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 （HHV）, 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 （HELD） 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 HHV, 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 too）, among 50 adult recipients, complications occurred in 13 （26%） cases and 4 （8%） died postoperatively within 3 mo. Their 1-year actual survival rate was 92%.CONCLUSION： When preoperative CT volumetry shows volume of remnant liver is more than 350, 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.

Small-for-size syndrome in adult-to-adult living-related liver transplantation

Small-for-size syndrome (SFSS) in adult-to-adult living-related donor liver transplantation (LRLT) remains the greatest limiting factor for the expansion of segmental liver transplantation from either cadaveric or living donors. Portal hyperperfusion, venous pathology, and the arterial buffer response signif icantly contribute to clinical and histopathological manifestations of SFSS. Here, we review the technical aspects of surgical and radiological procedures developed to treat SFSS in LRLT, along with the pathophysiology of this condition.

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'.

Adult-to-adult living donor liver transplantation for acute liver failure in China

AIM:To investigate the long-term outcome of recipients and donors of adult-to-adult living-donor liver transplantation(AALDLT) for acute liver failure(ALF).METHODS:Between January 2005 and March 2010,170 living donor liver transplantations were performed at West China Hospital of Sichuan University.All living liver donor was voluntary and provided informed consent.Twenty ALF patients underwent AALDLT for rapid deterioration of liver function.ALF was defined based on the criteria of the American Association for the Study of Liver Diseases,including evidence of coagulation abnormality [international normalized ratio(INR) ≥ 1.5] and degree of mental alteration without pre-ex-isting cirrhosis and with an illness of < 26 wk duration.We reviewed the clinical indications,operative procedure and prognosis of AALDTL performed on patients with ALF and corresponding living donors.The potential factors of recipient with ALF and corresponding donor outcome were respectively investigated using multivariate analysis.Survival rates after operation were analyzed using the Kaplan-Meier method.Receiver operator characteristic(ROC) curve analysis was undertaken to identify the threshold of potential risk factors.RESULTS:The causes of ALF were hepatitis B(n = 18),drug-induced(n = 1) and indeterminate(n = 1).The score of the model for end-stage liver disease was 37.1 ± 8.6,and the waiting duration of recipients was 5 ± 4 d.The graft types included right lobe(n = 17) and dual graft(n = 3).The mean graft weight was 623.3 ± 111.3 g,which corresponded to graft-torecipient weight ratio of 0.95% ± 0.14%.The segment Ⅴor Ⅷ hepatic vein was reconstructed in 11 right-lobe grafts.The 1-year and 3-year recipient's survival and graft survival rates were 65%(13 of 20).Postoperative results of total bilirubin,INR and creatinine showed obvious improvements in the survived patients.However,the creatinine level of the deaths was increased postoperatively and became more aggravated compared with the level of the survived recipients.Multivariate analysis showed that waiting duration was independently correlated with increased mortality(P = 0.014).Furthermore,ROC curve revealed the cut-off value of waiting time was 5 d(P = 0.011,area under the curve = 0.791) for determining the mortality.The short-term creatinine level with different recipient's waiting duration was described.The recipients with waiting duration ≥ 5 d showed the worse renal function and higher mortality than those with waiting duration < 5 d(66.7% vs 9.1%,P = 0.017).In addition,all donors had no residual morbidity.Furthermore,univariate analysis did not show that short assessment time induced the high morbidity(P = 0.573).CONCLUSION:Timely AALDLT for patients with ALF greatly improves the recipient survival.However,further systemic review is needed to investigate the optimal treatment strategy for ALF.

