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Introduction
Preoperative assessment of the portal vein (PV), hepatic
artery (HA) and bile duct (BD) systems is essential for safe
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work undertaken in the study conformed to the provisions of the Declaration
of Helsinki.
starting the 1-h scan procedure. The BD course relative to the PV was evaluated
by CT. All images were evaluated by at least two radiologists.
Grafts were selected as previously described (15). Left lobe grafts were
used as the primary graft type if the desired graft volume/standard liver
volume ratio (GV/SLV) was 35%. Right lobe grafts were used if the
simulated GV/SLV of the left lobe graft was <35% and the donors remnant
liver volume was 35%. Other factors, such as anatomical variations and the
recipients condition, were also taken into account to achieve the optimal
outcome for each patient. No donors were considered unsuitable based on
vascular factors and/or BD anatomy alone.
Definitions
Anatomical evaluation
PV and HA anatomies were evaluated by preoperative angiography before
January 2002 and by 3DCT thereafter. Preoperative multi-detector helical CT
images were obtained with 2-mm-thick slices. Enhancement was achieved by
intravenous administration of a nonionic contrast medium (Iopamion; Schering,
Erlangen, Germany) at a speed of 5 mL/s. 3D reconstruction of the HA and PV
was performed using Zio M900 software (Zio Software, Inc., Tokyo, Japan) until
March 2013 and with Vincent software (Fujifilm Holdings Corporation, Tokyo,
Japan) thereafter. BD anatomy was evaluated by preoperative CT cholangiography. CT cholangiography was performed on a multi-detector CT scanner. As a
biliary contrast agent, 100 mL of meglumine iotroxate (50 mg/mL; Biliscopin;
Schering, Berlin, Germany) was administered over a period of 30 min, before
Data analysis
JMP software version 7J (SAS Institute, Cary, NC) was used for all analyses.
Statistical comparisons were conducted using Pearsons chi-square test or
Fishers exact test for qualitative variables. Values of p < 0.05 were
considered statistically significant.
Figure 1: Classification of portal vein, hepatic artery and bile duct anatomies in 407 donors. BD, bile duct; CHA, common hepatic
artery; HA, hepatic artery; LBD, left bile duct; LGA, left gastric artery; LHA, left hepatic artery; LPV, left portal vein; PV, portal vein; RABD,
right anterior bile duct; RBD, right bile duct; RAPV, right anterior portal vein; RHA, right hepatic artery; RPBD, right posterior bile duct;
RPPV, right posterior portal vein; SMA, superior mesenteric artery.
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Results
Figure 1 depicts the anatomies of normal and variant PVs,
HAs and BDs, as well as the frequency of each variant in the
cohort of 407 donors. Three types of PV were identified.
Figure 3: Rare anatomical variants of the portal vein and hepatic artery that could not be classified under other anatomical types.
A4, hepatic artery of segment 4 branch; AHA, anterior hepatic artery; CHA, common hepatic artery; DPA, dorsal pancreatic artery; GDA,
gastroduodenal artery; HA, hepatic artery; LHA, left hepatic artery; LPV, left portal vein; MHA, middle hepatic artery; P4, portal vein of
segment 4 branch; P5, portal vein of segment 5 branch; P8, portal vein of segment 8 branch; PHA, posterior hepatic artery; RAPV, right
anterior portal vein; RHA, right hepatic artery; RPPV, right posterior portal vein.
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Normal PV (n 361)
Variant PV (n 46)
Normal BD
(n 306)
Variant BD
(n 101)
80% (288/361)
39% (18/46)
20% (73/361)
61% (28/46)
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Discussion
In this study, PV, HA and BD anatomical variants were
found in 11%, 25% and 25% of 407 donors, respectively.
These rates are consistent with the previously reported
rates of 8.330% in living liver donors (2,3,13,14,16,17),
16.846% in patients undergoing liver resection (1), and
2844% in radiological imaging studies (12,18). We also
found that donors with a variant PV were more likely to
have a variant BD than were donors with a normal PV
(p < 0.0001), which is also consistent with previous
reports (1,2,12,14,19). Furthermore, 61% of donors with
a variant PV had a variant BD, but 80% of donors with a
normal PV did not, implying that the presence of PV
abnormalities might help to predict whether the BD is
anatomically normal or not.
In our current study, 88% of the donors had a supraportal
RPBD while 12% had an infraportal RPBD, consistent with
previous reports (6,12). An infraportal RPBD was significantly more common in donors with a variant PV than in
donors with a normal PV (p 0.0004). To our knowledge,
this study is the first to show that the RPBD course is
associated with the course and anatomy of the PV. In
addition, we found that types 2 and 3 BDs are mostly
associated with a supraportal RPBD, whereas type 4 BDs
are mostly associated with an infraportal RPBD. Yoshizumi
et al (20) reported that donors with a supraportal BD are
unsuitable candidates for right posterior sector grafts.
Another study revealed that biliary complications occurred
in 0% of grafts including the infraportal RPBD compared
with 52.6% of grafts including a short stump of the
supraportal RPBD (21). Shimizu et al (6) reported that
patients with hilar cholangiocarcinoma and an infraportal
RPBD had a greater negative margin and more secure
reconstruction than patients with a supraportal RPBD.
These results suggest that preoperative evaluation of the
RPBD course in relation to the right PV may be clinically
useful in graft selection and the management of hilar
cholangiocarcinoma. However, in some patients with a hilar
cholangiocarcinoma, it may be difficult to precisely
determine the RPBD course relative to the right PV
because of BD obstruction. Therefore, predicting the
RPBD course based on the anatomy of the PV may be
clinically useful. We analyzed the anatomical relationship
between the right posterior hepatic artery (RPHA) and the
PV in the same way as we did for the RPBD. Of 307 donors
American Journal of Transplantation 2015; 15: 155160
PV type
Type 1 PV (normal) (n 361)
Type 2 PV (trifurcation) (n 25)
Type 3 PV (RAPV from LPV) (n 19)
Type 1 BD
(normal)
(n 306)
Type 2 BD
(trifurcation)
(n 39)
Type 3 BD
(Bp into LBD)
(n 36)
Type 4 BD
(Bp into CHD)
(n 24)
80% (288/361)
40% (10/25)
42% (8/19)
7.8% (28/361)
36% (9/25)
11% (2/19)
8.0% (29/361)
8.0% (2/25)
26% (5/19)
4.3% (16/361)
16% (4/25)
21% (4/19)
PV, portal vein; RAPV, right anterior portal vein; LPV, left portal vein; BD, bile duct; Bp, bile duct branch of the right posterior sector; LBD, left
bile duct; CHD, common hepatic duct.
Normal HA (n 303)
Variant HA (n 104)
Normal BD
(n 306)
Variant BD
(n 101)
76% (230/303)
73% (76/104)
24% (73/303)
27% (28/104)
Supraportal
RPBD (n 357)
Infraportal
RPBD (n 50)
90% (325/361)
70% (32/46)
10% (36/361)
30% (14/46)
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9.
10.
Disclosure
The authors of this manuscript have no conflicts of interest
to disclose as described by the American Journal of
Transplantation.
11.
12.
13.
14.
15.
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