Middle hepatic vein reconstruction in adult right lobe living donor liver transplantation improves recipient survival
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摘要
Background: The efficacy and necessity of middle hepatic vein(MHV) reconstruction in adult-to-adult right lobe living donor liver transplantation(LDLT) remain controversial. The present study aimed to evaluate the survival beneficiary of MHV reconstructions in LDLT. Methods: We compared the clinical outcomes of liver recipients with MHV reconstruction( n = 101) and without MHV reconstruction( n = 43) who underwent LDLT using right lobe grafts at our institution from January 2006 to May 2017. Results: The overall survival(OS) rate of recipients with MHV reconstruction was significantly higher than that of those without MHV reconstruction in liver transplantation( P = 0.022; 5-yr OS: 76.2% vs 58.1%). The survival of two segments(segments 5 and 8) hepatic vein reconstruction was better than that of the only one segment(segment 5 or segment 8) hepatic vein reconstruction( P = 0.034; 5-yr OS: 83.6% vs 67.4%). The survival of using two straight vascular reconstructions was better than that using Y-shaped vascular reconstruction in liver transplantation with two segments hepatic vein reconstruction( P = 0.020; 5-yr OS: 100% vs 75.0%). The multivariate analysis demonstrated that MHV tributary reconstructions were an independent beneficiary prognostic factor for OS(hazard ratio = 0.519, 95% CI: 0.282–0.954, P = 0.035). Biliary complications were significantly increased in recipients with MHV reconstruction(28.7% vs 11.6%, P = 0.027). Conclusions: MHV reconstruction ensured excellent outflow drainage and favored recipient outcome. The MHV tributaries(segments 5 and 8) should be reconstructed as much as possible to enlarge the hepatic vein anastomosis and reduce congestion.
Background: The efficacy and necessity of middle hepatic vein(MHV) reconstruction in adult-to-adult right lobe living donor liver transplantation(LDLT) remain controversial. The present study aimed to evaluate the survival beneficiary of MHV reconstructions in LDLT. Methods: We compared the clinical outcomes of liver recipients with MHV reconstruction( n = 101) and without MHV reconstruction( n = 43) who underwent LDLT using right lobe grafts at our institution from January 2006 to May 2017. Results: The overall survival(OS) rate of recipients with MHV reconstruction was significantly higher than that of those without MHV reconstruction in liver transplantation( P = 0.022; 5-yr OS: 76.2% vs 58.1%). The survival of two segments(segments 5 and 8) hepatic vein reconstruction was better than that of the only one segment(segment 5 or segment 8) hepatic vein reconstruction( P = 0.034; 5-yr OS: 83.6% vs 67.4%). The survival of using two straight vascular reconstructions was better than that using Y-shaped vascular reconstruction in liver transplantation with two segments hepatic vein reconstruction( P = 0.020; 5-yr OS: 100% vs 75.0%). The multivariate analysis demonstrated that MHV tributary reconstructions were an independent beneficiary prognostic factor for OS(hazard ratio = 0.519, 95% CI: 0.282–0.954, P = 0.035). Biliary complications were significantly increased in recipients with MHV reconstruction(28.7% vs 11.6%, P = 0.027). Conclusions: MHV reconstruction ensured excellent outflow drainage and favored recipient outcome. The MHV tributaries(segments 5 and 8) should be reconstructed as much as possible to enlarge the hepatic vein anastomosis and reduce congestion.
Background: The efficacy and necessity of middle hepatic vein(MHV) reconstruction in adult-to-adult right lobe living donor liver transplantation(LDLT) remain controversial. The present study aimed to evaluate the survival beneficiary of MHV reconstructions in LDLT. Methods: We compared the clinical outcomes of liver recipients with MHV reconstruction( n = 101) and without MHV reconstruction( n = 43) who underwent LDLT using right lobe grafts at our institution from January 2006 to May 2017. Results: The overall survival(OS) rate of recipients with MHV reconstruction was significantly higher than that of those without MHV reconstruction in liver transplantation( P = 0.022; 5-yr OS: 76.2% vs 58.1%). The survival of two segments(segments 5 and 8) hepatic vein reconstruction was better than that of the only one segment(segment 5 or segment 8) hepatic vein reconstruction( P = 0.034; 5-yr OS: 83.6% vs 67.4%). The survival of using two straight vascular reconstructions was better than that using Y-shaped vascular reconstruction in liver transplantation with two segments hepatic vein reconstruction( P = 0.020; 5-yr OS: 100% vs 75.0%). The multivariate analysis demonstrated that MHV tributary reconstructions were an independent beneficiary prognostic factor for OS(hazard ratio = 0.519, 95% CI: 0.282–0.954, P = 0.035). Biliary complications were significantly increased in recipients with MHV reconstruction(28.7% vs 11.6%, P = 0.027). Conclusions: MHV reconstruction ensured excellent outflow drainage and favored recipient outcome. The MHV tributaries(segments 5 and 8) should be reconstructed as much as possible to enlarge the hepatic vein anastomosis and reduce congestion.
