Measures for increasing the safety of donors in living donor liver transplantation using right lobe grafts

BACKGROUND: The safety of donors in living donor liver transplantation (LDLT) should be the primary consideration. The aim of this study was to report our experience in increasing the safety of donors in LDLTs using right lobe grafts. METHODS: We retrospectively studied 37 living donors of right lobe grafts from January 2002 to March 2006. The measures for increasing the safety of donors in LDLT included carefully selected donors, preoperative evaluation by ultrasonography, angiography and computed tomography; and necessary intraoperative cholangiography and ultrasonography. Right lobe grafts were obtained using an ultrasonic dissector without inflow vascular occlusion on the right side of the middle hepatic vein. The standard liver volume and the ratio of left lobe volume to standard liver volume were calculated. RESULTS: There was no donor mortality in our group. Postoperative complications only included bile leakage (I donor), biliary stricture (1) and portal vein thrombosis (1). All donors recovered well and resumed their previous occupations. In recipients, complications included acute rejection (2 patients), hepatic artery thrombosis (1), bile leakage (1), intestinal bleeding (1), left subphrenic abscess (1) and pulmonary infection (1). The mortality rate of recipients was 5.4% (2/37); one recipient with pulmonary infection died from multiple organ failure and another from occurrence of primary disease. CONCLUSIONS: The first consideration in adult-to-adult LDLT is the safety of donors. The donation of a right lobe graft is safe for adults if the remnant hepatic vasculature and bile duct are ensured, and the volume-of the remnant liver exceeds 35% of the total liver volume.

Reducing biliary complications in adult-to-adult living donor liver transplantation using right lobe graft:experience of 124 cases

The aim of this paper is to summarize our experience of using right lobe liver grafts to reduce biliary complications in adult-to-adult(A-A)living donor liver transplantation(LDLT).From January 2002 to October 2007,124 adult patients underwent living donor liver transplantation using right lobe grafts at the West China Hospital,Sichuan University Medical School,China.There was no death in all donors.Biliary reconstruction for 178 hepatic duct orifices from 124 donor grafts was performed which included 106 reconstructions of duct-to-duct anastomoses and 72 cholangiojejunostomy.Nine recipients had biliary complications including six bile lea-kages(four from the anastomotic site and two from the cut surface of the liver graft)and three biliary strictures.With the improved techniques for biliary reconstruction,we have achieved good results in 124 recipients of A-A LDLT.We ascribe our success to the introduction of microsurgical techniques and the use of fixed operators which help in decreasing the biliary complications of LDLT.

Outcomes of right-lobe and left-lobe living-donor liver transplantations using small-for-size grafts

AIM To analyze the outcomes of living-donor liver transplantation(LDLT) using left-lobe(LL) or right-lobe(RL) small-for-size(SFS) grafts.METHODS Prospectively collected data of adult patients who underwent LDLT at our hospital in the period from January 2003 to December 2013 were reviewed. The patients were divided into the RL-LDLT group and the LL-LDLT group. The two groups were compared in terms of short-and long-term outcomes, including incidence of postoperative complication, graft function, graft survival, and patient survival. A SFS graft was defined as a graft with a ratio of graft weight(GW) to recipient standard liver volume(RSLV)(GW/RSLV) of < 50%. The Urata formula was used to estimate RSLV.RESULTS Totally 218 patients were included for analysis, with 199 patients in the RL-LDLT group and 19 patients in the LL-LDLT group. The two groups were similar in terms of age(median, 53 years in the RL-LDLT group and 52 years in the LL-LDLT group, P = 0.997) but had significantly different ratios of men to women(165:34 in the RL-LDLT group and 8:11 in the LL-LDLT group, P < 0.0001). The two groups were also significantly different in GW(P < 0.0001), GW/RSLV(P < 0.0001), and graft cold ischemic time(P = 0.007). When it comes to postoperative complication, the groups were comparable(P = 0.105). Five patients died in hospital,4(2%) in the RL-LDLT group and 1(5.3%) in the LLLDLT group(P = 0.918). There were 38 graft losses, 33(16.6%) in the RL-LDLT group and 5(26.3%) in the LL-LDLT group(P = 0.452). The 5-year graft survival rate was significantly better in the RL-LDLT group(95.2% vs 89.5%, P = 0.049). The two groups had similar 5-year patient survival rates(RL-LDLT: 86.8%, LL-LDLT: 89.5%, P = 0.476).CONCLUSION The use of SFS graft in LDLT requires careful tailormade surgical planning and meticulous operation. LLLDLT can be a good alternative to RL-LDLT with similar recipient outcomes but a lower donor risk. Further research into different patient conditions is needed in order to validate the use of LL graft.

