Lobe Donation Research Articles

Not All Donor No‐Goes Should Go

To the Editor: In this issue of the American Journal of Transplantation, Dr. Vij and colleagues have presented their results vis-à-vis live right lobe donor ‘no-go’ hepatectomies. They note a no-go rate of 2%, lower than our reported rate at the University of Toronto (4.7%) and from the A2ALL group trial (3.2%) (1-4). The most significant difference is the presence of only one anatomical reason for donor abortion—a left-sided gallbladder. The authors argue that a narrow crotch between the left and right bile duct should not be considered a contraindication to the donor procedure, since the ducts tend to fall open with transsection of the liver. They do agree that devascularization of the left duct is a valid concern. In reply, we would like to emphasize several points that we feel are of paramount importance. First, even the most rigorous preoperative radiological workup can fail to uncover subtle anatomical relationships or biliary anomalies (4). It will, however, reveal obvious anomalies prior to surgery. Secondly, devascularisation or compromise of the donor biliary system is a real concern and not one to be taken lightly. We never approach the right hepatic artery from the right side for this reason, in order to limit dissection around the biliary complex. The rate of complications following a right lobe hepatectomy is low but significant (1-4) and the long-term consequences of right lobe donation remain to be defined. Every effort should be made not to compromise the donor biliary tree. We continue to advocate regarding a narrow crotch between the left and right biliary systems as a relative contraindication for donation. In the final analysis, the gold standard evaluation of biliary and vascular anatomy and of organ suitability, remains intraoperative. The donor surgeon should not have the mindset of proceeding at any cost, but should have a reasonable threshold for backing out of the procedure. Experience and improved radiological imaging should lower the rate of no-go right lobe donor hepatectomies, but the unexpected is always possible and donor safety must trump all other concerns. The authors of this manuscript have no conflict(s) of interest as defined by the American Journal of Transplantation.

Surgery-Related Morbidity in Living Donors for Liver Transplantation

Complications occur in a considerable proportion of living donors for liver transplantation. In this study, the surgery-related morbidity in living donors for more than 1000 liver transplantations was investigated. The donor morbidity between June 1990 and August 2007 was analyzed retrospectively and classified by the graft type and time period. The complication severity was graded using the Clavien scoring system. During the study period, 1262 living donors underwent donor operations for liver transplantation. The donors were divided into two groups by the graft type: group RG (n=500), comprising right and extended right lobe grafts, and group LG (n=762), comprising non-right lobe grafts. The overall complication rate was significantly higher in group RG than that in group LG (44.2% vs. 18.8%, P<0.05). The complication severity was worse in group RG than in group LG. Although biliary complications were the most common complications in both the groups, the frequencies differed significantly (RG: 12.2% vs. LG: 4.9%; P<0.05). Short-term complications (within 4 weeks after the donor operation) occurred in 308 donors (24.4% of all donors). Complications after 4 weeks occurred in only 17 donors. Donor age, right lobe donation, and prolonged operation time were found to be independent risk factors for complications by multivariate analyses. Biliary complications were the most common and feared complications in living donors. There were more frequent and severe complications for right and extended right lobe donation than for non-right lobe donation. The possible risks of donor morbidity for different graft types should be understood and carefully considered.

Fifteen millimeters of mercury

Fifteen millimeters of mercury

Biliary complications including single-donor mortality: experience of 207 adult-to-adult living donor liver transplantations with right liver grafts

