(Radiographics. 2001;21:39-52.)
© RSNA, 2001
Use of Imaging for Living Donor Liver Transplantation1
Matthew J. Bassignani, MD,
Ann S. Fulcher, MD,
Richard A. Szucs, MD, 2,
Wui K. Chong, MBBS,
Uma R. Prasad, MD and
Amadeo Marcos, MD, 3
1 From the Departments of Radiology (M.J.B., A.S.F., R.A.S., W.K.C., U.R.P.) and Transplant Surgery (A.M.), Medical College of Virginia of Virginia Commonwealth University, Richmond. Recipient of a Certificate of Merit award for a scientific exhibit at the 1999 RSNA scientific assembly. Received April 14, 2000; revision requested May 19 and received July 26; accepted July 28. Address correspondence to M.J.B., Department of Radiology, University of Virginia Health Sciences Center, Lee St, Box 800170, Charlottesville, VA 22908-0170 (e-mail: mjb4f@virginia.edu).
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Abstract
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Living donor liver transplantation is emerging as an alternative to cadaveric liver transplantation. The authors present multimodality images obtained in 44 cases of living donor liver transplantation. The images in this article were derived from the pre-, intra-, and postoperative imaging protocol for their institutional transplantation program. Preoperative magnetic resonance (MR) imaging in the donor allows detection of focal liver lesions and accurate determination of liver volume. The latter is crucial to ensure adequate postoperative liver function for donors and recipients. MR cholangiography depicts donor biliary anatomy. MR angiography and digital subtraction arteriography are performed to assess vascular anatomy. Intraoperative ultrasonography (US) helps determine the resection plane during donor hepatectomy. Postoperative MR imaging documents liver regrowth. MR imaging, US, and computed tomography help assess complications in donors and recipients.
Index Terms: Liver, CT, 761.12112 • Liver, MR, 761.121412, 761.121415, 761.12143 • Liver, transplantation, 761.451, 761.458 • Liver, US, 761.12982, 761.12983 • Transplantation, 761.451, 761.458
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Introduction
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During the past 10 years, there has been a linear increase in the number of liver transplantations performed, but the number of available organs has not increased (1). In view of the critical shortage of organs, the indications for living donor liver transplantation have broadened as experience and success with the procedure have been achieved. In living donor liver transplantation, part of a living donor's liver is transplanted into the recipient after the diseased liver is resected. The first successful living donor liver transplantations were performed in children, with use of the left lateral hepatic segment (1–6). Living related and unrelated liver transplantations have recently been performed in adults with use of both left-lobe and right-lobe transplants (7–13).
As of April 2000, 44 living donor liver transplantations were performed at our institution. The donor and recipient were related in 30 cases, and they were genetically unrelated in 14. During a mean follow-up period of 200 days, four recipients died, but no donors died or experienced significant loss of liver function.
The major advantage of living donor liver transplantation is that it increases the number of organs available for transplantation. In addition, living donor liver transplantation allows performance of surgery on an elective basis and frees the recipient from awaiting the availability of a cadaveric organ. These factors may reduce morbidity, mortality, and cost. The reduction in cold ischemia time (the time an ex vivo organ is not perfused with blood) and the use of healthy donor livers are additional advantages of living donor liver transplantation.
Living donor liver transplantation is a radiology-intensive process that, at our institution, involves the performance of preoperative magnetic resonance (MR) imaging (including MR cholangiography and MR angiography) and digital subtraction angiography (DSA) to assess donor anatomy and evaluate for adequate liver volume. Intraoperative ultrasonography (US) is used to determine the plane of dissection for removal of the donor's right hepatic lobe. MR imaging, US, and computed tomography (CT) are used at the surgeon's discretion to evaluate for complications.
This article illustrates the important role of imaging before, during, and after living donor liver transplantation. The images represent the authors' experience with multimodality imaging of liver transplantation donors and recipients, with emphasis on MR imaging, MR cholangiography, MR angiography, and DSA for preoperative evaluation of donors; intraoperative US for guidance of right-lobe resection; and MR imaging, CT, and US for assessment of postoperative complications.
