Hepatic venoplasty in right lobe live donor liver transplantation

Back table Preparation of the Right Lobe Live Donor Liver Allograft: A Crucial Part of the Adult Live Donor Liver Transplant Procedure

INTRODUCTION

We aimed to describe our procedure for vascular reconstruction and back table bench preparation for the right lobe live donor allograft. Live donor liver transplantation (LDLT) remains an important option for the expansion of the donor pool. The procedure has been widely used, and its success is dependent on a technically perfect operation with appropriate inflow and outflow of the allograft. Adequate preparation of the right lobe (RL) allograft prior to implantation remains a vital part of the procedure.

METHODS

Our technique of back table vascular reconstruction of the RL allograft has been performed using a hepatic vein patch venoplasty, inferior hepatic vein inclusion, portal vein reconstruction, and segment V and VIII reconstruction for all of our LDLTs.

RESULTS

Between March 2009 and January 2020, 321 consecutive adult LDLTs were performed and underwent back table reconstruction with the techniques described. During that time period, no patients had hepatic insufficiency. There was a single thrombosis of a superior mesenteric vein (SMV) to PV jump conduit.

CONCLUSIONS

Our technique of back table reconstruction of the LDLT right lobe graft remains a crucial part of the operative procedure. Our experience with RL grafts without middle hepatic vein (MHV) and our systematic approach for inflow and outflow reconstruction has yielded excellent results with no technical outflow issues and minimal inflow complications.

Transferability of Liver Transplantation Experience to Complex Liver Resection for Locally Advanced Hepatobiliary Malignancy - Lessons Learnt From 3 Decades of Single Center Experience

OBJECTIVE

To study the impact of LT experience on the outcome of CLR for locally advanced hepatobiliary malignancy SUMMARY OF BACKGROUND DATA:: Despite evolution in LT knowledge and surgical techniques in the past decades, there is yet data to evaluate the significance of LT experience in performing CLR.

METHODS

Postoperative outcome after CLR between 1995 and 2019 were reviewed and correlated with LT experience in a single center with both LT and CLR service. CLR was defined as hepatectomy with vasculobiliary reconstruction, or multivisceral resection, central bisectionectomy (S4/5/8), or associating liver partition and portal vein ligation for staged hepatectomy. Spearman rank correlation and receiver operating characteristic analysis were used to define the association between CLR-related outcomes and LT experience.

RESULTS

With cumulative single-center experience of 1452 LT, 222 CLR were performed during the study period [hepatectomy with biliary (27.0%), or vascular (21.2%) reconstruction, with multivisceral resections (9.9%), with associating liver partition and portal vein ligation for staged hepatectomy (18.5%)] mainly for hepatocellular carcinoma (53.2%), and hilar cholangiocarcinoma (14%). Median tumor size was 7.0 cm. Other features include macrovascular invasion (23.4%), and juxta-visceral invasion (14%). Major postoperative complication rate was 25.2% and mortality rate was 6.3%. CLR-complication rate was inversely associated with LT experience (R = -0.88, P < 0.005). Receiver operator characteristic analysis revealed the cutoff for LT experience to have the greatest influence on CLR was 95 with a sensitivity of 100% and Youden index of 1. Multivariable analysis showed that blood transfusion, prolonged operating time, LT experience </=95 were associated with major postoperative complications.

CONCLUSION

LT experience was complimentary to CLR for locally advanced hepatobiliary malignancy with improved postoperative outcome.

The influence of the middle hepatic vein and its impact on outcomes in right lobe living donor liver transplantation

BACKGROUND

In adult right lobe living donor liver transplantation, the decision to include the middle hepatic vein (MHV) remains controversial.

METHODS

A retrospective analysis of 50 R-LDLTs between January 2008 and June 2016 was performed.

RESULTS

Twenty-one procedures were performed using a MHV+ graft (42.0%) and 29 procedures using a MHV- graft (58%). MHV- donors were taller (173 vs 166 cm, p = 0.004) with a larger standard liver volume (1351 vs 1245 mls, p = 0.014) compared to MHV+ donors. The duration of operation for donors was significantly longer in the MHV+ group (530 (313-975) mins) compared to the MHV- group (489 (336-708) mins) (p = 0.029). Similarly, the operative time for recipients was longer in the MHV+ group (660 (428-831) mins) compared to MHV- (579 (359-1214) mins) (p = 0.023). MHV- grafts were heavier compared to MHV+ grafts (918 vs 711 g, p = 0.017). Recipient mortality rates and Kaplan-Meier survival analysis were comparable (p = 0.411). All donors were well at last review.

