Lobe Living Donor Liver Transplantation Research Articles

A Comparative Study of the Biliary Outcome in Roux-en-Y Hepaticojejunostomy versus Duct to Duct Biliary Anastomosis in Right Lobe Living Donor Liver Transplantation in Adults

Abstract Background Recently, liver transplantation settled to be a real breakthrough in surgery as the only curable treatment to deal with fatal liver diseases. Living donor liver transplantation (LDLT) is the only available option in Egypt owing to the inactive deceased donor program. Most of the patients indicated for LDLT do not have the luxury of having an ideal living donor although we have big families in Egypt. Surgeons of recipient’s operation should occupy refined surgical skills and experience to reduce the risk of complications. The incidence of biliary complications (BCs) ranges from 5.3% to 40.6%. Leaks occur in 0% to 21.9% while strictures occur in 3.7% to 25.3%. Duct-to-duct anastomosis (D2D) and hepaticojejunostomy (HJ) are the two most common techniques of bile duct anastomosis in LDLT. D2D is gaining popularity over HJ, because of shorter operative time, fewer septic complications, a better physiologic gastrointestinal function and rapid recovery beside easier endoscopic approach to the reconstructed biliary tract. Patients and Methods The current surgical methodology is a prospective study with nonrandomized convenient sampling that was conducted at Liver Transplantation Unit in Air Forces Specialized Hospital and Nasser Institute for Research and Treatment, Cairo, Egypt, between August 2019 to August 2021. During this study, 40 patients candidate for LDLT was divided into two groups according to type of biliary anastomosis, group A included 20 recipients who had stentless duct-to-duct biliary anastomosis compared to group B including 20 recipients underwent Roux-en-Y hepaticojejunostmy. Results A total of 40 recipients were divided into two equal groups according to biliary reocstruction into group A duct-to-duct biliary anastomosis, and group B Roux-en-Y hepaticojejunostmy. The incidence of biliary related complications was higher in group A reaching 30%, double that recorded in group B (15%, p = 0.262). Upon stratification of those complications, the incidence of biliary leakage was reversed being doubled in group B 10% versus 5% in group A (p = 0.553). After exclusion of seven mortalities (one in group A and 6 in group B) who did not complete the 6 months follow-up period necessary for complete observation of BAS, there was insignificant difference between the two groups. The overall mortality was 17.5% (7 out of 8 recipients), and all died from non-biliary complication related causes. The only recipient died from biliary sepsis following ERCP and stenting for BAS, was included in the results as he died after 5 months from the operation. In a trial to understand the relation between the biliary reconstruction and the complication rate (Table 8), we found that there was a higher frequency of complications in both 1x1 and 2x2 technique in group A (33% each). In contrast, all complication happened in group B was in 1x1 technique. In addition, we could not apply the statement that the higher the number of ducts the higher the rate of complications in the study as 2 ducts grafts represent 66.7% of complications in group A compared to 100% in single duct graft in group B. Conclusion BC is a bottleneck along the path of a successful LDLT as it is multifactorial making it impossible to specify a single predictable risk factor to avoid. The advantages of D2D over HJ; especially the beneficial use of ERCP in management of complications, are buffered by the higher incidence of biliary complication that is involved with D2D. Therefore, we think that surgeons should master both reconstruction techniques and weight the risk-and-benefit case by case.