Outcome of patients undergoing right lobe living donor liver transplantation with small-for-size grafts

AIM:To investigate the outcome of living donor liver transplantation(LDLT)recipients transplanted with small-for-size grafts(SFSGs).METHODS:Between November 2001 and December2010,196 patients underwent LDLT with right lobe liver grafts at our center.Recipients were divided into 2 treatment groups:group A with an actuarial graft-to-recipient weight ratio(aGRWR)<0.8%(n=45)and group B with an aGRWR≥0.8%(n=151).We evaluated serum liver function markers within 4 wk after transplantation.We also retrospectively evaluated the outcomes of these patients for potential effects related to the recipients,the donors and the transplantation procedures based upon a review of their medical records.RESULTS:Small-for-size syndrome(SFSS)developed in 7 of 45 patients(15.56%)in group A and 9 of 151patients(5.96%)in group B(P=0.080).The levels of alanine aminotransferase and aspartate aminotransferase in group A were higher than those in group B during early period after transplantation,albeit not significantly.The cumulative 1-,3-and 5-year liver graft survival rates were 82.22%,71.11%and 71.11%for group A and 81.46%,76.82%,and 75.50%for group B patients,respectively(P=0.623).However,univariate analysis of risk factors associated with graft survival in group A demonstrated that the occurrence of SFSS after LDLT was the only significant risk factor affecting graft survival(P<0.001).Furthermore,multivariate analysis of our data did not identify any additional significant risk factors accounting for poor graft survival.CONCLUSION:Our study suggests that LDLT recipients with an aGRWR<0.8%may have liver graft outcomes comparable to those who received larger size grafts.Further studies are required to ascertain the safety of using SFSGs.

Experience of donor right lobe hepatectomy in adult-to-adult live donor liver transplantation: clinical analysis of 89 cases

Objective: To review the experience of donor selec- tion and right lobe hepatectomy in adult-to-adult live donor liver transplantation. Methods: From May 1996 to December 2001, 89 live donor liver transplants using right lobe grafts were performed at Queen Mary Hospital, Hong Kong. All donors had received psychological counseling before donor operations. They were screened by laboratory tests including complete blood cell count, liver and renal biochemistry, and viral serology studies. Com- puted tomography (CT), CT volumetry and hepatic arteriography were routinely performed. All donors underwent the operations using the method designed by us. Results: The median duration of the operations was 8.8 hours. The median blood loss recorded 466 ml. The median intensive care unit and hospital stays were 2 and 10 days, respectively. There was no do- nor mortality. Complications of donor operations in- cluded wound infection, urinary tract infection, bili- ary stricture, cholestasis, subphrenic collection, bowel obstruction and incision hernia, etc. All do- nors have recovered and returned to their previous occupations. Conclusions: Live donation of right lobe grafts for a- dult-to-adult liver transplantation is safe, provided that donor selection is strict and utmost care is exer- cised during the operation.

Middle hepatic vein reconstruction in adult right lobe living donor liver transplantation improves recipient survival

Background: The efficacy and necessity of middle hepatic vein(MHV) reconstruction in adult-to-adult right lobe living donor liver transplantation(LDLT) remain controversial. The present study aimed to evaluate the survival beneficiary of MHV reconstructions in LDLT. Methods: We compared the clinical outcomes of liver recipients with MHV reconstruction( n = 101) and without MHV reconstruction( n = 43) who underwent LDLT using right lobe grafts at our institution from January 2006 to May 2017. Results: The overall survival(OS) rate of recipients with MHV reconstruction was significantly higher than that of those without MHV reconstruction in liver transplantation( P = 0.022; 5-yr OS: 76.2% vs 58.1%). The survival of two segments(segments 5 and 8) hepatic vein reconstruction was better than that of the only one segment(segment 5 or segment 8) hepatic vein reconstruction( P = 0.034; 5-yr OS: 83.6% vs 67.4%). The survival of using two straight vascular reconstructions was better than that using Y-shaped vascular reconstruction in liver transplantation with two segments hepatic vein reconstruction( P = 0.020; 5-yr OS: 100% vs 75.0%). The multivariate analysis demonstrated that MHV tributary reconstructions were an independent beneficiary prognostic factor for OS(hazard ratio = 0.519, 95% CI: 0.282–0.954, P = 0.035). Biliary complications were significantly increased in recipients with MHV reconstruction(28.7% vs 11.6%, P = 0.027). Conclusions: MHV reconstruction ensured excellent outflow drainage and favored recipient outcome. The MHV tributaries(segments 5 and 8) should be reconstructed as much as possible to enlarge the hepatic vein anastomosis and reduce congestion.

