Adult-to-adult living donor liver transplantation using extended right lobe grafts

Adult-to-adult living donor liver transplantation for acute liver failure in China

AIM: To investigate the long-term outcome of recipients and donors of adult-to-adult living-donor liver transplantation (AALDLT) for acute liver failure (ALF).

METHODS: Between January 2005 and March 2010, 170 living donor liver transplantations were performed at West China Hospital of Sichuan University. All living liver donor was voluntary and provided informed consent. Twenty ALF patients underwent AALDLT for rapid deterioration of liver function. ALF was defined based on the criteria of the American Association for the Study of Liver Diseases, including evidence of coagulation abnormality [international normalized ratio (INR) ≥ 1.5] and degree of mental alteration without pre-existing cirrhosis and with an illness of < 26 wk duration. We reviewed the clinical indications, operative procedure and prognosis of AALDTL performed on patients with ALF and corresponding living donors. The potential factors of recipient with ALF and corresponding donor outcome were respectively investigated using multivariate analysis. Survival rates after operation were analyzed using the Kaplan-Meier method. Receiver operator characteristic (ROC) curve analysis was undertaken to identify the threshold of potential risk factors.

RESULTS: The causes of ALF were hepatitis B (n = 18), drug-induced (n = 1) and indeterminate (n = 1). The score of the model for end-stage liver disease was 37.1 ± 8.6, and the waiting duration of recipients was 5 ± 4 d. The graft types included right lobe (n = 17) and dual graft (n = 3). The mean graft weight was 623.3 ± 111.3 g, which corresponded to graft-to-recipient weight ratio of 0.95% ± 0.14%. The segment Vor VIII hepatic vein was reconstructed in 11 right-lobe grafts. The 1-year and 3-year recipient’s survival and graft survival rates were 65% (13 of 20). Postoperative results of total bilirubin, INR and creatinine showed obvious improvements in the survived patients. However, the creatinine level of the deaths was increased postoperatively and became more aggravated compared with the level of the survived recipients. Multivariate analysis showed that waiting duration was independently correlated with increased mortality (P = 0.014). Furthermore, ROC curve revealed the cut-off value of waiting time was 5 d (P = 0.011, area under the curve = 0.791) for determining the mortality. The short-term creatinine level with different recipient’s waiting duration was described. The recipients with waiting duration ≥ 5 d showed the worse renal function and higher mortality than those with waiting duration < 5 d (66.7% vs 9.1%, P = 0.017). In addition, all donors had no residual morbidity. Furthermore, univariate analysis did not show that short assessment time induced the high morbidity (P = 0.573).

CONCLUSION: Timely AALDLT for patients with ALF greatly improves the recipient survival. However, further systemic review is needed to investigate the optimal treatment strategy for ALF.

Relationship between preoperative volume and weight of the right liver lobe graft, with and without the middle hepatic vein, in living-donor transplantation

BACKGROUND

The aim of this study was to assess the relationship between the preoperative volume of the right liver lobe (as determined by computed tomography) and the intraoperative graft weight with or without the middle hepatic vein.

METHODS

Sixty-three patients who underwent liver transplantation were included in this study. The preoperative volumes of both the left and the right liver lobe were measured in all patients using computed tomography. The intraoperative weight of the right liver lobe was also measured with (group 1, n = 29) and without (group 2, n = 34) the middle hepatic vein. The results were compared with respect to gender, age, body weight, height, body mass index (BMI), weights of the left and right liver lobes as measured by computed tomography, and intraoperative weight of the right liver lobe.

RESULTS

A 21.64 % difference was observed between the weight of the right liver lobe as measured by computed tomography and the weight of the right lobe without the hepatic vein as measured intraoperatively (group 2). Moreover, a 12.38 % difference was observed between the weight of the right liver lobe as measured by computed tomography and the weight of the right lobe plus the middle hepatic vein as measured intraoperatively (group 1).

CONCLUSIONS

The weight of the right liver lobe graft in a living-donor transplantation is less than that calculated by preoperative computed tomography, and the inclusion of the middle hepatic vein in the right liver lobe graft resulted in a statistically significant decrease in this difference.

The "carving" liver partitioning technique for graft hepatectomy in live donor liver transplantation: a single-center experience

BACKGROUND

In adult live donor liver transplantation, postoperative venous congestion of graft and remnant livers can lead to life-threatening complications. The purpose of this study was to evaluate the safety and benefits of our 3-dimensional, computed tomographic, computer-assisted donor hepatectomy using the "carving" partitioning technique.

METHODS

Eighty-three consecutive adult live donor liver transplantations were performed based on data obtained from individualized preoperative 3-dimensional, computed tomographic reconstructions and virtual graft hepatectomies.

RESULTS

There were 71 right and 12 left grafts. Small grafts (graft volume body weight ratio, <1.0) were used in 20 cases. We observed no clinically important differences in postoperative function between right and left grafts. Four recipients developed lethal small-for-size syndrome. Reversible small-for-size syndrome was observed in a right graft recipient and in 2 right graft donors.

CONCLUSION

Preoperative 3-dimensional, computed tomographic, computer-assisted planning using virtual liver partitioning allowed for: (1) an individualized carving technique based on specific donor anatomic characteristics, (2) donor safety based on individualized patterns of venous outflow, and (3) optimized drainage of the medial area of the graft based on the preferential inclusion of the middle hepatic vein.

Hepatic artery reconstruction in living donor liver transplantation: running suture under surgical loupes by cardiovascular surgeons in 180 recipients

OBJECTIVES

The aim of our study was to retrospectively investigate the outcomes of hepatic artery (HA) reconstruction by cardiovascular surgeons in adult-to-adult living donor liver transplantation (A-A LDLT).

METHODS

From April 2007 to April 2011, 187 recipients underwent A-A LDLT. After excluding seven ABO-incompatible transplant recipients, we reviewed the courses of 180 patients including 125 men and 55 women of mean age 52.5±9.2 years (range=23-71). One hundred seventy-seven patients received right-lobe grafts with inclusion of middle hepatic vein (MHV); two, right-lobe grafts without MHV; and one, left-lobe graft. A continuous, single-stitch, running suture with the parachute technique was used for HA reconstruction. The anastomosis was performed by cardiovascular surgeons employing surgical loupes with 4.5× magnification.

RESULTS

The mean time for an arterial reconstruction was 10.7±4.0 minutes (median=10, range=4-30). Hepatic arterial thrombosis (HAT) was encountered in 3 (1.66%) patients. One HAT that developed on postoperative day 1 was successfully rescued by the intra-arterial infusion of urokinase. Another patient required reoperation due to a redundant kinked HA. A third HAT patient underwent successful retransplantation with a cadaveric graft on postoperative day 6. In our series, no delayed HAT was detected and no recipient deaths were related to HAT.

