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Toshima T, Harada N, Itoh S, Tomiyama T, Toshida K, Morita K, Nagao Y, Kurihara T, Tomino T, Kosai-Fujimoto Y, Mimori K, Yoshizumi T. What Are Risk Factors for Graft Loss in Patients Who Underwent Simultaneous Splenectomy During Living-donor Liver Transplantation? Transplantation 2024; 108:1593-1604. [PMID: 38409686 DOI: 10.1097/tp.0000000000004952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND The consensus that portal venous pressure modulation, including splenectomy (Spx), prevents portal hypertension-related complications after living-donor liver transplantation (LDLT) has been established. However, little evidence about the risk factors for graft loss after simultaneous Spx during LDLT is available. This study aimed to identify the independent predictors of graft loss after simultaneous Spx during LDLT. METHODS Data of 655 recipients who underwent LDLT between 1997 and 2021 were collected and separated into the simultaneous Spx group (n = 461) and no-Spx group (n = 194). RESULTS The simultaneous Spx group had significantly lower serum total bilirubin levels, drained ascites volumes, and prothrombin time-international normalized ratios on postoperative day 14 than the no-Spx group ( P < 0.001 for each). Incidences of small-for-size graft syndrome ( P < 0.001), acute cellular rejection ( P = 0.002), and sepsis ( P = 0.007) were significantly lower in the Spx group. Graft survival of the Spx group was significantly better than that of the no-Spx group ( P < 0.001; hazard ratio [HR], 1.788; 95% confidence interval, 1.214-2.431). A multivariate analysis revealed that 3 variables, platelet count ≤4.0 × 10 4 /mm 3 ( P = 0.029; HR, 2.873), donor age ≥60 y old ( P = 0.013; HR, 6.693), and portal venous pressure at closure ≥20 mm Hg ( P = 0.010; HR, 3.891), were independent predictors of graft loss within 6 mo after simultaneous Spx during LDLT. CONCLUSIONS Spx is a safe inflow modulation procedure with a positive impact on both postoperative complications and prognosis for most patients. However, patients with the 3 aforementioned independent factors could experience graft loss after LDLT.
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Affiliation(s)
- Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Surgery, Kyushu University Beppu Hospital, Beppu, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takahiro Tomiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Katsuya Toshida
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazutoyo Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Nagao
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Kurihara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takahiro Tomino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukiko Kosai-Fujimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koshi Mimori
- Department of Surgery, Kyushu University Beppu Hospital, Beppu, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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2
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Matsushima H, Soyama A, Hara T, Maruya Y, Fujita T, Imamura H, Adachi T, Hidaka M, Eguchi S. Outcomes of living donor liver transplant recipients receiving grafts with the graft-to-recipient weight ratio less than 0.6%: A matched pair analysis. Liver Transpl 2024; 30:519-529. [PMID: 37788305 DOI: 10.1097/lvt.0000000000000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023]
Abstract
We sometimes experience living donor liver transplantation (LDLT) involving very small grafts with graft-to-recipient weight ratio (GRWR) < 0.6% when the actual graft size is smaller than predicted. The outcomes in this situation have not been fully investigated. The present study aimed to determine the graft outcomes of LDLT with GRWR < 0.6%. We retrospectively reviewed 280 cases of adult LDLT performed at our institution between January 2000 and March 2021. In our institution, the lower limit for graft volume/standard liver volume ratio was 30%. The patients were divided into 2 groups according to the cutoff value of 0.6% for actual GRWR. Graft survival and surgical outcomes, including small-for-size syndrome (SFSS), were compared between the groups using propensity score matching analysis. Risk factors associated with SFSS in recipients with GRWR < 0.6% were also evaluated. Fifty-nine patients received grafts with GRWR < 0.6%. After propensity score matching, similar graft survival rates were observed for GRWR < 0.6% (n = 53) and GRWR ≥ 0.6% (n = 53) ( p = 0.98). However, patients with GRWR < 0.6% had a significantly worse 3-month graft survival rate (86.8% vs. 98.1%, p = 0.03) and higher incidence of SFSS ( p < 0.001) than patients with GRWR ≥0.6%. On multivariate analysis, Model for End-Stage Liver Disease score and donor age were associated with SFSS in patients with GRWR < 0.6%. The same factors were also associated with graft survival. In conclusion, although similar overall graft survival rates were observed for LDLT with GRWR < 0.6% and GRWR ≥ 0.6%, GRWR < 0.6% was associated with an increased risk of SFSS. Appropriate donor and recipient selection is important for successful LDLT with very small grafts.
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Affiliation(s)
- Hajime Matsushima
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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3
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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4
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Kow AWC, Liu J, Patel MS, De Martin E, Reddy MS, Soejima Y, Syn N, Watt K, Xia Q, Saraf N, Kamel R, Nasralla D, McKenna G, Srinvasan P, Elsabbagh AM, Pamecha V, Palaniappan K, Mas V, Tokat Y, Asthana S, Cherukuru R, Egawa H, Lerut J, Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Emond J, Ascher N, Rammohan A, Bhangui P, Rela M, Kim DS, Ikegami T. Post Living Donor Liver Transplantation Small-for-size Syndrome: Definitions, Timelines, Biochemical, and Clinical Factors for Diagnosis: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2226-2237. [PMID: 37749812 DOI: 10.1097/tp.0000000000004770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND When a partial liver graft is unable to meet the demands of the recipient, a clinical phenomenon, small-for-size syndrome (SFSS), may ensue. Clear definition, diagnosis, and management are needed to optimize transplant outcomes. METHODS A Consensus Scientific committee (106 members from 21 countries) performed an extensive literature review on specific aspects of SFSS, recommendations underwent blinded review by an independent panel, and discussion/voting on the recommendations occurred at the Consensus Conference. RESULTS The ideal graft-to-recipient weight ratio of ≥0.8% (or graft volume standard liver volume ratio of ≥40%) is recommended. It is also recommended to measure portal pressure or portal blood flow during living donor liver transplantation and maintain a postreperfusion portal pressure of <15 mm Hg and/or portal blood flow of <250 mL/min/100 g graft weight to optimize outcomes. The typical time point to diagnose SFSS is the postoperative day 7 to facilitate treatment and intervention. An objective 3-grade stratification of severity for protocolized management of SFSS is proposed. CONCLUSIONS The proposed grading system based on clinical and biochemical factors will help clinicians in the early identification of patients at risk of developing SFSS and institute timely therapeutic measures. The validity of this newly created grading system should be evaluated in future prospective studies.
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Affiliation(s)
- Alfred Wei Chieh Kow
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore
- Liver Transplantation, National University Center for Organ Transplantation (NUCOT), National University Health System Singapore, Singapore
| | - Jiang Liu
- Department of Surgery, Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- Department of Surgery, LKS Faculty of Medicine, HKU-Shenzhen Hospital, University of Hong Kong, Hong Kong/Special Administrative Region (SAR), China
| | - Madhukar S Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eleonora De Martin
- Department of Hepatology, APHP, Hospital Paul Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, FHU Hepatinov, Villejuif, France
| | - Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Yuji Soejima
- Department of Surgery, Shinshu University, Japan
| | - Nicholas Syn
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore
- Liver Transplantation, National University Center for Organ Transplantation (NUCOT), National University Health System Singapore, Singapore
| | - Kymberly Watt
- Division of Gastroenterology/Hepatology, Mayo Clinic, Rochester, MN
| | - Qiang Xia
- Department of Surgery, Division of Liver Transplantation, Renji Hospital, Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine, China
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-the Medicity, New Delhi, India
| | - Refaat Kamel
- Department of Surgery, Ain Shams University, Cairo, Egypt
| | - David Nasralla
- Department of HPB Surgery and Liver Transplantation, Royal Free London, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Greg McKenna
- Department of Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Parthi Srinvasan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ahmed M Elsabbagh
- Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Vinayendra Pamecha
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Kumar Palaniappan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Valeria Mas
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD
| | - Yaman Tokat
- International Liver Center, Acibadem Healthcare Hospitals, Turkey
| | - Sonal Asthana
- Department of Surgery, Integrated Liver Care Aster CMI Hospital, Bangalore, India
| | - Ramkiran Cherukuru
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Hiroto Egawa
- Hamamatsu Rosai Hospital, Hamamatsu, Shizuoka, Japan
| | - Jan Lerut
- Pôle de chirurgie expérimentale et transplantation, Université Catholique De Louvain, Louvain, Belgium
| | - Dieter Broering
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Hepatology and Liver Transplant Unit, Fundación Para La Investigación Del Hospital Universitario La Fe De La CCVV, IIS La Fe, Ciberehd, University of Valencia, Valencia, Spain
| | - Mark Cattral
- Department of Surgery, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | | | - Chao-Long Chen
- Department of Surgery, Chang Gung Memorial Hospital Kaoshiung, Taiwan
| | - Samir Shah
- Institute of Liver Disease, HPB Surgery and Rransplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Department of HPB Surgery and Liver Transplantation, Beijing Friendship Hospital, Beijing, China
| | - Jean Emond
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Nancy Ascher
- Division of Transplant Surgery, University of California San Francisco, San Francisco, CA
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-the Medicity, New Delhi, India
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Dong-Sik Kim
- Department of Surgery, Korea University Medical Center, Anam Hospital, Seoul, South Korea
| | - Toru Ikegami
- Department of Surgery, Centennial Hall Kyushu University School of Medicine, Kyushu, Japan
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5
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Hakeem AR, Mathew JS, Aunés CV, Mazzola A, Alconchel F, Yoon YI, Testa G, Selzner N, Sarin SK, Lee KW, Soin A, Pomposelli J, Menon K, Goyal N, Kota V, Abu-Gazala S, Rodriguez-Davalos M, Rajalingam R, Kapoor D, Durand F, Kamath P, Jothimani D, Sudhindran S, Vij V, Yoshizumi T, Egawa H, Lerut J, Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Ascher N, Bhangui P, Rammohan A, Emond J, Rela M. Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2203-2215. [PMID: 37635285 DOI: 10.1097/tp.0000000000004769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Small-for-size syndrome (SFSS) is a well-recognized complication following liver transplantation (LT), with up to 20% developing this following living donor LT (LDLT). Preventing SFSS involves consideration of factors before the surgical procedure, including donor and recipient selection, and factors during the surgical procedure, including adequate outflow reconstruction, graft portal inflow modulation, and management of portosystemic shunts. International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplant Society of India Consensus Conference was convened in January 2023 to develop recommendations for the prediction and management of SFSS in LDLT. The format of the conference was based on the Grading of Recommendations, Assessment, Development, and Evaluation system. International experts in this field were allocated to 4 working groups (diagnosis, prevention, anesthesia, and critical care considerations, and management of established SFSS). The working groups prepared evidence-based recommendations to answer-specific questions considering the currently available literature. The working group members, independent panel, and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and evidence-based recommendations provided by working group 2 that can be implemented to prevent SFSS in LDLT patients.
