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.

Small for size syndrome difficult dilemma: Lessons from 10 years single centre experience in living donor liver transplantation

AIM To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome(SFSS) after living donor liver transplantation(LDLT). METHODS Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT(A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range(0-144 m). RESULTS SFSS was diagnosed in 20(11.5%) of our recipients. While extra-small graft [small for size graft(SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis(P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis(P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10(40%) SFSS vs 3/7(42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe(RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10(28.6%) SFSS vs 52/152(34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7-and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7-and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference(P = 0.00). CONCLUSION SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention(i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).

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.

Graft-to-recipient weight ratio lower to 0.7% is safe without portal pressure modulation in right-lobe living donor liver transplantation with favorable conditions

BACKGROUND: The low graft-to-recipient weight ratio(GRWR) in adult-to-adult living donor liver transplantation(LDLT) is one of the major risk factors affecting graft survival. The goal of this study was to evaluate whether the lower limit of the GRWR can be safely reduced without portal pressure modulation in right-lobe LDLT. METHODS: From 2005 to 2011, 317 consecutive patients from a single institute underwent LDLT with right-lobe grafts without portal pressure modulation. Of these, 23 had a GRWR of less than 0.7%(group A), 27 had a GRWR of ≥0.7%, 【0.8%(group B), and 267 had a GRWR of more than and equal to 0.8%(group C). Medical records, including recipient, donor, operation factors, laboratory findings and complications were reviewed retrospectively. RESULTS: The baseline demographics showed low model for end-stage liver disease score(mean 16.3±8.9) and high percentage of hepatocellular carcinoma(231 patients, 72.9%). Three groups by GRWR demonstrated similar characteristics except recipient body mass index and donor gender. For smallforsize syndrome, there were 3(13.0%) in group A, 1(3.7%) in group B, and 2 patients(0.7%) in group C(P【0.001). Hepatic artery thrombosis was more frequently observed in group A than in groups B and C(8.7% vs 3.7% vs 1.9%, P=0.047). However, among the three groups, graft survival rates at 1 year(100% vs 96.3% vs 93.6%) and 3 years(91.7% vs 73.2% vs 88.1%) were not different(P=0.539). In laboratory measurements,there was no group difference in total bilirubin and albumin. However, prothrombin time was longer in group A within postoperative 1 week and platelet count was lower in groups A and B within postoperative 1 month. CONCLUSION: A GRWR lower to 0.7% is safe and does not need to modulate portal pressure in adult-to-adult LDLT using the right-lobe in favorable conditions including low model for end-stage liver disease score.

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'.

Challenge to ABO blood type barrier in living donor liver transplantation

ABO incompatible living donor liver transplantation has the potential to expand the donor pool for patients with end stage liver diseases on the expense of challenges to overcome immunological barriers across blood type.There is a profound impact of age on incidence and severity of antibody mediated rejection(AMR).Even children older than 1 year have chances of AMR;children aged 8 years or older have risks of hepatic necrosis similar to adult liver recipients.The mechanism of AMR is based on circulatory disturbances secondary to inflammation and injury of the vascular endothelium caused by an antibody-antigen-complement reaction.The strategy to overcome ABO blood type barrier is based on both pre-transplant desensitization and adequate treatment of this phenomenon.Nowadays,rituximab is the standard means of desensitization but unfortunately an insufficient aid to treat AMR.Because of low incidence(less than 5%in the rituximab era),in practice of AMR only some case reports about the treatment of clinical AMR are available in the literature.Initial experiences revealed that the proteasome inhibitor,bortezomib might be a promising treatment based on its capacity to deplete plasma cell agents.Although ABO blood type barrier has been counteracted in 95%of patients by applying“rituximab-desensitization”,many issues,such as prediction of high-risk patients of infection and AMR and secure treatment strategies for evoked AMR,remain to be resolved.

Survival outcomes of right-lobe living donor liver transplantation for patients with high Model for End-stage Liver Disease scores

