Domino Liver Transplantation Research Articles

Operative Risks of Domino Liver Transplantation for the Familial Amyloid Polyneuropathy Liver Donor and Recipient: A Double Analysis

Although domino liver transplantation (LT) is an established procedure, data about the operative risks are limited. This study aimed at evaluating the operative risks of domino LT. Two retrospective analyses were conducted (comparison of familial amyloid polyneuropathy [FAP] liver donors [61 patients] vs. FAP nondonors [39 patients] and FAP liver recipients [61 patients] vs. deceased donor liver recipients [61 patients]). First analysis showed a 60-day mortality of 6.6% for FAP donors and 7.7% for FAP nondonors (p = 1.0). No patient developed primary graft nonfunction. Acute rejection was higher in FAP nondonors compared to FAP donors (38.5% vs. 13.1%). Both groups had similar vascular and biliary complication rates. ICU stay was similar, whereas total hospitalization was longer for FAP nondonors. Both groups had similar 1- and 5-year patient and graft survival rates (83.4% vs. 87.2%, and 79.8% vs. 71.8%, p = 0.7) and (83.3% vs. 87.2%, and 79.1% vs.71.8%, p = 0.7). The second analysis showed a 1.6% mortality for FAP liver recipients vs. 3.2% of the control group (p = 1). Both groups had similar morbidity and technical complication rates (18.0% vs. 13.1%, p = 0.45) and (0.18 vs. 0.15, p = 0.65). The domino procedure does not add any risk to FAP donor or recipient. It increases the organ pool allowing transplantation of marginal recipients who otherwise are denied deceased donor liver transplantation.

Domino versus deceased donor liver transplantation: Association with early graft function and perioperative bleeding

This study sought to evaluate the potential impact of domino liver transplantation (DLT) on initial graft function and early postoperative outcome in patients with cirrhosis in a Portuguese liver transplantation center. A retrospective comparative analysis was performed between 77 domino recipients (from familial amyloidotic polyneuropathy donors) and 91 deceased donor recipients, all submitted to primary elective whole liver transplantation, using the piggyback technique, in a 42-month period. Outcome parameters included graft dysfunction (defined as either primary nonfunction or initial poor function, according to the Ploeg-Maring criteria) and Clavien II-IV complications in the first postoperative week. Domino and deceased donor recipients had similar preoperative severity indices (Child-Pugh classification and Model for End-Stage Liver Disease score) and immediate postoperative severity scores (APACHE II [Acute Physiology and Chronic Health Evaluation II] and SAPS II [Simplified Acute Physiology Score II]). In DLT, donors were younger, cold ischemia time was shorter, and intraoperative transfusion requirements of packed red blood cells and fresh-frozen plasma were significantly lower. Graft dysfunction incidence was 3.4-fold lower in DLT: 5.2% (only 4 cases of initial poor function) versus 18.0% (1 primary nonfunction and 15 cases of initial poor function), P = 0.010. Postoperative bleeding was the most frequent early Clavien II-IV complication (n = 29, 17.3%), with an incidence 2.2-fold lower in domino recipients. A statistically significant difference was not found in the other analyzed Clavien II-IV complications, intensive care unit stay, mechanical ventilation time, intensive care unit mortality, and 1-year survival rate. In conclusion, in this study the younger donors and shorter ischemic time associated with DLT may provide a protective role in regards to graft dysfunction and perioperative bleeding, which are 2 important determinants of early morbidity after liver transplantation.

Risk of transmission of systemic transthyretin amyloidosis after domino liver transplantation

