Background & Aims: One of the challenges in Segmental Liver Transplantation is the reconstruction of Hepatic Vein (HV). The occurrence of Hepatic Vein Outflow Obstruction (HVOO) can result in graft loss. The aim of this study was to describe the outcomes in different Types of HV distribution of Left Lateral Segments (LLS) grafts.

Patients & Methods: Children (< 18 years) who underwent a Living Donor Liver Transplantation (LDLT) with LLS grafts during the period from February 2017 to August 2021 with follow-up until February 2022. Retrospective cohort study through data review of medical records and from a prospectively collected data base. The LLS grafts were classified according to the number and distance between HV – Graft Hepatic Vein (GVH) classification, determining the vascular reconstruction performed. Type I: a single orifice; type II: two close orifices – wedge unification; Type IIIa: two separated orifices up to 20 mm distance – venoplasty to achieve a single orifice and Type IIIb (Anomalous Hepatic Vein – AHV): two separated orifices beyond 20 mm distance – Homolog Vein Graft (HVG) interposition. Recipient and Intraoperative variables included age, diagnosis, recipient weight, PELD scores, ascites, Graft-to-Recipient Weight Ratio (GRWR), Graft Hepatic Vein (GHV) diameter, Recipient Hepatic Vein (RHV) diameter, GHV and RHV correlation, Cold Ischemia Time (CIT), Warm Ischemia Time (WIT), need for IVC exclusion during implant, use of PV graft and mesh closure. Post-LT outcomes included the occurrence of HVOO, early (≤ 30 days) portal vein thrombosis (EPVT), late (> 30 days) portal vein thrombosis (LPVT), hepatic artery thrombosis (HAT), and retransplantation.

Results: 303 LDLT were performed in which LLS grafts were used. According to the GHV classification, the distribution of the LLS grafts was Type I: 174 (57.42%), Type II: 97 (32.01%), Type IIIa: 25 (8.26%) and Type IIIb: 7 (2.31%). Comparative analysis of recipient and intraoperative variables showed Type IIIb grafts presented a higher proportion of larger LLS and consequently a higher GRWR, as well as a higher mean of GHV, consequently higher GVH/RVH correlation. It was observed a higher CIT average in the LLS that required vascular reconstruction in the bench surgery – Types IIIa and IIIb grafts. There was no statistically significant difference between the LLS graft Types, in the post-transplant outcomes. Up to last follow up no HVOO was observed in this cohort study. The comparative analysis of the cumulative graft survival rate showed no difference according to the LLS graft Type used.

Conclusion: The reconstruction of venous drainage plays as essential role in the surgical management of LDLT with LLS grafts. The use of HVG interposition is a good surgical strategy in the use of LLS grafts that have AHV.