Lobe Lobe Living Donor Liver Transplantation Research Articles

Current status of left lobe adult to adult living donor liver transplantation.

This review describes the history and current state of left lobe living donor liver transplantation (LDLT). The transplant community continues to face an organ shortage on a global scale, and the expansion of LDLT is attractive because it allows us to provide life-saving liver transplants to individuals without drawing from, or depending on, the limited deceased donor pool. Donor safety is paramount in LDLT, and for this reason, left lobe LDLT is particularly attractive because the donor is left with a larger remnant. This article reviews the donor and recipient evaluations for left lobe LDLT, discusses small for size syndrome and the importance of portal inflow modification, and reviews recipient outcomes in right lobe versus left lobe LDLT. Left lobe LDLT was the first adult-to-adult LDLT ever to be performed in Japan in 1993. Since that time, the use of both right and left lobe LDLT has expanded immensely. Recent work in left lobe LDLT has emphasized the need for inflow modification to reduce portal hyperperfusion and early graft dysfunction following transplant. Accumulating evidence suggests, however, that even though early graft dysfunction following LDLT may prolong hospitalization, it does not predict graft or patient survival.

Endoscopic treatment of biliary complications in left lobe living donor liver transplantation.

PurposeAlmost all of the publications regarding the treatment of biliary complications after liver transplantation are related to biliary complications after right lobe living donor liver transplantation (LDLT) and cadaveric liver transplantation (LT). The number of publications regarding endoscopic treatment of biliary complications after left lobe LDLT is negligible. In this study, we aimed to present the results of endoscopic treatments applied in the management of biliary complications developed in left-lobe duct-to-duct LDLT patients.Patients and methodsBetween 2008 and 2018, patients with duct-to-duct anastomosis who underwent ERCP due to biliary complication after left lobe LDLT were included in the study. Clinical data included patient demographics, indications for LDLT, duration till the first ERCP after LDLT, number of ERCP procedures, ERCP indications (stricture or leak), and treatment outcomes, including the need for percutaneous and surgical interventions.ResultsAmong 13 patients who underwent ERCP, 2 (15%) had biliary leakage and 11 (8%) had an anastomotic stricture. Our endoscopic success rate was 100% in patients with biliary stricture. Despite the implementation of ERCP on two patients with leakage, they died due to the biliary complication.ConclusionOur results suggest that endoscopic treatment methods are successful in the management of biliary stricture complication in patients with left lobe LDLT and duct-to-duct anastomosis. Although our findings show that endoscopic treatments fail when there is a leakage after left lobe LDLT, there is a need for further studies that include more patients to reach a definite conclusion.

Reconstruction of Anomalous Portal Venous Branching in Right Lobe Living Donor Liver Transplantation: Malatya Approach.

Reconstruction of anomalous portal vein branching (APVB) during right lobe living donor liver transplantation (LDLT) can be challenging. The goal of this article is to describe our surgical technique, named the Malatya Approach, in case of APVB during right lobe LDLT. The technique unifies the APVB and obtains a funnel-shaped common extension with a circumferential fence by a saphenous vein conduit. In total, 126 (10.6%) of 1192 right lobe grafts had APVB that were divided into 2 groups according to the adopted surgical techniques: the Malatya Approach group (n = 91) and the previously defined other techniques group (n = 35). Both groups were compared regarding portal vein thrombosis (PVT), postoperative 90-day mortality and survival. PVT developed in 3 patients (3.3%) in the Malatya Approach group and developed in 10 (28.6%) patients for the other group (P < 0.001). There were 8 (8.8%) 90-day mortalities in the Malatya Approach group (1 PVT related) and 15 patients (9 PVT related) died in the other techniques group (P < 0.001). Mean follow-up time for both groups was similar (999.1 days for the Malatya Approach group versus 1024.7 days for the other group; P = 0.47), but longterm survival in the Malatya Approach group was better than in the other group (84.6% versus 40%; P < 0.001). Multivariate analysis revealed that the Malatya Approach group showed less PVT development and longer survival (P < 0.001). This technique is promising to avoid PVT and mortalities in cases of APVB during right lobe LDLT. Liver Transplantation 23 751-761 2017 AASLD.

