Application of intraoperative cine-portogram to detect spontaneous portosystemic collaterals missed by intraoperative doppler exam in adult living donor liver transplantation.

Adequate portal inflow is essential to the regeneration of a partial liver graft after adult living donor liver transplantation (LDLT). A recipient having large spontaneous portosystemic collaterals with or without portal vein (PV) stenosis would require surgical interruption of large collaterals and/or correction of PV stenosis to prevent postoperative "portal flow steal phenomenon." Intraoperative Doppler ultrasound (IOUS) has been used to estimate the adequacy of portal inflow, but it has a limitation to identify the correct anatomical and hemodynamic parameters of portosystemic collaterals. We initiated to utilize intraoperative cine-portogram (IOCP) to overcome the limitations of IOUS. The spontaneous portosystemic large collaterals in 5 of 156 adult LDLTs from March 2003 to February 2004 were precisely identified not by IOUS but by IOCP, and successfully interrupted. In addition, 3 of these patients had stenotic PV (<1 cm in diameter), which was interfering with the hepatopetal portal flow and the PVs were effectively widened by the placement of intraoperative PV stenting. In conclusion, IOCP seems to be an effective tool for precise detection of the persistent large portosystemic collaterals that were not detected by IOUS, and for monitoring their complete interruption.