DOI:10.2214/AJR.07.2586
AJR 2007; 189:W338-W343
© American Roentgen Ray Society
Complications in Living Liver Donors After Partial Liver Procurement: An Illustrative Radiologic Review
Heon-Ju Kwon1,
Kyoung Won Kim1,
Ji Yeon Park1,
Seung Soo Lee1,
Min Ju Kim1,2,
Moon-Gyu Lee1 and
Sung Gyu Lee3
1 Department of Radiology, University of Ulsan College of Medicine, Asan Medical
Center, 388-1, Pungnap 2-dong, Songpa-ku, Seoul 138-736, Korea.
2 Department of Radiology, National Cancer Center, Goyang, Korea.
3 Department of General Surgery, University of Ulsan College of Medicine, Asan
Medical Center, Seoul 138-736, Korea.
Received May 16, 2007;
accepted after revision July 23, 2007.
WEB This is a Web exclusive article.
Address correspondence to K. W. Kim.
Abstract
OBJECTIVE. The purpose of this article is to present an illustrative
radiologic review of the usual postoperative findings and of various
postoperative complications in living liver donors.
CONCLUSION. Radiologic studies can reveal various complications in
living liver donors after partial liver resection. Meticulous radiologic
surveillance is mandatory for living liver donors during the early
postoperative period because their safety is of primary concern in living
donor liver transplantation.
Keywords: living donor liver transplantation • postoperative complications
Introduction
Because of the shortage of cadaveric donors, living donor liver
transplantation has become widely accepted as an alternative method of
treatment for patients with end-stage liver disease. However, despite the
overwhelming benefit, concern for the safety of the healthy living donors must
not be minimized. In a large survey at five Asian medical centers, the overall
donor complication rate was approximately 15%
[1]. Although there have been
no reported hospital mortalities, some complications may become fatal if
diagnosis and treatment are delayed. Therefore, early detection of
postoperative complications is of the utmost importance to ensure timely
intervention, and meticulous clinical and radiologic surveillance is mandatory
during the early postoperative period.
Because radiologic studies often have a key role in the screening of
postoperative complications, the purpose of this article is to present an
illustrative radiologic review of the usual postoperative findings and of
various postoperative complications in living liver donors.
Hemiliver Resection for Living Donor Liver Transplantation
A sufficient graft volume is the key to a successful outcome of living
donor liver transplantation. The right hemiliver accounts for approximately
two thirds of the entire liver volume and usually meets the graft-to-recipient
weight ratio of 1.0%, which is generally agreed to be a safe limit for adult
recipients [2,
3]. In a donor with a large
left hemiliver or for a small recipient, a left lobe graft can be used. The
middle hepatic vein is a major draining vein of the right anterior and left
medial hepatic sectors. Although the middle hepatic vein usually remains in
donors in cases of right hemiliver donation, it is harvested together with the
left hemiliver in cases of living donor liver transplantation using a left
lobe graft.
Therefore, left hemihepatectomy can result in varying degrees of hepatic
congestion in the remnant right anterior sector. However, because the right
hemiliver constitutes 60-70% of the total liver volume, the congestion-free
remnant liver volume is usually sufficient to accommodate the donor's
metabolic demand. In addition, venous drainage of the congested area may
improve with the development of intrahepatic collaterals between the
tributaries of the middle and right hepatic veins (Fig.
1A,
1B,
1C). It has been reported that
this type of functional anastomosis is gradually seen within 10 days of
hepatic outflow obstruction
[4].
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Fig. 1A —35-year-old woman with hepatic vein thrombosis after left
hemiliver donation. Contrast-enhanced CT scan during portal venous phase
obtained on postoperative day 7 shows area of hepatic congestion
(asterisk) seen as area of hypoattenuation surrounded by
hyperattenuation and nonopacification of middle hepatic vein
(arrowhead).
