Between April 1993 and May 1995, 17 adult orthotopic liver transplant recipients were found to have early hepatic artery thrombosis (HAT) after a median of 7 postoperative days (mean, 11). The HAT was diagnosed in all cases by duplex ultrasound. Thrombectomy was performed with urgent revascularization (UR), using an interposition arterial graft procured from the cadaveric liver donor, and arterial patency was verified with intraoperative angiography. In seven cases, intra-arterial urokinase was administered after the thrombectomy. Fifteen (88%) of the livers remained arterialized throughout the follow-up period (median, 15 months); the remaining two patients developed recurrent HAT after 6 and 8 months. Although there was a high rate of subsequent complications, 11 (65%) of the patients are alive without retransplantation, with a mean follow-up of 17 months. Despite having a patent hepatic artery, the remaining six patients (35%) died from infectious complications that usually were present before the UR. Thus, UR effectively restored arterial inflow in 88% of the patients with early HAT. The ultimate outcome was determined mainly by the presence of intra-abdominal complications at the time of UR. In conclusion, UR, rather than retransplantation, should be considered the prime treatment option for patients who develop early posttransplant HAT.
Split liver transplantation for two adults offers a valuable opportunity to expand the donor pool for adult recipients. However, its application is mainly hampered by the physiological limits of these partial grafts. Small for size syndrome is a major concern during transplantation with partial graft and different techniques have been developed in living donor liver transplantation to prevent the graft dysfunction. Herein, we report the first application of synergic approaches to optimise the hepatic hemodynamic in a split liver graft for two adults. A Caucasian woman underwent liver transplantation for alcoholic cirrhosis (MELD 21) with a full right liver graft (S5-S8) without middle hepatic vein. Minor and accessory inferior hepatic veins were preserved by splitting the vena cava; V5 and V8 were anastomosed with a donor venous iliac patch. After implantation, a 16G catheter was advanced in the main portal trunk. Inflow modulation was achieved by splenic artery ligation. Intraportal infusion of PGE1 was started intraoperatively and discontinued after 5 d. Graft function was immediate with normalization of liver test after 7 d. Nineteen months after transplantation, liver function is normal and graft volume is 110% of the recipient standard liver volume. Optimisation of the venous outflow, inflow modulation and intraportal infusion of PGE1 may represent a valuable synergic strategy to prevent the graft dysfunction and it may increase the safety of split liver graft for two adults.
Transplantation; Split liver; Portal flow; Ultrasound; Prostaglandin
Technical problems such as graft and vascular size are more common in living donor liver transplantation (LDLT) than in deceased donor liver transplantation. It is usually possible to get enough length of vessels on the graft, but the opposite situation is devastating. Finding the suitable vessel graft is life-saving in those situations. In this paper we present a case of gonodal vein interpositioning for hepatic artery reconstruction in an LDLT recipient. To the best of our knowledge, this is the first such case to be reported in the literature.
A 36-year-old man with cirrhosis secondary to hepatitis B underwent LDLT. Within minutes after completing the anastomosis, the artery was thrombosed. Disrupting the anastomosis showed subintimal dissection of the recipient right hepatic artery extending to the gastro-duodenal junction. A 4 cm segment of gonodal vein, which matched the diameter of the recipient hepatic artery, was used as a bridge. The patient’s postoperative recovery was excellent and Doppler ultrasonography demonstrated sufficient hepatic arterial blood flow. At long-term follow-up (18th months), the patient’s graft is still functioning.
