Surgical Science, 2011, 2, 485-487
doi:10.4236/ss.2011.210106 Published Online December 2011 (
Copyright © 2011 SciRes. SS
A Simple and New Device to Avoid Hepatic Venous Outflow
Obstruction in Adult Liver Transplantation
Dino Donataccio1, Salvatore Grosso2, M att eo Donat acc io 1*
1Liver Transplant Unit, Azienda Ospedaliera Universitaria Integrata , Verona, Italy
2Anesthesia and Resuscitation Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
E-mail: *
Received August 30, 2011; revised November 17, 2011; accepted November 30, 2011
Hepatic venous drainage in liver transplantation may be reduced to the level of caval anastomosis producing
an obstruction degree and leading to serious vascular complication such as the acute Budd-Chiari syndrome,
which may result in organ loss. Outflow obstruction may be caused by lack of technique in caval anastomo-
sis or by allograft malposition as a consequence of anatomical graft and recipient conditions. Fixation of the
round ligament, placement of bowel loops and use of tissue expanders have been described to stabilize graft
position during liver transplantation with related procedure complications. We report our experience of a
simple homemade device using a surgical glove expander that allowed us to successfully avoid outflow ob-
struction in all of nine treated patients. No device related complications occurred. In malposed liver al-
lografts, we strongly suggest the use of this simple and safe device to avoid hepatic venous outflow obstruc-
tion on condition that the device is early removed within 48 hours.
Keywords: Outflow Obstruction, Allograft Malposition, Liver Transplantation, Surgical Glove Expander,
1. Introduction
Outflow obstruction in liver transplantation causes graft
dysfunction and eventual graft loss. In the allograft, par-
tial mechanical hepatic outflow obstru ction is unco mmon
but not rare. Venous drainage after liver transplantation
(LT) may be hindered by the level of caval anastomosis,
producing an obstruction degree leading to the most se-
rious acute Budd- Chiar i syndrome (B-C) which may lead
to organ loss. It may be caused by lack of technique in
caval anastomosis construction resulting in a stenosis of
anastomosis, and by graft and/or recipient anatomical
conditions resulting in an allogr aft malposition. Acute B-
C is an early postoperative vascular complication that
accounts for about 3% of LTs. This complication usually
occurs in recipient vena cava preserving techniques, more
frequently in piggy-back (PB) technique due to the graft
mobility along two orthogonal planes, antero-posterior
and latero-lateral (Figure 1). In latero-lateral (L-L) caval
anastomosis technique, especially with a wide anastomo-
sis, graft mobility is only allowed along the lateral plane.
Thus the caval anastomosis proves to be a sort of hinge
which does not allow antero-pos terior mobility (Figure 2 )
[1,2]. In recipients the presence of a deep fovea hepatis
and a wide empty subphrenic space may allow a venous
twisting caused by displaced liver graft after reposition-
ing into the abdomen, leading to a consequent hepatic
venous outflow obstruction. Another cause may be iden-
tified by the donor/recipient dimensional mismatch: a too
bulky graft may cause a compression of caval anastomo-
sis during the abdominal incision closure and vice versa
a too small graft may rotate towards the hepatic fossa
producing a twisting of the caval anastomosis and there-
fore an hindrance to the venous outflow of the graft. In
paediatric split liver transplantation [3] and in living do-
nor liver transplantation [4], the rate of hepatic venous
outflow obstruction may be much higher, up to 6.6% and
9.5% respectively, due to a venous twisting favored by a
greater mobility of a smaller graft.
This form of obstruction should be early recognized
and promptly relieved to prevent complications and graft
failure. We experienced this complication intraopera-
tively in nine patients undergoing liver transplant. These
patients presented an unexplainable hypotension after
portal reperfusion. In all cases, doppler ultrasonography,
by determining vascular flow patterns and velocities, was
Figure 1. Piggy-Back caval anastomosis.
Figure 2. Latero-lateral caval anastomosis.
able to detect the cause of venous outflow obstruction.
The use of tissue expanders has been described to stabi-
lize graft position during liv er transplantation [5]. In this
study, we applied a surgical glove filled up with 200 /300
ml of saline solution to improve hepatic vein outflows.
We retrospectively reviewed our experience and ana-
lyzed the efficacy and safety of this procedure.
