AJR 2003; 181:1133-1138
© American Roentgen Ray Society
Spectrum of Imaging Findings After Pediatric Liver Transplantation: Part 1, Posttransplantation Anatomy
Karin M. Unsinn1,2,
Martin C. Freund2,
Helmut Ellemunter1,
Ruth Ladurner3,
Ingmar Gassner1,
Alfred Koenigsrainer3 and
Werner R. Jaschke2
1 Department of Pediatrics, Leopold-Franzens University, Anichstr. 35, Innsbruck
A-6020, Austria.
2 Department of Radiology, Leopold-Franzens University, Innsbruck A-6020,
Austria.
3 Department of Surgery, Leopold-Franzens University, Innsbruck A-6020,
Austria.
Received December 16, 2002;
accepted after revision February 14, 2003.
Address correspondence to K. M. Unsinn.
Introduction
Liver transplantation is the only treatment for end-stage liver
disease in infants and children. The volume of liver required for
transplantation depends on the age of the infant or child undergoing the
procedure. The number of whole pediatric livers available for transplanting
into young children, especially those younger than 2 years, is limited because
of the low death rate in this age group.
Segmental liver transplantation reduces mortality among children waiting
for an appropriately sized liver to become available. In most instances, left
lateral segments (II and III) can be obtained by splitting the liver of either
an adult cadaver or a living related donor. For standard liver
transplantation, the recipient's and donor's common hepatic artery, portal
vein, hepatic veins, and inferior vena cava must be patent. The most commonly
performed transplantation procedures in children are whole pediatric cadaveric
or segmental (split) adult cadaveric organ graft or living related adult organ
graft (segments II and III or segments II, III, and IV)
[1,
2].
Early diagnosis of organ-related complications is essential for achieving
the best short- and long-term results
[3]. Therefore, knowledge of
the types of transplantation procedures used in children and the postoperative
imaging appearance of the anatomy of the transplanted liver graft is essential
for radiologists
[4–7].
Our pictorial essay illustrates the critical steps of the two most common
liver transplantation procedures performed in children who have standard
vascular and biliary anatomies. We have supplemented our essay with examples
of typical anatomy as shown on various imaging modalities—sonography,
CT, MRI, and angiography.
Orthotopic Liver Transplantation with Whole Pediatric Cadaveric Organ
Graft
In Figure 1A,
1B,
1C,
1D, the anatomies of the donor
and the recipient are depicted as they appear during pediatric orthotopic
liver transplantation of a whole pediatric cadaveric organ graft
[5]. During explantation of the
liver of the matched donor, the various vascular segments, including the
portal vein, vena cava, common hepatic artery, and common bile duct are
excised as distally as possible to preserve their lengths. Care in preserving
the lengths of these structures results in a tension-free anastomosis,
especially in recipients who have undergone multiple prior operations and thus
require large-scale resection during explantation of the liver. Typically
during explantation, the donor's inferior vena cava is removed along with the
liver. The suprahepatic part of the inferior vena cava is excised with a
margin of diaphragmatic tissue, and the infrahepatic part above the renal vein
is divided. The celiac trunk is dissected with a small aortic patch, and the
portal vein is dissected at the confluence of the superior mesenteric vein and
the splenic vein. The common bile duct is ligated as distally as possible, and
a cholecystectomy is also performed (Fig.
1A).
View larger version (130K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —Schematic illustrations of whole pediatric cadaveric liver
graft transplantation. CBD = common bile duct, CHA = common hepatic artery, CT
= celiac trunk, LGA = left gastric artery, SMV = superior mesenteric vein,
SPDA = superior pancreaticoduodenal artery, SPV = segmental portal vein, PV =
portal vein, VC = vena cava. (Reprinted and modified from
[5] with permission) Depiction
of intraoperative appearance of donor site at end of explantation procedure
shows that suprahepatic and infrahepatic parts of inferior vena cava, celiac
trunk with small aortic patch, and portal vein at confluence of superior
mesenteric and splenic veins have been dissected. Bile duct has been ligated
as distally as possible.
|
|
View larger version (149K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —Schematic illustrations of whole pediatric cadaveric liver
graft transplantation. CBD = common bile duct, CHA = common hepatic artery, CT
= celiac trunk, LGA = left gastric artery, SMV = superior mesenteric vein,
SPDA = superior pancreaticoduodenal artery, SPV = segmental portal vein, PV =
portal vein, VC = vena cava. (Reprinted and modified from
[5] with permission) Depiction
of intraoperative appearance of recipient site after removal of diseased
liver. Inferior vena cava has been clamped and excised above renal veins and
below diaphragm. Proper hepatic artery distal to junction of gastroduodenal
artery has been preserved. Common hepatic duct has been isolated close to
junction of left and right hepatic ducts.