Management of the middle hepatic vein and its tributaries in right lobe living donor liver transplantation

BACKGROUND: Left liver graft from a small donor will not meet the metabolic demands of a larger adult recipient. To overcome the problem of graft size insufficiency, living donor liver transplantation (LDLT) using the right lobe has become a standard method for adult patients. As the drainage of the median sector (segments V, VIII and IV) is mainly by the middle hepatic vein (MHV), the issue of whether the MHV should or should not be taken with the graft or whether the MHV tributaries (V5, V8) should be reconstructed in the recipient remains to be settled. DATA SOURCES: An English-language literature search was conducted using MEDLINE (1985-2006) on right lobe living donor liver transplantation, middle hepatic vein, vein graft, hepatic venoplasty and other related subjects. RESULTS: Some institutions had proposed their policy for the management of the MHV and its tributaries. Dominancy of the hepatic vein, graft-to-recipient weight ratio, and remnant liver volume as well as the donor-to-recipient body weight ratio, the volume of the donor's right lobe to the recipient's standard liver volume and the size of MHV tributaries are the major elements for the criteria of inclusion of the MHV, while for the policy of MHV tributaries reconstruction, the proportion of congestive area and the diameter of the tributaries are the critical elements. Optimal vein grafts such as recipient's portal vein and hepatic venoplasty technique have been used to obviate hepatic congestion and venous drainage disturbance. CONCLUSIONS: Taking right liver grafts with the MHV trunk (extended right lobe grafts) or performing the MHV tributaries reconstruction in modified right lobe grafts, according to the criteria proposed by the institutions with rich experience, can solve the congestion problem of the right paramedian sector and help to improve the outcomes of the patients. The additional use of optimal vein grafts and hepatic venoplasty also can guarantee excellent venous drainage.

成人间活体肝移植研究

目的探讨提高成人间活体肝移植存活率的手术方法。方法2005年3月至6月，我院施行了13例成人间右半肝活体肝移植，术中采用了改良的手术技术包括右肝静脉的重建，肝中静脉分支的搭桥，肝动脉搭桥及改进的胆道重建技术。结果全组供体无严重并发症及死亡；受体发生并发症4例．其中包括肝动脉栓塞、胆漏、右膈下脓肿及肺部感染各1例。1例再移植因术后肺部感染，并发多器官功能衰竭（MOF）死亡。13例行右肝静脉与下腔静脉（IVC）直接吻合，其中5例加行右肝下静脉重建．另5例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建，保证了右肝的流出道通畅。移植物与受体重量比（GRWR）为0．72％～1．24％，其中9例〈1．0％，2例〈0．8％，无小肝综合症发生。结论采用改进的手术技术，特别是肝静脉流出道的充分重建可有效的避免小肝综合症，从而使活体右半肝移植成为比较安全的手术。

50例成人活体肝移植分析

目的探讨成人间右半肝移植中如何保证供、受体的安全。方法分析2002年1月至2006年7月施行的50例成人活体右半肝移植,包括47例不含肝中静脉(MHV)的右半肝移植及3例双供肝肝移植。受体原发病主要包括:乙肝肝硬变30例(60%,含急性肝衰12例),肝细胞肝癌15例(30%)。供体常规行三维CT计算全肝体积及右半肝体积,对供、受体采用了一系列术前评价及手术技术改进。结果52例供体共摘取49例右半肝及3例左半肝,49例右半肝均不含肝中静脉,质量为400～850g(中位质量550g),与受体标准肝质量比为31.74%～71.68%(平均45.35%),供体残肝体积均大于全肝体积的35%。52例供体发生并发症4例(7.69%),无死亡,术后住院时间7～30d(中位11d)。50例受体(含3例双供肝受体),随访2～52个月(中位9个月),发生并发症13例(26%),4例(8%)死亡,1年实际生存率92%。结论采用不包含MHV的右半肝移植术,术前CT测量残肝体积>35%和右半肝移植物与受体标准肝质量比>40%,是保证供、受体安全的有效指标。