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Fig. 1B —35-year-old woman with hepatic vein thrombosis after left
hemiliver donation. Color Doppler sonogram obtained 4 weeks after A
shows reversed flow of middle hepatic vein tributary (arrowhead),
suggesting development of intrahepatic collateral drainage into right hepatic
vein (arrow).
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Fig. 1C —35-year-old woman with hepatic vein thrombosis after left
hemiliver donation. Follow-up contrast-enhanced CT scan during portal venous
phase shows intrahepatic collateral circuit (circle).
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In donors with left lateral sectionectomy, the remnant part of segment IV
may undergo ischemia or infarct as the portal branches to segment IV are
interrupted (Fig. 2A,
2B). The caudate lobe is
somewhat autonomous in that it is perfused directly from small branches of the
left or right portal vein or from both and then drains directly into the
inferior vena cava. Therefore, the caudate lobe is usually left in donors
after right or left hemihepatectomy, and ischemia or infarct is not unusual
(Fig. 3A,
3B,
3C).
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Fig. 2A —31-year-old man with hepatic infarction in remnant segment IV
after left lateral sectionectomy. Contrast-enhanced CT scan during portal
venous phase obtained 4 weeks after left lateral sectionectomy shows
well-defined area of hepatic infarction (arrowheads) seen as marked
low attenuation.
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Fig. 2B —31-year-old man with hepatic infarction in remnant segment IV
after left lateral sectionectomy. Follow-up contrast-enhanced CT scan obtained
4 months after initial postoperative CT scan shows marked shrinkage of remnant
segment IV.
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Fig. 3A —23-year-old man with caudate lobe ischemia after left
hemiliver donation. Preoperative oblique coronal maximum-intensity-projection
image clearly shows large and protruded papillary process of caudate lobe
(arrows) supplied by small branch (arrowheads) of left
portal vein.
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Fig. 3B —23-year-old man with caudate lobe ischemia after left
hemiliver donation. Contrast-enhanced CT scan obtained on postoperative day 7
shows hypoattenuation and swelling of caudate lobe (arrows),
suggesting infarction due to deprivation of portal inflow. CT scan also shows
mottled air density in hypoattenuation area, suggesting combined
infection.
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Fig. 3C —23-year-old man with caudate lobe ischemia after left
hemiliver donation. Follow-up contrast-enhanced CT scan obtained 1 month after
the initial postoperative CT shows marked shrinkage of caudate lobe
(arrows).
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Bleeding
Although meticulous hemostasis is usually performed after hemiliver
harvesting, arterial spasm may intraoperatively obscure bleeding foci, and
bleeding may therefore occur during the early postoperative period (Fig.
4A,
4B,
4C). Thus, close scrutiny of
the arterial stump is mandatory in the postoperative CT evaluation of living
liver donors. It is also worthwhile to keep in mind that retraction or
dissection injury to the diaphragm or perihepatic tissues may result in
bleeding from the right inferior phrenic vessels
[5].
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Fig. 4A —21-year-old man with massive peritoneal bleeding from right
hepatic artery stump after right hemiliver donation. Unenhanced CT scan shows
acute hematoma on postoperative day 1, seen as high attenuation
(arrows) in right subphrenic area. CT scan also shows postoperative
pneumoperitoneum and right pleural effusion.
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Fig. 4B —21-year-old man with massive peritoneal bleeding from right
hepatic artery stump after right hemiliver donation. Axial contrast-enhanced
CT scan during hepatic arterial phase shows active extravasation
(arrowheads) of contrast agent from right hepatic artery stump.
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Fig. 4C —21-year-old man with massive peritoneal bleeding from right
hepatic artery stump after right hemiliver donation. Oblique coronal
maximum-intensity-projection image clearly shows active extravasation
(arrowheads) of contrast agent from right hepatic artery stump. At
surgery, active bleeding from right hepatic artery stump with dislodgement of
hemoclip was found.