BACKGROUND: Controversy exists over whether living donor liver transplantation (LDLT) should be offered to patients with high Model for End-stage Liver Disease (MELD) scores. This study tried to determine whether a high MELD score would result in inferior outcomes of right-lobe LDLT. METHODS: Among 411 consecutive patients who received right-lobe LDLT at our center, 143 were included in this study. The patients were divided into two groups according to their MELD scores: a high-score group (MELD score ≥25; n=75) and a low-score group (MELD score 【25; n=68). Their demographic data and perioperative conditions were compared. Univariable and multivariable analyses were performed to identify risk factors affecting patient survival. RESULTS: In the high-score group, more patients required preoperative intensive care unit admission (49.3% vs 2.9%; P【0.001), mechanical ventilation (21.3% vs 0%; P【0.001), or hemodialysis (13.3% vs 0%; P=0.005); the waiting time before LDLT was shorter (4 vs 66 days; P【0.001); more blood was transfused during operation (7 vs 2 units; P【0.001); patients stayed longer in the intensive care unit (6 vs 3 days; P【0.001) and hospital (21 vs 15 days; P=0.015) after transplantation;more patients developed early postoperative complications (69.3% vs 50.0%; P=0.018); and values of postoperative peak blood parameters were higher. However, the two groups had comparable hospital mortality. Graft survival and patient overall survival at one year (94.7% vs 95.6%; 95.9% vs 96.9%), three years (91.9% vs 92.6%; 93.2% vs 95.3%), and five years (90.2% vs 90.2%; 93.2% vs 95.3%) were also similar between the groups. CONCLUSIONS: Although the high-score group had signifi-cantly more early postoperative complications, the two groups had comparable hospital mortality and similar satisfactory rates of graft survival and patient overall survival. Therefore, a high MELD score should not be a contraindication to right-lobe LDLT if donor risk and recipient benefit are taken into full account.

Effect of donor age on graft function and longterm survival of recipients undergoing living donor liver transplantation

BACKGROUND： Donor shortage is the biggest obstacle in organ transplantation. Living donor liver transplantation（LDLT） has been considered as a valuable approach to shortening waiting time. The objectives of this study were to investigate the feasibility of utilizing donors older than 50 years in LDLT and to evaluate the graft function and recipient survival.METHODS： All LDLT cases（n=159） were divided into the older（donor age ≥50 years, n=10） and younger（donor age 〈50 years,n=149） donor groups. Donor graft and recipient condition pre-,intra- and post-operation were compared between the two groups.In particular, graft functions and recipient survivals were analyzed.RESULTS： The median donor age was 58.5（52.5-60.0） years in the older donor group and 25.0（23.0-32.0） in the younger donor group. There was no significant difference in cold ischemic time, anhepatic phase and operation time between the older and younger donor groups（P〉0.05）. However, the volume of red blood cell transfused in operation was greater in the older donor group than in the younger donor group（1900 vs 1200 m L, P=0.023）. The 1-, 3- and 5-year graft survival rates were 90%, 80% and 80% for the older donor group, and 92%, 87% and 87% for the younger donor group, respectively（P=0.459）.The 1-, 3- and 5-year survival rates were 100%, 90% and 90% for recipients with older grafts, and 93%, 87% and 87% for those with younger grafts, respectively（P=0.811）.CONCLUSION： It is safe for a LDLT recipient to receive liver from donors older than 50 years, and there is no significant adverse effect on graft function and long-term patients’ survival.

A retrospective analysis of the safety and efficacy of low dose tacrolimus (FK506) for living donor liver transplant recipients

We sought to evaluate the efficacy and effects of low-dose tacrolimus （FK506） to recipients with living donor liver transplantation （LDLT）. A total of 66 patients who underwent LDLT between 2001 and 2007 were enrolled in this study. According to different doses of tacrolimus, the recipients were randomly divided into two groups： the low-dose tacrolimus group （group A） and the normal-dose tacrolimus group （group B）. The blood concentration of tacrolimus and its side effects including infection, hyperglycemia, hypertension, high blood creatinine and jaundice were monitored once a week at the perioperative period, and once a month thereafter. Besides, the survival rates of the recipients were analyzed at the 1and 3-year time point after operation. Among these patients, no significant acute rejection was detected after LDLT. The incidences of infection, hyperglycemia, liver dysfunction and renal impairment in group A were markedly lower than those in group B. However, no significant differences were detected in the incidence of hypertension between the two groups. Moreover, the recipients in each group had a similar survival rate according to the results of 1and 3-year follow-up. The incidence of side effects that associated with tacrolimus positively correlated with tacrolimus blood concentration. In conclusion, long-term and low-dose administration of tacrolimus is a safe and effective treatment for LDLT recipients.

Hepatic vein in living donor liver transplantation

Right lobe living donor liver transplantation(LDLT)is a major development in adult LDLT that has significantly increased the donor pool by providing larger graft size and by decreasing risk of small-for-size graft syndrome.However,right lobe anatomy is complex,not only from the inflow but also from the outflow perspective.Outflow reconstruction is one of the key requirements of a successful LDLT and venous drainage of the liver graft is just as important as hepatic inflow for the integrity of graft function.Outflow complications may cause acute graft failure which is not always easy to diagnose.The right lobe graft consists of two sections and three hepatic venous routes for drainage that require reconstruction.In order to obtain a congestion free graft,several types of vascular conduits and postoperative interventions are needed to assure an adequate venous allograft drainage.This review described the anatomy,functional basis and the evolution of outflow reconstruction in right lobe LDLT.

