Right-lobe Grafts Research Articles

Left Lobe First With Purely Laparoscopic Approach: A Novel Strategy to Maximize Donor Safety in Adult Living Donor Liver Transplantation.

Evaluate outcome of left-lobe graft (LLG) first combined with purely laparoscopic donor hemihepatectomy (PLDH) as a strategy to minimize donor risk. An LLG first approach and a PLDH are 2 methods used to reduce surgical stress for donors in adult living donor liver transplantation (LDLT). But the risk associated with application LLG first combined with PLDH is not known. From 2012 to 2023, 186 adult LDLTs were performed with hemiliver grafts, procured by open surgery in 95 and PLDH in 91 cases. LLGs were considered first when graft-to-recipient weight ratio ≥0.6%. Following a 4-month adoption process, all donor hepatectomies, since December 2019, were performed laparoscopically. There was one intraoperative conversion to open (1%). Mean operative times were similar in laparoscopic and open cases (366 vs 371 minutes). PLDH provided shorter hospital stays, lower blood loss, and lower peak aspartate aminotransferase. Peak bilirubin was lower in LLG donors compared with right-lobe graft donors (1.4 vs 2.4 mg/dL, P < 0.01), and PLDH further improved the bilirubin levels in LLG donors (1.2 vs 1.6 mg/dL, P < 0.01). PLDH also afforded a low rate of early complications (Clavien-Dindo grade ≥ II, 8% vs 22%, P = 0.007) and late complications, including incisional hernia (0% vs 13.7%, P < 0.001), compared with open cases. LLG was more likely to have a single duct than a right-lobe graft (89% vs 60%, P < 0.01). Importantly, with the aggressive use of LLG in 47% of adult LDLT, favorable graft survival was achieved without any differences between the type of graft and surgical approach. The LLG first with PLDH approach minimizes surgical stress for donors in adult LDLT without compromising recipient outcomes. This strategy can lighten the burden for living donors, which could help expand the donor pool.

Multimodal Management for Refractory Biliary Stricture After Living Donor Liver Transplantation

Biliary stricture is a common complication of living donor liver transplantation (LDLT). Endoscopic retrograde biliary drainage (ERBD) is the primary treatment of biliary stricture, which is sometimes refractory. This study aimed to evaluate the risk factors for biliary stricture after LDLT and present successful management for refractory biliary stricture. Data from 26 patients who underwent LDLT were retrospectively analyzed. The relationship between the incidence of biliary strictures and clinical variables, including pre/intra/postoperative factors, was assessed. Univariate analysis showed that ABO incompatibility (P=.037) was a significant risk factor for biliary strictures. Case 1 was a 57-year-old woman who underwent LDLT using a left-lobe graft for primary biliary cholangitis (PBC) and developed a biliary stricture 1 month after surgery. Percutaneous transhepatic cholangiodrainage (PTCD) and embolization of the portal vein and hepatic artery were performed. Thereafter, ethanol was injected into the biliary duct, and the intervention was successfully completed. Case 2 was a 54-year-old woman who underwent LDLT using a right-lobe graft and duct-to-duct biliary reconstruction for PBC. Internal plastic stent insertion by ERBD was unsuccessful due to the significantly bending bile duct. After PTCD, the gun-site technique for the posterior branch and dual hepatic vascular embolization of the anterior branch was performed. The patient was followed up without an external fistula tube. ABO incompatibility was a risk factor for refractory biliary stricture. Appropriate procedures should be chosen based on stricture types.

Assessment of Liver Regeneration in Patients Who Have Undergone Living Donor Hepatectomy for Living Donor Liver Transplantation.

