Improving hepatic and portal venous flows using tissue expander and Foley catheter in liver transplantation

Background and objective: Vascular reconstruction is important in liver transplantation because its obstruction causes graft failure and eventual loss. Vascular outflow obstruction may be due to graft malposition. We describe our experience with liver allograft repositioning using tissue expander and Foley catheter to improve hepatic and portal venous outflows. Patients and methods: A total of seven patients who received liver transplantation at our institution developed hepatic and/or portal venous obstruction during final graft positioning detected by Doppler ultrasonography (hepatic vein flow < 10 cm/s; portal vein flow < 12 cm/s). Chart and operative records of these patients were reviewed. Technique of operation, donor-recipient characteristics, use of tissue expander or Foley catheter to improve venous outflow, complications, and outcome were analyzed. Results: Hepatic and/or portal venous obstruction were detected after portal reperfusion. We used commercially available tissue expander used in plastic surgery and Foley catheter to reposition the graft. Tissue expanders were used in three recipients (age: 27-46 yr). Foley catheters were used in four recipients (age: 7 months-53 yr). One recipient used both tissue expander and Foley catheter. Expanders were filled with 300-770mL saline and placed into the right subphrenic space. Foley catheters were filled with 15-75mL saline. Significant improvements in hepatic and/or portal venous outflow were detected by Doppler ultrasonography post-graft repositioning. Aspiration of expander and Foley catheter contents was started from 6th to 27th postoperative day under sonographic guidance. All expanders and catheters were removed by the 19th-56th postoperative day (mean: 38 d). Complications included chylous ascites (1/7), bile leak (1/7), tube drain infection (2/7), septicemia (2/7). All complications were successfully managed by non-operative interventions. There was no outflow obstruction detected by ultrasonography before and after removal of expanders and catheters. One- and two-year graft and patient survivals were both 100%. Conclusion: The use of tissue expanders and Foley catheters to improve hepatic and portal venous outflow in malposed liver allografts is a simple and safe method after liver transplantation.