Syndrome In Living Donor Liver Transplantation Research Articles

Graft Inflow Modulation in Living-Donor Liver Transplantation: Hepatic Hemodynamic Changes in Splenic Artery Ligation and Splenectomy.

BackgroundExcessive portal flow to an allograft was a key mechanism for small-for-size syndrome in living-donor liver transplantation (LDLT). Good outcomes in LDLT by graft inflow modulation (GIM) using a small graft were reported, but the effect on hepatic hemodynamics is undefined. This report summarizes our experience with GIM and compares the effects of splenic artery ligation (SAL) and splenectomy on hepatic hemodynamic changes.Material/MethodsNinety-nine patients who underwent adult-to-adult LDLT from June 2014 to December 2020 were included in this study. GIM was performed in 36 patients (17 patients with SAL and 19 with splenectomy).ResultsThe GIM group had lower graft-to-recipient weight compared to the no-modulation group (median, 0.91% versus 1.04%, P=0.022). Initial portal venous flow (PVF) was higher in the GIM group (median, 311 versus 156 ml/min/100 g, P<0.001). After GIM, PVF decreased to 224 ml/min/100 g. One-year graft survival with GIM was 89.9%, and for the no-modulation group it was 86.6% (P=0.945). In the subgroup analysis, the efficacy of decompressing PVF was higher in the splenectomy subgroup (median, 14.3% versus 41.8%, P=0.002).ConclusionsGIM was useful for grafts with high PVF. Splenectomy modulated excessive PVF more effectively than did SAL. Perioperative hepatic hemodynamic changes could assist surgeons in selecting different GIM strategies.

Liver regeneration rate particularities in living donor liver transplantation

Introduction: Liver surgery has developed importantly making possible the use of partial liver grafts for living donor liver transplantation (LDLT). Nonetheless, LDLT indication still depends on the graft size used, due to the development of “small for size syndrome” which can be better understood through the study of hepatocellular regeneration. Methods: A retrospective study was performed in Hospital Clinic of Barcelona analyzing the liver regeneration in LDLT through radiologic imaging in the follow-up, with which we calculated a liver regeneration rate (LRR). We used SPSS v20 for statistical analysis. Results: From a 10 year period a total of 50 LDLT were performed. Forty-six of these transplants (92%) a right liver graft was transplanted, and in four (8%) we used the left liver as graft, we excluded all left graft donors, leaving a sample of 92 patients in total. We analyzed different clinical factors that could alter LRR. We found that the LRR was greater in the recipient than in the donor without significant difference. By analyzing factors associated with regeneration rate we found significant difference in recipients with VHC infection where regeneration rate was lower during the first 3 months. Conclusions: These findings give us a better understanding of the differences in recipients and donors of the liver regeneration rate in time. Also, the knowledge of clinical factors that could be associated or alter LRR, could allow physicians and surgeons to detect individual characteristics of donors and recipients that could prevent small-for-size syndrome in LDLT.

Retrospective Cohort Study to Compare Anesthesia in Living Donor Liver Transplantation Recipients Who Received Single and Dual Liver Grafts

ObjectiveDual graft living donor liver transplantation (LDLT) is an alternative way to overcome small-for-size syndrome in LDLT. Surgical technique and outcome of using dual grafts have been reported, but there are no reports regarding anesthetic management. The aim of the current study is to compare the anesthetic management of single graft and dual graft liver transplantation. Methods and PatientsAnesthesia records of 24 single graft liver transplantation recipients (GI) and 6 dual graft recipients (GII) were reviewed, analyzed, and compared retrospectively. Patient characteristics and intraoperative data between groups were compared with Mann-Whitney t test and Fisher's exact test where appropriate. P value less than .05 was regarded as significant. ResultsPatient characteristics and most of the intraoperative data were similar between groups. Significant difference was noted in the total anesthesia time and the anhepatic time. Both times were significantly longer in GII compared to GI. ConclusionDual graft living donor liver transplantation is surely a technically more challenging and demanding procedure. Therefore the total anesthesia time is longer, especially the anhepatic phase, because there are more graft vessels to be reconstructed before reperfusion. Overall the anesthetic management in terms of blood transfusion, fluid administration, sodium bicarbonate, calcium supplement, and the number of patients requiring fractional diluted noradrenaline support for maintenance of acceptable hemodynamic were not much different between the 2 groups.

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.

Octreotide prevents liver failure through upregulating 5'-methylthioadenosine in extended hepatectomized rats.

Insufficient liver regeneration and hepatocyte injury caused by excessive portal perfusion are considered to be responsible for post-hepatectomy liver failure (PLF) or small-for-size syndrome in living-donor liver transplantation. Somatostatin can decrease portal vein pressure (PVP) but simultaneously inhibits liver regeneration. This interesting paradox motivated us to investigate the outcome of PLF in response to somatostatin treatment. Rats receiving extended partial hepatectomy (90% PH) were treated with octreotide, a somatostatin analogue, or placebo. Animal survival, serum parameters and hepatic histology were evaluated. Metabolomic analysis was performed to investigate the effect of octreotide on hepatocyte metabolism. Despite significantly inhibiting early regeneration, octreotide application noticeably improved the hepatic histology, liver function and survival after PH but did not decrease the PVP level. Metabolomic analysis exhibited that octreotide profoundly and exclusively altered the levels of five metabolites that participate in or closely associate with the methionine cycle, a biochemical reaction that uniquely produces S-adenosylmethionine (SAMe), an active methyl residual donor for methyltransferase reactions. Among these metabolites, 5'-methylthioadenosine (MTA), a derivate of SAMe, increased three-fold and was found independently improve the hepatic histology and reduce inflammatory cytokines in hepatectomized rats. Octreotide exclusively regulates the methionine cycle reaction and augments the MTA level in hepatocytes. MTA prominently protects hepatocytes against shear stress injury and reduces the secondary inflammation, thereby protecting rats from PLF.

