Lobe Liver Transplantation Research Articles

Single-center experience of intraoperative ligation of the splenic artery for prevention of splenic artery steal syndrome in patients after living donor liver transplant

Background. Living donor liver transplant is an effective method of treatment in patients with different types of endstage liver diseases. Unfortunately, patients undergoing such a complex treatment sometimes develop various vascular complications. Splenic artery steal syndrome has emerged as a cause of graft ischemia in living donor liver transplant recipients and may lead to high liver enzyme levels, cholestasis, hepatic artery thrombosis, and even a graft loss in some severe cases.Objective. Evaluation of the first results in the experience of our center with a routine intraoperative ligation of the splenic artery during the procedure of right lobe living donor liver transplantation in adult recipients for the prevention of the steal syndrome development in the postoperative period.Material and methods. Living donor liver transplant recipients with known hepatic arterial flow impairment were retrospectively studied. Patients were allocated into groups with regard whether the splenic artery had been ligated or not during the transplant procedure. Arterial complications were reviewed in both groups.Results. None of 30 patients with ligated splenic artery developed splenic artery steal syndrome after living donor liver transplant. splenic artery steal syndrome occurred in 60% patients with non-ligated splenic artery. Surgical technique of performing arterial anastomosis was not related to the splenic artery steal syndrome development (p<0.01 There was no local ischemic necrosis noted in the spleen in patients with the ligated splenic artery.Conclusion. Based on the analysis of our own experience and literature data, the splenic artery ligation appears to be an effective and safe method for preventing a splenic artery steal syndrome in patients following right lobe liver transplantation, with a minimal risk of ischemic complications for the spleen. However, further studies with larger sample sizes are needed to obtain more reliable results. Ultrasound examination and endovascular intervention are the primary tools for an early detection of abnormalities and rapid restoration of arterial blood flow in the hepatic artery of the graft.

Biliary complications after living donor right lobe liver transplantation in adults

Biliary complications after living donor right lobe liver transplantation in adults

Peritoneum for Middle Hepatic Vein Conduit During Living Donor Liver Transplantation.

I have read with interest the article “Parietal Peritoneum as a Novel Substitute for Middle Hepatic Vein Reconstruction During Living Donor Liver Transplantation” published in your journal by Hong et al.1 The use of the parietal peritoneal graft as a venous conduit is not new and has been used as a substitute for several veins for this purpose. It has been shown to be beneficial in a rapid and effective way to repair the venous defects in the portomesenteric veins, hepatic vein, and vena cava.2-4 In the study of Hong et al, the parietal peritoneum was used for the middle hepatic vein during right lobe living donor liver transplantation. The authors wrote that the parietal peritoneum has never been used for this purpose before: “However, to the best of our knowledge, clinical use of the parietal peritoneum as a substitute for middle hepatic vein reconstruction, an essential procedure during LDLT using the right liver graft, has never been described.” During a living donor right lobe liver transplant, I have used the parietal peritoneum to correct the flow problem in the middle hepatic vein before. The result was successful, and I reported it in 2015.5 I just respectfully wanted to remind them of my experience on this occasion. I congratulate and support the authors’ success using the parietal peritoneum for middle hepatic vein conduits.

Outcome of Extended Right Lobe Liver Transplantations.

Split-liver transplantation offers a solution to the organ shortage problem. However, the outcomes of extended right lobe liver transplantation (ERLT) and whether it is a suitable alternative to full-size liver transplantation (FSLT) remain controversial. We compared the outcomes of ERLT and FSLT in adult recipients of 43,409 first deceased donor liver transplantations using Cox regression. We also analyzed 612 ERLT and 1224 FSLT 1:2 matched cases to identify factors that affect ERLT outcome. The risk of graft loss was significantly higher following ERLT than following FSLT during the first posttransplantation year in the matched and unmatched collective (hazard ratio [HR], 1.39 and 1.27 and P=0.01 and 0.006, respectively). Every additional hour of cold ischemia time (CIT) increased the risk of 1-year graft loss by 10% in the ERLT group compared with only 3% in the FSLT group (P=0.003 and <0.001, respectively). Importantly, the outcome of ERLT and FSLT did not differ significantly if the CIT was below 10hours (HR, 0.71; P=0.22). One-year graft and patient survival were lower in high-risk ERLT recipients with a Model for End-Stage Liver Disease (MELD) score of ≥20 (HR, 1.88; P=0.03 and HR, 2.03; P=0.02). In the male recipient-male donor combination, ERLT recipients had a higher risk of 1-year graft loss than FSLT recipients (HR, 2.44; P=0.006). This was probably because of the significantly higher MELD score in ERLT recipients (P=0.004). ERLT in adults is an adequate alternative to FSLT and offers an elegant solution to the problem of organ shortage as long as the cold storage is less than 10hours and the recipient's MELD score is <20.

