title: Posterior cavoplasty: a new approach to avoid venous outflow obstruction and symptoms for small-for-size syndrome in right lobe living donor liver transplantation.
abstract: OBJECTIVE
  A common and serious problem after living donor liver transplantation (LDLT) of small grafts is small-for-size syndrome (SFSS). Although hyperdynamic portal inflow and portal hypertension are cornerstones in the development of SFSS, inadequate outflow may aggravate SFSS. Therefore, enlargement of the portal outflow tract by incision of the anterior rim of the orifice of the right hepatic vein (RHV) has been advocated for right lobe LDLT. But backwards tilt of a small graft into a large abdominal cavity may lead to a choking of the otherwise large anastomosis and thus we propose posterior enlargement of the orifice of the RHV.
  
  
  METHODS
  In this test-of-concept study, we evaluated portal vein pressure (PVP), clinical parameters, and laboratory measurements in 22 patients that underwent right lobe LDLT and either received standard end-to-end anastomosis of the RHV or posterior cavoplasty.
  
  
  RESULTS
  In patients that underwent posterior cavoplasty, we observed significantly lower PVP and less hyperbilirubinemia. There was a non-significant trend to lower incidence of SFSS. Other laboratory measurements and clinical parameters were not significantly different.
  
  
  CONCLUSIONS
  We recommend posterior cavoplasty for enlargement of the hepatic venous outflow tract in right lobe LDLT as a method to avoid portal hypertension, hyperbilirubinemia, and possibly SFSS, especially in patients that receive small grafts.
authors.affiliation: Department of General and Visceral Surgery, University Medical Center Göttingen, Robert-Koch-Strasse 40, Göttingen, Germany. agoralczyk@med.uni-goettingen.de
authors.forename: Armin D
authors.initials: AD
authors.lastname: Goralczyk
authors.forename: Aiman
authors.initials: A
authors.lastname: Obed
authors.forename: Alexander
authors.initials: A
authors.lastname: Beham
authors.forename: Tung Yu
authors.initials: TY
authors.lastname: Tsui
authors.forename: Thomas
authors.initials: T
authors.lastname: Lorf
mesh_terms: D000328:Adult; D000714:Anastomosis, Surgical / Q000379:methods; D016022:Case-Control Studies; D003251:Constriction, Pathologic / Q000517:prevention & control; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006503:Hepatic Veins / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008102:Liver Circulation / Q000502:physiology; D016031:Liver Transplantation / Q000009:adverse effects / Q000379:methods*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000517:prevention & control; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D015996:Survival Rate; D016896:Treatment Outcome; D014654:Vascular Patency / Q000502:physiology; D014656:Vascular Surgical Procedures / Q000379:methods*; D014690:Venous Pressure