CONCLUSION

HA reconstruction with a running suture under surgical loupes is a feasible technique in A-A LDLT. A speedy reconstruction can be performed by an experienced cardiovascular surgeon with a low incidence of HAT.

A learning curve for living donor liver transplantation

BACKGROUND

The number of living donor liver transplantations performed has increased rapidly in many Eastern transplant centres. However, the impact of the transplant centres' experience and learning on the transplant outcomes are not well established. Aim of the study was to evaluate the learning curve for living donor liver transplantation in our centre.

METHODS

Data from 156 recipients and 156 donors who underwent surgery were reviewed. Intraoperative data and postoperative outcomes of both donors and recipients were retrospectively analysed. Recipients and donors were divided into three groups that consisted of 52 consecutive cases each.

RESULTS

Surgical duration and intraoperative blood loss during donor surgery were decreased significantly between the earlier and the more recent cases (423±39 vs. 400±44 min and 959±523 vs. 731±278 mL, respectively; P<0.01). Rates of postoperative complications and functional changes were not statistically different amongst the three donor groups. Immediate complication rate of the first 52 recipients was higher than those of the second and third cohorts. Long-term survival rates of the three recipient groups were similar.

CONCLUSIONS

The learning curve greatly influenced immediate outcomes of recipients during the early transplant period. However, it had little influence on donor outcome; long-term outcome improvement of recipients did not depend on the accumulation of experience alone.

Outcome of right hepatectomy for living liver donors: a single Egyptian center experience

BACKGROUND

This study aims to evaluate living liver donor outcome after right hepatectomy in a single Egyptian center.

PATIENTS AND METHODS

Between April 2004 and July 2010, 100 living donors underwent right hepatectomy. Their medical records and postoperative follow-up visits were retrospectively revised. Perioperative complications were reported. Postoperative complications were classified according to the five tier version of Clavien system.

RESULTS

There were 71 males and 29 females. The mean age was 27.6 ± 7.4 years. The mean graft weight was 999 ± 167 g and the mean volume percent of the remaining liver was 36.8 ± 8%. The mean ICU and hospital stay were 2.6 ± 2.7 and 12.4 ± 9.1, respectively. A total of 57 complications developed in 38 donors (38%). The commonest complication type was biliary complications. There were 22 grade I, 6 grade II, 15 grade IIIa, 12 grade IIIb, 1 grade IVa, and 1 grade V complications. One donor died due to posttransfusion ARDS on the 30th postoperative day. On follow-up, no donor developed long lasting disability. A donor died in a road traffic accident 1 year after donation.

DISCUSSION AND CONCLUSIONS

Donor right hepatectomy is not an entirely safe procedure. Biliary complications are the commonest early postoperative complications.

Systematic review: extracorporeal bio-artificial liver-support system for liver failure

BACKGROUND

Orthotopic liver transplantation (OLT) is the only effective long-term treatment for liver failure by now. However, it is not yet a perfect choice due to donor-organ shortage and the need of a lifelong immunosuppressive therapy. Therefore, it is necessary to find a new approach to fighting the disease. Several published clinical trials have reported the therapeutic effect of bio-artificial liver (BAL) for liver failure.

OBJECTIVE

To overview and evaluate the current clinical application and outcomes of extracorporeal BAL support system during the past 15 years.

METHODS

Relevant studies were retrieved from PubMed and Cochrane Library databases. Independent assessments and the final consensus decision were performed by three independent reviewers. Acceptable study designs included randomized controlled trials, controlled clinical trials, and case reports. A total of 31 studies were tabulated and critically appraised in terms of characteristics, methods, and outcomes.

RESULTS

There was a trend of falling into the normal ranges with the clinical and biochemical parameters after the BAL treatment. The neurological status of most patients was improved or stabilized during BAL treatment as well. No significant effect on survival could be seen after the BAL treatment.

CONCLUSIONS

Although BAL system proved to be a success in some clinical cases reported, it still needs to be improved greatly.

"Inherent limitations" in donors: control matched study of consequences following a right hepatectomy for living donation and benign liver lesions

OBJECTIVE

The aim of this study was to identify "inherent limitations" in healthy donors who are responsible for donor morbidity after right hepatectomy (RH) for adult-to-adult living donor liver transplantation (ALDLT).

BACKGROUND

Right hepatectomy for ALDLT remains a challenging procedure without significant improvement in morbidity over time. This suggests some "inherent limitations" in healthy individuals, which are beyond the recent improvements in the donor evaluation and selection process and refinements in surgical technique during the learning curve.

METHODS

To identify response of RH in ALDLT, we prospectively studied 32 patients requiring an RH for benign liver lesions (BL), matched with 32 living donors (LD) operated by same team. All patients underwent liver volume evaluation by computed tomographic (CT) volumetry preoperatively and 1 week after RH, postoperative complications graded with Clavien's system.

RESULTS

The comparison (LD vs BL) showed that remnant liver volume (RLV) on preoperative CT volumetry was higher in the BL group (450 ± 150 vs 646 ± 200 mL, P < 0.001) representing 31% ± 7% in LD group versus 36% ± 7% of the total liver volume in BL group (P = 0.03). On postoperative day 7, the RLV was similar in the 2 groups (866 ± 162 vs 941 ± 153 mL) resulting from a significantly higher regeneration rate in the LD group (89% vs 55%, P = 0.009). Overall complications rate was lower in the BL group (46% vs 21%, P = 0.035).

CONCLUSIONS

Right hepatectomy in LDLT induces a more severe deprivation of liver volume than in BL, which induce an accelerated regeneration. Accelerated regeneration could represent "inherent limitation" in healthy donors that makes them more vulnerable for postoperative complications.

Clinical anatomy related to the hepatic veins for right lobe living donor liver transplantation

The complexity of liver reconstruction has limited partial right lobe living donor liver transplantation. It is largely due to the difficulty of dealing with the middle hepatic vein. We sought to define the anatomic features of hepatic veins. Forty-one fresh adult livers, 43 formalin-fixed adult cadaver livers, and 91 adult liver corrosion casts were used for the study. We determined the number of branches, the maximum diameter, the whole length, the extrahepatic length of the hepatic veins, and the deviation of the middle hepatic vein from the main portal fissure. Nakamura and Tsuzuki's classification of hepatic vein types was used. Type A, B, and C accounted for 59.4, 27.8, and 12.8% of all specimens in this study, respectively. The middle and left hepatic veins formed a common trunk in 60.3% of the specimens, and the length of the common trunk was 1.12 ± 0.62 cm. The degree of deviation to the right of the middle hepatic vein from the main portal fissure was 14.11° ± 12.65°. The frequency of hepatic vein types and the degree of deviation to the right of the middle hepatic vein in this study is markedly different from that reported in other literature. The anatomic features of the hepatic veins in this study suggest that right lobe living donor liver transplantation is more suitable for Chinese.

