Left Lobe Living Donor Liver Transplantation Research Articles

Comment on "Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy: A Promised Land for Small Left Lobe Grafts".

We would like to congratulate the authors for publishing this important article on the outcome of utilizing left lobe grafts in their series of living donor liver transplantation (LDLT).1 Their study represents one of the largest series of utilizing left lobe grafts in the West and showed favorable 1-, 3-, and 5-year graft survival of 97%, 94%, and 89% comparable to the right lobe graft survival of 99%, 96%, and 93% (P = 0.97). This contrasts sharply from the European experience of 46 left lobe LDLTs from 4 centers showing a relatively poor 1-year graft survival of 59.4% due to a high rate of small for size syndrome (SFSS) and hepatic artery thrombosis.2 The key to their excellent outcomes was achieved by the use of venous outflow augmentation and liberal use of splenectomy to modulate portal inflow. From their series, 61 of 130 (47%) recipients received left lobe graft. Donor/recipient selection likely played a huge role to their highly favorable outcomes. The Kyoto group previously showed that the overall survival was significantly worse when using left lobe graft compared with right lobe graft in recipients who were considered high risk (at least 2 risk factors of: model for end-stage liver disease [MELD] score > 20; preoperative hospitalization; recent preoperative bacterial infection).3 In contrast, no difference in survival were found between left lobe or right lobe recipient if only 1 risk factor was present. The Kyushu group reported donor age ≥ 48 years, MELD score ≥ 19, and end portal venous pressure ≥ 19 mm Hg as the important factors for the development of SFSS.4 These factors reflect on the poor graft quality from higher donor age, poor clinical status of the recipient and excessive portal flow after reperfusion of the partial graft. To highlight the important of graft selection, the Kyushu group has also devised a scoring system that incorporates factors such as graft size, donor age, MELD score, and the presence of portosystemic shunts, which correlate well with graft survival and can be employed for graft selection.5 Although there is currently no consensus on the selection criteria when comes to choosing left lobe graft, most groups have demonstrated that donor age, and MELD score as crucial deciding factors as mentioned. In fact, the European cohort with poor outcome with left lobe grafts reported MELD score >14 as the most significant factor for the development of SFSS.2 Looking at the Cleveland cohort, it is very clear that this is a highly selected group of donors and recipients when considering for left lobe graft with a donor median age of 36 years (interquartile range, 31–41 years), low median MELD score of 12 (interquartile range, 10, 16), and less severe portal hypertension as evident by the low median splenic volume (611 mL for left lobe graft compared with 918 for right lobe graft). Their left lobe graft experience has been accumulated over 8 years from 2013 to 2020 sharing between the 2 centers ranging from 5 to 17 left lobe grafts per year (mean 7 to 8 per year). This likely represents only a fraction of their overall liver transplant activity and further suggests that the recipients chosen for left lobe graft were highly selected. As regards to the use of inflow modulation such as splenectomy in this series, a group from Tokyo has described in their series of 42 LDLTs using exclusively left lobe graft without the use of any inflow modulation technique with a very good 1-, 3-, and 5-year graft survival rate of 100%, 97%, and 91%, despite 38% of their recipients had graft-to-recipient weight ratio (GRWR) of less than 0.8%.6 Therefore, it is unclear how much contribution to current reported outcomes were related to patient selection or the use of splenectomy, the use of which has been shown to be a protective for graft dysfunction here. Although the reported morbidities with splenectomy were acceptable in this series, with sicker recipients, the added morbidity of splenectomy may become problematic and could lead to worse outcomes. It has been well established that the grafts are considered small for size when the GRWR is less than 0.8% or the standard liver volume is less than 35%.7 This article has also reported the graft outcome when actual size of the graft was smaller than the expected minimum GRWR of 0.6%. While the 5-year graft survival of 88% and only 1 mortality amongst the 9 left lobe recipients is impressive, this is still small numbers, from selected donors and recipients. Until there are more data and replication of this practice in other centers, we feel that the usage of small left lobe grafts remains an option for very few and not a promised land for the many.

Role of percutaneous radiological treatment in biliary complications associated with adult left lobe living donor liver transplantation: a single-center experience.