Management of the Middle Hepatic Vein in Right Lobe Living Donor Liver Transplantation: A Meta-analysis

Summary： Living donor liver transplantation （LDLT） is a curative treatment for end stage liver disease. It is advantageous due to the shortage of deceased donors. However, in LDLT, whether the middle he- patic vein （MHV） should be preserved in donors remains controversial. We conducted searches in Pub- reed, Embase, Cochrane Library, Web of Science, Ovid, and Google Scholar using the key words ＂living donor liver transplantation＂ and ＂middle hepatic vein＂. Due to ethical issues, there were no randomized control trails focusing on MHV in LDLT. The majority of reports were retrospective studies. We exam- ined the reference lists to identify related investigations. Google Scholar was then used to obtain full texts. Nine observational studies were analyzed. There were no significant differences in liver function （WMD, -5.51; P=0.12） and complications （RR, 0.98; P=0.89） in donors with or without MHV. How- ever, the liver function in recipients was greatly improved after LDLT with MHV （WMD, -78.32; P=0.01）. No definite conclusion was obtained in terms of the liver regeneration indices between LDLT with or without MHV. It was conclude that grafts with MHV in LDLT favor recipient outcomes and do not harm the living donor if a careful preoperative evaluation is oerformed.

Weight loss interventions in living donor liver transplantation as a tool in expanding the donor pool: A systematic review and metaanalysis

BACKGROUND With increasing rates of liver transplantation and a stagnant donor pool,the annual wait list removals have remained high.Living donor liver transplantation(LDLT)is an established modality in expanding the donor pool and is the primary method of liver donation in large parts of the world.Marginal living donors,including those with hepatic steatosis,have been used to expand the donor pool.However,due to negative effects of steatosis on graft and recipient outcomes,current practice excludes overweight or obese donors with more than 10%macro vesicular steatosis.This has limited a potentially important source to help expand the donor pool.Weight loss is known to improve or resolve steatosis and rapid weight loss with short-term interventions have been used to convert marginal donors to low-risk donors in a small series of studies.There is,however,a lack of a consensus driven standardized approach to such interventions.AIM To assess the available data on using weight loss interventions in potential living liver donors with steatotic livers and investigated the feasibility,efficacy,and safety of using such donors on the donor,graft and recipient outcomes.The principal objective was to assess if using such treated donor livers,could help expand the donor pool.METHODS We performed a comprehensive literature review and meta-analysis on studies examining the role of short-term weight loss interventions in potential living liver donors with hepatic steatosis with the aim of increasing liver donation rates and improving donor,graft,and recipient outcomes.RESULTS A total of 6 studies with 102 potential donors were included.Most subjects were males(71).All studies showed a significant reduction in body mass index postintervention with a mean difference of-2.08(-3.06,1.10,I2=78%).A significant reduction or resolution of hepatic steatosis was seen in 93 of the 102(91.2%).Comparison of pre-and post-intervention liver biopsies showed a significant reduction in steatosis with a mean difference of-21.22(-27.02,-15.43,I2=56%).The liver donation rates post-intervention was 88.5(74.5,95.3,I2=42%).All donors who did not undergo LDLT had either recipient reasons or had fibrosis/steatohepatitis on post intervention biopsies.Post-operative biliary complications in the intervention group were not significantly different compared to controls with an odds ratio of 0.96[(0.14,6.69),I2=0].The overall post-operative donor,graft,and recipient outcomes in treated donors were not significantly different compared to donors with no steatosis.CONCLUSION Use of appropriate short term weight loss interventions in living liver donors is an effective tool in turning marginal donors to low-risk donors and therefore in expanding the donor pool.It is feasible and safe,with comparable donor,graft,and recipient outcomes,to non-obese donors.Larger future prospective studies are needed.

Optimizing biliary outcomes in living donor liver transplantation:Evolution towards standardization in a high-volume center

Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation.While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction,our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors,in particular,our surgical protocols.We present herein,the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts.Over this period of transition,our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0%to 10.2%.

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.

Caudal shifting of hepatic vein anastomosis in right liver living donor liver transplantation

BACKGROUND: In right liver living donor liver transplantation, hepatic venous anastomosis is performed using the recipient's right hepatic vein orifice. There may be situations that the portal vein is short or the right liver graft is small, leading to difficulty in portal vein, hepatic artery or duct-to-duct anastomosis. METHODS: The recipient's right hepatic vein orifice is closed partially for 2 cm at the cranial end or totally, and a new venotomy is made caudal to the right hepatic vein orifice. Hepatic vein anastomosis is performed with the new venotomy. RESULTS: The distance between the liver graft hilum and hepatoduodenal ligament is reduced. Portal vein, hepatic artery and biliary anastomosis could be performed without tension or conduit. CONCLUSION: Caudal shifting of hepatic vein anastomosis facilitates implantation of a right liver living donor graft.