Left lobe adult-to-adult living donor liver transplantation: Should portal inflow modulation be added?

Recently, the successful application of portal inflow modulation has led to renewed interest in the use of left lobe grafts in adult-to-adult living donor liver transplantation (LDLT). However, data on the hepatic hemodynamics supporting portal inflow modulation are limited, and the optimal portal circulation for a liver graft is still unclear. We analyzed 42 consecutive adult-to-adult left lobe LDLT cases without splenectomy or a portocaval shunt. The mean actual graft volume (GV)/recipient standard liver volume (SLV) ratio was 39.8% ± 5.7% (median = 38.9%, range = 26.1%-54.0%). The actual GV/SLV ratio was less than 40% in 24 of the 42 cases, and the actual graft-to-recipient weight ratio was less than 0.8% in 17 of the 42 recipients. The mean portal vein pressure (PVP) was 23.9 ± 7.6 mm Hg (median = 23.5 mm Hg, range = 9-38 mm Hg) before transplantation and 21.5 ± 3.6 mm Hg (median = 22 mm Hg, range = 14-27 mm Hg) after graft implantation. The mean portal pressure gradient (PVP - central venous pressure) was 14.5 ± 6.8 mm Hg (median = 13.5 mm Hg, range = 3-26 mm Hg) before transplantation and 12.4 ± 4.4 mm Hg (median = 13 mm Hg, range = 1-21 mm Hg) after graft implantation. The mean posttransplant portal vein flow was 301 ± 167 mL/minute/100 g of liver in the 38 recipients for whom it was measured. None of the recipients developed small-for-size syndrome, and all were discharged from the hospital despite portal hyperperfusion. The overall 1-, 3-, and 5-year patient and graft survival rates were 100%, 97%, and 91%, respectively. In conclusion, LDLT with a left liver graft without splenectomy or a portocaval shunt yields good long-term results for adult patients with a minimal donor burden.

Estimates of early death, acute liver failure, and long-term mortality among live liver donors

BACKGROUND & AIMS

We sought to estimate the risk of perioperative mortality or acute liver failure for live liver donors in the United States and avoid selection or ascertainment biases and sample size limitations.

METHODS

We followed up 4111 live liver donors in the United States between April 1994 and March 2011 for a mean of 7.6 years; deaths were determined from the Social Security Death Master File. Survival data were compared with those from live kidney donors and healthy participants of the National Health and Nutrition Examination Survey (NHANES) III.

RESULTS

Seven donors had early deaths (1.7 per 1000; 95% confidence interval [CI], 0.7-3.5); risk of death did not vary with age of the liver recipient (1.7 per 1000 for adults vs 1.6 per 1000 for pediatric recipients; P = .9) or portion of liver donated (2.0 per 1000 for left lateral segment, 2.8 per 1000 for left lobe, and 1.5 per 1000 for right lobe; P = .8). There were 11 catastrophic events (early deaths or acute liver failures; 2.9 per 1000; 95% CI, 1.5-5.1); similarly, risk did not vary with recipient age (3.1 per 1000 adult vs 1.6 per 1000 pediatric; P = .4) or portion of liver donated (2.0 per 1000 for left lateral segment, 2.8 per 1000 for left lobe, and 3.3 per 1000 for right lobe; P = .9). Long-term mortality of live liver donors was comparable to that of live kidney donors and NHANES participants (1.2%, 1.2%, and 1.4% at 11 years, respectively; P = .9).

CONCLUSIONS

The risk of early death among live liver donors in the United States is 1.7 per 1000 donors. Mortality of live liver donors does not differ from that of healthy, matched individuals over a mean of 7.6 years.

Quantitative radiology: automated CT liver volumetry compared with interactive volumetry and manual volumetry

OBJECTIVE

The purpose of this study was to evaluate automated CT volumetry in the assessment of living-donor livers for transplant and to compare this technique with software-aided interactive volumetry and manual volumetry.

MATERIALS AND METHODS

Hepatic CT scans of 18 consecutively registered prospective liver donors were obtained under a liver transplant protocol. Automated liver volumetry was developed on the basis of 3D active-contour segmentation. To establish reference standard liver volumes, a radiologist manually traced the contour of the liver on each CT slice. We compared the results obtained with automated and interactive volumetry with those obtained with the reference standard for this study, manual volumetry.

RESULTS

The average interactive liver volume was 1553 ± 343 cm(3), and the average automated liver volume was 1520 ± 378 cm(3). The average manual volume was 1486 ± 343 cm(3). Both interactive and automated volumetric results had excellent agreement with manual volumetric results (intraclass correlation coefficients, 0.96 and 0.94). The average user time for automated volumetry was 0.57 ± 0.06 min/case, whereas those for interactive and manual volumetry were 27.3 ± 4.6 and 39.4 ± 5.5 min/case, the difference being statistically significant (p < 0.05).

CONCLUSION

Both interactive and automated volumetry are accurate for measuring liver volume with CT, but automated volumetry is substantially more efficient.

Living donor hepatectomy: the importance of the residual liver volume

Living liver donation is a successful treatment for patients with end-stage liver disease. Most adults are provided with a right lobe graft to ensure a generous recipient liver volume. Some centers are re-exploring the use of smaller left lobe grafts to potentially reduce the donor risk. However, the evidence showing that the donor risk is lower with left lobe donation is inconsistent, and most previous studies have been limited by potential learning curve effects, small sample sizes, or poorly matched comparison groups. To address these deficiencies, we conducted a case-control study. Forty-five consecutive patients who underwent left hepatectomy (LH; n = 4) or left lateral segmentectomy (LLS; n = 41) were compared with matched controls who underwent right hepatectomy (RH) or extended right hepatectomy (ERH). The overall complication rates of the 3 groups were similar (31%-37%). There were no grade 4 or 5 complications. There were more grade 3 complications for the RH patients (13.3%) and the ERH patients (15.6%) versus the LH/LLS patients (2.2%). The extent of the liver resection significantly correlated with the peak international normalized ratio (INR), the days to INR normalization, and the peak bilirubin level. A univariate analysis demonstrated that hepatectomy, the spared volume percentage, and the peak bilirubin level were strongly associated with grade 3 complications. A higher peak bilirubin level, which correlated with a lower residual liver volume, was associated with grade 3 complications in a multivariate analysis (P = 0.005). RH and grade 3 complications were associated with an increased length of stay (>7 days) in a multivariate analysis. In conclusion, this analysis demonstrates a significant correlation between the residual liver volume and liver dysfunction, serious adverse postoperative events, and longer hospital stays. Donor safety should be the first priority of all living liver donor programs. We propose that the surgical procedure removing the smallest amount of the liver required to provide adequate recipient graft function should become the standard of care for living liver donation.

