Dual Graft Living Donor Liver Transplantation Research Articles

Advocating for a "shift-to-left" in transplant oncology: left grafts, RAPID and dual graft.

The extension of liver transplantation to new oncologic indications might exacerbate the shortage of grafts. Living donor liver transplantation (LDLT) may emerge as a viable resource, although its diffusion in the Western world is still very limited. Several groups have advocated for minimizing the impact on donors by reducing the extent of donor hepatectomy, i.e., shifting from right-lobe to left-lobe or left-lateral segment donation ("shift-to-left"). This is particularly relevant when dealing with non-established indications and could make it more acceptable both for potential donors and for the recipients. Left grafts can be transplanted straightforward, despite a higher risk of small-for-size syndrome, or they can be used in the setting of dual-graft LDLT or RAPID procedures, despite technical complexity. This review will expose the most relevant features of each technique, highlighting their strengths and pitfalls and focusing on outcomes. This wide set of tools should be available at high-volume transplant centers, to propose the best technique to adapt to donor-recipient matching.

Dual Graft Living Donor Liver Transplantation for High Acuity Patients: A Single-Center Experience

The outcomes of dual graft living donor liver transplantation (DGLDLT) in high acuity patients remain underreported. The objective of this study was to report long-term outcomes from a single center in this select group of patients. This was a retrospective review of patients who underwent DGLDLT between 2012 and 2017 (n= 10). High acuity patients were defined as patients with model for end stage liver disease (MELD) ≥30 or Child Pugh score ≥11. We looked at 90-day morbidity and mortality and 5-year overall survival (OS). The median MELD score and Child Pugh score were 30 (26.7-35) and 11 (11-11.2). The median recipient weight was 105 (95.2-113.7) and ranged from 82 to 132kg. Out of 10 patients, 4 (40%) required perioperative renal replacement therapy, and 8 (80%) required hospital admission for optimization. The estimated graft to recipient weight ratio (GRWR) with right lobe graft alone was <0.8 in all patients, between 0.75 and 0.65 in 5 (50%) patients, and <0.65 in 5 (50%) patients. The 90-day mortality was 3/10 (30%), and there were 3/10 (30%) deaths during long-term follow-up. Among 155 high acuity patients, the 1-year OS with standard LDLT, standard LDLT with GRWR <0.8, and DGLDLT was 82%, 76%, and 58%, respectively (P= 0.123). With a median follow-up of 40.6 (1.9-74.4) months, the 5-year OS for DGLDLT was 50%. The use of DGLDLT in high acuity patients should be prudent and low GRWR grafts should be considered a viable alternative in selected patients.

Magnetic compression anastomosis for treatment of post-transplant biliary stricture: A case report with dual-graft living donor liver transplantation

Magnetic compression anastomosis for treatment of post-transplant biliary stricture: A case report with dual-graft living donor liver transplantation

Feasibility of Dual Living Donor Liver Transplantation From Donors With Complex Portal Vein Variations

Living donor liver transplantation (LDLT) from donors with complex portal vein anomalies has been considered a challenging procedure because vasculobiliary variations of the donor’s liver may lead to significant increases in donor and recipient complications. The use of donors with anatomic variations may be considered under the accurate preoperative planning if a more suitable donor is not available. We report a successful dual LDLT for 2 donors with portal vein anomaly to overcome the small-for-size graft syndrome and secure donor safety. A 62-year-old man was referred to our institution for liver transplant because of hepatitis B–related liver cirrhosis with hepatocellular carcinoma. The only available donors were his son and his daughter-in-law, one with type IV portal venous anatomic variation and the other with type III variation. Neither of the 2 available donors were suitable as a single donor because of the complexity of the portal vein reconstruction and the donor’s safety. Therefore, the decision was made to perform LDLT using dual graft, and we planned to harvest the right posterior sector graph from the first donor together with the left lobe graft of the second donor. Donor hepatectomy and recipient total hepatectomy were performed in the usual manner. He has recovered well with normal graft function, and there has been no tumor recurrence after dual LDLT. Dual graft LDLT using right posterior sector and left lobe graft could be undertaken successfully to overcome the small-for-size graft syndrome and secure the safety of donors in cases with the complex portal vein anomalies.