Biliary complications develop at a higher rate in living donor liver transplantation (LDLT) compared with cadaveric liver transplantation. Almost all studies about biliary complications after LDLT were made with the right lobe. The aim of this study was to determine the frequency of biliary complications developing after adult left lobe LDLT and to evaluate the efficacy of the algorithm followed in diagnosis and treatment, particularly percutaneous radiological treatment. A total of 2185 LDLT operations performed in our center between May 2009 and December 2019 were retrospectively reviewed and patients receiving left lobe LDLT were analyzed regarding biliary complications and treatments. Biliary complications were treated via percutaneous drainage under ultrasound (US) guidance, endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC)/ percutaneous transhepatic biliary drainage (PTBD). Patient demographics, ERCP procedures before percutaneous treatment, and percutaneous treatment indications were analyzed. A total of 69 adult patients received left lobe LDLT. Biliary complications requiring endoscopic and/or percutaneous treatment developed in 28 patients (40%). Of these patients, 4 had bile leakage (14%), 20 had anastomosis stricture (72%), and 4 had both leakage and anastomosis stricture (14%). External drainage treatment under ultrasound guidance was sufficient for 2 of 4 patients with bile leakage, and these cases were accepted as minor bile leakage (7%). Overall, 26 patients underwent ERCP; of these, 8 were referred for PTC/PTBD because the guidewire and/or balloon-stent could not pass the anastomosis stricture (n=7) and common bile duct cannulation could not be obtained because of duodenal diverticulum (n=1). Diagnostic PTC was performed in 10 patients, 8 were referred after inadequate/failed ERCP procedure and two were referred directly without ERCP. Anastomosis stricture was found in 7 patients and anastomosis stricture and bile leakage in 3. In 7 patients determined to have stricture, balloon dilatation was applied and then biliary drainage was performed. In 3 patients who had leakage and anastomosis stricture, balloon dilatation was applied for stricture; after dilatation, an IEBD catheter was placed through the leakage region in 2 patients, while a covered metallic stent passing through the leakage region was placed in one patient. Generally, ERCP is the first preferred method in biliary complications of LDLT; however, in cases where a response cannot be obtained by endoscopic treatment or require complex and/or aggressive treatment, percutaneous radiological treatment should be the treatment of choice before surgery in left lobe LDLT.

A New Approach for Increasing Availability of Liver Grafts and Donor Safety in Living Donor Liver Transplantation: LD-RAPID Procedure in the Cirrhotic Setting With Hepatocellular Carcinoma.

One of the main limitations of Living Donor Liver Transplantation (LDLT) is the availability of donors with adequate liver volume. Here, we describe a novel approach inspired by the LD-RAPID (Living Donor - Resection And Partial Liver Segment 2-4 Liver Transplantation With Delayed Total Hepatectomy) Procedure, a two-stage hepatectomy with partial liver transplantation, first described for patients with colorectal liver metastases. The patient was a 49 year-old woman, with cirrhosis and a 3 cm mass consistent with HCC. She weighed 88 kilograms (kg) with a BMI of 35. Her only donor, a 43-year-old man, with an estimated left lobe of 24% of total liver volume and an estimated GRWR of 0.41 for the Left-Lobe (LL) LDLT. In the first stage; a left lateral sectionectomy and orthotopic LL LDLT (314grams, GRWR:0.35) was performed with a hemi-portacaval shunt formation. Twenty-two days after first stage graft volume reached to 490 ml (GRWR.0.6), (60% increase) that is followed by the completion of resection of remnant diseased liver with shunt closure. The patient recovered uneventfully and doing well 1 year after LL LDLT no evidence of tumor recurrence. This is the first reported case of the Rapid procedure in the cirrhotic setting with hepatocellular carcinoma which can potentially provide a timely curative treatment for patients with cirrhosis who have limited donor options.

Outcome of Left Lobe Living-Donor Liver Transplantation in Tokushima

Introduction There is the risk of small-for-size graft (SFSG) in left lobe living-donor liver transplantation (LL-LDLT) for adult patients. However, to minimize donor’s risk, LL-LDLT might be an ideal option in adult-to-adult LDLT. The aim of the study was to assess the outcome and feasibility of adult-to-adult LL-LDLT in our hospital. Patients Between 2005 and 2017, twenty-four consecutive LDLTs were performed at Tokushima University Hospital. Of the 24 adults, 21 patients underwent LDLT using LL-grafts with (n=16) or without (n=5) the caudate lobe. Four of 7 patients with HCC had HCC beyond the Milan criteria. Four cases with ABO-incompatible LDLT were included. Results The mean graft weight of LL-grafts was 440g (340-520g), GV/SLV and GRWR were 39.1% (29.3-50.8%) and 0.77% (0.55-1.13). SFSG, defined as graft volume-to-recipient standard liver volume (GV/SLV) <40% or graft-to recipient weight ratio (GRWR) <0.8, was identified in 13 cases. Postoperative complications were dissection of hepatic artery (n=1), sepsis (n=1), hemophagocytic syndrome (n=1), small-for-size syndrome (n=1), hemorrhage (n=3), refractory CMV infection (n=1), severe pneumonia (n=1). No significant difference was observed in the incidence of postoperative complications between the SFSG group and non SFSG group. The overall 1-, 3-, 5- and 10-year patient survival rates in LL-LDLT were 95%, 90%, 90% and 84%, respectively. Two HCC patients were lost due to recurrence. There was no significant difference in patient survival between the SFSG group and non SFSG group. Four cases with ABO-incompatible LDLT are all alive without antibody mediated acute rejection. Conclusion Adult-to-adult LL-LDLT, even if SFSG was used, was found to be feasible without affecting patient survival. Utilization of LL-grafts should be undertaken to keep the chance of donor morbidity and mortality minimal.

