Right-lobe Liver Grafts Research Articles

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.

Results of Using the Cystic Duct for Reconstruction of One of the Multiple Bile Ducts in Right Lobe Living Donor Liver Transplantation

In right-lobe liver grafts, variations in the biliary tree anatomy can result in multiple bile duct orifices. We present our experience of 10 patients in which biliary reconstruction was performed with the cystic duct for 1 of the anastomoses with 2 separated ducts. Also, we investigated whether the bile duct anastomosis technique, number of bile duct anastomoses, and use of biliary stents affect the rate of biliary complications. We evaluated patients who underwent right-lobe living donor liver transplantation (LDLT) at İstinye University Hospital and İstanbul Aydın University Hospital between December 2017 and June 2020. The patients were divided into 4 groups: duct-to-duct (D-D), duct-to-sheath, double duct-to-duct, and duct-to-duct plus cystic duct-to-duct. Biliary complication rates were compared among these 4 groups, between single- and double-duct groups, and between stent (+) and stent (-) groups. Ninety-three patients who underwent right-lobe LDLT (60 men, 33 women) with a mean age of 51 ± 13 years were included. Mean follow-up time was 18.5 ± 8.3 months. The overall biliary complication rate was 17.2% for all patients, 12.1% for the D-D (single-duct) group (33 patients), 16.1% for the duct-to-sheath group (31 patients), 26.3% for the double duct-to-duct group (19 patients), 20% for the duct-to-duct plus cystic duct-to-duct group (10 patients), 20% for the double-duct group (60 patients), 14.5% for the stent (+) group (69 patients), and 25% for the stent (-) group (24 patients). There were no significant differences among these groups in terms of biliary complication rates. Bile stricture occurred in only 1 cystic duct anastomosis (10%), and no bile leakage was observed. Multiple D-D biliary reconstruction using the cystic duct with external drainage tubes is feasible and safe for LDLT.

Utility of Polyethylene Terephthalate (Dacron) Vascular Grafts for Venous Outflow Reconstruction in Living-Donor Liver Transplantations

BackgroundVenous outflow reconstruction of modified right-lobe liver grafts has been shown to prevent the occurrence of graft congestion and subsequent complications, including graft loss. In the present study, we aimed to investigate the safety and efficacy of Dacron grafts for venous reconstruction in living donor liver transplantation (LDLT). MethodsBetween January 2016 and January 2018, Dacron grafts were used in 148 liver transplants. Of these, 104 patients who had a follow-up computerized tomography (CT) scan were enrolled into the study. A total of 179 outflow hepatic veins including V5, V8, partial middle hepatic vein, and accessory inferior right hepatic veins (IRHV) were reconstructed using synthetic Dacron grafts. Graft patency was evaluated with both intraoperative Doppler ultrasonography following reconstruction, and a follow-up CT was performed on the postoperative day 7 (±1). Retrospective data collection included demographics, parameters for small-for-size (laboratory tests [bilirubin, International Normalized Ratio] and ascites) syndrome, postoperative morbidity, and mortality. ResultsFollow-up CT revealed graft patency in 155 out of 179 (86.6%) vascular grafts. Postoperative seventh-day patency rates for each reconstructed vein were as follows: V5, 87.5% (70/80); V8, 87.7% (50/57); partial middle hepatic vein, 100% (11/11); and IRHV, 77.4% (24/31). No major graft-related complications (early graft dysfunction, graft infection) or graft-related mortality were observed. None of the recipients developed small-for-size syndrome based on laboratory tests and clinical findings. ConclusionsDacron vascular grafts appear as an advantageous and useful alternative for venous outflow reconstruction in LDLT.