Inflammation and the associated immune pathways are among the most important factors in liver regeneration after living donor hepatectomy. Various biomarkers, especially liver function tests, are used to show liver regeneration. The aim of this study was to evaluate the course of liver regeneration following donor hepatectomy (LDH) by routine and regeneration-related biomarkers. Data from 63 living liver donors (LLDs) who underwent LDH in Inonu University Liver Transplant Institute were prospectively analyzed. Serum samples were obtained on the preoperative day and postoperative days (POD) 1, 3, 5, 10, and 21. Regenerative markers including alfa-fetoprotein (AFP), des carboxy prothrombin (DCP), ornithine decarboxylase (ODC), retinol-binding protein 4 (RBP4), and angiotensin-converting enzyme isotype II (ACEII) and liver function tests including alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP) and total bilirubin levels were all analyzed. The median age of the LLDs was 29.7 years and 28 LLDs were female. Eight LLDs developed postoperative complications requiring relaparotomy. The routine laboratory parameters including AST (<0.001), ALT (<0.001), ALP (<0.001), and total bilirubin (<0.001) showed a significant increase over time until postoperative day (POD) 3. For the regeneration-related parameters, except for the RBP4, all parameters including ACEII (p = 0.006), AFP (p = 0.002), DCP (p = 0.007), and ODC (p = 0.002) showed a significant increase in POD3. The regeneration parameters showed a different pattern of change. In right-lobe liver grafts, ACEII (p = 0.002), AFP (p = 0.035), and ODC (p = 0.001) showed a significant increase over time. DCP (p = 0.129) and RBP4 (p = 0.335) showed no significant changes in right-lobe liver grafts. Regenerative markers are increased in a sustained fashion following LDH. This is more prominent following right-lobe grafts which are indicative of progenitor-associated liver regeneration.

Association of Early Bifurcation of Hepatic Artery With Arterial Injury in Right-Sided Living-Donor Hepatectomy: Retrospective Analysis of 500 Cases.

The aim of this study was to explore the incidence of early bifurcation of the right hepatic artery (RHA) and the right posterior hepatic artery (RPHA), which is crucial in right lobe graft (RLG) and right posterior sector graft (RPSG) procurement for living-donor liver transplantation. Early bifurcation of the hepatic artery tends to induce oversight of one of the bifurcated arteries and its injury in RLG/RPSG procurement. Unrecognizable on conventional 3-dimensional (3-D) images, its significance is underestimated. We enrolled 500 patients who underwent preoperative imaging for scheduled surgeries at two major transplant centers. All-in-one 3-D images consisting of the hepatic artery, portal vein, and bile duct were constructed. Early bifurcation of the RHA and the RPHA was defined as the arteries bifurcating proximal to the cutting line of the right hepatic duct and the right posterior duct, respectively. Early bifurcation of the RHA was seen in 11.3% of cases of an infra-portal RPHA and in 46.0% of cases of a supraportal RPHA ( P < 0.001). Early bifurcation of the RPHA was encountered in 35.3% of cases of an infra-portal RPHA, in no cases of a supra-portal RPHA, and in 100% of cases in which the arteries to segment 6/7 arose individually from the RHA. The overall incidence of early bifurcation was 19.9% for RHA and 43.6% for RPHA. Early bifurcation of the RHA and the RPHA is frequently encountered and requires caution for RLG/RPSG procurement. Special attention should be paid to supraportal RPHA for RLG procurement.

Outflow augmentation in adult living donor liver transplantation

Background: There is a clear consensus on the paramount importance of optimal hepatic vein outflow in adult living donor liver transplantation (LDLT). We, herein, describe outflow augmentation technique in left lobe graft (LLG) and right lobe graft (RLG).

Back Table Preparation of the Right Lobe Live Donor Liver Allograft: A Crucial Part of the Adult Live Donor Liver Transplant Procedure

IntroductionWe aimed to describe our procedure for vascular reconstruction and back table bench preparation for the right lobe live donor allograft. Live donor liver transplantation (LDLT) remains an important option for the expansion of the donor pool. The procedure has been widely used, and its success is dependent on a technically perfect operation with appropriate inflow and outflow of the allograft. Adequate preparation of the right lobe (RL) allograft prior to implantation remains a vital part of the procedure. MethodsOur technique of back table vascular reconstruction of the RL allograft has been performed using a hepatic vein patch venoplasty, inferior hepatic vein inclusion, portal vein reconstruction, and segment V and VIII reconstruction for all of our LDLTs. ResultsBetween March 2009 and January 2020, 321 consecutive adult LDLTs were performed and underwent back table reconstruction with the techniques described. During that time period, no patients had hepatic insufficiency. There was a single thrombosis of a superior mesenteric vein (SMV) to PV jump conduit. ConclusionsOur technique of back table reconstruction of the LDLT right lobe graft remains a crucial part of the operative procedure. Our experience with RL grafts without middle hepatic vein (MHV) and our systematic approach for inflow and outflow reconstruction has yielded excellent results with no technical outflow issues and minimal inflow complications.