Gonodal vein interposition for hepatic artery reconstruction in living donor liver transplantation has not been previously reported. In light of the urgency of this situation, we believe it can be a life-saving reconstruction.
liver transplantation; hepatic artery; gonodal vein
We evaluated the efficacy of reconstruction of the hepatic artery for intraoperative or postoperative thrombosis in orthotopic liver transplantation. Of 37 grafts with artery thrombosis, 13 (35.1%, 6 intraoperative and 7 postoperative) underwent reconstruction of the hepatic artery. The arterial flow was reestablished and maintained in 5 (38.5%) of the 13. Recurrent thrombosis in the other 8 grafts developed 2 to 24 days (mean, 13.8 days) after transplantation. Reconstruction was successful in 50% (4/8) of the adults, compared with only 20% (1/5) of the children. Satisfactory results were obtained when a definitive cause of thrombosis could be identified. We conclude that early recognition and correction of the cause of hepatic artery thrombosis during or after orthotopic liver transplantation, especially in adults, is often a graft-saving and lifesaving procedure worthy of consideration.
We report the reuse of a liver graft after brain death of the first recipient. The liver donor was an 8-year-old male who died as a result of head injury. The graft was implanted first to a 4-year-old girl for fulminant hepatic failure. Unfortunately she developed progressive coma and brain death on fifth day of transplantation. The graft functions were normal, and reuse of the liver graft was planned. After informed consent, the graft was transplanted to a 31-year-old female recipient who has hepatocellular carcinoma with an underlying cryptogenic liver cirrhosis. The patient was discharged to home on 9th day after an uneventful postoperative period. However, she was readmitted to hospital with an acute abdominal pain 30 days after the operation. Hepatic artery thrombosis was diagnosed, and the attempt to open the artery by interventional radiology was unsuccessful. She died of sepsis and multiorgan failure on 37th posttransplant day.
Primary biliary cirrhosis is a frequent indication for liver transplantation. The purpose of this report is to present our experience with liver transplantation for primary biliary cirrhosis. Attention is given to the causes of hepatic dysfunction seen in allografts. In addition, we review the postoperative problems encountered and the quality of life at time of last follow-up in patients with transplants for primary biliary cirrhosis. A total of 97 orthotopic liver transplant procedures were performed in 76 patients with advanced primary biliary cirrhosis at the University of Pittsburgh from March 1980 through September 1985. The transplant operation was relatively easy to perform. The most common technical complications experienced were fragmentation and intramural dissection of the recipient hepatic artery, which required an arterial graft in 20% of the cases. Most of the postoperative mortality occurred in the first 6 mo after transplantation, with an essentially flat actuarial life survival curve from that time point to a projected 5-yr survival of 66%. Common causes of death included rejection and primary graft nonfunction. Thirteen of the 76 patients had some hepatic dysfunction at the time of the last follow-up, although none were jaundiced. Recurrence of primary biliary cirrhosis could not be demonstrated in any of the patients. Antimitochondrial antibody was detected in the serum of almost all of the patients studied postoperatively for it. Most important, almost all of the 52 surviving patients have been rehabilitated socially and vocationally.
Living donor liver transplantation (LDLT), since its advent in late 1980’s and early 1990’s, has rapidly increased especially in countries like Japan, Korea and India where cadaveric programmes are not as well established as in the western world. The main advantage of LDLT is the availability of an organ in the elective setting in the course of a progressive liver disease. This is most applicable in patients with Cirrhosis and Hepatocellular carcinoma. LDLT, from the donor’s perspective does carry a risk of not only morbidity but mortality. To date the surgical mortality risk is estimated at 0.1% for left lateral donation and 0.5% for right liver donation. Donor mortality has been reported from various centres in India. There are reports of complications like Hepatic artery thrombosis, portal vein thrombosis and especially biliary leaks and strictures occurring at a significantly increased frequency after living as compared to deceased donor liver transplantation. The key to reduce donor morbidity and mortality is meticulous donor selection and thorough donor work up. In the present study we will analyse the factors that contributed to donor mortality and morbidity and prepare a detailed work up plan, intraoperative and post-operative strategy to reduce donor morbidity and mortality.