Three-dimensional computed tomography analysis of variations in the middle hepatic vein tributaries: proposed new classification

To evaluate the anatomical variations in the middle hepatic vein tributaries (V5/V8) for determining the reconstruction strategy in right lobe living donor liver transplantation (LDLT). The V5/V8 variations were examined in 268 patients and were classified into three and two types, respectively. The reconstruction rate (RR), patency rate (PR) and clinical outcomes were retrospectively evaluated in 46 right lobe LDLT cases. In terms of V5 variations, the RR and PR were significantly higher for type 2 than type 3 (82.6 vs. 44.4 % and 73.7 vs. 25.0 %, respectively). The alanine aminotransferase level on postoperative day (POD) 5 in the V5 patent group was significantly lower than in the occluded group (123 vs. 191 IU/dL). Regarding V8 variations, the RR and PR were significantly higher for type 1 than type 2 (44.4 vs. 17.6 % and 75.0 vs. 33.3 %, respectively). The aspartate aminotransferase level on POD 3 was significantly lower in the V8 patent group than in the occluded group (50 vs. 121 IU/dL). For right lobe grafts with single large V5 (type 2) or V8 (type 1) variations, reconstruction is necessary. Our new classification of the MHV tributaries is useful for determining the reconstruction strategy to use in right lobe LDLT.

Selective policy of inferior right hepatic vein reconstruction in right lobe living donor liver transplantation does not affect post-transplant graft outcomes

Background: Over a third of donors assessed for right lobe living donor liver transplantation (LDLT) have one or more significant inferior right hepatic veins (IRHV) contributing to the drainage of the right posterior sector. While some centres routinely reconstruct them in the recipient, we follow a selective policy of reconstruction of IRHV based on size of IRHV and extent of congestion in the graft.Aim: To compare the early outcomes of transplanting right lobe grafts without IRHV, with IRHV but not reconstructed and with IRHV which were reconstructed.Methods: Data of all adult right lobe living donor liver transplants (rl-LDLT) between Jan 2010 and August 2012 were analysed. Patients were classified as those receiving grafts without IRHV (wIRHV), grafts with IRHV which were not reconstructed (nIRHV) and grafts with IRHV which were reconstructed (rIRHV). Differences in early post-operative outcomes and incidence of complications were compared within the three groups. The statistical significance of the differences was evaluated using ANOVA.Results: Data from 51 rl-LDLT grafts were analysed. IRHV was demonstrated at donor surgery in 19 (37%) cases. Amongst these, the IRHV was reconstructed in 6 patients (11.7%) while it was ligated in the remaining 13 (25.5%) patients. There was no significant differences in recipient age, recipient BMI, MELD score, donor age, donor BMI, GRWR at surgery or cold ischemia times between the three groups. There was no significant difference in peak liver biochemical tests (peak AST, ALT, bilirubin), peak INR, prolonged ascites drainage, incidence of post-operative ‘small for size syndrome’, need for renal support, infections, hospital stay or mortality.Conclusion: A selective policy of IRHV reconstruction does not adversely affect post-operative graft outcomes in adult right lobe LDLT. Background: Over a third of donors assessed for right lobe living donor liver transplantation (LDLT) have one or more significant inferior right hepatic veins (IRHV) contributing to the drainage of the right posterior sector. While some centres routinely reconstruct them in the recipient, we follow a selective policy of reconstruction of IRHV based on size of IRHV and extent of congestion in the graft. Aim: To compare the early outcomes of transplanting right lobe grafts without IRHV, with IRHV but not reconstructed and with IRHV which were reconstructed. Methods: Data of all adult right lobe living donor liver transplants (rl-LDLT) between Jan 2010 and August 2012 were analysed. Patients were classified as those receiving grafts without IRHV (wIRHV), grafts with IRHV which were not reconstructed (nIRHV) and grafts with IRHV which were reconstructed (rIRHV). Differences in early post-operative outcomes and incidence of complications were compared within the three groups. The statistical significance of the differences was evaluated using ANOVA. Results: Data from 51 rl-LDLT grafts were analysed. IRHV was demonstrated at donor surgery in 19 (37%) cases. Amongst these, the IRHV was reconstructed in 6 patients (11.7%) while it was ligated in the remaining 13 (25.5%) patients. There was no significant differences in recipient age, recipient BMI, MELD score, donor age, donor BMI, GRWR at surgery or cold ischemia times between the three groups. There was no significant difference in peak liver biochemical tests (peak AST, ALT, bilirubin), peak INR, prolonged ascites drainage, incidence of post-operative ‘small for size syndrome’, need for renal support, infections, hospital stay or mortality. Conclusion: A selective policy of IRHV reconstruction does not adversely affect post-operative graft outcomes in adult right lobe LDLT.

Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation

Hepatic outflow block is one of the major complications leading to severe graft dysfunction after left lobe living donor liver transplantation (LDLT). Medical records of 46 recipients of a left lobe LDLT were reviewed. The method of outflow reconstruction and post-transplant morphological changes of hepatic veins were investigated. The subjects were followed up until September 2008, with a median follow-up period of 2.0 yr (range: 0.5-5.9 yr). There were no multiple outflow tracts to be reconstructed, and the median caliber of the single orifices with or without venoplasty was 32.0 mm. The difference between the angle of hepatic veins to the sagittal plane measured on computed tomography was calculated for pre-operative donors and post-operative recipients a month after LDLT. Both left and middle hepatic veins showed a significantly greater change in angle than the right hepatic vein. Both left and middle hepatic veins more frequently showed a nearly flat wave form on Doppler study one month after LDLT. In the 46 recipients of left lobe grafts, three developed outflow block (6.5%). The middle and left hepatic veins tend to distort and stretch during graft regeneration. These characteristics seem to be associated with outflow disturbances.

Initial Clinical Effect of Intraportal Insulin Administration on Liver Graft Regeneration in Adult Patients Underwent Living Donor Right Lobe Liver Transplantation

Objective Insulin is one factor responsible for hepatotrophic regeneration in animal models. This study assessed the clinical effects of intraportal administration of insulin on liver graft regeneration in adult patients undergoing right lobe living donor liver transplantation (LDLT). Methods Between July 2005 and September 2007, 19 right lobe LDLT adult recipients voluntarily received posttransplant intraportal insulin administration. The present study describes 15 patients without postoperative vascular and bile duct complications, with more than 1 month survival and with complete clinical data who were enrolled to receive intraportal insulin therapy (group I; n = 15). Another consecutive 15 right lobe LDLT adult recipients without any stimulation regeneration who met the same criteria were enrolled in as noninsulin therapy control group (group NI; n = 15). Group I recipients were treated postoperatively with intraportal insulin infusion, as follows. An 18-gauge catheter was inserted into right gastro-omental vein during surgery, to administer regular insulin just after the operation at the rate of 2 U/h for 1 week. Graft volume (GV) was measured by computed tomography on postoperative days (POD) 7 and 30. Liver functions and serum insulin levels were also measured at POD 7 and POD 30. The liver graft regeneration rate was defined as ratio of posttransplant GV/harvested GV and posttransplant graft-to-recipient weight ratio (GRWR)/operative GRWR. Results The rate defined as ratio of POD 7 GV/harvested GV among group I was significantly greater than that of group NI (186.07 ± 35.40% vs 160.61 ± 22.11%; P < .05). The rate defined as ratio of POD 7 GRWR/operation GRWR was also significantly higher in group I than group NI (178.95 ± 35.84% vs 156.56 ± 18.53%; P < .05), whereas there was no significant difference in terms of regeneration rates at 1 month post-LDLT. Intraportal insulin administration may significantly downregulate POD 7 total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels ( P < .05). These results suggested that intraportal insulin administration augmented liver regeneration during the first postoperative week by improving hepatic function in LDLT recipients.