Readdressing the Middle Hepatic Vein in Right Lobe Liver Donation: Triangle of Safety

For equipoising donor safety and optimal recipient outcomes, we adopted an algorithmic "triangle of safety" approach to retrieve 3 types of right lobe liver grafts (RLGs), namely, the modified extended right lobe graft (MERLG), the partial right lobe graft (PRLG), and the modified right lobe graft (MRLG). Reconstruction to achieve a single wide anterior sector outflow was ensured in all patients. We present donor and recipient outcomes based on our approach in 665 right lobe (RL) living donor liver transplantations (LDLTs) performed from January 2013 to August 2015. There were 347 patients who received a MERLG, 117 who received a PRLG, and 201 who received a MRLG. A right lobe graft (RLG) with a middle hepatic vein was retrieved only in 3 out of 18 donors with steatosis >10%. Cold ischemia time was significantly more and remnant volume was less in the MRLG group. Of the donors, 29.3% had complications (26% Clavien-Dindo grade I, II) with no statistically significant difference among the groups. The Model for End-Stage Liver Disease score was higher in the MERLG group. There were 34 out of 39 with a graft-to-recipient weight ratio (GRWR) of <0.7% who received a MERLG with inflow modulation. Out of 4 patients who developed small-for-size syndrome in this group, 2 died. The 90-day patient survival rate was similar among different GRWRs and types of RLG. In conclusion, a selective and tailored approach for RL donor hepatectomy based on optimal functional volume and metabolic demands not only addresses the key issue of double equipoise in LDLT but also creates a safe path for extending the limits.

Donor BMI >30 Is Not a Contraindication for Live Liver Donation.

The increased prevalence of obesity worldwide threatens the pool of living liver donors. Although the negative effects of graft steatosis on liver donation and transplantation are well known, the impact of obesity in the absence of hepatic steatosis on outcome of living donor liver transplantation (LDLT) is unknown. Consequently, we compared the outcome of LDLT using donors with BMI <30 versus donors with BMI ≥30. Between April 2000 and May 2014, 105 patients received a right-lobe liver graft from donors with BMI ≥30, whereas 364 recipients were transplanted with grafts from donors with BMI <30. Liver steatosis >10% was excluded in all donors with BMI >30 by imaging and liver biopsies. None of the donors had any other comorbidity. Donors with BMI <30 versus ≥30had similar postoperative complication rates (Dindo-Clavien ≥3b: 2% vs. 3%; p=0.71) and lengths of hospital stay (6 vs. 6 days; p=0.13). Recipient graft function, assessed by posttransplant peak serum bilirubin and international normalized ratio was identical. Furthermore, no difference was observed in recipient complication rates (Dindo-Clavien ≥3b: 25% vs. 20%; p=0.3) or lengths of hospital stay between groups. We concluded that donors with BMI ≥30, in the absence of graft steatosis, are not contraindicated for LDLT.

Predictors of Biliary Leakage After T-Tube Removal in Living Donor Liver Transplantation Recipients

BackgroundBiliary leakage after T-tube removal is a frequent cause of morbidity in liver transplant recipients. The aim of this study was to determine the factors that predict the development of biliary leakage after T-tube removal in living donor liver transplantation (LDLT) recipients. MethodsOf the 144 patients who underwent LDLT with right-lobe liver grafts during the period January 2007 to May 2013 at a single medical center, 40 received biliary anastomosis with T-tube placement. Subjects were grouped into either a biliary leakage or non-biliary leakage group on the basis of the presence or absence of abdominal symptoms associated with signs of peritoneal irritation after T-tube removal. Recipient, graft, operative, and postoperative factors were included in a forward, stepwise multiple logistic regression model to identify the most important risk factors for biliary leakage after T-tube removal. ResultsBiliary leakage developed in 9 (22.5%) patients after T-tube removal. Risk factors associated with biliary leakage included the number of abdominal surgeries performed [odds ratio (OR) = 12.6, 95% confidence interval (CI): 2.1–20.4] and duration of T-tube placement (OR = 6.9, 95% CI: 1.2–10.7). ConclusionsBiliary leakage after T-tube removal is associated with significant morbidity in LDLT recipients. We suggest that T-tube placement be used sparingly in LDLT biliary reconstruction. When used, a T-tube should not be removed earlier than 8 months after placement, especially in recipients who have received primary abdominal surgery.