Live-related liver transplant; Donor safety; Donor mortality; Donor morbidity
During fiscal year 1986, 40 out of 196 patients (21%) developed hyperamylasemia following orthotopic liver transplantation. The placement of a retropancreatic aortohepatic arterial interposition graft was associated with hyperamylasemia (p < 0.025). Eight patients (20%) developed clinically significant acute pancreatitis and its sequelae; abscesses and pseudocysts each in 2. Pancreatitis was attributable to the retropancreatic arterial graft in 4, viral infection in 2 and obstruction of the pancreatic duct in 1 patient. All 4 patients with arterial graft-related pancreatitis exhibited poor graft function immediately postoperatively, of whom 2 required retransplantation – both of which failed to function. Five patients died (63%); 2 from primary graft non-function, 2 due to sepsis and 1 from systemic cytomegalovirus infection. We conclude that acute pancreatitis after liver transplantation is a life-threatening complication which is often associated with graft non-function.
liver transplantation; pancreatitis; pseudocyst; abscess
Donor gonadal vein is a readily available vascular reconstruction material for vascular reconstruction, for difficult situations, in living related renal transplantation. Vein extension with the gonadal vein has been described as a simple and safe method to elongate renal vein especially in right living donor kidneys. We applied the donor gonadal vein for lacerated accessory renal artery and renal vein reconstruction.
Materials and Methods:
The donor gonadal vein was used to reconstruct the lacerated accessory renal artery in one patient. The donor gonadal vein was isolated, used as an interposition graft to bridge the gap between transected accessory renal artery and external iliac artery of the recipient. In another patient, gonadal vein was used to reconstruct short right renal vein, which got damaged during retrieval.
This technique resulted in a tension-free anastomosis. There were no procedure related complications. The ischemia time remained within acceptable limits and grafts showed excellent outcomes.
The use of gonadal vein for renal vascular reconstruction seems to be an acceptable option during living related renal transplantation, lest the need arise, with no increased graft morbidity.
Donor gonadal vein; laparoscopic donor nephrectomy; renal transplantation
Two-hundred-and-twenty-seven children underwent orthotopic liver transplantation between March 1980 and March 1986. Seventy (31 %) patients died during the study period. Four patients who died within 24 hours of the initial liver transplant and 5 patients who died outside of our institution were excluded from the analysis. Liver failure, related to either thrombosis of the hepatic artery, primary non-function of the graft or rejection accounted for 25 of the remaining 61 deaths. In 21 patients death was related to overwhelming sepsis while 7 patients died from excessive bleeding. Eight of the deaths were due to a miscellaneous group of causes. Twenty percent of the 150 patients who received a single liver transplant died compared to a death rate of 50% in patients who underwent three transplants. Eighty-five percent of the deaths occurred within 6 months after the initial liver transplant. Liver failure was the cause in the majority of the early deaths whereas the later deaths were more likely to be due to sepsis. This detailed analysis of the causes of death after pediatric liver transplantation in a large group of patients has revealed that advances in certain areas could lead to even better results.
death; liver transplantation; cyclosporine; steroids
Though split-liver and living-related transplantation are routinely performed, they are done almost exclusively for primary liver transplantation because of potential surgical difficulties. These difficulties are generally related to arterial revascularization, particularly if there is hepatic artery thrombosis. According to UNOS data, of the hepatic retransplantations performed between 1996 and 2007, only 8.7% were done using right or extended right grafts from deceased donors, and 14.3% using right grafts from live donors. Here we report our experience with 5 hepatic retransplantations in which right partial grafts resulting from conventional in situ splits, and one right lobe resulting from an adult-to-adult living-related transplant, were successfully used with different modalities of graft arterialization.
Hepatic artery; Liver transplantation; Split liver; Living related transplantation; Hepatic retransplantation
A single donor surgeon's experience procuring the livers from 132 donors is described. Thirty-seven grafts (28.9%) had hepatic arterial anomalies, 19 (14.4%) of which required arterial reconstruction prior to transplantation. Of the 121 grafts evaluated for early function, 103 grafts (85.2%) functioned well, whereas 14 grafts (11.6%) functioned poorly and 4 grafts (3.3%) failed to function at all. The variables associated with less than optimal function of the graft consisted of donor age (P < 0.05), duration of donor's stay in the intensive care unit (P < 0.005), abnormal graft appearance (P < 0.05), and such recipient problems as vascular thromboses during or immediately following transplantation (P < 0.005). A new preservation fluid, University of Wisconsin solution, allowed safe and longer cold storage of the liver allograft than did Euro-Collins' solution (P < 0.0001). A parameter of liver allograft viability, which is simple and predictive of allograft function prior to the actual transplant procedure, is urgently needed.