2. Patients and Methods
Between December 2002 and January 2011, 142 conse-
cutive adult LTs were performed in 139 patients. Surgi-
cal technique was performed by the same experienced
surgeon in all patients. Hepatectomy with recipient vena
cava preservation and without venous bypass was possi-
ble in 100% of surgical procedures. Caval anastomosis
was performed in latero-lateral technique aiming the
widest anastomosis possible up to seven centimeter. This
was achieved in all but two patients. The first one was a
recipient with a double inferior vena cava confluencing
at diaphragmatic caval ostium and a termino-lateral an-
astomosis was constructed; in the other on e, with a donor
vena cava encircled by caudate lobe, a PB implantation
was performed. The donor/recipient body weight mis-
match acceptable was up to 30% in favor of the donor.
In nine cases (6.3%), a graft venous outflow obstruc-
tion was clinically diagnosed after portal reperfusion.
The blood pressure fell down due to hypovolemia and a
reduced central venous pressure was registered. The graft
was congested with a high risk of bleeding. Lifting and
rotating to the left side of the graft allowed immediate
hemodynamic recovery. Then a surgical glove was filled
with 200/300 ml of saline solution and pushed under the
right side of the graft supporting to counteract the venous
outflow obstruction (Figure 3). The glove was removed
within 48 hours with a very slight reopening under he-
modynamic monitoring.
3. Results
We experienced venous outflow obstruction in nine cases
(6.3%), seven whole liver and two right split graft. In
three cases the caval anastomosis was compressed by a
too bulky graft. In the other six cases the graft fell into a
too deep fovea hepatis causing an outflow obstruction.
Our glove device effectively overcame this complication.
In all cases the glove was removed within 48 hours. No
venous ou tflow obstruction h as been d etected by doppler
ultrasound monitoring during and after removal of the
glove. No technique related complications have been
registered and no graft has been lost due to venous out-
flow complications. The median follow-up is 32 months
(range 3 - 88).
4. Discussion
The early venous outflow obstruction is a rare but poten-
tially fatal complication of LT. Despite refinement in
surgical technique, mechanical outflow obstructions from
malpositioning of the graft may happen. Oftentimes, it
mimics hypovolemia because of decreased venous return.
Hypotension, as a result of hepatic outflow obstruction,
is a temporary hypovolemia. To treat abnormal data from
hemodynamic monitoring, blind resuscitation with fluids
will not solve the problem. Once detected, outflow block-
ade must be relieved immediately usually by surgical in-
tervention. Mechanical obstruction from vessel anasto-
mosis, thrombosis, kinking and twisting should be man-
aged surgically by meticulous venous anastomosis and/or
adjusting the position of the graft [6]. This can be done
by maneuvers such as fixation of the round ligament to
Figure 3. Glove expander.
Copyright © 2011 SciRes. SS
Copyright © 2011 SciRes. SS
fix the graft in position, placement of bowel loop to lift
the graft, additional side-to-side cavo-cavostomy [5,7,8],
placement of a Blakemore-Sengstaken tube [9] or use of
tissue expander [5,10]. Conservatively, it may be treated
by angioplasty but restenosis is frequent, or by position-
ing a vascular stent with resolution of clinical symptoms
in 73% to 100% of cases [11]. The surgical procedure
with an additional cavo-caval anastomosis or by retrans-
plantation, entails a high mortality rate [12,13].
In 2005 W ang et al. [14] reported that the use of tissue
expander and Foley catheter improved venous inflow and
outflow; all expanders were removed within the 19th -
56th postoperative day; seven complications occurred in
five out of seven treated patients.
All our devices were removed early within 48 posto-
perative hours without any complications. We were never
compelled to reposition the volumetric support. In two
cases, a fluid collection in the residual space after device
removal persisted several months before reabsorption
without any infective complications. No graft has been
lost due to venous outf low complications. In our opinion
the graft compliance to the recipient subphrenic space is
much more than commonly believed and rapidly allows
the graft to reach stability, thus overcoming venous out-
flow obstruction. An early removal of device can avoid
related complications.
In conclusion, after liv er trans plan tatio n in ca se o f intra-
operative not suture related venous outflow obstruction,
a simple and low cost homemade volumetric support
may allow the graft to adapt to the available space and
overcome a critical congestion.
5. References
[1] P. Parrilla, F. Sánchez -Bueno, J. Figueras, E. Jaurrieta, J.
Mir, C. Margarit, J. Lázaro, L. Herrera, M. Gómez-
Fleitas, E. Varo, E. Vicente, R. Robles and P. Ramirez,
“Analysis of the complications of the Piggy-Back Tech-
nique in 1112 Liver Transplants,” Transplantation, Vol.
67, No. 9, 1999, pp. 1214-1217.
[2] F. Navarro, M. C. Le Moine, J. M. Fabre, J. Belghiti, D.