CONCLUSION

Both MHV+ and MHV- grafts are safe for the donor and recipient. The decision to take the MHV should be based on specific donor-recipient characteristics.

Diamond-shaped patch technique for right hepatic vein reconstruction in living-donor liver transplant: A simple method to prevent stenosis

Patency of the right hepatic vein (RHV) of the liver graft is essential for successful living-donor liver transplant (LDLT). We developed a simple technique for RHV reconstruction that does not require the use of cadaveric veins or additional time to prevent stenosis.Of 159 patients who underwent LDLT at our institution between May 2010 and April 2016, we included 152 in this study. Conventional RHV reconstruction was performed in 100 patients, while the diamond-shaped patch (D-patch) technique was performed in 53. For the D-patch technique, the posterior aspect of the RHV needs to be dissected from the liver parenchyma during donor hepatectomy, which prevents stenosis due to liver rotation after graft regeneration. A D-patch obtained from the hepatic vein of the recipient liver was used on the anterior aspect of the RHV for reconstruction. The Student's t test and χ test were used for statistical analysis.Rates of intervention for RHV stenosis during the first month were significantly different between the conventional reconstruction and D-patch groups (19.2% vs 3.8%; P = .01). The time taken to perform the D-patch technique was similar to that for conventional reconstruction (anhepatic period, 104.9 ± 47.3 minutes vs 106.7 ± 42.0 minutes; P = .82).The D-patch technique for RHV reconstruction in LDLT is a simple, fast, and feasible surgical technique that can be performed without using cadaveric or saphenous veins.

Is Portal Venous Pressure or Porto-systemic Gradient Really A Harbinger of Poor Outcomes After Living Donor Liver Transplantation?

BACKGROUND

Portal hyperperfusion as a cause of small for size syndrome (SFSS) after living donor liver transplantation (LDLT) remains controversial. Portal venous pressure (PVP) is often measured indirectly and may be confounded by central venous pressure (CVP).

METHODS

In 42 adult cirrhotics undergoing elective LDLT, PVP was measured by direct canulation of portal vein and porto systemic gradient (PSG) was obtained after subtracting CVP from PVP. None underwent portal inflow modulation. SFSS was looked in 27 patients after excluding 15 with technical complications.

RESULTS

Clinical features of SFSS found in 6 patients, 5 with graft recipient weight ratio (GRWR) > 0.8% and PVP < 20 mm of Hg. One with GRWR < 0.8% could truly be labeled as SFSS. Incidence of SFSS was not higher in patients with elevated PVP > 20 mm of Hg (14.3% vs 0%, P = 0.259) or PSG > 13 mm of Hg (33.3% vs 0%, P = 0.111). Intensive care unit (ICU) stay was longer in patients with elevated PVP (14.55 vs 9.13 days, P = 0.007) and PSG (16.8 vs 9.72 days, P = 0.009). There was no difference in graft functions, post-operative complications and mortality in first month post-LDLT.

CONCLUSION

Elevated PVP or PSG increased morbidity but neither predicted SFSS nor affected survival.

Longterm outcomes of stent placement for hepatic venous outflow obstruction in adult liver transplantation recipients

The purpose of this study was to evaluate the longterm outcomes of stent placement for a hepatic venous outflow obstruction in adult liver transplantation recipients. From June 2002 to March 2014, 23 patients were confirmed to have a hepatic venous outflow obstruction after liver transplantation (18 of 789 living donors [2.3%] and 5 of 449 deceased donors [1.1%]) at our institute. Among these patients, stent placement was needed for 16 stenotic lesions in 15 patients (12 males, 3 females; mean age, 51.7 years). The parameters that were documented retrospectively were technical success, clinical success, complications, recurrence, and the patency of the stent. The technical success rate was 100% (16/16). Clinical success was achieved in 11 of the 15 patients (73.3%). A major complication occurred in only 1 patient-a hepatic vein laceration during the navigation of the occluded segment. The median follow-up period was 33.5 months (range, 0.5-129.3 months), and the overall 1-, 3-, and 5-year primary patency rates of the stent were all 93.8%. One case of occlusion of the stent without clinical signs and symptoms was observed 5 days after the initial procedure. In this patient, the stent was recanalized by balloon angioplasty and showed patent lumen for 48 months of the subsequent follow-up period. In conclusion, stent placement is a safe and effective treatment modality with favorable longterm outcomes to treat hepatic venous outflow obstruction in adult liver transplantation recipients. Liver Transplantation 22 1554-1561 2016 AASLD.

