Middle hepatic vein outflow reconstruction in right lobe liver transplantation: experience of two cases
Soin, A.S.; Gupta, S.; Jain, P.; Sewkani, A.; Singhal, D.; Verma, V.; Somashekar, U.; Kumar, M. and Nundy, S. (2002) Middle hepatic vein outflow reconstruction in right lobe liver transplantation: experience of two cases. Journal of Gastroenterology and Hepatology, 17 (Suppl). A24.
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Background: 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 analyzed. 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 5 mm. The patients were a 43-year-oldmale 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 8 mm that were drained using an autogenous saphenous Y graft anastomosed to the recipient MHV orifice. Patient 2 had one 10 mm 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 h 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 670 g to 1130 g by day 10 and from 880 g to 1220 g by day 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 5 mm.
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