Liver transplantation; procurement - Procurement; of the liver - Arterial anomalies and liver procurement
Liver transplantation is the most effective treatment for various end-stage liver diseases. Living donor liver transplantation (LDLT) was first developed in Asia due to the severe lack of cadaveric graft in this region. The Liver Transplant Service at Queen Mary Hospital (QMH), Hong Kong, has pioneered the application of LDLT to patients using both left lobe and right lobe grafts. The QMH liver transplant programme is the largest of its kind in China and Southeast Asia.
Ultrasound (US) is often employed in the initial work-up of potential donor and recipient of LDLT. It is the imaging technique of choice to assess the early and late complications of LDLT, with colour Doppler ultrasound being the most useful in the evaluation of post-LDLT vascular complications. The use of ultrasound contrast agents improves the visualisation of the hepatic vasculature, possibly delaying or removing the need for more invasive investigations. Intra-operative ultrasound facilitates the determination of the resection plane during donor hepactectomy.
Computed tomography (CT) or magnetic resonance imaging (MRI) can be used as the single imaging modality in the evaluation of LDLT candidates.
Ultrasound is most useful as the initial screening test in detecting hepatic parenchymal abnormalities, while CT or MRI is the modality of choice in the demonstration of vascular and biliary anatomy of the potential liver donor.
Biliary complications are more common in LDLT than in cadaveric liver transplantation. The ductal dilatation, resulting from biliary stricture, is clearly demonstrated by ultrasound. Bilomas can be aspirated under ultrasound guidance to confirm the diagnosis and to promote healing. Perihepatic fluid collections and abscesses are also common after LDLT. Intra-hepatic collections may represent seromas, haematomas or infarction. Ultrasound is a sensitive means of detecting these collections and can be employed to guide drainage in suitable patients.
Transplant-related malignancies include recurrent neoplasia and post-transplant lymphoproliferative disease (PTLD). Ultrasound can be used to screen for recurrent disease and to detect PTLD in the transplanted liver.
Ultrasound; living donor; liver; transplantation
Advanced atherosclerosis or thrombosis of iliac vessels can constitute an absolute contraindication for heterotopic kidney transplantation. We report the case of a 42-year-old women with end-stage renal disease due to lupus nephritis and a history of bilateral thrombosis of iliac arteries caused by antiphospholipid antibodies. Occlusion had been treated by the bilateral placement of wall stents which precluded vascular anastomosis. The patient was transplanted with a right kidney procured by laparoscopic nephrectomy from her HLA semi-identical sister. The recipient had left nephrectomy after laparoscopical transperitoneal dissection. The donor kidney was orthotopically transplanted with end-to-end anastomosis of graft vessels to native renal vessels and of the graft and native ureter. Although, the patient received full anticoagulation because of a cardiac valve and antiphospholipid antibodies, she had no postoperative complication in spite of a short period of delayed graft function. Serum creatinine levels three months after transplantation were at 1.0 mg/dl. Our case documents that orthotopical transplantation of laparoscopically procured living donor kidneys at the site of recipient nephrectomy is a feasible procedure in patients with surgical contraindication of standard heterotopic kidney transplantation.