引文
[1]Hashikura Y,Makuuchi M,Kawasaki S,Matsunami H,Ikegami T,Nakazawa Y,et al.Successful living-related partial liver transplantation to an adult patient.Lancet 1994;343:1233-1234.
[2]Makuuchi M,Sugawara Y.Technical progress in living donor liver transplantation for adults.HPB(Oxford)2004;6:95-98.
[3]Liu CL,Fan ST.Adult-to-adult live-donor liver transplantation:the current status.J Hepatobiliary Pancreat Surg 2006;13:110-116.
[4]Shi XM,Tao YF,Fu ZR,Ding GS,Wang ZX,Xiao L.Reconstruction of the middle hepatic vein tributary in adult right lobe living donor liver transplantation.Hepatobiliary Pancreat Dis Int 2011;10:581-586.
[5]Lee SG.A complete treatment of adult living donor liver transplantation:a review of surgical technique and current challenges to expand indication of patients.Am J Transplant 2015;15:17-38.
[6]Yu PF,Wu J,Zheng SS.Management of the middle hepatic vein and its tributaries in right lobe living donor liver transplantation.Hepatobiliary Pancreat Dis Int 2007;6:358-363.
[7]Peng CJ,Wang XF,Li B,Wei YG,Yan LN,Wen TF,et al.Efficacy of middle hepatic vein reconstruction in adult right-lobe living donor liver transplantation.Hepatobiliary Pancreat Dis Int 2010;9:135-138.
[8]Wu J,Wang W,Zhang M,Shen Y,Liang T,Yu P,et al.Reconstruction of middle hepatic vein in living donor liver transplantation with modified right lobe graft:a single center experience.Transpl Int 2008;21:843-849.
[9]Kim DG,Moon IS,Kim SJ,Lee YJ,Lee MD.Effect of middle hepatic vein reconstruction in living donor liver transplantation using right lobe.Transplant Proc2006;38:2099-2101.
[10]Hwang S,Jung DH,Ha TY,Ahn CS,Moon DB,Kim KH,et al.Usability of ringed polytetrafluoroethylene grafts for middle hepatic vein reconstruction during living donor liver transplantation.Liver Transplant 2012;18:955-965.
[11]Yi NJ,Suh KS,Lee HW,Cho EH,Shin WY,Cho JY,et al.An artificial vascular graft is a useful interpositional material for drainage of the right anterior section in living donor liver transplantation.Liver Transplant 2007;13:1159-1167.
[12]Kim JD,Choi DL,Han YS.Simplified one-orifice venoplasty for middle hepatic vein reconstruction in adult living donor liver transplantation using right lobe grafts.Clin Transplant 2014;28:561-568.
[13]Ou QJ,Hermann RE.The role of hepatic veins in liver operations.Surgery1984;95:381-391.
[14]Maetani Y,Itoh K,Egawa H,Shibata T,Ametani F,Kubo T,et al.Factors influencing liver regeneration following living-donor liver transplantation of the right hepatic lobe.Transplantation 2003;75:97-102.
[15]Zheng SS,Xu X,Wu J,Chen J,Wang WL,Zhang M,et al.Liver transplantation for hepatocellular carcinoma:hangzhou experiences.Transplantation2008;85:1726-1732.
[16]Shimizu S,Onoe T,Ishiyama K,Ide K,Ohira M,Tahara H,et al.Multiple hepatic vein reconstruction using an all-in-one sleeve patch graft technique in living donor liver transplantation:a case report.Transplant Proc 2014;46:982-985.
