Standard Liver Volume Research Articles

3-Dimensional liver volume assessment in patients with hepatitis B virus-related liver cirrhosis during long-term oral nucleos(t)ide analogues therapy.

AIMTo assess the effect of long-term oral nucleos(t)ide analogues (NUCs) therapy on liver volume change in patients with suppress hepatitis B virus (HBV)-related liver cirrhosis.METHODSWe reviewed the data of naïve patients with HBV-related liver cirrhosis, who had taken oral NUCs therapy, between 2003 and 2007 at Chonbuk University Hospital. We analyzed two consecutive sets of abdominal computerized tomography scans-one at the time of treatment initiation and another at the second-year follow-up. Liver volume was calculated by 3-dimensional liver extraction volumetry program.RESULTSA total of 55 patients (34 males) were included. There was 114.3 mL ± 167.8 mL (12.9% ± 17.9%) of increase in liver volume during the two years of NUCs therapy (993.8 mL ± 242.8 mL at baseline vs 1108.1 mL ± 263.3 mL at two-year follow-up, P < 0.001). The ratio of the measured baseline liver volume to the estimated standard liver volume was improved from 70.8% to 78.0%. An increase in liver volume was shown not only in patients with compensated cirrhosis (P = 0.046) but also in those with decompensated cirrhosis (P < 0.001). Significant factors for volume increases were Child-Turcotte-Pugh grade and model for end-stage liver disease score improvement without virological breakthrough. In multiple linear regression analysis, delta albumin and delta alanine aminotransferase levels showed a significant association with the increase in liver volume (P = 0.002 and 0.005, respectively).CONCLUSIONLong-term oral NUCs therapy in patients with HBV-related liver cirrhosis lead to significant increase in liver volume assessed with 3-dimensional liver extraction volumetry program.

Left lobe living donor liver transplantation in adults: What is the safety limit?

Small-for-size syndrome (SFSS) is the most significant cause of graft loss after living donor liver transplantation (LDLT), especially after left lobe (LL) LDLT in adults. The safety limit of applying LL-LDLT in adults without severe SFSS with a high rate of lethality needs to be determined. A total of 207 LL-LDLTs in adults since September 2005 were evaluated to analyze the risk factors for severe SFSS, defined as a serum total bilirubin concentration of ≥20.0 mg/dL after LDLT. Although there were no significant differences in cumulative graft survival after LDLT between medium grafts (graft volume [GV] to standard liver volume [SLV] ratio ≥ 40.0%), small grafts (35.0% ≤ GV/SLV < 40.0%), and extra small grafts (GV/SLV < 35.0%), patients with severe SFSS showed a significantly lower 5-year graft survival rate than those without (42.9% versus 94.3%, respectively; P < 0.001). Multivariate analysis for severe SFSS after LL-LDLT showed that donor age of ≥48 years (P = 0.01), Model for End-Stage Liver Disease (MELD) score of ≥ 19 (P < 0.01), and end portal venous pressure of ≥19 mm Hg (P = 0.04) were the significant and independent factors for severe SFSS after LL-LDLT. Within such high-risk subgroups of patients with a donor age of ≥48 years or MELD score of ≥ 19 before LDLT, operative blood loss volume of ≥8.0 L was a risk factor for severe SFSS. LL-LDLT in adults could be indicated and provide acceptable outcomes for the combinations of donors aged < 48 years and recipients with a MELD score of <19. Smaller grafts might yield acceptable outcomes in appropriately selected donor-recipient combinations. Liver Transplantation 22 1666-1675 2016 AASLD.

Impact of split completeness on future liver remnant hypertrophy in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma: Complete-ALPPS versus partial-ALPPS

Recent evidence suggested that associating liver partition and portal vein ligation for staged hepatectomy with a partial split could effectively induce the same degree of future liver remnant hypertrophy as a complete split in non-cirrhotic and non-cholestatic livers with better postoperative safety profiles. Our aim was to evaluate if the same phenomenon could be applied to hepatitis-related chronic liver diseases. In the study, 25 patients who underwent associating liver partition and portal vein ligation for staged hepatectomy from October 2013 to January 2016 for hepatocellular carcinoma were analyzed. Partial-associating liver partition and portal vein ligation for staged hepatectomy (n=12) was defined as 50-80% of the transection surface split and complete-associating liver partition and portal vein ligation for staged hepatectomy (n=13) was split down to inferior vena cava. Perioperative outcomes stratified by split completeness were evaluated. There was no significant difference in operating times and blood loss for stage I and II operations between complete-associating liver partition and portal vein ligation for staged hepatectomy and partial-associating liver partition and portal vein ligation for staged hepatectomy. All patients underwent stage II operation without any inter-stage complications. Complete split induced greater future liver remnant hypertrophy than partial split (hypertrophy rate: 31.2 vs 17.5mL/day, P=.022) with more pronounced effect in chronic hepatitis (P=.007) than cirrhosis (P=.283). Complete-associating liver partition and portal vein ligation for staged hepatectomy was more likely to attain a future liver remnant/estimated standard liver volume ratio >35% within 10days (76.9% vs 33.3%, P=.024) and proceed to stage II within 14days after stage I (100% vs 58.4%, P=.009). The overall postoperative morbidity (≥grade 3a) after stage II was 16% (complete versus partial split: 7.7% vs 25%, P=.238) and hospital mortality after stage II was 8% (complete versus partial split: 0% vs 16.7%, P=.125). Complete-associating liver partition and portal vein ligation for staged hepatectomy induced more rapid future liver remnant hypertrophy than partial-associating liver partition and portal vein ligation for staged hepatectomy without increased perioperative risk in chronic liver diseases.

