Combined reconstruction of the middle hepatic vein in the right lobe split liver transplantation

Combined reconstruction of the middle hepatic vein in the right lobe split liver transplantation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Combined reconstruction of the middle hepatic vein in the right lobe split liver transplantation Zhengwei Lin, Fei Feng, Qi Yu, Yingpeng Ye, Yong Yang, Hongda Zhu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5786030/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose There are few studies on the reconstruction of the middle hepatic vein (MHV) in split liver transplantation (SLT) using right lobe grafts. This study aimed to compare the outcomes of patients with MHV combined with right hepatic vein (RHV) reconstruction and those with separate reconstruction. Methods Clinical data of 114 patients who underwent SLT from March 2021 to December 2023 were retrospectively collected. We analyzed and compared the postoperative outcomes and reconstructed MHV patency between different modalities of MHV reconstruction in the right lobe SLT. Results Forty-five right lobe grafts were reconstructed with the MHV and were divided into two groups according to the type of reconstruction. Group 1 (n = 19) received separate reconstruction, while Group 2 (n = 26) received combined reconstruction. The duration of warm ischemia in Group 2 was significantly less than that in Group 1 (47.9 ± 7.8 vs. 59.7 ± 15.6 min, P = 0.002), and the ICU hospitalization time was significantly less in Group 2 than in Group 1 (2 vs. 3 days, P = 0.022). The rate of complete patency of the reconstructed MHV at 30 days postoperatively was higher in Group 2 than in Group 1 (96.2% vs. 68.4%, P = 0.031). The rates of postoperative complications were comparable between the two groups. Conclusion Combined reconstruction of the MHV and RHV in SLT improves the rate of complete patency of the reconstructed MHV, reduces warm ischemia time, and shortens the length of ICU stay. split liver transplantation middle hepatic vein right lobe patency Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction The anatomy of the liver must be appropriately managed in split liver transplantation (SLT) to ensure that both grafts have a complete vascular and biliary supply[ 1 ]. The middle hepatic vein (MHV) drains both the right and left lobes of the liver and is usually preserved in the left lobe. Consequently, a lack of MHV drainage causes congestion in the right anterior segment, leading to a decrease in functional graft volume[ 2 ]. In contrast, reconstruction of the MHV can provide more functioning liver tissue to the right lobe, which is physiologically and functionally equivalent to an extended right liver graft[ 3 ]. Although techniques for reconstructing the MHV to restore drainage continue to evolve, the method for optimal outflow reconstruction in right lobe grafts has been inconclusive to date. Most of the past studies were based on living donor liver transplantation, and the materials used to reconstruct the MHV were mostly expanded polytetrafluoroethylene (ePTFE) due to the shortage of materials and even diverse in the same study, which would limit the interpretation of the results[ 4 – 6 ]. Recently, we started to reconstruct the MHV with iliac vessels in SLT and then combined the reconstructed MHV with the right hepatic vein (RHV) to the inferior vena cava (IVC). This study aimed to assess the feasibility of combined reconstruction of the MHV using iliac vessels in SLT and to compare the postoperative outcomes with separate reconstruction. Materials and Methods Patients Clinical data of 114 patients who underwent SLT from March 2021 to December 2023 were retrospectively collected. The exclusion criteria were as follows: (1) patients with left lobe grafts; (2) patients with insufficient clinical data; (3) patients without reconstruction of the MHV; and (4) patients with extended right liver graft (Fig. 1 ). Based on the surgical method, the patients were divided into Group 1 and Group 2, with 19 patients in Group 1(MHV tributaries and the RHV anastomosed separately to the IVC) and 26 patients in Group 2(MHV tributaries and the RHV combined to anastomose to the IVC). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This research was approved by the Ethics Committee of The Affiliated Lihuili Hospital of Ningbo University (approval number:KY2024SL239). Variables and definitions The basic patient data acquired from our center's liver transplant database included age, sex, etiology, whether accompanied by liver cancer, model for end-stage liver disease (MELD) score, and Child-Pugh classification. Perioperative indicators included cold ischemia time, warm ischemia time, operation time, intraoperative bleeding, graft weight, graft to recipient weight ratio (GRWR), type of vessel grafts, number of segment 5 (V5), and segment 8 (V8) reconstructions, reconstructed MHV diameter, postoperative liver function test at 1, 3, and 7 days, postoperative complications, ICU hospitalization time, postoperative length of stay, postoperative 7 and 30days patency of the reconstructed MHV. Cold ischemia time was defined as the period from the start of graft perfusion with cold perfusate to the time the graft was taken out of the ice basin ready for implantation into the recipient. Warm ischemia time was defined as the time from the removal of the graft from the ice basin to the time of receiving reperfusion of the recipient's portal vein blood flow. Serious complications were defined as complications with a grade ≥ III according to the Clavien‒Dindo classification [ 7 ]. Reconstructed MHV occlusion was defined as the absence of blood flow on the venous phase of the abdominal contrast-enhanced computed tomography (CECT). Patency is defined as the presence of at least one patent branch of the reconstructed MHV, and complete patency is defined as the presence of blood flow in all branches of the reconstructed MHV. The patency of the reconstructed MHV was evaluated by daily Doppler ultrasound within 3 days after surgery, and abdominal CECT was performed 7 days after surgery and repeated 30 days postoperatively. Donor operation First, the gallbladder was resected, the common bile duct was ligated along the superior border of the pancreas, and the right hepatic artery and the right branch of the portal vein were exposed and slung. Intraoperative Doppler ultrasound was used to localize the MHV and its branches; the right hepatic artery and the right branch of the portal vein were clamped, and the splitting lines were marked to the right of the ischemic line. The liver was mobilized by dividing its ligaments, a retrohepatic tunnel was established, and a sling was placed on the left side of the RHV and below the bifurcation of the portal vein to traction the liver. The parenchyma was transected along the right side of the MHV using a Cavitron Ultrasonic Surgical Aspirator (CUSA), and the V5/V8 larger than 5 mm were preserved. After dissection of the parenchyma, cholangiography was performed through the severed end of the common bile duct to define the anatomy of the biliary system, and then the bile duct was dissected. Intravenous heparin was given, and the donor liver was irrigated with University of Wisconsin (UW) solution and moved to the back table. Bilateral iliac vessels were obtained from the donor for backup. Benching MHV tributaries were reconstructed using cadaveric iliac vessels. Reconstruction of the MHV branches into one Y-shaped branch (Fig. 2 A) or two separate branches (Fig. 2 B) using 6 − 0 Prolene. The reconstructed MHV was prepared to anastomose with the IVC. In Group 2, we longitudinally dissected the IVC (Fig. 2 C) and took another IVC patch to reconstruct the reconstructed MHV and the RHV combined into a triangular outflow (Fig. 2 D). In two of the patients, the MHV was split along its center (Fig. 3 A) to form two grafts each containing half of the MHV (Fig. 3 B), which were reconstructed into a complete MHV using a venous patch (Fig. 3 C), and subsequently reconstructed with the RHV to form a triangular outflow tract (Fig. 3 D). Recipient operation The diseased liver was resected after clamping the IVC with side clamps. The RHV opening of the IVC was dissected longitudinally to form an oval orifice. The iliac vessels and the donor RHV in Group 1 were separately anastomosed to the recipient IVC in an end-to-side fashion (Fig. 4 A and B). From the opening of the RHV on the IVC in Group 2, the orifices of the MHV and the left hepatic vein were clipped to the left to form a triangular opening, and the common outflow was anastomosed to the recipient IVC using a 4 − 0 Prolene (Fig. 4 C and D). The portal vein was anastomosed end-to-end with 6 − 0 Prolene, the portal vein and IVC were successively opened to restore graft perfusion, and finally, the hepatic artery and bile duct were anastomosed in an end-to-end fashion. Intraoperative Doppler ultrasound was used to detect the graft outflow. Statistical analysis The data were processed using IBM SPSS Statistics (version 26.0, IBM Corp., Armonk, NY, USA). Student's t-test was used to analyze normally distributed continuous variables, which were reported as means and standard deviation (SD). The Mann-Whitney U test was used to analyze continuous variables that were not normally distributed. These variables were reported as the median and interquartile range (IQR). Categorical variables were examined using Fisher's exact test or the Chi-squared test, and they were reported as numbers and percentages. Postoperative liver function curves were plotted using GraphPad Prism software version 9.5. Intergroup differences were deemed statistically significant when P < 0.05. Results Of the 45 patients, 41 were male and 4 were female, with a mean age of 54.2 ± 8.2 years. The etiology was mainly related to chronic viral hepatitis B, accounting for 68.4% and 73.1% of Group 1 and Group 2, respectively. It was accompanied by hepatocellular carcinoma in more than half of the recipients, 73.7% (14/19) in Group 1 and 69.2% (18/26) in Group 2. The baseline demographic of the two groups is shown in Table 1 . No statistical differences were observed between the baseline data of the two groups ( P > 0.05). Table 1 Demographic characteristics of the recipients and donors in SLT Characteristic Group1 Group2 p-Value (n = 19) (n = 26) Recipient Age, years 52.6 ± 8.8 55.3 ± 7.7 0.276 Sex, male: female 18/1 23/3 0.841 Etiology 0.330 Hepatitis B cirrhosis Hepatitis C cirrhosis Alcoholic cirrhosis 13(68.4) 1(5.3) 4(21.1) 19(73.1) 1(3.8) 1(3.8) Autoimmune hepatitis Cryptogenic 1(5.3) 0 4(15.4) 1(3.8) Accompanying HCC 14(73.7) 18(69.2) 0.745 Child-Pugh classification 0.671 A 6(31.6) 11(42.3) B 10(52.6) 10(38.5) C 3(15.8) 5(19.2) MELD score Donor 11(8–15) 12(7.75-16) 0.972 Age, years 39.7 ± 11.6 42.4 ± 11.4 0.441 Sex, male: female 17/2 24/2 1.000 Data are presented as mean ± standard deviation or median (interquartile range) or n (%). HCC, hepatocellular carcinoma; MELD, model for end stage liver disease; Warm ischemia time was significantly longer in Group 1 than in Group 2 (59.7 ± 15.6 vs. 47.9 ± 7.8min, P = 0.002). Group 1 required a longer duration of ICU stay (3 vs. 2d, P = 0.022). No statistically significant difference was observed between the two groups in terms of operative time, intraoperative bleeding, graft weight, GRWR, type of vessel grafts, number of V5 and V8 reconstructions, reconstructed MHV diameter, cold ischemia time, serious complications, and hospital stay (Table 2 ). Table 2 Intraoperative characteristics and postoperative parameters of the recipients in SLT Characteristic Group1 Group2 p-Value (n = 19) (n = 26) Operation time, min 526.1 ± 127.9 489.2 ± 88.8 0.259 Blood loss, ml 1000(600–1800) 900(750–1500) 0.826 Graft weight, g 857.6(758–1070) 952.4(852.3-1032.2) 0.605 GRWR, % 1.38 ± 0.29 1.43 ± 0.37 0.650 Type of vessel grafts Iliac vein graft Iliac artery graft 4(21.1) 15(78.9) 5(19.2) 21(80.8) 1.000 V5 reconstruction None Single Double 4(21.1) 15(78.9) 0 4(15.4) 19(73.1) 3(11.5) 0.373 V8 reconstruction None Single 3(15.8) 16(84.2) 9(34.6) 17(65.4) 0.158 Reconstructed MHV diameter, mm 9(8–12) 9(7–10) 0.384 Warm ischemia time, min 59.7 ± 15.6 47.9 ± 7.8 0.002 Cold ischemia time, min 240(210–330) 299(251-372.3) 0.206 ICU stay, days 3(2–4) 2(1-3.25) 0.022 Serious complication 6(31.6) 8(30.8) 0.954 Postoperative length of stay, days 21(14–32) 20.5(12-32.75) 0.954 Patency of the reconstructed MHV, % POD 7 Patency rate 18(94.7) 26(100) 0.422 Full patency rate 17(89.5) 26(100) 0.173 POD 30 Patency rate 17(89.5) 25(96.2) 0.788 Full patency rate 13(68.4) 25(96.2) 0.034 Data are presented as mean ± standard deviation or median (interquartile range) or n (%). GRWR, graft to recipient weight ratio; MHV, middle hepatic vein; ICU, intensive care unit; The incidence of serious postoperative complications in Group 1 was 31.6% (6/19), including one case of intestinal perforation, which was treated with reoperation; two cases of biliary anastomotic stenosis, treated with interventional therapy; one case of gastrointestinal hemorrhage, treated with gastroscopy, but died after complication of multiorgan failure; and two cases of abdominal hemorrhage treated by reoperation. The incidence of serious complications in Group 2 was 30.8% (8/26). Four cases of abdominal hemorrhage were re-treated surgically, including one case each of bleeding from the vessels of the lesser curvature of the stomach and the greater curvature of the stomach, one case of perforated bleeding from a gastric ulcer combined with cardiac failure that led to the patient's death and one case of bleeding from the anastomosis of the hepatic artery; one case of gastric retention was treated by endoscopic placement of an enteral nutritional tube; one case of choledochal necrosis that led to a bile leakage was treated by choledochoenteric anastomosis; one case of biliary anastomotic stenosis was treated with interventional therapy; and one case of acute renal failure was treated with hemodialysis. Most liver function indexes peaked on POD 1 and then gradually decreased. POD 1, 3, and 7 aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (TBIL), and international normalized ratio of prothrombin time (PT-INR) showed no statistically significant differences between the two groups (Fig. 5 ). The patency rate of reconstructed MHV at POD 7 was 94.7% in Group 1 and 100% in Group 2 ( P = 0.422), and the complete patency rate was 89.5% and 100%, respectively ( P = 0.173). The patency rate of the reconstructed MHV at POD 30 was 89.5% in Group 1 and 96.2% in Group 2 ( P = 0.788), and the complete patency rate was 68.4% and 96.2%, respectively ( P = 0.034). In most patients, blood flow was visible in the reconstructed MHV on postoperative CECT (Fig. 6 A). In contrast, when the reconstructed MHV was completely obstructed, the right anterior segment often showed severe congestion (Fig. 6 B). Discussion A right lobe without an MHV often experiences right anterior segment congestion, which can lead to severe graft dysfunction and septic complications[ 8 ]. Reconstruction of MHV tributaries to restore drainage to the right anterior segment used to be considered time-consuming and added to the complexity of liver transplantation until Lee et al.