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.

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.

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 December 2010, 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 151 patients (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 sig-nificantly. 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. (c) 2014 Baishideng Publishing Group Co., Limited. All rights reserved.

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.

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.

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.

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.

Risks faced by donors of right lobe for living donor liver transplantation

BACKGROUND: Because of the shortage of deceased donors with livers fit for transplantation, living donor liver transplantation (LDLT) is becoming an attractive alternative. Attention should be paid to the donors, especially to those of the right lobe. In this study, we evaluated the risks faced by donors of the right lobe for adult-to-adult LDLT. METHODS: The perioperative data from 105 consecutive living donors of the right lobe performed in West China Hospital from January 2002 to December 2007 were retrospectively studied. Preoperative evaluation included CT, MRCP, and intraoperative cholangiography, showing liver volume, hepatic vasculature and the biliary system. The standard liver volume (SLV) and the ratio of left lobe volume to SLV were calculated. The right lobe grafts were obtained by transecting the liver on the right side of the middle hepatic vein without inflow vascular occlusion, using an ultrasonic dissector. After operation the donors were monitored in the Intensive Care Unit for about three days. Each donor was followed up for at least 6 months. RESULTS: There was no donor mortality. Major complications occurred in 14 donors (13.3%), of whom 3 received conservative treatment, 8 required invasive paracentesis, and 3 required further surgery. All donors were recovered well and resumed their previous occupations. CONCLUSIONS: Donors of the right lobe face low risks. The preoperative evaluation, especially evaluation of the volume of the remnant liver, should be exact. During the operation, the patency of the remnant hepatic vasculature and bile duct must be preserved, and the extent of injury to the remnant liver should be limited as much as possible. The detection and treatment of postoperative complications should be diligently performed.

Efficacy of middle hepatic vein reconstruction in adult right-lobe living donor liver transplantation

BACKGROUND: Congestion of the right anterior segment may lead to graft dysfunction in right-lobe living donor liver transplantation (LDLT) without a middle hepatic vein (MHV) trunk. Selective reconstruction of MHV tributaries with the interposition of vascular grafts has been introduced to overcome this problem. However, there is still no consensus on the definite criteria of MHV reconstruction. METHODS: LDLT patients were reviewed to evaluate the effects of MHV reconstruction. From March 2005 to September 2008 in our transplantation center, 120 consecutive LDLTs were performed using a right-lobe graft without a MHV. Excluding 11 patients, among the remainder, 73 (67%) had reconstructed MHV tributaries, and the others 36 (33%) did not. The values of liver functional index and liver graft regeneration ratio were compared between the two groups. RESULTS: There was a prolonged period of liver functional recovery in patients with small-for-size grafts and a graft-recipient weight ratio (GRWR) <1.0%, and without MHV reconstruction. The ratio of liver regeneration 1 month postoperatively in reconstruction cases was 81%, versus 78% in patients without reconstruction (P=0.352), but among small-for-size grafts, there was a significant difference between the two groups (95% vs. 80%). CONCLUSION: Our study shows that reconstruction of MHV tributaries is not necessary in all patients, but is beneficial for patients with GRWR <1.0%. (Hepatobiliary Pancrent Dis Int 2010; 9: 135-138)

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.

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.

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.

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.

Sonographic evaluation of vessel grafts in living donor liver transplantation recipients of the right lobe