Recent reports of the transmission of systemic transthyretin (TTR) amyloidosis after domino liver transplantation (DLT) using grafts from patients with familial amyloid polyneuropathy (FAP) have raised concerns about the procedure. The aim of this study was to evaluate the transmission incidence of systemic TTR amyloidosis after DLT with a complete clinical, neurological, and pathological assessment. At our institution, DLT has been performed 31 times with livers from patients with FAP. Seventeen of the 19 patients still alive in 2008 agreed to enter the study. This cross-sectional study of this cohort of patients included clinical assessments, rectal biopsy, and electroneuromyography (as well as sural nerve biopsy when it was indicated). The mean follow-up at the time of the study was 62.6 ± 2.9 months. Clinically, 3 patients complained of weak dysesthesia. When a focused study was performed, 8 patients reported some kind of neurological and/or gastrointestinal disturbance. Six of the rectal biopsy samples showed amyloid deposits (TTR-positive). Electromyography (EMG) showed signs of mild sensorimotor neuropathy in 3 cases and moderate to severe sensorimotor neuropathy in 1 case. Only 2 of the 4 patients with EMG signs of polyneuropathy showed amyloid deposits in their rectal biopsy samples. Sural nerve biopsy revealed amyloid deposits (TTR-positive) in all 4 patients with EMG signs of polyneuropathy. Two patients with normal EMG findings had TTR-positive amyloid deposits in their sural nerve biopsy samples. In conclusion, de novo systemic amyloidosis after DLT may be more frequent and appear earlier than was initially thought. In our opinion, however, the graft shortage still justifies DLT in selected patients, despite the risk of de novo systemic amyloidosis. Sural nerve biopsy with EMG and clinical correlation is mandatory for confirming the disease. Indeed, other causes of neuropathy should be excluded.

Early Renal Failure After Domino Liver Transplantation Using Organs From Donors With Primary Hyperoxaluria Type 1

Organ shortage is responsible for high mortality rates of patients awaiting liver transplantation (LT). Domino transplantation has had reported success in patients with metabolic disorders. Primary hyperoxaluria type 1 (PH1) is a rare metabolic disorder. There are a few case reports that suggest that PH1 livers originating from donors that have undergone combined liver-kidney transplantation can be successfully used for domino transplantation. In the last decade, five patients received a domino liver transplant from patients with PH1 in the EUROTRANSPLANT region. In this study, we report the clinical course and outcome of these five patients who were received a domino graft transplant. All patients, with the exception of one, suffered from multifocal hepatocellular carcinoma and underwent domino LT from patients undergoing combined liver-kidney transplantation for PH1. Within the first 4 weeks, all the domino recipients developed dialysis-dependent kidney failure despite good liver function. Four of the five patients died. The only survivor underwent retransplantation due to hepatic artery thrombosis. Twenty months after transplantation, this patient is doing well and has had no recurrence of hepatocellular carcinoma. Domino LT using donors with PH1 results in early renal failure and cannot be recommended for transplantation unless preventive strategies have been identified.

Acquired amyloid neuropathy in a Portuguese patient after domino liver transplantation

Familial amyloid polyneuropathy (FAP) is a progressive neuropathy with autonomic dysfunction. Domino liver transplantation (DLT), in which the liver of an FAP patient is transplanted into another patient, is routinely applied to compensate for the shortage of available organs. We report a patient who developed a clinical picture of FAP 9 years after a DLT from an FAP donor. Electrophysiological, neuropathological, and autonomic tests were administered. The patient presented with typical clinical features of FAP. Electrophysiological investigation confirmed a moderate sensorimotor axonal and autonomic neuropathy. Sural nerve biopsy confirmed the presence of amyloid deposits in the endoneurium. Skin biopsy at the ankle showed reduced intraepidermal nerve fiber density. Our report shows that FAP can develop in a recipient of an FAP liver. This suggests that careful longitudinal study is required to evaluate the risk of FAP polyneuropathy in patients who undergo domino liver transplantation.

Liver disease recurrence after liver transplantation

Liver transplantation has become a standard option in the management of patients with end-stage liver disease. It is now evident that the most common etiology of long-term graft dysfunction is the recurrence of the primary liver disease. Autoimmune liver disorders such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis recur between 15 to 30% of the graft recipients. The clinical expression of this recurrence tends to be milder; the diagnosis is only established in many patients by findings in the liver biopsy. This milder clinical expression may be due to the use of immunosuppressive therapy for the prevention of organ rejection and it may also be modulating immune mechanisms that underlie these conditions. The recurrence of hepatitis C virus infection is characterized by an accelerated progression towards cirrhosis and hepatic failure due to the lack of an effective immunoprophylaxis program and an effective antiviral therapy. The recurrence of hepatitis B is uncommon due to the availability on an effective immunoprophylaxis program with effective antiviral agents. The familial amyloidotic polyneuropathy is a genetic condition residing in the hepatocyte that produces a mutation of transthyretin; this abnormal protein is deposited in peripheral nerves, gastrointestinal tract, heart, and kidneys. The liver from these patients, apart from producing this abnormal protein, is otherwise normal, and has been used as an organ for recipients in dire need of a liver transplant, such as patients with hepatocellular carcinoma. This approach is known as domino liver transplantation. As these recipients are followed long term, they may develop de novo amyloidosis. In summary, the underlying liver condition that led to endstage liver disease and liver transplantation may recur after liver transplantation. The clinical expression of the recurrence of the hepatic disease is modulated by the immunosuppression program unless we have an effective immunoprophylaxis and antiviral agents such as in hepatitis B.