[ 9 ] reconstructed all V5 and V8 larger than 5 mm with favorable results. Current studies have shown that right anterior segment regeneration in right lobe grafts with reconstructed MHV is significant compared to that without MHV reconstructed[ 10 , 11 ] and improves the survival of the recipients[ 12 ]. However, no consensus exists on the standard technique for outflow reconstruction. In this study, combined reconstruction of MHV and RHV increases the rate of complete patency of the reconstructed MHV at POD 30 and reduces warm ischemia time contributing to postoperative recovery. Furthermore, to the best of our knowledge, this is the first study comparing two different outflow reconstruction modalities in SLT using right lobe grafts. Most centers have adopted separate reconstruction of the RHV and V5/V8 for those who need to reconstruct the MHV, influenced by living donor liver transplantation. However, some studies have reported that the graft will regenerate in all directions after implantation in the recipient's right subphrenic, and due to the lack of space in the right subphrenic, the liver will regenerate mainly to the left and ventral side, the enlarged graft will compress the IVC and anastomosis of the RHV from the dorsal side will result in outflow obstruction[ 13 ]. Furthermore, an enlarged graft will result in kinking and angulation of the reconstructed MHV, leading to occlusion of the MHV tributaries. To overcome these problems, Ito et al.[ 14 ] sutured the MHV tributaries, the RHV, and the inferior right hepatic vein to a homologous IVC patch and performed a side-to-side anastomosis with the recipient IVC to form a double vena cava. The additional vena cava was able to tolerate compression from liver regeneration and surrounding tissues. Their other approach is to anastomose the reconstructed MHV to the donor RHV to form a common orifice and then to suture it to a vein patch to form the anterior wall of the IVC. Both techniques use enlargement of the outflow tract to relieve external compression. Kim et al.[ 15 ] reconstructed the MHV with an ePTFE before anastomosing it to the RHV and suturing a long saphenous vein patch around the common outflow, which can offset the distortion caused by graft regeneration and effectively enlarge the outflow. In this study, cadaveric iliac vessels were used to reconstruct the MHV tributaries and then anastomosed with the donor RHV to form a common outflow and to make the anastomosis in a triangular shape (Fig. 4 D), which is less prone to be twisted and narrowed compared to the original linear anastomosis (Fig. 4 B), and without the need for additional patches or artificial vessels. Combined reconstruction of the RHV with MHV tributaries enlarges the outflow, mimicking the natural venous outflow and creating physiologic laminar flow, thereby improving the postoperative prognosis[ 16 ]. In the present study, AST and ALT were lower in postoperative Group 2 as compared to Group 1, although the difference was not statistically significant. The ICU stay was also shorter in Group 2, suggesting that combined reconstruction of the outflow may be beneficial for postoperative recovery. Right lobe graft outflow reconstruction is performed in a narrow and deep-in space. Excessive anastomosis operations will lead to prolonged warm ischemia time, aggravate ischemia-reperfusion injury, and affect the recovery of graft function in the early postoperative period. Most of the anastomotic procedures in Group 2 were completed on the back table, effectively reducing the warm ischemia time. Our study showed that the warm ischemia time was significantly shorter in Group 2 (47.9 ± 7.8 vs. 59.7 ± 15.6min, P = 0.002), while the cold ischemia time was not significantly prolonged. Early patency of the reconstructed MHV seems to be of greater concern than long-term patency, and 1 to 2 weeks of patency of the reconstructed MHV is sufficient for graft function, as intrahepatic collateral circulation will be established in approximately 1 week postoperatively[ 9 , 17 ]. The patency rates of the reconstructed MHV at POD 7 were 94.7% and 100% ( P = 0.422) in Groups 1 and 2 in this study; the complete patency rates were 89.5% and 100% ( P = 0.173), respectively. The patency rates were similar to those reported in other studies[ 16 , 18 ]. The patency rates at POD 30 were 89.5% and 96.2% ( P = 0.565) for Groups 1 and 2, and 68.4% and 96.2% ( P = 0.031) for complete patency, respectively. The rate of complete patency was significantly higher in Group 2 than in Group 1 at POD 30. We observed more V5 occlusion in Group 1, probably due to the fact that V5 is usually longer than V8 and undergoes distortion and angulation after liver regeneration, resulting in slower blood flow and gradual occlusion of the vessel, whereas in Group 2, the outflow tracts were reconstructed into triangular shapes and enlarged the outflow tracts, thus effectively increasing the rate of complete patency. As to how to improve the patency of the reconstructed MHV in right lobe transplantation, we also explored the technique of splitting the MHV, which preserves all the tiny branches on the MHV, and theoretically, it seems to be more favorable to the drainage of the right anterior segment of the liver (Fig. 3 B); meanwhile, with the splitting of the MHV in this way, the reconstructed MHV and the RHV are also made into a common opening, which may be more favorable to the patency after liver regeneration; however, at present, the sample size is still small, and we will make another comparison in a future study. There are several limitations to this study. This was a retrospective and small-sample study. Owing to this, the liver function did not show significant differences between the two groups postoperatively. Moreover, the number of patients was too small, limiting the study further. Further prospective randomized controlled studies are still needed to validate our findings. Conclusion In conclusion, combined RHV and MHV reconstruction of the outflow increases the rate of complete patency of the reconstructed MHV in the early postoperative period, shortens the warm ischemia time, facilitates postoperative recovery, improves the patient's prognosis, and provides more choices for the reconstruction of the right lobe graft outflow in SLT. Declarations Conflict of interest The authors declare no competing interests. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of The Affiliated Lihuili Hospital of Ningbo University (approval number: KY2024SL239), and individual consent for this retrospective analysis was waived. Funding This work was supported partly by the following funding: Ningbo Public Welfare Science and Technology Plan Project (2024S155). Author Contribution Z.L. and J.F. participated in the conception and design of the research. All authors participated in the acquisition of the data. Z.L., Y.Y., and H.Z. participated in the analysis and interpretation of the data. Z.L. participated in the writing of the paper. All authors participated in the revision and final approval of the manuscript. Acknowledgement This work was supported by the Ningbo Public Welfare Science and Technology Plan Project (2024S155). Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author on reason able request. References Chaib E, Ribeiro MA Jr., Saad WA, Gama-Rodrigues J (2005) The main hepatic anatomic variations for the purpose of split-liver transplantation. 