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Affiliation(s)
- Abdul Rahman Hakeem
- Department of Hepatobiliary and Liver Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Johns Shaji Mathew
- Department of GI, HPB & Multi-Organ Transplant, Rajagiri Hospitals, Kochi, India
| | - Carmen Vinaixa Aunés
- Hepatología y Trasplante Hepático, Servicio de Medicina Digestiva, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Alessandra Mazzola
- Sorbonne Université, Unité Médicale de Transplantation Hépatique, Hépato-gastroentérologie, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Felipe Alconchel
- Department of Surgery and Transplantation, Virgen de la Arrixaca University Hospital, Murcia, Spain
- Biomedical Research Institute of Murcia, IMIB-Pascual Parrilla, Murcia, Spain
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, Seoul, South Korea
| | - Giuliano Testa
- Department of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Nazia Selzner
- Multi-Organ Transplant Program, Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Arvinder Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - James Pomposelli
- University of Colorado School of Medicine, Division of Transplant Surgery, Department of Surgery, Aurora, CO
| | - Krishna Menon
- Institute of Liver Diseases, King's College Hospital, London, United Kingdom
| | - Neerav Goyal
- Liver Transplant and Hepato-Pancreatobiliary Surgery Unit (LTHPS), Indraprastha Apollo Hospital, New Delhi, India
| | - Venugopal Kota
- Department of HPB Surgery and Liver Transplantation, Yashoda Hospitals, Secunderabad, Hyderabad, Telangana, India
| | - Samir Abu-Gazala
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Manuel Rodriguez-Davalos
- Liver Center, Primary Children's Hospital; Transplant Services, Intermountain Transplant Center, Primary Children's Hospital, Salt Lake City, UT
| | - Rajesh Rajalingam
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Dharmesh Kapoor
- Department of Hepatology and Liver Transplantation, Yashoda Hospitals, Secunderabad, Hyderabad, Telangana, India
| | - Francois Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy University Paris Cité, Paris, France
| | - Patrick Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Surendran Sudhindran
- Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences, Kochi, India
| | - Vivek Vij
- Department of HPB Surgery and Liver Transplantation, Fortis Group of Hospitals, New Delhi, India
| | | | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Institute for Experimental and Clinical Research (IREC), Université catholique Louvain (UCL), Brussels, Belgium
| | - Dieter Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Unit, Ciberehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Universidad Valencia, Valencia, Spain
| | - Mark Cattral
- Multi-Organ Transplant Program, Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Zürich, Switzerland
| | - Chao-Long Chen
- Liver Transplantation Centre, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Jean Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
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6
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Fujiki M, Pita A, Kusakabe J, Sasaki K, You T, Tuul M, Aucejo FN, Quintini C, Eghtesad B, Pinna A, Miller C, Hashimoto K, Kwon CHD. Left Lobe First With Purely Laparoscopic Approach: A Novel Strategy to Maximize Donor Safety in Adult Living Donor Liver Transplantation. Ann Surg 2023; 278:479-488. [PMID: 37436876 DOI: 10.1097/sla.0000000000005988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Evaluate outcome of left-lobe graft (LLG) first combined with purely laparoscopic donor hemihepatectomy (PLDH) as a strategy to minimize donor risk. BACKGROUND An LLG first approach and a PLDH are 2 methods used to reduce surgical stress for donors in adult living donor liver transplantation (LDLT). But the risk associated with application LLG first combined with PLDH is not known. METHODS From 2012 to 2023, 186 adult LDLTs were performed with hemiliver grafts, procured by open surgery in 95 and PLDH in 91 cases. LLGs were considered first when graft-to-recipient weight ratio ≥0.6%. Following a 4-month adoption process, all donor hepatectomies, since December 2019, were performed laparoscopically. RESULTS There was one intraoperative conversion to open (1%). Mean operative times were similar in laparoscopic and open cases (366 vs 371 minutes). PLDH provided shorter hospital stays, lower blood loss, and lower peak aspartate aminotransferase. Peak bilirubin was lower in LLG donors compared with right-lobe graft donors (1.4 vs 2.4 mg/dL, P < 0.01), and PLDH further improved the bilirubin levels in LLG donors (1.2 vs 1.6 mg/dL, P < 0.01). PLDH also afforded a low rate of early complications (Clavien-Dindo grade ≥ II, 8% vs 22%, P = 0.007) and late complications, including incisional hernia (0% vs 13.7%, P < 0.001), compared with open cases. LLG was more likely to have a single duct than a right-lobe graft (89% vs 60%, P < 0.01). Importantly, with the aggressive use of LLG in 47% of adult LDLT, favorable graft survival was achieved without any differences between the type of graft and surgical approach. CONCLUSIONS The LLG first with PLDH approach minimizes surgical stress for donors in adult LDLT without compromising recipient outcomes. This strategy can lighten the burden for living donors, which could help expand the donor pool.
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Affiliation(s)
- Masato Fujiki
- Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Alejandro Pita
- Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Jiro Kusakabe
- Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Kazunari Sasaki
- Department of Surgery, Division of Abdominal Transplant, Stanford University, Palo Alto, CA
| | - Taesuk You
- Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Munkhbold Tuul
- Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Cristiano Quintini
- General Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Bijan Eghtesad
- Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Antonio Pinna
- Transplant Center, Cleveland Clinic Florida, Weston, FL
| | - Charles Miller
- Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Department of General Surgery, Cleveland Clinic, Cleveland, OH
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Parente A, Cho HD, Kim KH, Schlegel A. Association between Hepatocellular Carcinoma Recurrence and Graft Size in Living Donor Liver Transplantation: A Systematic Review. Int J Mol Sci 2023; 24:ijms24076224. [PMID: 37047199 PMCID: PMC10093934 DOI: 10.3390/ijms24076224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
The aim of this work was to assess the association between graft-to-recipient weight ratio (GRWR) in adult-to-adult living donor liver transplantation (LDLT) and hepatocellular carcinoma (HCC) recurrence. A search of the MEDLINE and EMBASE databases was performed until December 2022 for studies comparing different GRWRs in the prognosis of HCC recipients in LDLT. Data were pooled to evaluate 1- and 3-year survival rates. We identified three studies, including a total of 782 patients (168 GRWR < 0.8 vs. 614 GRWR ≥ 0.8%). The pooled overall survival was 85% and 77% at one year and 90% and 83% at three years for GRWR < 0.8 and GRWR ≥ 0.8, respectively. The largest series found that, in patients within Milan criteria, the GRWR was not associated with lower oncological outcomes. However, patients with HCC outside the Milan criteria with a GRWR < 0.8% had lower survival and higher tumor recurrence rates. The GRWR < 0.8% appears to be associated with lower survival rates in HCC recipients, particularly for candidates with tumors outside established HCC criteria. Although the data are scarce, the results of this study suggest that considering the individual GRWR not only as risk factor for small-for-size-syndrome but also as contributor to HCC recurrence in patients undergoing LDLT would be beneficial. Novel perfusion technologies and pharmacological interventions may contribute to improving outcomes.
