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 malignant metastatic melanoma to the liver

BACKGROUND. Metastases from malignant melanoma to the liver are rare in China, and surgical resection may be of potential benefit. Liver transplantation for this disease has never been reported. METHODS. We report a case of adult-to-adult living donor liver transplantation (A-A LDLT) for metastatic melanoma. With a surgical history of ocular melanoma, the recipient presented with emaciation from a large right hepatic mass which also probably had portal vein invasion. A-A mur was successfully performed and no postoperative complications were observed in either the donor or the recipient. Postoperative pathology confirmed the diagnosis of metastatic malignant melanoma; however no adjuvant chemotherapy was employed after transplantation. We also reviewed the literature on the surgical treatment of metastatic malignant melanoma to the liver and discussed the LDLT indications. RESULT: Recurrence occurred 6 months after surgery and the patient died from recurrence of the disease 8 months post-transplant. CONCLUSIONS. Review of the literature suggested that only a small subset of selected patients may benefit from liver resection. Large metastatic disease in the liver potentially involving a major vessel, as in this case, should be contraindicated for liver transplantation. (Hepatobiliary Pancreat Dis Int 2010; 9: 329-332)

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.

Liver transplantation and resection in patients with hepatocellular cancer and portal vein tumor thrombosis: Feasible and effective?

Patients with locally advanced hepatocellular cancer(HCC)and portal vein tumor thrombosis(PVTT)have a dismal prognosis since limited treatment options are available for them.In recent years,effective systemic therapy,and advances in the understanding of technicalities and effectiveness of ablative therapies especially radiotherapy,have given some hope to prolong survival in them.This review summarized recent evidence in literature regarding the possible role of liver resection(LR)and liver transplantation(LT)in patients with locally advanced HCC and PVTT with no extrahepatic disease.Downstaging therapies have helped make curative resection or LT a reality in selected patients.This review emphasizes on the key points to focus on when considering surgery in these patients,who are usually relegated to palliative systemic therapy alone.Meticulous patient selection based on tumor biology,documented downstaging based on imaging and decrease in tumor marker levels,and an adequate waiting period to demonstrate stable disease,may help obtain satisfactory long-term outcomes post LR or LT in an intention to treat strategy in patients with HCC and PVTT.

Outcome of split liver transplantation vs living donor liver transplantation:A systematic review and meta-analysis

BACKGROUND The outcomes of liver transplantation(LT)from different grafts have been studied individually and in combination,but the reports were conflicting with some researchers finding no difference in both short-term and long-term outcomes between the deceased donor split LT(DD-SLT)and living donor LT(LDLT).AIM To compare the outcomes of DD-SLT and LDLT we performed this systematic review and meta-analysis.METHODS This systematic review was performed in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.The following databases were searched for articles comparing outcomes of DD-SLT and LDLT:PubMed;Google Scholar;Embase;Cochrane Central Register of Controlled Trials;the Cochrane Database of Systematic Reviews;and Reference Citation Analysis(https://www.referencecitationanalysis.com/).The search terms used were:“liver transplantation;”“liver transplant;”“split liver transplant;”“living donor liver transplant;”“partial liver transplant;”“partial liver graft;”“ex vivo splitting;”and“in vivo splitting.”RESULTS Ten studies were included for the data synthesis and meta-analysis.There were a total of 4836 patients.The overall survival rate at 1 year,3 years and 5 years was superior in patients that received LDLT compared to DD-SLT.At 1 year,the hazard ratios was 1.44(95%confidence interval:1.16-1.78;P=0.001).The graft survival rate at 3 years and 5 years was superior in the LDLT group(3 year hazard ratio:1.28;95%confidence interval:1.01-1.63;P=0.04).CONCLUSION This meta-analysis showed that LDLT has better graft survival and overall survival when compared to DD-SLT.

