Middle hepatic vein (MHV) reconstruction with vessel graft interposition is an accepted standard procedure for living-donor liver transplantation (LDLT) using modified right lobe grafts [1,2]. Various interposition materials have been used, including homologous and autologous vessels and synthetic vascular grafts. Since the supply of iliac vein allografts was often very limited, we used cryopreserved aorta allografts (CAG) with small-artery patches, which demonstrated acceptably high patency rates in comparison with ringed polytetrafluoroethylene (PTFE) grafts [3]. However, the patients who have been treated using PTFE grafts have problems with accidental gastric and duodenal penetration by the PTFE graft sporadically [4]. To replace PTFE grafts with other available vessel allografts, we used CAG more frequently used than before. However, the duodenal ulceration for using steroids and the strong forces which endure the pressure from around tissues could cause problems like penetration to adjacent hollow viscous organs, similar to PTFE. We present a case of a patient who underwent an emergency operation for hematochezia four months after LDLT using CAG for MHV reconstruction.

A 56-year-old male patient was admitted to our institution for hepatitis B virus-associated liver cirrhosis with recurrent hepatocellular carcinoma (HCC). The patient was suffering from hematemesis due to variceal bleeding (Fig. 1A), and the model for end-stage liver disease score was 20. Because there was a low chance for deceased donor liver transplantation, he underwent LDLT using a modified right liver graft (Fig. 1B). The donor was his 26-year-old daughter. The right liver graft weighed 630 g, making a graft-to-recipient weight ratio of 0.81. The graft MHV branches were reconstructed using a cryopreserved aorta allograft conduit. The CAG had been cryopreserved under 80℃ for two months. And we did not perform an endarterectomy. The right liver graft had single bile duct openings, and duct-to-duct anastomoses were performed using the orifices of the recipient’s right hepatic ducts (Fig. 1C). A 4 cm-sized HCC was identified in the explant liver (Fig. 1D). The patient recovered uneventfully from the LDLT operation and was discharged at 21 days from our institution. And the patient was followed up regularly every 3 to 4 months. The immunosuppressant regimen was administered monotherapy with tacrolimus, and the target trough level was 6 ng/mL to 8 ng/mL. The Steroid had been used for one month. To prevent duodenal ulceration from using steroids after LDLT, we use proton pump inhibitors and aluminum hydroxide during the periods of the steroids use.

Figure 1. (A) Preventive endoscopic variceal ligation (#6). (B) Computed tomography taken 4 days after living donor liver transplantation using a modified right liver graft shows the usual posttransplant findings. (C) Direct topography taken shows normal anatomy of bile duct tree. (D) The explant liver shows advanced liver cirrhosis with tumors.

Four months after LDLT, he was admitted to the intensive care unit via the emergency department because of syncope. Decreased hemoglobin level led to the performance of abdomen computed tomography, in which a large hematoma in the duodenum was identified (Fig. 2A). The patient was referred to the internal medicine department for further evaluation. Duodenoscopy showed about a 1.2 cm-sized ulcer with a clot on it at the 2nd portion of the duodenum (Fig. 2B). However, one day later, a large amount of hematochezia occurred again. And the hemoglobin level was dropped from 11.8 g/dL to 7.1 g/dL. Although the specialist tried two more times to stop the bleeding with endoscopic clipping, it was failed. Therefore, we decided to explo-laparotomy.

Figure 2. (A) Duodenal ulcer bleeding with clots formation. (B) A large amount of hematoma along the duodenal wall, 1st and 2nd portion of the duodenum.

We had access through the previous surgical site. The stomach and duodenum were firmly attached to the hepatic resection surface. Therefore, we meticulously dissected the duodenum from the resection margin of the modified right lobe graft. During operation, we found the fistula formation of the duodenum with the CAG. After excising the fistula, we closed the opening hole with 5-0 Prolene, a continuous suture manner (Fig. 3). The duodenum was severely distended, and the mucosal integrity looked very vulnerable. Therefore, we performed gastrojejunostomy with feeding jejunostomy without closing passage from the stomach to the duodenum.

Figure 3. (A) Middle hepatic vein reconstructed with cryopreserved aorta graft, sutured. (B) Duodenal ulcer perforation site.

This patient recovered uneventfully from the surgery without significant surgical complications and was discharged from our institution 25 days after the operation (Fig. 4A). The patient has been doing well for three months after the operation without any evidence of tumor recurrence or duodenal ulceration (Fig. 4B, C). The postoperative follow-up surveillance protocol for the patient is the same as that for the usual HCC-transplant patients.

Figure 4. (A) Computed tomography (CT) taken at postoperative 20 days showed the normal contour of the duodenum. (B) CT taken one year after living-donor liver transplantation shows the usual findings following transplantation using a modified right graft. (C) Gastroduodenoscopy taken one year after the event shows normal appearance of mucosal integrity without ulceration.

There are some debates regarding the superiority of interposition materials for MHV reconstruction [5,6]. When considering availability, diameter, and length, the cryopreserved iliac vein allograft has been regarded as the most suitable interposition material for MHV reconstruction. Interestingly, the CAG demonstrated superior patency compared to cryopreserved iliac vein allografts in the previous study [2]. The patency of the CAG appears to be higher than expected. The only differences between CAG and iliac vein allograft are wall thickness and diameter. Although the CAG has those merits, such as the large diameter and the protective effect of the wall thickness against extrinsic compression, we did not know that it could make a problem. The ringed PTFE grafts have the same effect as the outer rings against extrinsic compression. Therefore, the PTFE could make accidental gastric penetration sporadically, and most PTFE grafts remain as a foreign body after thrombotic luminal obliteration. However, because the CAG is the biomaterials, the fistular with the other hollow viscus organ can occur when extrinsic pressure is on the wall continuously. Furthermore, if the CAG was atherosclerotic or calcified, the hardness could be one of the factors in making a fistula (Fig. 5). The patient who underwent LDLT usually had steroids that have risks of making gastroduodenal ulcers, and the fistular formation can be accelerated.

Figure 5. Calcification was seen in the wall of cryopreserved aortic graft (A, arrows) and there was adhesion of reconstructed middle hepatic vein with duodenum (B, arrows).

Even though it has a problem, this case is scarce. Therefore, we cannot find any report about this complication. Moreover, using the CAG combined with small-artery patches demonstrated high patency rates that surpass other vessel grafts.

Therefore, in the case of using CAG, caution is required because there is a possibility of serious occurrence of adhesions, fistulas, and bleeding when using CAG with severe calcification or atherosclerosis.

There was no funding related to this study.

All authors have no conflicts of interest to declare.

Conceptualization: SHK, GSC. Data curation: SJH, SHK, ISS. Methodology: SJH, SHK. Visualization: SHK, GSC. Writing - original draft: SHK, ISS. Writing - review & editing: SHK.