BackgroundAfter right lobe donation, biliary complication is the main cause of morbidity. Mortality after right lobe donation has been estimated to be less than 0.5%. Patients and methodsBetween November 2001 and December 2008, 207 adult-to-adult living donor liver transplantations (ALDLT) were undertaken using right lobe grafts. Donors included 173 men and 34 women with a mean age of 28.4 ± 5.2 years. ResultsSiblings comprised 144 (69.6%) cases whereas unrelated donors comprised 63 (30.4%) with a mean body mass index (BMI) of 25.2 ± 2.4. Single and multiple right hepatic ducts (RHD) were present in 82 (39.6%) and 125 (60.3%) donors, respectively. Mean operative time was 360 ± 50min with an estimated blood loss of 950 ± 450ml and returned cell-saver amount of 450 ± 334ml. Mean donor remnant liver volume was 33.5 ± 3.2%. Mean intensive care unit (ICU) stay was 3 ± 0.7 days and mean hospital stay was 14 ± 3.5 days. Modified Clavien classifications were used to stratify all donor biliary complications The overall biliary complications occurred in 27 cases (13.0%). After modified Clavien classification, biliary complications were graded as grade I (n= 10), grade II (n= 2), grade III (n= 14) and grade V (n= 1). Grade I and II (n= 12) biliary complications were successfully managed conservatively. Grade III cases were treated using ultrasound-guided aspiration (USGA), endoscopic retrograde cholangiography (ERCP) and surgery in 10, 2 and 2 donors, respectively. Single donor mortality (Grade V) (0.4%) occurred after uncontrolled biliary leakage with peritonitis that necessitated exploration followed by ERCP with stent insertion but the donor died on day 43 as a result of ongoing sepsis. ConclusionAlthough the majority of biliary complications are minor and can be managed conservatively, uncontrolled biliary leakage is a serious morbidity that should be avoided as it could lead to mortality.

Right-sided diaphragmatic hernia in an adult after living donor liver transplant: a rare cause of post-transplant recurrent abdominal pain

Right-sided diaphragmatic hernia (DH) after living donor liver transplant in adult recipients has not been described previously. There have been a few reports of right-side DH in paediatric living donor liver transplant recipients and following right lobe donor hepatectomy. We herein describe the first instance of right-sided DH in a 44-year-old man who underwent left lobe live donor liver transplant. Twenty-eight months later, he presented with recurrent right upper abdominal pain. Radiographic workup revealed a right-sided DH. He underwent laparotomy and primary repair of the diaphragmatic defect. Seven months after the repair, the patient remains well and free from symptoms, with a normal chest X-ray. Right-sided DH is rare but may occur after living donor liver transplant. Successful outcome can be achieved by an early diagnosis and prompt management.

The International Position on Laparoscopic Liver Surgery

To summarize the current world position on laparoscopic liver surgery. Multiple series have reported on the safety and efficacy of laparoscopic liver surgery. Small and medium sized procedures have become commonplace in many centers, while major laparoscopic liver resections have been performed with efficacy and safety equaling open surgery in highly specialized centers. Although the field has begun to expand rapidly, no consensus meeting has been convened to discuss the evolving field of laparoscopic liver surgery. On November 7 to 8, 2008, 45 experts in hepatobiliary surgery were invited to participate in a consensus conference convened in Louisville, KY, US. In addition, over 300 attendees were present from 5 continents. The conference was divided into sessions, with 2 moderators assigned to each, so as to stimulate discussion and highlight controversies. The format of the meeting varied from formal presentation of experiential data to expert opinion debates. Written and video records of the presentations were produced. Specific areas of discussion included indications for surgery, patient selection, surgical techniques, complications, patient safety, and surgeon training. The consensus conference used the terms pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique to define laparoscopic liver procedures. Currently acceptable indications for laparoscopic liver resection are patients with solitary lesions, 5 cm or less, located in liver segments 2 to 6. The laparoscopic approach to left lateral sectionectomy should be considered standard practice. Although all types of liver resection can be performed laparoscopically, major liver resections (eg, right or left hepatectomies) should be reserved for experienced surgeons facile with more advanced laparoscopic hepatic resections. Conversion should be performed for difficult resections requiring extended operating times, and for patient safety, and should be considered prudent surgical practice rather than failure. In emergent situations, efforts should be made to control bleeding before converting to a formal open approach. Utilization of a hand assist or hybrid technique may be faster, safer, and more efficacious. Indications for surgery for benign hepatic lesions should not be widened simply because the surgery can be done laparoscopically. Although data presented on colorectal metastases did not reveal an adverse effect of the laparoscopic approach on oncological outcomes in terms of margins or survival, adequacy of margins and ability to detect occult lesions are concerns. The pure laparoscopic technique of left lateral sectionectomy was used for adult to child donation while the hybrid approach has been the only one reported to date in the case of adult to adult right lobe donation. Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety. A prospective randomized trial appears to be logistically prohibitive; however, an international registry should be initiated to document the role and safety of laparoscopic liver resection. Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.