Segmental regeneration in right‐lobe liver grafts in adult living donor liver transplant

Our aim is to evaluate the relationship and impact of right-lobe (RL) liver grafts procured with or without the middle hepatic vein (MHV) trunk and MHV tributary reconstruction on segmental regeneration of these grafts in adult living donor liver transplantation (ALDLT). Patients underwent primary ALDLT using a RL liver graft were divided into three groups according to graft type: with MHV tributary reconstruction (group I), without MHV tributary reconstruction (group II), and with inclusion of the MHV trunk (group III). The overall graft volume and the volumes of the anterior and posterior segments of the grafts six months post-transplant, evaluated using computed tomography, were calculated as the regeneration indices. Optimal regeneration of the RL liver graft was achieved in the three groups of patients. There was no significant difference in the regeneration indices between groups I (149.4%) and III (143.6%). However, in group II (112.4%) without MHV or tributary reconstruction, the anterior regenerative index was lower than the other two groups and exhibited transient prolonged hyperbilirubinemia. Segmental graft regeneration is maximized by adequate venous drainage. Inclusion of the MHV trunk or MHV tributary reconstruction influences segmental liver regeneration and preclude transient hyperbilirubinemia in the early post-liver transplant phase.

Hemodynamic alterations in anterior segment of liver graft after right-lobe living-donor liver transplantation: computed tomography perfusion imaging findings

To identify hemodynamic alterations in anterior segment of liver graft after living-donor liver transplantation (LDLT) using CT perfusion imaging. Perfusion images of 19 recipients 4 weeks after LDLT without reconstruction of the middle hepatic vein (MHV) tributaries were retrospectively identified. According to major MHV tributaries diameter in the right lobe graft, recipients were divided into large (≥ 5 mm) and small size groups (<5 mm). Blood flow (BF), blood volume (BV), and mean transit time (MTT) of anterior and posterior segments were calculated. In large size group, significantly decreased BF (66.98 ± 15.79 mL/min/100 g, corresponded to 37.08%), BV (8.27 ± 2.29 mL/100 g, 41.71%), and increased MTT (11.79 ± 2.10 s, 23.71%) were detected in the anterior segment compared to the posterior segment. In small size group, compared to the posterior segment, BF, BV in the anterior segment decreased 19.12%, 18.48%, respectively, and MTT increased 6.78%, where decreased BF (86.40 ± 21.39 mL/min/100 g) and BV (11.50 ± 2.59 mL/min/100 g) reached statistical significance. Perfusion imbalance in large size group was more remarkable than those in small size group. CT liver perfusion imaging enabled quantification of hemodynamic alterations in right-lobe liver graft after LDLT. Compared to small ones, ligation of large MHV tributaries could bring about more marked perfusion imbalance between anterior and posterior segments.

The Use of Recipient Superficial Femoral Vein as a Venous Graft for Portal Vein Reconstruction in Right Lobe Living Donor Liver Transplantation

In living donor liver transplantation (LDLT), portal vein thrombosis (PVT) in the recipient is frequently regarded as a contraindication. To reconstruct the PV of a right-lobe liver graft (RLG) using an interposition or jump graft from the splenomesenteric junction, various vein grafts and technical modifications have been introduced. The internal jugular, external iliac, or great saphenous veins have been utilized in such reconstructive procedures. However, the superficial femoral vein (SFV) is preferable to the autologous vein grafts in terms of caliber, wall thickness, and length. We employed the recipient SFV to reconstruct PVT among 40 adult LDLT using RLG. Thirty-three were reconstructed by single end-to-end anastomosis with the right or left recipient PV. Three patients were transplanted with a RLG using 2 separated PVs reconstructed by double anastomoses with both the right and left PVs of the recipient. The remaining 4 patients required venous grafting for portal reconstruction. We used the recipient SFV as an interposition or jump graft from the splenomesenteric junction to the graft PV. There were 2 cases of anastomotic PV stenosis; 1 in portal reconstruction without a venous graft and the other with a SFV graft. Both were treated successfully by balloon angioplasty. The recipient SFV is an excellent size match for the PV reconstruction as a long interposition or jump conduit when the venous system from the deceased donor is not available. The indication for LDLT in patients with complete PVT should be carefully decided before transplantation in terms of portal reconstruction.