Technical aspects of biliary reconstruction in adult living donor liver transplantation

BACKGROUND

The last decade has witnessed great progress in living donor liver transplantation worldwide. However, biliary complications are more common in partial liver transplantation than in whole liver transplantation. This is due to an impaired blood supply of the hilar bile duct during organ procurement and recipient surgery, commonly encountered anatomical variations, a relatively small graft duct, and complicated surgical techniques used in biliary reconstruction.

DATA SOURCES

MEDLINE and PubMed were searched for articles on "living donor liver transplantation", "biliary complication", "anatomical variation", "biliary reconstruction", "stenting" and related topics.

RESULT

In this review, biliary complications were analyzed with respect to anatomical variation, surgical techniques in biliary reconstruction, and protection of the arterial plexus of the hilar bile duct.

CONCLUSION

Transecting the donor bile duct at the right place to secure a larger bile duct stump, anastomosing techniques, and stenting methods as well as preserving the blood supply to the bile duct are all important in reducing biliary complications.

Morphometric analysis of conformational changes in hepatic venous system after right lobe living donor liver transplantation

AIM

  After living donor liver transplantation (LDLT), the graft liver regenerates to the standard liver volume. However, little is known about the influence of this phenomenon on the hepatic venous system.

METHODS

  Fourteen right lobe LDLT without the middle hepatic vein were included in this study. Computed tomography before and 1 month after LDLT was performed to measure the inflow angle of the right hepatic vein (RHV), the aspect ratio of the inferior vena cava (IVC), the coordinate position of IVC and diameter of RHV. In addition, the regeneration index (RI) was determined on each liver segment.

RESULTS

  RHV showed a clockwise rotation at early postoperative months, the average increase of the inflow angle being 14.5 ± 15.6 (mean ± standard deviation) degrees. IVC was shifted from right to left with a deformity to a long oval shape on horizontal sections. The center of IVC moved dorsally at an average of 0.55 ± 0.77 cm and leftward at an average of 0.82 ± 0.89 cm. Diameter of RHV decreased at an average of 0.65 ± 0.39 cm at its root. The extent of liver regeneration was more prominent in the posterior segment as compared to the anterior segment, the average RI values being 1.65 ± 0.65 and 1.17 ± 0.44, respectively (P < 0.05). Hepatic vein outflow block (HVOB) was encountered in two patients with a marked conformational deformity observed in the hepatic venous system at early postoperative months after LDLT.

CONCLUSION

  After right lobe LDLT, the hepatic venous system exhibits a profound conformational change, which most likely plays a role in the onset of HVOB.

Strategies for widening liver donor pool

Liver transplantation is a life-saving treatment modality, but is hindered by the scarcity of deceased-donor liver grafts. To acquire more liver grafts and thus save more lives, various techniques have been devised and policies adopted, including living-donor, split-graft and sequential liver transplantation; extended donor criteria; and donation after cardiac death. However, with these techniques and policies come a range of entailed medical concerns and concomitant ethical dilemmas, mainly bearing on the welfare of donors and potential donors. In this article, we provide an overview of how the transplant community works towards the end of extending the liver donor pool, with the aim of ensuring that more liver transplant candidates receive their transplant as early as possible. The current strategies in Hong Kong in this regard are also reviewed.

Bile duct anastomotic stricture after adult-to-adult right lobe living donor liver transplantation

Duct-to-duct anastomosis (DDA) and hepaticojejunostomy (HJ) are options for biliary reconstruction in patients undergoing adult-to-adult right lobe living donor liver transplantation (ARLDLT), after which biliary anastomotic stricture (BAS) is common as a complication. The risk factors for BAS are not clearly defined. We aimed to determine the rate of post-ARLDLT BAS in our center and its associated factors. In 265 ARLDLT recipients, 55 (20.8%) developed postoperative BAS. The diagnosis was based on clinical, biochemical, histological, and radiological results. The BAS rates were 21.4% (43/201) for recipients undergoing DDA during transplantation, 18.9% (10/53) for recipients undergoing HJ, and 18.2% (2/11) for recipients undergoing both procedures. BAS and non-BAS patients had comparable demographics. The number of graft bile duct openings (P = 0.516) and the size of the graft's smallest bile duct (5 versus 5 mm, P = 0.4) were not significantly different between BAS and non-BAS patients. Univariate analysis showed that the factors associated with postoperative BAS were the recipient warm ischemia time (55 versus 51 minutes, P = 0.026), graft cold ischemia time (120 versus 108 minutes, P = 0.046), stent use (21.8% versus 7.1%, P = 0.001), postoperative acute cellular rejection (29.1% versus 11.0%, P = 0.001), and University of Wisconsin solution use (21.8% versus 7.1%, P = 0.001). Multivariate analysis showed that the cold ischemia time (odds ratio = 1.012, 95% confidence interval = 1.002-1.023, P = 0.014) and acute rejection (odds ratio = 3.180, 95% confidence interval = 1.606-6.853, P = 0.002) were significant factors. The graft survival rates of BAS and non-BAS patients were comparable. One patient required retransplantation for secondary biliary cirrhosis. In conclusion, BAS remains common after ARLDLT regardless of DDA or HJ. The graft cold ischemia time and postoperative acute cellular rejection are significantly associated with postoperative BAS.

Short- and long-term donor morbidity in right lobe living donor liver transplantation: 91 consecutive cases in a European Center

The lack of use of a common grading system in reporting morbidity impedes estimation of the true risk to a right lobe living donor (RLLD). We report outcomes in 91 consecutive RLLD's using the validated 5-tier Clavien grading and a quality of life (QOL) questionnaire. The median follow-up was 79 months. The donors were predominantly female (66%), 22 (24%) received autologous blood transfusions. Fifty-three complications occurred in 43 donors (47% morbidity), 19 (37%) were ≥ Grade III, biliary fistula (14%) was the most common. There was no donor mortality. Two intraoperative complications could not be graded and two disfiguring complications in female donors were graded as minor. Two subgroups (first 46 vs. later 45 donors) were compared to study the presence if any, of a learning curve. The later 45 donors had lesser autologous transfusions, lesser rehospitalization and no reoperation and a reduction in the proportion of ≥ Grade III (major) complications (24% vs. 50%; p = 0.06). In the long term, donors expressed an overall sense of well being, but some sequelae of surgery do restrain their current lifestyle. Our results warn against lackadaisical vigilance once RLLD hepatectomy becomes routine.