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8
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Spaggiari M, Martinino A, Ray CE, Bencini G, Petrochenkov E, Di Cocco P, Almario-Alvarez J, Tzvetanov I, Benedetti E. Hepatic Arterial Buffer Response in Liver Transplant Recipients: Implications and Treatment Options. Semin Intervent Radiol 2023; 40:106-112. [PMID: 37152797 PMCID: PMC10159717 DOI: 10.1055/s-0043-1767690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Alessandro Martinino
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Charles E. Ray
- Department of Radiology, University of Illinois College of Medicine, Chicago, Illinois
| | - Giulia Bencini
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Egor Petrochenkov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Jorge Almario-Alvarez
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
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9
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Giglio MC, Zanfardino M, Franzese M, Zakaria H, Alobthani S, Zidan A, Ayoub II, Shoreem HA, Lee B, Han HS, Penna AD, Nadalin S, Troisi RI, Broering DC. Machine learning improves the accuracy of graft weight prediction in living donor liver transplantation. Liver Transpl 2023; 29:172-183. [PMID: 37160073 DOI: 10.1002/lt.26578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 07/29/2022] [Accepted: 09/06/2022] [Indexed: 01/28/2023]
Abstract
Precise graft weight (GW) estimation is essential for planning living donor liver transplantation to select grafts of adequate size for the recipient. This study aimed to investigate whether a machine-learning model can improve the accuracy of GW estimation. Data from 872 consecutive living donors of a left lateral sector, left lobe, or right lobe to adults or children for living-related liver transplantation were collected from January 2011 to December 2019. Supervised machine-learning models were trained (80% of observations) to predict GW using the following information: donor's age, sex, height, weight, and body mass index; graft type (left, right, or left lateral lobe); computed tomography estimated graft volume and total liver volume. Model performance was measured in a random independent set (20% of observations) and in an external validation cohort using the mean absolute error (MAE) and the mean absolute percentage error and compared with methods currently available for GW estimation. The best-performing machine-learning model showed an MAE value of 50 ± 62 g in predicting GW, with a mean error of 10.3%. These errors were significantly lower than those observed with alternative methods. In addition, 62% of predictions had errors <10%, whereas errors >15% were observed in only 18.4% of the cases compared with the 34.6% of the predictions obtained with the best alternative method ( p < 0.001). The machine-learning model is made available as a web application ( http://graftweight.shinyapps.io/prediction ). Machine learning can improve the precision of GW estimation compared with currently available methods by reducing the frequency of significant errors. The coupling of anthropometric variables to the preoperatively estimated graft volume seems necessary to improve the accuracy of GW estimation.
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Affiliation(s)
- Mariano Cesare Giglio
- Division of Hepato-biliary-pancreatic, Minimally Invasive and Robotic surgery, and Transplantation Service , Federico II University Hospital , Naples , Italy
| | | | | | - Hazem Zakaria
- Hepatopancreatobiliary and Liver Transplant Surgery , National Liver Institute, Menoufia University , Menoufia , Egypt.,Organ Transplant Center , King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Salah Alobthani
- Organ Transplant Center , King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Ahmed Zidan
- Organ Transplant Center , King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia.,Department of General Surgery , Assiut University , Assiut , Egypt
| | - Islam Ismail Ayoub
- Hepatopancreatobiliary and Liver Transplant Surgery , National Liver Institute, Menoufia University , Menoufia , Egypt
| | - Hany Abdelmeguid Shoreem
- Hepatopancreatobiliary and Liver Transplant Surgery , National Liver Institute, Menoufia University , Menoufia , Egypt
| | - Boram Lee
- Department of Surgery , Seoul National University Bundang Hospital , Seoul , Korea
| | - Ho-Seong Han
- Department of Surgery , Seoul National University Bundang Hospital , Seoul , Korea
| | - Andrea Della Penna
- Department of General, Visceral, and Transplant Surgery , University Hospital Tübingen , Tübingen , Germany
| | - Silvio Nadalin
- Department of General, Visceral, and Transplant Surgery , University Hospital Tübingen , Tübingen , Germany
| | - Roberto Ivan Troisi
- Division of Hepato-biliary-pancreatic, Minimally Invasive and Robotic surgery, and Transplantation Service , Federico II University Hospital , Naples , Italy
| | - Dieter Clemens Broering
- Organ Transplant Center , King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
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10
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Kim KH, Kim SH, Cho HD. The short- and long-term outcomes in living-donor liver transplantation using small-for-size graft: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100747. [PMID: 36821946 DOI: 10.1016/j.trre.2023.100747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND A standard graft-to-recipient weight ratio (GRWR) ≥0.8% is widely accepted in living-donor liver transplantation (LDLT); however, the potential donor pool is expanded to patients adopting small-for-size graft (SFSGs) with GRWR <0.8%. This study aimed to investigate the effect of SFSG on short- and long-term outcomes following LDLT. METHODS Electronic databases were searched from January 1995 to January 2022 for studies comparing short- or long-term outcomes between patients with SFSG (GRWR <0.8%, SFSG group) and sufficient volume graft (GRWR ≥0.8%, non-SFSG group). The primary outcomes were one-, three-, and five-year overall survival (OS) and graft survival (GS), while the secondary outcome was postoperative complications. RESULTS Twenty-four studies comprising 7996 patients were included. In terms of OS, SFSG group had poor three-year OS (HR: 1.48, 95% CI [1.01, 2.15], p = 0.04), but there were no significant differences between two groups in one-year OS (HR: 1.50, 95% CI [0.98, 2.29], p = 0.06) and five-year OS (HR: 1.40, 95% CI [0.95, 2.08], p = 0.02). In GS, there were no significant differences in one-year (HR 1.31, 95% CI [1.00, 1.72], p = 0.05), three-year (HR 1.33, 95% CI [0.97, 1.82], p = 0.07), and five-year GS (HR 1.17, 95% CI [0.95, 1.44], p = 0.13). The SFSG group had comparable postoperative complications, except for a high incidence of vascular complications and small-for-size syndromes. CONCLUSIONS Expanding the potential donor pool in LDLT to SFSG with GRWR <0.8% can be acceptable in terms of comparable long-term OS and GS, despite the risk for vascular complications and small-for-size syndrome.
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Affiliation(s)
- Ki-Hun Kim
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Sang-Hoon Kim
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hwui-Dong Cho
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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11
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Granieri S, Bracchetti G, Kersik A, Frassini S, Germini A, Bonomi A, Lomaglio L, Gjoni E, Frontali A, Bruno F, Paleino S, Cotsoglou C. Preoperative indocyanine green (ICG) clearance test: Can we really trust it to predict post hepatectomy liver failure? A systematic review of the literature and meta-analysis of diagnostic test accuracy. Photodiagnosis Photodyn Ther 2022; 40:103170. [PMID: 36302467 DOI: 10.1016/j.pdpdt.2022.103170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Post hepatectomy liver failure (PHFL) still represents a potentially fatal complication after major liver resection. Indocyanine green (ICG) clearance test represents one of the most widely adopted examinations in the preoperative workup. Despite a copious body of evidence which has been published on this topic, the role of ICG in predicting PHLF is still a matter of debate. METHODS A systematic review of the literature was conducted according to PRISMA-DTA guidelines. The primary outcome was the assessment of diagnostic performance of ICG in predicting PHLF. The secondary outcome was the mean ICGR15 and ICGPDR in patients experiencing PHLF. RESULTS Seventeen studies, for a total of 4852 patients, were deemed eligible. Sensitivity ranged from 25% to 83%; Specificity ranged from 66.1% to 93.8%. ICG clearance test pooled AUC was 0.673 (95% CI: 0.632-0.713). The weighted mean ICGR15 was 11 (95%CI: 8.3-13.7). The weighted mean ICGPDR was 16.5 (95%CI: 13.3-19.8). High risk of bias was detected in all examined domains. CONCLUSIONS Preoperative ICG clearance test alone may not represent a reliable method to predict post hepatectomy liver failure. Its diagnostic significance should be framed within multiparametric models involving clinical and imaging features.
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Affiliation(s)
- Stefano Granieri
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy.
| | - Greta Bracchetti
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy; University of Milan, Via Festa del Perdono, 7, Milan 20122, Italy
| | - Alessia Kersik
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy; University of Milan, Via Festa del Perdono, 7, Milan 20122, Italy
| | - Simone Frassini
- University of Pavia, Corso Str. Nuova, 65, Pavia 27100, Italy; General Surgery Unit, Department of surgery, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia 27100, Italy
| | - Alessandro Germini
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy
| | - Alessandro Bonomi
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy; University of Milan, Via Festa del Perdono, 7, Milan 20122, Italy
| | - Laura Lomaglio
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy
| | - Elson Gjoni
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy
| | - Alice Frontali
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy
| | - Federica Bruno
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy
| | - Sissi Paleino
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy
| | - Christian Cotsoglou
- General Surgery Unit, Vimercate Hospital, ASST Vimercate, Azienda Socio Sanitaria Territoriale della Brianza, Via Santi Cosma e Damiano, 10, Vimercate, MB 20871, Italy
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12
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Bell R, Begum S, Prasad R, Taura K, Dasari BVM. Volume and flow modulation strategies to mitigate post-hepatectomy liver failure. Front Oncol 2022; 12:1021018. [PMID: 36465356 PMCID: PMC9714434 DOI: 10.3389/fonc.2022.1021018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/20/2022] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION Post hepatectomy liver failure is the most common cause of death following major hepatic resections with a perioperative mortality rate between 40% to 60%. Various strategies have been devised to increase the volume and function of future liver remnant (FLR). This study aims to review the strategies used for volume and flow modulation to reduce the incidence of post hepatectomy liver failure. METHOD An electronic search was performed of the MEDLINE, EMBASE and PubMed databases from 2000 to 2022 using the following search strategy "Post hepatectomy liver failure", "flow modulation", "small for size flow syndrome", "portal vein embolization", "dual vein embolization", "ALPPS" and "staged hepatectomy" to identify all articles published relating to this topic. RESULTS Volume and flow modulation strategies have evolved over time to maximize the volume and function of FLR to mitigate the risk of PHLF. Portal vein with or without hepatic vein embolization/ligation, ALPPS, and staged hepatectomy have resulted in significant hypertrophy and kinetic growth of FLR. Similarly, techniques including portal flow diversion, splenic artery ligation, splenectomy and pharmacological agents like somatostatin and terlipressin are employed to reduce the risk of small for size flow syndrome SFSF syndrome by decreasing portal venous flow and increasing hepatic artery flow at the same time. CONCLUSION The current review outlines the various strategies of volume and flow modulation that can be used in isolation or combination in the management of patients at risk of PHLF.
