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American Journal of Transplantation 2015; 15: 155160


Wiley Periodicals Inc.

Copyright 2014 The American Society of Transplantation


and the American Society of Transplant Surgeons
doi: 10.1111/ajt.12965

Correlation Between Portal Vein Anatomy and Bile


Duct Variation in 407 Living Liver Donors
K. Takeishi1,*, K. Shirabe1, Y. Yoshida1,
Y. Tsutsui1, T. Kurihara1, K. Kimura1, S. Itoh1,
N. Harimoto1, Y.-I. Yamashita1, T. Ikegami1,
T. Yoshizumi1, A. Nishie2 and Y. Maehara1
1

Department of Surgery and Science, Graduate School of


Medical Sciences, Kyushu University, Fukuoka, Japan
2
Department of Clinical Radiology, Graduate School of
Medical Sciences, Kyushu University, Fukuoka, Japan

Corresponding author: Kazuki Takeishi,
ktake@surg2.med.kyushu-u.ac.jp
Our aim was to determine whether variant bile duct
(BD) anatomy is associated with portal vein (PV) and/or
hepatic artery (HA) anatomy. We examined the associations between BD anatomy and PV and/or HA
anatomy in 407 living donor transplantation donors.
We also examined whether the right posterior BD
(RPBD) course was associated with the PV and/or HA
anatomy. Variant PV, HA and BD anatomies were found
in 11%, 25% and 25%, respectively, of 407 donors
enrolled in this study. The presence of a variant BD was
more frequently associated with a variant PV than with
a normal PV (61% vs. 20%, p < 0.0001). By contrast, the
presence of a variant HA was not associated with a
variant BD. A supraportal RPBD was found in 357 donors
(88%) and an infraportal RPBD was found in 50 donors
(12%). An infraportal RPBD was significantly more
common in donors with a variant PV than in donors
with a normal PV (30% vs. 10%, p 0.0004). Variant PV,
but not variant HA, anatomies were frequently associated with variant BD anatomy. Additionally, an
infraportal RPBD was more common in donors with a
variant PV than in donors with a normal PV.
Abbreviations: BD, bile duct; CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; HA, hepatic artery; IVC, inferior vena cava;
MRCP, magnetic resonance cholangiopancreatography; PV, portal vein; RABD, right anterior bile duct;
RPBD, right posterior bile duct; RPHA, right posterior
hepatic artery; 3D, three-dimensional
Received 05 June 2014, revised 14 July 2014 and
accepted for publication 31 July 2014

hepatectomy (1,2). In living donor liver transplantation,


careful manipulation of the vasculobiliary system is critical
to avoid causing injury to the BD, PV and HA in the residual
liver and/or the graft (25). In addition, prompt identification
of anatomical anomalies can help the surgeon to determine
whether cancer located at the porta hepatis is operable or
not (6).
HA and PV anatomies can be determined noninvasively by
three-dimensional (3D) computed tomography (CT) (7,8).
Although magnetic resonance cholangiopancreatography
(MRCP), endoscopic retrograde cholangiopancreatography
(ERCP) and CT cholangiography are generally used to
assess BD anatomy, these procedures have some
limitations. For example, a previous study showed that
the sensitivity of MRCP for recognizing variant BD anatomy
was only 74% (9). Meanwhile, ERCP is a relatively invasive
procedure. Additionally, about 1.53.5% of individuals
undergoing CT cholangiography developed allergic reactions to the contrast agent (10,11). Therefore, intraoperative cholangiography, which does not provide preoperative
information on BD anatomy, is still the gold standard
method for evaluating BD anatomy in individuals undergoing liver resection (2). Preoperative prediction of BD
anatomy based on PV and/or HA anatomy could be clinically
significant by helping to avoid injury to these critical
structures.
Previous several studies have demonstrated an association
between BD and HA or PV anatomy; however, the findings
were controversial (1,2,1214). There are also very few
reports describing the spatial relationship between the BD
and PV, including the infraportal or supraportal course of the
right posterior BD (RPBD). Therefore, the purpose of this
retrospective study was to evaluate whether variant PV
and/or HA anatomy was more frequently associated with a
variant BD anatomy, taking into account the spatial
relationship of the RPBD course relative to the PV or HA.