Biliary Complications After Single- and Dual-Graft Living-Donor Liver Transplantation Using a Right Posterior Section Graft of Donor with a Type III Portal Vein Variation

BackgroundWhen the donor’s left lobe volume is <30%, donor selection for the right posterior section graft (RPSG) is based on the type III portal vein (PV) anatomic variation. Herein, we validated the selection of a donor with a type III PV variation for RPSG to prevent biliary complications (BCs) after single-graft (SG) and dual-graft (DG) living-donor liver transplantation (LDLT). MethodsThe clinical data of recipients and donors with a type III PV variation for LDLT using an RPSG performed between January 2004 and June 2018 were retrospectively collected and analyzed to determine the occurrence of BCs. ResultsThe 26 LDLTs performed using an RPSG, including 20 DG LDLT cases, accounted for 0.6% of all LDLT cases (n=4292). BCs developed in 6 recipients (23.0%), including biliary stricture in 4 (15.3%) and bile leakage in 2 (7.6%). No vascular complications occurred. The RPSG volume was significantly smaller in recipients with BCs than in those without BCs (400.8±79.9 vs 504.1±96.5 mL, P = .015). The bile duct types were A, B, C1, C2, and D in 6 (18.8%), 5 (15.6%), 3 (9.4%), 13 (40.6%), and 5 (15.6%) patients, respectively. All the RPSGs had a single-orifice bile duct. The bile duct size of the RPSG was relatively smaller in recipients with BCs than in those without BCs (2.8±1.0 vs 3.6±1.4 mm, P = .237). ConclusionsWhen the left liver volume is disproportionately small, selection of a donor with a type III PV variation can prevent BCs after SG and DG LDLTs using an RPSG.

Living donor liver transplantation.

As experience grows, living donor liver transplantation (LDLT) has become an effective treatment option to overcome the deceased donor organ shortage. Donor safety is the highest priority in LDLT. Strict donor selection according to structured protocols and center experience are the main factors that determine donor safety. However, with increased experience, many centers have explored increasing organ availability within living donation by means of ABO incompatible LDLT, dual graft LDLT, and anonymous living donation. Also, this growing experience in LDLT has allowed the transplant community to cautiously explore the role of liver transplantation for hepatocellular carcinoma outside of Milan criteria and patients with unresectable colorectal liver metastases. LDLT has become established as a viable strategy to ameliorate the organ shortage experienced by centers around the world. Improved understanding of this technique has allowed the improved utilization of live donor graft resources, without compromising donor safety. Moreover, LDLT may offer some advantages over deceased donor liver transplantation and a unique opportunity to assess the broader applicability of liver transplantation.

Dual-graft living donor liver transplantation: An innovative surgical procedure for live liver donor pool expansion

Dual-graft living donor liver transplantation: An innovative surgical procedure for live liver donor pool expansion

Simultaneous implantation of bilateral liver grafts in living donor liver transplantation by fusion venoplasty

Small-for-size syndrome is a serious complication after living donor liver transplantation (LDLT). LDLT using dual grafts offers an alternative to solve this problem. In case of a right and left liver graft adopted for dual graft LDLT, sequential implantation of the right graft followed by the left graft is the usual approach. However, left hepatic vein and portal vein anastomosis could be challenging when the right subphrenic space is occupied by the right liver graft, and this problem could be avoided by simultaneous implantations of bilateral grafts. In this video, the technique of simultaneous implantation of bilateral living donor liver grafts via fusion venoplasty (FV) in a 59-year old patient with acute liver failure was presented. We performed FV at the backtable to join the right hepatic vein (RHV) and middle hepatic vein (MHV) to create one venous outflow in the right liver graft, the left liver was approximated to the right liver graft at the backtable followed by FV joining the left hepatic vein to the R/MHV venous cuff before anastomosis with the inferior vena cava. The right and left portal veins were then joined together to create one common orifice before anastomosis with the recipient's main portal vein. The graft right and left hepatic artery were anastomosed with the recipient's right and left hepatic artery respectively. Biliary reconstruction was performed via a duct-to-duct anastomosis for the right liver graft and a hepaticojejunostomy for the left liver graft. [Bilateral liver grafts after fusion venoplasty]

Living donor liver transplantation using dual grafts: Experience and lessons learned from cases worldwide.