Considering extended right lobe grafts as major extended donor criteria in liver transplantation is justified.

The outcomes of split-liver transplantation are controversial. This study compared outcomes and morbidity after extended right lobe liver transplantation (ERLT) and whole liver transplantation (WLT) in adults. MEDLINE and Web of Science databases were searched systematically and unrestrictedly for studies on ERLT and its impact on graft and patient survival, and postoperative complications. Graft loss and patient mortality odds ratios (OR) and 95% confidence intervals (CI) were assessed by meta-analyses using Mantel-Haenszel tests with a random-effects model. Vascular and biliary complications, primary nonfunction, 3-month, 1-, and 3-year graft and patient survival, and retransplantation after ERLT and WLT were analyzed. The literature search yielded 10594 articles. After exclusion, 22 studies (n=75799 adult transplant patients) were included in the analysis. ERLT was associated with lower 3-month (OR=1.43, 95% CI=1.09-1.89, P=0.01), 1-year (OR=1.46, 95% CI=1.08-1.97, P=0.01), and 3-year (OR=1.37, 95% CI=1.01-1.84, P=0.04) graft survival. WL grafts were less associated with retransplantation (OR=0.57; 95% CI=0.41-0.80; P<0.01), vascular complications (OR=0.53, 95% CI=0.38-0.74, P<0.01) and biliary complications (OR=0.67; 95% CI=0.47-0.95; P=0.03). Considering ERLT as major Extended Donor Criteria is justified because ERL grafts are associated with vasculobiliary complications and the need for retransplantation, and have a negative influence on graft survival.

Biliary reconstruction during right lobe living donor liver transplantation: state of the problem, options and classification

Objective. To study the features and results of biliary reconstruction in right lobe living donor liver transplantation. To propose a classification of biliary reconstruction, which allows reflecting all its existing and possible variants, taking into account the anatomy of the bile ducts of the graft and recipient and technical features of reconstruction. Materials and methods. From May 2010 to June 2019 a retrospective and prospective analysis of the results of the right lobe living donor liver transplantation was performed for 256 recipients and their donors. One observation was excluded due to lack of data. Results. When the right lobe liver transplantations were performed, grafts with two bile ducts requiring biliary reconstruction most often (52%) were observed, less often grafts with one duct (32%), three ducts (12%), four ducts (3%) and in one case five ducts (<1%) were observed. With the multiple nature of the ducts in 31 cases (12% of all operations) unification ductoplasty was used. Moreover, in the group of reconstructions with the presence of two ducts and in the group with the presence of three or more ducts ductoplasty was used with equal frequency – in 18% of cases. The duct-to-duct anastomoses was formed in 157 cases (61%), bilio-entero anastomoses – in 91 cases (36%) and the combined variant – only in 7 cases (3%). In the first variant (duct-to-duct) during reconstruction in 43 cases (27% of all formed duct-to-ducts, 17% of all transplants performed), the so-called high-order bile ducts (right or left lobar, as well as cystic bile ducts) were used. This article proposes a coding and classification system for the technical features of biliary reconstruction in right lobe living donor liver transplantation. Conclusion. Right lobe living donor liver transplantation accompanied by high variability of the stage of biliary reconstruction, depending on the number of bile ducts in the graft, their condition and relative position. The analysis of our own material made it possible to propose a universal classification and coding method for the types of biliary reconstruction during right lobe living donor liver transplantation. The classification allows to reflect all existing options for biliary reconstruction, depending on the anatomy of the bile ducts of the graft and recipient, the technical features of its implementation. It also simplifies the analysis and statistical processing of the bile duct reconstruction stage in liver transplantation.