Efficacy of Right Anterior Sector Drainage Reconstruction in Right-Lobe Live-Donor Transplantation

Background Without including the middle hepatic vein (MHV) into right-lobe grafts, venous drainage of the anterior segment (AS) has always been a concern. The efficacy and the necessity of additional venous reconstruction in the AS for graft viability and function are still controversial. Methods Since February 2002, 57 right-lobe grafts were implanted into adult recipients. The mean graft to ideal recipient weight ratio (GRWR) was 1.3% (minimum: 0.8%, maximum 2.1%). All minor venous tributaries to the MHV less than 5 mm in diameter were ligated. The management of MHV tributaries was categorized into three groups: (A) no major tributaries (n = 33); (B) major tributaries ligated (n = 11); and (C) major tributaries reconstructed (n = 13). Reconstructions were established using vascular grafts (PTF, n = 8; cadaveric, n = 2) or joining with right hepatic vein orifice (n = 6). The groups were homogenous in age, gender, MELD (17 ± 6, 16 ± 4, 18 ± 7), graft weight (817 ± 181, 838 ± 152, and 855 ± 159 g), and graft/ideal liver weight ratio (0.54 ± 0.12, 0.57 ± 0.13, and 0.57 ± 0.1, respectively). We investigated the volume of ascites, serum bilirubin, albumin, and liver enzyme levels and INR on postoperative day 4 (POD4) and POD21. Results Two patients died of MRSA sepsis on POD18 and POD23 (MELD: 24 and 28) after initial graft function. Their graft weights were 800 g and 980 g, and their volumes were 47% (group B) and 62% (group A) of the ideal liver mass of the recipients, respectively. One PTF and another cadaveric vascular graft were found occluded 4 and 7 days after implantation without any negative consequence. At 6-month follow-up, the remaining 55 patients were alive with primary liver grafts. Vascular reconstructions were patent except for 2 early occlusions. Among the 3 groups, no significant difference was found on POD4. Three weeks after transplantation, the mean AST level in the major ligation group (46.7 ± 8.14) was significantly higher than in the minor ligatation group (29.6 ± 8.6) but not in the major reconstruction group (33.7 ± 3.7; P = .03 and P = .29). The mean albumin level was highest after minor ligation (3.2 ± 0.18), which was significantly better than the major reconstruction (2.7 ± 0.1) but not the major ligation (3.1 ± 0.14) cohorts ( P = .02 and P = .13). Conclusions In this study of a limited number of cases, right-lobe liver grafts with GRWR of ≥1.1% displayed optimal graft function without additional venous reconstruction to the AS.

Impact of venous drainage on regeneration of the anterior segment of right living‐related liver grafts

The effect of additional venous reconstruction on morphologic and functional regeneration of the anterior segment of right-lobe liver grafts was compared among three groups according to graft type: right liver graft without the middle hepatic vein (MHV) or MHV tributaries (n=7), with MHV tributaries (n=25) and with the MHV (n=10). Whole graft volume (GV) and anterior segment volume (ASV) were estimated from CT scans and post-operative laboratory data and daily ascitic fluid volume were examined. Peak GV in each group was reached two or three wk after surgery. The ASV/GV ratios of the grafts with the MHV or MHV tributaries were higher than those of grafts without additional venous reconstruction. However, the asparate aminotransferase and ascitic fluid volume values in the group that received grafts with MHV tributaries were higher than in the group that received grafts with the MHV in the same period. Although rapid enlargement of the anterior segment of right-lobe grafts with MHV tributaries occurred in the early post-operative period, complete functional liver regeneration may not occur even after additional tributary reconstruction. These results suggest that the selection of right-lobe grafts with the MHV is more beneficial for recipients, as long as donor safety is protected and that as many MHV tributaries as possible should be reconstructed in right-lobe grafts without MHV.