Use of middle hepatic vein in right lobe living donor liver transplantation

The harvesting of the middle hepatic vein (MHV) with the right lobe graft for living-donor liver transplantation allows an optimal venous drainage for the recipient; however, it is an extensive operation for the donor. This is a prospective, nonrandomized study evaluating liver functions and early clinical outcome in donors undergoing right hepatectomy with or without MHV harvesting. From August 2005 to July 2007, a total of 100 donor right hepatectomies were performed with (n = 49) or without (n = 51) the inclusion of the MHV. The decision to take MHV was based on an algorithm that considers various donor and recipient factors. There was no donor mortality in donors in either group. Overall complication rate was higher in MHV (+) donor group, however when remnant liver volume was kept above 30%, complication rates were similar between the groups. The results of this study show that right hepatectomy including the MHV neither affects morbidity nor impairs early liver function in donors when remnant volume is kept above 30%. The decision, therefore, of the extent of right lobe donor hepatectomy should be tailored to the particular conditions considering the graft quality and metabolic demand of the recipient.

Congestion of the donor remnant right liver after extended left lobe donation

The clinical importance of congestion of the remnant right lobe has not yet been fully elucidated in donors who donate their left lobe with the middle hepatic vein. The impact of congestion on clinical course and liver regeneration in 52 donor remnant livers were evaluated. The donors were divided into three groups according to the degree of the congestion: the mild [congestion ratio (CR) < 10%], moderate (CR ranged from 10% to 25%) and severe congestion groups (CR > 25%). The regeneration ratio of the graft at postoperative day 7 (7 POD) was 22.0 +/- 14.3% and inversely correlated with the CR in the remnant right lobe (P = 0.003). Aspartate aminotransferase and alanine aminotransferase at 7 POD were significantly higher in the severe CR group in comparison to the mild CR group (P = 0.003 and 0.019, respectively), but those of the three groups were comparable at 30 POD. The hospital stays were significantly longer in the severe CR group (P = 0.010). In conclusion, the congestion of the donors' remnant right liver can lead the transient liver dysfunction and poor regeneration. Therefore, the conversion of the graft from the left to right lobe might be appropriate according to the degree of the congestion.

Liver regeneration in donors and adult recipients after living donor liver transplantation

In living donor liver transplantation, the safety of the donor operation is the highest priority. The introduction of the right lobe graft was late because of concerns about donor safety. We investigated donor liver regeneration by the types of resected segments as well as recipients to assess that appropriate regeneration was occurring. Eighty-seven donors were classified into 3 groups: left lateral section donors, left lobe donors, and right lobe donors. Forty-seven adult recipients were classified as either left or right lobe grafted recipients. Volumetry was retrospectively performed at 1 week, 1, 2, 3, and 6 months, and 1 year after the operation. In the right lobe donor group, the remnant liver volume was 45.4%, and it rapidly increased to 68.9% at 1 month and 89.8% at 6 months. At 6 months, the regeneration ratios were almost the same in all donor groups. The recipient liver volume increased rapidly until 2 months, exceeding the standard liver volume, and then gradually decreased to 90% of the standard liver volume. Livers of the right lobe donor group regenerated fastest in the donor groups, and the recipient liver regenerated faster than the donor liver. Analyzing liver regeneration many times with a large number of donors enabled us to understand the normal liver regeneration pattern. Although the donor livers did not reach their initial volume, the donors showed normal liver function at 1 year. The donors have returned to their normal daily activities. Donor hepatectomy, even right hepatectomy, can be safely performed with accurate preoperative volumetry and careful decision-making concerning graft-type selection.

Current concept of small-for-size grafts in living donor liver transplantation

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size (SFS) graft syndrome." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extension to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by an SFS graft, such as a portosystemic shunt or splenectomy, have been trialed with some positive results. To establish an effective strategy for transplanting SFS grafts and preventing SFS graft syndrome, it is essential to have precise knowledge and tactics to evaluate graft quality and graft volume, when performing these LDLTs with portal pressure control. We reviewed the updated literature on the pathogenesis of and strategies for using SFS grafts.

