Right lobe living donor liver transplantation-addressing the middle hepatic vein controversy

Abstract

Objective: To describe our approach in the decision-making for taking the middle hepatic vein with the graft or leaving it with the remnant liver in right lobe live donor liver transplantation.

Summary background data: Right lobe living donor liver transplantation has been successfully performed. However, the extent of donor hepatectomy is still a subject of debate and the main considerations in the decision making are graft functional adequacy and donor safety.

Methods: An algorithm based on donor-recipient body weight ratio, right lobe-to-recipient standard liver volume estimate, and donor hepatic venous anatomy was used to decide the extent of donor hepatectomy. This algorithm was applied in 25 living donor liver transplant operations performed between January 1999 and January 2002. In grafts taken without the middle hepatic vein, anterior segment tributaries draining into it were not reconstructed. Outcomes between right lobe liver transplants with (Group I) and without (Group II) the middle hepatic vein were compared.

Results: Ten grafts included the middle hepatic vein and 15 did not. The mean graft to recipient standard liver volume ratio was 58% and 64% in Groups I and II, respectively, and the difference was not statistically significant. Donors from both groups had comparable recovery, with 2 complications, 1 from each group, requiring a percutaneous drainage procedure. The recipient outcomes were, likewise, comparable and there was 1 case of structural outflow obstruction in Group I, which required venoangioplasty and stenting. There were 2 recipient mortalities, 1 due to a biliary complication and the other to recurrent hepatitis C. Another patient required retransplantation for secondary biliary cirrhosis. The overall actuarial graft and patient survival rates are 84% and 96%, respectively, at a median follow-up of 16 months.

Conclusion: Based on certain preoperative criteria, a right lobe graft can be taken with or without the middle hepatic vein with equally successful outcomes in both the donors and recipients. The decision, therefore, of the extent of right lobe donor hepatectomy should be tailored to the particular conditions of each case.

FIGURE 1. Algorithm for determining the extent of donor hepatectomy in right lobe living donor liver transplantation, with or without the middle hepatic vein (MHV). DRBW, donor-recipient body weight ratio; RLRSLV, right lobe-to-recipient standard liver volume estimate; V5, draining vein of segment V; V8, draining vein of segment VIII; RHV, right hepatic vein.

FIGURE 2. Comparison of serial postoperative (A) aspartate aminotransferase (AST), (B) alanine aminotransferase (ALT), and (C) total bilirubin (TB) between right lobe donors who donated (Group I) and retained (Group II) the MHV.