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Affiliation(s)
- Richard Bell
- Department of Hepatobiliary and Transplant Surgery, St. James’s University Hospital, Leeds, United Kingdom
| | - Saleema Begum
- Department of Hepatobiliary and Pancreatic (HPB) and Transplant Surgery, University Hospital Birmingham, Birmingham, United Kingdom
| | - Raj Prasad
- Department of Hepatobiliary and Transplant Surgery, St. James’s University Hospital, Leeds, United Kingdom
| | - Kojiro Taura
- Division of Hepatobiliary and Pancreatic (HPB) Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Bobby V. M. Dasari
- Department of Hepatobiliary and Pancreatic (HPB) and Transplant Surgery, University Hospital Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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13
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Fujiki M, Hashimoto K, Quintini C, Aucejo F, Kwon CHD, Matsushima H, Sasaki K, Campos L, Eghtesad B, Diago T, Iuppa G, D'amico G, Kumar S, Liu P, Miller C, Pinna A. Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy: A Promised Land for Small Left Lobe Grafts. Ann Surg 2022; 276:838-845. [PMID: 35894443 DOI: 10.1097/sla.0000000000005630] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Living donor liver transplantation (LDLT) using small grafts, especially left lobe grafts (H1234-MHV) (LLG), continues to be a challenge due to small-for-size syndrome (SFSS). We herein demonstrate that with surgical modifications, outcomes with small grafts can be improved. METHODS Between 2012 and 2020, we performed 130 adult LDLT using 61 (47%) LLG (H1234-MHV) in a single Enterprise. The median graft-to-recipient weight ratio was 0.84%, with graft-to-recipient weight ratio <0.7% accounting for 22%. Splenectomy was performed in 72 (56%) patients for inflow modulation before (n=50) or after (n=22) graft reperfusion. In LLG-LDLT, venous outflow was achieved using all three recipient hepatic veins. In right lobe graft (H5678) (RLG)-LDLT, the augmented graft right hepatic vein was anastomosed to the recipient's cava with a large cavotomy. Outcome measures include SFSS, early allograft dysfunction (EAD), and survival. RESULTS Graft survival rates at 1, 3, and 5 years were 94%, 90%, and 83%, respectively, with no differences between LLG (H1234-MHV) and RLG (H5678). Splenectomy significantly reduced portal flow without increasing the complication rate. Despite the aggressive use of small grafts, SFSS and EAD developed in only 1 (0.8%) and 18 (13.8%) patients, respectively. Multivariable logistic regression revealed model for end-stage liver disease score and LLG (H1234-MHV) as independent risk factors for EAD and splenectomy as a protective factor (odds ratio: 0.09; P =0.03). For LLG (H1234-MHV)-LDLT, patients who underwent prereperfusion splenectomy tended to have better 1-year graft survival than those receiving postreperfusion splenectomy. CONCLUSIONS LLG (H1234-MHV) are feasible in adult LDLT with excellent outcomes comparable to RLG (H5678). Venous outflow augmentation and splenectomy help lower the threshold of using small-for-size grafts without compromising graft survival.
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Affiliation(s)
| | | | | | | | | | | | | | - Luis Campos
- Transplant Center, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - Teresa Diago
- Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Giuseppe Iuppa
- Transplant Center, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - Shiva Kumar
- Transplant Center, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Peter Liu
- Department of Radiology, Cleveland Clinic, Cleveland, OH
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Splenic Artery Ligation: An Ontable Bail-Out Strategy for Small-for-Size Remnants after Major Hepatectomy: A Retrospective Study. J Pers Med 2022; 12:jpm12101687. [PMID: 36294827 PMCID: PMC9605094 DOI: 10.3390/jpm12101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/06/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022] Open
Abstract
It has been reported that the prevention of acute portal overpressure in small-for-size liver grafts leads to better postoperative outcomes. Accordingly, we aimed to investigate the feasibility of the technique of splenic artery ligation in a case series of thirteen patients subjected to major liver resections with evidence of small-for-size syndrome and whether the maneuver results in the reduction of portal venous pressure and flow. The technique was successful in ten patients, with splenic artery ligation alleviating portal hypertension significantly. Three patients required the performance of a portocaval shunt for the attenuation of portal hypertension. Portal inflow modulation via splenic artery ligation is a technically simple technique that can prove useful in the context of major hepatectomies as well as in liver transplantations and the early evaluation and modification of portal venous pressure post hepatectomy can be used as a practical tool to guide the effect of the intervention.
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15
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Patel MS, Egawa H, Kwon YK, Chok KSH, Spiro M, Raptis DA, Vij V, Chaudhary A, Genyk Y. The role of graft to recipient weight ratio on enhanced recovery of the recipient after living donor liver transplantation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14630. [PMID: 35258108 DOI: 10.1111/ctr.14630] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/01/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND There continues to be debate about the lower limit of graft-to-recipient weight ratio (GRWR) for living donor liver transplant (LDLT). OBJECTIVES To identify the lower limit of GRWR compatible with enhanced recovery after living donor liver transplant and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies assessing how GRWR affects recipient outcomes such as small for size syndrome, other complications, patient and graft survival, and length of stay were included. PROTOCOL REGISTRATION CRD42021260794. RESULTS Twenty articles were included in the qualitative synthesis, and all were retrospective observational studies. There was heterogeneity in the definition of study cohorts and key outcome measures such as small-for-size syndrome. Most studies lacked risk adjustment given limited single-center sample size. GRWR of ≥ .8% is associated with enhanced recovery. Recipients of grafts with GRWR < .8%, however, were found to have similar outcomes as those with ≥ .8% when appropriate consideration is made for portal flow modulation and recipient illness severity. CONCLUSIONS GRWR ≥ .8% is often compatible with enhanced recovery, but grafts < .8% can be used in selected LDLT recipients with optimal donor-recipient selection, surgical technique, and perioperative management (Quality of Evidence; Low | Grade of Recommendation; Strong).
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Affiliation(s)
- Madhukar S Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yong Kyong Kwon
- Department of Surgery, Keck Medical Center of University of Southern California, Los Angles, California, USA
| | - Kenneth Siu Ho Chok
- Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Vivek Vij
- Liver Transplant and Hepatobiliary Surgery, Fortis Hospital, Noida, UP, India
| | - Abhideep Chaudhary
- Department of HPB Surgery & Liver Transplant, BL Kapur Superspeciality Hospital, Delhi, India
| | - Yuri Genyk
- Department of Surgery, Keck Medical Center of University of Southern California, Los Angles, California, USA
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Rammohan A, Rela M, Kim DS, Soejima Y, Kasahara M, Ikegami T, Spiro M, Aristotle Raptis D, Humar A. Does modification of portal pressure and flow enhance recovery of the recipient after living donor liver transplantation? A systematic review of literature and expert panel recommendations. Clin Transplant 2022; 36:e14657. [PMID: 35344628 DOI: 10.1111/ctr.14657] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/11/2022] [Accepted: 03/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Portal inflow modulation (PIM) aimed at reducing portal hyperperfusion is commonly used in living donor liver transplantation (LDLT) to reduce the risk of small-for-size syndrome (SFSS). Many different techniques, both pharmacological and surgical have been used for this purpose. There is, however, little consensus on the best method of PIM, its exact role in preventing SFSS and on early post-LDLT recovery. OBJECTIVES To identify whether modifications of portal pressures and flows enhance recovery after LDLT and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO ID CRD42021260997. RESULTS Five hundred and ninety four articles were identified through databases' search. Of the 24 included for a final review by the working group (WG), there were five randomized control trials, four prospective studies and 15 retrospective series. Six outcome measures which were likely to influence early recovery after LDLT, especially in small-for-size grafts (SFSG) were shortlisted. These included acute kidney injury, SFSS, morbidity including sepsis, length of ICU and hospital stay, morbidity of the PIM technique and overall mortality. The WG noted that PIM in this subset of LDLT recipients had a beneficial effect on all the outcomes measures. CONCLUSIONS Considering all decision domains, the panel recommends pre- and intraoperative actual graft weight validation, portal pressure/flow measurements, and a comprehensive donor evaluation for the determination of potentially small-for-size/ small-for-flow grafts as mandatory. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) Pharmacological PIM helps improve early renal function in LDLT recipients. (Quality of Evidence: High | Grade of Recommendation: Strong) In selected patients with SFSG, PIM helps reduce SFSS/EAD and sepsis. (Quality of Evidence: Moderate | Grade of Recommendation: Strong) PIM in the form of splenectomy has increased morbidity compared to splenic artery ligation (SAL). (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, PIM may help reduce morbidity/mortality. (Quality of Evidence: Low | Grade of Recommendation: Strong) In LDLT recipients with SFSG, modification of portal pressures and flows enhances recovery after LDLT. (Quality of Evidence: Moderate | Grade of Recommendation: Strong).