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Surgical Procedure
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Cadaveric liver transplantation has become increasingly successful with the advent of modern immune suppression and surgical techniques. As a result of the critical shortage of donor organs available for pediatric patients, the first successful living related liver transplantations were performed in children with use of the left lateral hepatic segment (1–6). This procedure has been performed extensively in Japan where, until recently, cadaveric transplantation was prohibited. Left lateral segment transplantation is a relatively straightforward procedure and supplies the recipient with a reduced amount of liver tissue that is suitable for a child recipient.
The first living donor liver transplantations in adults were performed with the left lateral hepatic segment (7,8) and were limited by concern for adequate graft volume for the recipient (9). It is believed that 50% of normal hepatic volume is required to support the recipient (10). Although the precise amount of liver required to sustain an adult has not been quantified, it is postulated that 1% of the recipient's body mass should be sufficient (10). The first transplantation of a right hepatic lobe from a living related donor was performed for reasons concerning the aberrant blood supply to the donor's lateral segment (11). Concern for adequate liver volume for the recipient led to development of a technique with a right-lobe graft (12,13). Right hepatic lobe transplantation is the procedure of choice for the adult population (Fig 1) (12).
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Figure 1. Right lobectomy. Diagram shows the right hepatic lobe lifted out of the peritoneal cavity. IVC = inferior vena cava, MPV = main portal vein, PV = remnant of the right portal vein, RHV = right hepatic vein.
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Intraoperative US is performed to help identify the plane of dissection for right lobectomy. At the dome of the liver, a plane is created 1 cm lateral to the middle hepatic vein. This plane is extended inferiorly to the bifurcation between the right and left portal veins. Surgeons isolate the right hepatic artery, portal vein, hepatic vein, and bile duct with vessel loops. Once control over these vital structures is achieved, the vessels and bile duct are severed, and the right hepatic lobe is removed (Fig 2). A second team of surgeons, who have already removed the recipient's diseased liver, transplants the donor's right hepatic lobe. Vascular anastomoses and a biliary-enteric anastomosis are created.
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Preoperative Evaluation of Donors
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Abdominal MR Imaging and Volumetric Liver Analysis
In an assessment for abnormalities such as focal hepatic lesions, abdominal MR imaging was conducted with breath-hold T1-weighted gradient-echo sequences with or without fat suppression and with breath-hold T2-weighted fat-suppressed sequences (Fig 3). MR examinations were performed with a 1.0-T magnet (Magnetom Expert, Siemens, Erlangen, Germany; maximum gradient strength, 20 mT/m; rise time, 1 msec). A circularly polarized phased-array body coil was used in all cases.
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Figure 3a. Normal liver in a donor. Gadolinium-enhanced T1-weighted fat-suppressed MR image (200/4.4, flip angle of 70°, section thickness of 8 mm, gap of 20%) (a) and T2-weighted fat-suppressed MR image (3,500/138, section thickness of 8 mm, gap of 25%) (b) depict the liver parenchyma, portal vein branches (arrows), and hepatic veins (arrowheads).
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Figure 3b. Normal liver in a donor. Gadolinium-enhanced T1-weighted fat-suppressed MR image (200/4.4, flip angle of 70°, section thickness of 8 mm, gap of 20%) (a) and T2-weighted fat-suppressed MR image (3,500/138, section thickness of 8 mm, gap of 25%) (b) depict the liver parenchyma, portal vein branches (arrows), and hepatic veins (arrowheads).
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Pulse sequences included precontrast T1-weighted breath-hold spoiled gradient-echo MR imaging (repetition time msec/echo time msec of 148/5, flip angle of 70°, section thickness of 10 mm, gap of 30%), pre- and postcontrast T1-weighted fat-suppressed MR imaging (200/4.4, flip angle of 70°, section thickness of 8 mm, gap of 20%), and precontrast T2-weighted breath-hold fast spin-echo MR imaging (3,500/138, section thickness of 8 mm, gap of 25%).
Gadopentetate dimeglumine (Magnevist; Berlex Laboratories, Wayne, NJ) was administered intravenously in a dose of 0.1 mmol per kilogram of body weight as a bolus followed by a 10-mL normal saline flush to evaluate the solid organs of the abdomen, particularly the liver, for focal lesions. Imaging was conducted immediately after administration of gadopentetate dimeglumine and at 1 and 5 minutes thereafter. The time required to perform this component of the MR examination was approximately 25 minutes.