Effects of Hepatic Artery Type And Number on Bile Complications in Right Lobe Living Donor Liver Transplant Recipients: Single Center Experience Without Hepatic Artery Thrombosis

Purpose: Hepatic artery provides blood supply to the biliary tract of the graft, one of the causes of the biliary complications that may occur in the post-transplant period may be the problems of the recipient's hepatic artery. We examined the effect of post-transplant biliary complications according to the type and number of recipient hepatic artery. Materials and Methods: One hundred eighty five patients older than 18 years of age who underwent right lobe LDLT for end-stage liver cirrhosis were included in the study. The recipient's right hepatic artery (RHA), left hepatic artery (LHA), propria hepatic artery (PHA) and common hepatic artery (CHA), which were anastomosed to the graft artery and double hepatic artery anastomoses formed of the right and left hepatic arteries, were examined. Biliary complications were analyzed statistically in terms of single or double artery anastomosis and anastomoses with the right or the other hepatic arteries. Results: There was no statistically significant difference between single and dual artery anastomoses in terms of bile duct stricture or leakage (p=0.767). No statistically significant difference was observed between RHA, LHA, PHA, CHA, and between single and dual arteries in the evaluation of artery selection between those with and without biliary tract complications (p=0.445) Conclusion: Hepatic artery type selection and number of the recipient does not change the biliary tract complication.

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.

Venous reconstruction using a round ligament-covered prosthetic vascular graft in right‑lobe living‑donor liver transplantation: a technical report.

To evaluate the short term-outcomes of venous reconstruction using a round ligament-covered prosthetic vascular graft and assess its effectiveness in the prevention of prosthetic vascular graft migration in right‑lobe living donor liver transplantation (LDLT). Thirty patients underwent reconstruction of the middle hepatic vein (MHV) tributaries during right lobe LDLT between January, 2021 and October, 2022. These patients were divided into the autologous vascular graft group (A group, n = 24) and the round ligament-covered prosthetic vascular graft group (RP group, n = 6). The computed tomography (CT) density ratio of the drainage area in the posterior segment of patent grafts was significantly higher in the RP group than in the A group (0.91 vs. 1.06, p = 0.0025). However, the patency rates of reconstructed MHV tributaries in the A and RP groups were 61% and 67%, respectively, with no significant difference between the groups (p = 0.72). Prosthetic vascular graft migration did not occur in the RP group. Venous reconstruction using round ligament-covered prosthetic vascular grafts is a feasible and simple method to prevent prosthetic vascular graft migration in right-lobe LDLT.

Blood flow reconstruction in portal vein anatomical variations in right lobe living donor liver transplantation

Background. Adequate restoration of blood flow through the portal vein in the graft is only possible with a clear understanding of its anatomy in the donor.The aim was to describe new and extend current data on the portal vein anatomy in a donor of the right liver lobe, to describe variants and formulate principles of portal reconstruction in right lobe living donor liver transplantation.Material and methods. 306 living donor liver transplantations were performed from 2009 to 2021 in the State Research Center – Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency. The vascular anatomy of 518 potential donors was analyzed. Portal vein variants of the anatomy of right lobe graft were assessed.Results. Nine types and 3 subtypes of portal vein branching were evaluated. A, B, C, D, E types match the types described earlier in Nakamura classification. Subtypes B1, B2 и D1 are specifications of types B and D. Types F, G, H, I have been described additionally. The incidence of types and subtypes where reconstruction was made: type A (82%), B (4.6%), B1 (3.9%), B2 (1.3%), C (3.9%), D (3.9%). The incidence of E, G, H, I types among 518 potential donors was 0.4%, 0.6%, 0.2%, 0.4%, respectively. The recipient portal vein complications were detected in 12 cases (3.9%), where 3(25%) were Class 3b according to Clavien-Dindo and 9(75%) of Clavien-Dindo Class 2. There were no correlations between portal vein complications and the method of portal vein reconstruction. (p<0.05). No complications occurred with portal vein in donors.Conclusion. The existing classification of right liver graft portal vein has been updated and detailed. A certain way of reconstruction has been proposed for each portal vein type. Anatomical types in which donation and transplantation are contraindicated have been specified.