Risk Factors for Intractable Ascites After Adult-to-Adult Living Donor Liver Transplantation Using Left Lobe.

BackgroundIntractable ascites is one of the causes of graft loss after adult-to-adult living donor liver transplantation (LDLT) using a small graft. Identification of factors associated with increasing posttransplant ascites has important implications for prevention and treatment.MethodsAll 59 consecutive adult patients who underwent left lobe LDLT without portal inflow modulation between October 2002 and February 2016 were prospectively enrolled. Factors associated with the average daily amount of ascites for 2 weeks after LDLT were assessed.ResultsThe median daily amount of ascites during the 2 weeks was 1052 mL (range, 52-3480 mL). Although 16 of the 59 patients developed intractable ascites, exceeding 1500 mL daily (massive ascites group), the remaining 43 patients produced less than 1500 mL of ascites daily (nonmassive ascites group). The presence of pretransplant ascites (P = 0.001), albumin (P = 0.011), albumin/globulin ratio (P = 0.026), cold ischemia time (P = 0.004), operation time (P = 0.022), and pretransplant portal vein pressure (PVP) (P = 0.047) differed significantly between the 2 groups. Neither posttransplant PVP nor portal vein flow differed between the 2 groups. The variables associated with intractable ascites that remained significant after logistic regression analysis were pretransplant PVP (P = 0.047) and cold ischemia time (P = 0.049). After appropriate fluid resuscitation for intractable ascites, 58 (98%) of the 59 recipients were discharged from hospital after removal of the indwelling drains.ConclusionsIt is important to shorten the scold ischemia time to reduce massive ascites after LDLT. Pretransplant portal hypertension is more closely associated with ascites production than posttransplant hemodynamic status.

Impact of Graft Type in Living Donor Liver Transplantation: Remnant Liver Regeneration and Outcome in Donors

ObjectivesLiver regeneration and donor safety in right-lobe (RL) and left-lobe (LL) grafts are essential for donors in living donor liver transplantation (LDLT). Our aim was to compare the liver regeneration rate and postoperative outcome between different donor graft types in LDLT. Materials and MethodsA total of 95 donors were divided into 2 groups: RL (n = 42) and LL (n = 53). The remnant liver of LL donors were subdivided into 3 subgroups according to the different hepatic venous drainage pattern that dominates from right hepatic vein (dominant RHV; n = 34), middle hepatic vein (dominant MHV; n = 10), and include MHV for left lateral segment (LLS) graft (n = 9). The demographic data, postoperative laboratory data, complications, remnant liver volume (RLV), and remnant liver regeneration rate (RLRR) 6 months after surgery were compared. ResultsThe postoperative total bilirubin (TB), prothrombin time (PT), and intensive care unit (ICU) stays of the LL group were lower than the RL group (P < .05). The LL group has no significant better regeneration rate 6 months after surgery than the RL group. However, dominant RHV and LLS groups have significantly better RLRR than the RL group (89.2% vs 86% and 95.1% vs 86%, respectively, P < .05), but no significance in the dominant MHV group. ConclusionIn conclusion, different hepatic venous drainage patterns of remnant liver grafts may affect the regeneration rate in LL LDLT, especially with dominant RHV donors, may have more comparable outcomes with that of RL, and should be a favorable option during donor selection.

