Segment IV preserving middle hepatic vein retrieval in right lobe living donor liver transplantation. J Am Coll Surg. 2011;213:e5-16. [PMID: 21641832 DOI: 10.1016/j.jamcollsurg.2011.04.027]

Incorporating Tumor Biology to Predict Hepatocellular Carcinoma Recurrence in Patients Undergoing Living Donor Liver Transplantation Using Expanded Selection Criteria

Conventional selection criteria for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) are based on tumour size/number only, and do not consider vital surrogates of tumor biology such as alpha-fetoprotein (AFP) and tumor [¹⁸ F]fluorodeoxyglucose positron emission tomography ([¹⁸ F]FDG PET) avidity. We analyzed survival outcomes, and predictors of HCC recurrence in 405 patients with cirrhosis and HCC (HCC-cirr) who underwent living donor LT (LDLT) using our expanded selection criteria: no extrahepatic disease or major vascular invasion, irrespective of tumor size/number. Fifty-one percent patients had tumours beyond Milan, and 43% beyond the University of California San Francisco [UCSF] criteria. The 5-year overall survival (OS) and recurrence-free survival (RFS) were 64% and 70%, respectively. Three preoperatively available factors predicted recurrence: pre-LT AFP ≥100 ng/mL (P = 0.005; hazard ratio [HR], 2.190), tumor burden beyond the UCSF criteria (P = 0.001; HR, 2.640), and [¹⁸ F]FDG PET avidity (P = 0.004; HR, 2.442). A prognostic model based on the number and combination of the aforementioned preoperative risk factors was developed using a competing-risk RFS model. Three risk groups were identified: low (none or a single risk factor present, 9.3% recurrence), moderate (AFP ≥100 ng/mL and [¹⁸ F]FDG PET avidity, or beyond UCSF tumor and [¹⁸ F]FDG PET avidity, 25% recurrence), and high (AFP ≥100 ng/mL and beyond UCSF, or presence of all 3 risk factors, 46% recurrence). Acceptable long-term outcomes were achieved using our expanded selection criteria. Our prognostic model to predict recurrence based on preoperative biological and morphological factors could guide pretransplant management (downstaging versus upfront LDLT) with the aim of reducing post-LDLT recurrence.

A Worldwide Survey of Live Liver Donor Selection Policies at 24 Centers With a Combined Experience of 19 009 Adult Living Donor Liver Transplants

BACKGROUND

Although surgical technique in living donor liver transplantation (LDLT) has evolved with a focus on donor safety and recipient challenges, the donor selection criteria remain considerably disparate.

METHODS

A questionnaire on donor selection was sent to 41 centers worldwide. 24 centers with a combined experience of 19 009 LDLTs responded.

RESULTS

Centers were categorized into predominantly LDLT (18) or deceased donor liver transplantation (6), and high- (10) or low-volume (14) centers. At most centers, the minimum acceptable graft-to-recipient weight ratio was 0.7 or less (67%), and remnant was 30% (75%). The median upper limit of donor age was 60 years and body mass index of 33 kg/m. At 63% centers, age influenced the upper limit of body mass index inversely. Majority preferred aspartate transaminase and alanine transaminase less than 50 IU/mL. Most accepted donors with nondebilitating mild mental or physical disability and rejected donors with treated coronary artery disease, cerebrovascular accident and nonbrain, nonskin primary malignancies. Opinions were divided about previous psychiatric illness, substance abuse and abdominal surgery. Most performed selective liver biopsy, commonly for steatosis, raised transaminases and 1 or more features of metabolic syndrome. On biopsy, all considered macrovesicular and 50% considered microvesicular steatosis important. Nearly all (92%) rejected donors for early fibrosis, and minority for nonspecific granuloma or mild inflammation. Most anatomical anomalies except portal vein type D/E were acceptable at high-volume centers. There was no standard policy for preoperative or peroperative cholangiogram.

CONCLUSIONS

This first large live liver donor survey provides insight into donor selection practices that may aid standardization between centers, with potential expansion of the donor pool without compromising safety.