Volumetric liver analysis (14,15) was conducted with gadolinium-enhanced T1-weighted fat-suppressed MR imaging sequences (Fig 4). Before transplantation, it is important to determine the volumes of the right hepatic lobe that will be resected and of the left hepatic lobe, because sufficient liver parenchyma must be present to sustain adequate liver function in both the recipient and donor (9,10,12,13). The volumes of the right hepatic lobe, medial and lateral segments of the left hepatic lobe, and caudate lobe were calculated by radiologists (M.J.B., A.S.F., R.A.S.) who electronically traced the margins of these structures on each image. Computer-calculated areas were then generated from these tracings and were multiplied by the section thickness (including the gap) to yield a volume (Fig 5).
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Figure 4a. Volumetric analysis of the liver. (a) Gadolinium-enhanced T1-weighted fat-suppressed axial MR image (200/4.4, flip angle of 70°, section thickness of 8 mm, gap of 20%, field of view of 380 mm, one signal acquired, matrix of 128 x 256) obtained near the liver dome shows the right (arrows) and middle (arrowheads) hepatic veins. The electronic tracings show the margins of the right hepatic lobe (Rt), the medial (Med) and lateral (Lat) segments of the left hepatic lobe, and the caudate lobe (C). These tracings allow calculation of the areas (upper right corner). (b) Gadolinium-enhanced T1-weighted fat-suppressed axial MR image (200/4.4) obtained at the level of the main portal vein (MPV) shows lobar and segmental anatomy. The electronic tracings show the margins of the right hepatic lobe (Rt) and the medial (Med) and lateral (Lat) segments of the left hepatic lobe. These tracings allow calculation of the areas (upper right corner).
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Figure 4b. Volumetric analysis of the liver. (a) Gadolinium-enhanced T1-weighted fat-suppressed axial MR image (200/4.4, flip angle of 70°, section thickness of 8 mm, gap of 20%, field of view of 380 mm, one signal acquired, matrix of 128 x 256) obtained near the liver dome shows the right (arrows) and middle (arrowheads) hepatic veins. The electronic tracings show the margins of the right hepatic lobe (Rt), the medial (Med) and lateral (Lat) segments of the left hepatic lobe, and the caudate lobe (C). These tracings allow calculation of the areas (upper right corner). (b) Gadolinium-enhanced T1-weighted fat-suppressed axial MR image (200/4.4) obtained at the level of the main portal vein (MPV) shows lobar and segmental anatomy. The electronic tracings show the margins of the right hepatic lobe (Rt) and the medial (Med) and lateral (Lat) segments of the left hepatic lobe. These tracings allow calculation of the areas (upper right corner).
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Figure 5. Illustration demonstrates summation of liver MR images (200/4.4) (arrows) for volumetric analysis. Representative axial MR images of the liver obtained at sequential levels (right) are used in the calculation of the lobar and segmental liver volumes (left).
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CT and CT angiography were performed in donors to help assess for focal and diffuse liver disease or vascular abnormalities and anomalies, as well as to help calculate liver volumes. Kamel et al (16) report that findings at multidetector spiral CT serve well in this capacity and allow accurate calculation of liver volume and visualization of third-order intrahepatic arteries. CT is associated with disadvantages, however, such as exposure of healthy donors to ionizing radiation and nephrotoxic contrast material.
MR Cholangiography
MR cholangiography was performed in conjunction with abdominal MR imaging (Fig 6). To provide scout images of the abdomen, MR imaging of the abdomen was initially conducted in the coronal plane without fat suppression, with use of a half-Fourier rapid acquisition with relaxation enhancement (RARE) sequence (
/60 [effective], refocusing flip angle of 150°, section thickness of 8 mm, gap of 10%, field of view of 400 x 400 mm, one signal acquired, matrix of 208 x 256 [phase encoding x frequency encoding], acquisition time of 22 seconds). The biliary tract was then localized with fat-suppressed thick-slab RARE MR imaging (/1,100 [effective], refocusing flip angle of 180°, section thickness of 40 mm, field of view of 270 x 270 mm, one signal acquired, matrix of 240 x 256 [phase encoding x frequency encoding], acquisition time of 7 seconds) in the coronal-oblique (25°) and axial planes.
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Figure 6. Normal biliary tract. Coronal half-Fourier RARE MR image (/60 [effective]) shows the normal right and left intrahepatic bile ducts (arrows) and the normal extrahepatic bile duct (arrowhead).