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Liver Transpl 13(8):1159–1167. https://doi.org/10.1002/lt.21213 Durairaj MS, Shaji Mathew J, Mallick S, Nair K, Manikandan K, Titus Varghese C et al (2021) Middle hepatic vein reconstruction in adult living donor liver transplantation: a randomized clinical trial. Br J Surg 108(12):1426–1432. https://doi.org/10.1093/bjs/znab346 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5786030","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401816323,"identity":"24be55d3-abbe-4480-a571-fb5bcb7340f0","order_by":0,"name":"Zhengwei Lin","email":"","orcid":"","institution":"The Affiliated Lihuili Hospital of Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Zhengwei","middleName":"","lastName":"Lin","suffix":""},{"id":401816324,"identity":"ee3b0e85-d39a-43f7-9818-6ecdfa9c2ae5","order_by":1,"name":"Fei Feng","email":"","orcid":"","institution":"The Affiliated Lihuili Hospital of Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Feng","suffix":""},{"id":401816325,"identity":"f8af572c-f716-4cf1-a490-0093e9da564e","order_by":2,"name":"Qi Yu","email":"","orcid":"","institution":"The Affiliated Lihuili Hospital of Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Qi","middleName":"","lastName":"Yu","suffix":""},{"id":401816326,"identity":"4079732f-f546-4be3-81d3-59f8e660609e","order_by":3,"name":"Yingpeng Ye","email":"","orcid":"","institution":"The Affiliated Lihuili Hospital of Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Yingpeng","middleName":"","lastName":"Ye","suffix":""},{"id":401816327,"identity":"e601e41e-c65b-4fcd-bf4a-0bb44567cdd0","order_by":4,"name":"Yong Yang","email":"","orcid":"","institution":"The Affiliated Lihuili Hospital of Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Yang","suffix":""},{"id":401816328,"identity":"e095ec64-4940-4b59-821b-c42721d0419b","order_by":5,"name":"Hongda Zhu","email":"","orcid":"","institution":"The Affiliated Lihuili Hospital of Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Hongda","middleName":"","lastName":"Zhu","suffix":""},{"id":401816329,"identity":"ffe4a753-2df5-42ec-b260-d44991255450","order_by":6,"name":"Caide Lu","email":"","orcid":"","institution":"The Affiliated Lihuili Hospital of Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Caide","middleName":"","lastName":"Lu","suffix":""},{"id":401816330,"identity":"a3797f22-7cd5-4d17-8cfd-39f09312ea94","order_by":7,"name":"Jiongze Fang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBAC9gYgIWEAZjM+ABI8fIS08BxAaGEGUTxsRGmBAjYJMElQC/vZwy8sCmzy5P0PH6v8mmMnw8bA/PDRDXxaePLSLCQM0ooNDxxLuy27LRnoMDZj4xw8WuwZcswMJAwOJ25s7DG7LbmNGaiFh00anxYe/jdQLc3834olt9UToUUix/gBSMt8Nh42xo/bDhOj5Y0ZMJDTEjfwsBlLM247zsPGTMAvPPw5xp8l/tgkzu8//PDjz23V9vzszQ8f49MCBGzSoPgwOACMSx4Qnxm/crCSjx+ApHwDMMX8IKx6FIyCUTAKRiAAAG4lQhoL+aWkAAAAAElFTkSuQmCC","orcid":"","institution":"The Affiliated Lihuili Hospital of Ningbo University","correspondingAuthor":true,"prefix":"","firstName":"Jiongze","middleName":"","lastName":"Fang","suffix":""}],"badges":[],"createdAt":"2025-01-08 06:08:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5786030/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5786030/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73867761,"identity":"90cf1f2a-85fb-4cad-953b-e351ffaa5de9","added_by":"auto","created_at":"2025-01-15 12:01:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":222902,"visible":true,"origin":"","legend":"\u003cp\u003eThe patients flow in this study\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5786030/v1/2867cb1e3cc0142f7bab3e60.png"},{"id":73867763,"identity":"d5e2163f-440f-46e5-bad2-d2070bf32884","added_by":"auto","created_at":"2025-01-15 12:01:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":751415,"visible":true,"origin":"","legend":"\u003cp\u003eReconstruction of the middle hepatic vein in the right lobe liver (\u003cstrong\u003eA\u003c/strong\u003e) Reconstruction of the middle hepatic vein with Y-shaped vessel; (\u003cstrong\u003eB\u003c/strong\u003e) Reconstruction of the middle hepatic vein with linear vessels; (\u003cstrong\u003eC\u003c/strong\u003e) Incision of inferior vena cava; (\u003cstrong\u003eD\u003c/strong\u003e) Reconstructed middle hepatic vein and right hepatic vein form a common outflow\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5786030/v1/d218c58a690d109e0595dd55.png"},{"id":73867762,"identity":"4ce2519a-1f64-4906-8dcd-48964ea50708","added_by":"auto","created_at":"2025-01-15 12:01:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":885708,"visible":true,"origin":"","legend":"\u003cp\u003eReconstruction of the outflow by use of a split middle hepatic vein (\u003cstrong\u003eA\u003c/strong\u003e) Clipping the posterior wall of the middle hepatic vein; (\u003cstrong\u003eB\u003c/strong\u003e) Acquire two grafts with half of the middle hepatic vein; (\u003cstrong\u003eC\u003c/strong\u003e) Reconstruction into two grafts with intact middle hepatic vein; (\u003cstrong\u003eD\u003c/strong\u003e) Completion of reconstruction of outflow\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5786030/v1/04259a8dcae6cf5d05c6db7f.png"},{"id":73867767,"identity":"e5f764de-3e02-4d39-82fe-05d9f0472b6e","added_by":"auto","created_at":"2025-01-15 12:01:06","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":581361,"visible":true,"origin":"","legend":"\u003cp\u003eRight lobe graft implantation with different types of outflow tract reconstruction (\u003cstrong\u003eA\u003c/strong\u003e) Schematic illustration of right lobe graft implantation in group 1; (\u003cstrong\u003eB\u003c/strong\u003e) End-to-side anastomosis of the right hepatic vein to the inferior vena cava; (\u003cstrong\u003eC\u003c/strong\u003e) Schematic illustration of right lobe graft implantation in group 2; (\u003cstrong\u003eD\u003c/strong\u003e) Anastomosis of a triangular outflow over the inferior vena cava\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-5786030/v1/84279c4907b7637ae35c6647.png"},{"id":73867768,"identity":"516bbc2e-fc17-4fe1-88bb-3e021a558d62","added_by":"auto","created_at":"2025-01-15 12:01:06","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":275578,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative liver function tests in the recipients\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-5786030/v1/340c2211f0b1a674a04b71e6.png"},{"id":73869290,"identity":"e94fb2b1-b489-4d8a-83e8-60620145ef78","added_by":"auto","created_at":"2025-01-15 12:09:07","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":268722,"visible":true,"origin":"","legend":"\u003cp\u003eReconstructed middle hepatic vein patency assessed by contrast-enhanced CT (\u003cstrong\u003eA\u003c/strong\u003e) A patient with reconstructed middle hepatic vein (arrow) patency on CT 30 days after surgery; (\u003cstrong\u003eB\u003c/strong\u003e) A patient with reconstructed middle hepatic vein obstruction with right anterior lobe congestion (arrow) 7 days after surgery\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-5786030/v1/cab5841f5e68089f279fb086.png"},{"id":73871756,"identity":"94c7606e-16a6-46d9-9ee1-de08f842cfed","added_by":"auto","created_at":"2025-01-15 12:25:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3608830,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5786030/v1/7949f46d-60c9-4781-ab46-6ea10a1cbf98.