Recurrencia de la enfermedad hepática primaria después del trasplante hepático

Liver transplantation has become a standard option in the management of patients with end-stage liver disease. It is now evident that the most common etiology of long-term graft dysfunction is the recurrence of the primary liver disease. Autoimmune liver disorders such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis recur between 15 to 30% of the graft recipients. The clinical expression of this recurrence tends to be milder; the diagnosis is only established in many patients by findings in the liver biopsy. This milder clinical expression may be due to the use of immunosuppressive therapy for the prevention of organ rejection and it may also be modulating immune mechanisms that underlie these conditions. The recurrence of hepatitis C virus infection is characterized by an accelerated progression towards cirrhosis and hepatic failure due to the lack of an effective immunoprophylaxis program and an effective antiviral therapy. The recurrence of hepatitis B is uncommon due to the availability on an effective immunoprophylaxis program with effective antiviral agents. The familial amyloidotic polyneuropathy is a genetic condition residing in the hepatocyte that produces a mutation of transthyretin; this abnormal protein is deposited in peripheral nerves, gastrointestinal tract, heart, and kidneys. The liver from these patients, apart from producing this abnormal protein, is otherwise normal, and has been used as an organ for recipients in dire need of a liver transplant, such as patients with hepatocellular carcinoma. This approach is known as domino liver transplantation. As these recipients are followed long term, they may develop de novo amyloidosis. In summary, the underlying liver condition that led to endstage liver disease and liver transplantation may recur after liver transplantation. The clinical expression of the recurrence of the hepatic disease is modulated by the immunosuppression program unless we have an effective immunoprophylaxis and antiviral agents such as in hepatitis B.

Outcomes of Domino Liver Transplantation: A Single Institution's Experience

Aims Domino liver transplantation (DLT) is a strategy to increase the donor pool. Explanted liver from patients with familial amyloidotic polyneuropathy (FAP) are often used as domino grafts, because the liver is normal apart from the production of the mutated transthyretin variant. We present the outcomes for both donors and recipients of DLT. Materials and Methods Retrospective analysis of initial DLT for 16 consecutive adult patients performed between July 2004 and July 2009. All cases of FAP donor to grafts were removed preserving the cava vein with reconstruction of the hepatic veins, except the first and seventh cases, where in we removed the retrohepatic vena cava with the liver without venovenous bypass. The postoperative follow-up period for surviving DLT recipients at the end of September 2009 was 2–62 months (mean, 26). Results Two patients out of 8 FAP donors died due to pulmonary thromboembolism on the 31st postransplant day, or sepsis at 35 days namely, an overall survival of 75%. One patient out of 8 recipients died namely, an early portal thrombosis on the 22nd postransplant day) with a crude survival of 87.5% in the recipient group ( P = no significant [NS]). Four grafts from 8 FAP donors were lost—2 deaths and 2 retransplants due to thrombotic events on the first and second postransplant day—with a crude survival of 50%. Two of 8 recipients lost their grafts: 1 death and 1 retransplantation for an acute Budd-Chiari syndrome on the first postransplant day with a crude survival of 75% in the recipient group ( P = not significant [NS]). Conclusion We believe that the FAP liver graft is an excellent option for selected patients. Special care must be taken with thrombotic events.