Terminal branches portal vein embolization for planed hepatectomy

To explore the application of the technique of terminal branches portal vein embolization(TBPVE)for planed hepatectomy. From February 2016 to June 2016, 4 patients with hepatocellular carcinoma underwent TBPVE and liver resection in Yuebei People's Hospital (n=3) and Jiangxi Ji'an Central People's Hospital (n=1). All of them were male and were 50, 64, 39 and 47 years old respectively. All the tumors located in the right lobe. All patients had the liver function of Child-Pugh A classification and liver cirrhosis level of G2S4. The standard liver volume (SLV) were 1 291, 1 109, 1 177 and 1 242 ml and estimated future liver remnant(FLR) were 315, 347, 306 and 323 ml respectively. The puncture site of TBPVE was determined by the three-dimensional reconstruction of portal vein. Three patients were punctured in the segment Ⅵ and the other one punctured in the segment Ⅲ. CT scan was repeated 2 weeks after TBPVE and FLR and FLR/SLV were calculated. All patients underwent right hepatectomy 2 weeks after TBPVE. On the 14(th) day after TBPVE, the FLR of 4 patients were 529, 462, 469 and 498 ml which increased 67.9%, 33.1%, 53.3% and 54.2% compared with that before TBPVE, and FLR/SLV were 41.0%, 41.7%, 39.8% and 40.1% respectively. No severe complication occurred. Right hepatectomy were performed 2 weeks after TBPVE. No inflow blood control applied during the liver resection. The mean blood loss was 950 ml and the mean operating time was 3.3 hours (ranging from 3 to 4 hours). One patient had respiratory infection and two had slight jaundice and ascites for a short period. No other complication occurred. The TBPVE could induce a rapid and large FLR volume that give chances to patients with small FLR to have liver resection for hepatocellular carcinoma.

Safety assessment of hepatectomy for huge hepatocellular carcinoma by three dimensional reconstruction technique

To explore the effectiveness of three-dimentional(3D)reconstruction technique in safety assessment of hepatectomy for large hepatocellular carcinoma(HCC). The clinical records of 28 patients who underwent resection of HCC greater than 10 cm in diameter from January 2013 to December 2015 at Department of Hepatic Surgery, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology were studied retrospectively. All patients underwent enhanced computer tomography (CT), then 3D images of liver and tumor were reconstructed by uploading the CT imaging data to IQQA-Liver system. The individual surgery plan was simulated and liver volume (LV), standard liver volume(LV), tumor volume(TV), functional liver volume(FLV), excised liver volume(ELV), excised functional liver volume (EFLV), residual functional liver volume (RELV) were calculated. Simulated surgery plans were compared with actual procedures. ELV was compared with actual excised liver volume (AELV) by paired Student's t test. Postoperative complications and motility were analyzed. The correlation between TV and EFLV, RFLV, RFLV/FLV, RFLV/SLV were calculated by Spearman test. TV ranged from 202 cm(3) to 2 125 cm(3,) RELV ranged from 401 cm(3) to 1 633 cm(3).There were 13 patients whose RFLV/LV<30% and 28 patients whose RFLV/FLV>30%(34.8%-94.0%). RFLV/SLV ranged from 35.9% to 139.0%.All simulated surgery plans matched with the actual operation procedure. ELV was equal to AELV, which confirmed by the high precision of IQQA-Liver system(t=0.636, P>0.05). No severe complications (hepatic encephalopathy or liver failure) and perioperative death occurred after operation. Positive correlation was observed between TV and RFLV, TV and RFLV/FLV, TV and RFLV/SLV(r=0.641, 0.629 and 0.732, all P<0.01). Negative correlation was observed between TV and EFLV (r=-0.539, P<0.01). 3D reconstruction technique could accurately simulate surgery procedure, calculate liver volume and evaluate the safety of hepatectomy for huge hepatocellular carcinoma. When the anatomical liver resection was performed, the larger tumor volume means the smaller excision functional liver volume and larger residual liver volume.