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The thick-slab MR cholangiograms were then used as guides to help prescribe the appropriate angles of acquisition for the multisection thin-slab (5-mm) MR cholangiographic technique (/88.0 [effective], refocusing flip angle of 140°, section thickness of 5.0 mm with no gap, field of view of 270 x 270 mm, one signal acquired, matrix of 240 x 256 [phase encoding x frequency encoding], acquisition time of 18 seconds). Multisection thin-slab (5-mm) MR cholangiography was performed in the coronal-oblique plane parallel to the long axis of the extrahepatic bile duct. Thirteen images were obtained during each 18- to 20-second acquisition. Fat suppression was used in all cases. Both the thick- and thin-slab images were obtained during a breath hold. Performance of MR cholangiography required approximately 10 minutes.
MR cholangiography permits preoperative detection of abnormalities and anatomic variants of the biliary tract that may complicate resection of the right hepatic lobe (17,18). In our patients, such variants included a trifurcation anomaly (Fig 7) and a dorsocaudal branch of the right hepatic duct that drained into the left hepatic duct (Fig 8). Although such variant anatomy may be delineated at intraoperative cholangiography, the preoperative detection of variant anatomy allowed surgeons to plan their approach before beginning the resection.
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Figure 8. Variant bile duct anatomy. Coronal thick-slab MR cholangiogram (/1,100 [effective]) provides a comprehensive image of the biliary tract that demonstrates the dorsocaudal branch (arrows) of the right hepatic duct entering the central left hepatic duct.
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MR Angiography
MR angiography was performed in the same examination time slot as were abdominal MR imaging and MR cholangiography. MR angiography was conducted with a breath-hold two-dimensional time-of-flight sequence, in the coronal plane (Fig 9a, 9b). Although three-dimensional images were generated from the source images with the use of a maximum intensity projection algorithm, all diagnostic decisions were based on the source images. MR angiography helps detect variant anatomy such as a common trunk of the right and middle hepatic veins (19), a repositioned right hepatic artery, and anomalies of the portal vein such as trifurcations (20). In addition, MR angiography also helps confirm patency of the portal vein.
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Figure 9a. (a) Coronal T1-weighted breath-hold spoiled gradient-echo MR angiogram (148/5, flip angle of 70°, section thickness of 10 mm, gap of 30%) shows a normal main portal vein (arrow) and normal right and left portal veins (arrowheads). (b) MR angiogram (148/5) obtained 5 mm anterior to a shows normal hepatic (arrow) and splenic (arrowhead) arteries. (c) DSA image depicts the hepatic (arrow) and splenic (arrowheads) arteries as normal.
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Figure 9b. (a) Coronal T1-weighted breath-hold spoiled gradient-echo MR angiogram (148/5, flip angle of 70°, section thickness of 10 mm, gap of 30%) shows a normal main portal vein (arrow) and normal right and left portal veins (arrowheads). (b) MR angiogram (148/5) obtained 5 mm anterior to a shows normal hepatic (arrow) and splenic (arrowhead) arteries. (c) DSA image depicts the hepatic (arrow) and splenic (arrowheads) arteries as normal.
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Figure 9c. (a) Coronal T1-weighted breath-hold spoiled gradient-echo MR angiogram (148/5, flip angle of 70°, section thickness of 10 mm, gap of 30%) shows a normal main portal vein (arrow) and normal right and left portal veins (arrowheads). (b) MR angiogram (148/5) obtained 5 mm anterior to a shows normal hepatic (arrow) and splenic (arrowhead) arteries. (c) DSA image depicts the hepatic (arrow) and splenic (arrowheads) arteries as normal.
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DSA Examination
DSA was performed as the final radiologic evaluation in the potential donor only after all other imaging evaluations failed to reveal contraindications to donation (Fig 9c). The DSA examination involved evaluation of the abdominal aorta, branches of the celiac axis, and superior mesenteric artery. The portal vein was evaluated with delayed DSA images obtained after selective catheterization of the celiac axis and superior mesenteric artery and administration of papaverine hydrochloride. Important observations included variant vascular anatomy (Fig 10) and the varied arterial supply to segment IV (Couinaud nomenclature). DSA shows the relationship of the portal vessels to one another, especially in segment IV (12), and helps confirm patency of the main portal vein. Although many anatomic variants are detected with MR angiography, DSA is usually required to depict variant anatomy of the small segmental arteries that might complicate right hepatic lobe resection, such as variant branches to segment IV that arise from the right hepatic artery. Recognition and preservation of this vascular supply to segment IV is mandatory to ensure functioning of this segment in the donor (21). Improvements in MR imaging hardware and software may result in MR angiography that depicts segmental arterial anatomy, which may obviate DSA.