Evaluation of Esophagogastric Varices after Adult-to-Adult Living Donor Liver Transplantation Using a Left Lobe Graft

Background: There is little information on whether living donor liver transplantation (LDLT) reduces the supply of blood to esophagogastric varices. The aim of the present study was to assess the effects of LDLT on esophagogastric varices using both endoscopy and transendoscopic microvascular Doppler sonography (EMDS). Patients and Methods: 16 LDLT recipients were enrolled in the present study. Esophagogastric varices were assessed by endoscopy before and after LDLT. Direct measurement of variceal blood velocity was performed using EMDS in 12 of the 16 patients, and portal vein pressure before and after graft implantation was measured in 10 of them. Results: The median interval between LDLT and endoscopic examination was 129 days (range 20-624). Endoscopy demonstrated improvement of esophageal varices in 15 patients and of gastric varices in 4 of 5 patients assessed. The mean blood flow velocity in esophageal varices after LDLT was significantly lower than that before LDLT (8.8 w 3.6 vs. 0.9 w 1.2 cm/s, p < 0.001). The mean portal vein pressure did not decrease significantly after LDLT in comparison with that before LDLT (from 25.2 w 5.2 to 23.1 w 3.6 mm Hg, p = 0.22). Conclusion: Although portal vein pressure does not decrease immediately after left lobe LDLT, esophagogastric varices are ameliorated after a few months, and variceal blood flow velocity is reduced in almost all patients. i 2014 S. Karger AG, Basel

Domino liver graft with hepatocellular carcinoma used as bridge therapy for a patient with acute liver failure: A case report

We report a unique case of orthotopic domino livertransplantation for a patient with ALF: a noncirrhoticliver graft with HCC was used as bridge therapy untila permanent deceased donor graft became available.A 42-year-old Hispanic woman presenting with ALFwas admitted to the emergency department and waspromptly listed for emergency liver transplantation.However, her clinical deterioration progressed rapidly,the patient required mechanical ventilatory support,and an epidural intracranial pressure monitor wasplaced. The patient developed intracranial hyperten-sion (25-30 mm Hg), which was successfully con-trolled with medical therapy. Synchronously,scheduled living donor liver transplantation (LDLT)was being performed for a 60-year-old female patientwith a history of recurrent HCC in a noncirrhotic liver.This patient had previously undergone a series of sur-gical and ablative treatments. The actual tumor bur-den was 2 HCC lesions (each 20 mm in diameter), theserum alpha-fetoprotein level was 2.4 ng/mL, and novascular or extrahepatic metastasis was found at thetime of LDLT.Progressive worsening of an already critical clinicalcondition in the first patient, the absence of either adeceased donor or a living donor after 5 days on thewaiting list, and no access to liver support systems orbioartificial devices at that time led the transplantteam to consider a domino liver transplant using theexplanted noncirrhotic liver with HCC from the secondpatient undergoing synchronous LDLT as bridge ther-apy. Consent was obtained from both the recipientand donor families, the institutional ethics committee,and the Instituto Nacional Central Unico Coordinadorde Ablacion e Implante. A sequential triple-procedureschedule was followed: left lobe LDLT; back-tableresection of the two 2-cm HCC lesions in segments VIand IV; and, finally, domino implantation of the HCCliver graft with the piggyback technique. The coldischemia time lasted 4 hours, and the warm ischemiatime was 40 minutes. Shortly after transplantation,vasopressor infusion was discontinued, and the intra-cranial pressure parameters improved to 15 to 17 mmHg (Fig. 1). Twelve hours after the domino procedure,a deceased donor graft from a 49-year-old female,located 600 km from the hospital, was made availablefor this patient. The deceased donor liver transplanta-tion procedure began 11 hours after the completion ofthe bridge domino liver transplant with the resectedHCC graft, and it lasted a total of 165 minutes with acold ischemia time of 6 hours.A pathological examination of the explanted dominoHCC liver graft confirmed 2 small HCC nodules: one

Strategies for Successful Left-Lobe Living Donor Liver Transplantation in 250 Consecutive Adult Cases in a Single Center