Multiple Graft Bile Ducts Do Not Affect the Postoperative Outcomes of Right Lobe Living Donor Liver Transplantation

Multiple graft duct openings are associated with a high incidence of biliary complications (BCs), and biliary reconstruction for multiple graft bile ducts (BDs) remains a surgical challenge during living donor liver transplantation (LDLT). In particular, biliary reconstruction using "high biliary radicals (HBR)" of recipients for multiple graft BDs has a high probability of BCs. Herein, we analyzed outcomes by retrospectively reviewing 283 patients who underwent right lobe LDLT from January 2013 to September 2019. In total, 112 LDLT procedures using grafts with multiple BDs have been performed under our policies. In recent cases with 2 orifices located on the same hilar plate, we did dunking with a mucosal eversion technique instead of ductoplasty. When 2 orifices are located far apart on different hilar plates, we attempted to perform separate duct-to-duct anastomosis (DDA) using HBR of the recipient instead of hepaticojejunostomy. Among patients with multiple graft BDs, 20 underwent ductoplasty, 50 were treated using dunking with mucosal eversion technique, and 40 underwent separate DDA using HBR (HBR group). The incidence rates of biliary leakage and stricture were 8.9% and 10.7% in the multiple BD group, respectively, congruent with the outcomes of the single BD group. In subgroup analysis, we compared clinical outcomes between the HBR and single BD groups; the incidence of BCs in the HBR group was 15.0%, comparable to that of the single BD group. In conclusion, multiple graft BDs do not negatively impact the BC rate compared with single-graft BD when applying our technique to prevent BCs.

Thrombectomized autologous portal Y-graft inflow construction can be an option in living-donor liver transplantation: a case report

BackgroundIn living-donor liver transplantation (LDLT), portal Y-graft interposition using the recipient’s portal vein (PV) bifurcation has been used for right lobe grafts with double PV orifices. We herein report the use of thrombectomized autologous portal Y-graft interposition for a recipient with preoperative portal vein thrombosis (PVT) in a right lobe LDLT with double PV orifices.Case presentationThe recipient was a 54-year-old male with end-stage liver disease due to alcoholic liver cirrhosis. There was PV thrombus in the recipient’s PV. The living liver donor was his 53-year-old spouse, and a right lobe graft was planned for the transplantation. Since the donor's liver had a type III PV anomaly, autologous portal Y-graft interposition after thrombectomy was planned for PV reconstruction in the LDLT. The portal Y-graft was resected from the recipient and a thrombus extending from the main PV to the right PV branch was removed on the back table. The portal Y-graft was anastomosed to the anterior and posterior portal branches of the right lobe graft. Followed by venous reconstruction, the Y-graft was anastomosed to the recipient’s main PV. The operation time was 545 min and the intraoperative blood loss was 1355 ml. The recipient was discharged on postoperative day 13 without any complications. The recipient remains well with the patency of the portal Y-graft one year after the liver transplantation.ConclusionWe herein report the successful use of autologous portal Y-graft interposition after thrombectomy on the back table for a recipient with PVT in a right lobe LDLT.

Outflow Reconstruction in Right Lobe Living Donor Liver Transplant: Middle Hepatic Vein Reconstruction Versus Separate Tributaries to Inferior Vena Cava Anastomosis

In right lobe living donor liver transplant, proper reconstruction of the segment 5 vein and segment 8 vein is essential. Herein, we compared 2 different techniques for segment 5 vein reconstruction. This prospective nonrandomized study included all recipients of modified right lobe living donor liver transplant who had reconstruction of the segment 5 vein, with or without segment 8 veins, from October 2018 to October 2021. Patients were grouped into group A (classical technique) and group B (modified technique). For group A, the segment 5 (and segment 8, if present) vein was anastomosed in an end-to-side fashion to a polytetrafluoroethylene synthetic graft positioned parallel to the cut surface of the liver graft; then, during implant, its proximal end was anastomosed to recipient's middle hepatic or middle-left hepatic veins unified orifice. In group B (modified technique), the stumps of segment 5 (and segment 8 if present) were anastomosed in an end-to-end fashion to 2 different polytetrafluoroethylene grafts; then during implant, the other ends of the segment 5 grafts were anastomosed directly to the inferior vena cava. Postoperative segment 5 vein patency and graft recovery were compared. Forty patients were included: 22 in group A and 18 group B. There were no significant differences in the demographic data or characteristics of donors, grafts, and recipients between the groups. There was better patency in segment 5 synthetic grafts in group A at all time points compared with group B, but this difference was statistically significant only at 1 month (18 [81.8%] vs 9 [50%, respectively; P = .046).There was no statistically significant difference in the markers of graft recovery in both groups. Reconstruction of the segment 5 vein by polytetrafluoroethylene synthetic graft in a fashion to resemble the native middle hepatic vein in modified right lobe living donor liver transplant has better patency than anastomosis of the segment 5 vein in an end-to-end fashion to the synthetic graft and then to the inferior vena cava. Both techniques did not affect graft recovery.