Accuracy and Efficiency of Right-Lobe Graft Weight Estimation Using Deep-Learning-Assisted CT Volumetry for Living-Donor Liver Transplantation.

CT volumetry (CTV) has been widely used for pre-operative graft weight (GW) estimation in living-donor liver transplantation (LDLT), and the use of a deep-learning algorithm (DLA) may further improve its efficiency. However, its accuracy has not been well determined. To evaluate the efficiency and accuracy of DLA-assisted CTV in GW estimation, we performed a retrospective study including 581 consecutive LDLT donors who donated a right-lobe graft. Right-lobe graft volume (GV) was measured on CT using the software implemented with the DLA for automated liver segmentation. In the development group (n = 207), a volume-to-weight conversion formula was constructed by linear regression analysis between the CTV-measured GV and the intraoperative GW. In the validation group (n = 374), the agreement between the estimated and measured GWs was assessed using the Bland–Altman 95% limit-of-agreement (LOA). The mean process time for GV measurement was 1.8 ± 0.6 min (range, 1.3–8.0 min). In the validation group, the GW was estimated using the volume-to-weight conversion formula (estimated GW [g] = 206.3 + 0.653 × CTV-measured GV [mL]), and the Bland–Altman 95% LOA between the estimated and measured GWs was −1.7% ± 17.1%. The DLA-assisted CT volumetry allows for time-efficient and accurate estimation of GW in LDLT.

Importance of reconstruction of middle hepatic vein tributaries of right-lobe grafts in living donor liver transplantation: demonstration of the reconstruction technique.

The aim of the present study on living donor liver transplantation (LDLT) using a right-lobe graft without the middle hepatic vein (MHV) was to investigate the clinical impact of MHV tributary reconstruction using our criteria and techniques. The medical records of 40 patients who underwent adult LDLT using a right-lobe graft without the MHV between April 2008 and December 2020 were retrospectively reviewed. In this cohort, the criterion for MHV tributary reconstruction was estimated drainage volume of each MHV tributary greater than 100mL. The drainage vein of segment 8(V8) was reconstructed as the common orifice of the right hepatic vein and V8 using a venous patch graft, and that of segment 5 was reconstructed using artificial vascular grafts. The outcomes were compared between the groups with and without MHV tributary reconstruction. Factors associated with postoperative massive ascites were also investigated. Twenty patients underwent MHV tributary reconstruction. There were no significant differences in the amount of postoperative ascites, Clavien-Dindo classification ≥ III postoperative complications, and 90-day in-hospital mortality between the groups (P = 0.678, P = 1.000, and P = 0.244, respectively). On multivariate analyses, a low-estimated functional graft-to-recipient weight ratio, which was calculated using estimated graft volume minus the territory of MHV tributaries that was not reconstructed, was identified as an independent predictor of postoperative massive ascites (odds ratio, 40.479; 95% confidence interval, 3.823-428.622). The present study suggests that selective MHV tributary reconstruction might be useful for achieving successful graft function.

ABO-Incompatible Living Donor Liver Transplantation With a Simplified Desensitization and Immunosuppression Protocol: A Single-Center Retrospective Study.

New desensitization strategies have made ABO-incompatible living donor liver transplant an attractive option for patients with end-stage liver disease. We aimed to report our experience with 20 consecutive patients who underwent ABO-incompatible living donor liver transplant using a simplified desensitization and immunosuppression regimen. We retrospectively analyzed 20 ABO-incompatible living donor liver transplant cases (August 2015 to July 2019). The ABO-incompatible living donor liver transplant protocol involved rituximab administration (375 mg/m2 body surface area) at 2 to 3 weeks before transplant, subsequent plasma exchanges (target isoagglutinin titer of ≤1:8), basiliximab administration (20 mg on day of surgery and on postoperative day 4), and intravenous immunoglobulin administration (2 g/day from day of surgery to postoperative day 7). No graft local infusion therapy or splenectomy was performed. The living donor liver transplant procedure involved a modified rightlobe graft(18 patients), a right posterior segment graft (1 patient), or a left lobe (1 patient). The most common reason for liver transplant was hepatitis B virus-associated liver cirrhosis (16 patients); 14 patients had hepatocellular carcinoma. The mean age was 55.4 ± 6.3 years, mean Model End-stage LiverDisease score was 14.7 ± 7.7, and mean graft-to-recipient weight ratio was 1.07 ± 0.2%. The median initial anti-ABO antibody titers were 1:16 forimmunoglobulin M (range, 1:2 to 1:256) and 1:48 for immunoglobulin G (range, 1:4 to 1:>2048). The median number of plasma exchanges was 2 (range, 0-12). No patients had biopsy-confirmed antibody-mediated rejection. No bacterial or fungal infections were observed. Biliary anastomotic stricture was observed in 9 patients. This ABO-incompatible living donor liver transplant protocol with rituximab, plasma exchange, low-dose intravenous immunoglobulin, and immunosuppression (equivalent to ABO-compatible living donor liver transplant) could be a safe and effective way to overcome antibody-mediated rejection and other complications.