In living donor liver transplantation (LDLT), insufficient graft volume could result in small-for-size syndrome in recipients, whereas major liver donation predisposes the donor to a high risk of posthepatectomy liver failure. Dual graft LDLT is therefore introduced to obtain combined graft sufficiency. To date, 367 patients have been reported worldwide. We reviewed all the relevant literature, with a special focus on 43 case reports containing enough data to extract and analyze. A simple decision-making algorithm was developed. Dual graft LDLT is indicated when (1) a single donation is unacceptable due to graft-to-recipient size mismatch; (2) the future liver remnant is insufficient in the single donor after major resection; or (3) there is a significant underlying disorder or anatomical variation within the donor liver. The outcome of dual graft LDLT is reported to be comparable with that of single donor LDLT. Unilateral graft atrophy was found in 7 of the 43 patients, predominantly in the right-sided, heterotopic and initially smaller grafts. Technically, the heterotopic implantation and complex vascular reconstruction are the most demanding. Elaborate surgical planning and modification are needed. Ethical concerns about involving a second living donor need to be addressed. In conclusion, dual graft LDLT should be prudently performed in select cases by surgeons of proven expertise when single donation is unacceptable and a second living donor is available. The decision-making criteria need to be standardized. More surgical modification and clinical research are needed.

Living donor liver transplantation.

Living donor liver transplantation (LDLT) continues to evolve, generating interesting issues on the applicability and safety of new techniques. Specific selection criteria and standardized surgical techniques with high ethical and medical standards are needed to minimize donor risk. In this aspect, minimally invasive donor hepatectomy has caused controversies. The reproducibility and safety of pure laparoscopic major hepatectomy in LDLT remains uncertain. Therefore, a stepwise approach is needed to avoid unnecessary donor risk. To expand the living donor pool, dual graft and ABO-incompatible LDLT have emerged as well tolerated and effective methods. The extended selection criteria for hepatocellular carcinoma in LDLT appear acceptable to balance donor risk and recipient outcome. However, these criteria should be validated based on the risk-benefit ratio. Despite technical advances, technical challenges persist such as Budd-Chiari syndrome and portal vein thrombosis. To address these issues, several innovative surgical techniques have been proposed and have shown promising results. LDLT is associated with donor safety concerns, technical complexity, and small-for-size issues. Nonetheless, accumulated experience and technical know-how from large-volume Asian LDLT centers have led to progress in LDLT. Further technical refinement and investigation to overcome the disadvantages of partial grafts will broaden the applicability of LDLT.

Renoportal anastomosis for dual-graft living donor liver transplantation using an artificial graft and a left renal vein-connected inferior vena cava cuff

Renoportal anastomosis for dual-graft living donor liver transplantation using an artificial graft and a left renal vein-connected inferior vena cava cuff