Clinical symptomatic de novo systemic transthyretin amyloidosis 9 years after domino liver transplantation

Four years ago, Stangou et al.1 reported a patient who developed clinical symptoms of amyloidosis 8 years after domino liver transplantation (DLT). In order to alleviate the graft shortage, livers from patients with familial amyloidotic polyneuropathy (FAP) are used as domino grafts for other patients under the assumption that several decades will pass before clinical symptoms due to amyloid accumulation emerge. We now report on another case, the third reported case in the literature, of de novo systemic amyloidosis in a 75-year-old woman 9 years after DLT. The patient underwent DLT at 65 years of age for hepatocellular carcinoma exceeding the Milan criteria in hepatitis C cirrhosis. Transarterial chemoembolization was performed before liver transplantation. During treatment, progressive cachexia and increasing B symptoms occurred. Therefore, DLT was finally considered in this patient. The posttransplant course was uneventful. In 2006, the patient described progressive dysesthesia in the lower extremities. Immunosuppression was switched from a calcineurin inhibitor to a mammalian target of rapamycin inhibitor. Other reasons for neuropathy were excluded. A rectal biopsy specimen at this time was free of amyloid deposition. In 2007, neurological symptoms further deteriorated: burning pain and progressive sensory loss in the lower limbs occurred. In March 2008, amyloid deposition was detected in the gastrointestinal wall, reflecting de novo FAP in this patient. A literature review revealed 2 case reports of symptomatic patients: in the first patient, dysesthesia of the lower limb 8 years after DLT was described,1 and in the second patient, decreased temperature sensation and pain in the toes and fingertips 7 years after DLT were reported.2 Interestingly, in our patient and in both previously reported patients, neuropathic symptoms occurred after comparable intervals after DLT (7 and 8 versus 9 years), and the indication for DLT was hepatocellular carcinoma with underlying hepatitis C cirrhosis in the first described patient1 and our patient. All the patients had received an FAP graft with a transthyretin mutation; the former 2 received grafts with a Val30Met mutation, and our patient received a graft with a Gly47Glu mutation. In individuals with both inherited mutations, neurological symptoms usually occur within the age range of 20 to 35 years.3 After DLT, the onset of symptoms was thus significantly earlier than the onset in inherited FAP patients. Despite the risk of emerging amyloidosis in recipients, the graft shortage and increasing death rates on the waiting lists prompt alternative approaches to providing grafts. DLT is a feasible technique and may, therefore, be justified in selected patients. Nevertheless, our data reinforce the need for additional caution and meticulous follow-up programs. Ana Paula Barreiros*, Christian Geber , Frank Birklein , Peter R. Galle*, Gerd Otto , * Department of Internal Medicine I, Johannes Gutenberg University, Mainz, Germany, Department of Neurology, Johannes Gutenberg University, Mainz, Germany, Department of Transplantation Surgery, Johannes Gutenberg University, Mainz, Germany.

Bridge venoplasty: A new technique to simplify venous outflow reconstruction in living donor domino liver transplantation

IN DOMINO LIVER TRANSPLANTATION, when the first recipient or the domino donor (DD) receives a living donor (LD) graft, both transplants are performed in an inferior vena cava (IVC) preserving piggyback fashion. The main technical challenge lies in ensuring a well-constructed venous outflow in the second (domino) recipient (DR) because the right hepatic vein (RHV), middle hepatic vein (MHV), and left hepatic vein (LHV) present as separate orifices in the domino graft. The techniques used to reconstitute venous outflow in the DR include anastomosis of hepatic vein stumps to circular venotomies in a vein patch or Y-grafts using either portal vein bifurcation or cadaveric iliac vein confluence. We describe a new method using a cryopreserved portal vein graft, which is split open and used as a vein patch to bridge the gap between the RHV and the common channel of MHV and LHV. This simple technique (Fig 1, A--C) permits a wide, triangulated outflow anastomosis (Fig 2) in which the natural lie of hepatic veins is preserved.

The influence of the explant technique on the hemodynamic profile during sequential domino liver transplantation in familial amyloid polyneuropathy patients