Cherqui, R. Adam, F. R. Pruvot, C. Letoublon and J. Do-
mergue, “Specific Vascular Complications of Orthotopic
Transplantation with Preservation of the Retrohepatic
Vena Cava: Review of 1361 Cases,” Transplantation,
Vol. 68, No. 5, 1999, pp. 646-650.
[3] G. Krishna Kumar, K. Sharif, D. Mayer, D. Mirza, K.
Foster, D. Kelly and A. J. Millar, “Hepatic Venous Out-
flow Obstruction in Paediatric Liver Transplantation,”
Pediatric Surgery International, Vol. 26, No. 4, 2010, pp.
[4] G. Y. Ko, K. B. Sung, H. K. Yoon, K. R. Kim, J. H. Kim,
D. I. Gwon and S. G. Lee, “Early Posttransplant Hepatic
Venous Outflow Obstruction: Long-Term Efficacy of Pri-
Mary Stent Placement,” Liver Transplantation, Vol. 14,
No. 10, 2008, pp. 1505-1511.
[5] Y. Inomata, K. Tanaka, H. Egawa, S. Uemoto, T. Kiuchi,
K. Satomura, S. Uyama and H. Okajima, “Application of
a Tissue Expander for Stabilizing Graft Position in Liv-
ing-Related Liver Transplantation,” Clinical Transplan-
tation, Vol. 11, No. 1, 1997, pp. 56-59.
[6] B. Jawan, H. K. Cheung, C. C. Chen, Y. S. Chen, Y. C.
Chiang, C. C. Wang, Y. F. Cheng, T. L. Huang, H. L.
Eng, S. Goto, T. L. Pan, V. De Villa, P. P. Liu, S. H.
Wang, C. L. Lin and J. H. Lee, “Repeated Hypotensive
Episodes Due to Hepatic Outflow Obstruction during
Liver Transplantation in Adult Patients,” Journal of Cli-
nical Anesthesia, Vol. 12, No. 3, 2000, pp. 231-233.
[7] J. Lerut and P. Gertsch, “Side-To-Side Cavo-Cavostomy:
A Useful Aid in “Complicated” Piggy-Back Liver Trans-
plantation,” Transplant International, Vol. 6, No. 5, 1993,
pp. 299-301.
[8] A. C. Stieber, R. D. Gordon and N. Bassi, “A Simple So-
lution to a Technical Complication in “Piggyback” Liver
Transplantation,” Transplantation, Vol. 64, No. 4, 1997,
pp. 654-655.
[9] B. Malassagne, B. Dousset, P. P. Massault, D. Devictor,
O. Bernard and D. Houssin, “Intra-Abdominal Sengsta-
ken-Blakemore Tube Placement for Acute Venous Out-
flow Obstruction in Reduced-Size Liver Transplanta-
tion,” British Journal of Surgery, Vol. 83, No.8, 1996, p.
[10] J. C. Emond, T. G. Heffron, P. F. Whitington, C. E. Bro-
elsch, “Reconstruction of the Hepatic Vein in Reduced
Size Hepatic Transplantation,” Surgery, Gynecology &
Obstetrics, Vol. 176, No. 1, 1993, pp. 11-17.
[11] M. D. Darcy, “Management of Venous Outflow Compli-
cations after Liver Transplantation,” Techniques in Vas-
cular and Interventional Radiology, Vol. 10, No. 3, 2007,
pp. 240-245.
[12] J. Quintela, C. Fernàndez, J. Aquirrezabalaga, C. Gerardo,
M. Marini, F. Suarez and M. Gomez, “Early Venous Ob-
struction after Liver Transplantation and Treatment with
Cavo-Cavostomy,” Transplantation Proceedings, Vol. 41,
No. 6, 2009, pp. 2450-2452.
[13] A. Cavallari, M. Vivarelli, R. Bellusc i, E. Jovine, A. Ma-
zziotti and C. Rossi, “Treatment of Vascular Complica-
tions Following Liver Transplantation: Multidisciplinary
Approach,” Hepatogastroenterology, Vol. 48, No. 37,
2001, pp. 179-183.
[14] C. C. Wang, A. M. Concejero, C. C. Yong, Y. S. Chen, S.
H. Wang, C. C. Lin, Y. W. Liu, C. H. Yang, T. S. Lin, K.
C. Hung, B. Jawan, Y. F. Cheng, S. Ibrahim and C. L.
Chen, “Improving Hepatic and Portal Venous Flows Us-
ing Tissue Expander and Foley Catheter in Liver Trans-
plantation,” Clinical Transplantation, Vol. 20, No. 1,
2006, pp. 81-84.