Outcomes of adult-to-adult living donor liver transplantation： a single center experience

Background Since January 2002, adult-to-adult living donor liver transplantation （AALDLT） has gained increasing popularity in China in response to the shortage of cadaveric donor livers. This study presents a detailed analysis of the outcomes of AALDLT in a single center. Methods A total of 70 patients underwent AALDLT at our center between January 2002 and January 2007. Among these, 67 patients received a right lobe graft without the middle hepatic vein and 3 patients received dual grafts. Three-dimensional volumetric computed tomography, magnetic resonance imaging with angiography and cholangiography were performed preoperatively. Recipient operation time, intraoperative transfusion requirement, length of intensive care unit stay, length of hospital stay, liver function tests, coagulation tests and surgical outcomes were routinely investigated throughout this study. Results All donors survived the procedure with an overall complication rate of 15.3%. Overall recipient 1-year survival and complication rates were 87.1% and 34.2%, respectively. Among the 70 cases, average graft recipient weight ratio was 0.94% （0.72%-1.43%） and average graft volume/standard liver volume ratio was 46.42% （31.74%-71.68%）. All residual liver volumes exceeded 35%. Liver function and coagulation recovered rapidly within the first 7 days after transplantation. Conclusions AALDLT is a safe procedure for the donors and an effective therapy for patients with end-stage liver disease. Patient selection and timely decision-making for transplantation are essential in achieving good outcomes. With accumulation of experience in surgery and clinical management, timely feedback and proper modification, we foresee better outcomes in the future.

Current status of adult-to-adult living donor liver transplantation： surgical techniques and innovations

In response to critical organ shortage, transplant surgeons have utilized living donors in an attempt to decrease the mortality rate associated with waiting on the liver transplant list. Although the surgical techniques were first utilized clinically 15 years ago, the application of living donor liver transplantation （LDLT） has been somewhat limited by the steep learning curve associated with developing a program. Clinical success with LDLT in children was realized early, but the application of the techniques to adult patients has only occurred more recently. This procedure is now widely applied to adult recipients, with many technical improvements.

Adult-to-adult living-donor liver transplantation: The experience of the Université catholique de Louvain

Background: Liver transplantation is the treatment for end-stage liver diseases and well-selected malignancies. The allograft shortage may be alleviated with living donation. The initial UCLouvain experience of adult living-donor liver transplantation(LDLT) is presented. Methods: A retrospective analysis of 64 adult-to-adult LDLTs performed at our institution between 1998 and 2016 was conducted. The median age of 29(45.3%) females and 35(54.7%) males was 50.2 years(interquartile range, IQR 32.9–57.5). Twenty-two(34.4%) recipients had no portal hypertension. Three(4.7%) patients had a benign and 33(51.6%) a malignant tumor [19(29.7%) hepatocellular cancer, 11(17.2%) secondary cancer and one(1.6%) each hemangioendothelioma, hepatoblastoma and embryonal liver sarcoma]. Median donor and recipient follow-ups were 93 months(IQR 41–159) and 39 months(22–91), respectively. Results: Right and left hemi-livers were implanted in 39(60.9%) and 25(39.1%) cases, respectively. Median weights of right-and left-liver were 810 g(IQR 730–940) and 454 g(IQR 394–534), respectively. Graft-to-recipient weight ratios(GRWRs) were 1.17%(right, IQR 0.98%-1.4%) and 0.77%(left, 0.59%-0.95%). One-and five-year patient survivals were 85% and 71%(right) vs. 84% and 58%(left), respectively. Oneand five-year graft survivals were 74% and 61%(right) vs. 76% and 53%(left), respectively. The patient and graft survival of right and left grafts and of very small( < 0.6%), small(0.6%–0.79%) and large( ≥0.8%) GRWR were similar. Survival of very small grafts was 86% and 86% at 3-and 12-month. No donor died while five(7.8%) developed a Clavien–Dindo complication IIIa, IIIb or IV. Recipient morbidity consisted mainly of biliary and vascular complications; three(4.7%) recipients developed a small-for-size syndrome according to the Kyushu criteria. Conclusions: Adult-to-adult LDLT is a demanding procedure that widens therapeutic possibilities of many hepatobiliary diseases. The donor procedure can be done safely with low morbidity. The recipient operation carries a major morbidity indicating an important learning curve. Shifting the risk from the donor to the recipient, by moving from the larger right-liver to the smaller left-liver grafts, should be further explored as this policy makes donor hepatectomy safer and may stimulate the development of transplant oncology.