Split liver transplantation in two recipients for urgent indications: an example and logistics of interregional cooperation

Aim. To report a rare case of split liver transplantation in two urgent recipients treated in hospitals that are very far from each other. Material and methods. Partial liver grafts were obtained by controlled full-right/full-left in situ splitting. The left lobe was transplanted in a 7-year-old child with severe hepatic failure (PELD score 39) resulting, probably from an progressive intrahepatic familial cholestasis in Novosibirsk. The right lobe was used for re-transplantation in a 28-year-old patient with hepatic artery thrombosis (UNOS status 1A) after living donor right lobe liver transplantation in Moscow. Results. The course of the early post-operative period in recipient 1 was complicated by infected total pancreatonecrosis with the development of limited biliary leakage and the formation of a stricture, which required reconstructive cholangiojejunostomy 12 months after transplantation. Recipient 2 consistently underwent biliary leakage, arrosive arterial bleeding, graft artery thrombosis, all of which could become fatal. Complications were successfully eliminated by the consistent use of surgical and endovascular interventions. Conclusion. The presented observation is, firstly, an example of effective inter-center cooperation, and secondly, a demonstration of the existing problems of postmortem organ donation, which determine the need for such extreme surgery in critical situations.

A Feasible Technique for Middle Hepatic Vein Reconstruction in Right Lobe Liver Transplantation: Usage of Autologous Portal Vein With Bench Recanalized Umbilical Vein Graft.

Background Middle hepatic vein (MHV) reconstruction is necessary to achieve a good outcome in right lobe liver transplantation. Many successful reconstruction methods have been reported as there are anatomical variations in MHV tributaries. Some methods are time consuming to perform routinely and other methods are not applicable in all anatomical variations. Large series which describe routine use of portal vein (PV) and bench recanalized umbilical vein (UV) graft have not been reported. In this paper, we report our experience of this novel technique of MHV reconstruction as a standard protocol. Material and method From February 2017 to December 2018, there were 301 patients who received right lobe liver transplant in our Centre, and the new MHV in 268 grafts were reconstructed with autologous PV and bench recanalized UV. The length of the vein graft and distance between segment 5 branch and MHV orifice were measured. We divided these patients into 3 risk groups according to the MHV drainage area (congestion volume) of the right lobe (Low risk: under 30%, Medium risk: 31 to 45%, High risk: over 45%). Clinical data was collected, and perioperative data were compared between the 3 groups. Results The distance from V5 to MHV orifice, PV autologous graft only, and PV&UV was 9.5±2.5, 7.2±1.5, 13.5±2.2 cm respectively. The patency rate of our reconstructed MHV was 97% and 89% at 1 month and 1 year respectively. There was no significant difference in perioperative data among the 3 groups. The survival in medium and high groups were statistically equivalent to that in low risk group. Conclusion Autologous portal with bench recanalized umbilical vein graft shows a high patency rate and achieves satisfactory outcome in grafts with large MHV drainage area. This graft is able to deal with all the MHV tributary variations by a single method.

EUS-guided gastrojejunal anastomosis to facilitate endoscopic retrograde cholangiography in a patient with a right lobe liver transplant and Roux-en-Y anatomy.

EUS-guided gastrojejunal anastomosis to facilitate endoscopic retrograde cholangiography in a patient with a right lobe liver transplant and Roux-en-Y anatomy.

Features of right lobe liver transplantation from living related donor

Aim. To determine the peculiarities of liver transplantation using right lobe graft from living related donor with and without the middle hepatic vein inclusion.Materials and methods. The study has analyzed preoperative, intraoperative and postoperative data of 76 recipients who underwent right lobe living donor liver transplantation with different types of hepatic vein reconstruction: group 1 – patients who received a right lobe liver graft with a middle hepatic vein, and group 2 – recipients of right lobe liver graft without the middle hepatic vein. For comparative analysis, we used biochemical and regional hemodynamic parameters in both groups during the first week and on days 10, 14, 21 and 30 after transplantation.Results. In group 1, the higher values of Qpv – 649 ± 220 ml/min, 1222 ± 491 ml/min; 1264 ± 372 ml/min; 1166 ± 284 ml/min; 1016 ± 211 ml/min; 1095 ± 301 ml/min were observed compared to group 2 – 643 ± 230 ml/min; 1127 ± 385 ml/min; 1132 ± 372 ml/min; 1030 ± 263 ml/min; 980 ± 254 ml/min; 922 ± 293 ml/min on days 0, 1, 3, 5, 7 and 30 after transplantation, respectively, (P &lt; 0.05). Peak systolic velocity (PSV) and resistance index of hepatic artery (RIha) were increased to higher values in group 2 (from 0.54 m/s to 0.69 m/s and from 0.63 to 0.69, respectively, P &lt; 0.05) compared to group 1 (from 0.58 m/s up to0.62 m / s and from 0.62 to 0.69, respectively, P &lt; 0.05). In the postoperative period, the level of total bilirubin in group 1 (grafts with middle hepatic vein) was significantly lower and the level of transaminases was higher than in group2. In the group of recipients, who had a graft with middle hepatic vein, the frequency of small-for-size syndrome (SFSS) was lower compared with group 2 (17.94 % vs 27.00 %, P &lt; 0.05).Conclusions. When performing the right lobe liver transplantation, the middle hepatic vein presence in the graft is correlated with a decrease in the frequency of postoperative complications and small for size syndrome development. Adequate venous outflow with sufficient volume of right lobe liver graft determines the functional graft mass.