Smoothing the path: Reducing biliary complications, addressing small-for-size syndrome, and making other adaptations to decrease the risk for living donor liver transplant recipients

1. Over the course of the past 2 decades, living donor liver transplantation (LDLT) has become increasingly successful because many of the technical issues plaguing it have been resolved. 2. Although donor safety remains a concern, most challenges related to the recipient's surgery are now better understood, and they appear surmountable. 3. The following concepts need to be addressed for optimal recipient outcomes to be achieved: a. Reduction of the risk of small-for-size syndrome in LDLT (ie, the management of 4 factors: the recipient status, the portal pressure and inflow, the venous outflow, and the graft-to-recipient weight ratio/graft quality). b. Reduction of the risk of surgical complications (biliary complications, reconstitution of the middle hepatic vein outflow in the right lobe graft, and safe hepatic artery and portal vein reconstruction). c. Other adaptations for improving recipient outcomes (adaptations related to LDLT and adaptations common to deceased donor liver transplantation and LDLT).

The beneficial role of simultaneous splenectomy in living donor liver transplantation in patients with small-for-size graft

Small-for-size (SFS) graft syndrome is one of the major causes of graft loss in living donor liver transplantation (LDLT). We examined whether splenectomy is beneficial for overcoming SFS graft syndrome in LDLT. The patients were classified into two groups: the Sp (-) group (n=69), in which splenectomy was not performed, and the Sp (+) group (n=44), in which it was. The incidence of SFS graft syndrome was investigated. Risk factors of SFS graft syndrome were identified by univariate- and multivariate analysis. To clarify whether splenectomy is beneficial for patients with a SFS graft, subgroup analysis was performed for patients who had a graft weight-to-standard liver weight (GW-SLW) ratio of 40% or less (n=50). Thirty-one of 113 patients developed SFS graft syndrome. A multivariate analysis identified that having a male donor was an independent risk factor of SFS graft syndrome. SFS graft syndrome occurred in 11 of 50 patients with a GW-SLW ratio<40%, and Sp (-) was an independent risk factor for the occurrence of SFS graft syndrome in patients (P=0.014). Simultaneous splenectomy is favorable for overcoming SFS graft syndrome in LDLT patients with a GW-SLW of 40% or less.

Transient portocaval shunt for a small-for-size graft in living donor liver transplantation

We read with interest the article by Taniguchi et al. from Hokkaido University.1 They proposed the usefulness of transient portocaval shunt, closed with an endoloop, for the management of small-for-size graft syndrome in living donor liver transplantation (LDLT). Although we appreciated their tactful technique for shunt closure without laparotomy, we do not, however, agree with its universal application in LDLT using small grafts. There have been several concepts reported for the management of small-for-size graft syndrome in LDLT. A simple way is to increase the graft volume by the application of right-lobe LDLT or auxiliary LDLT.2, 3 Another way is decompression of the excessive portal pressure and flow into a small graft. This includes the formation of a portocaval shunt or performing splenectomy or splenic artery ligation.1, 4 As described in their report, the dilemma in the application of a portacaval shunt is that it itself may jeopardize the graft regeneration.1 The systemic venous pressure is always lower than the portal system pressure, and graft regeneration would still increase the intragraft portal pressure. It may possibly cause graft nonfunction caused through the decreased graft portal flow by a stealing mechanism. As we have previously reported, splenectomy or splenic artery ligation is a simple concept for decompression of portal hypertension. With these maneuvers, portal pressure can always be pulled down to around 20 cm H2O.4 The hemodynamic status over the recipient's posttransplant time course and the graft is much simpler in splenectomy or splenic artery ligation than in a portacaval shunt, which might need manual closure in association with graft regeneration.1 The positive points of a splenectomy include not only the decompression of portal hypertension but also increased leukocyte and platelet counts.4 Moreover, the surgical techniques for splenectomy have improved dramatically with the recent introduction of a vessel sealing system.5 Our indication for establishing a portocaval shunt is limited only by portal system pressure greater than 20 mm Hg after the performance of splenectomy or splenic artery ligation. Moreover, the graft volume/standard liver volume (GV/SLV) ratio described in the report by Taniguchi et al.1 is 35.8%. As we previously reported, our key GV/SLV value for the choice of graft is 35%.2 If the GV/SLV is less than 35% in the left-lobe graft, the right-lobe graft is chosen. However, several cases in our series eventually had GV/SLV < 30% with a 1-year graft survival of 80%.2 Thus, we question why they needed to perform temporary portacaval shunt for that case. Indeed, what are the details of their indication of temporary portacaval shunt? We would have just performed splenectomy for that GV/SLV = 35.6% case and might have undertaken a portacaval shunt if the portal pressure after splenectomy had been greater than 20 mm Hg. Toru Ikegami*, Satoru Imura*, Yusuke Arakawa*, Mitsuo Shimada*, * Department of Surgery, University of Tokushima, Kuramoto-cho Tokushima, Japan.