Living donor liver transplantation (LDLT) using left-lobe grafts was not generally recognized as feasible due to the problem of graft size. We retrospectively evaluated strategies for successful left-lobe LDLT in 250 consecutive cases stratified into 2 eras: Era 1 (n = 121), in which surgical procedures were continually refined, and Era 2 (n = 129), in which established procedures were used. Graft volume (GV) did not affect the incidence of graft function or survival. Era 2 patients had decreased portal vein (PV) pressure at closure (16.0 ± 3.5 mmHg vs 19.1 ± 4.6 mmHg, p < 0.01), increased PV flow/GV (301 ± 125 mL/min/100g vs 391 ± 142 mL/min/100g, p < 0.01), and improved graft survival rate (1-year: 90.6% vs 81.8%. p < 0.01) despite the smaller GV/standard volume (SLV) ratio (36.2% ± 5.2% vs 41.2% ± 8.8%, p < 0.01) compared with Era 1. Patients in Era 2 had lower PV pressure and greater PV flow (y = 598-5.7 x, p = 0.02) at any GV/SLV compared with cases in Era 1 (y = 480-4.3 x, p < 0.01), representing greater graft compliance. Univariate analysis for graft survival showed that Era 1, Model for End-Stage Liver Disease (MELD) score ≥ 20, inpatient status, closing portal venous pressure ≥ 20 mmHg, no splenectomy, and operative blood loss ≥ 10 L were the risk factors for graft loss, and multivariate analysis showed that Era 1 was the only significant factor (p < 0.01). During Era 2, development of primary graft dysfunction was associated with inpatient recipient status (p = 0.02) and donor age ≥ 45 years (p < 0.01). The outcomes of left-lobe LDLT were improved by accumulated experience and technical developments.

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.

Left Lobe Living Donor Liver Transplantation in Adults

Adult left lobe (LL) living donor liver transplantation (LDLT) has not generally been recognized as a feasible procedure because of the problem of graft size. The objectives of this study were to assess the feasibility and short- and long-term results of adult LL LDLT in comparison with right lobe (RL) LDLT. Data on 200 consecutive LL LDLTs, including five retransplants, were retrospectively compared with those of 112 RL LDLTs, in terms of survival, complications and donor morbidity. The mean graft weight to standard volume ratio of LL grafts was 38.7% whereas that of RL grafts was 47.6% (p < 0.0001). The 1-, 5- and 10-year patient survival rates of LL LDLT were 85.6%, 77.9% and 69.5%, respectively, which were comparable to those of RL LDLT (89.8%, 71.3% and 70.7%, respectively). The incidence of small-for-size syndrome was higher in LL LDLT (19.5%) than in RL LDLT (7.1%) (p < 0.01). The overall donor morbidity rates were comparable between LL (36.0%) and RL (34.8%), whereas postoperative liver function tests and hospital stay were significantly better (p < 0.0001) in LL donors. In conclusion, adult LL LDLT has comparable outcomes to that of RL LDLT. LL LDLT is viable and is the first choice in adult LDLT.

Donor Age Affects Liver Regeneration during Early Period in the Graft Liver and Late Period in the Remnant Liver after Living Donor Liver Transplantation

The aim of the present study was to evaluate the influence of donor age on liver regeneration and surgical outcomes in recipients and donors. Among 101 cases of adult-to-adult living donor liver transplantation (LDLT) between March 2002 and March 2011, according to donor age: younger (Y) <50 years of age or older (O) ≥ 50 years of age, the donors and recipients using right (R) or left (L) graft were divided into groups Y/R (n = 51) and O/R (n = 17), and groups Y/L (n = 26) and O/L (n = 7), respectively. Remnant liver volume (RemLV) and graft liver volume (GLV) were estimated by computed tomography (CT) volumetry. A disintegrin and metalloprotease with thrombospondin type I domain 13 (ADAMTS13) activities and von Willebrand factor (vWF) antigen levels were measured as factors reflecting thrombotic microangiopathy. Among the donors, RemLV/total liver volume (TLV) was lower in group O/R than in group Y/R, although there were no significant differences by t-test with the Bonferroni correction (rough p value = 0.02 at 6 months and rough p value > 0.05 at 1, 3, and 12 months). Donor age (≥ 50 years) was independently correlated with impaired remnant liver regeneration at 6 months in right lobe LDLT (p = 0.04). Among the recipients, GLV/standard liver volume (SLV) was lower during the first month, although there were no significant differences between the two groups by t-test with the Bonferroni correction (rough p value = 0.03 at 1 week and rough p value >0.05 at 2 weeks and 1 and 3 months). Donor age (≥ 50 years) was independently correlated with impaired graft liver regeneration at 1 week in both right and left lobe LDLT (p < 0.05). ADAMTS13 activities were lower in group O/R than in group Y/R, although there were no significant differences by t-test with the Bonferroni correction (rough p value = 0.049 on postoperative days (POD) 1 and 28 and rough p value >0.05 on POD 7 and 14). vWF/ADAMTW13 ratios were higher on POD 14, although there were no significant differences between the two groups by t-test with the Bonferroni correction (rough p value = 0.044 on POD 14 and rough p value >0.05 on POD 1, 7, 14, and 28). The surgical outcomes using older donor livers for LDLT were comparable to those using younger donor livers. When using older donor livers, however, we should pay attention to the liver volume for recipients as well as donors, because older donor livers might have impaired regenerative ability.