Dual graft living donor liver transplantation \u2013 a case report

BackgroundLiving donor liver transplantation (LDLT) has emerged as an equally viable option to deceased donor liver transplant for treating end stage liver disease patients. Optimising the recipient outcome without compromising donor safety is the primary goal of LDLT. Achieving the adequate graft to recipient weight ratio (GRWR) is important to prevent small for size syndrome which is an uncommon but potentially lethal complication of LDLT.Case presentationHere we describe a case of successful dual lobe liver transplant for a 32 years old patient with ethanol related end stage liver disease. A right lobe graft without middle hepatic vein and another left lateral sector graft were transplanted successfully. Recipient and both donors recovered uneventfully.ConclusionDual lobe liver transplant is a feasible strategy to achieve adequate GRWR without compromising donor safety.

Transjugular Liver Biopsy Following Left Lobe or Lateral Segment Transplantation in Pediatric Patients

To evaluate the efficacy and safety of transjugular liver biopsy in pediatric patients with left lobe or lateral segment liver transplant. This was a retrospective study of data from 104 transjugular liver biopsies (57 children) using an 18- or 19-G biopsy needle. Transjugular liver biopsy was selected due to coagulopathy and/or ascites in 56 (54%) procedures. The median patient age, body weight, and interval from liver transplantation were 56months, 16kg, and 2months, respectively. Technical success was defined as adequate liver specimens yield determined by the operator at the time of procedure. Complications, the longest length of obtained liver specimens according to needle type, and adequacy for histological diagnosis were analyzed. Biopsy using a biopsy needle was successfully achieved in 103 procedures (99%). In one procedure, liver samples were obtained using biopsy forceps following unsuccessful attempts with a biopsy needle. Major complication occurred in one procedure following biopsies using both a biopsy needle and biopsy forceps. The patient received transfusion to manage decreased blood pressure and hemoglobin levels although post-biopsy venography did not show extravasation. The median longest length of liver specimens using 18-G (n = 63) and 19-G (n = 40) needles were 10mm (range, 5-20) and 10mm (range, 5-20), respectively (p = 0.704). Liver specimens were adequate for histological diagnosis in all procedures. Transjugular liver biopsy using a biopsy needle appears to be a safe and effective method to obtain liver specimens for histological diagnosis in pediatric patients with left lobe or lateral segment liver transplant. Level 4, case series.

Right lobe liver transplantation for Wilson's disease from heterozygote donor: Case report

BackgroundUse of liver grafts from heterozygote genetic carriers for Wilson's disease was considered safe. We present a 14 year-old male patient with Wilson's disease who was undergone right lobe liver transplantation from his heterozygote mother. Case reportThe patient was admitted to our hospital with decompensated liver cirrhosis due to Wilson's disease as a liver recipient candidate. His Child score was 11 (Child C) and MELD score was 28. His weight was 52 kg. Total liver volume of his 40-year-old mother was calculated 1488 mL in computed tomography. Right and left liver lobe of the donor were calculated as 1044/444 (70.16%/29.84%) mL. Preoperative ceruloplasmin level, 24-h urinary copper excretion, serum copper level and liver biopsy of the donor were all normal. Right lobe liver transplant was performed. Recipient and donor were discharged from the hospital uneventfully. The patient's preoperative ceruloplasmin level was 15.3 mg/dL and increased to 22 mg/dL after liver transplant. Also urinary copper decreased from 1939 to 68 μg/day and serum copper improved from 72 to 82 mg/dL after liver transplant. There were no statistically difference between preoperative and postoperative serum copper, ceruloplasmin and 24 h urinary copper levels of the donor. DiscussionEqual outcomes of living related liver transplantation for Wilson's disease were reported for heterozygote and nonheterozygote donors previously. Usually left liver lobes were used for transplantation from heterozygous donors. The use of right liver lobe of the heterozygous donor has no negative impact on both the donor and recipient for Wilson's disease.