Living donor liver transplant: A strategy to increase transplant access

Living donor liver transplant: A strategy to increase transplant access

Portal Vein Pull-Through Technique and Thrombectomy for Extensive Portal Vein Thrombosis

Herein, a different technique is presented describing complete dissection of the entire portal vein (PV), superior mesenteric vein (SMV), and splenic vein, thus enabling a complete thrombectomy without the risk of uncontrolled hemorrhage due to blind thrombectomy. In cases where a thrombectomy would not be an option because of extensive thrombosis involving the confluence of the PV and SMV, small branches of the SMV, including the inferior mesenteric vein, were divided. Both the SMV and splenic vein were encircled separately. Then, the side branches of the PV above the pancreas, left gastric vein on the left side, and superior pancreatoduodenal vein on the right side were divided. The lateral and posterior part of the PV were dissected within the pancreas both from above and below, allowing the main PV completely free from attachments. At this point, the splenic vein and SMV were clamped, and the main PV was divided above the pancreas and then pulled back through the pancreatic tunnel. The thrombus was easily dissected of the vein under direct visualization, and afterward the PV was redirected to its original position. Then, the liver transplant was carried out in a regular fashion. This technique was applied to 2 patients. The first was a 43-year-old man who underwent a right lobe living donor liver transplant because of hepatitis B virus-related cirrhosis. The patient is still alive and well with stable liver function after 15 years of follow-up. The second was a 69-year-old woman who underwent a right lobe living donor liver transplant because of hepatitis C virus and hepatocellular carcinoma. She survived the procedure and her liver function was entirely normal afterward. She died of pneumonia and sepsis 5 months after transplant. This technique enables complete dissection of the entire PV, SMV, and splenic vein. Thus, complete thrombectomy under direct visualization without the risk of uncontrolled hemorrhage can be performed.

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.

Left vs Right hepatic arterial inflow for right lobe living donor liver transplantation – A randomized control trial

Left vs Right hepatic arterial inflow for right lobe living donor liver transplantation – A randomized control trial

Is a Preservation Solution for Living Donor Liver Transplantation Needed? Adding a New Chapter in LDLT!

Background.Preservation solutions are required for organ viability in deceased donor liver transplantation (LT). However, their role in live donor LT (LDLT) has not been standardized.Methods.Eighty adult recipients who underwent right lobe LDLT at the Department of Liver Transplantation Surgery, Gambat, Pakistan, were studied. Based on shorter cold ischemia time and no back table reconstruction work, recipients were assigned to receive “no preservation solution” (cases/non–histidine-tryptophan-ketoglutarate group; n = 40) or “HTK group” (controls; n = 40). Early allograft dysfunction (bilirubin, transaminases, and international normalized ratio), postoperative complications (biliary and vascular), hospital stay, and 1-y survival were reported. The direct cost was also reported.Results.Demographics and clinical characteristics were comparable in the 2 groups. Comparing cases versus controls, mean bilirubin, alanine aminotransferase, aspartate aminotransferase, and international normalized ratio on postoperative day 7 were similar in the 2 groups. Five (12.5%) cases and 4 (10%) controls developed early allograft dysfunction (P = 0.72). Post-LT complications (biliary leak 2.5% in cases versus 0 in control), strictures (15% in cases versus 17.5% in controls), hepatic artery thrombosis (2.5% versus 00%)‚ and portal vein thrombosis (0 versus 2.5%) were comparable. Mean hospital stay (10.80 + 2.36 and 11.78 + 2.91 d) and 30 d mortality (2.5% versus 5%) were also comparable. Finally, 1-y survival based on Kaplan-Meier analysis was comparable in both groups (ie, 92.5%; non-HTK group versus 90%; HTK group) (P = 0.71). The direct cost of using a non-HTK–based approach was less than the HTK solution.Conclusion.In a selected cohort of right lobe LDLT recipients, preservation solutions can be avoided safely with comparable outcomes.