Left lobe adult-to-adult living donor liver transplantation: Should portal inflow modulation be added?

Recently, the successful application of portal inflow modulation has led to renewed interest in the use of left lobe grafts in adult-to-adult living donor liver transplantation (LDLT). However, data on the hepatic hemodynamics supporting portal inflow modulation are limited, and the optimal portal circulation for a liver graft is still unclear. We analyzed 42 consecutive adult-to-adult left lobe LDLT cases without splenectomy or a portocaval shunt. The mean actual graft volume (GV)/recipient standard liver volume (SLV) ratio was 39.8% ± 5.7% (median = 38.9%, range = 26.1%-54.0%). The actual GV/SLV ratio was less than 40% in 24 of the 42 cases, and the actual graft-to-recipient weight ratio was less than 0.8% in 17 of the 42 recipients. The mean portal vein pressure (PVP) was 23.9 ± 7.6 mm Hg (median = 23.5 mm Hg, range = 9-38 mm Hg) before transplantation and 21.5 ± 3.6 mm Hg (median = 22 mm Hg, range = 14-27 mm Hg) after graft implantation. The mean portal pressure gradient (PVP - central venous pressure) was 14.5 ± 6.8 mm Hg (median = 13.5 mm Hg, range = 3-26 mm Hg) before transplantation and 12.4 ± 4.4 mm Hg (median = 13 mm Hg, range = 1-21 mm Hg) after graft implantation. The mean posttransplant portal vein flow was 301 ± 167 mL/minute/100 g of liver in the 38 recipients for whom it was measured. None of the recipients developed small-for-size syndrome, and all were discharged from the hospital despite portal hyperperfusion. The overall 1-, 3-, and 5-year patient and graft survival rates were 100%, 97%, and 91%, respectively. In conclusion, LDLT with a left liver graft without splenectomy or a portocaval shunt yields good long-term results for adult patients with a minimal donor burden.

Dual Left Lobe Living Donor Liver Transplantation Using Donors Unacceptable for Right Lobe Donation: A Case Report

Living donor liver transplantation (LDLT) has become a viable alternative for end-stage liver disease. The shortage of brain-dead donors has led to development of advanced surgical approaches. Dual lobe LDLT has been performed successfully in the recent years. The major indication for this complex procedure has been insufficient graft size from a single donor or insufficient remnant in the donor. We performed a dual left lobe LDLT using 2 donors who were unacceptable for right lobe donation.

Management of venous stenosis in living donor liver transplant recipients

To retrospectively evaluate the management and outcome of venous obstruction after living donor liver transplantation (LDLT). From February 1999 to May 2009, 1 intraoperative hepatic vein (HV) tension induced HV obstruction and 5 postoperative HV anastomotic stenosis occurred in 6 adult male LDLT recipients. Postoperative portal vein (PV) anastomotic stenosis occurred in 1 pediatric left lobe LDLT. Patients ranged in age from 9 to 56 years (median, 44 years). An air balloon was used to correct the intraoperative HV tension. Emergent surgical reoperation, transjugular HV balloon dilatation with stent placement and transfemoral venous HV balloon dilatation was performed for HV stenosis on days 3, 15, 50, 55, and 270 after LDLT, respectively. Balloon dilatation followed with stent placement via superior mesenteric vein was performed for the pediatric PV stenosis 168 d after LDLT. The intraoperative HV tension was corrected with an air balloon. The recipient who underwent emergent reoperation for hepatic stenosis died of hemorrhagic shock and renal failure 2 d later. HV balloon dilatation via the transjugular and transfemoral venous approach was technically successful in all patients. The patient with early-onset HV stenosis receiving transjugular balloon dilatation and stent placement on the 15th postoperative day left hospital 1 wk later and disappeared, while the patient receiving the same interventional procedures on the 50th postoperative day died of graft failure and renal failure 2 wk later. Two patients with late-onset HV stenosis receiving balloon dilatation have survived for 8 and 4 mo without recurrent stenosis and ascites, respectively. Balloon dilatation and stent placement via the superior mesenteric venous approach was technically successful in the pediatric left lobe LDLT, and this patient has survived for 9 mo without recurrent PV stenosis and ascites. Intraoperative balloon placement, emergent reoperation, proper interventional balloon dilatation and stent placement can be effective as a way to manage hepatic and PV stenosis during and after LDLT.

