Management of middle hepatic vein outflow in right lobe liver transplantation
Soni, A.S.; Gupta, S.; Jain, P.; Kumar, D.; Singhal, D.; Verma, V.; Somashekal, U.; Kumar, M. and Nundy, S. (2002) Management of middle hepatic vein outflow in right lobe liver transplantation. In: The 7th Congress of Asian Society of Transplantation, 2002.
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The optimal management of middle hepatic vein (MHV) drainage in a right lobe liver grafts remains controversial. Since MHV is the main outflow to the anterior segment (segments 5,8) in majority of cases, a right lobe graft lacking MHV outflow may suffer anterior segment congestion leading to hemorrhage, sepsis, cholestasis and lack of regeneration. Aims: To determine the effect of MHV outflow reconstruction on anterior segment congestion and its consequences in right lobe liver transplantation. Methods: Two cases of right lobe liver transplantation were analysed. Our policy is to preserve MHV drainage till a late stage in donor surgery, and then after division, reconstruct it on the bench using saline distended saphenous vein grafts anastomosed to segment 5/8 tributaries more than 5mm. The patients were a 43 year old male and a 38 year old female suffering from Hepatitis B cirrhosis and Primary Sclerosing Cholangitis respectively. In both, brothers were donors. Patient 1 had one vein each from segments 5 and 8 which were 7 and 8mm that were drained using an autogenous saphenous Y graft anastomosed to the recipient MHV orifice. Patient 2 had one 10mm segment 8 vein which was drained using a donor straight saphenous graft. In both cases, the MHV drainage was restored after portal reperfusion of the liver. Results: In both, anterior segments were firm and congested (dusky) after reperfusion and became soft and of normal colour after restoring flow in the MHV drainage veins. The patients were extubated 60 and 42 hours after operation. Both patients rapidly regained consciousness, their prothromin times normalized in 2 and 3 days respectively, their transaminases (SGOT/ SGPT) peaked at 258/365 and 285/426 and normalized at days 6 and 7, and their serum bilirubins peaked at 8 and 7.5 and declined from days 5 and 6 onwards respectively. Their respective graft volumes increased from 670g to 1130g by day 10 and from 880gtol220gbyday 11. Conclusion: Reconstruction of MHV drainage in right lobe grafts resulted in normal venous outflow of the anterior segment enabling early recovery of graft function and satisfactory liver regeneration without the added risk bleeding, prolonged cholestasis and sepsis. We recommend routine preservation of MHV drainage in right lobe grafts by reconstructing segment 5 and 8 veins more than 5mm.
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