Patients and Methods


Donors

Introduction
Preoperative assessment of the portal vein (PV), hepatic
artery (HA) and bile duct (BD) systems is essential for safe

A total of 515 living donors underwent graft procurement surgery between


October 1996 and May 2014 at the Department of Surgery and Science,
Graduate School of Medical Sciences, Kyushu University. Of these, 407
underwent preoperative CT cholangiography and were enrolled in this study.
The mean age of the donors was 36 years old, and 267 (66%) were male. The

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Takeishi et al
work undertaken in the study conformed to the provisions of the Declaration
of Helsinki.

starting the 1-h scan procedure. The BD course relative to the PV was evaluated
by CT. All images were evaluated by at least two radiologists.

Grafts were selected as previously described (15). Left lobe grafts were
used as the primary graft type if the desired graft volume/standard liver
volume ratio (GV/SLV) was 35%. Right lobe grafts were used if the
simulated GV/SLV of the left lobe graft was <35% and the donors remnant
liver volume was 35%. Other factors, such as anatomical variations and the
recipients condition, were also taken into account to achieve the optimal
outcome for each patient. No donors were considered unsuitable based on
vascular factors and/or BD anatomy alone.

Definitions

Anatomical evaluation
PV and HA anatomies were evaluated by preoperative angiography before
January 2002 and by 3DCT thereafter. Preoperative multi-detector helical CT
images were obtained with 2-mm-thick slices. Enhancement was achieved by
intravenous administration of a nonionic contrast medium (Iopamion; Schering,
Erlangen, Germany) at a speed of 5 mL/s. 3D reconstruction of the HA and PV
was performed using Zio M900 software (Zio Software, Inc., Tokyo, Japan) until
March 2013 and with Vincent software (Fujifilm Holdings Corporation, Tokyo,
Japan) thereafter. BD anatomy was evaluated by preoperative CT cholangiography. CT cholangiography was performed on a multi-detector CT scanner. As a
biliary contrast agent, 100 mL of meglumine iotroxate (50 mg/mL; Biliscopin;
Schering, Berlin, Germany) was administered over a period of 30 min, before

Normal PV anatomy was defined as a bifurcation of the PV into a normal right


and left PV (Figure 1A). Normal HA anatomy was defined as a bifurcation of
the proper HA into the left and right branches (Figure 1B). Normal BD
anatomy was defined as drainage of the right posterior duct (from posterior
segments 6 and 7) into the right hepatic duct and convergence of the right
and left hepatic ducts into the common hepatic duct (Figure 1C).
The confluence patterns of the right intrahepatic BDs were classified into
two patterns (supraportal and infraportal) according to the anatomical
relationship between the RPBD and the PV (Figure 2). The supraportal
pattern was defined as an RPBD that ran dorsally and cranially to the right or
the right anterior PV, and joined the distal BD at its cranial side. The
infraportal pattern was defined as an RPBD that ran ventrally and caudally to
the right or the right anterior PV, and joined the distal BD at its caudal side.

Data analysis
JMP software version 7J (SAS Institute, Cary, NC) was used for all analyses.
Statistical comparisons were conducted using Pearsons chi-square test or
Fishers exact test for qualitative variables. Values of p < 0.05 were
considered statistically significant.

Figure 1: Classification of portal vein, hepatic artery and bile duct anatomies in 407 donors. BD, bile duct; CHA, common hepatic
artery; HA, hepatic artery; LBD, left bile duct; LGA, left gastric artery; LHA, left hepatic artery; LPV, left portal vein; PV, portal vein; RABD,
right anterior bile duct; RBD, right bile duct; RAPV, right anterior portal vein; RHA, right hepatic artery; RPBD, right posterior bile duct;
RPPV, right posterior portal vein; SMA, superior mesenteric artery.

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American Journal of Transplantation 2015; 15: 155160

Portal Vein Anatomy and Bile Duct Variation

Most of the donors (89% [361/407]) had a normal


bifurcation pattern (type 1 PV). Variant PV anatomy could
be classified into two types. Twenty-five donors (6.1%) had
trifurcation (type 2 PV), which is characterized by the
absence of a right PV and both the right anterior PV and the
right posterior PV arising directly from the main PV.
Nineteen donors (4.7%) had a type 3 PV, which is
characterized by the absence of a right PV and the right
anterior PV arising directly from the left branch of the PV.
Two donors had a posterior and a segment 5 PV branch
originating from the left PV (Cases 1 and 2, respectively, in
Figure 3).
Figure 2: Illustrations of the supraportal and infraportal
courses of the right posterior bile duct. APV, anterior portal
vein; BD, bile duct; LBD, left bile duct; LPV, left portal vein; PPV,
posterior portal vein; PV, portal vein; RABD, right anterior bile duct;
RPBD, right posterior bile duct.