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Affiliation(s)
- Ashwin Rammohan
- Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Mohamed Rela
- Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Yuji Soejima
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute (STI), University of Pittsburgh Medical Center, Pittsburgh, USA
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Cheng P, Li Z, Fu Z, Jian Q, Deng R, Ma Y. Small-For-Size Syndrome and Graft Inflow Modulation Techniques in Liver Transplantation. Dig Dis 2022; 41:250-258. [PMID: 35753308 DOI: 10.1159/000525540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/30/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Partial liver transplantation has recently been proposed to alleviate organ shortages. However, transplantation of a small-for-size graft is associated with an increased risk of posttransplant hepatic dysfunction, commonly referred to as small-for-size syndrome (SFSS). This review describes the etiology, pathological features, clinical manifestations, and diagnostic criteria of SFSS. Moreover, we summarize strategies to improve graft function, focusing on graft inflow modulation techniques. Finally, unmet needs and future perspectives are discussed. SUMMARY In fact, posttransplant SFSS can be attributed to various factors such as preoperative status of the recipients, surgical techniques, donor age, and graft quality, except for graft size. With targeted improvement measures, satisfactory clinical outcomes can be achieved in recipients at increased risk of SFSS. Given the critical role of relative portal hyperperfusion in the pathogenesis of SFSS, various pharmacological and surgical treatments have been established to reduce or partially divert excessive portal inflow, and recipients will benefit from individualized therapeutic regimens after careful evaluation of benefits against potential risks. However, there remain unmet needs for further research into different aspects of SFSS to better understand the correlation between portal hemodynamics and patient outcomes. KEY MESSAGES Contemporary transplant surgeons should consider various donor and recipient factors and develop case-specific prevention and treatment strategies to improve graft and recipient survival rates.
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Affiliation(s)
- Pengrui Cheng
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhongqiu Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zongli Fu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Jian
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ronghai Deng
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi Ma
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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18
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Papamichail M, Pizanias M, Heaton ND, M P, M P, Nd H. Minimizing the risk of small-for-size syndrome after liver surgery. Hepatobiliary Pancreat Dis Int 2022; 21:113-133. [PMID: 34961675 DOI: 10.1016/j.hbpd.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS). DATA SOURCES This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS. RESULTS Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS. CONCLUSIONS With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.
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Affiliation(s)
- Michail Papamichail
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK.
| | - Michail Pizanias
- Department of General Surgery, Whittington Hospital, London N19 5NF, UK
| | - Nigel D Heaton
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Papamichail M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Pizanias M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Heaton Nd
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
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19
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Portocaval shunt can optimize transhepatic flow following extended hepatectomy: a short-term study in a porcine model. Sci Rep 2022; 12:1668. [PMID: 35102168 PMCID: PMC8803864 DOI: 10.1038/s41598-022-05327-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 12/15/2021] [Indexed: 11/08/2022] Open
Abstract
AbstractThe aim of this study was to evaluate whether the portocaval shunt (PCS) corrects these unwanted changes in transhepatic flow after extended hepatectomy (EH). Forty female Landrace pigs were divided into two main groups: (A) EH (75%) and (B) no EH. Group A was divided into 3 subgroups: (A1) EH without PCS; (A2) EH with side-to-side PCS; and (A3) EH with end-to-side PCS. Group B was divided into 2 subgroups: (B1) side-to-side PCS and (B2) end-to-side PCS. HAF, PVF, and PVP were measured in each animal before and after the surgical procedure. EH increased the PVF/100 g (173%, p < 0.001) and PVP (68%, p < 0.001) but reduced the HAF/100 g (22%, p = 0.819). Following EH, side-to-side PCS reduced the increased PVF (78%, p < 0.001) and PVP (38%, p = 0.001). Without EH, side-to-side PCS reduced the PVF/100 g (68%, p < 0.001) and PVP (12%, p = 0.237). PVP was reduced by end-to-side PCS following EH by 48% (p < 0.001) and without EH by 21% (p = 0.075). PCS can decrease and correct the elevated PVP and PVF/100 g after EH to close to the normal values prior to resection. The decreased HAF/100 g in the remnant liver following EH is increased and corrected through PCS.
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20
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Vijayashanker A, Chikkala BR, Ghimire R, Nidoni R, Acharya MR, Pandey Y, Dey R, Kaloo SB, Agarwal S, Gupta S. Do Natural Portosystemic Shunts Need to Be Compulsorily Ligated in Living Donor Liver Transplantation? J Clin Exp Hepatol 2022; 12:29-36. [PMID: 35068782 PMCID: PMC8766688 DOI: 10.1016/j.jceh.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/17/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Natural portosystemic shunt ligation practices in liver transplant vary widely across transplant centres and are frequently undertaken to prevent the serious consequence of portal steal phenomenon. No concrete indications have so far been convincingly identified for their management in living donor liver transplant. METHODS We retrospectively studied the outcome of 89 cirrhotic patients who either did (n = 63) or did not (n = 25) undergo shunt ligation during living donor liver transplantation between 2017 and 2020. RESULTS The incidence of early allograft dysfunction/nonfunction (P = 1.0) and portal venous complications (P = 0.555) were similar between the two groups. Although overall complications, biliary complications, and the composite of Grade III and IV complications were significantly higher in the nonligated group (P = 0.015, 0.052 and 0.035), 1- year graft and patient survival were comparable between them (P = 0.524). CONCLUSION We conclude that shunt ligation in living donor liver transplantation may not always be necessary if adequate portal flow, good vascular reconstruction, and good graft quality have been ensured.
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Key Words
- AKI, Acute Kidney Injury
- BCS, Budd Chiari Syndrome
- BMI, Body mass index
- C, Caudate
- CIT, Cold ischemia time
- EAD, Early Allograft Dysfunction
- FLR, Future Liver Remnant
- GRWR, Graft Recipient Weight Ratio
- HAT, Hepatic Artery Thrombosis
- HBV, Hepatitis B virus infection
- HCV, Hepatitis C virus infection
- HE, Hepatic encephalopathy
- HRS, Hepatorenal syndrome
- HVOTO, Hepatic venous outflow obstruction
- IHV, Inferior hepatic vein
- IVC, Infrahepatic Vena Cava
- LAI, Liver Attenuation Index
- LDLT, Living Donor Liver Transplant
- LL, Left lobe
- MELD, Model for End-stage Liver Disease
- MHV, Middle Hepatic Vein
- MRL, Modified Right lobe
- NASH, Nonalcoholic steatohepatitis
- PVT, Portal Vein Thrombosis
- RHV, Right Hepatic Vein
- SFSS, Small For Size Syndrome
- SMV, Superior mesenteric vein
- SRL, Standard right lobe
- WIT, Warm Ischemia Time
- living donor liver transplant
- natural portosystemic collateral
- shunt ligation
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Subhash Gupta
- Address for correspondence. Subhash Gupta, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, 1, Press Enclave Road, Saket, New Delhi, 110017, India. Tel.: +91 98110 75683.
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21
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Abstract
OBJECTIVE To survey the available literature regarding the use of auxiliary liver transplantation (ALT) in the setting of cirrhosis. SUMMARY BACKGROUND ALT is a type of LT procedure in which part of the cirrhotic liver is resected and part of the liver graft is transplanted. The cirrhotic liver left in situ acts as an auxiliary liver until the graft has reached sufficient volume. Recently, a two-stage concept named RAPID (Resection And Partial LIver segment 2/3 transplantation with Delayed total hepatectomy) was developed, which combines hypertrophy of the small graft followed by delayed removal of the native liver. METHODS A scoping review of the literature on ALT for cirrhosis was performed, focusing on the historical background of RAPID and the status of RAPID for this indication. The new comprehensive nomenclature for hepatectomy ("New World" terminology) was used in this review. RESULTS A total of 72 cirrhotic patients underwent ALT [heterotopic (n = 34), orthotopic (APOLT, n = 34 including 5 followed by resection of the native liver at the second stage) and RAPID (n = 4)]. Among the 9 two-stage LTs (APOLT, n = 5; RAPID, n = 4), portal blood flow modulation was performed in 6 patients by deportalization of the native liver (n = 4), portosystemic shunt creation (n = 1), splenic artery ligation (n = 3) or splenectomy (n = 1). The delay between the first and second stages ranged from 18 to 90 days. This procedure led to an increase in the graft-to-recipient weight ratio between 33% and 156%. Eight patients were alive at the last follow-up. CONCLUSIONS Two-stage LT and, more recently, the RAPID procedure are viable options for increasing the number of transplantations for cirrhotic patients by using small grafts.