Living donor liver transplantation: effect of the type of liver graft donation on donor mortality and morbidity

To investigate the influence of the type of liver graft donation on donor mortality and morbidity. The clinical course of 87 living liver donors operated on at our center between 2002 and 2009 was retrospectively analysed and data pertaining to all complications were retrieved. No donor mortality was observed and no donor suffered any life-threatening complication. Four donors (4.6%) developed biliary leakage, nine (10.3%) had to be readmitted to hospital and six (6.9%) required some or other type of reoperation related to the previous liver donation. Reoperations included incisional or diaphragmatic hernia repair (n = 4), biliary leakage repair (n = 1) and segmental colon resection combined with diaphragmatic hernia repair (n = 1). There was a statistically significant difference in hospital stay (P < 0.001), autologous blood transfusions (P < 0.001) and operating time (P < 0.005) when right lobe donations (Segments V-VIII) were compared with left lobe (Segments II-IV) and left lateral lobe (Segments II-III) donations, whereas no difference was found between these groups regarding hospital readmission, operative revisions and the incidence or severity of complications. Right lobe donation was associated with prolonged hospital stay, increased blood transfusions and prolonged operating time when compared with left and left lateral lobe donation, whereas donor mortality and morbidity did not differ between these groups.

History of hepatic surgery

This article describes the development of hepatic surgery from old anecdotes to spectacular progress achieved during the last 25 years. The door to this evolution was opened by anatomists who paved the way for a few courageous hepatic surgeons, who performed pioneering work between 1960 to 1980. Then, hepatic surgery and transplantation became widely accepted for the treatment of many diseases. Surgery on the liver has become safer with low postoperative mortality as a result of the creation of centers of excellence offering multidisciplinary expertise and technical innovation.

Safety of small-for-size grafts in adult-to-adult living donor liver transplantation using the right lobe

The problem of graft size is one of the critical factors limiting the expansion of adult-to-adult living donor liver transplantation (LDLT). We compared the outcome of LDLT recipients who received grafts with a graft-to-recipient weight ratio (GRWR) < 0.8% or a GRWR > or = 0.8%, and we analyzed the risk factors affecting graft survival after small-for-size grafts (SFSGs) were used. Between June 1997 and April 2008, 427 patients underwent LDLT with right lobe grafts at the Department of Surgery of Samsung Medical Center. Recipients were divided into 2 groups: group A with a GRWR < 0.8% (n = 35) and group B with a GRWR > or = 0.8% (n = 392). We retrospectively evaluated the recipient factors, donor factors, and operative factors through the medical records. Small-for-size dysfunction (SFSD) occurred in 2 of 35 patients (5.7%) in group A and in 14 of 392 patients (3.6%) in group B (P = 0.368). Graft survival rates at 1, 3, and 5 years were not different between the 2 groups (87.8%, 83.4%, and 74.1% versus 90.7%, 84.5%, and 79.4%, P = 0.852). However, when we analyzed risk factors within group A, donor age and middle hepatic vein tributary drainage were significant risk factors for graft survival according to univariate analysis (P = 0.042 and P = 0.038, respectively). Donor age was the only significant risk factor for poor graft survival according to multivariate analysis. The graft survival rates of recipients without SFSD tended to be higher than those of recipients with SFSD (85.3% versus 50.0%, P = 0.074). The graft survival rates of recipients with grafts from donors < 44 years old were significantly higher than those of recipients with grafts from donors > or = 44 years old (92.2% versus 53.6%, P = 0.005). In conclusion, an SFSG (GRWR < 0.8%) can be used safely in adult-to-adult right lobe LDLT when a recipient is receiving the graft from a donor younger than 44 years.

Computer-aided measurement of liver volumes in CT by means of geodesic active contour segmentation coupled with level-set algorithms

PURPOSE

Computerized liver extraction from hepatic CT images is challenging because the liver often abuts other organs of a similar density. The purpose of this study was to develop a computer-aided measurement of liver volumes in hepatic CT.

METHODS

The authors developed a computerized liver extraction scheme based on geodesic active contour segmentation coupled with level-set contour evolution. First, an anisotropic diffusion filter was applied to portal-venous-phase CT images for noise reduction while preserving the liver structure, followed by a scale-specific gradient magnitude filter to enhance the liver boundaries. Then, a nonlinear grayscale converter enhanced the contrast of the liver parenchyma. By using the liver-parenchyma-enhanced image as a speed function, a fast-marching level-set algorithm generated an initial contour that roughly estimated the liver shape. A geodesic active contour segmentation algorithm coupled with level-set contour evolution refined the initial contour to define the liver boundaries more precisely. The liver volume was then calculated using these refined boundaries. Hepatic CT scans of 15 prospective liver donors were obtained under a liver transplant protocol with a multidetector CT system. The liver volumes extracted by the computerized scheme were compared to those traced manually by a radiologist, used as "gold standard."

RESULTS

The mean liver volume obtained with our scheme was 1504 cc, whereas the mean gold standard manual volume was 1457 cc, resulting in a mean absolute difference of 105 cc (7.2%). The computer-estimated liver volumetrics agreed excellently with the gold-standard manual volumetrics (intraclass correlation coefficient was 0.95) with no statistically significant difference (F = 0.77; p(F < or = f) = 0.32). The average accuracy, sensitivity, specificity, and percent volume error were 98.4%, 91.1%, 99.1%, and 7.2%, respectively. Computerized CT liver volumetry would require substantially less completion time (compared to an average of 39 min per case by manual segmentation).

CONCLUSIONS

The computerized liver extraction scheme provides an efficient and accurate way of measuring liver volumes in CT.

Evolution of a reliable biliary reconstructive technique in 400 consecutive living donor liver transplants

BACKGROUND

Biliary complications (BCs) are a major cause of morbidity and mortality after living donor liver transplantation (LDLT). They occur because the graft hepatic ducts are often small, thin walled, multiple, and may become ischemic during transection.