Technical Refinement to Prevent Hepatic Outflow Disturbance in Right Lobe Living Donor Liver Transplantation: The New Simplified One-Orifice Venoplasty Technique

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). This article introduces the evolution of our MHV reconstruction technique and the excellent outcomes of a new simplified one-orifice venoplasty. We compared clinical outcomes among 3 types of one-orifice techniques through a retrospective review of 378 recipients who underwent LDLT using a modified right lobe graft at our institution from January 2008 to December 2018; group I (n=34) received separate outflow reconstruction, group II (n=166) received the one-orifice technique to create a wider single outflow with patchwork, and group III (n=178) received the more simplified one-orifice technique in which neo-MHV was reconstructed into the right hepatic vein without patch venoplasty. Patient demographic characteristics did not differ significantly among the 3 groups, but cold ischemic time and operative time in groups II and III were significantly shorter than those in group I. Moreover, the early patency rates of MHV in groups II and III were higher than those in group I. In particular, group I received an MHV or right hepatic vein stenting more frequently than group II or III during the early posttransplant period. In conclusion, this new simplified one-orifice technique could be an effective method to overcome technical difficulties and the outflow disturbance during right lobe LDLT without complex benchwork to create a large outflow.

S1229 The Feasibility and Safety of Selected Liver Grafts Flushed With Cold Normal Saline (NS) and Comparison With Liver Grafts Flushed With Histidine-Tryptophan-Ketoglutarate Solution in Living Donor Liver Transplantation