Selective Hemi-Portocaval Shunt Based on Portal Vein Pressure for Small-for-Size Graft in Adult Living Donor Liver Transplantation

We developed an algorithm of graft selection in which left lobe donation is considered primarily if the graft-to-recipient weight ratio (GRWR) is estimated to be greater than 0.6% in preoperative volumetry with utilization of a hemi-portocaval shunt (HPCS) based on portal vein pressure (PVP) more than 20 mmHg at the time of laparotomy. A total of 11 consecutive adult living donor liver transplantations with small-for-size graft according to our graft selection algorithm were performed between December 2005 and August 2007. Ten patients required HPCS using a vein graft all survived without small-for-size syndrome (SFSS) and shunt complications with a median follow-up of 296 days. One patient without HPCS died of chronic vascular rejection. In all cases, PVP were regulated successfully under 20 mmHg by HPCS. Graft volume reached in mean 84.3% of standard liver volume in right lobe grafts and mean 95.4% in left lobe grafts at 3 months after liver transplantation. Actuarial rate of shunt patency at 1, 3, 6 months and 1 year were 80%, 55%, 26% and 20%, respectively. Selective HPCS based on PVP is an effective procedure and results in excellent patient and graft survival with avoidance of SFSS in grafts greater than 0.6% of GRWR.

Significant Outcome Of Biliary Anastomosis In Living Related Donor Liver Transplantation

Variations in the anatomy of the intrahepatic bile ducts have long been recognized. Serious consideration of the surgical anatomy of the liver began, however, with the advent of minimally invasive therapeutic intervention for bile duct or hepatic resection, or partial liver transplantation. Thus, accurate knowledge of the anatomy of IHDs is critical. 30 cases were included in this study. Right lobe donation in 27 cases and left lobe donation in 3 cases. The main indication for transplantation was end stage liver disease: hepatitis C end stage liver cirrhosis in 29 cases, while hepatocellular carcinoma on top of liver cirrhosis was the remaining case. Pretransplantation preparation of both donors and recipients was done.No mortality was reported to either any of the donors or the recipients. Postoperative donor biliary complications occurred in 1 case and conservative treatment was followed with complete resolution of the condition .Postoperative recipient biliary complicatioins occurred in eleven cases in the form of biloma, biliary leakage, biliary stricture, cholangitis and peritonitis, six of them with two ducts anastomosis. They were managed and cured without residual pathology.

Significant Outcome Of Biliary Anastomosis In Living Related Donor Liver Transplantation

Variations in the anatomy of the intrahepatic bile ducts have long been recognized. Serious consideration of the surgical anatomy of the liver began, however, with the advent of minimally invasive therapeutic intervention for bile duct or hepatic resection, or partial liver transplantation. Thus, accurate knowledge of the anatomy of IHDs is critical. 30 cases were included in this study. Right lobe donation in 27 cases and left lobe donation in 3 cases. The main indication for transplantation was end stage liver disease: hepatitis C end stage liver cirrhosis in 29 cases, while hepatocellular carcinoma on top of liver cirrhosis was the remaining case. Pretransplantation preparation of both donors and recipients was done.No mortality was reported to either any of the donors or the recipients. Postoperative donor biliary complications occurred in 1 case and conservative treatment was followed with complete resolution of the condition .Postoperative recipient biliary complicatioins occurred in eleven cases in the form of biloma, biliary leakage, biliary stricture, cholangitis and peritonitis, six of them with two ducts anastomosis. They were managed and cured without residual pathology.

Right Hepatic Lobe Donation: Impact on Donor Quality of Life

The aim of this study was to assess the impact of living-donor liver transplantation on the donor’s quality of life. Among the 48 performed at our hospital from October 2003 to June 2006, 46 (27 men, 19 women; mean age, 37.4 years) were followed for more than 4 months (mean, 16.5±8 months). In April 2006, these donors participated in a survey that included medical and psychosocial outcomes. Seven complications occurred in four of 46 donors (8.6%): two biliary leaks, two wound infections, one incisional hernia, one portal vein thrombosis, and one deep venous thrombosis. For the donor with portal vein thrombosis, the vein was recanalized, and she recovered without treatment; a bile leak from the cut liver surface and an incisional hernia also developed in the same donor. The biliary leak was treated with percutaneous drainage, and the incisional hernia was repaired surgically. Fifteen donors were housewives, 31 worked outside the home, and 94% returned to their work. A change in body image was reported in 4.3% of the donors. None reported impaired sexual function. Complete recovery occurred in 86% of donors, 94% of the donors said that they would donate again if necessary, and 97% believe that they had benefited from the donation experience. In conclusion, almost all donors were able to return to their prior jobs within a few months of surgery, and most donors were satisfied with the donation procedure.

