A 63-year-old female patient with hepatitis B-related liver cirrhosis was transferred to Daegu Catholic University Medical Center because of refractory ascites and hepatic encephalopathy. Preoperative Doppler ultrasonography and multidimensional computed tomography (MDCT) revealed the diffuse PVT that extended to the superior mesenteric vein (SMV) and splenic vein. In addition, marked dilated paracholedochal veins around the PV were being fed from the gastroepiploic veins and pancreaticoduodenal veins (Fig. 1A). Mesenteric venography demonstrated several findings, including complete invisibility of the main PV and SMV and large tortuous paracholedochal veins that extended to the proximal SMV (Fig. 1B). The donor was her 59-year-old brother. The estimated graft volume of the donor's right lobe as calculated by CT volumetry was 798 mL, 63.7% of the whole liver and the estimated graft-to-recipient weight ratio (GRWR) was 1.42%. Therefore, LDLT using a modified right lobe graft from her younger brother was performed. After complete mobilization of the recipient's liver, hepatic hilar dissection was attempted. However, dissection of the vascular pedicle at the hilum was too difficult due to severe fibrosis and a complex network of tortuous paracholedochal varices. Thus, after dissection and ligation of the hepatic arteries were performed, the PV and bile duct were clamped and transected en masse. Dissection of the native PV revealed that it had no obvious lumen and was replaced by a fibrotic, thrombosed cord. We identified two collateral veins with large orifices around the bile duct and transformed these large dilated collaterals into a common orifice with a venoplasty at their confluence. Several small collaterals which were not suitable for portal inflow were ligated. After declamping of the hilum, we ensured that the blood flow was adequate for portal inflow by spurting through the common orifice. We carried out usual end-to-end anastomosis of the donor PV to the large common orifice formed by the confluence of the markedly dilated paracholedochal veins using a running suture of 6-0 prolene (Fig. 2A). The graft was reperfused after completion of the PV anastomosis followed by hepatic artery reconstruction using a microsurgical technique. Roux-en-Y hepaticojejunostomy was performed because of severe periductal fibrosis and a narrowed caliber that could not maintain bile flow for duct-to-duct anastomosis. Intraoperative Doppler assessment showed adequate portal blood flow to the graft, and the PV patency was demonstrated by regular Doppler monitoring and MDCT (Fig. 2B).

The patient was discharged 3 weeks postoperatively without any complications and has been doing well for 22 months with normal graft function.

A 51-year-old man was admitted with massive ascites and general weakness due to alcoholic liver cirrhosis. Preoperative Doppler ultrasonography and MDCT demonstrated several dilated paracholedochal veins along hilum and diffuse PVT extended to SMV like the first case. The donor was his 30-year-old son. The preoperative CT volumetry demonstrated the estimated right to left lobe volumes to be 966 mL and 500 mL (65.9% and 34.1% in volume ratio) and the estimated GRWR was 1.19%. Thus, we planned to perform LDLT using a modified right lobe graft from his son. During the operation, we found chronic organized PVT with dilated paracholedochal collaterals along porta hepatis. The transected PV showed no venous flow; it contained chronic totally organized thrombi with fibrosis. Even though we tried to eversion thrombectomy, it was failed to obtain sufficient portal inflow to the graft. Unfortunately, the caliber of these collaterals was smaller than that of case 1 and venous flow through common orifice with venoplasty from their confluence was not sufficient for portal inflow. Because another approach to gain splanchnic inflow could not be available, we performed unification venoplasty with common colaca from paracholedochal veins and partially recanalized naitive PV to supplement unsatisfactory inflow through paracholedochal collaterals. This complex common orifice was anastomosed to the donor PV in end-to-end fashion as a single anastomosis (Fig. 3A). Hepatic artery and bile duct reconstruction was performed by the same method as case 1.

Intraoperative Doppler ultrasonography showed satisfactory portal blood flow in the liver graft and the good PV patency was demonstrated by serial postoperative Doppler studies(Fig. 3B) and MDCT. He was discharged without any serious complication and has remained stable without ascites, variceal bleeding for 21 months after transplantation.