Adult-to-adult live-donor liver transplantation: the current status

Adult-to-adult live-donor liver transplantation (ALDLT) has emerged successfully to partially relieve the refractory shortage of deceased donor grafts caused by the increasing demands of patients with endstage liver diseases. Following the first successful live-donor liver transplantation (LDLT) for a child with biliary atresia in 1989, further extension of the technique, using left-lobe liver grafts for LDLT for large adolescents and adults, has resulted in satisfactory graft and patient survival outcomes. However, small-for-size syndrome may occur in some patients with large body size, and in those with acute-on-chronic liver failure or severe portal hypertension. To overcome the problem of graft-to-body-size mismatch, ALDLT, using a right-lobe liver graft was developed. Although routine inclusion of the middle hepatic vein (MHV) in the right-lobe liver graft is still controversial, the importance of providing good venous drainage for the right anterior sector to ensure better early graft function has gained wide recognition. Preservation of the MHV in the donor is intuitively considered important in reducing the donor risk. However, there are scarce data supporting the contention that postoperative complication is related to the absence of the MHV in the left-liver remnant. Duct-to-duct biliary reconstruction has potential advantages over hepaticojejunostomy, and has become the preferred technique in ALDLT. However, biliary complications, especially biliary strictures on long-term follow-up, occur in about 30% of the recipients. The potential beneficial effect of internal or external biliary drainage in reducing the biliary complication rate after duct-to-duct biliary reconstruction in ALDLT also remains controversial. Dual-liver grafts and right-posterior sector grafts have been used in ALDLT, and are reported to result in satisfactory survival outcomes at selected transplant centers. There is no strong evidence supporting the postulate that patients with hepatitis C infection have an inferior survival outcome after ALDLT when compared with recipients of a deceased-donor liver transplant. ALDLT has contributed to satisfactory survival outcomes in patients with hepatocellular carcinoma (HCC). It allows early surgery for the patients and eliminates the uncertainty of prolonged waiting for a deceased-donor liver graft, and the risks of dropout related to disease progression. The exact selection criteria of patients with HCC for ALDLT have yet to be defined.

Fatal Pneumonia Caused by Panton-Valentine Leucocidine-Positive Methicillin-Resistant Staphylococcus aureus (PVL-MRSA) Transmitted from a Healthy Donor in Living-Donor Liver Transplantation

Severe infections are the most dangerous complications in liver transplantation and their prevention is one of the major goals. A 60-year-old Saudi-Arabian female with decompensated hepatitis C liver cirrhosis received a right-lobe liver graft from her healthy daughter. After 9 days, the patient developed a rapidly progressive necrotizing pneumonia that was fatal in spite of extracorporal lung assist. The pneumonia was due to a Panton-Valentine Leucocidine-positive (PVL) methicillin-resistant Staphylococcus aureus (MRSA), or "community-acquired" MRSA, that had not been detectable in the patient preoperatively. The same strain of PVL-MRSA could be demonstrated in the nares of the asymptomatic donor, but not of other relatives, patients, or medical staff. These findings strongly suggest transmission of PVL-MRSA from the donor to the recipient. This case demonstrates a previously unknown, and potentially fatal, risk in living-donor liver transplantation: transmission of a severe infection from a healthy donor to the recipient.

Experience With Recipient’s Superficial Femoral Vein as Conduit for Middle Hepatic Vein Reconstruction in a Right-Lobe Living Donor Liver Transplant Procedure

Middle hepatic vein reconstruction during the right-lobe living donor liver transplant procedure has been recognized to be a significant factor. We initially reconstructed only a single middle hepatic vein orifice draining into segment 8. In cases where the right-lobe liver graft has several major middle hepatic vein tributaries, including veins draining segment 5 that are remote from the right hepatic vein orifice, a long and thick interposition conduit is necessary for reconstruction. Among 11 consecutive adult patients who received a right-lobe liver graft without a middle hepatic vein at our institution, 8 underwent reconstruction of all major middle hepatic vein tributaries using a vein graft from the recipient’s superficial femoral vein. The remaining 3 patients had no major middle hepatic vein tributaries. Posttransplant-computed tomography imagings showed increased liver mass with a patent superficial femoral vein graft in 8 patients. In the absence of a venous system from a deceased donor, a recipient superficial femoral vein offers an excellent size match to maintain the venous outflow of middle hepatic vein tributaries. Reconstruction with recipient superficial femoral vein plays an important role in maximizing liver function and minimizing morbidity in the early posttransplant period.