|
|
View larger version (134K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —Schematic illustrations of whole pediatric cadaveric liver
graft transplantation. CBD = common bile duct, CHA = common hepatic artery, d
= donor, r = recipient, SMV = superior mesenteric vein, SPDA = superior
pancreaticoduodenal artery, SPV = segmental portal vein, PV = portal vein, VC
= vena cava. (Reprinted and modified from
[5] with permission) Depiction
of intraoperative appearance of recipient site after implantation shows
end-to-end anastomosis of supra- and infrahepatic inferior vena cava.
|
|
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D. —Schematic illustrations of whole pediatric cadaveric liver
graft transplantation. CBD = common bile duct, CHA = common hepatic artery, d
= donor, r = recipient, SMV = superior mesenteric vein, SPDA = superior
pancreaticoduodenal artery, SPV = segmental portal vein, PV = portal vein, VC
= vena cava. (Reprinted and modified from
[5] with permission) Liver
hilum of recipient at end of transplantation procedure is depicted. End-to-end
anastomosis of bile duct and end-to-side anastomosis between donor's celiac
trunk and recipient's common hepatic artery were performed.
|
|
In the recipient, removal of the diseased liver is accompanied by excision
of the inferior vena cava above the renal veins and below the diaphragm. A
long segment of the proper hepatic artery is preserved distal to the junction
with the superior gastroduodenal artery. The common hepatic duct is isolated
close to the junction of the left and right hepatic ducts
(Fig. 1B).
The transplantation procedure begins with anastomosis of the inferior vena
cava (Fig. 1C) followed by the
revascularization of the portal vein and common hepatic artery. When pediatric
whole liver transplantations first began to be performed, surgeons used an
end-to-side anastomosis of the donor's celiac trunk and the recipient's common
hepatic artery (Fig. 1D).
Currently, an arterial end-to-end anastomosis of the donor's and the
recipient's proper hepatic arteries is the preferred technique. The final step
in whole liver transplantation is duct-to-duct anastomosis in children without
bile duct abnormalities or hepaticojejunostomy in children with biliary
atresia. Figures 2A,
2B and
3A,
3B,
3C show the typical appearance
of normal postoperative anatomy on CT, sonography, and cholangiography.
View larger version (162K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A. —Contrast-enhanced single-detector helical CT scans obtained
40 days after whole liver transplantation in 3-year-old girl with Alagille
syndrome. Patent anastomosis (arrow) between donor's and recipient's
suprahepatic inferior venae cavae is noted as well as normal contrast
enhancement of all three hepatic veins.
|
|
View larger version (165K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B. —Contrast-enhanced single-detector helical CT scans obtained
40 days after whole liver transplantation in 3-year-old girl with Alagille
syndrome. Standard proximal end-to-end anastomosis (arrow) between
donor's proper hepatic artery and recipient's common hepatic artery is shown.
Focal hypodensity (asterisk) in spleen represents splenic
infarction.
|
|
View larger version (150K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A. —Images obtained 16 weeks after whole liver transplantation in
13-year-old boy with liver cirrhosis caused by cystic fibrosis.
Contrast-enhanced single-detector helical CT scan shows standard end-to-end
anastomosis of portal vein (arrow) at liver hilum. Although portal
hypertension has been normalized, persistent dilatation is seen in splenic
vein (white arrowhead) and in varicose collaterals next to splenic
hilum (black arrowheads).
|
|
View larger version (191K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B. —Images obtained 16 weeks after whole liver transplantation in
13-year-old boy with liver cirrhosis caused by cystic fibrosis. Abdominal
sonogram of liver hilum shows standard end-to-end anastomosis (arrow)
of portal vein.
|
|
View larger version (178K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C. —Images obtained 16 weeks after whole liver transplantation in
13-year-old boy with liver cirrhosis caused by cystic fibrosis. Percutaneous
cholangiogram obtained after transplantation shows standard end-to-end
choledocho–choledochostomy (arrow) evidenced by slightly larger
bile duct (single white arrowhead) in donor compared with more narrow
bile duct (double white arrowheads) in recipient; discrepancy in
diameter of bile ducts results from difference in size of organs in donor and
recipient. Incomplete filling of the donor's bile duct is due to low-pressure
injection of contrast material. Small contrast material extravasation
(black arrowheads) is seen near recipient's bile duct after initial
puncture.
|
|
Orthotopic Liver Transplantation with Segmental Adult Organ
Graft
Because of the increasing demand for pediatric liver transplantation and
the limited availability of pediatric cadaveric donor livers, segmental organ
grafts obtained from either cadavers or living related adult donors have
become important for pediatric liver transplantation. In a typical split liver
graft procedure, the left lateral segments (II and III) or the whole left lobe
(segments II, III, and IV) of the liver
[2,
3] are used. Figure
4A,
4B,
4C schematically depicts the
surgical procedure and postoperative anatomy of orthotopic segmental liver
transplantation [5].