Estimation of liver volume in the western Indian population.

A number of formulae to estimate standard liver volume (SLV) exist. However, studies have shown that only certain formulae are applicable to a particular patient population, whereas the other formulae have not been accurate in estimating the SLV. Aim of this study was to assess which formula is most accurate in estimating SLV in the western Indian population. Data for donors of living donor liver transplantation from September 2014 to July 2015 was analyzed. Liver volumes were measured using computed tomography volumetry (CTV). SLV was calculated using formulae by the currently existing formulae. The mean SLV and CTV, percentage error in the SLV, and the correlation between SLV and CTV were calculated. Fifty-nine healthy subjects underwent donor hepatectomy [28 (47.5%) males]. The mean age, mean body mass index (BMI), and mean body surface area (BSA) were 31.8 ± 8.8years, 23.8 ± 3.7kg/m(2), and 1.6 ± 0.4, respectively. Mean CTV was 1178 ± 246.8mL. Difference between mean SLV and mean CTV ranged from -133.5 (±189) mL to 632.2 (±190.2) mL. Mean SLV was significantly different from CTV by all the formulae except Urata. Percentage of population whose SLV was within 15% of the mean CTV ranged from 1.7 % to 67.8%, with the highest percentage obtained by using Fu-Gui's formula. However, there was wide inter-individual variation on scatter plots between SLV and CTV by both these formulae. Currently existing formulae were not accurate in estimating SLV in our population.

Impact of Graft Selection on Donor and Recipient Outcomes After Living Donor Liver Transplantation.

Balancing donor and recipient risks in living donor liver transplantation remains an issue of debate. This study assessed the impact of graft selection on outcomes and complications for left lobe (LL) versus right lobe (RL) donors and recipients. The medical records of donors and recipients, who underwent living donor liver transplantation at our institution between 2003 and 2015, were reviewed. For donors, we evaluated graft volume, residual liver volume per standard liver volume, length of hospital stay (LOS), complications, and readmissions. For recipients, we looked at graft and patient survival, graft function at postoperative days 7 and 14, graft volume, LOS, biliary complications, Model for End-Stage Liver Disease at transplant, and hepatitis C virus status. At 5 years posttransplant, there were no significant differences in graft survival for LL recipients (86% [95% confidence interval, 74-93]) compared with 82% (95% confidence interval, 69-89) for RL recipients (P = 0.85) or recipient survival (90% vs 84%; P = 0.44). In LL recipients, postoperative days 7 and 14 median international normalized ratio (1.5 and 1.2, respectively) and total bilirubin (4.6 and 2.7) were significantly greater compared with RL recipients (7 and 14 days international normalized ratio [1.2, P < 0.001; 1.1, P = 0.001] and total bilirubin (2.7, P = 0.001; 2.1, P = 0.05)). The LL recipients also had a significantly greater median LOS (14 vs 10, P = 0.008). Median donor LOS was significantly greater for RL donors (7 [interquartile range, 7-8] vs 7 [interquartile range, 6-7] days, P < 0.001). The RL and LL grafts provide comparable long-term outcomes in properly selected donor-recipient pairs and the appropriate use of LL grafts does not impact graft or patient survival at 5 years posttransplant.

Percutaneous microwave or radiofrequency ablation liver partition and portal vein embolization for planned hepatectomy

Objective To explore the clinical outcome of percutaneous microwave/radiofrequency ablation liver partition and portal vein embolization for planned hepatectomy (PAPEP)for the treatment of hepatocelullar carcinoma (HCC) with insufficient future liver remnant (FLR). Methods The retrospective descriptive research method was taken. The clinical data of 2 patients of giant primary HCC (FLR complicated with cirrhosis) who were admitted to the Zhejiang Province People′s Hospital from November 2015 to January 2016 were collected. Treatment plan: ultrasound-guided percutaneous microwave ablation (PMA) or percutaneous radio-frequency ablation (PRA) was performed on patients under intravenous anesthesia, at the same time portal vein embolization (PVE) was conducted. FLR was measured by rescan of computed tomography (CT) at 7-9 days postoperatively, according to FLR hyperplasia and general situation of the patient, right trisegmentectomy and expanded right hemihepatectomy were implemented respectively. Observation indicatiors indicators included (1)standard liver volume (SLV) and FLR before PRA/PVE treatment, (2)liver function, body temperature, FLR and time of FLR hyperplasia after PRA/PVE treatment, (3)liver function, body temperature, complications, FLR and duration of hospital stay after hepatectomy. Follow-up using outpatient examination and telephone interview was performed to detect carcinoma recurrence and other follow-up contents up to March 2016. Results (1)Before PRA+ PVE, SLVs of 2 patients were 1 103 mL and 1 132mL, FLRs of 2 patients were respectively 417 mL and 297 mL which occupied the SLV at the percentage of 37.8% and 26.2% respectively. (2)After PRA+ PVE treatment, there were no changes in liver function and fever. After PRA+ PVE treatment, FLR of 2 patients increased to 652 mL and 522 mL, respectively, which occupied the SLV at the percentage of 59.1% and 46.1% respectively, with increased rates of 56.4% and 75.6% and time of FLR hyperplasia of 10 days and 17 days. The two patients received successful hepatectomy, without intraoperative red blood cell infusion. (3)At postoperative day 3, albumin (Alb), alanine transaminase (ALT), aspartate transaminase (AST) and total bilirubin (TBil) of liver function were 28.0 g/L, 63 U/L, 39 U/L and 19.0 μmol/L in patient 1 with a temperature of 38 degree, and 24.3 g/L, 78 U/L, 11 U/L and 38.1 μmol/L in patient 2 with a normal temperature. Liver function of 2 patients was improved after conservative treatment. No severe complications were occurred. Rescan of CT showed the FLR of patients continued increasing. The duration of hospital stay of 2 patients was 10 days and 14 days, respectively. Conclusion PAPEP for HCC with insufficient FLR is safe and effective. Key words: Liver neoplasms; Associating liver partition and portal vein ligation for staged hepatectomy; Microwave ablation; Radiofrequency ablation; Future liver remrant; Planned hepatectomy