Introduction: Preservation solutions are required for organ viability in deceased donor liver transplantation (LT). However, their role in live donor LT (LDLT) has not been standardized. The aim of this study is to compare the outcomes of selected liver grafts flushed with cold normal saline (NS) with Histidine-Tryptophan-Ketoglutarate (HTK) solution. Methods: One hundred consecutive adult recipients who underwent right lobe LDLT from February 2020 to December 2020 at Gambat, Pakistan were studied. Recipients were assigned to receive “no preservation solution” (cases/non-HTK group; n=50) based on shorter CIT & no back Table reconstruction work or “HTK group” (controls; n=50) requiring standard back Table reconstruction. Various outcomes, including early graft dysfunction (bilirubin, transaminases, and INR), postoperative complications (biliary & vascular), hospital stay, and one-year survival, were compared between the two groups. The direct cost was also reported. Results: Demographics and clinical characters were comparable in the two groups. Comparing cases vs. controls, mean bilirubin, ALT, AST, and INR on the 7thpostoperative day were similar in the two groups. 5(10%) cases and 4(8%) controls developed EAD(p=0.72). Post-LT complications (biliary leak 2% in cases vs. 0 in control), strictures (12% in cases vs. 16% in controls), hepatic artery thrombosis (4% vs. 2%) and portal vein thrombosis (0 vs. 2%) were equally distributed. Mean hospital stay (11.02 + 2.63 and 12.06 + 3.68 days) and 30-day mortality (8% vs 8%) were also comparable in two groups. Finally, 1-year survival (92% vs 90%) based on Kaplan-Meier analysis was also comparable (p-value:0.71). The cost of using a non-HTK-based approach was much lesser than the HTK solution. (Figure) Conclusion: To our knowledge, this is the first innovative report on avoiding preservative solutions in LDLT recipients. We found that EAD including liver function tests; post-operative complications (biliary and vascular), 30 days’ mortality, and 1-year survival were comparable in the two groups. We also found that avoiding the preservative solution has an impact on saving direct costs. (Table). In our study, the postoperative complications and the overall one-year survival rate in the non-preservation group (92%) and the HTK group (90%) were equal and matched with other studies from the region. From an economic perspective, we also found that avoiding the use of preservation solutions is very attractive.Figure 1.: Kaplan-Meier showing a comparable survival rate in non-HTK and HTK groups at 1-year post-liver transplantation Table 1. - Recipient demographics, clinical characteristics, laboratory values, and complications in study groups Recipient demographics, clinical characteristics, laboratory values, and complications in study groups. Variables non-HTK group (n=50) HTK group (n=50) p-value Recipients Age(years) 39.18+11.69 36.84+6.77 0.224 Gender 44(88%) 46 (92%) 0.741 Male 6(12%) 4 (08%) Female BMI(kg/m2) 22.46±4.29 22.84±4.24 0.657 Etiology Viral 47 (94%) 45 (90%) NASH 2 (04%) 1 (02%) Alcoholic 00 (00%) 00 (00%) Budd Chiari 00 (00%) 1 (02%) PBC 00 (00%) 1 (02%) Wilson 1 (02%) 1 (02%) PSC 00 (00%) 1 (02%) HCC 11 (22%) 02 (04%) 0.015 Co-Morbidities DM 4 (08%) 2 (04%) 0.67 HTN 00 (00%) 3 (06%) 0.24 CVD 00 (00%) 00 (00%) 0.00 CTP score 0.59 A 3 (06%) 1 (02%) B 9 (18%) 9 (18%) C 38 (76%) 40 (80%) MELD-Na 19.53±5.51 20.88±4.75 0.19 Operation time (min) 537±70.66 534.60±60.72 0.85 Blood loss(ml) 1622±317.70 1512±300.775 0.07 Hospital stays(days) 11.02±2.63 12.06±3.68 0.10 Mean Post-operative labs (at day 07) Total bilirubin (mg/dL)INR (IU/L)ALT (IU/L)AST (IU/L) 2.96 ± 2.97 3.06 ± 3.24 0.91 1.44 ± 0.24 1.39 ± 0.18 0.82 186.79 ± 144.95 137.69 ± 97.28 0.05 119.69 ± 133.45 93.78 ± 85.65 0.26 Complication EAD 4 (8%) 5(10%) 0.727 PNF 00 1 (2%) 0.315 ACR 3(6%) 4 (8%) 0.695 HAT 2 (4%) 1(2%) 0.558 Sepsis 5 (10%) 4 (8%) 0.727 PVT 00 1 (2%) 0.315 Biliary complicationsStrictureLeak 6 (12%)1 (2%) 8 (16%)00 0.5640.315 Clavin-dindo Grade>III 11 (22%) 13 (26%) 0.64 30-day Mortality 4 (8%) 4 (8%) 1.00 1-year mortality (excluding 1st month) 00 1 (2%) 0.315 BMI: body mass index; HCC: hepatocellular carcinoma; HTN: hypertension; CVD: cardiovascular disease; CTP: Child Turcotte Pugh; INR: international normalized ratio; ALT: alanine aminotransferase; AST: aspartate aminotransferase; EAD: early graft dysfunction; PNF: primary non-function; ACR: acute cellular rejection; HAT: hepatic artery thrombosis; PVT: portal vein thrombosis.

Right Lobe Versus Left Lobe Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Donor and Recipient Outcomes.