A 66-year-old female with cryptogenic cirrhosis complicated by ascites, hepatic encephalopathy, variceal bleeding and malnutrition with MELD of 34 underwent orthotopic deceased donor liver transplantation performed with piggyback technique. Extensive eversion thromboendovenectomy was performed for a portal vein thrombus which resulted in an excellent portal vein flow. The liver graft was recirculated without any hemodynamic instability. Subsequently, the patient became hypotensive progressing to asystole. She was resuscitated and a transesophageal probe was inserted which revealed a mobile right atrial thrombus and an underfilled poorly contractile right ventricle. The patient was noted to be coagulopathic at the time. She became progressively more stable with a TEE showing complete resolution of the intracardiac thrombus.
Liver transplantation; Cardiac thrombus; Reperfusion injury; Coagulopathy; Transesophageal echocardiogram
A 39 year-old patient with cholangiocarcinoma and pre-existing ulcerative colitis was successfully treated by orthotopic liver transplantation. He was given low doses of prednisone and azathioprine and survived for more than 9 months, dying with tumour metastases, thrombosis of the inferior vena cava and an intra-abdominal abscess. At autopsy the homograft showed little evidence of rejection. Preoperatively the patient had septicemia. Removal of his liver was difficult. The discrepancy between donor and recipient in size of blood vessels and the presence of two hepatic arteries in the donor caused problems during the vascular anastomoses. During the operation cardiac arrest occurred. Postoperatively there were several medical and surgical problems, including intraperitoneal and gastrointestinal hemorrhage, paralysis of the right dome of the diaphragm, sinus bradycardia, massive diuresis, peroneal nerve palsy, and one major and three minor episodes of rejection, which were reversed by giving pulse doses of methylprednisolone intravenously.
A 60-year-old male underwent orthotopic liver transplantation because of hepatitis C virus related cirrhosis. After 12 d, the patient underwent re-transplantation due to primary graft non function. One year later the patient developed a thrombosis of the main portal vein needing a surgical revision. After 11 years the patient was operated on because of a clinical picture of intestinal occlusion. As an incidental finding, a large aneurysm of the main portal vein was diagnosed. The incidence of intra- and extrahepatic Portal vein aneurysms (PVAs) is not clear. To the best of our knowledge, only one case of intrahepatic PVA in a liver transplant has been reported in the literature. In addition, we have found no documented cases of extrahepatic PVAs in liver transplanted patients.
Portal vein aneurysm; Late complication; Liver transplantation; Portal hypertension; Doppler ultrasound
Various treatments for liver diseases, including liver transplant (particularly partial liver resection from a living donor), treatment of liver tumors, and TIPS, require detailed knowledge of the complex vascular anatomy of the liver. The hepatic artery and portal vein provide the organ with a double blood supply whereas venous drainage is furnished by the hepatic veins.
Multislice computed tomography and magnetic resonance imaging provide undeniably excellent information on these structures. On ultrasound, the inferior vena cava, the openings of the hepatic veins, and the main branch of the portal vein can always be visualized, but intrasegmental vessels (portal, arterial, accessory hepatic venous branches) can be only partially depicted and in some cases not at all.
In spite of its difficulty and limitations, hepatic sonography is frequently unavoidable, particularly in critically ill patients, and the results are essential for defining diagnostic and therapeutic strategies. For this reason, a thorough knowledge of the sonographic features of hepatic vascular anatomy is indispensable.
Sonography, liver; Hepatic artery; Portal vein; Hepatic veins
AIM: To retrospectively investigate microsurgical hepatic artery (HA) reconstruction and management of hepatic thrombosis in adult-to-adult living donor liver transplantation (A-A LDLT).
METHODS: From January 2001 to September 2009, 182 recipients with end-stage liver disease underwent A-A LDLT. Ten of these patients received dual grafts. The 157 men and 25 women had an age range of 18 to 68 years (mean age, 42 years). Microsurgical techniques and running sutures with back-wall first techniques were performed in all arterial reconstructions under surgical loupes (3.5 ×) by a group of vascular surgeons. Intimal dissections were resolved by interposition of the great saphenous vein (GSV) between the donor right hepatic artery (RHA) and recipient common HA (3 cases) or abdominal aorta (AA) (2 cases), by interposition of cryopreserved iliac vessels between the donor RHA and recipient AA (2 cases).