Early post-operative complications in living donor liver transplantation:prevention,detection and management

Living donor liver transplantation (LDLT) is now performed with high rates of success due to judicious recipient and donor selection,careful preoperative planning, excellent anesthesia management, and prompt detection and treatment of complications. The indications for LDLT for adult and pediatric recipients should be the same as for deceased donor liver transplantation. Early postoperative complications are often defined as complications occurring within the first 3 months

Comment on pediatric living donor liver transplantation decade progress in Shanghai: Characteristics and risks factors of mortality

Since the first successful liver transplantation was performed five decades ago,pediatric liver transplantation has become the gold standard treatment choice for pediatric liver disease,including metabolic diseases,liver tumors,and some acute liver failure.With improvements in immunosuppression,surgical techniques,and postoperative medical care,long-term outcomes of patients after liver transplantation have markedly improved,especially in pediatric patients.

Uses of a dedicated 3D reconstruction software with augmented and mixed reality in planning and performing advanced liver surgery and living donor liver transplantation(with videos)

The development of digital intelligent diagnostic and treatment technology has opened countless new opportunities for liver surgery from the era of digital anatomy to a new era of digital diagnostics,virtual surgery simulation and using the created scenarios in real-time surgery using mixed reality.In this article,we described our experience on developing a dedicated 3 dimensional visualization and reconstruction software for surgeons to be used in advanced liver surgery and living donor liver transplantation.Furthermore,we shared the recent developments in the field by explaining the outreach of the software from virtual reality to augmented reality and mixed reality.

Impact of intra-operative cholangiography and parenchymal resection to donor liver function in living donor liver transplantation

BACKGROUND: Living donor liver transplantation(LDLT)has been widely accepted over the past decade, and hepatic dysfunction often occurs in the donor in the early stage after liver donation. The present study aimed to evaluate the effect of intraoperative cholangiography(IOC) and parenchymal resection on liver function of donors in LDLT, and to assess the role of IOC in influencing the biliary complications and improving the overall outcome.METHODS: Data from 40 patients who had donated their right lobes for LDLT were analyzed. Total bilirubin(TB), alanine aminotransferase(ALT), aspartate aminotransferase(AST),alkaline phosphatase(ALP) and γ-glutamyl transpeptidase(GGT)at different time points were compared, and the follow-up data and the biliary complications were also analyzed.RESULTS: The ALT and AST values were significantly increased after IOC(P<0.001) and parenchymal resection(P<0.001).However, the median values of TB, ALP and GGT were not significantly influenced by IOC(P>0.05) or parenchymal resection(P>0.05). The biochemical changes caused by IOC or parenchymal resection were not correlated with the degree of post-operative liver injury or the recovery of liver function. The liver functions of the donors after operation were stable, and none of the donors suffered from biliary stenosis or leakage during the follow-up.CONCLUSIONS: IOC and parenchymal resection may induce a transient increase in liver enzymes of donors in LDLT, but do not affect the recovery of liver function after operation. Moreover,the routine IOC is helpful to clarify the division line of the hepatic duct, thus reducing the biliary complication rate.

Outcomes of side-to-side conversion hepaticojejunostomy for biliary anastomotic stricture after right-liver living donor liver transplantation

BACKGROUND:Conversion hepaticojejunostomy is considered the salvage intervention for biliary anastomotic stricture,a common complication of right-liver living donor liver transplantation with duct-to-duct anastomosis,after failed endoscopic treatment.The aim of this study is to compare the outcomes of side-to-side hepaticojejunostomy with those of endto-side hepaticojejunostomy.METHODS:Prospectively collected data of 402 adult patients who had undergone right-liver living donor liver transplantation with duct-to-duct anastomosis were reviewed.Diagnosis of biliary anastomotic stricture was made based on clinical,biochemical,histological and radiological results.Endoscopic treatment was the first-line treatment of biliary anastomotic stricture.RESULTS:Interventional radiological or endoscopic treatment failed to correct the biliary anastomotic stricture in 13 patients,so they underwent conversion hepaticojejunostomy.Ten of them received end-to-side hepaticojejunostomy and three received side-to-side hepaticojejunostomy.In the end-to-side group,two patients sustained hepatic artery injury requiring repeated microvascular anastomosis,two developed restenosis requiring further percutaneous transhepatic biliary drainage and balloon dilatation,and two required revision hepaticojejunostomy.In the side-to-side group,one patient developed re-stenosis requiring further endoscopic retrograde cholangiography and balloon dilatation.No re-operation was needed in this group.Otherwise,outcomes in the two groups were similar in terms of liver function and graft survival.CONCLUSIONS:Despite the similar outcomes,side-to-side hepaticojejunostomy may be a better option for bile duct reconstruction after failed interventional radiological or endoscopic treatment because it can decrease the chance of hepatic artery injury and allows future endoscopic treatment if re-stricture develops.However,more large-scale studies are warranted to validate the results.