2500 Cases of Adult Living Donor Liver Transplantations in Single Institution

Background: Although there has been continuing concern about donor safety, living donor liver transplantation (LDLT) has been settled as feasible therapeutic option for end-stage liver disease. In this study, we introduce fifteen-year experience in adult living donor liver transplantation and present evolving steps in technical advancement in donor and recipient surgery. And we analyzed survival results and the risk factors affecting short-term and long term outcome of recipient. Method: We analyzed the data of 2500 adult LDLTs which have been performed from February 1997 to August 2011, retrospectively. Result: We started adult LDLT program from February 1997 with left lobe LDLT. The mean age of recipient was 49.6±8.8 (18˜76) years. The sex ratio was 1870 (74.8%)/630 (Male/Female). The most common cause of LDLT was HBV-LC (74.6%). Total 1103 (44.1%) were accompanied by HCC. The mean MELD score was 20.1±10.4 (3˜40). The most commonly used graft type was modified right lobe graft (73.6%). The mean GRWR 1.06±0.21 (0.49˜2.43)%. The overall in-hospital mortality (IHM) was 5.6%. The IHM in early experience was significantly higher (33.3%) but has been lowered to around 5% recently by the refinement of surgical techniques and advancement of postoperative care. The 1-, 3-, 5-year patient survival rate was 90.4, 84.2 and 78.7%, respectively which was significantly higher than that of deceased donor liver transplantation during same period. When we analyzed risk factors affecting recipient outcome, preoperative recipient condition (MELD>30, recipient age >60, preoperative ventilator support or renal replacement therapy), GRWR (< 0.7%) and donor age (>50 years) were significant risk factors. The most common postoperative complication during immediate postoperative period (< 1month) was postoperative bleeding but overall most common complication was biliary stricture (13.2%). The most common cause of early death (< 3 month) was septic complication and that of late death was HCC recurrence. During this period, total 321 dual graft LDLT were performed. Therefore, 2819 living donors excluding 2 deceased donors were involved. The mean age of donor was 27.8±8.1 (16˜57). There was no donor mortality. The incidence of donor morbidity was higher (8.1%) during early experience and significantly higher in right lobe donor (10.7%) than left lobe donor (2.6%). But, it has been decreased to around 1% and no difference in graft type. Conclusion: Adult LDLT is most useful and effective therapeutic option for end-stage liver disease in the country with scarcity of deceased donor. However, the special concern should be paid for the safety of donor. We should improve recipient outcome by continuing refinement of surgical techniques and postoperative care to justify the inevitable donor risk.

Regeneration and outcome of dual grafts in living donor liver transplantation

In living donor liver transplantation (LDLT), the essential aims are to provide an adequate graft volume to the recipient and to keep a sufficient remnant liver volume in the donor. In some instances, these aims cannot be met by a single donor and LDLT using dual grafts from two donors is a good solution. From 2002 to 2009, five recipients in our hospital received dual graft LDLT. Two recipients received one right lobe and one left lobe grafts; the other three received two left lobe grafts. The mean final liver regeneration rate was 91.2%. Left lobe graft atrophy in the long term was observed in recipients who received a right and a left lobe grafts. The initial bigger volume graft in all recipients was noted to have better regeneration than the smaller volume grafts. Portal flow and bilateral grafts volume size discrepancy were considered as two major factors influencing graft regeneration in this study. We also noted that the initial graft volume correlated with portal flow in the separate grafts and finally contribute to individual graft regeneration. Because of compensatory hypertrophy of the other graft, recipients who experienced atrophy of one graft did not show signs of liver dysfunction.

Living donor liver transplantation using dual grafts: Ultrasonographic evaluation

To evaluate the dual-graft living donor liver transplantation (LDLT) with ultrasonography, with special emphasis on the postoperative complications. From January 2002 to August 2007, 110 adult-to-adult LDLTs were performed in West China Hospital of Sichuan University. Among them, dual-graft implantations were performed in six patients. Sonographic findings of the patients were retrospectively reviewed. All the six recipients survived the dual-graft adult-to-adult LDLT surgery. All had pleural effusion. Four patients had episodes of postoperative abdominal complications, including fluid collection between the grafts in three patients, intrahepatic biliary dilatation in two, hepatofugal portal flow of the left lobe in two, and atrophy of the left lobe in one. Although dual-graft LDLT takes more efforts and is technically complicated, it is safely feasible. Postoperative sonographic monitoring of the recipient is important.

Dual living donor liver transplantation with ABO-incompatible and ABO-compatible grafts to overcome small-for-size graft and ABO blood group barrier

ABO blood group compatibility has been regarded as an essential prerequisite for successful adult living donor liver transplantation (LDLT). Novel strategies for overcoming the ABO blood group barrier, however, have markedly improved the results of ABO-incompatible (ABOi) LDLT. We describe our strategies for dual graft LDLT to cope with ABO-incompatibility and small-for-size graft syndrome in 3 patients who underwent dual graft LDLT with ABOi and ABO-compatible (ABOc) grafts. One patient received a modified right lobe graft from an ABOi living donor and a left lateral section graft from an ABOc deceased donor, whereas the other 2 patients received 2 left lobe or left lateral section grafts from ABOi and ABOc living donors. To overcome the ABO-blood barrier, each patient was treated with preoperative anti-CD20 antibody (rituximab 375 mg/m(2)), perioperative plasma exchange, and hepatic arterial infusion. All 3 patients were males, of mean age 47.7 years (range, 40 approximately 52 years) and mean Model for End-Stage Liver Disease score 12.3 (range, 9 approximately 15). The mean graft-to-recipient weight ratio was 0.99%. All patients remain alive after a mean follow-up period of 9.5 months (range, 8.0 approximately 10.7 months). All 6 grafts have functioned normally. There were no episodes of antibody-mediated rejection or biliary complication. Dual LDLT with ABOi and ABOc grafts can be a feasible solution for simultaneously overcoming both the ABO blood group barrier and small-for-size graft syndrome.