成人间活体右半肝移植供体手术技巧探讨

目的探讨活体肝移植(living donor liver transplantation,LDLT)的供肝切取技术。方法对2002年1月至2006年6月期间,我中心进行的47例活体肝移植中不含肝中静脉的右半肝供体切取技术进行回顾性分析。术前CT对供肝管道系统、体积充分评估;术中使用血液回收器回收出血。用超声刀(CUSA)、电刀、滴水双极电凝切取供肝,术中不阻断入肝血流;注意保留>5mm的右肝下静脉、肝Ⅴ段(V5)、肝Ⅷ段(V8)静脉以备重建。结果供体术后无严重并发症和死亡。右半肝切取的中位手术时间为425min(380～620min),术中失血250～735mL,平均345mL,术中收集自体血并回输0～500mL,平均263mL,仅4例输异体血(自2005年供体切取已常规不输血)。并发症包括切口脂肪液化2例,乳糜漏1例,门静脉血栓1例,腹腔内出血1例。47例供体中,有31例出现粗大的V5静脉和(或)V8静脉、右肝下静脉,并进行了流出道重建。全部供体术后随访至今,供体生活和工作正常。结论在切取供肝过程中,CUSA、双极电凝和电刀联合使用,仔细及精良的供肝切取技术值得推广;通过流出道的充分重建,不包含肝中静脉右半供肝可以降低供体的风险,是较为安全的手术方式。

采用不含肝中静脉的右半肝行成人间活体肝移植

目的 探讨采用不含肝中静脉的右半肝行成人间活体肝移植的可行性及安全性。方法 2002年1月至2005年8月，我院施行了16例成人间右半肝活体肝移植．术中采用了不含肝中静脉的右半肝移植物，同时进行了一系列改良的手术技术包括肝右静脉的重建，右肝下静脉的重建，肝中静脉分支的搭桥等改进。结果 全组供者无严重并发症及死亡。前2例受者中，1例发生肝静脉吻合口狭窄，1例因发生小肝综合征，死于肝功进行性恶化。后14例受者中发生并发症5例：急性排斥反应，肝动脉栓塞．胆漏，左膈下脓肿及肺部感染各1例；1例再移植术后肺部感染死于MODS。14例中除肝右静脉与下腔静脉（IVC）直接吻合外，其中5例加行右肝下静脉重建．另5例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建，保征了右肝的流出道通畅。移植物与受者重量比（GRWR）为0．72％～1．15％，11例＜1．0％．其中2例〈0．8％，无小肝综合征发生。结论 采用了改进的手术技术，特别是肝静脉流出道的充分重建可有效的避免小肝综合征，从而使采用不含肝中静脉的活体右半肝移植成为安全可靠的手术方式。

活体右半肝移植静脉流出道重建技术的改进

目的探讨在不包含肝中静脉(middle hepatic vein,MHV)的成人间活体右半肝移植(living donorliver transplantation,LDLT)流出道的重建模式。方法对我院肝移植中心47例不含MHV成人间活体右半肝移植,其受体流出道重建的临床资料进行回顾性分析。移植肝右肝静脉(RHV)与受体下腔静脉的吻合口成形为"三角形";右肝下静脉(IRHV)与下腔静脉直接吻合,MHV粗大属支即肝Ⅴ段(V5)、Ⅷ段(V8)静脉用大隐静脉搭桥后,分别开口与下腔静脉垂直式吻合。结果本组供体术后无严重并发症和死亡。受体47例发生并发症9例,其中肝静脉狭窄1例,小肝综合征1例,肝动脉栓塞1例,肠肠吻合口出血1例,胆漏2例,隔下脓肿1例,肺部感染2例。死亡3例,死因为小肝综合征1例,多器官功能衰竭2例。47有31例重建V5、V8和(或)右肝下静脉,其流出道重建率65.96%(31/47),其中重建1支静脉为36.17%(17/47),重建2只静脉为21.28%(10/47),重建3只静脉为8.51%(4/47)。所有病例术后随访2～48月,CT和超声检查1例肝静脉狭窄,4例在7～25d发现血栓,但侧枝循环已建立。结论采用"多口垂直式吻合"的方式重建流出道,可保证移植肝的有效静脉回流,预防小肝综合征,减少供体的手术风险。