Adult Living Donor Liver Transplantation Using the Right Lobe

Background This article reviewed our experience with right lobe donor hepatectomy in living donor liver transplantations (LDLT), particularly in the context of preserving donor safety. Materials and methods From January 2000 to August 2005, we performed 206 adult LDLT operations using the right lobe. The donor characteristics, operative findings, postoperative results including the peak values of liver enzymes (aspartate transferase [AST], alanine transferase [ALT], and bilirubin) and regeneration volumes, as evaluated by computed tomography volumetry, were reviewed at 1 week, as well as 3 and 6 months after surgery. The effects of three risk factors on donor safety were analyzed: age (<55 years, ≥55 years): fatty change in the donor liver (<10%, ≥10%); and remnant volume (<35%, ≥35%). Results The liver enzymes and regeneration volumes showed no significant difference according to age, only ALT was significant increased associated with the severity of fatty change ( P < .05). There were significant differences in postoperative AST, ALT, and regeneration volume between the group with <35% and the group with ≥35% remnant liver volume ( P < .05). Upon further analysis with combinations of two out of three risk factors, the group according to remnant volume and fatty change was meaningful. Follow-up data on donor ALT showed a return normal levels and after postoperative 3 months there was regeneration of the remnant liver to more than 70% of the whole liver preoperatively. There was no donor mortality, but postoperative complications were observed in 39 patients (39/206, 18.9%). Biliary complications were encountered in 24 patients: one bile duct injury, 22 bile leakages, and one bile duct stricture. Other complications consisted of pleural effusion ( n = 8), delayed gastric emptying ( n = 6), atelectasis ( n = 1), and hepatic encephalopathy ( n = 1). Conclusion In cases of careful donor selection, a right lobectomy can be performed safely with minimal risks when the remnant liver volume exceeds 35% of the total liver volume and shows less than 10% fatty changes.

Anomalia anatômica da veia porta: uma causa rara de impossibilidade de doação do lobo direito em transplante hepático intervivos

Living related liver transplantation is being increasingly used for patients that can not wait for a cadaveric organ. We describe a case of a right lobe donor who had a type III portal vein anomaly. On this anomaly the portal vein gives branches first to the right posterior vein and then to the right anterior vein and the left portal vein. The recipient had portal vein thrombosis that was recognized only during the surgery. The Doppler examination performed before the operation did not detect this thrombosis. The transplant was not accomplished. Anatomical anomaly of the portal vein may be a rare cause impossibility to organ donation in living related liver transplantation.

A Report of the Vancouver Forum on the Care of the Live Organ Donor: Lung, Liver, Pancreas, and Intestine Data and Medical Guidelines

An international conference of transplant physicians, surgeons, and allied health professionals was held in Vancouver, Canada, on September 15 and 16, 2005 to address the care of the live lung, liver, pancreas, and intestine organ donor. The Vancouver Forum was convened under the auspices of the Ethics Committee of The Transplantation Society. Forum participants included over 100 leaders in organ transplantation, representing many countries from around the world, including participants from the following continents: Africa, Asia, Australia, Europe, North and South America. The objective of the Vancouver Forum was to develop an international standard of care for the live lung, liver, pancreas and intestinal organ donor. This Vancouver Forum followed a conference convened in Amsterdam on the care of the live kidney donor (1, 2). There were four organ specific work groups at the Vancouver Forum: lung, liver, pancreas and intestine. Each organ work group addressed the following topics in concert and reported their findings in a plenary presentation to all participants:

Feasibility of Left Lobe Living Donor Liver Transplantation Between Adults: An 8-Year, Single-Center Experience of 107 Cases