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Intraoperative US in Donors
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Owing to the extreme variability of hepatic arterial and venous supply to the liver, particularly the varied supply to segment IV (12), intraoperative US guidance was required during resection of the donor's right hepatic lobe. The liver was exposed by using a standard inverted Y incision. Intraoperatively, the surgeons and radiologist reviewed the superficial anatomy of the exposed liver. The dome of the liver was visually inspected to identify the suprahepatic portion of the inferior vena cava and the branches of the hepatic veins.
A curved 8-4-MHz intraoperative US probe (ATL, Bothell, Wash) was draped in sterile fashion. The probe was placed on the liver at the suprahepatic inferior vena cava and moved along the anterior surface of the liver in the transverse plane (Fig 11) to help identify the normal vascular structures. An effort was made to identify accessory hepatic veins, because they contribute significantly to the outflow of the right lobe (12). The transplant surgeon followed with an argon beam coagulator and scored the liver surface with small bursts from the laser, which created visible dots along the surface of the liver (Fig 11). These dots were seen on the US scan as an echogenic interface with strong posterior acoustic shadowing (Fig 12). Scoring was performed at 1-cm increments from the suprahepatic inferior vena cava to demarcate the hepatic veins through the right portal vein (Fig 13) down to the gallbladder fossa. Once the proper plane was confirmed, a burst from the argon laser was made from the liver dome to the gallbladder fossa to connect the dots on the liver surface (Fig 14). This line defined a relatively avascular dissection plane that was used to divide the liver (Fig 15). At this point, the surgeons proceeded with the right hepatectomy, while preserving 1 cm of tissue just to the right of the middle hepatic vein.
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Figure 11. Illustration A demonstrates intraoperative US performed to map the plane of dissection 1 cm lateral to the middle hepatic vein. Diagram B depicts the argon laser as it scores the liver surface.
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Figure 12. Delineation of dissection plane. Color Doppler US scan demonstrates an artifact (arrow) created by scoring of the liver that is 1 cm lateral to the middle hepatic vein (MHV). IVC = inferior vena cava, RHV = right hepatic vein.
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Figure 13. Delineation of dissection plane. Gray-scale US scan demonstrates an artifact (arrow) created by scoring of the liver that demarcates the plane of dissection through the right portal vein (arrowheads).
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Figure 15. Liver dissection. The liver is split along the plane mapped with US. Vessel loops (arrows) isolate the major hepatic vascular and biliary structures before right lobectomy.
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Postoperative Evaluation of Donor and Recipient
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Regeneration of Liver Volumes
Our protocol prescribes performance of MR imaging in donors and recipients on postoperative days 7 and 30 to document regeneration of liver volumes (Fig 16). Liver volumes are then calculated by using the previously described method.
The liver has a remarkable capacity for regeneration after major resection (22,23), particularly normal livers. A recent report of 37 donors who underwent MR imaging after left lateral segmentectomy or left lobectomy shows that the volume of the remnant liver is restored to some extent within 4 weeks (23). The precise mechanism of regeneration is not completely understood. In the early phase (first 2 postoperative weeks), there was rapid regeneration with associated vascular engorgement and tissue edema (Figs 17, 18). In the second phase (1–2 months after resection), the volume actually decreased, probably secondary to reduced vascular engorgement and edema. In the third phase (
1 year), there was a continued slow increase in liver volume, which eventually reached a plateau (23).
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Figure 17a. Postoperative day 7 in a donor. (a) Gadolinium-enhanced T1-weighted axial fat-suppressed MR image (200/4.4) shows the hypertrophic lateral segment (*) of the left hepatic lobe and reorientation of the portal vein (arrow). (b) In the more cephalic section, a small postoperative fluid collection (F) is shown at the resection site.