Hepatic venous outflow reconstruction in adult right lobe living donor liver transplantation without middle hepatic vein

Background It is difficult and challenging to reconstruct hepatic venous outflow in adult right lobe living donor liver transplantation （LDLT） without the middle hepatic vein （MHV）. Excessive perfusion of the portal vein and venous outflow obstruction will lead to acute congestion of the graft, ultimately resulting in primary nonfunction. Although various reconstruction patterns have been explored in many countries, there is currently no clear consensus. In this study we describe a technique to prevent ＂chocking＂ of the graft at the outflow anastomosis with the inferior vena cava （IVC） in LDLT using right lobe graft without the MHV. Methods A retrospective analysis was conducted on clinical data from 55 recipients undergoing LDLT using right lobe grafts without the MHV or reconstruction of hepatic venous outflow. The donor＇s right hepatic vein （RHV） was anastomosed with a triangular opening of the recipient IVC; the inferior right hepatic vein （IRHV）, if large enough, was anastomosed directly to the IVC. The great saphenous vein （GSV） was used for reconstruction of significant MHV tributaries. Results No deaths occurred in any of the donors. Of the 55 recipients, complications occurred in 6, including hepatic vein stricture （1 case）, small-for-size syndrome （1）, hepatic artery thrombosis （1）, intestinal bleeding （1）, bile leakage （1）, left subphrenic abscess and pulmonary infection （1）. A total of three patients died, one from small-for-size syndrome and two from multiple system organ failure. Conclusions The multiple-opening vertical anastomosis was reconstructed with hepatic vein outflow. This technique alleviates surgical risk of living donors, ensures excellent venous drainage, and prevents vascular thromboses and primary nonfunction.

活体肝移植右半供肝切取的临床经验总结(附157例报告)

目的总结活体右半供肝切取的经验。方法对2002年1月至2009年8月在四川大学华西医院肝脏移植中心施行活体右半肝供体手术的157例患者的资料进行回顾性分析。全部供者均自愿无偿捐肝,其捐赠行为均经医院伦理学委员会批准。了解术前计算机体层摄影术(CT)评估供肝体积的效果:术前应用CT测定供体的全肝体积、右半肝体积(不含肝中静脉),从而计算残余左半肝体积比;术后测定切取的右半肝重量、应用华西严律南公式计算标准肝脏体积(standard liver volume,SLV),计算残余左半肝体积重量比,比较术前供肝CT测定全肝体积与SLV的差异。供体均行不含肝中静脉的右半供肝切除术。静脉复合麻醉,取双侧(后期改进为右侧)肋缘下并延至剑突的切口,游离右侧肝脏,确定切肝线,不阻断入肝血流,用超声吸引刀离断肝组织直至整个右半肝游离,依次阻断并切断肝右动脉,门静脉右支及肝右静脉,将供肝移至后台进行灌注及修整。了解供者术中情况,包括供体取肝手术时间、术中失血量、术中有否发现不适合作为供体的病例及其原因。了解供者术后随访情况,术后并发症采用Clavien系统分级评价。结果供体的术前CT供肝体积测定结果:全肝体积(1301±174)ml,右半肝体积(724±137)ml,残余左半肝体积比(45.5±6.9)%。实测值:右半肝重量(558±77)g,SLV(1055±129)ml,残余左半肝重量比(46.7±6.2)%,其中30%～35%者10例(6%),>35%者147例(94%)。CT测定供体全肝体积比SLV平均大23%。供体术中平均失血量493ml,手术时间(431±68)min。术中探查发现不适合作为供体而未完成右半肝切除4例,包括肝总管进入肝圆韧带左纵沟内再发出肝右管1例、多支肝右管1例、中度脂肪肝(超过30%的肝组织大泡型脂肪变性)1例和肝硬化1例。术后共54例发生61例次并发症,其中发生ClavienⅢ级及以上并发症18例次,包括胸腔积液12例次、肝功能不全2例次、门静脉血栓形成1例次、胆漏1例次、腹腔内出血1例次、切口裂开1例次,经对症治疗后均痊愈。所有供体恢复良好,随访3年均健康存活。结论术前准确掌握CT测定供肝体积的准确性和偏差程度,应用经临床验证有效的评估公式进行验证,并按正确切线断肝,对完成手术计划,保证供、受体安全具有重要的临床意义。