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Combined reconstruction of the middle hepatic vein in the right lobe split liver transplantation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe anatomy of the liver must be appropriately managed in split liver transplantation (SLT) to ensure that both grafts have a complete vascular and biliary supply[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The middle hepatic vein (MHV) drains both the right and left lobes of the liver and is usually preserved in the left lobe. Consequently, a lack of MHV drainage causes congestion in the right anterior segment, leading to a decrease in functional graft volume[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In contrast, reconstruction of the MHV can provide more functioning liver tissue to the right lobe, which is physiologically and functionally equivalent to an extended right liver graft[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough techniques for reconstructing the MHV to restore drainage continue to evolve, the method for optimal outflow reconstruction in right lobe grafts has been inconclusive to date. Most of the past studies were based on living donor liver transplantation, and the materials used to reconstruct the MHV were mostly expanded polytetrafluoroethylene (ePTFE) due to the shortage of materials and even diverse in the same study, which would limit the interpretation of the results[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Recently, we started to reconstruct the MHV with iliac vessels in SLT and then combined the reconstructed MHV with the right hepatic vein (RHV) to the inferior vena cava (IVC). This study aimed to assess the feasibility of combined reconstruction of the MHV using iliac vessels in SLT and to compare the postoperative outcomes with separate reconstruction.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eClinical data of 114 patients who underwent SLT from March 2021 to December 2023 were retrospectively collected. The exclusion criteria were as follows: (1) patients with left lobe grafts; (2) patients with insufficient clinical data; (3) patients without reconstruction of the MHV; and (4) patients with extended right liver graft (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Based on the surgical method, the patients were divided into Group 1 and Group 2, with 19 patients in Group 1(MHV tributaries and the RHV anastomosed separately to the IVC) and 26 patients in Group 2(MHV tributaries and the RHV combined to anastomose to the IVC). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This research was approved by the Ethics Committee of The Affiliated Lihuili Hospital of Ningbo University (approval number:KY2024SL239).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVariables and definitions\u003c/h3\u003e\n\u003cp\u003eThe basic patient data acquired from our center's liver transplant database included age, sex, etiology, whether accompanied by liver cancer, model for end-stage liver disease (MELD) score, and Child-Pugh classification. Perioperative indicators included cold ischemia time, warm ischemia time, operation time, intraoperative bleeding, graft weight, graft to recipient weight ratio (GRWR), type of vessel grafts, number of segment 5 (V5), and segment 8 (V8) reconstructions, reconstructed MHV diameter, postoperative liver function test at 1, 3, and 7 days, postoperative complications, ICU hospitalization time, postoperative length of stay, postoperative 7 and 30days patency of the reconstructed MHV. Cold ischemia time was defined as the period from the start of graft perfusion with cold perfusate to the time the graft was taken out of the ice basin ready for implantation into the recipient. Warm ischemia time was defined as the time from the removal of the graft from the ice basin to the time of receiving reperfusion of the recipient's portal vein blood flow. Serious complications were defined as complications with a grade\u0026thinsp;\u0026ge;\u0026thinsp;III according to the Clavien‒Dindo classification [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Reconstructed MHV occlusion was defined as the absence of blood flow on the venous phase of the abdominal contrast-enhanced computed tomography (CECT). Patency is defined as the presence of at least one patent branch of the reconstructed MHV, and complete patency is defined as the presence of blood flow in all branches of the reconstructed MHV. The patency of the reconstructed MHV was evaluated by daily Doppler ultrasound within 3 days after surgery, and abdominal CECT was performed 7 days after surgery and repeated 30 days postoperatively.\u003c/p\u003e\n\u003ch3\u003eDonor operation\u003c/h3\u003e\n\u003cp\u003eFirst, the gallbladder was resected, the common bile duct was ligated along the superior border of the pancreas, and the right hepatic artery and the right branch of the portal vein were exposed and slung. Intraoperative Doppler ultrasound was used to localize the MHV and its branches; the right hepatic artery and the right branch of the portal vein were clamped, and the splitting lines were marked to the right of the ischemic line. The liver was mobilized by dividing its ligaments, a retrohepatic tunnel was established, and a sling was placed on the left side of the RHV and below the bifurcation of the portal vein to traction the liver. The parenchyma was transected along the right side of the MHV using a Cavitron Ultrasonic Surgical Aspirator (CUSA), and the V5/V8 larger than 5 mm were preserved. After dissection of the parenchyma, cholangiography was performed through the severed end of the common bile duct to define the anatomy of the biliary system, and then the bile duct was dissected. Intravenous heparin was given, and the donor liver was irrigated with University of Wisconsin (UW) solution and moved to the back table. Bilateral iliac vessels were obtained from the donor for backup.\u003c/p\u003e\n\u003ch3\u003eBenching\u003c/h3\u003e\n\u003cp\u003eMHV tributaries were reconstructed using cadaveric iliac vessels. Reconstruction of the MHV branches into one Y-shaped branch (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA) or two separate branches (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB) using 6\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene. The reconstructed MHV was prepared to anastomose with the IVC. In Group 2, we longitudinally dissected the IVC (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC) and took another IVC patch to reconstruct the reconstructed MHV and the RHV combined into a triangular outflow (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). In two of the patients, the MHV was split along its center (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA) to form two grafts each containing half of the MHV (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB), which were reconstructed into a complete MHV using a venous patch (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC), and subsequently reconstructed with the RHV to form a triangular outflow tract (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD).\u003c/p\u003e\n\u003ch3\u003eRecipient operation\u003c/h3\u003e\n\u003cp\u003eThe diseased liver was resected after clamping the IVC with side clamps. The RHV opening of the IVC was dissected longitudinally to form an oval orifice. The iliac vessels and the donor RHV in Group 1 were separately anastomosed to the recipient IVC in an end-to-side fashion (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA and B). From the opening of the RHV on the IVC in Group 2, the orifices of the MHV and the left hepatic vein were clipped to the left to form a triangular opening, and the common outflow was anastomosed to the recipient IVC using a 4\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC and D). The portal vein was anastomosed end-to-end with 6\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene, the portal vein and IVC were successively opened to restore graft perfusion, and finally, the hepatic artery and bile duct were anastomosed in an end-to-end fashion. Intraoperative Doppler ultrasound was used to detect the graft outflow.