Biliary Reconstruction in Right Lobe Living-Donor Liver Transplantation

To assess the incidence of biliary complications after right lobe living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy or Roux-en-Y choledochojejunostomy reconstruction. Biliary tract complications remain one of the most serious morbidities following liver transplantation. No large series has yet been carried out to compare the 2 techniques in LDLT. This study undertook a retrospective assessment of the relation between the method of biliary reconstruction used and the complications reported. Between February 1998 and June 2004, 321 patients received right lobe LDLT. Biliary reconstruction was achieved with Roux-en-Y choledochojejunostomy in 121 patients, duct-to-duct choledochocholedochostomy in 192 patients, and combined Roux-en-Y and duct-to-duct choledochocholedochostomy in 8 patients. The number of graft bile duct and anastomosis, mode of anastomosis, use of stent tube, and management of biliary complications were analyzed. The overall incidence of biliary complications was 24.0%. Univariate analysis revealed that hepatic artery complications, cytomegalovirus infections, and blood type incompatibility were significant risk factors for biliary complications. The respective incidence of biliary leakage and stricture were 12.4% and 8.3% for Roux-en-Y, and 4.7% and 26.6% for duct-to-duct reconstruction. Duct-to-duct choledochocholedochostomy showed a significantly lower incidence of leakage and a higher incidence of stricture; however, 74.5% of the stricture was managed with endoscopic treatment. The authors found an increase in the biliary stricture rate in the duct-to-duct choledochocholedochostomy group. Because of greater physiologic bilioenteric continuity, less incidence of leakage, and easy endoscopic access, duct-to-duct reconstruction represents a feasible technique in right lobe LDLT.

Approach to anatomic variations of the graft portal vein in right lobe living-donor liver transplantation.

Right lobe living-donor liver transplantation (LDLT) is often not attempted in donors with anomalous portal venous branching (APVB). The authors describe their experience with portal vein (PV) reconstruction in 17 cases of APVB in right lobe LDLT. From July 1997 to December 2001, 214 right liver LDLT were performed at the Asan Medical Center. Seventeen of the donors had APVB and successfully underwent right lobectomy. The APVB were type II (trifurcation) in nine cases, type III (independent posterior segmental branching from main PV trunk) in seven, and unclassified in one. All 17 donors and recipients are alive, with good liver function. In type II APVB, the donor PV branches were obtained with separate openings that were joined as a common orifice at the back table in two, with a discoid-patch single opening in four, and with one common opening in three. In type III APVB, the donor PV were divided with two openings in four and with a discoid-patch single opening in three. The discoid-patch defect in the remnant PV was repaired with a vein patchplasty in two donors and resected with end-to-end anastomosis in five. However, one donor developed portal vein thrombosis (PVT) that was managed successfully by re-exploration and insertion of a metallic vascular stent. Of the four type III APVB obtained with two separate PV openings, the first two liver grafts were each reconstructed as double PV anastomoses. One of them required re-exploration because of PVT. In the two succeeding cases, a Y-graft interposition technique using a cryopreserved cadaveric iliac vein or the recipient's own portal confluence was successfully applied. To minimize the risk of PVT in donors with APVB, discoid-patch excision followed by repair with vein patchplasty or segmental resection should be avoided. Individual division of the PV branches creating two separate openings instead is recommended. To decrease the recipient's risk of PVT, interposition Y-graft venous reconstruction at the back table is superior to double PV anastomoses.