Results
Figure 1 depicts the anatomies of normal and variant PVs,
HAs and BDs, as well as the frequency of each variant in the
cohort of 407 donors. Three types of PV were identified.

Four main types of HA were found. Overall, 303 (75%)


donors had a normal HA (type 1 HA), in which the common
HA arises from the celiac trunk forming the gastroduodenal
and proper HAs, and the proper HA subsequently divides
distally into right and left branches. Thirty-eight donors
(9.3%) had a type 2 HA, which was characterized by
a replaced or accessory left HA arising from the left
gastric artery. Fifty-nine donors (14%) had a type 3 HA,
which was characterized by a replaced or accessory right
HA originating from the superior mesenteric artery. Two
donors (0.5%) had a type 4 HA, in which the right and left

Figure 3: Rare anatomical variants of the portal vein and hepatic artery that could not be classified under other anatomical types.
A4, hepatic artery of segment 4 branch; AHA, anterior hepatic artery; CHA, common hepatic artery; DPA, dorsal pancreatic artery; GDA,
gastroduodenal artery; HA, hepatic artery; LHA, left hepatic artery; LPV, left portal vein; MHA, middle hepatic artery; P4, portal vein of
segment 4 branch; P5, portal vein of segment 5 branch; P8, portal vein of segment 8 branch; PHA, posterior hepatic artery; RAPV, right
anterior portal vein; RHA, right hepatic artery; RPPV, right posterior portal vein.

American Journal of Transplantation 2015; 15: 155160

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Takeishi et al

HAs arise from the superior mesenteric artery and the


left gastric artery, respectively. The other five donors had
rare variants: Cases 3 and 4 had a middle HA originating
from the gastroduodenal artery or common HA, respectively (Figure 3); Case 5 had a segment A3 branch
originating from the common HA; Case 6 had a replaced
right HA originating from the dorsal pancreatic artery; and
Case 7 had a right posterior branch originating from the
common HA.
The anatomy of the BD could be classified into four types.
Most of the donors had a BD with a normal bifurcation (type
1 BD; 75% [306/407]). Thirty-nine donors (9.6%) had a BD
with a trifurcation into the left BD, right anterior BD and
RPBD (type 2 BD). In 37 donors (9.1%), the RPBD
converged into the left BD (type 3 BD). In 25 donors
(6.1%), the RPBD converged into the common hepatic duct
or common BD (type 4 BD). There were no rare cases that
could not be classified into the one of these four BD
anatomical types.
The anatomy of the hepatic vein was evaluated by 3DCT. Of
407 donors, 199 donors (49%) had a segment 6 vein
draining into the inferior vena cava (IVC) directly. There was
no significant difference in the frequency of a segment 6
vein draining into IVC among the PV types (Type 1, Type 2
and Type 3: 55%, 71% and 60%, respectively, p 0.229).
Variant BD anatomy was significantly more common in
donors with a variant PV than in cases with a normal PV
(61% [28/46] vs. 20% [73/361], p < 0.0001; Table 1). By
contrast, a type 2 PV (i.e. trifurcation) was more frequently
associated with a type 2 BD (i.e. trifurcation) than with other
BD variants. Meanwhile, a type 3 PV was more frequently
associated with type 3 or 4 BD than type 2 BD (Table 2). As
shown in Table 3, however, donors with a variant BD were
not more likely to have a variant HA than a normal HA (27%
[28/104] vs. 24% [73/303]; p 0.600).
A supraportal RPBD was found in 357 donors (88%) and an
infraportal RPBD was found in 50 donors (12%) (Figure 2).
The infraportal type of RPBD was significantly more
common in donors with a variant PV than in donors with
a normal PV (30% [14/46] vs. 10% [36/361]; p 0.0004;
Table 4). All of the donors with a type 2 BD (i.e. trifurcation)
or a type 3 BD (i.e. RPBD draining into the left BD) had a
supraportal RPBD, while all of the donors with a type 4 BD
(i.e. RPBD converging into the common hepatic duct) had
an infraportal RPBD. The frequency of an infraportal RPBD
Table 1: Association between variant portal vein and variant bile
duct

Normal PV (n 361)
Variant PV (n 46)

Normal BD
(n 306)

Variant BD
(n 101)

80% (288/361)
39% (18/46)

20% (73/361)
61% (28/46)

BD, bile duct; PV, portal vein.