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An additional risk of postoperative bleeding is related to preoperative
percutaneous biopsy performed for the histologic grading of hepatic steatosis
(Fig. 5A,
5B). Because the right
hemiliver is more commonly used as a graft, we usually obtain hepatic tissue
from the right hemiliver. The decision whether to harvest the right or left
hemiliver is determined by the liver volumetry results in terms of the
graft-to-recipient weight ratio and the remnant liver volume. Therefore, in
living liver donors who have undergone left hemihepatectomy, the site of the
preoperative biopsy in the right hemiliver may eventually become a possible
location of postoperative bleeding
[6]. Right adrenal hemorrhage
after hepatectomy is well known
[7]. CT usually renders an
accurate diagnosis (Fig.
6).
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Fig. 5A —33-year-old woman after left hemiliver donation with
subcapsular postbiopsy hematoma. Unenhanced CT scan obtained on postoperative
day 1 shows large subcapsular hematoma (arrowheads), seen as
heterogeneous high attenuation compared with hepatic parenchyma.
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Fig. 5B —33-year-old woman after left hemiliver donation with
subcapsular postbiopsy hematoma. Contrast-enhanced CT scan of liver during
arterial phase shows congestion of compressed hepatic parenchyma
(asterisk, right anterior sector), seen as high attenuation compared
with normal parenchyma (arrowheads, right posterior sector). CT scan
also shows early opacification of right anterior portal vein
(arrows), supporting hypothesis that portal vein may act as draining
vein in acute hepatic outflow obstruction.
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Fig. 6 —44-year-old man with right adrenal hemorrhage after left
hemiliver donation. Unenhanced CT scan obtained on postoperative day 19 shows
acute hematoma (arrowheads) in right adrenal gland, seen as
high-attenuation lesion (> 70 H). Follow-up contrast-enhanced CT scans
obtained 1 month after initial postoperative CT showed decreased size and
attenuation of right adrenal hematoma (not shown).
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Biliary Complications
Bile leakage and bile duct strictures also occur frequently after living
donor liver transplantation. If an appropriate procedure for biliary diversion
is not performed early enough, there can be a deterioration of liver function,
abscess formation, and even sepsis
[8].
On hepatobiliary scanning, bile leakage is diagnosed when radioisotopes
accumulate in the perihepatic space during the excretory and late phases (Fig.
7A,
7B). Bile leakage is usually
successfully managed by biliary diversion accomplished by placement of a
biliary stent. However, biliary leaks can occasionally cause biloma or bile
peritonitis. Biloma may require radiologic or surgical intervention
[9] when it has a mass effect
causing congestion of the hepatic parenchyma (Fig.
8A,
8B,
8C) or when it evolves into an
abscess (Fig. 9A,
9B).
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Fig. 7A —22-year-old woman with biloma after right hemiliver donation.
Contrast-enhanced CT scan during portal venous phase obtained on postoperative
day 36 reveals persistent fluid collection (arrowheads) in right
posterior subphrenic space adjacent to hepatic resection margin and right
pleural effusion.
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Fig. 7B —22-year-old woman with biloma after right hemiliver donation.
Hepatobiliary scans using 99mTc-diisopropyl iminodiacetic acid
(DISIDA) show focal bile activity (arrowheads) at posterior aspect of
resection margin during excretion phase, suggesting bile leakage.
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Fig. 8A —21-year-old man with biloma after right hemiliver donation.
Color Doppler sonogram obtained on postoperative day 13 shows biloma
(asterisk) at resection margin in right subphrenic area and
displacement of middle hepatic vein. Doppler spectrogram showed dampened and
monotonous venous flow (not shown).
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Fig. 8B —21-year-old man with biloma after right hemiliver donation.
Color Doppler sonogram shows reversal of portal flow (arrows), shown
in blue, in segment IV and in left portal vein umbilical segment.
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Fig. 8C —21-year-old man with biloma after right hemiliver donation.
Contrast-enhanced CT scan during hepatic arterial phase shows biloma
compressing hepatic parenchyma. CT scan also shows early opacification of
portal branch (arrowhead) in segment VIII. CT and color Doppler
sonogram after removal of biloma showed recovery of hepatic venous and portal
flow (not shown).