Living donor liver transplantation (LDLT) is an established treatment for advanced liver disease. Whether right lobe (RL) or left lobe (LL) LDLT provides the best outcomes for donors and recipients remains contentious. MedLine, Embase, PubMed, and Cochrane Central were searched to identify studies comparing RL- and LL-LDLT and reporting donor and/or recipient outcomes. Effect sizes were pooled using random-effect meta-analysis. Meta-regressions were used to explore heterogeneity. Sixty-seven studies were included. RL donors were more likely to experience major complications (relative risk [RR] = 1.63; 95% confidence interval [CI] = 1.30-2.05; I2 = 19%) than LL donors; however, no difference was observed in the risk of any biliary complication (RR = 1.41; 95% CI = 0.91-2.20; I2 = 59%), bile leaks (RR = 1.56; 95% CI = 0.97-2.51; I2 = 52%), biliary strictures (RR = 0.99; 95% CI = 0.43-1.88; I2 = 27%), or postoperative death (RR = 0.51; 95% CI = 0.25-1.05; I2 = 0%). Among recipients, the incidence of major complications (RR = 0.85; 95% CI = 0.68-1.06; I2 = 21%), biliary complications (RR = 1.10; 95% CI = 0.91-1.33; I2 = 8%), and vascular complications (RR = 0.79; 95% CI = 0.44-1.43; I2 = 0%) was similar. Although the rate of small for size syndrome (RR = 0.47; 95% CI = 0.30-0.74; I2 = 0%) and postoperative deaths (RR = 0.62; 95% CI = 0.44-0.87; I2 = 0%) was lower among RL-LDLT recipients, no differences were observed in long-term graft (hazard ratio = 0.87; 95% CI = 0.55-1.38; I2 = 74%) and overall survival (hazard ratio = 0.86; 95% CI = 0.60-1.22; I2 = 44%). LL donors experience fewer complications than RL donors, and LL-LDLT recipients had similar outcomes to RL-LDLT recipients. These findings suggest that LL-LDLT offers the best outcomes for living donors and similar outcomes for recipients when measures are taken to prevent small for size syndrome.

Artery Reconstruction in Right Lobe Living Donor Liver Transplantation: Donor-Recipient Vessel Ratio Is Key to Choosing Recipient Artery.

The aims of this study were to investigate if recipient artery choice in right lobe living donor liver transplant affects postoperative complications and discuss solutions accordingly. Three hundred fourteen right lobe living donor liver transplantation patients were divided into 2 groups: 163 patients using right hepatic artery as the recipient vessel and 151 patients using left hepatic artery as the recipient vessel. Cases involving 2 recipient blood vessels or the use of other blood vessels as recipient vessels were excluded. Overall vascular embolism rate in both groups was 1.3%, and our complication rate was lower than those in previous studies. There was no significant difference in complication rate between the groups, but a significant difference in recipient/donor artery size ratio was noted. Although left hepatic artery's anatomical position makes it less affected by bile duct anastomosis and thus fewer postoperative complications, we believe that the ratio of the donor-recipient blood vessel size and the length of the anastomosis vessel stumps are the key factors that affect the outcome of the vascular anastomosis.

Comparison of liver regeneration between donors and recipients after adult right lobe living-donor liver transplantation.