活体右半肝供体外科并发症预防、诊断和处理

目的分析活体肝移植供体右半肝切除术后外科并发症的临床特征及预防和处理措施。方法总结2年间,65例活体供体右半肝切取术后的临床资料,分析外科并发症发生情况及预防、处理措施。结果术后累计发生外科并发症14例次(21.54%);其中切口脂肪液化、感染(4例,6.15%)及肝断面胆汁漏(4例,6.15%)是最常见的并发症;肺部感染、腹腔内出血、门静脉左支狭窄、腹腔引流管折断、胆管狭窄和小肝综合征各1例(1.54%)。门静脉左支狭窄病例术中当即采用自体大隐静脉血管补片修补右支残端;胆管狭窄病例术中当即留置T形管;腹腔内出血、引流管折断和肝断面胆漏(1例)再次剖腹探查;另3例肝断面胆漏经皮穿刺引流痊愈。结论右半肝供体有相当高的外科并发症,精细的手术技巧和及时处理是改善外科并发症预后的关键。

Modified techniques for adult-to-adult living donor liver transplantation

BACKGROUND: Because of critical organ shortage, transplant professionals have utilized living donor liver transplantation (LDLT) in recent years. We summarized our experience in adult-to-adult LDLT with grafts of right liver lobe by a modified technique. METHODS: From January 2002 to August 2005, 24 adult patients underwent living donor liver transplantation with grafts of the right liver lobe at West China Hospital, Sichuan University, China. Twenty-two patients underwent modi-Bed procedures designed to improve the reconstruction of the right hepatic vein and the tributaries of the middle hepatic vein by interposing a great saphenous vein ( GSV) graft and the anastomosis of the hepatic arteries and bile ducts. RESULTS: No severe complications and death occurred in all donors. In the first 2 patients, (patients 1 and 2), operative procedure was not modified. One patient suffered from 'small-for-size syndrome' and the other died of sepsis with progressive deterioration of graft function. In the rest 22 patients (patients 3 to 24), however, the procedure of venous reconstruction was modified, and better results were obtained. Complications occurred in 7 recipients including acute rejection (2 patients), hepatic artery thrombosis (1), bile leakage (1), intestinal bleeding (1), left sub-phrenic abscess (1), and pulmonary infection (1). One patient with pulmonary infection died of multiple organ failure (MOF). The 22 patients underwent direct anastomosis of the right hepatic vein to the inferior vena cava (IVC), 9 direct anastomosis plus the reconstruction of the right inferior hepatic vein, and 10 direct anastomosis plus the reconstruction of the tributaries of the middle hepatic vein by in-terpos-ing a GSV graft to provide sufficient venous outflow. Trifurcation of the portal vein was met in 3 patients. Venoplasty or separate anastomosis was performed. The ratio of graft to recipient body weight ranged from 0.72% to 1.17%. Among these patients, 19 had the ratio <1.0% and 4 <0.8%, and the ratio of graft weight to recipient standard liver volume was between 31.86% and 62.48%. Among these patients, 10 had the ratio <50% and 2 <40%. No 'small-for-size syndrome' occurred in the 22 recipients who were subjected to modified procedures. CONCLUSIONS: With the modified surgical techniques for the reconstruction of the hepatic vein to obtain an adequate outflow and provide a sufficient functioning liver mass, living donor liver graft in adults using the right lobe can be safe to prevent the 'small-for-size syndrome'.