Outcomes of endo-radiological approach to management of bile leakage after right lobe living donor liver transplantation

BACKGROUND AND AIM

Bile leakage is a major complication after right lobe living donor liver transplantation (RLDLT). It can result in significant morbidities and, occasionally, mortalities. Endo-radiology is a non-surgical means that has been used to manage this complication. This study reviews the outcomes of the endo-radiological approach to the management of bile leakage after RLDLT with duct-to-duct anastomosis (DDA) at a high-volume center.

METHOD

A retrospective study was conducted on all adult patients who received RLDLT at our center between January 2001 and December 2013. There were 496 RLDLTs performed during the study period. Only patients who had DDA as the only bile duct reconstruction method were included in the study.

RESULTS

Twelve (3.7%) out of the 328 study subjects developed bile leakage after RLDLT. Six out of these 12 patients were successfully treated with the endo-radiological approach without the need for laparotomy. They had endoscopic retrograde cholangiography with stenting followed by percutaneous drainage of biloma. One of the 12 patients died from recurrence of hepatocellular carcinoma 37 months after transplantation. The remaining 11 patients are all alive.

CONCLUSION

The endo-radiological approach should be the first-line management for bile leakage for selected patients with DDA as the bile duct reconstruction method.

Long-term outcome of endovascular intervention in hepatic venous outflow obstruction following pediatric liver transplantation

The purpose of our study was to address the long-term outcome of angioplasty and stent placement for hepatic venous outflow obstruction following pediatric liver transplantation. From October 1999 to December 2011, 20 stenotic lesions were confirmed to constitute hepatic venous outflow obstruction in 18 pediatric patients (13 boys, 5 girls) among 152 pediatric patients following liver transplantation and were managed with endovascular intervention. Stent placement was favored over additional angioplasty in patients of preadolescent or adolescent age (>8 years old), after 1 or 2 sessions of balloon angioplasty. The primary patency and assisted primary patency were estimated using the Kaplan-Meier method. A total of 32 procedures (24 balloon angioplasties, 8 stent placements) were conducted. The technical success rate was 90.6% (29/32). Clinical success was achieved in 15 of 18 patients (clinical success rate of 83.3%). Major complications did not occur in our study. Median follow-up was 91.5 months (interquartile range, 54.7-137.3 months) for the 18 patients. The 1-year, 3-year, 5-year, and 10-year primary patencies of the 20 treated lesions were 63.5%, 57.8%, 57.8%, and 57.8%, respectively. The 1-year, 3-year, 5-year, and 10-year assisted-primary patencies of the lesions were 100%, 100%, 100%, and 100%, respectively. Of the 6 patients of preadolescent or adolescent age, 5 patients underwent stent placement procedures, and the stents were patent during the follow-up period of 57.3-162.5 months (median, 72.7 months). In conclusion, endovascular intervention is very effective in hepatic venous outflow obstruction following pediatric liver transplantation. In addition, early stent placement in patients of preadolescent or adolescent age can provide a safe and favorable long-term outcome.

A retrospective study on risk factors associated with failed endoscopic treatment of biliary anastomotic stricture after right-lobe living donor liver transplantation with duct-to-duct anastomosis

OBJECTIVE

This aim of this study is to determine the risk factors in failed endoscopic retrograde cholangiography (ERC).

BACKGROUND

Endoscopic treatment is considered the first-line intervention for biliary anastomotic stricture (BAS) after right-lobe living donor liver transplantation with duct-to-duct anastomosis.

METHODS

A retrospective study was performed on 287 patients who received right-lobe living donor liver transplantation with duct-to-duct anastomosis. The morphology of BAS was defined according to the shape of the distal side of duct-to-duct anastomosis shown on cholangiogram and was categorized into 3 types: pouched, intermediately pouched, and triangular. All cases of ERC were performed by operating surgeons.

RESULTS

Fifty-nine patients (20.6%) had BAS and received ERC and balloon dilatation with or without stenting. The success rate was 73.2%. The median number of sessions needed for successful ERC was 3. In the 15 patients with failed ERC, 4 were successfully treated with percutaneous transhepatic biliary drainage and balloon dilatation and 11 underwent conversion hepaticojejunostomy (6 had external percutaneous transhepatic biliary drainage as a temporizing measure). On multivariate analysis, recipient age [odds ratio (OR): 0.922; 95% confidence interval (CI): 0.85-1.00; P = 0.049], operation time (OR: 1.007; 95% CI: 1.001-1.013; P = 0.025), and morphology of stricture (OR: 6.722; 95% CI: 1.31-34.48; P = 0.022) were independent risk factors associated with failed ERC. The success rates for the 3 types of BAS-pouched, intermediately pouched, and triangular-were 42.9%, 63.6%, and 88.9%, respectively (P = 0.021). Association was found between bile leak and pouched BAS (P = 0.008).