158

was not significantly associated with the frequency of a


variant HA (p 0.484).
We reviewed all of the CT-cholangiography images from
donors with a type 3 BD to identify the relationship between
bifurcation of the RPBD and the BD branch of segment 1.
Of 33 donors with a type 3 BD, 15 donors had a bifurcation
of the RPBD proximal to the segment 1, while the other
18 donors had the same bifurcation of RPBD in segment 1.

Discussion
In this study, PV, HA and BD anatomical variants were
found in 11%, 25% and 25% of 407 donors, respectively.
These rates are consistent with the previously reported
rates of 8.330% in living liver donors (2,3,13,14,16,17),
16.846% in patients undergoing liver resection (1), and
2844% in radiological imaging studies (12,18). We also
found that donors with a variant PV were more likely to
have a variant BD than were donors with a normal PV
(p < 0.0001), which is also consistent with previous
reports (1,2,12,14,19). Furthermore, 61% of donors with
a variant PV had a variant BD, but 80% of donors with a
normal PV did not, implying that the presence of PV
abnormalities might help to predict whether the BD is
anatomically normal or not.
In our current study, 88% of the donors had a supraportal
RPBD while 12% had an infraportal RPBD, consistent with
previous reports (6,12). An infraportal RPBD was significantly more common in donors with a variant PV than in
donors with a normal PV (p 0.0004). To our knowledge,
this study is the first to show that the RPBD course is
associated with the course and anatomy of the PV. In
addition, we found that types 2 and 3 BDs are mostly
associated with a supraportal RPBD, whereas type 4 BDs
are mostly associated with an infraportal RPBD. Yoshizumi
et al (20) reported that donors with a supraportal BD are
unsuitable candidates for right posterior sector grafts.
Another study revealed that biliary complications occurred
in 0% of grafts including the infraportal RPBD compared
with 52.6% of grafts including a short stump of the
supraportal RPBD (21). Shimizu et al (6) reported that
patients with hilar cholangiocarcinoma and an infraportal
RPBD had a greater negative margin and more secure
reconstruction than patients with a supraportal RPBD.
These results suggest that preoperative evaluation of the
RPBD course in relation to the right PV may be clinically
useful in graft selection and the management of hilar
cholangiocarcinoma. However, in some patients with a hilar
cholangiocarcinoma, it may be difficult to precisely
determine the RPBD course relative to the right PV
because of BD obstruction. Therefore, predicting the
RPBD course based on the anatomy of the PV may be
clinically useful. We analyzed the anatomical relationship
between the right posterior hepatic artery (RPHA) and the
PV in the same way as we did for the RPBD. Of 307 donors
American Journal of Transplantation 2015; 15: 155160

Portal Vein Anatomy and Bile Duct Variation


Table 2: Association between portal vein anatomy and bile duct anatomy
BD type

PV type
Type 1 PV (normal) (n 361)
Type 2 PV (trifurcation) (n 25)
Type 3 PV (RAPV from LPV) (n 19)

Type 1 BD
(normal)
(n 306)

Type 2 BD
(trifurcation)
(n 39)

Type 3 BD
(Bp into LBD)
(n 36)

Type 4 BD
(Bp into CHD)
(n 24)

80% (288/361)
40% (10/25)
42% (8/19)

7.8% (28/361)
36% (9/25)
11% (2/19)

8.0% (29/361)
8.0% (2/25)
26% (5/19)

4.3% (16/361)
16% (4/25)
21% (4/19)

PV, portal vein; RAPV, right anterior portal vein; LPV, left portal vein; BD, bile duct; Bp, bile duct branch of the right posterior sector; LBD, left
bile duct; CHD, common hepatic duct.