Cadaver iliac vein outflow reconstruction in living donor right lobe liver transplantation.

m m i g v v v iving donor liver transplantation has been widely acepted as a therapeutic option for adult patients with nd-stage liver disease. Living donor liver transplantaion using a right-lobe graft is becoming a standard proedure to mitigate graft-size mismatching and fulfill the etabolic demands of a larger recipient. There is the otential risk of congestion in the paramedian segment and 8 because of interruption of venous drainage into he middle hepatic vein (MHV). A substantial proporion of right-lobe liver grafts without MHV experience orphologic congestion of the paramedian segments in he early phase after transplantation, which may lead to raft dysfunction. Graft congestion and congestive nerosis have been reported as causes of graft failure and atient death. My colleagues and I have adopted the technique, first escribed by Malago and colleagues, of using a previusly procured cadaveric donor iliac vein to create an nterposition conduit that allows drainage of all intraheatic veins with a diameter 5 mm draining the segents 5 and 8 into the MHV. The advantage of this econstruction is that it necessitates only one venous nastomosis with the vena cava at the time of transplanation. This technique utilizes an iliac vein composite including common and external iliac) harvested at the ime of a cadaveric multiorgan procurement. This conuit is anastomosed to each individual accessory hepatic ein and to the anterior lip of the right hepatic vein.

Efficacy of anterior segment drainage reconstruction in right-lobe liver grafts from living donors1

The efficacy of additional venous reconstruction in the anterior segment has not been fully investigated for graft congestion in right-lobe liver grafts. Posttransplant graft venous congestion in the anterior segment was evaluated using magnetic resonance imaging in right-lobe living-donor liver transplantation. Additional venous reconstruction was categorized into two types: reconstruction of tributaries from segment 5 or 8 (n=11) and reconstruction of the middle hepatic vein (MHV) (n=9). Forty-five grafts only with right-sided hepatic vein(s) including the right hepatic vein served as controls. No significant difference in congestion score of the anterior segment was observed between grafts with V5/8 and standard grafts 1 month after transplantation despite the patency of reconstruction. Only grafts with the MHV showed no congestion (P <0.01). Drainage reconstruction of tributaries from the anterior segment produces only suboptimal benefits when evaluated radiologically. The addition of the main trunk of the MHV with its surrounding communication has the best effect on the congestion of the anterior segment.

Live-donor liver transplantation for acute-on-chronic hepatitis B liver failure.

The survival results of patients demonstrating acute-on-chronic liver failure and undergoing live-donor liver transplantation (LDLT) have been reported to be poor. This study evaluates the survival outcomes of patients who underwent LDLT using right-lobe liver grafts for acute-on-chronic hepatitis B liver failure. The study comprised 32 patients who demonstrated acute-on-chronic hepatitis B liver failure with mean (+/- standard error of mean) Model for End-Stage Liver Disease scores of 36+/-1.8. The mean preoperative intensive care unit stay was 2.4 days. LDLT using a right-lobe liver graft including the middle hepatic vein was performed in all patients. Oral lamivudine 100 mg daily was used for hepatitis B prophylaxis. The patients received liver grafts that were 52%+/-2% of the estimated standard liver weight. Hospital mortality occurred in two patients, and two other patients died on follow-up. At a median follow-up of 23 months, both patient and graft survival rates were 88%. The survival results were not different from those of 49 patients who underwent right-lobe LDLT for elective conditions during the same study period (graft survival=82%, P=0.55; patient survival=84%, P=0.75). Two (6.3%) patients developed hepatitis B virus DNA breakthrough 47 and 53 months, respectively, after transplantation, but they remained well after treatment with adefovir. Right-lobe LDLT is an effective therapeutic option for patients with acute-on-chronic hepatitis B liver failure. It results in satisfactory survival outcomes comparable to those in patients undergoing LDLT for elective conditions.

Background and clinical impact of tissue congestion in right-lobe living-donor liver grafts: a magnetic resonance imaging study.

Although right-lobe liver grafts from living donors have been widely accepted as an option for adult patients, impact of middle hepatic vein (MHV) deprivation is a recent controversy. Fifty recipients of right-lobe living-donor liver grafts without MHV or drainage reconstruction in anterior segment were evaluated for posttransplant tissue congestion with T2-weighted magnetic resonance imagings. Age of recipients and donors ranged from 19 to 69 (median 50) and 19 to 64 (46) years, respectively. Graft-to-recipient weight ratio ranged from 0.74% to 1.66% (1.06%). Cavoplasty was provided during right hepatic vein reconstruction to avoid anastomotic stricture. Congestion was observed in 88% of segments V and 85% of segments VIII in the first month. Congestion positively correlated with anatomic dependency on MHV. Also, donors were significantly older in age in grafts with more congestion. However, congestion improved within several months in most grafts. Graft congestion was associated neither with morbidities nor with graft loss except for temporary correlation with ascites production in the third and fourth posttransplant weeks. A significant proportion of right-lobe liver grafts without MHV experience morphologic congestion of the anterior segment in the early phase after transplantation, which is dependent on venous anatomy and donor age. However, the congestion spontaneously resolves in most cases. These results suggest that reconstruction of drainage vein(s) from the anterior segment is not necessary for all grafts provided good outflow through compensatory routes is secured. Additional reconstruction may be indicated in grafts with marginal size, anatomy, and quality.