RESULTS: In the 58 incipient patients in this series, hepatic arterial thrombosis (HAT) was encountered in 4 patients, and was not observed in 124 consecutive cases (total 192 grafts, major incidence, 2.08%). All cases of HAT were suspected by routine color Doppler ultrasonographic examination and confirmed by contrast-enhanced ultrasound and hepatic angiography. Of these cases of HAT, two occurred on the 1st and 7th d, respectively, following A-A LDLT, and were immediately revascularized with GSV between the graft and recipient AA. HAT in one patient occurred on the 46th postoperative day with no symptoms, and the remaining case of HAT occurred on the 3rd d following A-A LDLT, and was cured by thrombolytic therapy combined with an anticoagulant but died of multiorgan failure on the 36th d after A-A LDLT. No deaths were related to HAT.
CONCLUSION: Applying microsurgical techniques and selecting an appropriate anastomotic artery for HA reconstruction are crucial in reducing the high risk of HAT during A-A LDLT.
Adult-to-adult living donor liver transplantation; Hepatic arterial thrombosis; Microsurgical reconstruction
A technique of orthotopic liver transplantation using a segmental graft from living donors was
developed in the dog. Male mongrel dogs weighing 25–30 kg were used as donors and 10–15 kg as
recipients. The donor operation consists of harvesting the left lobe of the liver (left medial and left
lateral segments) with the left branches of the portal vein, hepatic artery and bile duct, and the left
hepatic vein. The grafts are perfused in situ through the left portal branch to prevent warm ischemia.
The recipient operation consists of two phases: 1total hepatectomy with preservation of the inferior
vena cava using total vascular exclusion of the liver and veno-venous bypass, 2implantation of the graft
in the orthotopic position with anastomosis of the left hepatic vein to the inferior vena cava and portal,
arterial and biliary reconstruction. Preliminary experiments consisted of four autologous left lobe
transplants and nine non survival allogenic left lobe transplants. Ten survival experiments were
conducted. There were no intraoperative deaths in the donors and none required transfusions. One
donor died of sepsis, but all the other donor dogs survived without complication. Among the 10 grafts
harvested, one was not used because of insufficient bile duct and artery. Two recipients died
intraoperatively of air embolus and cardiac arrest at the time of reperfusion. Three dogs survived, two
for 24 hours and one for 48 hours. They were awake and alert a few hours after surgery, but eventually
died of pulmonary edema in 2 cases and of an unknown reason in the other. Four dogs died 2–12 hours
postoperatively as a result of hemorrhage for the graft's transected surface. An outflow block after
reperfusion was deemed to be the cause of hemorrhage in these cases. On histologic examination of the
grafts, there were no signs of ischemic necrosis or preservation damage.
This study demonstrates the technical feasibility of living hepatic allograft donation. It shows that it is
possible, in the dog, to safely harvest non ischemic segmental grafts with adequate pedicles without
altering the vascularization and the biliary drainage of the remaining liver. We propose that this
technique is applicable to human anatomy.
AIM: To investigate contrast-enhanced ultrasound (CEUS) for early diagnosis of postoperative vascular complications after right-lobe living donor liver transplantation (RLDLT).
METHODS: The ultrasonography results of 172 patients who underwent RLDLT in West China Hospital, Sichuan University from January 2005 to June 2008 were analyzed retrospectively. Among these 172 patients, 16 patients’ hepatic artery flow and two patients’ portal vein flow was not observed by Doppler ultrasound, and 10 patients’ bridging vein flow was not shown by Doppler ultrasound and there was a regional inhomogeneous echo in the liver parenchyma upon 2D ultrasound. Thus, CEUS examination was performed in these 28 patients.