CONCLUSIONS

ERC is highly effective in treating BAS. A success rate of 73%, the highest ever reported, has been achieved. Morphology of stricture is associated with outcome of ERC. Radiological or surgical intervention should be considered for patients with pouched BAS after endoscopic treatment fails for the first time.

Anomalous hepatic vein anatomy of left lateral section grafts and customized unification venoplasty for pediatric living donor liver transplantation

In liver transplantation, a left lateral section (LLS) graft may have an unusual variant left hepatic vein (LHV) anatomy. This study was designed to analyze the incidence of unusual LHV variants and to determine technical methods for effective reconstruction in infant recipients weighing approximately 10 kg or less. The study comprised 3 parts: an LHV variation analysis, a simulation-based design for the technical modification of graft LHV venoplasty, and its clinical application. The LHV anatomy of 300 potential LLS graft donors was classified into 4 types according to the number and location of the hepatic vein openings: (1) a single opening (n = 218 or 72.7%); (2) 2 large adjacent openings (n = 29 or 9.7%); (3) 2 adjacent openings, 1 large and 1 small (n = 34 or 11.3%); and (4) 2 widely spaced openings (n = 19 or 6.3%). Types 2 and 3 required wedged unification venoplasty, and type 4 required additional vein interposition. In a series of 49 cases using LLS grafts, the graft hepatic vein complication rate was 4.5% at 3 years; stenting was necessary for 1 of the 36 type 1 LHV grafts (2.8%) and for 1 of the 13 type 2-4 LHV grafts (7.7%, P = 0.46). A customized interposition-wedged unification venoplasty technique for coping with type 4 vein variations was developed with a simulation-based approach, and it was successfully applied to a 10-month-old male infant receiving an LLS graft with a type 4 LHV. In conclusion, nearly all LHV variations can be effectively managed with customized unification venoplasty. These venoplasty techniques represent beneficial surgical options as part of graft standardization for hepatic vein reconstruction in pediatric living donor liver transplantation.

Portal inflow and pressure changes in right liver living donor liver transplantation including the middle hepatic vein

The middle hepatic vein may be included in right liver living donor liver transplantation (LDLT) to optimize hepatic venous outflow. We studied the graft's ability to relieve portal hypertension and accommodate portal hyperperfusion with portal manometry and ultrasonic flowmetry. Surgical outcomes with respect to portal hemodynamometry were also investigated. The ages of the recipients and donors for 46 consecutive LDLT procedures were 50 (range, 16-66 years) and 31 years (range, 18-54 years), respectively. The graft to standard liver volume ratio was 47.4% (range, 32.4%-69.0%). The hospital mortality rate was 4.4% as 2 recipients died from a subarachnoid hemorrhage and sepsis. The portal pressure dropped by 8 mm Hg (range, -7 to 19 mm Hg) from 23 (range, 8-37 mm Hg) to 14 mm Hg (range, 10-26 mm Hg) after graft implantation. The portal inflow positively correlated with the portal pressure before native liver hepatectomy (R(2) = 0.305, P = 0.001) and not with the graft size. The portal inflow increased from 81 mL/minute/100 g (range, 35-210 mL/minute/100 g) before donor right hepatectomy to 318 mL/minute/100 g (range, 102-754 mL/minute/100 g) after graft implantation. The graft portal inflow had a positive linear correlation with the recipient portal pressure before native liver total hepatectomy (R(2) = 0.261, P = 0.001) but not after graft implantation, and it had a negative correlation with the graft to standard liver volume ratio (R(2) = 0.247, P = 0.001). Only 1 of the graft biopsies showed moderate sinusoidal congestion. Twelve recipients had Clavien grade 2+ complications that were not related to the portal inflow and pressure or graft size. Right liver LDLT including the middle hepatic vein effectively lowered the recipient portal pressure by allowing unimpeded venous outflow.

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.

Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation

BACKGROUND

Hepatic outflow block is one of the major complications leading to severe graft dysfunction after left lobe living donor liver transplantation (LDLT).

METHODS

Medical records of 46 recipients of a left lobe LDLT were reviewed. The method of outflow reconstruction and post-transplant morphological changes of hepatic veins were investigated. The subjects were followed up until September 2008, with a median follow-up period of 2.0 yr (range: 0.5-5.9 yr).

RESULTS

There were no multiple outflow tracts to be reconstructed, and the median caliber of the single orifices with or without venoplasty was 32.0 mm. The difference between the angle of hepatic veins to the sagittal plane measured on computed tomography was calculated for pre-operative donors and post-operative recipients a month after LDLT. Both left and middle hepatic veins showed a significantly greater change in angle than the right hepatic vein. Both left and middle hepatic veins more frequently showed a nearly flat wave form on Doppler study one month after LDLT. In the 46 recipients of left lobe grafts, three developed outflow block (6.5%).