Initial experience with right lobe living donor liver transplantation

THE feasibility of right lobe living donor liver transplantation (LDLT) has been demonstrated and its practice is gaining popularity. Although the supply of organs is not enough the world over, LDLT is probably more warranted in societies where cadaveric donation is severely restricted. Such is the situation in Taiwan with only 0.5 liver grafts available per million population per year (data from the Organ Donation Association, Taiwan). Whereas the left lateral segment is usually enough for pediatric recipients, a bigger graft would be required for larger pediatric or adult candidates to provide adequate functional mass. The Liver Transplant Program of the Chang Gung Memorial Hospital caters to both adult and pediatric recipients and its living donor program, which began in 1994, has thus far been limited to left lobe allografting. This report aims to describe an initial experience with right lobe LDLT in this institution, which is also the first of its kind in Taiwan. The recipient was a 17-year old male weighing 63 kg with end-stage liver cirrhosis secondary to Wilson’s disease who suffered frequent variceal bleeding. The donor was his 42-year-old father weighing 56 kg who was blood group identical. With the size discrepancy between father and son, a right lobe graft was the better option to provide a graft-recipient weight ratio of at least 1%. Preoperative imaging studies revealed complicated right lobe hepatic venous anatomy in the donor with two right hepatic veins (RHV), two middle hepatic veins (MHV), and two right inferior hepatic veins (RIHV). There were likewise two right hepatic ducts, one of them a right posterior segment duct draining into the left hepatic duct. An extended right lobectomy including the MHV was performed in the father and the operation lasted for 12 hours with a blood loss of 110 mL. The procedure was well tolerated and the donor was discharged on the seventh postoperative day without any complications. The graft weighed 798 g and the graft-recipient ratio was 1.3%. Graft implantation was done with preservation of the inferior vena cava (IVC) without crossclamping. Venoplastics of the two RHVs and two MHVs in the graft to create a single outflow orifice for each main hepatic vein was performed and anastomosed to the recipient RHV and common trunk of MHV and left hepatic vein (LHV), respectively. The smaller (3 mm) of the two RIHVs was ligated and the larger one (5 mm) was anastomosed to a separate venotomy on the IVC. Right-to-right portal vein and hepatic artery anastomoses were made. The two bile ducts were close to each other and anastomosed as one Roux-en-Y hepatodochojejunostomy. Graft function was good although massive ascites of up to 2 L/d persisted. The recipient had recurrent variceal bleeding 1 week posttransplant, which was successfully managed by band ligation. Biopsy-proven acute cellular rejection was diagnosed on the 19th day posttransplant and was effectively treated with three boluses of intravenous steroids. He was on cyclosporine-based triple drug immunosuppression. Hepatic outflow obstruction was suspected and suggested by Doppler ultrasound which revealed poorly detectable hepatic veins with velocities of 11 to 16 cm/sec and flat to borderline biphasic waveforms. The portal vein and hepatic artery exhibited good flow. Computed tomography showed congestion of segment 7 of the liver while longitudinal magnetic resonance imaging showed narrowing of the MHV anastomosis. Percutaneous venography with pressure studies demonstrated significant gradients across the RHV and MHV compatible with outflow obstruction. The RHV stricture was dilated by balloon angioplasty while the MHV stenosis was not corrected by dilatation alone. The narrowing was believed to be due to torsion and was corrected by deployment of a Wallstent metallic prosthesis (12 3 50 mm, Wallstent, Schneider, Switzerland). Pressure gradients dropped from 17 to 14 cmH2O and from 34 to 12 cmH2O in the RHV and MHV, respectively. Doppler ultrasound demonstrated a marked increase in flow velocities and a change from monophasic to biphasic waveforms in the hepatic veins after the interventional procedures. The ascites gradually decrease after venoangioplasty of the RHV and stenting of the MHV and the patient’s overall condition improved until discharge 1 month after the procedure. At 8 months posttransplant the patient continues to do well with normal liver function. The latest CT