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were processed using IBM SPSS Statistics (version 26.0, IBM Corp., Armonk, NY, USA). Student's t-test was used to analyze normally distributed continuous variables, which were reported as means and standard deviation (SD). The Mann-Whitney U test was used to analyze continuous variables that were not normally distributed. These variables were reported as the median and interquartile range (IQR). Categorical variables were examined using Fisher's exact test or the Chi-squared test, and they were reported as numbers and percentages. Postoperative liver function curves were plotted using GraphPad Prism software version 9.5. Intergroup differences were deemed statistically significant when \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 45 patients, 41 were male and 4 were female, with a mean age of 54.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 years. The etiology was mainly related to chronic viral hepatitis B, accounting for 68.4% and 73.1% of Group 1 and Group 2, respectively. It was accompanied by hepatocellular carcinoma in more than half of the recipients, 73.7% (14/19) in Group 1 and 69.2% (18/26) in Group 2. The baseline demographic of the two groups is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. No statistical differences were observed between the baseline data of the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of the recipients and donors in SLT\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep-Value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecipient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male: female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.841\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis B cirrhosis\u003c/p\u003e \u003cp\u003eHepatitis C cirrhosis\u003c/p\u003e \u003cp\u003eAlcoholic cirrhosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(68.4)\u003c/p\u003e \u003cp\u003e1(5.3)\u003c/p\u003e \u003cp\u003e4(21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(73.1)\u003c/p\u003e \u003cp\u003e1(3.8)\u003c/p\u003e \u003cp\u003e1(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutoimmune hepatitis\u003c/p\u003e \u003cp\u003eCryptogenic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(5.3)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(15.4)\u003c/p\u003e \u003cp\u003e1(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccompanying HCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(73.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild-Pugh classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD score\u003c/p\u003e \u003cp\u003eDonor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(8\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(7.75-16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.972\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male: female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range) or n (%). HCC, hepatocellular carcinoma; MELD, model for end stage liver disease;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWarm ischemia time was significantly longer in Group 1 than in Group 2 (59.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6 vs. 47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8min, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Group 1 required a longer duration of ICU stay (3 vs. 2d, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.022). No statistically significant difference was observed between the two groups in terms of operative time, intraoperative bleeding, graft weight, GRWR, type of vessel grafts, number of V5 and V8 reconstructions, reconstructed MHV diameter, cold ischemia time, serious complications, and hospital stay (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative characteristics and postoperative parameters of the recipients in SLT\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep-Value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e526.1\u0026thinsp;\u0026plusmn;\u0026thinsp;127.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e489.2\u0026thinsp;\u0026plusmn;\u0026thinsp;88.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.259\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1000(600\u0026ndash;1800)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e900(750\u0026ndash;1500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraft weight, g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e857.6(758\u0026ndash;1070)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e952.4(852.3-1032.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGRWR, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.650\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of vessel grafts\u003c/p\u003e \u003cp\u003eIliac vein graft\u003c/p\u003e \u003cp\u003eIliac artery graft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(21.1)\u003c/p\u003e \u003cp\u003e15(78.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(19.2)\u003c/p\u003e \u003cp\u003e21(80.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eV5 reconstruction\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eSingle\u003c/p\u003e \u003cp\u003eDouble\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003e4(21.1)\u003c/p\u003e \u003cp\u003e15(78.9)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003e4(15.4)\u003c/p\u003e \u003cp\u003e19(73.1)\u003c/p\u003e \u003cp\u003e3(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003e0.373\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eV8 reconstruction\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003e3(15.8)\u003c/p\u003e \u003cp\u003e16(84.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003e9(34.6)\u003c/p\u003e \u003cp\u003e17(65.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026nbsp;\u003c/p\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReconstructed MHV diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(8\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(7\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.384\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWarm ischemia time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCold ischemia time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e240(210\u0026ndash;330)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e299(251-372.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU stay, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(1-3.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerious complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative length of stay, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21(14\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.5(12-32.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatency of the reconstructed MHV, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOD 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatency rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18(94.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull patency rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOD 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatency rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(96.