Author Affiliations: Starzl Unit of Abdominal Transplantation, University Hospitals Saint Luc, Université Catholique Louvain UCL Brussels, Belgium (Pinheiro RS); Department of Gastroenterology, São Paulo University School of Medicine, São Paulo, Brazil (Pinheiro RS, Lai Q, Dahrenmoller C and Lerut J)

Corresponding Author: Rafael S Pinheiro, MD, Department of Gastro­enterology, University of São Paulo, Hospital das Clínicas, Rua Dr. Enéas de Carvalho Aguiar, 255, 9° andar - sala 9113/9114, CEP 05403-900 - São Paulo - SP, Brazil (Tel: 55-11-26613323; Fax: 55-11-26616250; Email: rsnpinheiro@gmail.com)

 

© 2014, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(14)60014-X

 

 

Contributors: LJ proposed the study. PRS and LQ performed research and wrote the first draft. DC collected and analyzed the data. All authors contributed to the design and interpretation of the study and to further drafts. LJ is the guarantor.

Funding: None.

Ethical approval: Not needed.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 

 

ABSTRACT: Domino liver transplantation has been accepted as a safe procedure to further expand the organ donor pool. The most important technical challenge of the procedure resides in restoring a proper hepatic venous allograft outflow in the familial amyloidotic polyneuropathy-liver recipient. To overcome this issue, combined techniques were used to perform an innovative outflow reconstruction. A domino liver transplantation was successfully performed with reconstruction of complex venous outflow. The inferior vena cava sparing hepatectomy technique in the familial amyloidotic polyneuropathy-donor was used to cut the hepatic vein to the liver parenchyma. To overcome this issue the venous outflow tract was reconstructed using a longitudinally opened iliac vein graft from a post-mortem donor to create a new outflow tract using a diamond patch between the right and middle/left hepatic veins.

 

(Hepatobiliary Pancreat Dis Int 2014;13:98-100)

 

KEY WORDS: liver transplantation; intraoperative; anatomy; hepatic vein

Domino liver transplantation (DLT) has been introduced in clinical practice in 1997 by Furtado with the aim to expand the liver donor pool.^[1] Larger experiences have shown that this procedure, using mostly livers from familial amyloidotic polyneuropathy (FAP) patients, can be safely used not only in older or cancer recipients but also in younger patients presenting with benign diseases.^[2]

 

The most important technical challenges of the procedure reside in the realization of a FAP-liver harvest without harming the FAP-donor and in restoring a proper hepatic venous allograft outflow in the FAP-liver recipient. To overcome this issue, we have combined techniques to perform an innovative outflow reconstruction.

 

 

A successful DLT with complex venous outflow reconstruction was done. The inferier vena cava (IVC) sparing hepatectomy technique in the FAP-donor was used to cut the hepatic veins (HVs) flush to the liver parenchyma. The distance between the right hepatic vein (RHV) and the left hepatic vein (LHV) and median hepatic vein (MHV) was very large. Moreover, the (outside) procurement team of the post-mortem liver allograft implanted in the FAP-donor omitted the procurement of supplementary vascular grafts. To overcome both problems, the venous outflow tract was reconstructed using a longitudinally opened iliac vein graft from another post-mortem donor. A three by one cm, diamond shaped, the patch was sutured to the median borders of the RHV and MHV (Fig. 1). Afterwards, the venous patch graft (2 cm wide) was sutured circumferentially to all three HV orifices including the inlay patch. Finally, the two lateral parts of the iliac vein graft were sutured vertically to each other in order to obtain a nice cylindrical cone having the shape of the suprahepatic IVC cuff (Fig. 2). The newly created outflow tract was anastomosed to the cuff of the MHV and LHV of the recipient. There was no congestion at revascularization, and repetitive Doppler ultrasound examinations showed a normal tri-phasic outflow signal (Fig. 3). The patient was discharged after 20 days, her outcome was excellent and she was doing well 14 months after transplantation. The 12 months protocol biopsy did not show any sign of outflow obstruction.

 

 

With growing experience in the field of living donor liver transplantation (LDLT) and DLT, technical modifications were introduced aiming at enhancing the safety of the FAP-donor and the FAP-liver recipient.^{[3, 4]} Harvesting the FAP-liver without the IVC has nowadays become the procedure of choice as it allows almost always the intervention without the use of veno-venous bypass (VVB). Whilst favoring the FAP-donor, this technique puts the FAP-liver recipient at disadvantage by possibly compromising the venous outflow of allograft. Safe FAP-liver implantation therefore needs a back-table reconstruction of the tract of venous outflow.^[5-8] This is usually done by anastomosing all three HV orifices to a free cavo-iliac, cavo-renal or pulmonary bifurcation venous graft. In case of the unavailability of such grafts or in case of HV anomalies, a more complex back-table procedure may be necessary.

 

This technique for hepatic venous reconstruction may be a life-saver in DLT, especially when vascular allografts originating from the post-mortem donor or the recipient are unavailable.

 

 

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