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22
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Hessheimer AJ, Vengohechea J, Martínez de la Maza L, Muñoz J, Vendrell M, Sanahuja JM, Torroella A, Adel Al Shwely F, Riquelme F, Muñoz C, García R, Taurá P, Fondevila C. Somatostatin Therapy Improves Stellate Cell Activation and Early Fibrogenesis in a Preclinical Model of Extended Major Hepatectomy. Cancers (Basel) 2021; 13:3989. [PMID: 34439143 PMCID: PMC8392429 DOI: 10.3390/cancers13163989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022] Open
Abstract
Liver resection treats primary and secondary liver tumors, though clinical applicability is limited by the remnant liver mass and quality. Herein, major hepatic resections were performed in pigs to define changes associated with sufficient and insufficient remnants and improve liver-specific outcomes with somatostatin therapy. Three experimental groups were performed: 75% hepatectomy (75H), 90% hepatectomy (90H), and 90% hepatectomy + somatostatin (90H + SST). Animals were followed for 24 h (N = 6) and 5 d (N = 6). After hepatectomy, portal pressure gradient was higher in 90H versus 75H and 90H + SST (8 (3-13) mmHg vs. 4 (2-6) mmHg and 4 (2-6) mmHg, respectively, p < 0.001). After 24 h, changes were observed in 90H associated with stellate cell activation and collapse of sinusoidal lumen. Collagen chain type 1 alpha 1 mRNA expression was higher, extracellular matrix width less, and percentage of collagen-staining areas greater at 24 h in 90H versus 75H and 90H + SST. After 5 d, remnant liver mass was higher in 75H and 90H + SST versus 90H, and Ki-67 immunostaining was higher in 90H + SST versus 75H and 90H. As well, more TUNEL-staining cells were observed in 90H versus 75H and 90H + SST at 5 d. Perioperative somatostatin modified portal pressure, injury, apoptosis, and stellate cell activation, stemming changes related to hepatic fibrogenesis seen in liver remnants not receiving treatment.
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Affiliation(s)
- Amelia J. Hessheimer
- General & Digestive Surgery Service, Hospital Clínic, 08036 Barcelona, Spain; (A.J.H.); (L.M.d.l.M.); (A.T.); (F.A.A.S.); (F.R.); (C.M.); (R.G.)
- CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (J.V.); (J.M.)
| | - Jordi Vengohechea
- CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (J.V.); (J.M.)
| | - Lilia Martínez de la Maza
- General & Digestive Surgery Service, Hospital Clínic, 08036 Barcelona, Spain; (A.J.H.); (L.M.d.l.M.); (A.T.); (F.A.A.S.); (F.R.); (C.M.); (R.G.)
| | - Javier Muñoz
- CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (J.V.); (J.M.)
| | - Marina Vendrell
- Anesthesiology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (J.M.S.); (P.T.)
| | - Josep Martí Sanahuja
- Anesthesiology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (J.M.S.); (P.T.)
| | - Alba Torroella
- General & Digestive Surgery Service, Hospital Clínic, 08036 Barcelona, Spain; (A.J.H.); (L.M.d.l.M.); (A.T.); (F.A.A.S.); (F.R.); (C.M.); (R.G.)
| | - Farah Adel Al Shwely
- General & Digestive Surgery Service, Hospital Clínic, 08036 Barcelona, Spain; (A.J.H.); (L.M.d.l.M.); (A.T.); (F.A.A.S.); (F.R.); (C.M.); (R.G.)
| | - Francisco Riquelme
- General & Digestive Surgery Service, Hospital Clínic, 08036 Barcelona, Spain; (A.J.H.); (L.M.d.l.M.); (A.T.); (F.A.A.S.); (F.R.); (C.M.); (R.G.)
| | - César Muñoz
- General & Digestive Surgery Service, Hospital Clínic, 08036 Barcelona, Spain; (A.J.H.); (L.M.d.l.M.); (A.T.); (F.A.A.S.); (F.R.); (C.M.); (R.G.)
| | - Rocío García
- General & Digestive Surgery Service, Hospital Clínic, 08036 Barcelona, Spain; (A.J.H.); (L.M.d.l.M.); (A.T.); (F.A.A.S.); (F.R.); (C.M.); (R.G.)
| | - Pilar Taurá
- Anesthesiology, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain; (M.V.); (J.M.S.); (P.T.)
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Clínic, 08036 Barcelona, Spain; (A.J.H.); (L.M.d.l.M.); (A.T.); (F.A.A.S.); (F.R.); (C.M.); (R.G.)
- CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (J.V.); (J.M.)
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De Rudder M, Dili A, Stärkel P, Leclercq IA. Critical Role of LSEC in Post-Hepatectomy Liver Regeneration and Failure. Int J Mol Sci 2021; 22:8053. [PMID: 34360818 PMCID: PMC8347197 DOI: 10.3390/ijms22158053] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/20/2021] [Accepted: 07/24/2021] [Indexed: 02/07/2023] Open
Abstract
Liver sinusoids are lined by liver sinusoidal endothelial cells (LSEC), which represent approximately 15 to 20% of the liver cells, but only 3% of the total liver volume. LSEC have unique functions, such as fluid filtration, blood vessel tone modulation, blood clotting, inflammatory cell recruitment, and metabolite and hormone trafficking. Different subtypes of liver endothelial cells are also known to control liver zonation and hepatocyte function. Here, we have reviewed the origin of LSEC, the different subtypes identified in the liver, as well as their renewal during homeostasis. The liver has the exceptional ability to regenerate from small remnants. The past decades have seen increasing awareness in the role of non-parenchymal cells in liver regeneration despite not being the most represented population. While a lot of knowledge has emerged, clarification is needed regarding the role of LSEC in sensing shear stress and on their participation in the inductive phase of regeneration by priming the hepatocytes and delivering mitogenic factors. It is also unclear if bone marrow-derived LSEC participate in the proliferative phase of liver regeneration. Similarly, data are scarce as to LSEC having a role in the termination phase of the regeneration process. Here, we review what is known about the interaction between LSEC and other liver cells during the different phases of liver regeneration. We next explain extended hepatectomy and small liver transplantation, which lead to "small for size syndrome" (SFSS), a lethal liver failure. SFSS is linked to endothelial denudation, necrosis, and lobular disturbance. Using the knowledge learned from partial hepatectomy studies on LSEC, we expose several techniques that are, or could be, used to avoid the "small for size syndrome" after extended hepatectomy or small liver transplantation.
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Affiliation(s)
- Maxime De Rudder
- Laboratory of Hepato-Gastroenterology, Institute of Experimental and Clinical Research, UCLouvain, 1200 Brussels, Belgium; (M.D.R.); (A.D.); (P.S.)
| | - Alexandra Dili
- Laboratory of Hepato-Gastroenterology, Institute of Experimental and Clinical Research, UCLouvain, 1200 Brussels, Belgium; (M.D.R.); (A.D.); (P.S.)
- HPB Surgery Unit, Centre Hospitalier Universitaire UCL Namur, Site Mont-Godinne, 5530 Yvoir, Belgium
| | - Peter Stärkel
- Laboratory of Hepato-Gastroenterology, Institute of Experimental and Clinical Research, UCLouvain, 1200 Brussels, Belgium; (M.D.R.); (A.D.); (P.S.)
- Department of Hepato-Gastroenterology, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Isabelle A. Leclercq
- Laboratory of Hepato-Gastroenterology, Institute of Experimental and Clinical Research, UCLouvain, 1200 Brussels, Belgium; (M.D.R.); (A.D.); (P.S.)
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Jo HS, Han JH, Choi YY, Seok JI, Yoon YI, Kim DS. The beneficial impacts of splanchnic vasoactive agents on hepatic functional recovery in massive hepatectomy porcine model. Hepatobiliary Surg Nutr 2021; 10:325-336. [PMID: 34159160 DOI: 10.21037/hbsn.2019.11.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Excessive portal pressure after massive hepatectomy can cause hepatic sinusoidal injury and have deleterious impacts on hepatic functional recovery, contributing to developing post-hepatectomy liver failure. This study aimed to assess the effects of splanchnic vasoactive agents on hepatic functional recovery and regeneration while clarifying the underlying mechanism, using a 70% hepatectomy porcine model. Methods Eighteen pigs undergoing 70% hepatectomy were involved in this study and divided into three groups: control (n=6), terlipressin (n=6), and octreotide (n=6). Terlipressin (0.5 mg) and octreotide (0.2 mg) were administered 3 times a day for each group with the first dose starting just before surgery until the 7th postoperative day, at which time the surviving pigs were sacrificed. During the period, portal pressure, liver weight, biochemical analysis, histological injury score, and molecular markers were evaluated and compared between groups. Results The 7-day survival rates in the octreotide, terlipressin, and control groups were 100%, 83.3%, and 66.7%, respectively. The portal pressures decreased in both terlipressin and octreotide groups than the control group at 30 minutes, 1 hour and 6 hours after hepatectomy. The amount of regeneration measured by liver weight to body weight ratio at the time of sacrifice in the terlipressin group was smaller than that in the control group (117% vs. 129%, P=0.03). Serum aspartate aminotransferase (AST) and total bilirubin levels at 1 and 6 hours after hepatectomy and prothrombin time/international normalized ratio (PT/INR) at 6 hours after hepatectomy were significantly improved in the terlipressin and octreotide groups compared to the control group. Serum endothelin-1 (ET-1) was significantly lower in the terlipressin group than that in the control group 6 hours after hepatectomy (P<0.01). The histological injury score in the control group was significantly higher than that in the terlipressin group on the 7th postoperative day (P<0.01). Conclusions Splanchnic vasoactive agents, such as terlipressin and octreotide, could effectively decrease portal pressure and attenuate liver injury after massive hepatectomy.