Safe use of right lobe living donor livers with moderate steatosis in adult-to-adult living donor liver transplantation: a retrospective study.

Hepatic steatosis (HS) beyond a certain degree can jeopardize living donor (LD) safety, particularly in right lobe (RL) donors, making it a major obstacle for donor pool expansion in adult-to-adult living donor liver transplantation (ALDLT). From July 2004 to June 2016, 58 LDs donated their RLs despite having moderate HS (30%-50% steatosis) determined by intraoperative biopsy at a single center. We performed greedy matching to compare the outcomes of the donors and recipients of this group with those of LDs with no HS. The mean left lobe (LL) HS value in the 58 cases was 20.9±12.4%, which was significantly lower than the mean RL HS value (38.8±6.7%, P<0.001). The mean ratio of the remnant LL to the total liver volume was 37.8±2.2. No differences were observed in the postoperative liver function and donor and recipient morbidity and mortality rates. The liver regeneration rates in recipients and donors at 1month, 6months, and 1year postoperatively did not differ significantly. The patient and graft survival rates of the recipients showed no differences. The use of well-selected RL grafts with moderate steatosis does not impair graft function, recipient outcomes, or donor safety.

Reproducibility and reliability of computed tomography volumetry in estimation of the right-lobe graft weight in adult-to-adult living donor liver transplantation: Cantlie's line vs portal vein territorialization.

In living-donor liver transplantation (LDLT), liver volume assessment is a mandatory step in determining donor appropriateness. This study aimed to compare reliability and reproducibility between two major methods to define virtual hepatectomy plane, based on Cantlie's line (CTV-Cantlie) and portal vein territorialization (CTV-PVT) for right-lobe graft weight estimation in LDLT. A total of 188 donors who underwent preoperative CT scans were included. The liver was divided into right and left lobes using CTV-Cantlie and CTV-PTV measurements by two readers. Intraclass correlation coefficient (ICC) was used to determine interreader variability of hepatic weight measured using each CTV method. Intraoperative graft weight (IOW) was used as reference standard of right-lobe graft weight. Pearson correlation test was performed to determine correlation coefficients between presumed graft weight by each CTV method and IOW. Intraclass correlation coefficients for total liver weight were roughly equivalent between the two CTV methods (CTV-Cantlie: 0.965 [95% CI, 0.954-0.974], CTV-PVT: 0.977 [0.970-0.983]). However, ICCs of right-and left-lobe weights between two readers were higher with CTV-PVT (0.997 and 0.850) than with CTV-Cantlie (0.829 and 0.668). The IOW was 716.0±162.0g. Correlation coefficients between presumed graft weight by CTV-Cantlie or CTV-PVT and IOW were 0.722 and 0.807, respectively (both P<.001). For estimation of the right-lobe graft weight in LDLT, CTV-PVT may provide higher reliability and reproducibility than CTV-Cantlie.

Strategy for selective middle hepatic vein reconstruction in living donor liver transplantation using right lobe graft

Introduction: In living donor liver transplantation (LDLT) using right lobe(RL) graft, the standardized technique for procuring the graft does not include middle hepatic vein (MHV) trunk and is left to the donor side. This procedure may increase the congestion area in the graft after reperfusion. To overcome such difficulties, MHV reconstruction is widely being performed at the bench procedure. However in the basis of sufficient right hepatic vein territory(RHV) this procedure can be extravagant. The aim of this study is to verify the safety and feasibility of our policy for MHV reconstruction in LDLT using RL graft. Method: 153 LDLTs, using right hemiliver grafts were performed in a tertiary hospital from 2006 to 2016. Among them, 52 selected cases where MHV reconstruction was not performed were compared with 101 recipients who underwent LDLT using right lobe graft with MHV reconstruction. Both groups were compared regarding indications for reconstruction, short-term and long-term complications and operative details and outcomes Result: Two groups differed only in cold ischemic time (108.19 49.81 versus 146.37 58.74 minutes), preoperatively. Also, no statistical difference was seen, regarding short-term post-transplant outcomes and long-term overall and disease-free survival rates. After propensity score matching in both groups with and without MHV reconstruction to annihilate selection bias, two groups were comparable. Conclusion: We found that our selection criteria, whether to reconstruct MHV in LDLT, using right hemiliver graft is feasible and safe.