AIM： To evaluate the vessel grafts （VG） used to reconstruct the middle hepatic vein （MHV） tributaries with ultrasonography. METHODS： Twenty-four patients undergone living donor liver transplantation were enrolled in our study. MHV tributaries larger than 5 mm in diameter were reconstructed with interposition VG. Blood flow of the graft and interposition VG was checked by Doppler ultrasonography daily in the first 2 postoperative weeks and monthly followed up after discharge. The sensitivity of VG detected by ultrasonography was assessed using surgical records as references. Student＇s t test was used to compare the velocity of VG and occluded VG in chronic patents （〉 3 mo）. RESULTS： Thirty-one VG were used to reconstruct the MHV tributaries. Ultrasonography identified 96.7% （30/31） of large MHV tributaries and 90.3% （28/31） of VG. The diameter of VG was 5.6 ± 0.8 mm and the velocity of VG was 19.7 ± 8.1 cm/s. Two VG （2/31, 6.5%） were occluded on the first postoperative day in one patient who suffered from persistent ascites and had a prolonged recovery of liver function. Twenty-six VG （26/31, 83.9%） were patent 2 wk after operation. Six （6/31, 19.4%） VG were patent over 3 mo after operation. Intrahepatic venous collaterals were detected in 29.2% （7/24） patients. The velocity of VG and occluded VG was 30.1 ± 5.6 cm/s, 16.5 ± 5.8 cm/s, respectively, in chronic patents. The difference between two groups was statistically significant （P 〈 0.001）. CONCLUSION： Our results indicate that most VG are patent in the first postoperative week while only a small portion with a higher velocity remains patent after 3 mo. Intrahepatic venous collaterals can be observed in some patients after occlusion of VG.

Problems in adult living donor liver transplantation using the right hepatic lobe

BACKGROUND: Adult living donor liver transplantation (LDLT) is now widely applied to patients, children or adults, and the graft extends from the left hepatic lobe to the right hepatic lobe. Harvesting the right hepatic lobe would mean putting the donor at high risk. The congestion of a graft may cause small-for-size syndrome. The safety of the donor and its evaluation, which are related to the outcome for the recipient,play an important role in LDLT. How to decrease the congestion of the graft is another challenge to transplant experts. DATA SOURCES: A literature search from MEDLINE about adult LDLT in recent years was made to analyze the safety of the living donor and the innovation of surgical techniques for preventing small-for-size syndrome. RESULTS: The top priority for adult LDLT is donor safety. Preoperative donor evaluation consists of three stages: phase 1 for general evaluation, phase 2 for laboratory tests, and phase 3 for radiological evaluation of graft volume and vessel anatomy. The potential pathogenic mechanisms of small-for-size syndrome seem to be related to persistent portal hypertension and portal overperfusion. Improved surgical techniques for decreasing portal hypertension and preventing congestion of a graft may reduce the incidence of small-for-size syndrome. The improved techniques include reconstruction of the tributaries of the middle hepatic vein, end-to-side portocaval shunting, ligation of the splenic artery, dual-graft transplantation, and modified reconstruction of hepatic veins. CONCLUSION: With the careful preoperative assessment and the safety of the living donor, as well as improved surgical techniques, adult LDLT using the right lobe is safe.

Is right lobe liver graft without main right hepatic vein suitable for living donor liver transplantation?

BACKGROUND Since the first living donor liver transplantation(LDLT)was performed by Raia and colleagues in December 1988,LDLT has become the gold standard treatment in countries where cadaveric organ donation is not sufficient.Adequate hepatic venous outflow reconstruction in LDLT is essential to prevent graft congestion and its complications including graft loss.However,this can be complex and technically demanding especially in the presence of complex variations and congenital anomalies in the graft hepatic veins.CASE SUMMARY Herein,we aimed to present two cases who underwent successful right lobe LDLT using a right lobe liver graft with rudimentary or congenital absence of the right hepatic vein and describe the utility of a common large opening drainage model in such complex cases.CONCLUSION Thanks to this venous reconstruction model,none of the patients developed postoperative complications related to venous drainage.Our experience with venous drainage reconstruction models shows that congenital variations in the hepatic venous structure of living liver donors are not absolute contraindications for LDLT.

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.

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.

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.

Versatility and viability of hepatic venoplasty in live donor liver transplantation using the right lobe with the middle hepatic vein

Including the middle hepatic vein in the right lobe liver graft has the advantage of providing direct venous drainage of the right anterior segment. To allow unimpeded passage of blood flow, we previously designed venoplasty of the middle and right hepatic veins. We found that venoplasty is also feasible when the inferior right hepatic vein is near to the right hepatic vein, or when multiple segment 8 hepatic vein orifices are exposed adjacent to the middle hepatic vein at the graft transection surface. By joining the hepatic vein orifices into a single opening, the anastomosis into the inferior vena cava is much facilitated. The technique is simple, yet versatile , and able to cope with variation of the configurations of the hepatic vein.