Adult-to-adult right lobe living donor liver transplantation:Comparison of endoscopic retrograde cholangiography with standard T2-weighted magnetic resonance cholangiography for evaluation of donor biliary anatomy

AIM: To compare the value of endoscopic retrograde cholangiography (ERC) and standard T2-weighted magnetic resonance cholangiography (MRC) in the evaluation process as adult-to-adult right lobe living donor liver transplantation (LDLTx) demands a successful outcome, and exact knowledge of the biliary tree is implicated to avoid biliary complications, postoperatively.METHODS: After starting the LDLTx program, 18 liver transplant candidates were selected for LDLTx by a stepwise evaluation process. ERC and standard T2-weighted MRC were performed to evaluate the biliary system of the donor liver. The anatomical findings of ERC and MRC mapping were compared using the Ohkubo classification. RESULTS: ERC allowed mapping of the whole biliary system in 15/15 (100%) cases, including 14/15 (93.3%) with biliary variants while routine MRC was only accurate in 2/13 (15.4%) cases. MRC was limited in depicting the biliary system proximal of the hepatic bifurcation. Postoperative biliary complications occurred in 2 donors and 8 recipients. Biliary complications were associated with Ohkubo type C, E or G in 6/8 recipients, and 2/3 recipients with biliary leak received a graft with multiple (≥2) bile ducts. CONCLUSION: Pretransplant ERC is safe and superior over standard MRC for detection of biliary variations that occur with a high frequency. However, precise knowledge of biliary variants did not reduce the incidence of postoperative biliary complications.

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.

Preliminary experience in adult-to-adult living donor liver transplantation in a single center in China

The aim of this paper is to report the authors’experience in performing adult-to-adult living donor liver transplantation(LDLT)by using a modified technique in using grafts of the right lobe of the liver.From January 2002 to September 2006,56 adult patients underwent LDLT using right lobe grafts at the West China Hospital,Sichuan University Medical School,China.All patients underwent a modified operation designed to improve the reconstruction of the right hepatic vein(RHV)and the tributariers of the middle hepatic vein(MHV)by interposing a vessel graft,and by anastomosing the hepatic arteries and bile ducts.There were no severe complications or deaths in all donors.Fifty-two(92.8%)recipients survived the operations.Among the 56 recipients,complications were seen in 15 recipients(26.8%),including hepatic vein stricture(one case),small-for-size syndrome(one case),hepatic artery thrombosis(two cases),intestinal bleeding(one case),bile leakage(two cases),left subphrenic abscess(one case),renal failure(two cases)and pulmonary infection(five cases).Within three months after transplantation,four recipients(7.14%)died due to smallfor-size syndrome(one case),renal failure(one case)and multiple organ failure(two cases).All patients underwent direct anastomoses of the RHV and the inferior vena cava(IVC),and in 23 cases,reconstruction of the right inferior hepatic vein was also done.In 24 patients,the reconstruction of the tributaries of the MHV was also done by interposing a vessel graft to provide sufficient venous outflow.Trifurcation of the portal vein was seen in nine cases.Thus,veno-plasty or separate anastomoses were performed.The graft and recipient body weight ratios(GRWR)were between 0.72%and 1.43%,and in three cases it was<0.8%.The graft weight to recipient standard liver volume ratios(GV/SLV)were between 31.86%and 71.68%,among which four cases had<40%.No“small-for-size syndrome”occurred.With modification of the surgical technique,especially in the reconstruction of the hepatic vein to provide sufficient venous outflow,living donor liver grafts in adults using the right lobe of the liver can become a relatively safe procedure and prevent the“small-for-size syndrome”.