Liver volume regeneration after living donor liver transplantation (LD/LDLTx) depends on segmental perfusion

Background: The ability for liver volume regeneration after LD/LDLTx depends on liver morphology, function, perfusion and ischemia reperfusion injury. Methods: Donor and recipient, each n=42. Preoperative CT-volumetry in donors. Preoperative liverfunction test (LiMAx) for donor and recipient. LD: right hemihepatectomy (right-lobe graft, RLG). During LDLTx 3 liver biopsies were taken: 0-biopsy, from RL while ischemia and after reperfusion and stained with HMGB1. After LD and LDLTx on 2.POD LiMAx, on 10.POD and after 6 month (6M) CT-Volumetry and LiMAx were performed. Results: HMGB1-translocation, ischemia time and liver morphology were nearly same in all donors. Liver function in donors is restored on 10. POD (n=14), in recipients on 2. POD (n=14) and increased with 6M (n=10). Donor remnant liver gained after 6M to approx. 85% of total liver volume (n=12) an the RLG in recipients (adjusted to standard liver volume, SLV) gained to approx. 100% of SLV. Segmental volume regeneration (SVR) in RLG is mainly related to portal vein segments P7 and P8 and less P5. Regarding venous segments only perfusion region of right hepatic vein is gaining in contrast to more outflow obstructed perfusion areas of middle hepatic and inferior hepatic vein. In donors portal SVR takes place in P2 and P3, venous SVR occurs only via left hepatic vein. Conclusion: Liver volume regeneration maybe optimized by reduction of outflow obstruction respectively necessary hepatic vein reconstruction.

Doppler ultrasound follow-up of middle hepatic vein tributaries-interposition vessel graft in recipients of living donor liver transplantation using modified right lobe grafts.

To investigate the value of Doppler ultrasound (US) in recipients of living donor liver transplantation (LDLT) using modified right-lobe grafts (mRLGs) with obstruction of the middle hepatic vein tributaries (MHVTs)-interposition vessel graft (IVG). This study included 240 consecutive LDLT recipients in whom 564 MHVTs (>5 mm) were reconstructed using IVG. Regular follow-up Doppler US was performed to assess the patency of the MHVTs-IVG and, if there was an obstruction, to evaluate for the establishment of collateral drainage. MHVTs with obstruction were subdivided into those with and without intrahepatic veno-venous collaterals on Doppler US and were correlated with CT scans. MHVTs-IVG obstruction was identified in 137 patients with 227 MHVTs on follow-up Doppler US (6.2 ± 4.7 months). 90 patients with 149 MHVTs in whom the time interval between Doppler US and contrast-enhanced dynamic CT scans was<1 week were classified into either collateral (68 patients with 121 MHVTs) or non-collateral (22 patients with 28 MHVTs) groups. The presence of intrahepatic veno-venous collaterals on Doppler US were significantly related to no remarkable hepatic venous congestion on CT by both per-patient and per-vein analyses (66 of 68 patients (97.1%) and 118 of 121 MHVTs (97.5%), p < 0.001 andp < 0.001, respectively). On Doppler US follow-up of LDLT recipients using mRLGs, identification of intrahepatic veno-venous collaterals associated with obstruction of MHVTs-IVG suggests no remarkable hepatic venous congestion. Advances in knowledge: When an obstruction of a MHVTs-IVG is encountered on Doppler US follow-up of LDLT recipients using mRLGs, no further evaluation with CT is warranted if intrahepatic veno-venous collaterals are observed on Doppler US, as this finding suggests no remarkable hepatic congestion.

Accuracy of preoperative CT liver volumetry in living donor hepatectomy and its clinical implications.