STUDY DESIGN

Of the 460 LDLTs done at our center before November 2009, the first 402 partial liver grafts had at least 3 months of follow-up. In the first 158, conventional hepatic duct isolation was used in the donor (group C). In the last 244 cases, the complete hilar plate and Glissonian sheath approach (HPGS) was used (group H). We compared the incidence and outcomes of BCs in the 2 groups.

RESULTS

The rate of BC was significantly lower in group H (5.3%) than in group C (15.8%, p = 0.000). The incidence of early (within 3 months of transplant) BCs was similarly significantly lower in group H (3.3%) than in group C (13.2%, P=0.000). The incidence of late BCs in the 145 patients in group H who had completed at least 12 months of follow-up was 2.8%.The proportion of BCs needing surgical correction was much higher in group C (44%) than in group H (7.7%, p = 0.022).

CONCLUSIONS

By providing a graft with a well-vascularized hepatic duct or ducts with a sheath of supporting tissue that holds sutures well, the HPGS approach minimizes the incidence and severity of BCs in LDLT.

Biliary complications including single-donor mortality: experience of 207 adult-to-adult living donor liver transplantations with right liver grafts

BACKGROUND

After right lobe donation, biliary complication is the main cause of morbidity. Mortality after right lobe donation has been estimated to be less than 0.5%.

PATIENTS AND METHODS

Between November 2001 and December 2008, 207 adult-to-adult living donor liver transplantations (ALDLT) were undertaken using right lobe grafts. Donors included 173 men and 34 women with a mean age of 28.4 +/- 5.2 years.

RESULTS

Siblings comprised 144 (69.6%) cases whereas unrelated donors comprised 63 (30.4%) with a mean body mass index (BMI) of 25.2 +/- 2.4. Single and multiple right hepatic ducts (RHD) were present in 82 (39.6%) and 125 (60.3%) donors, respectively. Mean operative time was 360 +/- 50 min with an estimated blood loss of 950 +/- 450 ml and returned cell-saver amount of 450 +/- 334 ml. Mean donor remnant liver volume was 33.5 +/- 3.2%. Mean intensive care unit (ICU) stay was 3 +/- 0.7 days and mean hospital stay was 14 +/- 3.5 days. Modified Clavien classifications were used to stratify all donor biliary complications The overall biliary complications occurred in 27 cases (13.0%). After modified Clavien classification, biliary complications were graded as grade I (n= 10), grade II (n= 2), grade III (n= 14) and grade V (n= 1). Grade I and II (n= 12) biliary complications were successfully managed conservatively. Grade III cases were treated using ultrasound-guided aspiration (USGA), endoscopic retrograde cholangiography (ERCP) and surgery in 10, 2 and 2 donors, respectively. Single donor mortality (Grade V) (0.4%) occurred after uncontrolled biliary leakage with peritonitis that necessitated exploration followed by ERCP with stent insertion but the donor died on day 43 as a result of ongoing sepsis.

CONCLUSION

Although the majority of biliary complications are minor and can be managed conservatively, uncontrolled biliary leakage is a serious morbidity that should be avoided as it could lead to mortality.

Adult Living Donor Liver Transplantation with ABO-Incompatible Grafts: A German Single Center Experience

Adult living donor liver transplantations (ALDLTs) across the ABO blood group barrier have been reported in Asia, North Americas, and Europe, but not yet in Germany. Several strategies have been established to overcome the detrimental effects that are attached with such a disparity between donor and host, but no gold standard has yet emerged. Here, we present the first experiences with three ABO-incompatible adult living donor liver transplantations in Germany applying different immunosuppressive strategies. Four patient-donor couples were considered for ABO-incompatible ALDLT. In these patients, resident ABO blood group antibodies (isoagglutinins) were depleted by plasmapheresis or immunoadsorption and replenishment was inhibited by splenectomy and/or B-cell-targeted immunosuppression. Despite different treatments ALDLT could safely be performed in three patients and all patients had good initial graft function without signs for antibody-mediated rejection (AMR). Two patients had long-term graft survival with stable graft function. We thus propose the feasibility of ABO-incompatible ALDLT with these protocols and advocate further expansion of ABO incompatible ALDLT in multicenter trials to improve efficacy and safety.

Analysis of complications in hepatic right lobe living donors

BACKGROUND AND OBJECTIVES

Living donor liver transplantation (LDLT) has been expanding to adult recipients by using right lobe grafts. However, the incidence of complications is more frequent than that involving left lobe grafts. Hence, we aimed to analyze postoperative complications in right lobe liver donors as a step to improve the results in the donors.

METHODS

Three hundred and eleven right lobe liver donors were retrospectively reviewed between February 1998 and December 2003.

RESULTS

The ages of the donors ranged from 19 to 64 years (median: 46 years). Their body mass index ranged from 16.6 to 34.3 (median: 22.1). The mean duration of the operation was 6.58 (1.25) hours and blood loss was 289 (254) mL. The estimated median donor residual liver volume was 42.2% (range: 20.6-60.3%) and the median hospital stay was 14.5 days (range: 6-267 days). One donor died of liver failure due to small residual liver volume (26%) and steatohepatitis. One hundred and twenty three complications occurred in 104 donors (33.4%). Donors experienced one or more complications. According to the Clavien classification, grade I complications occurred in 71 of the episodes (57.7%), grade II complications in 9 (7.3%), grade IIIa complications in 39 (31.7%), grade IIIb complications in 3 (2.5%), and grade V complications in 1 (0.8%). Biliary complications were the most common and occurred in 37 donors (12%).

CONCLUSION

Right lobe liver donation is a widely accepted procedure that results in the expansion of the indication for LDLT to adults and large children. However, remnant liver size and anatomical variations in the biliary tree represent important risk factors for postoperative complications.

Bioartificial liver support systems

A variety of bioartificial liver support systems were developed to replace some of the liver's function in case of liver failure. Those systems, in contrast to purely artificial systems, incorporate metabolically active cells to contribute synthetic and regulatory functions as well as detoxification. The selection of the ideal cell source and the design of more sophisticated bioreactors are the main issues in this field of research. Several systems were already introduced into clinical studies to prove their safety. This review briefly introduces a cross-section of experimental and clinically applied systems and tries to give an overview on the problems and limitations of bioartificial liver support.

Living-donor liver transplantation in adults

INTRODUCTION

The technique of paediatric living-donor liver transplantation (LDLT) has become standardized. In adults, however, there is scope for innovation. Unlike cadaveric whole-size liver transplantation and paediatric LDLT, size matching between the liver graft and the recipient by body weight has been a major challenge in adult LDLT because it is important to provide an adequate graft mass to the recipient while leaving a sufficient mass of remnant liver in the donor to ensure donor safety.