Remedial radiofrequency ablation or portal vein embolization combined with radiofrequency ablation-assistant associating liver partition and portal vein ligation for staged hepatectomy in the treatment of patients with hepatocellular carcinoma with cirrhosis

Objective To explore the clinical effect of remedial radiofrequency ablation (RFA) or portal vein embolization (PVE) combined with radiofrequency ablation-assistant associating liver partition and portal vein ligation for staged hepatectomy (RALPPS) in the treatment of patients with insufficient future liver remnant (FLR) after the first staged operation and hepatocellular carcinoma (HCC) with cirrhosis. Methods The retrospective and descriptive cross-sectional study was adopted. The clinical data of 5 patients with insufficient FLR after the first staged of RALPPS and HCC with cirrhosis who underwent remedial RFA or PVE at the Southwest Hospital of the Third Military Medical University between September 2014 and February 2016 were collected. Standard liver volume (SLV)=613.0×body surface area (BSA)+ 162.8, BSA=0.007 1×height+ 0.013 3×body mass. Patients with FLR<40% received RALPPS. In the first staged operation, RFA was used to cauterize a coagulated avascular area between the FLR and contralateral lobe, and then right branch of portal vein was ligated. After the operation, remedial RFA or PVE was performed in patients with insufficient FLR. Once the FLR achieved the target value, the second staged RALPPS was performed. Observation indicators included (1) perioperative complications and death, complications in stage IIIa and above of Clavien-Dindo as main complications, (2) changes of FLR and tumor progression, (3) intraoperative situation, (4) follow-up. The follow-up using outpatient examination was performed up to February 2016, including laboratory examination, tumor markers and imaging examinations (enhanced scan of computed tomography in the epigastric region or ultrasound). Measure-ment data with normal distribution were represented as ±s. Results (1) Perioperative complications and death: of 5 patients, 2 didn′t receive second staged RALPPS and 3 completed both stages. Five patients had no postoperative main complications and 1 died of renal failure and pulmonary infection after second staged RALPPS. (2) Changes of FLR and tumor progression: the average FLR and percentage of FLR to SLV were (329±80)cm3 , 25%±5% in 5 patients before first staged operation and (533±45)cm3, 43%±3% in 3 patients before second staged operation, with an average growth rate of 44%-113%. The average interval time of 5 patients was (29.0±2.2)days. For the 3 patients which completed both stages, the 1-week increased percentage of FLR was 33.5%-68.9% after first staged operation, 1.2%-14.3% and 9.7%-29.8% before and after remedial RFA or PVE. Two patients didn′t undergo the second staged operation, 1 patient was due to not reach standard of safe resection after 4 times remedial PVE, and 1 patient was due to tumor metastasis during intermittent stage after remedial RFA with average FLR after 2 weeks and average 1-week increased percentage of 762.0 cm3 and 10.6%. (3) Intraoperative situations: 1 patient underwent laparoscopic-assisted first staged RALPPS and 1 underwent RFA in the left lobe of liver. The first staged operation time, RFA time and volume of intraoperative blood loss were (240±43)minutes, (15±8)minutes and (190±136)mL, and no patient had blood transfusion. After first staged operation, 5 patients received 5 times remedial PVE and 7 times RFA. Two patients underwent right hemihepatectomy and 1 patient underwent hepatic trisegmentectomy in the second staged operation. The second staged operation time and volume of intraoperative blood loss of 3 patients were (257±33)minutes and (303±73)mL, and 3 patients received R0 resection and no intraoperative blood transfusion. (4) Follow-up: 1 patient was dead during hospitalization and 4 patients were followed up for 1-12 months with a median time of 6 months. Of 2 patients without second staged operation, 1 continued to undergo interventional treatment and then was dead after half year, and 1 continued to undergo transcatheter arterial chemoembolization (TACE) and had good survival up to the end of follow-up. Of the other 2 patients, 1 with tumor recurrence at postoperative month 2 received interventional treatment and traditional Chinese medicine and then was dead after 6 months, and 1 had no tumor recurrence and metastasis during the follow-up. Conclusion For the patients with HCC with cirrhosis who had insufficient FLR after the first staged RALPPS, remedial RFA or PVE could promote further regeneration of FLR and thus improve the completion rate of both stages. Key words: Liver neoplasms; Cirrhosis; Associating liver partition and portal vein ligation for staged hepatectomy; Radiofrequency ablation; Portal vein embolization; Future liver remnant