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

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

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

Background

An accurate preoperative volumetric assessment of donor liver is essential for successful living donor liver transplant by ensuring adequate remnant and graft recipient weight ratio (GRWR).

Methods

The study cohort consisted of 744 right lobe (RL), 65 left lobe (LL) and 33 left lateral sector (LLS) grafts from July 2010 to January 2014. A semi-automated interactive commercial software called AW Volume share 6 was used for volumetry. Bland Altman plot was used for assessing the agreement between estimated graft weight (EGW) and actual graft weight (AGW).

Results

There was no statistically significant difference between EGW and AGW for RL graft weight (722±134 vs. 717±126 gm; P=0.06). Although Bland Altman graph showed that 95% limits of agreement was more in LL (-164 to +110) than RL (-156 to +147) and LLS grafts (-137 to +239), CT scan significantly overestimated LL graft weight (EGW =460±118 gm vs. AGW =433±102 gm; P=0.003) and underestimated LLS graft weight (EGW =203±48 gm vs. AGW =254±49 gm; P<0.001).

Conclusions

CT volumetry overestimate LL graft and underestimate LLS graft weight. This should be factored in when selecting LL graft by taking higher GRWR.

Kinetics of liver regeneration in donors after living donor liver transplantation: A retrospective analysis of "2/3rd partial hepatectomy" model at 3 months

BACKGROUND/AIM

Right lobe living donor (2/3rd partial hepatectomy) model is the best way to accurately study liver regeneration process in human beings. We aimed to study the kinetics of liver regeneration after 2/3rd partial hepatectomy in donors.

METHODS

Retrospective analysis of prospectively maintained volumetric recovery data in donors was performed in 23 donors, who underwent 29 contrast-enhanced computed tomography within 3 months for various clinical indications.

RESULTS

The absolute volumetric growth percentages were as follows: 37.60 ± 21.74 at 1st week, 92 ± 53.27 at 2nd week, 115.55 ± 59.65 at 4th week, and 110.79 ± 64.47 at 3 months. On sub-group analysis of our cohort, we found that 4.3%, 17%, 30.4%, and 39% donors attended ≥ 90% volumetric recovery at 1st, 2nd, 4th week, and 3 months, respectively. One patient at 4th week revealed 128% volumetric recovery. There was one more patient who exceeded original total liver volumes (TLV) (111% of TLV) at 2.5 months. The serum bilirubin and INR values peaked at postoperative day (POD) 3rd and then started showing a downward trend from POD 5th onwards.

CONCLUSION

Our study is the first to document complete volumetric recovery in donors as early as 3 weeks. Two of the donors overshot their original TLV during the early regenerative phase.

Laparoscopic liver resection for living donation: Where do we stand?

In Western countries, living donor liver transplantation (LDLT) may represent a valuable alternative to deceased donor liver transplantation. Yet, after an initial peak of enthusiasm, reports of high rates of complications and of fatalities have led to a certain degree of reluctance towards this procedure especially in Western countries. As for living donor kidney transplantation, the laparoscopic approach could improve patient’s tolerance in order to rehabilitate this strategy and reverse the current trend. In this setting however, initial concerns regarding patient’s safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation and lack of evidence supporting the benefits of laparoscopy have delayed the development of this approach. Similarly to what is performed in classical resectional liver surgery, initial experiences of laparoscopy have therefore begun with left lateral sectionectomy, which is performed for adult to child living donation. In this setting, the laparoscopic technique is now well standardized, is associated with decreased donor blood loss and hospital stays and provides graft of similar quality compared to the open approach. On the other hand laparoscopic major right or left hepatectomies for adult-adult LDLT currently lack standardization and various techniques such as the full laparoscopic approach, the hand assisted approach and the hybrid approach have been reported. Hence, even-though several reports highlight the feasibility of these procedures, the true benefits of laparoscopy over laparotomy remain to be fully assessed. This could be achieved through standardization of the procedures and creation of international registries especially in Eastern countries where LDLT keeps on flourishing.

Use of ABO-incompatible grafts in living donor liver transplantation--first report from India

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

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).