Lobe Adult Living Donor Liver Research Articles

Liver Graft Regeneration in Right Lobe Adult Living Donor Liver Transplantation

Optimal portal flow is one of the essentials in adequate liver function, graft regeneration and outcome of the graft after right lobe adult living donor liver transplantation (ALDLT). The relations among factors that cause sufficient liver graft regeneration are still unclear. The aim of this study is to evaluate the potential predisposing factors that encourage liver graft regeneration after ALDLT. The study population consisted of right lobe ALDLT recipients from Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan. The records, preoperative images, postoperative Doppler ultrasound evaluation and computed tomography studies performed 6 months after transplant were reviewed. The volume of the graft 6 months after transplant divided by the standard liver volume was calculated as the regeneration ratio. The predisposing risk factors were compiled from statistical analyses and included age, recipient body weight, native liver disease, spleen size before transplant, patency of the hepatic venous graft, graft weight-to-recipient weight ratio (GRWR), posttransplant portal flow, vascular and biliary complications and rejection. One hundred forty-five recipients were enrolled in this study. The liver graft regeneration ratio was 91.2 +/- 12.6% (range, 58-151). The size of the spleen (p = 0.00015), total portal flow and GRWR (p = 0.005) were linearly correlated with the regeneration rate. Patency of the hepatic venous tributary reconstructed was positively correlated to graft regeneration and was statistically significant (p = 0.017). Splenic artery ligation was advantageous to promote liver regeneration in specific cases but splenectomy did not show any positive advantage. Spleen size is a major factor contributing to portal flow and may directly trigger regeneration after transplant. Control of sufficient portal flow and adequate hepatic outflow are important factors in graft regeneration.

Improvement in Survival Associated With Adult-to-Adult Living Donor Liver Transplantation

More than 2000 adult-to-adult living donor liver transplantations (LDLT) have been performed in the United States, yet the potential benefit to liver transplant candidates of undergoing LDLT compared with waiting for deceased donor liver transplantation (DDLT) is unknown. The aim of this study was to determine whether there is a survival benefit of adult LDLT. Adults with chronic liver disease who had a potential living donor evaluated from January 1998 to February 2003 at 9 university-based hospitals were analyzed. Starting at the time of a potential donor's evaluation, we compared mortality after LDLT to mortality among those who remained on the waiting list or received DDLT. Median follow-up was 4.4 years. Comparisons were made by hazard ratios (HR) adjusted for LDLT candidate characteristics at the time of donor evaluation. Among 807 potential living donor recipients, 389 underwent LDLT, 249 underwent DDLT, 99 died without transplantation, and 70 were awaiting transplantation at last follow-up. Receipt of LDLT was associated with an adjusted mortality HR of 0.56 (95% confidence interval [CI]: 0.42-0.74; P < .001) relative to candidates who did not undergo LDLT. As centers gained greater experience (>20 LDLT), LDLT benefit was magnified, with a mortality HR of 0.35 (95% CI: 0.23-0.53; P < .001). Adult LDLT was associated with lower mortality than the alternative of waiting for DDLT. This reduction in mortality was magnified as centers gained experience with LDLT. This reduction in transplant candidate mortality must be balanced against the risks undertaken by the living donors themselves.

Donor Outcomes in Right Lobe Adult Living Donor Liver Transplantation: Single-Center Experience in Egypt

Introduction and objectives Living donor liver transplantation (LDLT) is an alternative source of organs for patients with end-stage liver disease (ESLD) in absence of deceased donor LT. In LDLT the greatest concern is donor safety. Our objective was to evaluate the outcome of donors after right lobe liver donation in a single LT center in Egypt. Patients and methods Fifty LDL resections were performed from 2001 to 2004. The mean donor age was 29.2 ± 6.4 years. Residual liver volume was 41.1 ± 4.5%. Mean operative time was 560 ± 62.2 minutes; mean ICU stay, less than 24 hours; mean hospital stay, 15.4 ± 7.7 days; and mean follow-up period, 6 months. Results There was no mortality. The overall complication rate was 68% (34 donors). Major complications included intraoperative bleeding in one, biliary leak in two, and pneumonia in three donors. Minor complications included mild pleural effusion in 13 donors, transient ascites in 10, mild depression in 7, intra-abdominal collections in 3, and wound infections in 1 donor. Residual liver volume did not affect the complication rate. None required reoperation. Return to predonation activity occurred within 6 to 8 weeks. No liver impairment occurred during follow-up. Conclusion Right lobe adult LDLT is a safe procedure with regard to donor outcome. Major complications occurred in only 10% of our series.