Familial amyloidotic polyneuropathy (FAP) patients present adrenergic cardiac input blockade secondary to amyloid deposits and sympathetic neuropathy. Consequently, their capacity to compensate for hemodynamic changes is limited. To avoid hemodynamic disturbances in sequential liver transplants, a standard procedure with venovenous bypass or inferior vena cava preservation is contemplated. The aim of this study was to evaluate the impact of both techniques on the hemodynamic management and outcome of patients affected by FAP and scheduled for a domino liver transplantation program. We evaluated 36 FAP patients. Venovenous bypass was performed for 20 patients (the venovenous bypass group), whereas the vena cava preservation technique was used for the remaining 16 patients (the cava preservation group). The time that elapsed from FAP diagnosis to liver transplantation was 3.2 +/- 2.7 years. Peripheral neuropathy was present in all patients, autonomic dysfunction was present in 71%, and cardiac involvement was present in 69%. Renal and gastrointestinal manifestations were reported in 19% and 53% of patients, respectively. The 1-, 3-, and 5-year survival rates were 97%, 93%, and 93%, respectively. Intraoperative hemodynamic and cardiac disorders, need for vasoactive drugs, blood loss, and transfusion requirements were recorded. Postoperative outcome and cardiac and renal complications were also recorded. No significant differences in disease severity or demographic characteristics were observed. Among all the variables studied, only the total ischemia time and time in surgery were significantly longer in the venovenous bypass group patients (P < or = 0.05). During the postoperative period, the incidence of minor cardiovascular events, incidence of acute renal dysfunction, and outcomes were similar in the 2 groups. In conclusion, either preservation of the vena cava or the standard technique with venovenous bypass can be safely used in FAP patients during liver transplantation. Liver Transpl 15:869-875, 2009. (c) 2009 AASLD.

Domino liver transplantation using a graft from a donor with familial hypercholesterolemia: seven‐yr follow‐up

A 46-yr-old female with hepatocellular carcinoma and severe hepatitis B-related liver cirrhosis received a domino liver graft from a 25-yr-old female with homozygous familial hypercholesterolemia (HFHC) in September 2001. Hypercholesterolemia occurred in the graft recipient within one yr after transplantation and was partially controlled by atorvastatin. Three yr after transplantation, an autologous CD34(+) cell transplantation was performed in order to better control the hypercholesterolemia. Only preliminary results of this domino liver transplantation (DLT) were published in 2003, without a long-term analysis of the hypercholesterolemic effects in recipient. Subsequent to DLT, the average plasma cholesterol level in the domino donor rapidly normalized and seven yr after had a value of 182 mg/dL. After seven-yr follow-up, the domino recipient has no hepatocarcinoma recurrence. Moreover, no signs of cardiovascular or atherosclerotic lesions were noted despite an elevated plasma cholesterol level (339 mg/dL after seven yr of follow-up) resistant to drug therapy and stem cell autotransplantation. In conclusion, DLT using a liver graft from a patient with HFHC provides a viable option for marginal recipients.

La transplantation hépatique

The first liver transplantation (LT) was conducted in 1963. After a two-decade development phase with the improvement of surgical and anesthesia-resuscitation techniques, and a better control of allograft rejection, LT has become the benchmark treatment for the majority of end-stage liver diseases. Since the 1980s, indications of LT have gradually expanded and the current main indications in adults are hepatocellular carcinoma at an early stage (15 to 30% of indications), C cirrhosis (15 to 40% of indications) and alcoholic cirrhosis (20 to 25% of indications). Five thousand LTs are performed yearly in Europe, including 1000 LTs in France, with, over the 2000-2006 period, survival rates of 86, 75 and 68% at one, five and 10 years, respectively. Several advances have accompanied the increasing number of indications and these excellent results: (a) the development of more specific immunosuppressive drugs to prevent rejection, the incidence of which is currently less than 20%: tacrolimus, mycophenolic acid, anti-IL2 receptor antibodies, mTOR inhibitors, (b) a policy of active recruitment of organs together with surgical innovations (split liver, domino LT, living donor transplantation) contributing to the expansion of the pool of organs, (c) standardization of organ allocation policies, based on the sickest first policy. The applicability of LT, however, remains limited by the shortage of organs and the occurrence of long-term complications of immunosuppression. Due to the lack of effective alternative perspectives to LT for the treatment of end-stage liver diseases, the two major challenges for the liver transplant community should be the optimization of organ recruitment and the development of innovative immunosuppressive regimens able to overcome the side effects of current immunosuppressive drugs. The development of non heart beating donation and appropriate use of intrafamilial donation could partly compensate for the organ shortage in the midterm. The identification of molecular signatures in tolerant patients in whom immunosuppression could be stopped, and induction of tolerance, trough lymphocyte depletion or T lymphocyte costimulation blockade, are the most advanced research ways to reduce complications of immunosuppression.