Associating liver partition and portal vein ligation for staged hepatectomy in the treatment of hepatocellular carcinoma with cirrhosis

Objective To investigate the safety and clinical effect of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in the treatment of hepatocellular carcinoma (HCC) with cirrhosis. Methods The retrospective cohort study was adopted. The clinical data of 5 patients with primary HCC with cirrhosis who underwent ALPPS at the First Bethune Hospital of Jilin University between October 2014 and August 2015 were collected. The surgical plan was determined according to preoperative liver function and liver functional reserve. The patients underwent portal vein (PV) ligation and liver partition in the first staged surgery. The second staged surgery was performed when growing future live remnant (FLR) came up to the standard of safe section by rescan of computed tomography (CT) at 10, 14, 18 days after the first staged surgery, and hemi-hepatectomy and hepatic segmentectomy were applied to patients. (1) The intraoperative situations were observed, including the severity of liver cirrhosis, first staged surgery time, volume of intraoperative blood loss and FLR in the first staged surgery, interval time of surgery, growth rate of liver volume, ratio of FLR and standard liver volume (SLV), time and volume of intraoperative blood loss in the second staged surgery. (2) Pre- and post-operative biochemical indicators in the first and second staged surgeries were detected, including total bilirubin (TBil) and alanine phosphatase (ALT). (3) Postoperative situations were observed, including occurrence of complications, results of pathological examination and duration of hospital stay. (4) The follow-up using telephone reservation and outpatient examination was performed to detect tumors recurrence and metastasis and survival of patients by imaging examination and tumor marker test up to November 2015. Count data were represented as mean (range). Results (1) Intraoperative situations: of 5 patients, there were 1 patient with F3 of liver cirrhosis and 4 with F4 of liver cirrhosis. One patient was complicated with lots of peritoneal effusion, followed by acute renal failure, and didn't receive the second staged surgery. Four patients underwent successful ALPPS. The first staged surgery of 5 patients: average operation time, volume of intraoperative blood loss, FLR, interval time of surgery, growth rate of liver volume, ratio of FLR and SLV were 282 minutes (range, 240-320 minutes), 500 mL (range, 300-700 mL), 457 cm3 (range, 338-697 cm3), 15 days (range, 14-18 days), 58% (range, 46%-67%) and 42% (range, 32%-44%), respectively. Average operation time and volume of intraoperative blood loss in second staged surgery were 220 minutes (range, 200-260 minutes) and 412 mL (range, 300-600 mL). (2) Pre- and post-operative biochemical indicators: levels of TBil and ALT of 5 patients from pre-operation to postoperative day 12 in the first staged surgery were from 4.9-30.4 μmol/L to 9.8-56.1 μmol/L and from 12.9-156.1 U/L to 46.3-207.3 U/L, respectively. Levels of TBil and ALT of 4 patients from pre-operation to postoperative day 10 in the second staged surgery were from 10.1-21.2μmol/L to 6.9-38.0 μmol/L and from 30.8-55.5 U/L to 19.8-72.8 U/L, respectively. (3) Postoperative situations: there were no perioperative death and postoperative complications of liver failure and intraperitoneal infection. One patient complicated with bile leakage was cured by non-operative treatment for 30 days.Results of pathological examination: 5 patients were confirmed asⅡ-Ⅲ stage HCC, and 4 tumors had vascular tumor thrombi and negative resection margin with tumor size of 8-13 cm. Duration of hospital stay of 5 patients was 36 days (range, 28-48 days). (4) Results of follow-up: 4 patients undergoing successful ALPPS were followed up for 4-12 months. One patient was emerged with a new lesion of 2 cm in left half liver at postoperative month 7, level of AFP of which was 512 μg/L before the first staged surgery reduced to normal level at postoperative month 2, and then the patient received transcatheter arterial chemoembolization (TACE) and radio frequency ablation (RFA) treatments without tumor recurrence up to postoperative month 12. No tumor recurrence and new lesions in liver were detected in other 3 patients by abdominal enhanced scan of CT, with a normal level of AFP. Conclusion ALPPS is safe and feasible for HCC with cirrhosis, with a satisfactory short-term outcome. Key words: Liver neoplasms; Cirrhosis; Associating liver partition and portal vein ligation for staged hepatectomy; Future liver remnant; Liver regeneration

Outcomes of Living Donor Liver Transplantation Alone for Patients on Maintenance Renal Replacement Therapy in Japan: Results of a Nationwide Survey.

