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OUTFLOW RECONSTRUCTION IN PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION: LESSONS LEARNED FROM 126 CONSECUTIVE RECIPIENTS.

OUTFLOW RECONSTRUCTION IN PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION: LESSONS LEARNED FROM 126 CONSECUTIVE RECIPIENTS. Allan M Concejero, Chao-Long Chen, Chih-Chi Wang, Shih-Ho Wang, Yeuh-Wei Liu, Chih-Che Lin, CheeChien Yong, Chin-Hsiang Yang, Tsan-Shiun Lin, Yuan-Cheng Chiang. Liver Transplantation Program, Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung, Taiwan. Background and objective: Hepatic venous outflow reconstruction is one key in successful living donor liver transplantation because its obstruction leads to graft dysfunction and eventual loss. We review our experience in outflow reconstruction in pediatric living donor liver transplantation (LDLT). Patients and methods: From June1994 to September 2005, 126 children (63 male, 63 female) underwent LDLT. Seven (7) underwent recipient venoplasty of the middle and left hepatic veins (HV) prior to graft anastomosis; whereas 119 underwent recipient venoplasty comprising of the right, middle, and left HV. Twenty-eight (28) grafts underwent graft venoplasty prior to anastomosis with the recipient HV or vena cava. Results: There were 76 (60%) left lateral segment, 36 (29%) extended left lateral segment, 4 (3%) left lobe without middle hepatic vein, 4 (3%) left lobe with middle hepatic vein, 5 (4%) right lobe without middle hepatic vein, and 1 (1%) right lobe with middle hepatic vein grafts. Overall HV flow problems occurred in 8 (6%) recipients. Three (3) of the 7 recipients who underwent recipient venoplasty of the middle and left HV developed outflow narrowing where 2 had mild narrowing and 1 severe narrowing which required balloon dilatation and stenting. Of the 119 recipients who underwent venoplasty of the right, middle and left HV, 5 developed outflow problems including 4 moderate-severe narrowing which required balloon dilatation and 1 graft vessel malpositioning due to a tight abdominal wall closure. Two (2) of the 4 moderate-severe HV narrowing (implanted into recipients who underwent right, middle, and left HV venoplasty) underwent graft venoplasty. There was no recipient or graft loss due to HV complications. Conclusion: Hepatic venous outflow in pediatric LDLT must be constructed referentially with wide recipient and graft orifices to avoid narrowing. Graft venoplasty is an acceptable method of augmenting this orifice size; easily performed at backtable, and simplify graft-to-recipient cava anastomosis. In cases of stenosis, endovascular procedures are preferred management of choice followed by stent placement.