GROWING POINTS

In adult LDLT, liver grafts have been selected to meet graft-recipient size-matching requirements. In 1996, the Hong Kong group pioneered the use of the right-lobe grafts vein to overcome the volume insufficiency often encountered with the left-lobe liver grafts. Subsequently, the Asan group introduced modified right-lobe grafting with interposition vein grafts to drain the venous outflow of the anterior sector, thus increasing the functioning hepatocyte mass, and this group initiated dual left-lobe liver grafts to overcome both donor risk and volume insufficiency.

AREAS OF AGREEMENT AND CONTROVERSY

Although the surgical procedures for both donors and recipients are more complex for adult LDLT than for whole-organ deceased donor transplantation, the outcomes in large-volume centers are now similar. Accordingly, the indications for adult LDLT are continually being expanded.

AREAS TIMELY FOR DEVELOPING RESEARCH

In performing these procedures, it is crucial to minimize the risks of morbidity and mortality to the healthy live donor. This review focuses on the current technical development and discusses the ethical issues of adult LDLT.

Small-for-size liver graft injury--impact on tumor behavior

The success of liver transplantation has led to an ever-increasing demand for liver grafts. Since the first successful living donor liver transplantation, this surgical innovation has been well established in children and has significantly relieved the crisis of donor organ shortage for children. However, the extension of living donor liver transplantation to adult recipients is limited by the graft volume. The major concern of adult-to-adult living donor liver transplantation is the adequate graft that can be harvested from a living donor. Small-for-size graft injury is frequently observed. To develop novel effective treatments attenuating small-for-size liver graft injury during living donor liver transplantation, it is important to explore the precise mechanism of acute phase small-for-size graft damage. Recently, a number of clinical studies and animal experiments have been conducted to investigate the possible key issues on acute phase small-for-size liver graft injury, such as mechanical injury from shear stress, subsequent inflammatory responses, and imbalance of vasoregulatory factors. This review focuses on the mechanism of small-for-size liver graft injury based on the number of clinical and experimental studies. The latest research findings of the significance of acute phase liver graft injury on late phase tumor recurrence and metastasis are also addressed.

Complications of right lobe living donor liver transplantation

BACKGROUND/AIMS

Right lobar living donor liver transplantation (LDLT) has been controversial because of donor deaths and widely variable reports of recipient and donor morbidity. Our aims were to ensure full disclosure to donors and recipients of the risks and benefits of this procedure in a large University center and to help explain reporting inconsistencies.

METHODS

The Clavien 5-tier grading system was applied retrospectively in 121 consecutive adult right lobe recipients and their donors. The incidence was determined of potentially (Grade III), actually (Grade IV), or ultimately fatal (Grade V) complications during the first post-transplant year. When patients had more than one complication, only the seminal one was counted, or the most serious one if complications occurred contemporaneously.

RESULTS

One year recipient/graft survival was 91%/84%. Within the year, 80 (66%) of the 121 recipients had Grade III (n=54) Grade IV (n=16), or Grade V (n=10) complications. The complications involved the graft's biliary tract (42% incidence), graft vasculature (15%), or non-graft locations (9%). Complications during the first year did not decline with increased team experience, and adversely affected survival out to 5 years. All 121 donors survive. However, 13 donors (10.7%) had Grade III (n=9) or IV (n=4) complications of which five were graft-related.

CONCLUSIONS

Despite the satisfactory recipient and graft survival at our and selected other institutions, and although we have not had a donor mortality to date, the role of right lobar LDLT is not clear because of the recipient morbidity and risk to the donors.

Liver transplantation

Liver transplantation has become a lifesaving procedure for patients who have chronic end-stage liver disease and acute liver failure. The satisfactory outcome of liver transplantation has led to insufficient supplies of deceased donor organs, particularly in East Asia. Hence, East Asian surgeons are concentrating on developing and performing living-donor liver transplantation (LDLT). This review article describes an update on the present status of liver transplantation, mainly in adults, and highlights some recent developments on indications for transplantation, patient selection, donor and recipient operation between LDLT and deceased-donor liver transplantation (DDLT), immunosuppression, and long-term management of liver transplant recipients. Currently, the same indication criteria that exist for DDLT are applied to LDLT, with technical refinements for LDLT. In highly experienced centers, LDLT for high-scoring (>30 points) Model of End-Stage Liver Disease (MELD) patients and acute-on-chronic liver-failure patients yields comparably good outcomes to DDLT, because timely liver transplantation with good-quality grafting is possible. With increasing numbers of liver transplantations and long-term survivors, specialized attention should be paid to complications that develop in the long term, such as chronic renal failure, hypertension, diabetes mellitus, dyslipidemia, obesity, bone or neurological complications, and development of de novo tumors, which are highly related to the immunosuppressive treatment.

Surgical treatment of hepatocellular carcinoma

Local tumor control is still the most important consideration in the treatment of hepatocellular carcinoma (HCC). Surgical treatments, including liver resection and liver transplantation are, and will remain, the first-line therapeutic strategies for local control in patients with primary HCC. Although aggressive liver resection is often performed for advanced HCC in patients with a large tumor, multiple tumors, or tumors with vascular invasion, liver transplantation is the preferred option, after taking into consideration age and tumor-related factors, when there is poor liver functional reserve. Preventing deterioration in liver function is the second priority in the treatment of HCC. When performing liver resection, extensive removal of noncancerous liver parenchyma during lobectomy or hemihepatectomy, should be avoided as much as possible. Anatomic resection, which refers to systematic elimination of the main tumor with its minute metastases, preserves liver function and is highly recommended. A treatment algorithm based on published evidence is now available, which helps us decide on the most suitable therapeutic option for individual patients, depending on the tumor characteristics and liver functional reserve.

Experience of living donor liver transplantation in Iran: a single-center report

BACKGROUND

Living donor liver transplantation (LDLT) has been accepted as a valuable treatment for patients with end-stage liver disease seeking to overcome the shortage of organs and the waiting list mortality. The aim of this study was to report our experience with LDLT.

METHODS

We retrospectively analyzed 50 LDLTs performed in our organ transplant center from January 1997 to March 2008. We reviewed the demographic data, family history, operative and hospital stay durations as well as postoperation complications among donors and recipients. We also performed a retrospective analysis of recipient chemical and biochemical data.