Operative mortality for a right lobe (RL) donor in adult living donor liver transplantation (LDLT) is estimated to be as high as 0.5-1%. To minimize the risk to the donor, left lobe (LL)-LDLT might be an ideal option in adult LDLT. The aim of the study was to assess the feasibility of LL-LDLT between adults based on a single-center experience of 107 LL-LDLTs performed over 8 years. The mean graft weight of LL grafts was 452 g, which amounted to 40.5% of the estimated standard liver volume of the recipients. The overall 1-, 3- and 5-year patient survival rates in LL-LDLT were 81.4, 76.9 and 74.7%, respectively, which were comparable to those of RL-LDLT. Twenty-six grafts (24.3%) were lost for various reasons with three losses directly attributable to small-for-size graft syndrome. Post-operative liver function and hospital stay in LL donors were significantly better and shorter than that in RL donors, while the incidence of donor morbidity was comparable between LL and RL donors. In conclusion, LL-LDLT was found to be a feasible option in adult-to-adult LDLT. Further utilization of LL grafts should be undertaken to keep the chance of donor morbidity and mortality minimal.

Hypophosphatemia in Living Liver Donors

Background and aim Some patients who undergo donor hepatectomy for adult living donor liver transplantation develop hypophosphatemia postoperatively. Since this imbalance appears to be a factor in postoperative complications, some authors advocate routine supratherapeutic phosphorus repletion. The purpose of this study was to determine the frequency of hypophosphatemia after elective donor lobectomy for liver transplantation and to assess whether phosphorus repletion is necessary in this patient group. Methods The cases of 26 patients who donated 19 right lobe and seven left lateral lobe grafts between August 2004 and March 2005 were evaluated. Postoperative phosphorus levels and other relevant data were obtained from our institution’s transplant database. Presence/severity of hypophosphatemia was categorized as follows: normal (>2.5 mg/dL), mild (1.5 to 2.5 mg/dL), moderate (1.1 to 1.5 mg/dL), and profound (<1.0 mg/dL). Results No patients undergoing donor hepatectomy suffered profound or life-threatening hypophosphatemia and no donor required hyperalimentation for phosphate repletion. Twenty one donors (80.7%) did not have postoperative hypophosphatemia. In addition there appears to be no increased morbidity related to hypophosphatemia. A left lateral segment donor (3.8%) had moderate hypophosphatemia that alleviated with oral intake gradually. Four patients (15.5%; three of right lobe donor, one of left lateral segment donor) had mild hypophosphatemia. We also appropriately corrected the hypophosphatemia with encouragement of normal oral intake. By postoperative day 5, essentially all donor phosphorus levels were corrected to normal range. Conclusions The results suggest that hypophosphatemia after donor hepatectomy is not as common as previously reported. We find that appropriate early oral intake postoperatively effectively prevents/minimizes hypophosphatemia in patients who undergo donor hepatectomy.

Living Donor Liver Transplantation in Adult Patients: Our Experience

Introduction Living donation in adult liver transplantation (LDLTx) is an important resource because of the waiting list growth. We started a living donor program to overcome the shortage of cadaveric sources. Patients From May 2001 to May 2003, 36 patients underwent LDLTx: 27 received a right lobe, 8 received a left lobe, and 1 received segments II and III. Results The 1-year actuarial survival rate was 77.7%, with a mean follow-up, in survivors, of 754 ± 248 days. Eleven of 27 (40.7%) right lobe recipients died. Among left graft recipients, 3 patients died (33%). We undertook retransplantation in 4 cases, because of 2 “small for size” syndrome, 1 late hepatic artery thrombosis, and 1 early portal vein thrombosis. After a period of 797 days, all 36 donors returned to a normal social and working life. Two donors, who underwent right lobe donation, experienced major complications: 1 case of biliary stenosis, treated by stenting, and 1 case of biliary leak from the cut surface of the liver, requiring laparotomy and abscess drainage. Left lobe donors developed no complications. Conclusions LDLTx has a learning curve for experienced liver transplantation surgeons. Our last 18 cases showed better survivals than the first 18 (9 deaths vs 5), even if, in the latter group, we transplanted 8 left livers. In our experience, LDLTx of a left liver graft has an increased risk of “small for size syndrome,” but patients, both donors and recipients, report improved outcomes.