An Alternative Method of Reconstruction of Hepatic Venous Outflow in Domino Liver Transplantation

The double piggyback technique has been proposed for domino liver transplantation. To make this possible, it is necessary to reconstruct the venous outflow of the domino liver graft on the back table. We describe an alternative method of reconstruction of hepatic venous outflow, in which a neocaval segment is obtained using both common iliac veins from the cadaveric donor.

Domino liver graft from a patient with homozygous familial hypercholesterolemia

HFH is a metabolic disease caused by a defect in the gene that encodes the synthesis of the cellular receptor for LDL-Rs. A high plasma level of cholesterol is present from birth and leads to severe atherosclerosis in childhood, and death from myocardial infarction usually occurs before the age of 20 yr. The liver contains approximately 50-75% of the total body LDL-Rs; therefore, liver transplantation has been carried out to treat this metabolic disorder effectively. The rationale for using an HFH liver for a domino graft is that the absence of functional LDL-Rs in the liver may be compensated for by the extra-hepatic LDL-Rs. Therefore, an HFH liver can possibly be used as a domino graft for a recipient with a normal plasma cholesterol level before transplantation. We herein report a domino liver transplantation using an HFH liver as a domino graft with successful results. To expand the donor pool, especially in Asian countries, domino grafts from HFH should be encouraged by careful selection of the domino recipient.

Domino Liver Transplantation

In Taiwan, the first domino liver transplantation (DLTx) was successfully performed on December 22, 2007 in Taipei Veterans General Hospital. DLTx is also called sequential liver transplantation (SLTx). The meaning of DLTx is to implant the liver of the first liver transplant recipient (domino donor graft) to the second liver transplant recipient (domino recipient). This unusual type of liver transplantation is mainly for expanding organ availability. In this mini-review, the history, logical basis for the use of domino grafts and the surgical techniques will be described.

Pediatric liver transplantation in 31 consecutive children

Although liver transplantation has become a standard therapy for end-stage liver diseases, the experience of pediatric liver transplantation is limited in China. In this article we report our experience in pediatric liver transplantation, and summarize its characters in their indications, surgical techniques, and postoperative managements. Thirty-one children (< or = 18 years old) underwent liver transplantation in our centers. The mean age at transplantation was 12.4 years old (ranged from 5 months to 18 years) with 7 children being less than 4 years of age at transplantation. The most common diagnosis of patients who underwent liver transplantation were biliary atresia, Wilson's disease, primary biliary cirrhosis, glycogen storage disease, hepatoblastoma, urea cycle defects, fulminant hepatic failure, etc. The surgical procedures included 12 standard (without venovenous bypass), 6 pigyback, 6 reduced-size, 3 split, 3 living donor liver transplantation, and 1 Domino liver transplantation. The triple-drug (FK506, steroid, and mycophenolate mofetil) immunosuppressive regimen was used in most of patients. Patients were followed up for a mean of 21.8 months. Five of the 31 patients died during perioperative time; mortality rate was 16.1%. The reasons of death were infections, primary non-function, heart failure, and hypovolemic shock. Postoperative complications in 10 patients included biliary leakage, acute rejection, abdominal infection, hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, and pulmonary infection. Overall patient cumulative survival rate at 1-, 3-, and 5-year was 78.1%, 62.6%, 62.6%, respectively. The most common indications of pediatric liver transplantation were congenital end-stage liver diseases. According to patients' age and body weight, standard, piggyback, reduced-size, split, or living donor liver transplantation should be performed. Pediatric liver transplantation especially requires higher surgical skills. The early postoperative management is the key to success. Postoperative bile leak was common, but most patients underwent liver transplantation had a better prognosis.