View larger version (150K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A. —Schematic illustrations of segmental adult liver graft
transplantation. Ao = aorta, CBD = common bile duct, CHA = common hepatic
artery, CYD = cystic duct, d = donor, J = jejunum, LHA = left hepatic artery,
LHV = left hepatic vein, LLHA = left lateral hepatic artery, LMHA = left
median hepatic artery, PV = portal vein, r = recipient, SHD = segmental
hepatic duct, SPV = segmental portal vein, VC = vena cava. (Reprinted and
modified from [5] with
permission) Depiction of intraoperative appearance of donor site during
procurement of left lateral segments (II and III) shows dissection of left
hepatic artery and left portal vein, which is performed as distally as
possible.
|
|
View larger version (147K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B. —Schematic illustrations of segmental adult liver graft
transplantation. Ao = aorta, CBD = common bile duct, CHA = common hepatic
artery, CYD = cystic duct, d = donor, J = jejunum, LHA = left hepatic artery,
LHV = left hepatic vein, LLHA = left lateral hepatic artery, LMHA = left
median hepatic artery, PV = portal vein, r = recipient, SHD = segmental
hepatic duct, SPV = segmental portal vein, VC = vena cava. (Reprinted and
modified from [5] with
permission) Depiction of intraoperative appearance of recipient site after
removal of diseased liver shows that recipient's inferior vena cava has been
preserved (unlike in procedure used for whole liver transplantation). Large
triangular incision for venous anastomosis is also illustrated.
|
|
View larger version (142K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C. —Schematic illustrations of segmental adult liver graft
transplantation. Ao = aorta, CBD = common bile duct, CHA = common hepatic
artery, CYD = cystic duct, d = donor, J = jejunum, LHA = left hepatic artery,
LHV = left hepatic vein, LLHA = left lateral hepatic artery, LMHA = left
median hepatic artery, PV = portal vein, r = recipient, SHD = segmental
hepatic duct, SPV = segmental portal vein, VC = vena cava. (Reprinted and
modified from [5] with
permission) Depiction of implantation of segmental donor graft in recipient,
which begins with end-to-side anastomosis between donor's left hepatic vein
and recipient's vena cava. Portal and arterial end-to-end anastomoses are then
performed. If recipient's hepatic artery is too short, arterial end-to-end
anastomosis is performed between donor's hepatic artery via conduit and
recipient's infrarenal aorta. Biliary anastomosis is performed between donor's
left lateral hepatic duct and recipient's isolated jejunal loop.
|
|
The initial step of segmental liver transplantation is the harvesting of
the left lateral segments (Fig.
4A). A critical part of the procedure is the careful dissection of
the left hepatic artery and the left portal vein. If possible, the artery for
segment IV should be preserved. Portal vein branches to segment I can also be
transsected. The excised portions of the left hepatic artery and left portal
vein should be as long as possible to ensure a tension-free anastomosis and to
prevent portal vein stenosis if the growth of the donor's liver parenchyma is
disproportionate to that in the rest of the recipient's body. A vascular
pedicle that is too short requires use of a vascular conduit with autologous
iliac artery from the donor, which potentially increases the risk of vascular
complications. Parenchymal dissection is performed with an ultrasound
dissector and is a well-defined type of partial hepatectomy, involving removal
of approximately 25% of functional liver mass. Because the split graft
procedure does not involve formal dissection of all vital structures in the
hilum, the risk of potential long-term complications in the donor or recipient
is minimized.
The recipient site used in the split liver graft procedure (Fig.
4A,
4B,
4C) differs from the site used
in the whole liver graft procedure. In contrast to the whole liver graft
procedure, the split liver graft procedure preserves the recipient's inferior
vena cava because it is not removed with the segmental graft. The orifices of
the recipient's right hepatic vein are sealed, and a large triangular incision
of the middle and left hepatic veins and the vena cava is made. The donor's
left hepatic vein is then incised and enlarged to optimize hepatic venous
outflow. After implantation of the donor's graft, the surgeons first attempt
to perform portal and arterial end-to-end anastomoses. If the diameter of the
recipient's hepatic artery is too small for these procedures to be used, an
arterial end-to-end anastomosis is established via an extension graft between
the donor's hepatic artery and the recipient's infrarenal aorta. A biliary
anastomosis is established between the donor's left lateral hepatic duct and a
jejunal loop in the recipient (Fig.
