Successful Triple Hepatic Venoplasty for Hepatic Vein Reconstruction in Pediatric Living Donor Liver Transplantation with Graft Size Mismatching

Introduction: Hepatic venous outflow obstruction (HVOO) is a critical and life-threatening complication in pediatric living donor liver transplantation, especially in those with large-for-size graft without adequate drainage. Herein, we introduced our own unique triple hepatic venoplasty method and experience in 323 cases. Method: From June 1994 to October 2018, total 323 pediatric patients met the criteria for living donor liver transplantation. During transplantation, a triple hepatic venoplasty was performed at the recipient side to create an adequate outflow orifice. On the graft side, if two or more hepatic vein orifices were found, a venoplasty was performed to fashion a single wide outflow orifice for a single hepatic vein anastomosis. Patient demographics, surgical data, post-operative complications, graft and patient survival were compared and analyzed. Result: A total of 323 pediatric LDLTs were divided into 3 study groups based on their graft-to-recipient weight ratio (GRWR), which included 77 patients had a GRWR of <2.0% (Group A), 193 had a GRWR of ≥2.0% to <4.0% (Group B), and 53 had a GRWR ≥4.0% (Group C). Eight patients experienced hepatic vein outflow obstruction, with 3, 4, and 1 patient in Group A, Group B, and Group C, respectively. The overall incidence of hepatic vein outflow obstruction was 2.5%, and there was no significant difference among 3 groups (p=0.654). Three patients received balloon dilatation and the remaining five underwent stent placement successfully. None of these patients experienced graft failure. The overall 1- , 3- , 5- and 10- year graft survival rates were 92%, 91.5%, 91.1% and 88.4%. The subgroup graft survival rates were comparable. Conclusion: Our triple hepatic venoplasty method demonstrated a promising graft survival in children undergoing pediatric living donor liver transplantation with a low incidence of hepatic vein outflow obstruction, even in large-for-size grafts.