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Affiliation(s)
- Hye-Sung Jo
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Hyun Han
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon Young Choi
- Department of Biomedical Science, Korea University College of Medicine Graduate School, Seoul, Republic of Korea
| | - Jin-I Seok
- Department of Biomedical Science, Korea University College of Medicine Graduate School, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Sik Kim
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
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Ko GY, Sung KB, Gwon DI. The Application of Interventional Radiology in Living-Donor Liver Transplantation. Korean J Radiol 2021; 22:1110-1123. [PMID: 33739630 PMCID: PMC8236365 DOI: 10.3348/kjr.2020.0718] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/05/2020] [Accepted: 11/14/2020] [Indexed: 01/10/2023] Open
Abstract
Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.
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Affiliation(s)
- Gi Young Ko
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Kyu Bo Sung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Simultaneous splenectomy improves outcomes after adult living donor liver transplantation. J Hepatol 2021; 74:372-379. [PMID: 32827564 DOI: 10.1016/j.jhep.2020.08.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 07/28/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Small-for-size graft (SFSG) syndrome is a major cause of graft loss after living donor liver transplantation (LDLT). Splenectomy (Spx) is an option to prevent this catastrophic complication, but its effect remains controversial. Herein, we aimed to elucidate the effect of simultaneous Spx on graft function and long-term outcomes after LDLT. METHODS Three hundred and twenty patients were divided into 2 groups: those undergoing (n = 258) and those not undergoing (n = 62) simultaneous Spx. To overcome selection bias, propensity score matching (PSM) was performed (n = 50 in each group). RESULTS Before PSM, recipients undergoing simultaneous Spx showed better graft function on post-operative day (POD) 7 and 14, as well as lower sepsis frequency within 6 months after LDLT and better graft survival rates compared to those not undergoing Spx. After PSM, compared to patients not undergoing Spx, those undergoing Spx had a lower frequency of early graft dysfunction on POD 7 (p = 0.04); a lower frequency of SFSG syndrome (p = 0.01), lower serum total bilirubin levels (p = 0.001), and lower international normalized ratio (p = 0.004) on POD 14; lower sepsis frequency within 6 months after LDLT (p = 0.02), and better graft survival rates (p = 0.04). Univariate analysis revealed that not undergoing Spx (hazard ratio 3.06; 95% CI 1.07-11.0; p = 0.037) was the only risk factor for graft loss after LDLT. CONCLUSIONS Simultaneous Spx may prevent SFSG syndrome and is a predictive factor for graft survival after LDLT. Simultaneous Spx is recommended when a small graft (≤35% of standard liver weight) is predicted preoperatively, or for patients with portal hypertension or high portal pressure (above 20 mmHg) after reperfusion in LDLT. LAY SUMMARY Living donor liver transplantation (LDLT) for patients with acute or chronic liver failure is an alternative to overcome the deceased donor shortage. The potential mismatch between graft and body size is a problem that needs to be solved for LDLT recipients. Herein, we evaluated the impact of simultaneous splenectomy and showed that it was associated with favorable outcomes in patients undergoing LDLT.
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Gavriilidis P, Hammond JS, Hidalgo E. A systematic review of the impact of portal vein pressure changes on clinical outcomes following hepatic resection. HPB (Oxford) 2020; 22:1521-1529. [PMID: 32792308 DOI: 10.1016/j.hpb.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are evolving data correlating elevated post-hepatic resection portal vein pressure (PVP) with risk of developing post-resection liver failure (PLF) and other complications. As a consequence, modulation of PVP presents a potential strategy to improve outcomes following liver resection (LR). The primary aim of this study was to review the existing evidence regarding the impact of post-resection PVP on clinical outcomes in patients undergoing a LR. METHODS Systematic literature searches of electronic databases in accordance with PRISMA were conducted. Changes in PVP and clinical outcomes following liver resection were defined according to the existing literature. RESULTS Ten studies, consisting of 712 patients with a median age 61 (52-68) years, were identified that met the inclusion criteria. Of those, 77% (n = 550) underwent a major LR and 27% (n = 195) of patients had cirrhosis. Following LR, the median (range) PVP increased from 11.4 mmHg (median baseline, range 7.3-16.4) to 15.9 mmHg (7.9-19). The overall median incidence of PLF was 19%. Six of the ten studies found an elevated PVP after LR predicted PLF. One study found elevated PVP after LR predicted mortality after LR. CONCLUSION Elevated PVP following hepatic resection was associated with increased rates of PLF. It was not possible to define a specific threshold PVP for predicting PLF. Modulation of PVP therefore presents a potential strategy to mitigate the incidence of LR. Future studies should standardize on reporting liver remnant and haemodynamics to better characterize clinical outcomes following LR.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepato-Pancreatic-Biliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, W12 0HS, England, UK.
| | - John S Hammond
- Department of Hepato-Pancreatic-Biliary Surgery and Transplantation, Freeman Hospital, Newcastle upon Tyne, Engalnd, UK
| | - Ernest Hidalgo
- Department of Hepato-Pancreatic-Biliary Surgery and Transplantation, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Ikegami T, Onda S, Furukawa K, Haruki K, Shirai Y, Gocho T. Small-for-size graft, small-for-size syndrome and inflow modulation in living donor liver transplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:799-809. [PMID: 32897590 DOI: 10.1002/jhbp.822] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/18/2020] [Accepted: 08/18/2020] [Indexed: 01/10/2023]
Abstract
The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size syndrome (SFSS)." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extending 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 (GV) such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by a small-for-size graft (SFSG), such as a porto-systemic shunt or splenectomy and optimal outflow reconstruction, have been trialed with some positive results. To establish an effective strategy for transplanting SFSG and preventing SFSS, it is essential to have precise knowledge and tactics to evaluate graft quality and GV, when performing these LDLTs with portal pressure control and good venous outflow. Thus, we reviewed the updated literature on the pathogenesis of and strategies for using SFSG.
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Affiliation(s)
- Toru Ikegami
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Gocho
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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A Novel Method for the Prevention and Treatment of Small-for-Size Syndrome in Liver Transplantation. Dig Dis Sci 2020; 65:2619-2629. [PMID: 32006210 DOI: 10.1007/s10620-020-06055-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Currently there is no consensus on the optimal management of small-for-size syndrome following liver transplantation. Here we describe a technique to alleviate portal hypertension and improve the hepatocyte reperfusion in small-for-size liver transplantation in a Lewis rat model. METHODS The rats underwent trans-portal vein intra-hepatic portosystemic shunt using a self-developed porous conical tube (TPIPSS: Fig. 1) on small-for-size liver transplants (SFS) with right lobe graft. The treatment effect was evaluated by comparing hemodynamic parameters, morphological changes, serum parameters, ET-1 and eNOS expression, hepatocyte proliferation and apoptosis, CYP3A2 levels, postoperative complications, and survival between the two groups with SFS liver transplants. RESULTS Porous conical prosthesis prolonged the filling time of small-for-size grafts. Moreover, grafts with TPIPSS showed a lower portal vein pressure, improved microcirculatory flow, alleviated histological changes, decreased ET-1 and increased eNOS expressions, and significantly less damage to liver function comparing to grafts without TPIPSS. Mean survival and overall 30-day survival were significantly higher in the TPIPSS group. CONCLUSIONS These results demonstrate that porous conical tube as trans-portal vein intra-hepatic portosystemic shunt device is an effective way to alleviate portal vein hypertension and improve hepatocyte reperfusion after small-for-size liver transplantation.
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Low-Pressure Tactic: A Novel Intrahepatic Shunt Improves Outcomes in Experimental Small-for-Size Syndrome. Dig Dis Sci 2020; 65:2457-2458. [PMID: 32556968 DOI: 10.1007/s10620-020-06385-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Sharshar M, Yagi S, Iida T, Yao S, Miyachi Y, Macshut M, Iwamura S, Hirata M, Ito T, Hata K, Taura K, Okajima H, Kaido T, Uemoto S. Liver transplantation in patients with portal vein thrombosis: A strategic road map throughout management. Surgery 2020; 168:1160-1168. [PMID: 32861438 DOI: 10.1016/j.surg.2020.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Liver transplantation in the setting of portal vein thrombosis is an intricate issue that occasionally necessitates extraordinary procedures for portal flow restoration. However, to date, there is no consensus on a persistent management strategy, particularly with extensive forms. This work aims to introduce our experience-based surgical management algorithm for portal vein thrombosis during liver transplantation and to clarify some of the debatable circumstances associated with this problematic issue. METHODS Between 2006 and 2019, 494 adults underwent liver transplantation at our institute. Ninety patients had preoperative portal vein thrombosis, and 79 patients underwent living donor liver transplantation. Our algorithm trichotomized the management plan into 3 pathways based on portal vein thrombosis grade. The surgical procedures implemented included thrombectomy, interposition vein grafts, jump grafts from the superior mesenteric vein, jump grafts from a collateral and renoportal anastomosis in 56, 13, 11, 4, and 2 patients, respectively. Four patients with mural thrombi did not require any special intervention. RESULTS Thirteen patients experienced posttransplant portal vein complications. They all proved to have a patent portal vein by the end of follow-up regardless of the management modality. No significant survival difference was observed between cohorts with versus without portal vein thrombosis. The early graft loss rate was significantly higher with advanced grades (P = .048) as well as technically demanding procedures (P = .032). CONCLUSION A stepwise broad-minded strategy should always be adopted when approaching advanced portal vein thrombosis during liver transplantation. An industrious preoperative evaluation should always be carried out to locate the ideal reliable source for portal flow restoration.