[17]Fan ST,De Villa VH,Kiuchi T,Lee SG,Makuuchi M.Right anterior sector drainage in right-lobe live-donor liver transplantation.Transplantation2003;75:S25-S27.
[18]Sugawara Y,Makuuchi M,Sano K,Imamura H,Kaneko J,Ohkubo T,et al.Vein reconstruction in modified right liver graft for living donor liver transplantation.Ann Surg 2003;237:180-185.
[19]Lee S,Park K,Hwang S,Kim K,Ahn C,Moon D,et al.Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion.J Hepatobiliary Pancreat Surg 2003;10:16-25.
[20]Marcos A,Fisher RA,Ham JM,Shiffman ML,Sanyal AJ,Luketic VA,et al.Right lobe living donor liver transplantation.Transplantation 1999;68:798-803.
[21]Yamamoto H,Maetani Y,Kiuchi T,Ito T,Kaihara S,Egawa H,et al.Background and clinical impact of tissue congestion in right-lobe living-donor liver grafts:a magnetic resonance imaging study.Transplantation 2003;76:164-169.
[22]Kaneko T,Kaneko K,Sugimoto H,Inoue S,Hatsuno T,Sawada K,et al.Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation:observation by Doppler ultrasonography.Transplantation 20 0 0;70:982-985.
[23]Ito K,Akamatsu N,Tani K,Ito D,Kaneko J,Arita J,et al.Reconstruction of hepatic venous tributary in right liver living donor liver transplantation:the importance of the inferior right hepatic vein.Liver Transpl 2016;22:410-419.
[24]Lee SG,Park KM,Hwang S,Kim KH,Choi DN,Joo SH,et al.Modified right liver graft from a living donor to prevent congestion.Transplantation 2002;74:54-59.
[25]Mori A,Kaido T,Ogura Y,Ogawa K,Hata K,Yagi S,et al.Standard hepatic vein reconstruction with patch plasty using the native portal vein in adult living donor liver transplantation.Liver Transplant 2012;18:602-607.
[26]Suehiro T,Shimada M,Kishikawa K,Shimura T,Soejima Y,Yoshizumi T,et al.Impact of graft hepatic vein inferior vena cava reconstruction with graft venoplasty and inferior vena cava cavoplasty in living donor adult liver transplantation using a left lobe graft.Transplantation 2005;80:964-968.
[27]Takemura N,Sugawara Y,Hashimoto T,Akamatsu N,Kishi Y,Tamura S,et al.New hepatic vein reconstruction in left liver graft.Liver Transplant2005;11:356-360.
[2]Makuuchi M,Sugawara Y.Technical progress in living donor liver transplantation for adults.HPB(Oxford)2004;6:95-98.
[3]Liu CL,Fan ST.Adult-to-adult live-donor liver transplantation:the current status.J Hepatobiliary Pancreat Surg 2006;13:110-116.
[4]Shi XM,Tao YF,Fu ZR,Ding GS,Wang ZX,Xiao L.Reconstruction of the middle hepatic vein tributary in adult right lobe living donor liver transplantation.Hepatobiliary Pancreat Dis Int 2011;10:581-586.
[5]Lee SG.A complete treatment of adult living donor liver transplantation:a review of surgical technique and current challenges to expand indication of patients.Am J Transplant 2015;15:17-38.
[6]Yu PF,Wu J,Zheng SS.Management of the middle hepatic vein and its tributaries in right lobe living donor liver transplantation.Hepatobiliary Pancreat Dis Int 2007;6:358-363.
[7]Peng CJ,Wang XF,Li B,Wei YG,Yan LN,Wen TF,et al.Efficacy of middle hepatic vein reconstruction in adult right-lobe living donor liver transplantation.Hepatobiliary Pancreat Dis Int 2010;9:135-138.
[8]Wu J,Wang W,Zhang M,Shen Y,Liang T,Yu P,et al.Reconstruction of middle hepatic vein in living donor liver transplantation with modified right lobe graft:a single center experience.Transpl Int 2008;21:843-849.
[9]Kim DG,Moon IS,Kim SJ,Lee YJ,Lee MD.Effect of middle hepatic vein reconstruction in living donor liver transplantation using right lobe.Transplant Proc2006;38:2099-2101.