BackgroundBecause simultaneous liver and kidney transplantation has been limited as a standard practice because of a severe shortage of deceased donors in Japan, living donor (LD) liver transplantation alone (LTA) is indicated in most recipients with maintenance renal replacement therapy (MRRT).MethodsA retrospective nationwide survey of LD LTA was performed for liver transplant patients on MRRT. The characteristics of donors and recipients, postoperative complications, survival rate, and causes of death were analyzed.ResultsIn the adult cases (n = 28), the overall survival rate at 1 year and 5 years were 66.1% and 57.3%, respectively. When compared with those adults without MRRT (n = 237), it was significantly worse. In the 7 pediatric cases, the overall survival rate at 1 and 5 years were both 83.3%. Three adult recipients died of nonaneurysm cerebral hemorrhage after 1 year and 1 adult recipient died of acute heart failure after 7 months. In adult recipients with MRRT, graft weight versus standard liver volume, and duration and blood loss in LTA surgery were associated with poor outcomes after LD LTA. Multivariate analysis revealed that MRRT was highest hazard ratio on patient survival after LD LTA.ConclusionsEarly post-LD LTA mortality was higher in patients with MRRT than in those without MRRT with characteristic causes. Smaller grafts for size and a complicated surgery were associated with poor outcome after LD LTA. Thus, LD LTA in adult patients on MRRT should be carefully treated with meticulous postoperative management and follow-up.

Relationship Between Graft Liver Function and the Change of Graft Liver and Spleen Volumes After Technical Variant Liver Transplantation

BackgroundAlthough there have been a few reports describing the changes of graft liver and spleen volumes after liver transplantation (LT), little is known about the relationship between graft liver function and the changes of these volumes after technical variant liver transplantation (TVLT). We therefore performed a retrospective study to investigate the relationship between graft liver function and these volumes after TVLT. MethodsWe retrospectively investigated the cases of 140 TVLT procedures that were performed in our department between July 1987 and October 2012 and in which follow-up was conducted at our department. We calculated the graft liver volume to standard liver volume (GV/SLV) ratio, the spleen volume to standard spleen volume (SV/SSV) ratio, and the spleen volume to graft liver volume (S/L) ratio by CT volumetry. We clarified the relationship between graft liver function (according to the pathological findings) and the graft liver and spleen volumes at 2, 5, and 10 years after TVLT. ResultsIn the normal liver function group, the GV/SLV, SV/SSV, and S/L ratios decreased until 6 months after TVLT and then converged at 10 years after TVLT to 0.95, 1.27, and 0.27, respectively. In the graft liver failure group, the GV/SLV, SV/SSV, and S/L ratios at 10 years after TVLT were 0.67, 5.01, and 1.55, respectively. A significant correlation was observed between the GV/SLV ratio and the presence of mild liver fibrosis at 2 and 5 years after TVLT (P = .03 and P = .04, respectively). ConclusionsPost-transplant CT-volumetry is a noninvasive and effective means of evaluating graft liver status.

Living Liver Donor Selection and Resection at the University of Tokyo Hospital

ObjectivesDonor selection and operative procedures for adult-to-adult living donor liver transplantation at the University of Tokyo are presented. MethodsDonor selection criteria are as follows: age between 20 and 65 years, within 3 degrees of consanguinity, without coercion, free from any major comorbidities, body mass index (BMI) < 30, and ABO blood type identical or compatible. Liver biopsy is indicated for BMI > 25 kg/m2 or any liver function abnormality, and those with macroscopic steatosis >10% are rejected. Thereafter, an indocyanine green retention test and dynamic computed tomography are evaluated. Graft type is determined based on computed tomography volumetry. An estimated graft volume of 40% to recipient standard liver volume ratio is the lower limit. For donor safety, the left liver is the first choice, provided that it satisfies the lower limit. Otherwise, right liver harvesting is indicated, providing that the estimated remnant liver volume is >30% of the donor's total liver volume. A posterior sector graft is a possible option. ResultsBetween 1996 and 2014, 462 donor hepatectomies were performed, with 257 right livers, 179 left livers, and 26 posterior sectors. There was no mortality, and the incidence of morbidity grades I, II, IIIa, and IIIb was 16%, 5%, 5%, and 3%, respectively, without a difference between right and left liver grafts. The left liver was used without impairing recipient outcome. Two aborted hepatectomies (0.4%) and 3 near-miss events (0.6%) were encountered. ConclusionsMaximal effort should be applied to donor selection and operation for donor safety.