A Simple Hilar Dissection Technique Preserving Maximum Blood Supply to the Bile Duct in Living Donor Liver Transplantation

Duct-to-duct reconstruction is associated with a higher incidence in biliary strictures in living donor liver transplantation (LDLT). However, a standard dissection technique for the recipient's bile duct has not been established. Here, we describe a simple bile duct dissection technique preserving maximum vascular integrity during total hepatectomy of the recipient. The present technique might facilitate duct-to-duct bile duct reconstruction in both right and left lobe LDLT and, thus, contribute to reduce biliary complications such as biliary strictures. We believe that this technique can be a standard in the field of LDLT.

Donor Age in Living Donor Liver Transplantation

Background We sought to elucidate the influence of donor age in living donor liver transplantation (LDLT) using either left lobe (LL) or right lobe (RL) grafts. Methods Recipients ( n = 232) were categorized as: group O/LL (LL, donor age >50, n = 20); group Y/LL (LL, donor age ≤50, n = 140); Group O/RL (RL, donor age >50, n = 12); and group Y/RL (RL, donor age ≤50, n = 61). We compared post-LDLT graft functions. Results Among LL LDLT, the incidence of small-for-size syndrome was significantly greater for group O/LL compared with group Y/LL (60.0% vs 16.3%, P < .01). However, the cumulative 5-year graft survivals were 73.8% in group O and 76.7% in group Y without substantial difference. In RL LDLT, the post-LDLT morbidity and mortality were similar for group O/RL and group Y/RL. Conclusion Partial liver grafts, even though LL grafts, from older donors can be used safely with caution in LDLT.

Techniques of reconstruction of hepatic veins in living-donor liver transplantation, especially for right hepatic vein and major short hepatic veins of right-lobe graft

Living-donor liver transplantation (LDLT) is now widely accepted as a therapeutic option for adult patients with acute and chronic end-stage liver disease. In the early period, the left lobe was the major liver graft used in adult LDLT to ensure donor safety, especially in Eastern countries. However, the frequent extremes of graft-size insufficiency in left-lobe LDLT represented a greater risk of small-for-size graft syndrome in the recipient, which has focused attention on transplantation of the right lobe from a living donor. The major concern of right-lobe LDLT has focused on its safety for the donor and the necessity for including the middle hepatic vein (MHV) in the graft to avoid congestion of the right anterior segment. The MHV carries out important venous drainage for the right anterior segment and is essential for perfect graft function. The decision of whether to take the MHV with the liver graft (extended right lobe graft) or whether to retain it in the donor, with reconstruction of the MHV tributaries in the liver graft (modified right lobe graft) has been extensively discussed in numerous studies. However, adequate right hepatic vein and major short hepatic vein (middle and inferior right hepatic vein [RHV]) drainage of the liver graft is perhaps equally important as MHV outflow drainage for the integrity of right-lobe graft function. Herein, the author describes various techniques of venoplasty of the right hepatic vein (RHV) and the major short hepatic veins to obviate venous outflow obstruction in these veins.

Biliary strictures in living donor liver transplantation: Incidence, management, and technical evolution

Biliary complications, biliary strictures (BS) in particular, continue to be a significant cause of morbidity after LDLT despite technical refinement. In this study, we assessed the incidence of BS and their management in living donor liver transplantation (LDLT) with special reference to the type of biliary reconstruction. A total of 182 LDLTs performed at our institution for either adult (n = 157) or pediatric (n = 25) patients were included in the study. The duct-to-duct (DD) biliary reconstruction was performed for 106 cases, while the conventional Roux-en-Y hepaticojejunostomy (HJ) was utilized for the remaining 76 cases. Overall, BS developed in 46/182 (25.3%) of the cases (DD, 26.4%; HJ, 25.0%). The 1- and 3-year cumulative incidences of BS were 22.9% and 31.9%, respectively, in the DD group, and 15.2% and 29.1%, respectively, in the HJ group (P= not significant). The left-lobe LDLT was more prone to develop BS. Continuous anastomosis tended to be associated with the high incidence of BS in the DD group. The incidence of anastomotic leak was significantly lower in the DD group. Intervention via either pre-cutaneous or endoscopic approach was successful in the majority of cases, although recurrence could occur in some patients. In conclusion, BS was not associated with the type of reconstruction in LDLT. The primary radiological or endoscopic interventions were satisfactory treatments of choice. Technical refinement is an important factor to reduce the incidence of BS.