A twenty-year review of clinical liver transplantation

To review the development of adult and pediatric liver transplantation in Tianjin First Center Hospital, and to enhance academic exchanges, improve technological innovation, and jointly promote the progress and maturity in the field of liver transplantation. The development of liver transplantation in Tianjin First Center Hospital was analyzed. The clinical data of adult and pediatric liver transplantation from September 1998 to September 2018 were collected. The important events and technological innovation achievements of liver transplantation during the 20 years were summarized. The first clinical liver transplantation was attempted in Tianjin First Central Hospital in April 1980. The first long-term survival adult liver transplantation in China was completed in 1994 (11 years survival after the operation). The specialized team of liver transplantation was formally established in September 1998. The 20-year clinical exploration and progress reflected the characteristics of era changes and technological innovation during the rapid development of liver transplantation in China. Our center performed liver re-transplantation in January 1999, reduced-size pediatric liver transplantation in August 2000. In May 2001, we organized the formulation for the preventive and treatment plan for hepatitis B recurrence after liver transplantation. We performed combined liver and kidney transplantation in July 2002, split liver transplantation (SLT) in April 2004, the first domino liver transplantation (DLT) in August 2005. Pediatric living donor liver transplantation (LDLT) was initiated in October 2006, adult LDLT was carried out in August 2007. In September 2007, the first living donor combined liver and kidney transplantation from the same donor in Asia was performed. The first domino+living donor double grafts liver transplantation in the world was performed in January 2009. In March 2011, we performed laparoscopically assisted right hepatic lobe liver transplantation (LDLT) with middle hepatic vein. In May 2014, living donor laparoscopic left lateral lobe procurement was successfully established. In April 2016, simultaneous liver, pancreas and kidney multi-organ transplantation was completed. Domino donor-auxiliary liver transplantation was performed in February 2017. In December 2017, extracorporeal membrane oxygenation (ECMO)-supported liver transplantation in a patient with severe pulmonary hypertension was successfully completed. Liver transplantation combined with partial splenectomy was established in April 2018. Cross-domino liver transplantation (hypersensitive kidney transplantation with auxiliary liver transplantation+pediatric liver transplantation) was performed in May 2018. During the 20 years, the team has performed or assisted other centers in Beijing, Shanghai, Guangzhou and Shenzhen to carry out more than 10 000 cases of liver transplantations. A total of 7 043 cases of various types of liver transplantation were performed in the single center of the hospital (6 005 adult liver transplantations and 1 038 pediatric liver transplantations). Concerning adult liver transplantation, the cumulative 1-year, 3-year and 5-year survival rate from September 1998 to March 2003 were 83.1%, 73.0% and 69.0%, from April 2003 to March 2009 were 85.3%, 76.2% and 72.1% and from April 2009 to September 2018 were 87.5%, 79.2% and 75.1%, respectively. The cumulative 1-year, 3-year and 5-year survival rate for pediatric liver transplantation were 93.5%, 92.2% and 90.2%, respectively. The nucleoside (acid) analogue combined with low dose hepatitis B immunoglobulin (HBIG) was developed to prevent the recurrence of hepatitis B after liver transplantation, this plan has reduced the recurrence rate of hepatitis B and the 5-year re-infection rate of hepatitis B virus (HBV) after liver transplantation significantly. The risk assessment system for tumor recurrence after liver transplantation was established and individual treatment method was established based on this assessment system. Continuous exploration and improvement of liver transplantation for liver cancer, liver re-transplantation, liver transplantation with portal vein thrombosis, SLT, DLT and multi-organ combined transplantation have significantly improved the clinical efficacy of patients and the post-operative survival rate. The liver transplantation team of Tianjin First Center Hospital has carried out a scientific and technological exploration on the key problems and technical difficulties of clinical liver transplantation. This work strongly has initiated and promoted the rapid development of liver transplantation in China. The restrictive barrier of hepatitis B recurrence after liver transplantation has been overcome. The risk prevention and control system of tumor recurrence after liver transplantation has been established. A series of innovative achievements that can be popularized have been achieved in the field of complex liver transplantation and expansion of donor liver source. The iterative progress and sustainable development of liver transplantation have been realized.