An accurate preoperative volumetric assessment of donor liver is essential for successful living donor liver transplant by ensuring adequate remnant and graft recipient weight ratio (GRWR). The study cohort consisted of 744 right lobe (RL), 65 left lobe (LL) and 33 left lateral sector (LLS) grafts from July 2010 to January 2014. A semi-automated interactive commercial software called AW Volume share 6 was used for volumetry. Bland Altman plot was used for assessing the agreement between estimated graft weight (EGW) and actual graft weight (AGW). There was no statistically significant difference between EGW and AGW for RL graft weight (722±134 vs. 717±126 gm; P=0.06). Although Bland Altman graph showed that 95% limits of agreement was more in LL (-164 to +110) than RL (-156 to +147) and LLS grafts (-137 to +239), CT scan significantly overestimated LL graft weight (EGW =460±118 gm vs. AGW =433±102 gm; P=0.003) and underestimated LLS graft weight (EGW =203±48 gm vs. AGW =254±49 gm; P<0.001). CT volumetry overestimate LL graft and underestimate LLS graft weight. This should be factored in when selecting LL graft by taking higher GRWR.

Significance of Proper Graft Selection in Adult Living-Donor Liver Transplant Recipients with Preoperative Deteriorated Condition.

BACKGROUND The outcome of living-donor liver transplantation (LDLT) is poor for recipients with severely deteriorated preoperative condition. This study therefore evaluated the proper graft selection according to the recipients' preoperative condition. MATERIAL AND METHODS We evaluated the clinical outcomes in 66 patients who underwent adult LDLT from October 2003 to June 2016 in our institution, excluding fulminant liver failure and ABO-incompatible cases. Preoperative risk factors included MELD score >20, preoperative hospitalization for over 2 weeks or intensive care unit admission and bacterial infection within 1 month before LDLT. Patients were classified into those with 0-1 risk factors (Group LR, n=44) and those with 2-3 risk factors (Group HR, n=22). RESULTS The overall survival (OS) rate after LDLT was significantly lower in Group HR than in Group LR (1-year: HR 83.9% vs. LR 93%, 3-year: HR 70.8% vs. LR 90.5%, 5-year: HR 62% vs. LR 87.6%; p=0.029). In Group LR, OS rates did not differ significantly by graft type or donor age. In Group HR, OS rates at 1 (93.8% vs. 66.7%), 3 (85.2% vs. 50%), and 5 (75.8% vs.25%) years were significantly higher using right (n=16) vs. left (n=6) lobe grafts (p=0.046). CONCLUSIONS Proper graft selection is very important to improve the outcome of LDLT recipients in deteriorated preoperative condition. LDLT using right-lobe grafts may be recommended for high-risk severely deteriorated patients.

Estimation of Right-Lobe Graft Weight From Computed Tomographic Volumetry for Living Donor Liver Transplantation

BackgroundThe objective of the study was to establish a right-lobe graft weight (GW) estimation formula for living donor liver transplantation (LDLT) from right-lobe graft volume without veins (GVw/o_veins), including portal vein and hepatic vein measured by computed tomographic (CT) volumetry, and to compare its estimation accuracy with those of existing formulas. Right-lobe GW estimation formulas established with the use of graft volume with veins (GVw_veins) sacrifice accuracy because GW measured intra-operatively excludes the weight of blood in the veins. Right-lobe GW estimation formulas have been established with the use of right-lobe GVw/o_veins, but a more accurate formula must be developed. MethodsThe present study developed right-lobe GW estimation formulas based on GVw/o_veins as well as GVw_veins, using 40 cases of Korean donors: GW = 29.1 + 0.943 × GVw/o_veins (adjusted R2 = 0.94) and GW = 74.7 + 0.773 × GVw_veins (adjusted R2 = 0.87). The proposed GW estimation formulas were compared with existing GVw_veins- and GVw/o_veins-based models, using 43 cases additionally obtained from two medical centers for cross-validation. ResultsThe GVw/o_veins-based formula developed in the present study was most preferred (absolute error = 21.5 ± 16.5 g and percentage of absolute error = 3.0 ± 2.3%). ConclusionsThe GVw/o_veins-based formula is preferred to the GVw_veins-based formula in GW estimation. Accurate CT volumetry and alignment between planned and actual surgical cutting lines are crucial in the establishment of a better GW estimation formula.

Liver transplantation in Japan: Registry by the Japanese Liver Transplantation Society.