Microsurgical reconstruction of hepatic artery in A-A LDLT:124 consecutive cases without HAT

AIM:To retrospectively investigate microsurgical hepatic artery(HA) reconstruction and management of hepatic thrombosis in adult-to-adult living donor liver transplantation(A-A LDLT).METHODS:From January 2001 to September 2009,182 recipients with end-stage liver disease underwent A-A LDLT.Ten of these patients received dual grafts.The 157 men and 25 women had an age range of 18 to 68 years(mean age,42 years).Microsurgical techniques and running sutures with back-wall first techniques were performed in all arterial reconstructions under surgical loupes(3.5 ×) by a group of vascular surgeons.Intimal dissections were resolved by interposition of the great saphenous vein(GSV) between the donor right hepatic artery(RHA) and recipient common HA(3 cases) or abdominal aorta(AA)(2 cases),by interposition of cryopreserved iliac vessels between the donor RHA and recipient AA(2 cases).RESULTS:In the 58 incipient patients in this series,hepatic arterial thrombosis(HAT) was encountered in 4 patients,and was not observed in 124 consecutive cases(total 192 grafts,major incidence,2.08%).All cases of HAT were suspected by routine color Doppler ultrasonographic examination and confirmed by contrast-enhanced ultrasound and hepatic angiography.Of these cases of HAT,two occurred on the 1st and 7th d,respectively,following A-A LDLT,and were immediately revascularized with GSV between the graft and recipient AA.HAT in one patient occurred on the 46th postoperative day with no symptoms,and the remaining case of HAT occurred on the 3rd d following A-A LDLT,and was cured by thrombolytic therapy combined with an anticoagulant but died of multiorgan failure on the 36th d after A-A LDLT.No deaths were related to HAT.CONCLUSION:Applying microsurgical techniques and selecting an appropriate anastomotic artery for HA reconstruction are crucial in reducing the high risk of HAT during A-A LDLT.

Right hepatic lobe living donation: A 12 years single Italian center experience

Mini invasive techniques are taking over conventional open liver resections in the setting of left lateral segmentectomy for living liver donation,and hydride procedure are being implemented for the living related right hepatectomy.Our center routinely performs laparoscopic left lateral segmentectomy for pediatric recipient and has been the first in the Europe performing an entirely robotic right hepatectomy.Great emphasis is posed on living donor safety which is the first priority during the entire operation,then the most majority of our procedures are still conventional open right hepatectomy(RHLD),defined as removal of a portion of liver corresponding to Couinaud segments 5-8,in order to obtain a graft for adult to adult living related liver transplant.During this 10 years period some changes,herein highlighted,have occurred to our surgical techniques.This study reports the largest Italian experience with RHLD,focused on surgical technique evolution over a 10 years period.Donor safety must be the first priority in right-lobe living-related donation:the categorization of complications of living donors,specially,after this"highly sensitive"procedure,reflects the need for prompt and detailed reports.

Reconstruction of the middle hepatic vein tributary in adult right lobe living donor liver transplantation

BACKGROUND: In adult-to-adult living donor liver transplantation (LDLT), the use of a right lobe graft without the middle hepatic vein (MHV) can cause hepatic congestion and disturbance of venous drainage. To solve this problem, we successfully used cadaveric venous allografts preserved in 4 ℃ University of Wisconsin (UW) solution within 10 days as interposition veins for drainage of the paramedian portion of the right lobe in adult LDLT. METHODS: From June 2007 to January 2008, 11 adult LDLT patients received modified right liver grafts. The major MHV tributaries (greater than 5 mm in diameter) of 9 cases were preserved and reconstructed using cadaveric interposition vein allografts that had been stored for 1 to 10 days in 4 ℃ UW solution. The regeneration of the paramedian sector of the grafts and the patency of the interposition vein allografts were examined by Doppler ultrasonography after the operation. RESULTS: MHV tributaries were reconstructed in 9 recipients. Only 1 recipient died of renal failure and severe pulmonary infection on day 9 after transplantation without any hemiliver venous outflow obstruction. The other 8 recipients achieved long-term survival with a median follow-up of 30 months. The cumulative patency rates of the 8 recipients were 63.63% (7/11), 45.45% (5/11), 45.45% (5/11) and 36.36% (4/11) at 3, 6, 12 and 24 months, respectively. Regeneration of the paramedian sectors was equivalent.CONCLUSION: The cadaveric venous allograft preserved in 4 ℃ UW solution within 10 days serves as a useful alternative for interposition veins in facilitating implantation of a right lobe graft and guarantees outflow of the MHV.