RESULTS

Among 50 patients (30 males and 20 females) of overall mean age of 7.21 +/- 5.35 who underwent LDLT (10 right lobe, 38 left lobe, and 2 left lateral segments), 47 received a liver graft from their parent, two from a brother, and one from an uncle. The most common indications for LDLT were end-stage liver disease due to Wilson's disease (16%), cryptogenic cirrhosis (16%), tyrosinemia (14%), biliary atresia (12%), autoimmune hepatitis (12%), and progressive familial intrahepatic cholestasis (12%). The mean follow-up was 16.91 +/- 23.74 months. There were 13 (26%) recipient mortalities including vascular complications; three to sepsis after bowel perforation, two from liver dysfunction, two from chronic rejection due to noncompliance, and one from diffuse aspergillosis. The morbidity rate was 50%, including 19 reexplorations during the hospital course and five biliary complications.

CONCLUSION

This study demonstrated that LDLT can decrease the number of patients awaiting liver transplantation especially in the pediatric group. However, because of relatively high mortality and morbidity, we must improve our treatment outcomes.

Liver Transplantation in Asia: Past, Present and Future

With the technical advances and improvements in perioperative management and immunosuppressants, liver transplantation is the standard treatment for patients with end-stage liver diseases. In Asia, a shortage of deceased donor liver grafts is the universal problem to be faced with in all transplant centres. Many surgical innovations are then driven to counteract this problem. This review focuses on 3 issues that denote the development of liver transplantation in Asian countries. These include living donor liver transplantation (LDLT), split liver transplantation (SLT) and liver transplantation for hepatocellular carcinoma (HCC). Minimal graft weight, types of liver graft to donate and the inclusion of the middle hepatic vein with the graft are the main issues to be established in LDLT. The rapid growth and wide dissemination of LDLT has certainly alleviated the supply-and-demand problem of liver grafts in Asia. SLT is another attractive approach. Technical expertise, donor selection and graft allocation are the main determinants for its success. Liver transplantation plays a key role in the management of HCC in Asia. LDLT would be the main strategy in this aspect. The issue of extending the selection criteria for HCC patients for LDLT is still controversial. On the whole, future developments to increase the donor pool for the expanding recipient need in Asia would involve transplantation from non-heart beating donor and ABO incompatible transplantation.

Donor risk in adult-to-adult living donor liver transplantation: impact of left lobe graft

BACKGROUND

To ensure donor safety in adult-to-adult living donor liver transplantation, we established a selection criterion for donors in which left lobe (LL) was the first choice of graft.

METHODS

Two hundred six consecutive donors were retrospectively studied. Donors were divided into two groups according to graft type: LL graft (n=137) and right lobe (RL) graft (n=69).

RESULTS

Although mean intraoperative blood loss of LL was significantly increased compared with RL, mean peak postoperative total bilirubin levels and duration of hospital stay after surgery were significantly less for LL than RL (P<0.05). No donor died or suffered a life-threatening complication during the study period. The overall complication rate was 34.0%, including biliary complications in 5.3%. The number of biliary complications was four (2.9%) in LL and seven (10.1%) in RL (P<0.05). Logistic regression analysis revealed that only graft type (LL vs. RL) is significantly related to the occurrence of biliary complications (odds ratio 0.11; P=0.0012). The cumulative overall graft survival rates in the recipients with LL were not significantly different from that in the recipients with RL.

CONCLUSIONS

LL grafting should be considered favorably when selecting donors for adult-to-adult living donor liver transplantation.

Prevent small-for-size syndrome using dual grafts in living donor liver transplantation

BACKGROUND

The growing gap between the number of patients waiting for transplantation and available organs is still the main issue facing the transplant community. The major limitation of adult-to-adult living donor liver transplantation (LDLT) is the small-for-size problem because of the concern of donor safety. We report preliminary experiences for preventing small-for-size syndrome using dual grafts from one right lobe without the middle hepatic vein and one left lateral segment in adult-to-adult LDLT.

METHODS

One hundred ten cases of adult-to-adult LDLT were performed in West China Hospital of Sichuan University from January 2002 to August 2007, and there were 16 small-for-size (SFS) grafts in all grafts. Dual grafts LDLT was performed for six patients with end-stage liver disease, consisting of five cases from one right lobe without the middle hepatic vein and one left lateral segment, and one case from two left lobes.

RESULTS

All living donors underwent a full recovery from the operation without persistent complications. Four recipients died of sepsis, one recipient received re-transplantation, and three recipients received transplenic artery embolization in the recipients with SFS grafts. All recipients with dual grafts displayed good graft function and a majority of grafts showed normal triangular-shape regeneration of their respective liver grafts. Only in one left lateral segment atrophy occurred, graft hepatectomy was not required.

CONCLUSION

Dual grafts from one right lobe without the middle hepatic vein and one left lateral segment in adult-to-adult LDLT can prevent the small-for-size problem and yet secure the safety of the donors.

Surgical techniques according to anatomic variations in living donor liver transplantation using the right lobe

OBJECTIVES

In living donor liver transplantation, the right lobe has many anatomic variations in the vascular tree, which could lead to surgical complications. We need to define surgical technique according to anatomy.

METHODS

From January 2000 to September 2007, 310 living donor liver transplantations using the right lobe were performed in patients with end-stage liver disease. The vascular trees were evaluated preoperatively with computed tomography and magnetic resonance angiography. We classified anatomic points for safe harvest in the hepatic artery, portal vein, and hepatic vein and described technical points based on anatomic variations.

RESULT

There were many anatomic variations in the hepatic vasculature. Hepatic artery variations were observed in 16.8% of cases. Double hepatic artery was observed in 14 cases (4.5%). Of these 14 cases, reconstruction as a single artery was performed in 6 and dual reconstruction was performed in 8 cases. Portal vein variation was observed in 45 cases (14.5%): Dual anastomosis to right and left portal vein was performed in type III (n = 20; 6.4%) and type IV (n = 3; 1.0%) variations. There were 70 cases of portal vein thrombosis. In 8 of the 70, a jump or interposition graft with iliac vein was utilized. Of the middle hepatic vein variant, segment V vein only was reconstructed in 188 (60.6%) cases. In 21 (6.8%) cases, segment VIII vein only was reconstructed, and in 43 (13.9%) cases, both segment V and segment VIII veins were reconstructed using the recipient's portal vein, a cryopreserved iliac vein, or a prosthetic graft. The most common variation of right inferior hepatic vein was type II (n = 141; 45.5%), which has 1 right inferior hepatic vein.

CONCLUSION

Living donor liver transplantation using the right lobe can be performed safely, but there is a potential operative risk because of various anatomic variations. To minimize operative complications, anatomic variations should be kept in mind to ensure a safe and successful operation.