who underwent preoperative 3DCT, an infraportal RPHA


was found in 261 donors (85%) and a supraportal RPHA
was found in 46 donors (15%). All of the donors with a type
3 PV (i.e. RAPV from the left PV) had an infraportal RPHA,
but the frequency of the infraportal type of RPHA was not
significantly different between donors with a variant PV and
donors with a normal PV (data not shown).
The association between PV and BD variants might have an
embryological explanation. In embryos, intrahepatic BDs
develop from liver progenitor cells in contact with the
mesenchyme of the PV and are referred to as the ductal
plates. Remodeling of the ductal plate results in a BD
located in the periportal mesenchyme, which ultimately
develops into the portal tract. The intrahepatic biliary
system is in luminal continuity with the extrahepatic BD
throughout gestation at the porta hepatis. The major BDs at
the porta hepatis are fully formed by week 16 of
gestation (22). Accordingly, the PV and BD develop in an
interdependent manner, and the BD may go around the PV
between its divisions. Therefore PV abnormalities are
frequently accompanied by BD variations.
Of 407 donors, two donors had rare PV abnormalities and
five had rare HA abnormalities. In Case 1, who had a
posterior PV originating from the left PV, the RPBD drained
into the left BD. In Case 2, who had a segmental 5 PV
originating from the left PV, the RPBD converged into the
common BD. In four of the five donors with rare HA
abnormalities, the RPBD drained directly into the common
BD, but the BD was normal. A posterior graft was procured
from Case 1 because of the anatomy of the PV and BD. In
this cohort of 407 donors, we identified several rare PV and
HA anatomical abnormalities, and surgeons should con-

Table 3: Association between variant hepatic artery and variant


bile duct

Normal HA (n 303)
Variant HA (n 104)

Normal BD
(n 306)

Variant BD
(n 101)

76% (230/303)
73% (76/104)

24% (73/303)
27% (28/104)

BD, bile duct; HA, hepatic artery.

American Journal of Transplantation 2015; 15: 155160

sider the likelihood of similar, albeit rare, cases when


performing hepatectomy.
In this study, there was no significant difference in the
incidence of the complications after LDLT using the graft
between with a variant PV and normal PV (data not shown).
Ikegami et al (23) suggested that hilar anatomical variations
in right-lobe LDLT could be managed after preoperative
detailed evaluation of the graft and intraoperative appropriated surgical decision and techniques. Therefore the
detail evaluation of the hilar anatomical variations might be
absolutely necessary for safe surgery.
When performing left lobectomy, individuals with a type 3
BD (RPBD draining into the left BD) are at greater risk of
RPBD injury than individuals with other BD anatomical
types (1). According to our results, although type 3 PV was
more frequently associated with type 3 BD, it is difficult to
predict the presence of a type 3 BD based on the anatomy
of the PV alone. Indeed, we found that, of 33 donors with a
type 3 BD, the bifurcation of the RPBD was proximal to
segment 1 in 15 donors and was located in segment 1 in 18
donors; none of the donors had a bifurcation of the RPBD
distal to segment 1. Therefore, our results suggest that,
when performing left lobectomy, dissection of the left BD
at a location distal to the bifurcation of the segment 1
branch might avoid RPBD injury.
The main limitation of this study is that the PV anatomy
does not predict all cases with a variant BD. The
preoperative or intraoperative cholangiography should still
be performed for safe surgery. PV anatomy can be
preoperatively assessed by noninvasive radiologic imaging,
such as 3DCT. However imaging modalities for assessing

Table 4: Association between variant portal vein and right


posterior bile duct relating to right portal vein

Normal portal vein (n 361)


Variant portal vein (n 46)

Supraportal
RPBD (n 357)

Infraportal
RPBD (n 50)

90% (325/361)
70% (32/46)

10% (36/361)
30% (14/46)

RPBD, right posterior bile duct.

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Takeishi et al

BD anatomy have not yet been established (7,8). Therefore,


preoperative prediction of variant BD based on PV anatomy
may provide the surgeon with valuable information for
patients who cannot undergo preoperative cholangiography, and may help surgeons to consider the most
appropriate living donor for cases with two or more
candidates, without the need for invasive studies.

9.

10.

In conclusion, anatomical variants of the PV, but not of the


HA, frequently accompany anatomical variants of the BD.
Assessment of the PV anatomy could help surgeons to
predict the presence of anatomical variants of the BD. In
individuals with a variant PV, the RPBD more frequently
follows an infraportal course than a supraportal course.

Disclosure
The authors of this manuscript have no conflicts of interest
to disclose as described by the American Journal of
Transplantation.

11.

12.

13.
14.

15.

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American Journal of Transplantation 2015; 15: 155160

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