成人间右半肝活体肝移植的肝中静脉之争

成人右半肝活体肝移植的开展在很大程度上解决了供肝短缺的问题,但随之也引发了右半肝移植物中是否带肝中静脉的技术与伦理之争。本文论述了肝中静脉的解剖,以及右半肝活体肝移植中带与不带肝中静脉的双方观点、理论依据和临床实践经验。

Clinical study on safety of adult-to-adult living donor liver transplantation in both donors and recipients

AIM: To investigate the safety of adult-to-adult living donor liver transplantation (A-A LDLT) in both donors and recipients. METHODS: From January 2002 to July 2006, 50 cases of A-A LDLT were performed at West China Hospital, Sichuan University, consisting of 47 cases using right lobe graft without middle hepatic vein (MHV), and 3 cases using dual grafts (one case using two left lobe, 2 using one right lobe and one left lobe). The most common diagnoses were hepatitis B liver cirrosis, 30 (60%) cases; and hepatocellular carcinoma, 15 (30%) cases in adult recipients. Among them, 10 cases had the model of end-stage liver disease (MELD) with a score of more than 25. Donor screening consisted of reconstruction of the hepatic blood vessels and biliary system with 3-dimension computed tomography and volumetry of whole liver and right liver volume. Various improved surgical techniques were adopted in the procedures for both donors and recipients . RESULTS: Forty-nine right lobes and 3 left lobes (2 left lobe grafts for 1 recipient, 1 left lobe graft for 1 recipient who had received right lobe graft donated by relative living donor) were obtained from 52 living donors. The 49 right lobe grafts, without MHV, weighed 400 g-850 g (media 550 g), and the ratio of graft volume to recipient standard liver volume (GV/SLV) ranged from 31.74% to 71.68% (mean 45.35%). All donors' remnant liver volume was over 35% of the whole liver volume. There was no donor mortality. With a follow-up of 2-52 mo (media 9 mo), among 50 adult recipients, complications occurred in 13 (26%) cases and 4 (8%) died postoperatively within 3 mo. Their 1-year actualsurvival rate was 92%. CONCLUSION: When preoperative CT volumetry shows volume of remnant liver is more than 35%, the ratio of right lobe graft to recipients standard liver volume exceeding 40%, A-A LDLT using right lobe graft without MHV should be a very safe procedure for both donors and recipients, otherwise dual grafts liver transplantation should be considered.

成人活体肝移植(英文)

活体肝移植(LDLT)最初作为一种降低等待做肝移植患者死亡率的方法。日本京都大学LDLT开始于1990年6月,移植例数逐年增加,临床应用范围从小儿扩展到成人。肝脏右叶移植物的应用在LDLT具有重要临床意义,已经成为成人间LDLT标准方法。由于肝脏右叶移植物在LDLT移植后成功应用,近年来成人LDLT例数显著增加,自1990年6月至2005年12月,京都大学附属病院已完成了1 140例LDLT手术,其中包括477例成人LDLT手术(年龄大于18岁)。HBV和HCV相关性肝硬化和肝癌是LDLT最常见的适应证,截至2005年12月,随访统计结果表明成人LDLT术后总的5年生存率为69 .1 %。

活体右半肝移植供体术前评估的临床意义

目的探讨活体右半肝移植供体术前评估的必要性。方法回顾性评估2002年1月至2005年11月施行的23例活体右半肝移植中供体的情况。术前评估包括供体的一般情况,血管与胆管系统影像学,供肝体积及脂肪变性情况等。不阻断入肝血流,在肝中静脉右侧,用超声刀离断肝组织而得到右半肝。计算供体标准肝体积(standard liver volume,SLV)及残余左半肝的比例。结果术前影像学评估发现,4例门静脉主干有3分支,7例有粗大肝右后下静脉(≥0．5cm),5例有粗大(≥0．5 cm)肝V段静脉(V5),4例有V8,右肝管变异3例。而术中发现9例伴右后下静脉,5例V5,5例V8,右肝管变异4例。术中肝切取活检示2例供肝轻度脂肪变性。右半供肝切取平均失血462 ml,切取右半肝占SLV的39．7%～69．5%,残余左半肝占30．5%～60．3%。术后第1天肝功能均有不同程度损害,但术后1周恢复到接近正常水平。术后并发症包括1例腹内出血,1例乳糜漏,2例切口脂肪液化,1例门静脉狭窄伴血栓形成。所有供体均恢复良好。结论术前进行供肝血管系统与胆管系统、肝脏的体积与质量的详尽评估,选择出最适宜的供肝与供体,是手术成功的重要保证。