As of December 31, 2013, a total of 7474 liver transplants have been carried out at 66 institutions in Japan. This total included 7255 living-donor transplants and 219 deceased-donor transplants (216 from heart-beating donors and 3 from non-heart-beating donors). The annual total of liver transplants in 2013 decreased to 408, from 422 in 2012. The number of liver transplants from living donors decreased to 369, from 381, whereas the number of liver transplants from heart-beating deceased donors did not change significantly. The most frequent indication was cholestatic disease, followed by neoplastic disease. In terms of graft liver in living-donor cases, right-lobe graft was the most popular (36%). Patient survival following transplantations from heart-beating donors (1year, 85.9%; 3years, 82.6%; 5years, 81.3%; 10years, 73.8%) was similar to those from living donors (1year, 83.8%; 3years, 79.6%; 5years, 77.1%; 10years, 71.9%; 15years, 67.8%; 20years, 66.1%). Graft survival was very much the same as patient survival. As for ABO-incompatible transplantation, transplant period affected the outcome significantly, probably due to local infusion therapy and rituximab prophylaxis, which were introduced in many transplant centers after 2000 and 2004, respectively.

Feasibility and Midterm Results of Endovascular Treatment of Hepatic Artery Occlusion within 24 Hours after Living-Donor Liver Transplantation

PurposeTo evaluate the feasibility and midterm results of endovascular treatment of hepatic artery occlusion within 24 hours after living-donor liver transplantation (LDLT). Materials and MethodsFrom January 2012 to June 2014, 189 consecutive patients at a single institution underwent LDLT with right-lobe grafts. Among them, 10 were diagnosed with hepatic artery occlusion within 24 hours after LDLT. All 10 underwent endovascular treatment, including drug-eluting stent placement (n = 2), intraarterial thrombolysis (n = 5), or both (n = 3). Every patient received regular follow-up with multidetector computed tomography (CT). Data on primary technical success, primary and assisted primary patency, and biliary complications were analyzed. ResultsPrimary technical success was achieved in all 10 cases. Primary patency rates at 1 week, 3 months, and 6 months were all 70% (7 of 10), and the respective assisted primary patency rates were all 80% (8 of 10). Bleeding at the anastomotic site developed in 2 failed cases, prompting repeat liver transplantation. All 8 successfully recanalized cases showed hepatic artery patency on CT throughout follow-up (mean, 643.6 d; range, 236–1,081 d). Six of these cases had anastomotic biliary stricture, 4 of which were successfully treated by multisession biliary intervention. One patient had nonanastomotic biliary stricture and died of hepatic failure despite lifelong external drainage. ConclusionsEndovascular treatment could be an alternative therapeutic option for patients with hepatic artery occlusion within 24 hours after LDLT. It could help achieve long-term patency of the hepatic artery, but biliary stricture can potentially occur, and bleeding at the anastomotic site is a serious complication.

Graft selection strategy in adult-to-adult living donor liver transplantation: When both hemiliver grafts meet volumetric criteria.

To ensure donor safety in living donor liver transplantation (LDLT), the left and caudate lobe (LL) is the preferred graft choice. However, patient prognosis may still be poor even if graft volume (GV) selection criteria are met. Our aim was to evaluate the effects of right lobe (RL) donation when the LL graft selection criteria are met. Consecutive donors (n = 135) with preoperative LL graft volumetric GV/standard liver volume (SLV) of ≥35% and RL remnant of ≥35% were retrospectively studied. Patients were divided into 2 groups: LL graft and RL graft. Recipient's body surface area (BSA), Model for End-Stage Liver Disease (MELD) score, and the donor's age were higher in the RL group. The donor's BSA and preoperative volumetric GV/SLV of the LL graft were smaller in the RL group. The predicted score (calculated using data for graft size, donor age, MELD score, and the presence of portosystemic shunt, which correlated well with graft function and with 6-month graft survival) of the RL group, was significantly lower if the LL graft were used, but using the actual RL graft improved the score equal to that of the LL group. Six-month and 12-month graft survival rates did not differ between the 2 groups. In patients with a poor prognosis, a larger RL graft improved the predicted score and survival was equal to that of patients who received LL grafts. In conclusion, graft selection by GV, donor age, and recipient MELD score improves outcomes in LDLT. Liver Transplantation 22 914-922 2016 AASLD.