Minimum graft size calculated from preoperative recipient status in living donor liver transplantation.

Small-for-size graft syndrome is an inevitable complication in living donor liver transplantation (LDLT). We hypothesized that graft weight (GW) measured after graft procurement is one of the variables predicting postoperative graft function. A total of 138 consecutive recipients of adult-to-adult LDLT between March 1999 and October 2014 were included in this study. We investigated the factors associated with small-for-size-associated graft loss (SAGL) to determine the GW required for each patient. Both preoperatively assessed and postoperatively obtained risk factors for SAGL were analyzed in univariate and multivariate logistic regression analysis. Twelve (8.8%) of the transplant recipients had SAGL. In multivariate logistic regression analyses using preoperatively assessed variables, the preoperative Model for End-Stage Liver Disease (MELD) score (P < 0.001) and actual GW/recipient standard liver volume (SLV) ratio (P = 0.008) were independent predictors of SAGL. The recommended graft volume by preoperative computed tomography volumetry was calculated as SLV × (1.616 × MELD + 0.344)/100/0.85 (mL) [MELD ≥ 18.2], or SLV × 0.35 (mL) [MELD < 18.2]. The required allograft volume in LDLT can be determined by the preoperative MELD score of the recipient, and patients with higher MELD scores require larger grafts or deceased donor whole liver transplant to avoid SAGL. Liver Transplantation 22 599-606 2016 AASLD.

Reconstruction of hepatic venous tributary in right liver living donor liver transplantation: The importance of the inferior right hepatic vein.

Special care must be taken in hepatic vein reconstruction to avoid outflow block in living donor liver transplantation (LDLT) with a right liver graft. We have used cryopreserved homologous veins to reconstruct the right hepatic vein (RHV), middle hepatic vein (MHV), MHV tributaries (V5 and V8), and inferior right hepatic vein (IRHV). The reconstruction of V5, V8, and IRHV was based on the estimated congestive volume, calculated by the computed tomography volumetry, to secure the functional graft volume of 40% of the recipient standard liver volume. Among 262 right liver LDLT recipients, the number of reconstructed RHVs, MHVs, V5s, V8s, and IRHVs was 262, 48, 110, 111, and 147, respectively, and the overall patency was 95%, 100%, 36%, 58%, and 86%, respectively. Although the patency of the RHVs and MHVs was satisfactory, that of the V5s, V8s, and IRHVs was suboptimal. Patency of the IRHVs (86%, 126/147) was significantly better than that of both V5s (36%, 40/110) and V8s (58%, 64/111; P < 0.001). In addition, the estimated volume drained by IRHVs was significantly greater than that of V5s and V8s (IRHV, 176 ± 92 mL; V5, 105 ± 49 mL; V8, 127 ± 60 mL; P < 0.001). The patency of IRHV was significantly improved by applying the double inferior vena cava method (93%, 94/101) when compared to the direct anastomosis to vena cava (68%, 25/37; P < 0.001). The IRHV functioned as a main drainage route in cases of an obstructed RHV. In conclusion, reconstruction of the IRHV is recommended, not only to improve the functional reserve of the graft, but also to secure multiple drainage routes of the graft.

Percutaneous Microwave Ablation Liver Partition and Portal Vein Embolization for Rapid Liver Regeneration: A Minimally Invasive First Step of ALPPS for Hepatocellular Carcinoma.

Percutaneous Microwave Ablation Liver Partition and Portal Vein Embolization for Rapid Liver Regeneration: A Minimally Invasive First Step of ALPPS for Hepatocellular Carcinoma.

Caudate lobe as the sole remnant liver following anatomical hepatectomy for the treatment of hepatolithiasis