Vascular complications after adult living donor liver transplantation:Evaluation with ultrasonography

Living donor liver transplantation(LDLT) has beenwidely used to treat end-stage liver disease with improvement in surgical technology and the application of new immunosuppressants. Vascular complications after liver transplantation remain a major threat to the survival of recipients. LDLT recipients are more likely to develop vascular complications because of their complex vascular reconstruction and the slender vessels. Early diagnosis and treatment are critical for the survival of graft and recipients. As a non-invasive, cost-effective and non-radioactive method with bedside availability, conventional gray-scale and Doppler ultrasonography play important roles in identifying vascular complications in the early postoperative period and during the follow-up. Recently, with the detailed vascular tracing and perfusion visualization, contrastenhanced ultrasound(CEUS) has significantly improved the diagnosis of postoperative vascular complications. This review focuses on the role of conventional grayscale ultrasound, Doppler ultrasound and CEUS for early diagnosis of vascular complications after adult LDLT.

Current diagnosis and treatment of benign biliary stricturesafter living donor liver transplantation

Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation(LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.

Biliary strictures complicating living donor liver transplantation:Problems,novel insights and solutions

Biliary stricture complicating living donor liver transplantation(LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement(with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.

Living-donor vs deceased-donor liver transplantation for patients with hepatocellular carcinoma

With the increasing prevalence of living-donor liver transplantation(LDLT) for patients with hepatocellular carcinoma(HCC),some authors have reported a potential increase in the HCC recurrence rates among LDLT recipients compared to deceased-donor liver transplantation(DDLT) recipients.The aim of this review is to encompass current opinions and clinical reports regarding differences in the outcome,especially the recurrence of HCC,between LDLT and DDLT.While some studies report impaired recurrence- free survival and increased recurrence rates among LDLT recipients,others,including large database studies,report comparable recurrence- free survival and recurrence rates between LDLT and DDLT.Studies supporting the increased recurrence in LDLT have linked graft regeneration to tumor progression,but we found no association between graft regeneration/initial graft volume and tumor recurrence among our 125 consecutive LDLTs for HCC cases.In the absence of a prospective study regarding the use of LDLT vs DDLT for HCC patients,there is no evidence to support the higher HCC recurrence after LDLT than DDLT,and LDLT remains a reasonable treatment option for HCC patients with cirrhosis.

Doppler ultrasonography in living donor liver transplantation recipients: Intra- and post-operative vascular complications

Living-donor liver transplantation has provided a solution to the severe lack of cadaver grafts for the replacement of liver afflicted with end-stage cirrhosis, fulminant disease, or inborn errors of metabolism. Vascular complications remain the most serious complications and a common cause for graft failure after hepatic transplantation. Doppler ultrasound remains the primary radiological imaging modality for the diagnosis of such complications. This article presents a brief review of intra- and post-operative living donor liver transplantation anatomy and a synopsis of the role of ultrasonography and color Doppler in evaluating the graft vascular haemodynamics both during surgery and post-operatively in accurately defining the early vascular complications. Intra-operative ultrasonography of the liver graft provides the surgeon with useful real-time diagnostic and staging information that may result in an alteration in the planned surgical approach and corrections of surgical complications during the procedure of vascular anastomoses. The relevant intraoperative anatomy and the spectrum of normal and abnormal findings are described. Ultrasonography and color Doppler also provides the clinicians and surgeons early post-operative potential developmental complications that may occur during hospital stay. Early detection and thus early problem solving can make the difference between graft survival and failure.