4C). Figures 5,
6,
7A,
7B,
8A,
8B,
9 show normal postoperative
anatomy as it appears on various forms of imaging in patients who have
undergone split liver transplantation.
View larger version (130K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5. —Contrast-enhanced single-detector helical CT scan obtained 20
days after orthotopic split liver transplantation (segments II and III) of
13-year-old boy with liver cirrhosis resulting from cystic fibrosis. Scan
shows typical venous anastomosis (arrow) between donor's left hepatic
vein and recipient's inferior vena cava, persisting gastroesophageal varices
(arrowheads), and ascites (asterisk).
|
|
View larger version (189K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6. —Color Doppler sonogram obtained 25 days after orthotopic
split liver transplantation (segments II and III) in 1-year-old girl with
biliary atresia. Portal vein (arrows) and hepatic artery
(arrowheads) at hilum of transplanted liver segments are shown with
preserved blood flow. Apparent flow reversal (asterisk) is due to
tortuous course of long portal vein.
|
|
View larger version (128K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7A. —Maximum-intensity-projection reconstructions of
contrast-enhanced multidetector CT examinations obtained 35 days after split
liver transplantation (segments II and III) in 4-month-old girl with
extrahepatic biliary atresia. Standard end-to-end anastomosis of portal vein
(arrow) and hepatic artery (arrowhead) are shown.
|
|
View larger version (126K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7B. —Maximum-intensity-projection reconstructions of
contrast-enhanced multidetector CT examinations obtained 35 days after split
liver transplantation (segments II and III) in 4-month-old girl with
extrahepatic biliary atresia. Normal contrast enhancement of various segments
of common hepatic artery (arrowheads) indicates patency.
|
|
View larger version (145K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8A. —Images obtained 3 weeks after split liver transplantation
(segments II and III) in 13-year-old boy who had liver cirrhosis in cystic
fibrosis. Standard anastomosis of arterial conduit (arrow, A)
from donor's common hepatic artery to recipient's infrarenal aorta is shown in
contrast-enhanced single-detector helical CT scan (A) and selective
conduit angiogram (B).
|
|
View larger version (128K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 8B. —Images obtained 3 weeks after split liver transplantation
(segments II and III) in 13-year-old boy who had liver cirrhosis in cystic
fibrosis. Standard anastomosis of arterial conduit (arrow, A)
from donor's common hepatic artery to recipient's infrarenal aorta is shown in
contrast-enhanced single-detector helical CT scan (A) and selective
conduit angiogram (B).
|
|
View larger version (127K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9. —Contrast-enhanced single-detector helical CT scan obtained 5
months after split liver transplantation in 1-year-old girl with biliary
atresia. Liver transplant was obtained from segment II, segment III, and part
of segment IV in living related donor. Decreased density of liver parenchyma
represents fatty degeneration.
|
|
References
- Broelsch CE, Whitington PF, Emond JC, et al. Liver transplantation
in children from living related donors: surgical techniques and results.
Ann Surg 1991;214:428
–439[Medline]
- Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker AL,
Lichtor JL. Application of reduced-size liver transplants as split grafts,
auxiliary orthotopic grafts, and living related segmental transplants.
Ann Surg 1990;212:375
–377
- Miller CM, Gondolesi GE, Florman S, et al. One hundred nine living
donor liver transplants in adults and children: a single-center experience.
Ann Surg 2001;234:301
–312[Medline]
- Broelsch CE, Burdelski M, Rogiers X, et al. Living donor for liver
transplantation. Hepatology1994; 20[suppl]:49S
–55S[Medline]
- Broelsch CE. Atlas of liver surgery, 1st
ed. New York: Churchill Livingstone, 1993:119
–174
- Ametani F, Itoh K, Shibata T, Maetani Y, Tanaka K, Konishi J.
Spectrum of CT findings in pediatric patients after partial liver
transplantation. RadioGraphics2001; 21:53
–63[Abstract/Free Full Text]
- Lorenz JM, Funaki B, Leef JA, Rosenblum JD, Van Ha T. Percutaneous
transhepatic cholangiography and biliary drainage in pediatric liver
transplant patients. AJR2001; 176:761
–765[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
T. Berrocal, M. Parron, A. Alvarez-Luque, C. Prieto, and M. L. Santamaria
Pediatric liver transplantation: a pictorial essay of early and late complications.
RadioGraphics,
July 1, 2006;
26(4):
1187 - 1209.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Orthotopic Liver Transplantation...