Venoplasty of hepatic venous outflow with a venous patch in domino liver transplantation

The domino donor (DD) was a 16-year-old boy with homozygous familial hypercholesterolemia. He received a whole liver graft from a 9-year-old deceased donor. We designed the hepatic outflow to be reconstructed by side-to-side cavocaval anastomosis for the first liver transplantation, so the DD hepatectomy was performed with preservation of the inferior vena cava (IVC) and the stumps of 3 hepatic veins were preserved as long as possible. DD, domino donor; IVC, inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. At the back-table, the hepatic veins of the domino graft were jointed together easily (Fig. 1) by 6/0 prolene. A vein graft including the lower portion of the IVC in continuity with the left and right common iliac veins from the deceased donor was used. The graft was opened longitudinally to become a venous patch. One midline incision of the vein patch was done appropriately to be anastomosed with hepatic veins by 6/0 prolene sutures (Fig. 2). The external edge of the vein patch was further fashioned to be a wide cuff (Fig. 3). The domino liver graft. The orifices of RHV, MHV, and LHV were jointed together by 6/0 prolene sutures. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The midline of the venous patch was incised appropriately to be anastomosed with hepatic veins by 6/0 prolene sutures. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The external edge of the vein patch was further fashioned to be a wide cuff. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The second recipient was a 59-year-old man with hepatitis B cirrhosis and hepatocellular carcinoma. The recipient's hepatectomy was performed with preservation of the IVC. The domino liver was implanted in the standard piggyback fashion by the suturing of the reconstructed suprahepatic venous cuff to the junction of all 3 hepatic veins of the recipient with clamping of the IVC but without venous-venous bypass. The cold ischemic time, warm ischemic time, and operative blood loss were 480 minutes, 34 minutes, and 450 cc, respectively, for the DD and 435 minutes, 38 minutes, and 3300 cc, respectively, for the second recipient. The DD was discharged on the 19th postoperative day with an uneventful recovery. The second recipient was discharged on the 12th postoperative day but was readmitted for anastomotic bile leakage 8 days after discharge. He was treated by a percutaneous transhepatic biliary stent and subsequently was well with normal liver functions. The Doppler ultrasound showed normal triphasic flow into all major hepatic veins of the domino liver 6 weeks after transplantation. There have been a few reports regarding the techniques of outflow reconstruction for conditions similar to our case.1-4 Our case followed the technique described by Cescon et al.,4 and the successful outcome reassures us of the usefulness of this technique. In addition, we suggest side-to-side caval anastomosis5 for the first whole liver implantation in order to retrieve longer stumps of hepatic veins of the domino liver. The long stumps of hepatic veins are easily jointed together, and this in turn makes the vein-patch technique for outflow reconstruction of the domino liver graft easier.

Technical Solutions for Venous Outflow Reconstruction in Damaged Liver Grafts During Procurement: Case Reports

The incidence and clinical consequences of hepatic injuries (parenchymal, vascular, and biliary) due to surgical handling during multiorgan procurement are still underestimated. Surgical damage to liver grafts may lead to an increased mortality and graft dysfunction rate; therefore, multiorgan procurements require a high level of expertise and training. We report our experience in two cases of accidental venous outflow damage during liver procurement focusing on our repair strategies. In one case, a short suprahepatic inferior vena cava (IVC) was extended by a venous cuff obtained from a long infrahepatic IVC from the same liver graft. In the second case, we observed a complete transection of the middle hepatic vein during in situ splitting procedure. The damage was reconstructed by cadaveric iliac vein interposition. In both cases, liver transplantation was successfully performed without venous complication. An adequate surgical technique in liver procurement and venous reconstruction during living donor and domino liver transplantation are formidable tools to achieve successful liver transplantation with a damaged graft.

Domino Liver Transplantation: Risks and Benefits

Domino liver transplantation, wherein a patient who himself undergoes liver transplantation in turn donates his liver to another recipient, has been performed since the mid-1990s. Although livers from a handful of metabolic disorders cured by liver transplantation have been used for domino transplantation, familial amyloidotic polyneuoropathy (FAP) livers are by far the most common source. FAP is an inherited disorder never presenting its clinical manifestation before the age of 15. In many carriers, the genetic disorder never manifests during lifetime. Thus, only a proportion of patients with FAP develop disease symptoms, which has been the rationale for using such livers for other patients on the waiting list for liver transplantation. According to the Familial Amyloidotic Polyneuropathy World Transplant Registry (FAPWTR), only 2 out of more than 500 patients so far have developed symptoms after domino liver transplantation using an FAP liver. Domino recipients with nonmalignant indications for liver transplantation show excellent long-term survivals. With careful selection of recipients, the procedure helps to reduce the organ shortage and the time on the waiting list for patients with malignant disorders.