Viability and Outcomes of Right Hemi-Liver LDLT with Portal Vein Variations

Overview

This study assessed the incidence of right portal vein (RPV) anatomical variations in living liver donors and evaluated different surgical reconstruction techniques in right hemi-liver grafts. Various methods including direct venoplasty, autologous Y-graft interposition, and in situ dual anastomoses were utilized to manage these variations, demonstrating the feasibility and safety of LDLT in this context.

Background

Living-donor liver transplantation (LDLT) is the primary treatment option for end-stage liver disease in Egypt due to the absence of a deceased donor program. The right hemi-liver graft is preferred for adult recipients because of its adequate volume but is complicated by frequent vascular and biliary anatomical variations, particularly in the portal vein. Portal vein reconstruction is critical for successful transplantation, and anatomical variations of the right portal vein occur in 10-35% of donors. Various surgical techniques have been developed to address these variations, but the optimal approach remains debated.

Data Highlights

The study retrospectively reviewed LDLT cases from May 2004 to May 2022 at Mansoura University. Donors were classified by Cheng classification of portal vein anatomy: Type I (classical), Type II (trifurcation), Type III (right posterior PV as first branch), and Type IV (right anterior PV from left PV). Surgical techniques were tailored to the anatomical type, with direct venoplasty used for closely positioned branches (Type II), and autologous Y-graft or in situ dual anastomoses for widely separated branches (Types III and IV).

Key Findings

• RPV anatomical variations were identified and classified according to Cheng classification among living donors.
• Direct venoplasty was effective for Type II variations where branches were close, creating a single orifice for anastomosis.
• For Types III and IV with widely separated branches, autologous Y-graft interposition or in situ dual portal vein anastomoses were successfully employed.
• In situ dual anastomoses required favorable recipient portal vein angulation and allowed separate anastomoses to right and left portal branches.
• The study demonstrated the technical feasibility and safety of LDLT using right hemi-liver grafts with RPV anatomical variations.

Clinical Implications

Surgeons performing LDLT should anticipate and evaluate portal vein anatomical variations preoperatively using CT portography. Tailoring the portal vein reconstruction technique to the specific anatomical variation can optimize graft inflow and reduce surgical complications. The demonstrated techniques expand the donor pool by safely utilizing grafts with complex portal vein anatomy.

Conclusion

Right hemi-liver LDLT with portal vein anatomical variations is feasible and safe when appropriate reconstruction techniques are applied. This study supports the use of tailored surgical approaches to overcome anatomical challenges and improve transplantation outcomes.

References

1. Elshobary et al. 2023 -- Assessment of the Viability and Results of Living-Donor Liver Transplantation Using Right Hemi-Liver Grafts with Variations in Portal Vein Anatomy