Hepatic venous outflow obstruction in pediatric liver transplantation: technical considerations in prevention, diagnosis, and management.
HVOO creates significant diagnostic and management dilemmas in pediatric liver transplant recipients, particularly with TVGs (split or reduced-size grafts). Numerous technical variations for the hepatic vein to IVC anastomosis have been described to minimize the incidence of this complication, but no consensus for an optimal anastomotic technique exists. One hundred and thirty-four liver transplants (70 TVGs) were performed in 124 patients between 1994 and 2011. These were divided into two cohorts. Group 1 (95 transplants, 41 TVGs) utilized a continuous running anastomosis. Group 2 (39 transplants, 29 TVGs) implemented a triangulated (three-stitch) anastomosis. All were reviewed for demographics, diagnostics, interventions, and outcome. The overall HVOO incidence was seven of 134 transplants (5.2%) and six of 70 transplants utilizing TVGs (8.6%). Group 1 incidence was five of 41 (12.2%) compared with one of 29 (3.4%; p = 0.20, OR 3.89) in Group 2. Liver Doppler was employed in all patients, and only three suggested HVOO. All patients with HVOO underwent venogram, at a median of 81 days post-transplant. All underwent percutaneous venoplasty and required 1-6 treatments, all resulting in HVOO resolution. Incidence of HVOO has improved since adopting the triangulated anastomosis, although not to a level of statistical significance. US is not adequately sensitive to exclude HVOO. Venogram is recommended in patients with prolonged ascites, and venoplasty has been highly successful in HVOO treatment.
['Sommovilla|J|J|', 'Doyle|M M|MM|', 'Vachharajani|N|N|', 'Saad|N|N|', 'Nadler|M|M|', 'Turmelle|Y P|YP|', 'Weymann|A|A|', 'Chapman|W C|WC|', 'Lowell|J A|JA|']
D000714:Anastomosis, Surgical D006502:Budd-Chiari Syndrome D002675:Child, Preschool D015331:Cohort Studies D006085:Graft Survival D006503:Hepatic Veins D006801:Humans D015994:Incidence D007223:Infant D008099:Liver D017093:Liver Failure D016031:Liver Transplantation D019520:Living Donors D010690:Phlebography D015607:Stents D016896:Treatment Outcome D018608:Ultrasonography, Doppler D014682:Vena Cava, Inferior
hepatic vein venogram piggyback stenosis