CONCLUSIONS

The middle and left hepatic veins tend to distort and stretch during graft regeneration. These characteristics seem to be associated with outflow disturbances.

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.

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.

The right small-for-size graft results in better outcomes than the left small-for-size graft in adult-to-adult living donor liver transplantation

BACKGROUND

The recent outcome of adult-to-adult living donor liver transplantation (ALDLT) using small-for-size grafts (SFSGs; GRWR <0.8%) has been excellent after right grafts were exclusively used in large-volume ALDLT centers.

METHODS

We compared the outcome of ALDLTs using 11 right SFSGs (group R) with that using 18 left SFSGs (group L) of our center. The dysfunction of graft was defined dysfunction as hyperbilirubinemia (>5 mg/dl), prolonged prothrombin time (>2 INR), or uncontrolled ascites (>1,000 ml/day) on 3 consecutive days in posttransplant 7 days, and the dysfunction score (DS; the sum of points given per each sign) of the graft was used to describe the SFSG dysfunction severity.

RESULTS

The pretransplant recipient status was similar between the groups, but the 1-year mortality rate was 0% in group R and 33.3% (n = 6) in group L (p = 0.038). The ICU stay was longer in group L (20 days) than in group R (11 days; p = 0.004). Hyperbilirubinemia in group R vs. L was noted in 54.5% vs. 50%, prolonged prothrombin time in 18.2% vs. 50%, and uncontrolled ascites in 54.5% vs. 100%. The DS was lower in group R than in group L (1.3 vs. 2; p = 0.007). The DS was zero in four right liver recipients. On multivariate analysis, the only factor affecting DS was the graft side.

CONCLUSION

The clinical signs of SFSG dysfunction were less arduous and there was no 1-year mortality in cases in group R. Therefore, the right SFSG may be used for ALDLT in the future base on the transplant center's experience.

Current concept of small-for-size grafts in living donor liver transplantation

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size (SFS) graft syndrome." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extension to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by an SFS graft, such as a portosystemic shunt or splenectomy, have been trialed with some positive results. To establish an effective strategy for transplanting SFS grafts and preventing SFS graft syndrome, it is essential to have precise knowledge and tactics to evaluate graft quality and graft volume, when performing these LDLTs with portal pressure control. We reviewed the updated literature on the pathogenesis of and strategies for using SFS grafts.

Reconstruction of middle hepatic vein in living donor liver transplantation with modified right lobe graft: a single center experience

Although a right liver graft without the middle hepatic vein (MHV) can cause congestion in the anterior segment, the reconstruction of MHV tributaries and the complex procedure remain controversial. Between November 2006 and October 2007, right liver transplantation without the MHV was performed in 31 cases. A retrospective analysis was conducted on clinical data and two groups were formed: with MHV reconstruction (Group I, n=16) and without MHV reconstruction (Group II, n=15). We analyzed the serum liver function markers at 3 weeks postoperatively and evaluated vascular flow in the graft and interpositional vein daily by Doppler ultrasonography during the hospital stay and monthly follow-up after discharge. One patient (6.7%) died of liver congestion and acute hepatic rejection on the postoperative day 10 in Group II. Congestion was observed in another three cases (20%) of Group II and one case (6.25%) of Group I. The levels of alanine transferase and aspartate transferase in Group II was higher than those in Group I in the first week after transplantation, albeit not significantly. In Group I, most of the interpositional vein grafts were the recipient's portal veins. Venoplasty in the graft was performed in three cases. All the interpositional veins and tectonic outflow orifices were detected to be patent by ultrasonography within 14 days after transplantation. The reconstruction of the MHV tributaries is necessary in the right liver graft without MHV according to our policy and better criteria for MHV reconstruction should be established. The recipient's portal vein is an optimal choice for the interpositional vein and hepatic venoplasty in living donor liver transplantation can simplify the operation and ensure excellent venous drainage.

Effective anatomic reconstruction of the middle hepatic vein in modified right lobe graft living donor liver transplantation

INTRODUCTION

Adult liver transplantation using the right lobe graft without a middle hepatic vein (MHV; modified right lobe graft) has widely been used to compensate for the cadaveric organ shortage. To provide appropriate functional graft volume in the right lobe graft used for living donor liver transplantation (LDLT), successful reconstruction of the MHV is required. We have described herein the effectiveness of an anatomic MHV reconstruction technique with tailoring donor hepatectomy and uniformed MHV reconstruction for modified right lobe grafts.