[10]Hwang S,Jung DH,Ha TY,Ahn CS,Moon DB,Kim KH,et al.Usability of ringed polytetrafluoroethylene grafts for middle hepatic vein reconstruction during living donor liver transplantation.Liver Transplant 2012;18:955-965.
[11]Yi NJ,Suh KS,Lee HW,Cho EH,Shin WY,Cho JY,et al.An artificial vascular graft is a useful interpositional material for drainage of the right anterior section in living donor liver transplantation.Liver Transplant 2007;13:1159-1167.
[12]Kim JD,Choi DL,Han YS.Simplified one-orifice venoplasty for middle hepatic vein reconstruction in adult living donor liver transplantation using right lobe grafts.Clin Transplant 2014;28:561-568.
[13]Ou QJ,Hermann RE.The role of hepatic veins in liver operations.Surgery1984;95:381-391.
[14]Maetani Y,Itoh K,Egawa H,Shibata T,Ametani F,Kubo T,et al.Factors influencing liver regeneration following living-donor liver transplantation of the right hepatic lobe.Transplantation 2003;75:97-102.
[15]Zheng SS,Xu X,Wu J,Chen J,Wang WL,Zhang M,et al.Liver transplantation for hepatocellular carcinoma:hangzhou experiences.Transplantation2008;85:1726-1732.
[16]Shimizu S,Onoe T,Ishiyama K,Ide K,Ohira M,Tahara H,et al.Multiple hepatic vein reconstruction using an all-in-one sleeve patch graft technique in living donor liver transplantation:a case report.Transplant Proc 2014;46:982-985.
[17]Fan ST,De Villa VH,Kiuchi T,Lee SG,Makuuchi M.Right anterior sector drainage in right-lobe live-donor liver transplantation.Transplantation2003;75:S25-S27.
[18]Sugawara Y,Makuuchi M,Sano K,Imamura H,Kaneko J,Ohkubo T,et al.Vein reconstruction in modified right liver graft for living donor liver transplantation.Ann Surg 2003;237:180-185.
[19]Lee S,Park K,Hwang S,Kim K,Ahn C,Moon D,et al.Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion.J Hepatobiliary Pancreat Surg 2003;10:16-25.
[20]Marcos A,Fisher RA,Ham JM,Shiffman ML,Sanyal AJ,Luketic VA,et al.Right lobe living donor liver transplantation.Transplantation 1999;68:798-803.
[21]Yamamoto H,Maetani Y,Kiuchi T,Ito T,Kaihara S,Egawa H,et al.Background and clinical impact of tissue congestion in right-lobe living-donor liver grafts:a magnetic resonance imaging study.Transplantation 2003;76:164-169.
[22]Kaneko T,Kaneko K,Sugimoto H,Inoue S,Hatsuno T,Sawada K,et al.Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation:observation by Doppler ultrasonography.Transplantation 20 0 0;70:982-985.
[23]Ito K,Akamatsu N,Tani K,Ito D,Kaneko J,Arita J,et al.Reconstruction of hepatic venous tributary in right liver living donor liver transplantation:the importance of the inferior right hepatic vein.Liver Transpl 2016;22:410-419.
[24]Lee SG,Park KM,Hwang S,Kim KH,Choi DN,Joo SH,et al.Modified right liver graft from a living donor to prevent congestion.Transplantation 2002;74:54-59.
[25]Mori A,Kaido T,Ogura Y,Ogawa K,Hata K,Yagi S,et al.Standard hepatic vein reconstruction with patch plasty using the native portal vein in adult living donor liver transplantation.Liver Transplant 2012;18:602-607.
[26]Suehiro T,Shimada M,Kishikawa K,Shimura T,Soejima Y,Yoshizumi T,et al.Impact of graft hepatic vein inferior vena cava reconstruction with graft venoplasty and inferior vena cava cavoplasty in living donor adult liver transplantation using a left lobe graft.Transplantation 2005;80:964-968.
[27]Takemura N,Sugawara Y,Hashimoto T,Akamatsu N,Kishi Y,Tamura S,et al.New hepatic vein reconstruction in left liver graft.Liver Transplant2005;11:356-360.