Biliary Reconstruction and Complications of Left Lobe Living Donor Liver Transplantation

Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living donor liver transplantation. The aim of this study was to analyze the clinical implications of three methods of biliary reconstruction in left lobe adult living donor liver transplantation. We retrospectively compared three groups of patients who underwent various biliary reconstructions: those who had Roux-en-Y hepaticojejunostomy (HJ) ( n = 11); duct to duct hepaticohepaticostomy (HH) with an external stent ( n = 11); or HH with T-tube ( n = 6). The median follow-up for each group was 29, 28, and 8 months, respectively. Bile leaks were observed in 45.5% of both the HJ and the HH with external stent groups. Biliary anastomotic strictures occurred in 9.1% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with an external stent. No biliary complications were observed in the HH over a T-tube group ( P = .049). Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up, these encouraging preliminary results warrant further studies of this biliary reconstruction technique for left lobe adult living donor liver transplantations.

Relation between hepatic and portal veins in the right paramedian sector: proposal for anatomical reclassification of the liver.

Although a right liver graft without a middle hepatic vein resulted in potential venous congestion in the right paramedian sector, the details of the hepatic venous distribution in the right paramedian sector have not been established. In this study, the ramification patterns of the hepatic veins draining the right anterosuperior segment (S8) and the relation between the hepatic and portal veins were assessed using multislice computed tomography in 44 patients without lesions in the liver. All 52 drainage veins of the ventral area of S8 joined the middle hepatic vein, and all 48 drainage veins of the dorsal area joined the right hepatic vein. The hepatic vein crossing between the ventral and dorsal areas was observed in each patient examined. Therefore, we propose a reclassification wherein the right paramedian sector is divided into ventral and dorsal segments. This new classification may contribute to the development of new and safer surgical procedures, including more limited resection and right lobe adult living donor liver transplantation to avoid graft congestion.

Donor and recipient outcomes in right lobe adult living donor liver transplantation.

Severe donor organ shortage has provided the impetus for adult living donor liver transplantation (ALDLT). Despite rapid implementation and expansion of the procedure, outcome analysis of ALDLT is still incomplete. This study analyzed both donor and recipient outcomes after ALDLT at a single center. ALDLT performed at UCLA between August 1999 and November 2001 were reviewed retrospectively. Twenty recipients (14 men and 6 women) with a mean age of 48.8 +/- 9.7 (29 to 66) years underwent right lobe ALDLT. By computed tomograpy (CT), graft/recipient weight ratio (GRWR) was 1.3 +/- 0.3 (1 to 2.2). Overall 1-year patient and graft survival rates were 95% and 85%, respectively. One recipient died of heart failure with normal liver function 5 months after transplantation. Three grafts (14%) were lost and all three patients underwent successful cadaveric retransplantation. Complications were classified according to the Clavien grading system with all but 3 recipients encountering at least one complication. Nine (45%) had grade 1 (minor), 10 (50%) had grade 2 (potentially life threatening without residual disease/disability), 3 (14%) had grade 4A (retransplantation) and one grade 4B (death). Right lobectomy for living donation was performed in 20 patients (12 men, 8 women). Residual left lobe volumes were 36 +/- 5.3 (23.9 to 47.9)% of total donor liver volume. No donor required intensive care unit admission and median hospital stay was 7.5 (6 to 14) days. One donor was aborted after intraoperative biopsy showed > 50% macrovesicular steatosis. No donor mortality or long-term complications were encountered. Five grade 1 minor complications, by Clavien Classification, occurred in 4 of 20 (20%) donors. ALDLT using right lobe grafts is an effective procedure to expand a severely depleted donor, but is associated with a high complication rate despite good survival outcomes. Continuous standardized reporting of ALDLT outcomes is required to allow successful and safe implementation of the procedure.

Technical and logistical considerations of in situ split-liver transplantation for two adults: Part I. Creation of left segment II, III, IV and right segment I, V-VIII grafts.

,a technique used by our donor recovery teams toprocureleftsegmentII,III,andIVandrightsegmentI and V through VIII grafts was described. In thisissue,wedetailatechniqueforthecreationofalargerleft segment I through IV graft and right segment Vthrough VIII graft. Each of the described techniqueshas been applied by our donor recovery teams atoutside facilities during routine donor procurementwithout specialized equipment and simultaneouswith additional organ (heart, kidney, pancreas) pro-curement.

Technical challenges of hepatic venous outflow reconstruction in right lobe adult living donor liver transplantation.

A right lobe graft that is drained by the right hepatic vein (RHV) is obtained by transecting the liver on the right side of the middle hepatic vein (MHV). On occasion, a small RHV that only drains a portion of the right lobe, with the predominant outflow achieved by the MHV, is encountered. If such variation is not recognized while performing right lobe liver transplantation and the RHV only is used for reconstruction, venous outflow obstruction with subsequent graft congestion and eventual graft failure will occur. Additionally, preservation of the main MHV and its branch drainage of the left lobe is crucial to avoid outflow blockage to the remaining segment 4 in the donor. We report 4 cases showing a variant type of small RHV and large MHV branch that drain not only segments 5 and 8, but also segments 6 and 7. These variations were simultaneously associated with a large-caliber inferior RHV that also required reconstruction. The methods used to diagnose such anatomic variations and the techniques for reconstruction in the donor and recipient are described.

Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation

At the present time the preferred technique for biliary reconstruction in adult living donor liver transplantation (ALDLT) is the Roux-en-Y hepaticojejunostomy (HJ). Patients undergoing HJ are not drained through the normal physiologic route and may suffer from repeated bouts of ascending cholangitis. The inability to evaluate and treat biliary strictures and leaks by endoscopic retrograde cholangiography (ERCP) may complicate the postoperative management of patients undergoing HJ. Modifications aimed at preserving the blood supply to both the donor and recipient bile ducts may allow a direct duct-to-duct (D-D) biliary reconstruction in selected patients, and aid in visualization of the biliary tree and eliminate complications related to reflux cholangitis. Adult living donor liver transplantation, using a right lobe, is emerging as an effective treatment option for selected patients awaiting liver transplantation. Though many variations in technique exist between centers performing this procedure, most surgeons use an HJ as the preferred method for biliary-enteric reconstruction. The rationale for use of the HJ for biliary reconstruction in segmental liver grafts, such as those used in pediatric recipients, derives from the small size of the recipient bile duct and inadequate length of the donor bile duct. In addition, the underlying liver disease (eg, biliary atresia) often mandates an HJ. Finally, there are concerns relating to the vascular integrity of the anastomosis, especially with left-sided grafts, because important blood vessels may arise to the left hepatic duct from segment IV vessels. Although HJ remains the standard of care in pediatric segmental grafts, the use of HJ in adult segmental grafts, such as those used in ALDLT, would not appear to be mandatory for several reasons. First, most adult liver diseases do not prohibit a choledocho-choledochostomy. Second, the size of the adult bile duct is not a restricting factor; and finally, the vascular integrity of the anastomosis can be preserved by careful attention to surgical technique and a greater understanding of the vascular supply to the bile ducts. The fact that a D-D anastomosis is the preferred method for biliary reconstruction in cadaveric liver transplantation relates to its preservation of the normal physiologic sphincter mechanism and consequent reduction in the incidence of reflux cholangitis. In addition, it reduces operative time, allows easier access for radiologic evaluation of the biliary tract by ERCP, and avoids creation of an enteric anastomosis that may leak, cause infection, or act as a site for internal hernias. This article describes a modification of our standard procedure for ALDLT, which allows a well-vascularized and tension-free D-D anastomosis.

Surgical technique for right lobe adult living donor liver transplantation without venovenous bypass or portocaval shunting and with duct-to-duct biliary reconstruction.

To report the authors' experience with adult living donor liver transplantation (ALDLT) without venovenous bypass and to describe modifications that will allow for a direct duct-to-duct biliary reconstruction. Adult living donor liver transplantation is being evaluated as a method to alleviate the organ shortage. Descriptions of the procedure have emphasized the use of venovenous bypass, portocaval decompression, and the mandatory use of a Roux-en-Y biliary enteric anastomosis. The authors describe a technique for ALDLT without venovenous bypass, portocaval decompression, or caval clamping in 11 recipients and describe the modifications to the procedure that may allow a duct-to-duct biliary reconstruction in certain cases. Between March 1999 and March 2000, 11 ALDLTs were performed at the authors' institution. All procedures were performed without venovenous bypass, portocaval decompression, or caval clamping. After a modification to the procedure, five of the last six recipients underwent biliary reconstruction with a direct duct-to-duct anastomosis. Data regarding donor, recipient, and graft survival, complications, and graft function were collected. Recipients comprised five women and six men, mean age 48 years. Donors comprised five women and six men, mean age 36.5 years. Donor to recipient relationships included sibling, spouse, son, and daughter. Indications for transplantation were hepatitis C, hepatitis C with hepatocellular carcinoma, primary biliary cirrhosis, primary sclerosing cholangitis, ethanol, and cryptogenic. No case required venovenous bypass or portocaval shunting. The right hepatic vein of the donor graft was anastomosed to the confluence of the left and middle hepatic veins in all cases. All donors are alive and well, with no adverse complications reported. Recipient and graft survival rates were 91% and 82%, respectively, for ALDLT versus 92% and 92% for recipients of cadaveric organs during the same time period. One recipient died of multiple organ failure and sepsis. Biliary reconstruction was performed by Roux-en-Y hepaticojejunostomy in the six cases. In five of the last six recipients, direct duct-to-duct biliary reconstruction with a T tube was used. No anastomotic leaks or strictures occurred in the patients undergoing duct-to-duct reconstruction. Adult living donor liver transplantation can be performed safely and may help alleviate the organ shortage. Neither venovenous bypass nor portocaval shunting is necessary to perform the procedure, and modifications to both the donor and recipient hepatectomy procedures may allow biliary reconstruction to be performed by a direct duct-to-duct anastomosis in selected cases.