First Successful Application of Side-to-Side Intrahepatic Cholangiojejunostomy to Biliary Obstruction after Living-Donor Liver Transplantation

Biliary anastomotic stenosis has been the most intractable problem after living-donor liver transplantation (LDLT) (1, 2). We first applied the side-to-side intrahepatic cholangiojejunostomy to biliary obstruction after LDLT. We here report our surgical techniques and the successful outcome of the procedure after 34 months. A 49-year-old woman was diagnosed with primary biliary cirrhosis 15 years ago. She developed liver failure with gastrointestinal bleeding caused by esophageal varices and subsequently underwent LDLT. The donor was the patient’s brother. The left lobe of the liver was harvested. Biliary reconstruction included a duct-to-duct anastomosis between the left hepatic duct of the donor and the common hepatic duct of the recipient. After anastomosis, a 5 F stenting tube was inserted toward the graft hepatic duct from the stump of the cystic duct. LDLT was successfully completed, and the patient postoperatively recovered without biliary complications. However, 3 months later, the patient occasionally experienced delayed bile leakage when the stenting tube was removed. Immediately, continuous drainage for the leak space was started. Subsequently, complete obstruction of the biliary anastomosis remained. Therefore, the percutaneous transhepatic bile drainage (PTBD) tube was inserted. Recanalization by radiologic interventions was attempted several times without success. In this case, cholangiography showed no anatomical anomaly and communication between the bile ducts of segment II, III, and IV at the occurrence of biliary obstruction as well as at the first transplant operation. Thus, the bile duct of the segment III was reconstructed by intrahepatic cholangiojejunostomy 6 months after LDLT. For this technique, which has been described previously, the bile duct is exposed by dissecting the umbilical fissure, and the division of liver tissue is not required (3). However, in the present patient, the bile duct of segment III was not markedly dilated (5 mm in diameter), and thus the process of its sufficient expo- sure for anastomosis posed some technical challenges. First, we confirmed the glisson of segment III by using intraoperative ultrasonography and inserted the marking needle toward its proximal site. Along this needle, the liver parenchyma was transected to the left of the round ligament. After the glisson was exposed sufficiently, the bile duct was identified by examining its bulge when the PTBD tube was pressurized. The bile duct was incised approximately 3 cm longitudinally and anastomosed side-to-side to the Roux-en-Y limb of the jejunum with a 6–0 PDS suture in an interrupted fashion. A 5 F biliary stenting tube was introduced toward the graft hepatic duct from the Roux-en-Y limb of the jejunum (Fig. 1, A and B). The patient remained well without biliary complications during the follow-up period of 34 months (Fig. 1C).FIGURE 1.: Successful treatment of delayed-onset biliary obstruction after left-lobe living-donor liver transplantation (LDLT) by side-to-side intrahepatic segment III cholangiojejunostomy. (A) Schematic view of the procedure. The bile duct of segment III is exposed and incised approximately 3 cm longitudinally. It is anastomosed side-to-side to the Roux-en-Y limb of the jejunum with a 6–0 PDS suture in an interrupted fashion. A 5 F biliary stenting tube is introduced toward the graft hepatic duct from the Roux-en-Y limb of the jejunum. (B) Operative field photograph after completion of the procedure. (C) Magnetic resonance cholangiopancreatography 32 months after the reoperation showing patency of the anastomosis.Originally, this technique was used as a palliative treatment for obstructive jaundice caused by tumor involvement of the hepatic hilum (4). Although conversion to Roux-en-Y hepaticojejunostomy is usually used in the management of biliary obstruction after duct-to-duct anastomo-sis, it is always accompanied by the risk of injury to the important hilus structures. As for the intrahepatic cholangiojejunostomy, the Longmire technique has been widely recognized. However, it requires partial hepatectomy and is sometimes followed by anastomotic stenosis, especially when a small intrahepatic bile duct is anastomosed end-to-side to the jejunum (5). In contrast, this technique has the following advantages. First, it avoids manipulation of the hepatic hilum. Second, the bile duct of segment III is superficially located and easily accessible, and thus the reoperation can be performed at the minimal expense and without hepatic sacrifice. Finally, side-to-side reconstruction offered a sufficient anastomotic size. However, further investigation is necessary to substantiate the value of this technique. Motohide Shimazu Tomotaka Akatsu Go Wakabayashi Minoru Tanabe Shigeyuki Kawachi Ken Hoshino Masaki Kitajima Department of Surgery Keio University School of Medicine Tokyo, Japan