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Posterior cavoplasty: a new approach to avoid venous outflow obstruction and symptoms for small-for-size syndrome in right lobe living donor liver transplantation.

Goralczyk AD, Obed A, Beham A, Tsui TY, Lorf T - Langenbecks Arch Surg (2011)

Bottom Line: In patients that underwent posterior cavoplasty, we observed significantly lower PVP and less hyperbilirubinemia.There was a non-significant trend to lower incidence of SFSS.Other laboratory measurements and clinical parameters were not significantly different.

View Article: PubMed Central - PubMed

Affiliation: Department of General and Visceral Surgery, University Medical Center Göttingen, Robert-Koch-Strasse 40, Göttingen, Germany. agoralczyk@med.uni-goettingen.de

ABSTRACT

Purpose: A common and serious problem after living donor liver transplantation (LDLT) of small grafts is small-for-size syndrome (SFSS). Although hyperdynamic portal inflow and portal hypertension are cornerstones in the development of SFSS, inadequate outflow may aggravate SFSS. Therefore, enlargement of the portal outflow tract by incision of the anterior rim of the orifice of the right hepatic vein (RHV) has been advocated for right lobe LDLT. But backwards tilt of a small graft into a large abdominal cavity may lead to a choking of the otherwise large anastomosis and thus we propose posterior enlargement of the orifice of the RHV.

Method: In this test-of-concept study, we evaluated portal vein pressure (PVP), clinical parameters, and laboratory measurements in 22 patients that underwent right lobe LDLT and either received standard end-to-end anastomosis of the RHV or posterior cavoplasty.

Results: In patients that underwent posterior cavoplasty, we observed significantly lower PVP and less hyperbilirubinemia. There was a non-significant trend to lower incidence of SFSS. Other laboratory measurements and clinical parameters were not significantly different.

Conclusion: We recommend posterior cavoplasty for enlargement of the hepatic venous outflow tract in right lobe LDLT as a method to avoid portal hypertension, hyperbilirubinemia, and possibly SFSS, especially in patients that receive small grafts.

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Posterior cavoplasty by oval excision of the posterior sector of the orifice of the RHV. The anterior rim of the orifice of the MHV is left and also used for the anastomosis to avoid tension
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Fig3: Posterior cavoplasty by oval excision of the posterior sector of the orifice of the RHV. The anterior rim of the orifice of the MHV is left and also used for the anastomosis to avoid tension

Mentions: To address possible outflow obstruction in right liver grafts, Fan and colleagues [1] advocate anterior incision of the inferior vena cava (IVC) to enlarge the orifice of the right hepatic vein (RHV) and prevent outflow obstruction of the RHV (Fig. 1). But small grafts may also tilt laterodorsal into a large abdominal cavity, and this may lead to functional stenosis by choking on the outflow tract (Fig. 2). Therefore, we enlarged the orifice of the RHV by oval excision of the posterior sector of the orifice (Fig. 3) and compared our new technique of posterior cavoplasty to conventional end-to-end anastomosis of the RHV in a test-of-concept study.Fig. 1


Posterior cavoplasty: a new approach to avoid venous outflow obstruction and symptoms for small-for-size syndrome in right lobe living donor liver transplantation.

Goralczyk AD, Obed A, Beham A, Tsui TY, Lorf T - Langenbecks Arch Surg (2011)

Posterior cavoplasty by oval excision of the posterior sector of the orifice of the RHV. The anterior rim of the orifice of the MHV is left and also used for the anastomosis to avoid tension
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3044231&req=5

Fig3: Posterior cavoplasty by oval excision of the posterior sector of the orifice of the RHV. The anterior rim of the orifice of the MHV is left and also used for the anastomosis to avoid tension
Mentions: To address possible outflow obstruction in right liver grafts, Fan and colleagues [1] advocate anterior incision of the inferior vena cava (IVC) to enlarge the orifice of the right hepatic vein (RHV) and prevent outflow obstruction of the RHV (Fig. 1). But small grafts may also tilt laterodorsal into a large abdominal cavity, and this may lead to functional stenosis by choking on the outflow tract (Fig. 2). Therefore, we enlarged the orifice of the RHV by oval excision of the posterior sector of the orifice (Fig. 3) and compared our new technique of posterior cavoplasty to conventional end-to-end anastomosis of the RHV in a test-of-concept study.Fig. 1

Bottom Line: In patients that underwent posterior cavoplasty, we observed significantly lower PVP and less hyperbilirubinemia.There was a non-significant trend to lower incidence of SFSS.Other laboratory measurements and clinical parameters were not significantly different.

View Article: PubMed Central - PubMed

Affiliation: Department of General and Visceral Surgery, University Medical Center Göttingen, Robert-Koch-Strasse 40, Göttingen, Germany. agoralczyk@med.uni-goettingen.de

ABSTRACT

Purpose: A common and serious problem after living donor liver transplantation (LDLT) of small grafts is small-for-size syndrome (SFSS). Although hyperdynamic portal inflow and portal hypertension are cornerstones in the development of SFSS, inadequate outflow may aggravate SFSS. Therefore, enlargement of the portal outflow tract by incision of the anterior rim of the orifice of the right hepatic vein (RHV) has been advocated for right lobe LDLT. But backwards tilt of a small graft into a large abdominal cavity may lead to a choking of the otherwise large anastomosis and thus we propose posterior enlargement of the orifice of the RHV.

Method: In this test-of-concept study, we evaluated portal vein pressure (PVP), clinical parameters, and laboratory measurements in 22 patients that underwent right lobe LDLT and either received standard end-to-end anastomosis of the RHV or posterior cavoplasty.

Results: In patients that underwent posterior cavoplasty, we observed significantly lower PVP and less hyperbilirubinemia. There was a non-significant trend to lower incidence of SFSS. Other laboratory measurements and clinical parameters were not significantly different.

Conclusion: We recommend posterior cavoplasty for enlargement of the hepatic venous outflow tract in right lobe LDLT as a method to avoid portal hypertension, hyperbilirubinemia, and possibly SFSS, especially in patients that receive small grafts.

Show MeSH
Related in: MedlinePlus