Surgery-related morbidity in living donors of right-lobe liver graft: lessons from the first 200 cases.

Living-donor liver transplantation (LDLT) using the left lateral segment or left-lobe graft has been widely accepted, but currently, right-lobe grafts are more commonly used in many LDLT programs with yet unknown risks for donors. We investigated our initial 200 donors of righ-lobe grafts to focus on the incidence and variety of surgery-related morbidity. Changes in liver function tests were also analyzed to clarify the relation with donor age, steatosis of the liver, and residual liver volume (RLV). Complications were surveyed for a median period of 28.7 months. In all the donors, liver enzymes and bilirubin were normalized within 1 month. Enzymes on day 1 were significantly higher in donors with older age, macrovesicular steatosis, and larger RLV. Bilirubin on day 1 was significantly higher in donors with smaller RLV. Biliary enzyme was not normalized in the majority at 1 month after donation. Seventy-five complications occurred in 69 donors. Biliary complications were most common, which consisted of 26 bile leakages (13%) and 3 biliary strictures (1.5%) in 27 donors. No significant dependence of the incidence was observed either for donor age (>or=50 years), body mass index (BMI) (>or=25 kg/m2), estimated RLV (<40%), or medical history. None of the complications led either to mortality or to long-term sequelae. Complications occurred in a significant proportion of right-lobe donors irrespective of donor age, BMI, estimated RLV, and medical history. Living-liver donor surgery requires more care in right-lobe transplants.

Outcome of other organs recovered during in situ split-liver procurements

Split-liver transplantation is becoming a useful technique to expand the donor pool. Whether the split should be performed in situ or ex situ is not clear. One potential disadvantage of in situ splits is that prolonged surgical time and increased blood loss may negatively affect the function of other solid organs (kidneys, pancreas, and heart) procured from the same donor. Therefore, we studied the function of other organs posttransplantation. Between September 1, 1999, and March 31, 2000, we performed six in situ splits at the University of Minnesota (Minneapolis, MN). These six splits yielded six right-lobe liver grafts and six left-lobe liver grafts, which were transplanted into 12 adult-size recipients. Other grafts obtained from these six donors were as follows: kidney (n = 11), heart (n = 4), lungs (n = 1), pancreas (n = 2), and kidney-pancreas (n = 1). We then analyzed posttransplantation function of these grafts and the postoperative course of transplant recipients. All six donors were hemodynamically stable at the time of procurement. Mean donor age was 19.7 years. Mean surgical time for the procurement was 7.4 hours, with an average blood loss of 490 mL during in situ splitting of the liver. The 12 liver grafts showed good initial function with no primary nonfunction. The other organs also showed good function. Of 11 kidney recipients, only 1 patient developed delayed graft function, which resolved within 4 days. In addition, 1 kidney was lost early because of severe acute rejection. For the 10 recipients with functioning kidneys, mean creatinine level at hospital discharge was 2.0 mg/dL, and mean creatinine level after an average 9-month follow-up was 1.3 mg/dL. Of the 4 heart transplant recipients, 3 patients had good graft function immediately posttransplantation, with an ejection fraction greater than 60%, minimal inotropic requirements, and no surgical complications. The fourth heart transplant recipient, a critically ill status 1 patient, had poor initial function and a prolonged intensive care unit stay. At hospital discharge, pancreas and pancreas-kidney transplant recipients were all insulin free, with good urine amylase levels, no surgical or infectious complications, and no evidence of significant pancreatitis posttransplantation. The kidney of the pancreas-kidney transplant recipient functioned immediately; creatinine level after 7 months of follow-up was 1.2 mg/dL. Despite increased surgical time and blood loss, in situ splitting of liver grafts can be accomplished in stable donors without significant negative effects on other organs.