Living-donor liver transplantation (LDLT) is recognized as the standard treatment for end-stage liver diseases. The regeneration of the residual liver and graft after LDLT is important in evaluating surgical success. Previous studies have attempted to elucidate mechanisms, principles of liver regeneration after LDLT, or influencing factors. However, they have not ruled out patients with complications and reached a uniform conclusion. In this study, for the first time, we unified measurement methods of liver volumes and eliminated patients with complications to compare liver regeneration trends between donors and recipients after LDLT and search for potential influencing factors. A total of 61 donors and 62 recipients without complications after adult right lobe LDLT were included in this retrospective observational cohort study. The liver regeneration ratios (LRRs) at different time points in donors and recipients after LDLT were calculated and compared. Factors that affect LRRs include gender, age, graft with or without the middle hepatic vein (MHV), initial remnant liver (IRLV)/estimated standard liver volume (ESLV), initial graft volume (IGV)/ESLV, Child-Pugh grade, and model for end-stage liver disease (MELD) score of the recipients. Analysis of variance, independent-sample t-test, and correlation analysis were performed for statistical analyses. Significant differences were found in LRRs between the donors and recipients after LDLT (all P<0.05). The LRRs of donors at 0.5, 1, 3, and 6 months were 80.80%±24.12% (72.87%, 88.73%), 98.62%±37.47% (75.97%, 121.26%), 103.34%±23.47% (83.73%, 122.96%), and 130.18%±17.68% (102.04%, 158.32%), respectively. The LRRs of recipients at 0.5, 1, 3, and 6 months were 58.49%±26.67% (49.04%, 67.95%), 50.16%±27.25% (40.94%, 59.38%), 44.36%±26.75% (35.30%, 53.41%), and 31.19%±22.57% (20.91%, 41.47%), respectively. The former values were higher than the latter. The LRRs of recipients with the MHV was higher than those without MHV at 1 and 3 months (P<0.05). The LRRs at 1 month were 59.63%±27.48% and 41.68%±24.73%, and at 3 months were 57.25%±25.42% and 32.81%±22.79%, respectively. The IRLV/ESLV and IGV/ESLV were negatively correlated with LRRs at several times [r=-0.419 (-0.646, -0.134), -0.608 (-0.832, -0.318), respectively; P<0.05]. At 0.5 month, significant difference was found between Child-Pugh score of ≤9.55 and >9.55 (P<0.05) and MELD score of ≤14 and >14 (P<0.05). After LDLT, donors had more significant and faster liver regeneration than the recipients. Graft with or without MHV, initial liver volume, and preoperative liver function status of the recipients significantly affect liver regeneration.

Salvage Liver Transplant in the Treatment of a Child With Local Recurrence of Hepatoblastoma

Hepatoblastoma is the most common primary liver cancer of childhood, accounting for two-thirds of primary malignant hepatic neoplasms. Radical surgical removal combined with efficient chemotherapy is essential for cure. Despite a complete tumor resection, hepatoblastoma may recur as isolated local disease. Intrahepatic recurrence of hepatoblastoma after liver resection is among the indications for liver transplant. Here, we present a patient who underwent salvage liver transplant for the treatment of local recurrence of hepatoblastoma. A 13-year-old boy who was diagnosed with hepatocellular carcinoma arising from the left liver lobe and who had been treated with surgical resection was admitted to our outpatient oncology clinic for further evaluation because alpha-fetoprotein levels had started to increase after surgery. Histopathological reexamination of hemihepatectomy material showed a histological aspect of an epithelial hepatoblastoma. Magnetic resonance imaging revealed multifocal lesions in the right liver lobe compatible with local recurrence. Despite a favorable initial response to chemotherapy, the tumor showed progression with increased alpha-fetoprotein levels. The patient was deemed a viable candidate for an urgent liver transplant and underwent right lobe living donor liver transplant. He had excellent graft function without any complications or signs of malignancy in the last follow-up visit at 7 months posttransplant. Salvage liver transplant is a lifesaving and sometimes the only treatment option for patients with local recurrence of hepatoblastoma. Although transplant in the salvage setting has been associated with worse outcomes than primary transplant, recent data have indicated more favorable and acceptable outcomes. Further studies are warranted to better understand the role of salvage liver transplant in the treatment of hepatoblastoma. Early consultation with the liver transplant team is critical in children who are most likely to need extreme resection or liver transplant.

Vascular reconstruction and outcomes of adult-to-adult right lobe living donor liver transplantations: A single center experience in Vietnam

Vascular reconstruction and outcomes of adult-to-adult right lobe living donor liver transplantations: A single center experience in Vietnam