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Figure 17b. Postoperative day 7 in a donor. (a) Gadolinium-enhanced T1-weighted axial fat-suppressed MR image (200/4.4) shows the hypertrophic lateral segment (*) of the left hepatic lobe and reorientation of the portal vein (arrow). (b) In the more cephalic section, a small postoperative fluid collection (F) is shown at the resection site.
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Figure 18. Postoperative day 7 in a recipient. Gadolinium-enhanced T1-weighted axial fat-suppressed MR image (200/4.4) shows the transplanted right hepatic lobe (*), which has undergone hypertrophy.
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Complications and Postoperative Observations
Complications that occur as a result of living related liver transplantation are reported in left-lobe and left lateral segment transplantation (24–26). The major complications in donors include abscess, bile leakage, liver dysfunction owing to ligation of a major bile duct branch, hepatic artery injury, and duodenal ulcer. The major complications in recipients include stenosis of the biliary-enteric anastomosis, stenosis of the portal vein anastomosis, outflow obstruction of the hepatic vein anastomosis, portal vein thrombosis, hepatic artery thrombosis, bile leakage, abscess, and rejection.
Since relatively few right-lobe living donor liver transplantations have been performed, little information exists regarding the donor and recipient complications. In our series of patients, we identified several complications. Complications in donors included a simple fluid collection at the resection site without associated biliary obstruction (Fig 19), a hematoma at the resection site that resulted in biliary obstruction (Fig 20), and a stricture at the biliary resection site. Complications in recipients included isolated obstruction of a right hepatic duct branch due to stricture at the biliary-enteric anastomosis (Fig 21), obstruction of all branches of the right hepatic ducts due to a stricture at the biliary-enteric anastomosis (Fig 22), intraperitoneal abscess (Fig 23), reversal of flow in the main portal vein (Fig 24), and hepatic infarction (Fig 25).
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Figure 19. Postoperative day 7 in a donor. T1-weighted fat-suppressed axial MR image (200/4.4) demonstrates a perihepatic biloma (B) without associated biliary obstruction. The biloma is depicted as a low-signal-intensity collection that is inseparable from the cut surface of the liver (arrows).
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Figure 20a. Postoperative day 30 in a donor. (a) Coronal-oblique thin-slab (5-mm) MR cholangiogram (/88 [effective]) shows biliary obstruction due to a hematoma. Dilated ducts (arrows) are depicted in the residual left hepatic lobe. The intrapancreatic portion of the extrahepatic bile duct (arrowhead) is normal caliber (1 mm). (b) Gadolinium-enhanced T1-weighted fat-suppressed MR image (200/4.4) of the liver demonstrates that the dilated left hepatic duct (arrows) is obstructed at the cut surface of the liver. A hematoma (H) that is nearly isointense relative to the liver lies at the cut surface of the liver.
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Figure 20b. Postoperative day 30 in a donor. (a) Coronal-oblique thin-slab (5-mm) MR cholangiogram (/88 [effective]) shows biliary obstruction due to a hematoma. Dilated ducts (arrows) are depicted in the residual left hepatic lobe. The intrapancreatic portion of the extrahepatic bile duct (arrowhead) is normal caliber (1 mm). (b) Gadolinium-enhanced T1-weighted fat-suppressed MR image (200/4.4) of the liver demonstrates that the dilated left hepatic duct (arrows) is obstructed at the cut surface of the liver. A hematoma (H) that is nearly isointense relative to the liver lies at the cut surface of the liver.
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Figure 21. Postoperative day 30 in a recipient. Coronal half-Fourier RARE MR image (/60) of the abdomen shows segmental biliary obstruction. The transplanted right hepatic lobe (TP), a dilated branch of the right hepatic duct (arrows), and the portal vein (arrowhead) are depicted. Dilatation is not seen in all the branches of the right hepatic duct because multiple biliary-enteric anastomoses were created for different ductal segments that drain the liver.
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Figure 22a. Postoperative day 15 in a recipient. (a) Coronal US scan demonstrates segmental biliary obstruction with a dilated branch of the right hepatic duct (arrows). (b) Contrast materialenhanced (iohexol, Omnipaque; Nycomed, Princeton, NJ) axial abdominal CT scan shows the dilated hepatic duct (arrow), which parallels the posterior division (arrowhead) of the right portal vein. (c) Percutaneous transhepatic cholangiogram shows segmental dilation of the right hepatic duct (arrows) due to obstruction at the biliary-enteric anastomosis (arrowhead).