Comparison of Patients With and Without Anterior Sector Venous Drainage in Right Lobe Liver Transplantation From Live Donors in Terms of Complications, Rejections, and Graft Survival: Single-Center Experience

AimThe issue of performing an anastomosis of the anterior sector veins to the vena cava in living donor liver transplantation is still controversial. We aimed to research whether there was any difference in terms of complications, rejections, and graft survival between patients with and without anterior sector venous drainage to the vena cava. Patients and MethodsPatients were retrospectively investigated for demographic data and ratio of graft needed to available graft weight. Donors had volumetric calculations and middle hepatic vein anterior sector drainage documented in detail. ResultsSeventy-three donors with middle hepatic vein drainage were included. Thirty-five had anterior sector venous drainage performed and 38 patients did not have drainage procedures performed. The incidence of general complications was higher in the group without anterior sector drainage (78.3% and P = .002). Biloma linked to bile leaks were observed in 8 patients without drainage (72.8%) and 3 patients with drainage (27.2%). Late acute rejection occurring during follow up after transplantation was identified in 28 patients (11.6%). Of these, 1 (14.3%) had anterior sector drainage and 6 (85.7%) were in the patient group without drainage (P = .067). ConclusionAs a result of this study, for patients with grafts at the volume limit (graft weight to receiver weight ratio <0.8) and with congestion observed in the anterior sector after liver implantation and for patients with outflow problems identified on Doppler ultrasonography, anterior sector veins >5 mm should definitely be drained into the vena cava. Hence, both complication and rejection rates will reduce, and we can lengthen the graft, and thus patient, survival.

Vascular reconstruction and outcomes of 220 adult-to-adult right lobe living donor liver transplantations

Rationale: Adult-to-adult right lobe living donor liver transplantation is a viable alternative to whole liver transplantation from a deceased donor. The key aspect of the surgical procedure is the restoration of adequate graft blood flow and maintenance of sufficient volume of well vascularized parenchyma in the donor. Specific features of vascular anatomy in the donor and the recipient can be eventual cause for significant technical difficulties during transplantation. They can also increase the risk of complications and deteriorate graft functioning.Aim: To identify the incidence of various types of afferent and efferent vascularization of right lobe of the liver, potential techniques of vascular reconstructive procedures, rates and types of postoperative complications, as well as immediate surgical results.Materials and methods: We retrospectively analyzed the data on 220 right lobe liver transplantations adult patients, consecutively performed from 2010 to 2017 in one center. Specific characteristics of liver vascularization in donors and recipients were determined by pre-operative computed tomography and intra-operatively. The information on the types of vascular reconstruction, complications and results of surgical procedures was obtained from patients' medical files.Results: The following variants of blood supply to the right liver lobe were seen most frequently: portal vein trifurcation 22%, shortened trunk of the right portal vein branch 13%, supplementary v. hepatica from SgVIII with a diameter of &gt; 5 mm 22%, supplementary lower right v. hepatica 17%, isolated venous outflow from all right lobe segments 2%, two arteries 2%. In addition, 17% of the recipients had portal vein thrombosis and 1% portal vein fibrosis. During the follow-up all donors remained alive. The rate of surgical complications was 12.5%, among them bile pocket or biloma 8.5%, intra-abdominal bleeding 2.5%, wound complications 1.5%. The rate of early post-operative complications in the recipients was 31.5%, with 4.5% of them being vascular and 15.5% biliary. The 6-months and 4-years survival of the recipients (Kaplan-Meier) was 98% and 95%, respectively.Conclusion: Immediate and longterm survival of the recipients of living donor right lobe live grafts, as well as absence of fatalities among their donors, confirm high effectiveness and expedience of this type of intervention. The observed anatomic variety of blood supply to the right liver lobe stipulates stringent requirements to the quality of preoperative diagnostics, deliberate donor selection, thorough planning of the procedure and high qualification of the surgical team. A relatively high rate of postoperative complications warrants the necessity of an intensive diagnostic monitoring in the early post-operative period and active strategies of their correction.

A retrospective analysis of re-exploration after living donor right lobe liver transplantation: incidence, causes, outcomes, and risk factors.