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.788\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull patency rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(96.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range) or n (%). GRWR, graft to recipient weight ratio; MHV, middle hepatic vein; ICU, intensive care unit;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe incidence of serious postoperative complications in Group 1 was 31.6% (6/19), including one case of intestinal perforation, which was treated with reoperation; two cases of biliary anastomotic stenosis, treated with interventional therapy; one case of gastrointestinal hemorrhage, treated with gastroscopy, but died after complication of multiorgan failure; and two cases of abdominal hemorrhage treated by reoperation. The incidence of serious complications in Group 2 was 30.8% (8/26). Four cases of abdominal hemorrhage were re-treated surgically, including one case each of bleeding from the vessels of the lesser curvature of the stomach and the greater curvature of the stomach, one case of perforated bleeding from a gastric ulcer combined with cardiac failure that led to the patient's death and one case of bleeding from the anastomosis of the hepatic artery; one case of gastric retention was treated by endoscopic placement of an enteral nutritional tube; one case of choledochal necrosis that led to a bile leakage was treated by choledochoenteric anastomosis; one case of biliary anastomotic stenosis was treated with interventional therapy; and one case of acute renal failure was treated with hemodialysis.\u003c/p\u003e \u003cp\u003eMost liver function indexes peaked on POD 1 and then gradually decreased. POD 1, 3, and 7 aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (TBIL), and international normalized ratio of prothrombin time (PT-INR) showed no statistically significant differences between the two groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The patency rate of reconstructed MHV at POD 7 was 94.7% in Group 1 and 100% in Group 2 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.422), and the complete patency rate was 89.5% and 100%, respectively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.173). The patency rate of the reconstructed MHV at POD 30 was 89.5% in Group 1 and 96.2% in Group 2 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.788), and the complete patency rate was 68.4% and 96.2%, respectively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.034). In most patients, blood flow was visible in the reconstructed MHV on postoperative CECT (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eA). In contrast, when the reconstructed MHV was completely obstructed, the right anterior segment often showed severe congestion (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA right lobe without an MHV often experiences right anterior segment congestion, which can lead to severe graft dysfunction and septic complications[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Reconstruction of MHV tributaries to restore drainage to the right anterior segment used to be considered time-consuming and added to the complexity of liver transplantation until Lee et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reconstructed all V5 and V8 larger than 5 mm with favorable results. Current studies have shown that right anterior segment regeneration in right lobe grafts with reconstructed MHV is significant compared to that without MHV reconstructed[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and improves the survival of the recipients[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, no consensus exists on the standard technique for outflow reconstruction. In this study, combined reconstruction of MHV and RHV increases the rate of complete patency of the reconstructed MHV at POD 30 and reduces warm ischemia time contributing to postoperative recovery. Furthermore, to the best of our knowledge, this is the first study comparing two different outflow reconstruction modalities in SLT using right lobe grafts.\u003c/p\u003e \u003cp\u003eMost centers have adopted separate reconstruction of the RHV and V5/V8 for those who need to reconstruct the MHV, influenced by living donor liver transplantation. However, some studies have reported that the graft will regenerate in all directions after implantation in the recipient's right subphrenic, and due to the lack of space in the right subphrenic, the liver will regenerate mainly to the left and ventral side, the enlarged graft will compress the IVC and anastomosis of the RHV from the dorsal side will result in outflow obstruction[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Furthermore, an enlarged graft will result in kinking and angulation of the reconstructed MHV, leading to occlusion of the MHV tributaries. To overcome these problems, Ito et al.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] sutured the MHV tributaries, the RHV, and the inferior right hepatic vein to a homologous IVC patch and performed a side-to-side anastomosis with the recipient IVC to form a double vena cava. The additional vena cava was able to tolerate compression from liver regeneration and surrounding tissues. Their other approach is to anastomose the reconstructed MHV to the donor RHV to form a common orifice and then to suture it to a vein patch to form the anterior wall of the IVC. Both techniques use enlargement of the outflow tract to relieve external compression. Kim et al.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reconstructed the MHV with an ePTFE before anastomosing it to the RHV and suturing a long saphenous vein patch around the common outflow, which can offset the distortion caused by graft regeneration and effectively enlarge the outflow. In this study, cadaveric iliac vessels were used to reconstruct the MHV tributaries and then anastomosed with the donor RHV to form a common outflow and to make the anastomosis in a triangular shape (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eD), which is less prone to be twisted and narrowed compared to the original linear anastomosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB), and without the need for additional patches or artificial vessels. Combined reconstruction of the RHV with MHV tributaries enlarges the outflow, mimicking the natural venous outflow and creating physiologic laminar flow, thereby improving the postoperative prognosis[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the present study, AST and ALT were lower in postoperative Group 2 as compared to Group 1, although the difference was not statistically significant. The ICU stay was also shorter in Group 2, suggesting that combined reconstruction of the outflow may be beneficial for postoperative recovery.\u003c/p\u003e \u003cp\u003eRight lobe graft outflow reconstruction is performed in a narrow and deep-in space. Excessive anastomosis operations will lead to prolonged warm ischemia time, aggravate ischemia-reperfusion injury, and affect the recovery of graft function in the early postoperative period. Most of the anastomotic procedures in Group 2 were completed on the back table, effectively reducing the warm ischemia time. Our study showed that the warm ischemia time was significantly shorter in Group 2 (47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 vs. 59.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6min, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), while the cold ischemia time was not significantly prolonged.