Value of CT and Doppler Sonography in the Evaluation of Hepatic Vein Stenosis After Dual-Graft Living Donor Liver Transplantation

The purpose of this study was to evaluate the imaging findings and role of CT and Doppler sonography in the diagnosis of hepatic vein (HV) stenosis after dual-graft living donor liver transplantation (LDLT). Using hepatic venography as the reference standard, 73 grafts with venographic evaluation in 43 dual-graft LDLT recipients were classified into either a stenosis (n = 39) or a nonstenosis (n = 34) group. CT scans were evaluated for relative attenuation, enhancement pattern, and HV abnormality for each graft. Doppler sonography evaluation of the flow pattern of HVs for each graft was performed. CT and Doppler sonography findings were compared in the stenosis and nonstenosis groups using the independent sample Student's t test and Fisher's exact test. Multifactorial logistic regression analysis was performed to determine the best predictors of the diagnosis of HV stenosis. Heterogeneous enhancement (p = 0.046), abnormal HV on CT (p = 0.025), and HV wave pattern on Doppler sonography (p = 0.005) were significant findings. The accuracy for the diagnosis of HV stenosis was 60.0% for heterogeneous enhancement, 61.5% for abnormal HV, and 66.2% for a monophasic flow pattern. Heterogeneous enhancement and HV wave pattern were significant independent findings on multifactorial logistic regression analysis. The overall accuracy of the logistic model in the diagnosis of HV stenosis was 71.7%. Although CT and Doppler sonography can be helpful in diagnosing HV stenosis, given the low accuracy of individual imaging findings, the diagnosis of HV stenosis should be made cautiously, with both CT and Doppler sonography regarded as complementary examinations.

Resolution of severe graft steatosis following dual-graft living donor liver transplantation

Although severely steatotic liver grafts are not suitable for transplantation, they have been used when other, more optimal donors were not available, especially for living donor liver transplantation (LDLT) using two liver grafts. Here we present two cases of dual-graft LDLT in which the recipients showed rapid and complete clearing of fat from livers with previously severe steatosis. In the first case, two left lateral segment grafts were used, one of which was 70% steatotic. Preoperative and posttransplant two-week liver-to-spleen computed tomography-value (L/S) ratios were 0.48 and 1.25, respectively. A liver biopsy taken two weeks after transplantation showed that the fatty changes had almost disappeared. The second case used one left lobe and one left lateral segment graft, the latter of which was 80% steatotic. Preoperative and two-week L/S ratio were 0.58 and 1.34, respectively, and a liver biopsy taken two weeks after transplantation showed less than 3% steatosis. The two donors of the severely steatotic liver grafts recovered uneventfully. These findings show that the fat content of the liver grafts was rapidly removed after transplantation. This observation is helpful in understanding the recovery sequences following transplantation of steatotic liver grafts, as well as expanding the acceptability of steatotic liver grafts.

The first two cases of living donor liver transplantation using dual grafts in Europe

The major limitation in adult-to-adult living donor liver transplantation (LDLT) is an adequate graft size with special regard to the safety of the donor. Only 20% of the evaluated donors are suitable to donate the right liver, depending mainly on the critical remnant liver volume. We report 2 cases of adult-to-adult LDLT using dual grafts. In the first case we implanted a left lateral lobe together with a left lobe; in the second case we used a left lateral and a right lobe. Dual graft LDLT solves the problem of graft-size insufficiency and avoids critical right lobectomy in the donor. This procedure can be safely performed and opens up the possibility of LDLT to even more families in the Western world.