Despite technical difficulties, right lobe liver grafting is preferred in living donor liver transplantation because of the graft size. Re-exploration after living donor right lobe liver transplantation (LRLT) has never been separately analyzed. We aimed to analyze the incidence, causes, outcomes, and risk factors of re-exploration after LRLT. We reviewed medical records of 1016 LRLT recipients from October 2003 to July 2017 and identified recipients who underwent re-exploration within hospital stay. Separate analyses were also performed according to cause of re-exploration. The overall incidence of re-exploration was 17.0% (173/1016). The most common cause of re-exploration was bleeding (50%). Overall re-exploration was associated with clinical outcome, but different results were shown on analyses according to cause of re-exploration. Risk factors of re-exploration were underlying hepatocellular carcinoma and operative duration [Odds ratio (OR), 1.49; 95% confidence interval (CI), 1.05-2.12; P=0.03, and OR, 1.002; 95% CI, 1.001-1.004; P=0.0023, respectively]. Re-exploration after LRLT is relatively common, and is strongly associated with mortality and graft failure.

Two to tango – A case for dual lobe liver transplantation

Two to tango – A case for dual lobe liver transplantation

New Left Lobe Transplantation Procedure with Caval Reconstruction Using an Inverted Composite Graft for Chronic Budd-Chiari Syndrome in Living-Donor Liver Transplantation—A Case Report

When the Budd-Chiari syndrome (BCS) lesion extends to the inferior vena cava (IVC) or the orifices of the hepatic vein, the thickened IVC and/or hepatic vein wall must be removed and IVC reconstruction is required in living-donor liver transplantation (LDLT). In various reports about IVC resection in LDLT for BCS, there are none about left lobe liver transplantation with reconstruction of the retrohepatic IVC (rhIVC). To overcome removal and reconstruction of the rhIVC in LDLT for BCS, we introduced a composite IVC graft that is applicable to both right and left lobe partial liver grafts for LDLT for BCS. Pathogenic IVC was removed together with the native liver between the lower edge of the right atrium and 5 cm above the renal vein junction with the use of venovenous bypass. The e-polytetrafluoroethylene graft was anastomosed to the suprarenal intact IVC. Then the native part was detached at the level of just above the renal junction. The composite graft was inverted and a half rim of the native part of the graft was anastomosed to the posterior wall of the right atrium. Next, the common venous orifice of the left lobe graft was anastomosed to the wall defect which was composed of the anterior wall of the right atrium and the distal end of the native part of the composite graft. In conclusion, our inverted composite graft technique will overcome the weak points of LDLT for BCS, such as incomplete removal of the pathogenic caval wall and reconstruction of the rhIVC.

Clinical application of LDLT after reconstruction of IVC using artificial blood vessel in the treatment of HCC beyond Milan Criteria

Objective: To assess application of reconstruction of retrohepatic inferior vena cava using artificial blood vessel in right lobe living donor liver transplantation (LDLT) in the treatment of hepatocellular carcinoma (HCC) beyond Milan Criteria. Methods: The clinical data of 9 HCC patients who underwent right lobe liver transplantation after reconstruction of retrohepatic inferior vena cava using artificial blood vessel between June 2015 and Nov 2016 at Liver Transplantation Center of the First Affiliated Hospital of Nanjing Medical University were retrospectively analyzed. The liver of the patients was removed with retrohepatic inferior vena cava, and then the right donor graft was implanted by conventional orthotopic liver transplantation. Results: All 9 liver transplantations were performed successfully. The time of reconstruction of hepatic venous outflow of the donor graft was (22.6±3.0) min, anhepatic time was (45.0±7.1) min, and total operation time was (321.9±52.5) min. All patients recovered uneventfully, ICU and hospital stay day were (1.2±0.4) days and (18.4±3.0) days. 2 patients suffered from thrombosis of artificial blood vessel, one recovered after conservative treatment and another was treated by placement of vein stent. No abdominal/pulmonary infection and non-artificial blood vascular complications were found, and none died in perioperative period. Postoperative pathological results showed that all patients were hepatocellular carcinomas and vascular tumor thrombosis was found in 5 cases. All patients were follow up, 1 patient died of pulmonary and brain metastasis 10 months after operation. One patient survived with local recurrence of tumor in liver. The other patients had no tumor recurrence and metastasis. Conclusion: Replacement of retrohepatic inferior vena cava using artificial blood vessel in right lobe living donor liver transplantation is safe and feasible in the treatment of HCC beyond Milan Criteria, and might improve the resection rate of diseased liver and the prognosis of HCC patients after living donor liver transplantation.