MATERIALS AND METHODS

From December 2005 to August 2006, 15 adult patients received modified right lobe graft LDLT using a donor hepatectomy technique that exposed the right side of the MHV combined with a bench procedure that reconstructed the modified right lobe graft into the shape of extended right lobe graft, and a modified piggyback anastomosis.

RESULTS

A total of 42 V5/V8s were reconstructed with 15 newly formed MHVs. The mean estimated congestion area was 4.2+/-2.7% of the total graft volume on computed tomography. The mean pressure gradient between the reconstructed MHV and the recipient inferior vena cava was 2.1+/-1.6 mmHg on postoperative day (POD) 7. None of the patients required any procedure for an outflow problem. The patency rates of the reconstructed MHV and its tributaries were 100% (15/15) and 95.2% (40/42), respectively, at POD 30; 100% (15/15) and 73.8% (31/42) at POD 60; and 86.7% (13/15) and 54.8% (23/42) at POD 90. All recipients are currently alive with good liver function.

CONCLUSION

Our procedure seems to be effective for the reconstruction of MHV and its tributaries, and could make modified right lobe graft into the anatomic figure of extended right lobe graft as well as achieve the physiologic advantages of an extended right lobe graft.

Historical perspective of living donor liver transplantation

Living donor liver transplantation (LDLT) has gone through its formative years and established as a legitimate treatment when a deceased donor liver graft is not timely or simply not available at all. Nevertheless, LDLT is characterized by its technical complexity and ethical controversy. These are the consequences of a single organ having to serve two subjects, the donor and the recipient, instantaneously. The transplant community has a common ground on assuring donor safety while achieving predictable recipient success. With this background, a reflection of the development of LDLT may be appropriate to direct future research and patient-care efforts on this life-saving treatment alternative.

An artificial vascular graft is a useful interpositional material for drainage of the right anterior section in living donor liver transplantation

Congestion in the anterior section in a right liver (RL) without a middle hepatic vein (MHV) may lead to graft dysfunction. To solve this problem, an RL draining MHV branches with autologous or cryopreserved vessels can be introduced. However, these vessels are often unavailable, and their preparation is time-consuming. An expanded polytetrafluoroethylene (ePTFE) graft may be used for anterior section drainage. Between February and November 2005, 26 recipients underwent RL liver transplantation draining MHV branches with an ePTFE graft (group P). Twenty-six ePTFE grafts (6 or 7 mm in internal diameter) drained 35 MHV branches on the back table to the graft right hepatic vein or to the recipient's inferior vena cava. The patency of the ePTFE graft was checked with computed tomography scans of the liver. The outcome of group P was compared with those of an RL group with MHV (group M, n=17) and an RL group without reconstruction of MHV or its tributaries (group R, n=85). The 1-month and 4-month patency rates (PRs) of the ePTFE grafts were 80.8% (21/26) and 38.5% (10/26). All showing early obstruction of the ePTFE graft had congestion in the anterior section, but all showing late obstruction were asymptomatic. The 1-month PRs of group P were comparable to, but the 4-month PRs were lower than, those of group M (both 94.1%; P<0.05). However, 1-year patient and graft survival rates of group P (both 100%) were comparable to those of group M (94.1% and 100%) and better than those of group R (83.5% and 88.2%; P<0.05). In conclusion, the early PR of group P was good, and late obstruction of the ePTFE graft had no impact on congestion in the anterior section or patient survival. Therefore, an ePTFE graft may be a useful interposition material for anterior section drainage in RL transplantation without serious complications.

Graft selection algorithm based on congestion volume for adult living donor liver transplantation

A major concern in adult-to-adult living donor liver transplantation is the selection of graft type; that is, is it is better to use the right lobe with or without the middle hepatic vein (MHV)? This choice has a considerable impact on donor safety, vascular reconstruction and graft function in the recipient. To facilitate making an appropriate choice, on the basis of a preliminary study (n = 17), we herein propose a graft selection algorithm using three parameters: graft-to-recipient body weight ratio (GRWR), percentage remnant liver volume (%RLV) and estimated congestion ratio (ECR). The algorithm was evaluated with 50 consecutive cases with respect to postoperative liver function of donors and recipients and survival of recipients. Postoperative recovery was comparable between the two groups (p = NS). The overall cumulative 18-month survival rate was 86.7% for the 'with MHV graft group', and 76.1% for the gwithout MHV graft grouph (p = NS). For 41 cases (82%), graft types were chosen according to the algorithm, whereas the remaining 9 cases (18%) needed detailed discussion of donor, recipient and operative factors. In conclusion, we constructed a graft selection algorithm based on congestion volume, which will contribute to objective graft-type selection in adult-to-adult LDLT.