Objective To investigate the safety and short-term effect of anatomical hepatectomy for the treatment of hepatolithiasis with the caudate lobe as the sole remnant liver. Methods The clinical data of 1 patient with hepatolithiasis combined with liver atrophy-hypertrophy syndrome who was admitted to the Hunan Provincial People's Hospital in April 2014 were retrospectively analyzed.The stones were located in the left and right liver, the involved liver became fibroatrophy, and the hepatic caudate lobe not containing stones became hypertrophy.The body surface area of the patient was 1.65 m2, standard total liver volume was 1 167.63 mL. According to the result of CT, expected residual liver volume after hepatectomy was 706.12 mL, and the ratio of residual liver volume over the standard total liver was 60.47%.The radio of residual liver volume over the body mass index was 1. 21%.The patient received the second exploration of common bile ducts, hepatectomy with the caudate lobe as the sole remnant liver and T tube drainage.The follow-up including recurrence of calculus was performed by outpatient examination and telephone interview up to April 2015. Results The patient underwent caudate lobe as the sole remnant liver following anatomical hepatectomy successfully without blood transfusion.The operation time and volume of intraoperative blood loss were 380 minutes and 350 mL.The peritoneal drainage tube was removed at postoperative day 2 and the patient was discharged at postoperative day 8 with a good recovery of liver function.The postoperative pathological examination showed that there were focal biliary epithelial papillary hyperplasia combined with light-medium atypical hyperplasia and no canceration.The T tube cholangiography two month later showed that there were unobstructed lower bile duct and no residual intra-and extra-hepatic stones. The liver function was normal.Then T tube was removed and patient resumed normal life.During the 1-year follow-up, no chills and fever, jaundice and abdominal pain occurred, no calculus was detected by Bultrasonography, and computed tomography reexamination showed that remnant liver volume was increased and no intra-and extra-hepatic bile duct stones were detected. Conclusion Anatomical hepatectomy for the treatment of hepatolithiasis with the caudate lobe as the sole remnant liver is safe and feasible, with a good curative effect. Key words: Hepatolithiasis; Anatomical hepatectomy; Surgical procedures, operative

Ad Integrum Functional and Volumetric Recovery in Right Lobe Living Donors: Is It Really Complete 1 Year After Donor Hepatectomy?

The partial liver's ability to regenerate both as a graft and remnant justifies right lobe (RL) living donor liver transplantation. We studied (using biochemical and radiological parameters) the rate, extent of, and predictors of functional and volumetric recovery of the remnant left liver (RLL) during the first year in 91 consecutive RL donors. Recovery of normal liver function (prothrombin time [PT] ≥70% of normal and total bilirubin [TB] ≤20 µmol/L), liver volumetric recovery, and percentage RLL growth were analyzed. Normal liver function was regained by postoperative day's 7, 30, and 365 in 52%, 86%, and 96% donors, respectively. Similarly, mean liver volumetric recovery was 64%, 71%, and 85%; whereas the percentage liver growth was 85%, 105%, and 146%, respectively. Preoperative PT value (p = 0.01), RLL/total liver volume (TLV) ratio (p = 0.03), middle hepatic vein harvesting (p = 0.02), and postoperative peak TB (p < 0.01) were predictors of early functional recovery, whereas donor age (p = 0.03), RLL/TLV ratio (p = 0.004), and TLV/ body weight ratio (p = 0.02) predicted early volumetric recuperation. One-year post-RL donor hepatectomy, though functional recovery occurs in almost all (96%), donors had incomplete restoration (85%) of preoperative total liver volume. Modifiable predictors of regeneration could help in better and safer donor selection, while continuing to ensure successful recipient outcomes.

Postoperative neutrophil-to-lymphocyte ratio of living-donor liver transplant: Association with graft size

Issues related to small-for-size grafts in living donor liver transplantation (LDLT) are highly important. The neutrophil lymphocyte ratio (NLR) has been reported to be an inexpensive index of systemic inflammation for various diseases. We retrospectively evaluated the relationship between NLR and clinical course of 61 adult LDLT recipients in our institute until post-operative day 14. Patients were classified into two groups based on the graft volume divided by standard liver volume, as over 35% of graft volume divided by standard liver volume (GV/SLV) (Group L; n = 55) and under 35% of GV/SLV (Group S; n = 6). No differences were seen in background of the patients between the two groups. Also, absolute neutrophil, lymphocyte and platelet counts in both the groups showed no significant differences. In contrast, the NLR between the groups differed significantly from post-operative day 3 to 10, being higher in the Group S. In addition, the incidence of prolonged hyperbilirubinemia and small for size graft syndrome differed significantly between the two groups. Therefore, the elevation of post-operative NLR in the smaller graft group reflect suggestive pathophysiology of endothelial injuries that related to small for size graft syndrome in LDLT.

Assessment of Graft Selection Criteria in Living-Donor Liver Transplantation: The Jikei Experience.

In living-donor liver transplantation, graft selection is especially important for the safety of the live donor and an acceptable outcome for the recipient. The essential medical requirements for living liver donation at Jikei University Hospital are as follows: an adult aged 65 years or younger, in good general condition, with partial liver volume of more than 35% of the standard liver volume (SLV) for the recipient, and without severe liver steatosis. Based on our criteria, we performed 13 living-donor liver transplantations between 2007 and 2013, including 1 retransplantation. Three cases were outside our standard donor criteria, including age (18 and 66 years) and 33% graft volume (GV) to SLV ratio for the recipient on preoperative volumetry using computed tomography. In 2 cases, the actual GV to SLV ratio at transplantation was less than 35%. Median postoperative hospital stay was 11 days for the donors, and 29 days for the recipients. All donors returned to their preoperative status, and all recipients were discharged in good condition. Our medical requirements for living liver donation seem to be acceptable because of the good outcome.