\u003c/p\u003e \u003cp\u003eEarly patency of the reconstructed MHV seems to be of greater concern than long-term patency, and 1 to 2 weeks of patency of the reconstructed MHV is sufficient for graft function, as intrahepatic collateral circulation will be established in approximately 1 week postoperatively[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The patency rates of the reconstructed MHV at POD 7 were 94.7% and 100% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.422) in Groups 1 and 2 in this study; the complete patency rates were 89.5% and 100% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.173), respectively. The patency rates were similar to those reported in other studies[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The patency rates at POD 30 were 89.5% and 96.2% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.565) for Groups 1 and 2, and 68.4% and 96.2% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031) for complete patency, respectively. The rate of complete patency was significantly higher in Group 2 than in Group 1 at POD 30. We observed more V5 occlusion in Group 1, probably due to the fact that V5 is usually longer than V8 and undergoes distortion and angulation after liver regeneration, resulting in slower blood flow and gradual occlusion of the vessel, whereas in Group 2, the outflow tracts were reconstructed into triangular shapes and enlarged the outflow tracts, thus effectively increasing the rate of complete patency.\u003c/p\u003e \u003cp\u003eAs to how to improve the patency of the reconstructed MHV in right lobe transplantation, we also explored the technique of splitting the MHV, which preserves all the tiny branches on the MHV, and theoretically, it seems to be more favorable to the drainage of the right anterior segment of the liver (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB); meanwhile, with the splitting of the MHV in this way, the reconstructed MHV and the RHV are also made into a common opening, which may be more favorable to the patency after liver regeneration; however, at present, the sample size is still small, and we will make another comparison in a future study.\u003c/p\u003e \u003cp\u003eThere are several limitations to this study. This was a retrospective and small-sample study. Owing to this, the liver function did not show significant differences between the two groups postoperatively. Moreover, the number of patients was too small, limiting the study further. Further prospective randomized controlled studies are still needed to validate our findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, combined RHV and MHV reconstruction of the outflow increases the rate of complete patency of the reconstructed MHV in the early postoperative period, shortens the warm ischemia time, facilitates postoperative recovery, improves the patient's prognosis, and provides more choices for the reconstruction of the right lobe graft outflow in SLT.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of The Affiliated Lihuili Hospital of Ningbo University (approval number: KY2024SL239), and individual consent for this retrospective analysis was waived.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported partly by the following funding: Ningbo Public Welfare Science and Technology Plan Project (2024S155).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZ.L. and J.F. participated in the conception and design of the research. All authors participated in the acquisition of the data. Z.L., Y.Y., and H.Z. participated in the analysis and interpretation of the data. Z.L. participated in the writing of the paper. All authors participated in the revision and final approval of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis work was supported by the Ningbo Public Welfare Science and Technology Plan Project (2024S155).\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reason able request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChaib E, Ribeiro MA Jr., Saad WA, Gama-Rodrigues J (2005) The main hepatic anatomic variations for the purpose of split-liver transplantation. Transplant Proc. ;37(2):1063-6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.transproceed.2004.11.054\u003c/span\u003e\u003cspan address=\"10.1016/j.transproceed.2004.11.054\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSakamoto K, Ogawa K, Tamura K, Ito C, Iwata M, Sakamoto A et al (2022) Importance of reconstruction of middle hepatic vein tributaries of right-lobe grafts in living donor liver transplantation: demonstration of the reconstruction technique. 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Br J Surg 108(12):1426\u0026ndash;1432. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/bjs/znab346\u003c/span\u003e\u003cspan address=\"10.1093/bjs/znab346\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"split liver transplantation, middle hepatic vein, right lobe, patency","lastPublishedDoi":"10.21203/rs.3.rs-5786030/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5786030/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThere are few studies on the reconstruction of the middle hepatic vein (MHV) in split liver transplantation (SLT) using right lobe grafts. This study aimed to compare the outcomes of patients with MHV combined with right hepatic vein (RHV) reconstruction and those with separate reconstruction.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eClinical data of 114 patients who underwent SLT from March 2021 to December 2023 were retrospectively collected. We analyzed and compared the postoperative outcomes and reconstructed MHV patency between different modalities of MHV reconstruction in the right lobe SLT.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eForty-five right lobe grafts were reconstructed with the MHV and were divided into two groups according to the type of reconstruction. Group 1 (n\u0026thinsp;=\u0026thinsp;19) received separate reconstruction, while Group 2 (n\u0026thinsp;=\u0026thinsp;26) received combined reconstruction. The duration of warm ischemia in Group 2 was significantly less than that in Group 1 (47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 vs. 59.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6 min, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), and the ICU hospitalization time was significantly less in Group 2 than in Group 1 (2 vs. 3 days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.022). The rate of complete patency of the reconstructed MHV at 30 days postoperatively was higher in Group 2 than in Group 1 (96.2% vs. 68.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031). The rates of postoperative complications were comparable between the two groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCombined reconstruction of the MHV and RHV in SLT improves the rate of complete patency of the reconstructed MHV, reduces warm ischemia time, and shortens the length of ICU stay.\u003c/p\u003e","manuscriptTitle":"Combined reconstruction of the middle hepatic vein in the right lobe split liver transplantation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 12:01:01","doi":"10.21203/rs.3.rs-5786030/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"64f52153-5c38-4f60-a541-35dfd525bb18","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-15T12:01:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-15 12:01:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5786030","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5786030","identity":"rs-5786030","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}