RESULTS: Among the 16 patients without hepatic artery flow at Doppler ultrasound, CEUS showed nine cases of slender hepatic artery, six of hepatic arterial thrombosis that was confirmed by digital subtraction angiography and/or surgery, and one of hepatic arterial occlusion with formation of lateral branches. Among the two patients without portal vein flow at Doppler ultrasound, CEUS showed one case of hematoma compression and one of portal vein thrombosis, and both were confirmed by surgery. Among the 10 patients without bridging vein flow and with liver parenchyma inhomogeneous echo, CEUS showed regionally poor perfusion in the inhomogeneous area, two of which were confirmed by enhanced computed tomography (CT), but no more additional information about bridging vein flow was provided by enhanced CT.
CONCLUSION: CEUS may be a new approach for early diagnosis of postoperative vascular complications after RLDLT, and it can be performed at the bedside.
Contrast-enhanced ultrasound; Living donor liver transplantation; Postoperative complication; Vascular disease
The postoperative diagnostic imaging examinations of 44 children who underwent 59 orthotopic liver transplantations were reviewed. The imaging modalities used for the evaluation of suspected complications include plain roentgenography, ultrasonography (US), computed tomography (CT), nuclear scintigraphy, arteriography, percutaneous and operative cholangiography, and endoscopic retrograde cholangiopancreatography. The main postoperative complications included ischemia, thrombosis (hepatic artery and portal vein), infarction, obstruction or leakage of the biliary anastomosis, hepatic and perihepatic infection, and allograft rejection. US, the most frequently used abdominal imaging modality, was best suited for detection of biliary duct dilatation, fluid collections in or around the transplanted liver, and hepatic arterial, inferior vena caval, and portal vein thrombosis. CT was especially helpful in corroborating findings of infection and in locating abscesses. Technetium 99m sulfur colloid (early- and late-phase imaging) provided a sensitive, although nonspecific, means of assessing allograft vascularization and morphology. Angiography showed vascularity most clearly, and cholangiography was the most useful In the assessment of bile duct patency. A diagnostic imaging algorithm is proposed for evaluation of suspected complications.
Liver, transplantation, 76.45; Surgery, complications
Vascular variations in and around the porta hepatis are common. A sound knowledge of possible variations at these sites is vital for surgeons during laparoscopic cholecystectomy and surgical resection of the liver lobes. We report the case of several variations of the hepatic and cystic arteries in which, the common hepatic artery trifurcated into the gastroduodenal, right hepatic, and left hepatic arteries. The right gastric artery arose from the left hepatic artery and divided into a left and a right branch. The left branch entered the liver through the porta hepatis, while the right branch passed behind the common hepatic duct into the Calot's triangle, provided 2 branches to the gallbladder, and continued to supply the right hepatic lobe. Ligation of the right branch of the right hepatic artery in Calot's triangle during cholecystectomy could cause avascular necrosis of the liver segments it supplies.
Cystic artery; Hepatic artery; Celiac trunk; Calot's triangle; Right gastric artery
The knowledge of anatomical variations in hepatic artery are of importance to surgeons and radiologists while performing complicated procedures like liver transplantation and transarterial chemo-embolization for hepatic tumors. The incidence of accessory left hepatic artery is less common than the right accessory hepatic artery. Here we report an anomalous accessory left hepatic artery arising from common hepatic artery in a 55 year old male cadaver.
Common hepatic artery; Hepatic artery proper; Left hepatic artery; Right hepatic artery; Left accessory hepatic artery
liver transplantation can be the only treatment for acute liver failure.
PRESENTATION OF CASE
A 59 year-old female patient with acute liver failure due to mushroom poisoning underwent auxiliary liver transplantation. The liver graft was harvested from a brain-dead donor with a deep gunshot wound in the posterior sector of the graft. The postoperative course was uneventful with rapid recovery of the recipient and no complications associated with the gunshot wound.
Patients scheduled for urgent liver transplantation should have rapidly a liver graft otherwise the mortality rate is high. In our case, an injured liver graft by gunshot was successfully used allowing liver transplantation and increasing the pool of liver grafts.
A gunshot liver graft can be used if the major vascular or biliary structures are not injured.
Liver transplantation; Brain death donor; Gunshot wound