in S8, while in the right hepatic vein normal hepatofugal flow was observed. A communicating vein (arrowheads) was seen between the middle and right hepatic veins. IVC, inferior vena cava; MHV, middle hepatic vein; RHV, right hepatic vein; P, right paramedian portal pedicles.

Figure 4. Tissue saturation with oxygen in the normal, veno-occlusive, and veno-arterio-occlusive areas measured by near-infrared spectroscopy. Black circles indicate donors whose hepatic venous flow was undetectable (n = 7). White circles indicate donors with hepatic venous regurgitation (n = 4). *P = .03; **P < .001.