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Figure 22b. Postoperative day 15 in a recipient. (a) Coronal US scan demonstrates segmental biliary obstruction with a dilated branch of the right hepatic duct (arrows). (b) Contrast materialenhanced (iohexol, Omnipaque; Nycomed, Princeton, NJ) axial abdominal CT scan shows the dilated hepatic duct (arrow), which parallels the posterior division (arrowhead) of the right portal vein. (c) Percutaneous transhepatic cholangiogram shows segmental dilation of the right hepatic duct (arrows) due to obstruction at the biliary-enteric anastomosis (arrowhead).
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Figure 22c. Postoperative day 15 in a recipient. (a) Coronal US scan demonstrates segmental biliary obstruction with a dilated branch of the right hepatic duct (arrows). (b) Contrast materialenhanced (iohexol, Omnipaque; Nycomed, Princeton, NJ) axial abdominal CT scan shows the dilated hepatic duct (arrow), which parallels the posterior division (arrowhead) of the right portal vein. (c) Percutaneous transhepatic cholangiogram shows segmental dilation of the right hepatic duct (arrows) due to obstruction at the biliary-enteric anastomosis (arrowhead).
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Figure 23a. Postoperative day 21 in a recipient. (a) US scan of the right upper quadrant shows an intraperitoneal abscess (A). The hypoechoic collection with associated posterior acoustic enhancement (*) is representative of an abscess. (b) Gadolinium-enhanced T1-weighted fat-suppressed MR image (20/4.4) of the abdomen shows the abscess (A) as a low-signal-intensity structure medial to the liver (L). The abscess was drained surgically. Note the Gamna-Gandy bodies (arrows) in the spleen.
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Figure 23b. Postoperative day 21 in a recipient. (a) US scan of the right upper quadrant shows an intraperitoneal abscess (A). The hypoechoic collection with associated posterior acoustic enhancement (*) is representative of an abscess. (b) Gadolinium-enhanced T1-weighted fat-suppressed MR image (20/4.4) of the abdomen shows the abscess (A) as a low-signal-intensity structure medial to the liver (L). The abscess was drained surgically. Note the Gamna-Gandy bodies (arrows) in the spleen.
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Figure 24. Postoperative day 7 in a recipient. Duplex Doppler US scan demonstrates reversal of portal vein flow. In the right portal vein (arrow), flow is directed away from the transducer. Note that the waveform (arrowhead) lies below the baseline.
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Figure 25. Postoperative day 7 in a recipient. Contrast-enhanced CT scan of the liver shows an hepatic infarct. The wedge-shaped focus of low attenuation (arrows) in the anterior aspect of the transplanted right hepatic lobe represents the infarct.
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Summary
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Living donor liver transplantation increases the availability of organs for transplantation. It is a radiology-intensive procedure that requires specialized preoperative assessment of donor and recipient suitability. Preoperative MR imaging helps evaluate liver parenchyma and liver volumes and helps predict adequacy of liver volume in a prospective donor. Bile duct anatomy is shown with MR cholangiography, and vascular anatomy is mapped with MR angiography. We currently use DSA to delineate segmental hepatic arterial anatomy, although MR angiography may obviate DSA in the future. Intraoperative US is used to determine the optimal plane of resection at donor right hepatectomy. The donor liver must be divided along a plane that avoids major vessels while leaving both donor and recipient with sufficient viable liver parenchyma. Postoperative MR imaging helps evaluate donor and recipient liver regeneration. MR imaging, CT, and US help assess for complications. Complications peculiar to living donor liver transplantation include segmental biliary dilation due to obstruction at the biliary-enteric anastomosis and fluid collections at the resection margin.
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Acknowledgments
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The authors thank Laurie Persson for image preparation and Rhonda Hoyle, research assistant, for preparation of the manuscript for this article.
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Footnotes
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2 Current address: Department of Radiology, St Mary's Hospital, Richmond, Va. 
3 Current address: Department of Surgery, University of Rochester Medical Center, Rochester, NY.
Abbreviations: DSA = digital subtraction angiography,
RARE = rapid acquisition with relaxation enhancement
See also the article by Ametani et al (pp 53–63)
in this issue.
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Abstract
Introduction