Live donor liver transplantation in adults

Live donor liver transplantation (LDLT) was initiated in 1988 for children recipients. Its application to adult recipients was limited by graft size until the first right liver LDLT was performed in Hong Kong in 1996. Since then, right liver graft has become the major graft type. Despite rapid adoption of LDLT by many centers, many controversies on donor selection, indications, techniques, and ethics exist. With the recent known 11 donor deaths around the world, transplant surgeons are even more cautious than the past in the evaluation and selection of donors. The need for routine liver biopsy in donor evaluation is arguable but more and more centers opt for a policy of liberal liver biopsy. Donation of the middle hepatic vein (MHV) in the right liver graft was considered unsafe but now data indicate that the outcome of donors with or without MHV donation is about equal. Right liver LDLT has been shown to improve the overall survival rate of patients with chronic liver disease, acute or acute-on-chronic liver failure and hepatocellular carcinoma waiting for liver transplantation. The outcome of LDLT is equivalent to deceased donor liver transplantation despite a smaller graft size and higher technical complexity.

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

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

Biliary complications after living donor adult liver transplantation

The highest rate of complications characterizing the adult living donor liver transplantation (ALDLT) are due to biliary problems with a reported negative incidence of 22-64%. We performed 23 ALDLT grafting segments V-VIII without the middle hepatic vein from March 2001 to September 2005. Biliary anatomy was investigated using intraoperative cholangiography alone in the first five cases and magnetic resonance cholangiography in the remaining 18 cases. In 13 cases we found a single right biliary duct (56.5%) and in 10 we found multiple biliary ducts (43.7%). We performed single biliary anastomosis in 17 cases (73.91%) and double anastomosis in the remaining six (26%) cases. With a mean follow up of 644 days (8-1598 days), patient and graft survivals are 86.95% and 78.26%, respectively. The following biliary complications were observed: biliary leak from the cutting surface: three, anastomotic leak: two, late anastomotic strictures: five, early kinking of the choledochus: one. These 11 biliary complications (47.82%) occurred in eight patients (34.78%). Three of these patients developed two consecutive and different biliary complications. Biliary complications affected our series of ALDLT with a high percentage, but none of the grafts transplanted was lost because of biliary problems. Multiple biliary reconstructions are strongly related with a high risk of complication.

Operative outcomes of adult-to-adult right lobe live donor liver transplantation: a comparative study with cadaveric whole-graft liver transplantation in a single center

OBJECTIVE

To evaluate and compare the operative and survival outcomes of patients who underwent right lobe live donor liver transplantation (RLDLT) and cadaveric whole-graft liver transplant (CWLT) recipients in a single institution.

SUMMARY BACKGROUND DATA

Current data suggest that RLDLT has an inferior graft survival outcome when compared with CWLT.

PATIENTS AND METHODS

A prospective study was performed on 180 consecutive adult patients who underwent primary liver transplantation from January 2000 to February 2004. The operative and survival outcomes of RLDLT (n = 124) were compared with those of CWLT (n = 56).

RESULTS

Fifty-five (44%) and 16 (29%) patients were on high-urgency list in the RLDLT group and the CWLT group, respectively (P = 0.045). The preoperative Model for End-Stage Liver Disease scores were comparable in both groups. The waiting time for liver transplantation was significantly shorter in the RLDLT group. The graft weight to estimated standard liver weight ratio was significantly lower in the RLDLT group. The postoperative hospital stay and hospital mortality were comparable in the RLDLT group (1.6%) and the CWLT group (5.4%). Thirty-one (25%) patients in the RLDLT group and 3 (5%) patients in the CWLT group developed biliary stricture on follow-up (P = 0.002). At a median follow-up of 27 months, the actuarial graft and patient survival rates were 88% and 90%, respectively, in the RLDLT group, and both were 84% in the CWLT group.

CONCLUSION

RLDLT results in favorable operative outcomes comparable with those of CWLT. However, there is a significantly higher incidence of biliary stricture associated with RLDLT.

Ultrasound of living donor liver transplantation

Liver transplantation is the most effective treatment for various end-stage liver diseases. Living donor liver transplantation (LDLT) was first developed in Asia due to the severe lack of cadaveric graft in this region. The Liver Transplant Service at Queen Mary Hospital (QMH), Hong Kong, has pioneered the application of LDLT to patients using both left lobe and right lobe grafts. The QMH liver transplant programme is the largest of its kind in China and Southeast Asia.