Small for size syndrome following living donor and split liver transplantation

The field of liver transplantation is limited by the availability of donor organs. The use of living donor and split cadaveric grafts is one potential method of expanding the donor pool. However, primary graft dysfunction can result from the use of partial livers despite the absence of other causes such as vascular obstruction or sepsis. This increasingly recognised phenomenon is termed "Small-for-size syndrome" (SFSS). Studies in animal models and humans have suggested portal hyperperfusion of the graft combined with poor venous outflow and reduced arterial flow might cause sinusoidal congestion and endothelial dysfunction. Graft related factors such as graft to recipient body weight ratio < 0.8, impaired venous outflow, steatosis > 30% and pro- longed warm/cold ischemia time are positively predictive of SFSS. Donor related factors include deranged liver function tests and prolonged intensive care unit stay greater than five days. Child-Pugh grade C recipients are at relatively greater risk of developing SFSS. Surgi- cal approaches to prevent SFSS fall into two categories: those targeting portal hyperperfusion by reducing inflow to the graft, including splenic artery modulation and portacaval shunts; and those aiming to relieve paren-chymal congestion. This review aims to examine thecontroversial diagnosis of SFSS, including current strate-gies to predict and prevent its occurrence. We will also consider whether such interventions could jeopardize the graft by compromising regeneration.

Microsurgical reconstruction of hepatic artery in living donor liver transplantation:experiences and lessons

BACKGROUND: Hepatic artery (HA) reconstruction is one of the key steps for living donor liver transplantation (LDLT). The incidence of HA thrombosis has been reduced by the introduction of nucrosurgical techniques under a high resolution microscope or loupe. METHODS: We report our experience in 101 cases of HA reconstruction in LDLTs using the graft-artery-undamp and posterior-wall-first technique. The reconstructions were completed by either a plastic surgeon or a transplant surgeon. RESULTS: The rate of HA thrombosis was 2% (2/101). The risk factors for failed procedures appeared to be reduced by participation of the transplant surgeon compared with the plastic surgeon. For a graft with duplicate arteries, we considered no branches should be discarded even with a positive clamping test. CONCLUSIONS: HA reconstruction without clamping the graft artery is a feasible and simplified technique, which can be mastered by transplant surgeons with considerable microsurgical training.

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.

Clinical analysis of patients with hepatocellular carcinoma recurrence after living-donor liver transplantation

AIM: To evaluated patterns and outcomes of hepatocellular carcinoma(HCC) recurrence after living donor liver transplantation(LDLT).METHODS: From 2001 to 2014, 293 patients underwent LDLT for HCC at our transplant center. We retrospectively reviewed 54(18.4%) patients with HCC recurrence after LDLT. We evaluated patterns and outcomes of HCC recurrence after LDLT, with particular attention to the Milan criteria at transplantation, treatments for HCC-recurrent patients, and factors related to survival after HCC recurrence. Furthermore, we evaluated the efficacy of combination treatment of sorafenib and an mT OR inhibitor.RESULTS: The 1-, 2-, and 3-year overall survival rates after HCC recurrence were 41.1%, 20.5%, and 15.4%, respectively. The median time interval between LDLT and HCC recurrence was 6.5 mo. Although recurrence rates according to the Milan criteria at LDLT were significantly different, HCC recurrence patterns and survival rates after HCC recurrence were not significantly different between the two groups. Time to recurrence < 12 mo(P = 0.048), multiple recurrences at HCC recurrence(P = 0.038), and palliative treatment for recurrent tumors(P = 0.003) were significant independent prognostic factors for poor survival after HCC recurrence in a multivariate analysis. The combination treatment of sorafenib and sirolimus showedsurvival benefits in the palliative treatment group(P = 0.005).CONCLUSION: Curative treatment for recurrent HCC after LDLT is the most important factor in survival rates after HCC recurrence and combination treatments of sorafenib and an m TOR inhibitor could have survival benefits in patients with HCC recurrence after LT in the palliative treatment group.