Prospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 21, 2015; 21(19): 6008-6017
Published online May 21, 2015. doi: 10.3748/wjg.v21.i19.6008
Risk of venous congestion in live donors of extended right liver graft
Arnold Radtke, George Sgourakis, Ernesto P Molmenti, Susanne Beckebaum, Vito R Cicinnati, Hartmut Schmidt, Heinz-Otto Peitgen, Christoph E Broelsch, Massimo Malagó, Tobias Schroeder
Arnold Radtke, Department of General and Transplantation Surgery, University Hospital Tuebingen, D-72076 Tuebingen, Germany
George Sgourakis, Department of General Surgery of Red Cross Hospital, 11526 Athens, Greece
Ernesto P Molmenti, Department of Surgery, North Shore University Hospital, Manhasset, New York, NY 11030, United States
Susanne Beckebaum, Vito R Cicinnati, Christoph E Broelsch, Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, 45122 Essen, Germany
Hartmut Schmidt, Department of Transplant Medicine, University Hospital Muenster, D-48149 Münster, Germany
Heinz-Otto Peitgen, MeVis Center for Medical Diagnostic Systems and Visualization, University of Bremen, 28359 Bremen, Germany
Massimo Malagó, Department of Surgery-UCL Division of Surgical and Interventional Sciences, University College London, W1W 7EJ London, United Kingdom
Tobias Schroeder, Department of Diagnostic and Interventional Radiology, University Hospital Essen, 45122 Essen, Germany
Author contributions: Radtke A, Malagó M and Sgourakis G designed research; Radtke A, Beckebaum S and Cicinnati VR performed research; Schroeder T and Peitgen HO contributed 3D-anatomical physiological tools; Radtke A and Sgourakis G analyzed data; and Schmidt H, Molmenti EP and Broelsch CE critically reviewed the paper.
Supported by German Society for Research, No. 117/1-1:A2.2.
Informed consent: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest: All authors declare no conflicts of interest.
Data sharing: Consent was not obtained but the presented data are anonymized and risk of identification does not exist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: George Sgourakis, MD, PhD, FACS, Department of General Surgery of Red Cross Hospital, Athanasaki 1, Ampelokipi, 11526 Athens, Greece. ggsgourakis@yahoo.gr
Telephone: +30-694-7690163 Fax: +30-210-6716015
Received: November 23, 2014
Peer-review started: November 24, 2014
First decision: January 8, 2015
Revised: February 1, 2015
Accepted: April 3, 2015
Article in press: April 3, 2015
Published online: May 21, 2015
Processing time: 178 Days and 1.4 Hours
Abstract

AIM: To investigate middle hepatic vein (MHV) management in adult living donor liver transplantation and safer remnant volumes (RV).

METHODS: There were 59 grafts with and 12 grafts without MHV (including 4 with MHV-5/8 reconstructions). All donors underwent our five-step protocol evaluation containing a preoperative protocol liver biopsy Congestive vs non-congestive RV, remnant-volume-body-weight ratios (RVBWR) and postoperative outcomes were evaluated in 71 right graft living donors. Dominant vs non-dominant MHV anatomy in total liver volume (d-MHV/TLV vs nd-MHV/TLV) was constellated with large/small congestion volumes (CV-index). Small for size (SFS) and non-SFS remnant considerations were based on standard cut-off- RVBWR and RV/TLV. Non-congestive RVBWR was based on non-congestive RV.

RESULTS: MHV and non-MHV remnants showed no significant differences in RV, RV/TLV, RVBWR, total bilirubin, or INR. SFS-remnants with RV/TLV < 30% and non-SFS-remnants with RV/TLV ≥ 30% showed no significant differences either. RV and RVBWR for non-MHV (n = 59) and MHV-containing (n = 12) remnants were 550 ± 95 mL and 0.79 ± 0.1 mL vs 568 ± 97 mL and 0.79 ± 0.13, respectively (P = 0.423 and P = 0.919. Mean left RV/TLV was 35.8% ± 3.9%. Non-MHV (n = 59) and MHV-containing (n = 12) remnants (34.1% ± 3% vs 36% ± 4% respectively, P = 0.148. Eight SFS-remnants with RVBWR < 0.65 had a significantly smaller RV/TLV than 63 non-SFS-remnants with RVBWR ≥ 0.65 [SFS: RV/TLV 32.4% (range: 28%-35.7%) vs non-SFS: RV/TLV 36.2% (range: 26.1%-45.5%), P < 0.009. Six SFS-remnants with RV/TLV < 30% had significantly smaller RVBWR than 65 non-SFS-remnants with RV/TLV ≥ 30% (0.65 (range: 0.6-0.7) vs 0.8 (range: 0.6-1.27), P < 0.01. Two (2.8%) donors developed reversible liver failure. RVBWR and RV/TLV were concordant in 25%-33% of SFS and in 92%-94% of non-SFS remnants. MHV management options including complete MHV vs MHV-4A selective retention were necessary in n = 12 vs n = 2 remnants based on particularly risky congestive and non-congestive volume constellations.

CONCLUSION: MHV procurement should consider individual remnant congestive- and non-congestive volume components and anatomy characteristics, RVBWR-RV/TLV constellation enables the identification of marginally small remnants.

Keywords: Living donor liver transplantation; Liver volume; Remnant volume; Small-for-size; Small-for-size syndrome

Core tip: Prevention of liver failure in middle hepatic vein (MHV) inclusive right graft donors involves consideration of both congestive and non-congestive remnant volumes. MHV management should be individually based on MHV anatomy characteristics. Non-congestive volumes represent an important safety parameter in MHV management, especially in the setting of small for size remnants. The remnant-volume-body-weight ratios - remnant volumes/total liver volume constellation seems to have a synergistic (complementary) capacity for the identification of marginally small remnants with the highest risk potential of postoperative liver failure.