Ultrasound (US) is often employed in the initial work-up of potential donor and recipient of LDLT. It is the imaging technique of choice to assess the early and late complications of LDLT, with colour Doppler ultrasound being the most useful in the evaluation of post-LDLT vascular complications. The use of ultrasound contrast agents improves the visualisation of the hepatic vasculature, possibly delaying or removing the need for more invasive investigations. Intra-operative ultrasound facilitates the determination of the resection plane during donor hepactectomy.

Computed tomography (CT) or magnetic resonance imaging (MRI) can be used as the single imaging modality in the evaluation of LDLT candidates.

Ultrasound is most useful as the initial screening test in detecting hepatic parenchymal abnormalities, while CT or MRI is the modality of choice in the demonstration of vascular and biliary anatomy of the potential liver donor.

Biliary complications are more common in LDLT than in cadaveric liver transplantation. The ductal dilatation, resulting from biliary stricture, is clearly demonstrated by ultrasound. Bilomas can be aspirated under ultrasound guidance to confirm the diagnosis and to promote healing. Perihepatic fluid collections and abscesses are also common after LDLT. Intra-hepatic collections may represent seromas, haematomas or infarction. Ultrasound is a sensitive means of detecting these collections and can be employed to guide drainage in suitable patients.

Transplant-related malignancies include recurrent neoplasia and post-transplant lymphoproliferative disease (PTLD). Ultrasound can be used to screen for recurrent disease and to detect PTLD in the transplanted liver.

Donor graft outflow venoplasty in living donor liver transplantation

Hepatic venous outflow reconstruction is a key to successful living donor liver transplantation (LDLT) because its obstruction leads to graft dysfunction and eventual loss. Inclusion or reconstruction of most draining veins is ideal to ensure graft venous drainage and avoids acute congestion in the donor graft. We developed donor graft hepatic venoplasty techniques for multiple hepatic veins that can be used in either right- or left-lobe liver transplantation. In left-lobe grafts, venoplasty consisting of the left hepatic vein and adjacent veins such as the left superior vein, middle hepatic vein, or segment 3 vein is performed to create a single, wide orifice without compromising outflow for anastomosis with the recipient's vena cava. In right lobe graft where a right hepatic vein (RHV) is adjacent with a significantly-sized segment 8 vein, accessory RHV, and/or inferior RHV, venoplasty of the RHV with the accessory RHV, inferior RHV, and/or segment 8 vein is performed to create a single orifice for single outflow reconstruction with the recipient's RHV or vena cava. Of 35 venoplasties, 2 developed hepatic venous stenoses which were promptly managed with percutaneous interventional radiologic procedures. No graft was lost due to hepatic venous stenosis. In conclusion, these techniques avoid interposition grafts, are easily performed at the back table, simplify graft-to-recipient cava anastomosis, and avoid venous outflow narrowing.

Safety of donor right hepatectomy without abdominal drainage: a prospective evaluation in 100 consecutive liver donors

Although the role of routine abdominal drainage after liver resection for tumors has been questioned, abdominal drainage after donor right hepatectomy for live donor liver transplantation (LDLT) has been a routine practice in most transplant centers. The present study aimed to evaluate the safety of the procedure without abdominal drainage. A prospective study was performed on 100 consecutive liver donors who underwent right hepatectomy for LDLT from July 2000 to September 2003. Biliary anatomy was carefully studied with intraoperative cholangiography using fluoroscopy. The middle hepatic vein was included in the graft in all except 1 patient. Parenchymal transection was performed using an ultrasonic dissector. The right hepatic duct was transected at the hilum and the stump was closed with 6-O polydioxanone continuous suture. Absence of bile leakage was confirmed with methylene blue solution instilled through the cystic duct stump. The abdomen was closed after careful hemostasis without drainage in all donors. The median age of the donors was 36 years (range 18-56 years). Median operative blood loss and operating time were 350 mL (range 42-1,400 mL) and 7.5 hours (range 5.2-10.7 hours), respectively. None of the donors required any blood or blood product transfusion. There was no operative mortality. The median postoperative hospital stay was 8 days (range 5-30 days). Postoperative morbidity occurred in 19 patients (19%), most of which were minor complications. No donor experienced bile leakage, intraabdominal bleeding, or collection. None required surgical, radiologic, or endoscopic intervention for postoperative complications, except for 1 donor who developed late biliary stricture that required endoscopic dilatation. All donors were well with a median follow-up of 32 months (range 11-50 months). In conclusion, with detailed study of the biliary anatomy and meticulous surgical technique, donor right hepatectomy can be safely performed without abdominal drainage. Abdominal drainage is not a mandatory procedure after donor hepatectomy in LDLT.