Right anterior section graft for living-donor liver transplantation: A case report

Abstract

Rationale: In living-donor liver transplantation (LDLT), the right lobe graft is commonly utilized to prevent small-for-size syndrome, despite the considerable donor morbidity. Conversely, the feasibility of the left lobe graft and the right posterior section graft in smaller-sized recipients is now commonly employed with comparable outcomes to right lobe grafts. The efficacy of the right anterior section graft has rarely been reported.

Patient concerns: A 56-year-old man, a heavy alcoholic beverage drinker for 20 years, presented in the emergency department with massive ascites and lethargy. He was previously admitted twice due to bleeding esophageal varices.

Diagnosis: He was diagnosed with hepatic encephalopathy coma due to alcoholic liver cirrhosis. The Child-Turcotte-Pugh score was 11 (class C), and the Model for End-stage Liver Disease score was 21.62.

Intervention: A LDTL was offered to the patient as the best treatment option available. The patient's 26-year-old son was found to be the only donor-compatible candidate for the LDTL.Preoperatively, the right lobe of the donor occupied 76.2% of the total liver volume exposing the donor to a small residual liver volume. The right posterior section and left lobe volumes were insufficient, providing a graft-to-recipient weight ratio of 0.42% and 0.38%, respectively. However, the right anterior section could fulfill an acceptable GRWR of 0.83%. Thus, a living donor right anterior sectionectomy was performed.

Outcomes: Clinical signs and symptoms and liver function improved following anterior section graft transplantation without complications.

Lesson: The procurement of anterior section graft is technically feasible in selected patients, especially in high-volume liver centers.

Figure 1

Preoperative imaging studies. Computed tomography (CT) scan three-dimensional reconstruction showing a normal variant of the hepatic artery (A) and portal vein (B). The tributaries of the right hepatic vein (RHV) (black arrows) draining segment VII (C) and segment 5 (D). (E) The trifurcation of the biliary tree was noted on MRCP.

Figure 2

Intraoperative findings during right anterior sectionectomy. (A, B) Hilar structures were meticulously isolated and the exact locations of the right anterior hepatic duct (RAHD) and the right posterior hepatic duct (RPHD) were identified intraoperatively by probing method before transection of these structures. (C, D) The RPPV, right posterior hepatic artery (RPHA), and the RPHD were well preserved. (E) Completion cholangiogram showing an intact RPHD (white arrow) and LHD (black arrow).

Figure 3

Back table graft reconstruction. The tributaries of the right hepatic vein (RHV) draining segment V (A) and segment VIII (B) were reconstructed using an interposition graft. (C) The interposition graft was anastomosed to the middle hepatic vein (MHV) (white arrow). (D) Venous outflow reconstruction. Venotomy was created to enlarge the orifice of the MHV (black arrow).

Figure 4

Schematic presentation of the transplanted anterior section graft.

Figure 5

Functional liver recovery. (A) The INR and total bilirubin of the donor had returned to normal levels after the 5th postoperative day. (B) Initial rise of liver enzymes (alanine aminotransferase [SGPT] and aspartate aminotransferase [SGOT]) after surgery and return to normal at the 7th postoperative day. The INR activity and bilirubin level (C), as well as SGPT and SGOT (D) subsequently achieved normal levels after 15 days.

Figure 6

Postoperative imaging studies. (A) The donor's RPPV (white arrow) and the right posterior hepatic artery (RPHA) (yellow arrows) were intact. (B) A segmental branch of the LPV (white arrow). (C) The anastomotic site of the common channel formed by the graft (black arrow) and the middle hepatic vein (MHV) (white arrow) was intact. (D) The right anterior portal vein (RAPV) (white arrow) and the right anterior hepatic artery (RAHA) (black arrow) were also normal.