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Fig. 9A —28-year-old man with biloma after right hemiliver donation.
Oblique coronal sonogram obtained on postoperative day 7 shows large fluid
collection containing internal debris (asterisk) at resection margin,
suggesting biloma with secondary infection. Sonogram also shows right pleural
effusion.
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Fig. 9B —28-year-old man with biloma after right hemiliver donation.
Abscessogram reveals opacification of biliary tree and communicating tract
(arrowhead) between abscess and intrahepatic bile duct.
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Bile duct stricture is thought to be related to excessive dissection of the
bile duct in the porta hepatis. When this is suspected, MR cholangiography can
usually show the location and length of the stricture segment. Postoperative
bile duct strictures in donors are usually treated by interventional
radiologic management [9] (Fig.
10A,
10B).
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Fig. 10A —23-year-old man with bile stricture after right hemiliver
donation. MR cholangiogram obtained on postoperative day 22 shows segmental
narrowing (arrow) of proximal common hepatic duct.
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Vascular Complications
Portal vein thrombosis or stenosis may occasionally occur in donors after
hemihepatectomy; either can be fatal if diagnosis and treatment are delayed
[1,
10]. Although Doppler
sonography is considered a primary screening method for detecting
postoperative vascular complications, extensive bowel gas and hematomas can
sometimes obscure accurate results on sonographic studies. As an alternative
noninvasive technique for evaluating the hepatic vasculature, MDCT can provide
excellent visualization of filling defects within the portal vein or of focal
narrowing (Fig. 11A,
11B).
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Fig. 11A —21-year-old woman with portal vein thrombosis after right
hemiliver donation. Contrast-enhanced CT scan obtained on postoperative day 4
shows focal filling defect (arrowhead) in main portal vein,
suggesting thrombosis.
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Fig. 11B —21-year-old woman with portal vein thrombosis after right
hemiliver donation. Indirect portogram by splenic arteriography shows abrupt
cutoff of portal vein (arrowheads) and regurgitation of contrast
material into superior mesenteric vein. Surgical thrombectomy was performed,
and metallic stent was inserted into portal vein.
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Gastrointestinal Complications
Adhesions are commonly identified in patients who have undergone laparotomy
including hepatectomy. However, symptoms occur in few cases
(Fig. 12).
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Fig. 12 —41-year-old man with adhesive band ileus after right
hemiliver donation. Coronal reconstruction image obtained on postoperative day
7 shows diffuse small bowel ileus with close attachment of collapsed loops
(arrowheads) along abdominal incision wound.
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Gastric volvulus rarely occurs after hepatectomy. Cutting the gastrohepatic
ligament and the peritoneum covering the second part of the duodenum with a
dead space created by the liver resection may reduce the gastroduodenal
fixation thereby increasing gastric mobility. Gastric volvulus is relatively
benign, but there are reported cases of gastric necrosis caused by vascular
occlusion [11,
12]
(Fig. 13).
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Fig. 13 —37-year-old man with gastric volvulus after left hemiliver
donation. Upper gastrointestinal series shows upward rotation of distal
portion of stomach with mild contrast material passage disturbance probably
caused by fixation of distal stomach to liver resection margin, suggesting
gastric volvulus.
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Incisional hernia frequently occurs after laparotomy. If the hernia is left
untreated, bowel loops may become incarcerated
[6]. Incisional hernia can be
precisely diagnosed on MDCT along with visualization of the abdominal wall
defects and hernial contents and signs of bowel ischemia, if present
(Fig. 14).
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Fig. 14 —46-year-old man with incisional hernia after right hemiliver
donation. Contrast-enhanced CT scan obtained 5 months after right
hemihepatectomy shows small-bowel hernia (arrowheads) through
incisional site to subcutaneous fat. There is no evidence of strangulation or
obstruction.
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Abstract
Introduction