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Affiliation(s)
- Mohamed Sharshar
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Hepato-Pancreato-Biliary Surgery, National Liver Institute, Menoufia University, Shebin El kom, Egypt
| | - Shintaro Yagi
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Taku Iida
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Siyuan Yao
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Miyachi
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mahmoud Macshut
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Hepato-Pancreato-Biliary Surgery, National Liver Institute, Menoufia University, Shebin El kom, Egypt
| | - Sena Iwamura
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaaki Hirata
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Ito
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kojiro Taura
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Association of Graft-to-Recipient Weight Ratio with the Prognosis Following Liver Transplantation: a Meta-analysis. J Gastrointest Surg 2020; 24:1869-1879. [PMID: 32306226 DOI: 10.1007/s11605-020-04598-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies indicate that low graft-to-recipient weight ratio (GRWR) affect graft survival in adult-to-adult living donor liver transplantation. However, the potential role of GRWR in the prognosis of patients following living donor liver transplantation according to patient characteristics remains controversial. This study aimed to update the role of GRWR in patients following living donor liver transplantation. METHODS PubMed, Embase, and Cochrane Library were comprehensively searched for studies comparing low GRWR (< 0.8%) with normal GRWR (≥ 0.8%) in the prognosis following living donor liver transplantation from inception to March 2019. The 1-, 3-, and 5-year summary survival rates, small-for-size syndrome (SFSS), perioperative mortality, biliary complications, postoperative bleeding, and acute rejection were calculated using the random-effects model. RESULTS Eighteen studies comprising 4001 patients were included. Patients with low GRWR were associated with lower 1-year and 3-year survival rates compared to patients with normal GRWR, while no significant difference was found in the association of 5-year survival rate with low and normal GRWRs. Moreover, the risk of SFSS significantly increased in patients with low GRWR. Finally, no significant differences were observed in the association of low and normal GRWRs with the risk of perioperative mortality, biliary complications, postoperative bleeding, and acute rejection. CONCLUSION The results of this study indicated that low GRWR was associated with poor prognosis for patients following living donor liver transplantation, especially in terms of 1- and 3-year survival rates and SFSS.
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Govil S. The pathogenesis of portal hypertension differs between small for size syndrome (SFSS) and postoperative liver Failure(POLF). HPB (Oxford) 2020; 22:1222. [PMID: 32451235 DOI: 10.1016/j.hpb.2020.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 12/12/2022]
Abstract
The pathogenesis of portal hypertension differs in patients with small for size syndrome (SFSS) after living donor liver transplantation (LDLT) and postoperative liver failure (POLF) after liver resection. This difference has important implications in the prevention and management of POLF.
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Affiliation(s)
- Sanjay Govil
- Consultant Liver Transplant and HPB Surgeon, Apollo Hospital, Bangalore, India.
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Masuda Y, Yoshizawa K, Ohno Y, Mita A, Shimizu A, Soejima Y. Small-for-size syndrome in liver transplantation: Definition, pathophysiology and management. Hepatobiliary Pancreat Dis Int 2020; 19:334-341. [PMID: 32646775 DOI: 10.1016/j.hbpd.2020.06.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/20/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Since the first success in an adult patient, living donor liver transplantation (LDLT) has become an universally used procedure. Small-for-size syndrome (SFSS) is a well-known complication after partial LT, especially in cases of adult-to-adult LDLT. The definition of SFSS slightly varies among transplant physicians. The use of a partial liver graft has risks of SFSS development. Persistent portal vein (PV) hypertension and PV hyper-perfusion after LT were identified as the main factors. Hence, various approaches were explored to modulate PV flow and decrease PV pressure in order to alleviate this syndrome. Herein, the definition, clinical symptoms, pathophysiology, basic research, as well as preventive and treatment strategies for SFSS are reviewed based on an extensive review of the literature and on our own experiences. DATA SOURCES The articles were collected through PubMed using search terms "liver transplantation", "living donor liver transplantation", "living liver donation", "partial graft", "small-for-size graft", "small-for-size syndrome", "graft volume", "remnant liver", "standard liver volume", "graft to recipient body weight ratio", "sarcopenia", "porcine", "swine", and "rat". English publications published before March 31, 2020 were included in this review. RESULTS Many transplant surgeons performed PV flow modulation, including portocaval shunt, splenic artery ligation and splenectomy. With these techniques, patient outcome has been improved even when using a "small" graft. Other factors, such as preoperative recipients' nutritional and skeletal muscle status, graft congestion, and donor factors, were also identified as risk factors which all have been addressed using various strategies. CONCLUSIONS The surgical approach controlling PV flow and pressure could help to prevent SFSS especially in severely ill recipients. In the absence of efficacious medications to resolve SFSS, conservative treatments, including aggressive fluid balance correction for massive ascites, anti-microbiological therapy to prevent or control sepsis and intensive nutritional therapy, are all required if SFSS could not be prevented.
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Affiliation(s)
- Yuichi Masuda
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan.
| | - Kazuki Yoshizawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Yasunari Ohno
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Atsuyoshi Mita
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Akira Shimizu
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
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Ikegami T, Balci D, Jung DH, Kim JM, Quintini C. Living donor liver transplantation in small-for-size setting. Int J Surg 2020; 82S:134-137. [PMID: 32738547 DOI: 10.1016/j.ijsu.2020.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Small-for-Size Syndrome (SFSS) is one of the most feared complication of adult split liver and living donor liver transplantation. SFSS stems from a disproportionate/excessive portal vein flow relative to the volume of the implanted liver graft, and is currently one of the major practical limits to partial liver grafts' transplantation. In the last few decades many graft inflow modulation (GIM) techniques have been proposed to curtail the portal vein flow, allowing for successful transplantation of small partial liver grafts. Graft inflow modulation techniques span from Splenic Artery Ligation (SAL), to Splenectomy, Porto-Systemic Shunts and the lately proposed Splenic Devascularization. A patient tailored approach balancing the risk of SFSS with GIM specific morbidity, is more important than identifying the ideal GIM technique. Here we summarize the most recently published data to provide general indications in the challenging preoperative choice of a GIM techniques.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Deniz Balci
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
| | - Dong-Hwan Jung
- Department of Liver Transplantation and HBP Surgery, Ulsan University School of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Cristiano Quintini
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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Explorative study of serum biomarkers of liver failure after liver resection. Sci Rep 2020; 10:9960. [PMID: 32561884 PMCID: PMC7305107 DOI: 10.1038/s41598-020-66947-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 05/27/2020] [Indexed: 02/07/2023] Open
Abstract
Conventional biochemical markers have limited usefulness in the prediction of early liver dysfunction. We, therefore, tried to find more useful liver failure biomarkers after liver resection that are highly sensitive to internal and external challenges in the biological system with a focus on liver metabolites. Twenty pigs were divided into the following 3 groups: sham operation group (n = 6), 70% hepatectomy group (n = 7) as a safety margin of resection model, and 90% hepatectomy group (n = 7) as a liver failure model. Blood sampling was performed preoperatively and at 1, 6, 14, 30, 38, and 48 hours after surgery, and 129 primary metabolites were profiled. Orthogonal projection to latent structures-discriminant analysis revealed that, unlike in the 70% hepatectomy and sham operation groups, central carbon metabolism was the most significant factor in the 90% hepatectomy group. Binary logistic regression analysis was used to develop a predictive model for mortality risk following hepatectomy. The recommended variables were malic acid, methionine, tryptophan, glucose, and γ-aminobutyric acid. Area under the curve of the linear combination of five metabolites was 0.993 (95% confidence interval: 0.927–1.000, sensitivity: 100.0, specificity: 94.87). We proposed robust biomarker panels that can accurately predict mortality risk associated with hepatectomy.
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The Risk of Going Small: Lowering GRWR and Overcoming Small-For-Size Syndrome in Adult Living Donor Liver Transplantation. Ann Surg 2020; 274:e1260-e1268. [PMID: 32209906 DOI: 10.1097/sla.0000000000003824] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the outcomes of living donor liver transplantation (LDLT) according to various graft-to-recipient weight ratio (GRWR). BACKGROUND The standard GRWR in LDLT is >0.8%. Our center accepted predicted GRWR ≥0.6% in selected patients. METHODS Data from patients who underwent LDLT from 2001 to 2017 were included. Patients were stratified according to actual GRWR (Group 1:GRWR ≤0.6%; Group 2: 0.6%<GRWR≤ 0.8%; Group 3:GRWR >0.8%). RESULTS There were 545 LDLT (group 1 = 39; group 2 = 159; group 3 = 347) performed. Pretransplant predicted GRWR showed good correlation to actual GRWR (R = 0.834) and these figures differed within a ± 10%margin (P = 0.034) using an equivalence test. There were more left lobe grafts in group 1 (33.3%) than group 2 (10.7%) and 3 (2.9%). Median donor age was <35 years and steatosis >10% was rare.There was no difference in postoperative complication, vascular and biliary complication rate between groups. Over one-fifth (20.5%) of group 1 patients required portal flow modulation (PFM) and was higher than group 2 (3.1%) and group 3 (4%) (P = 0.001). Twenty-six patients developed small-for-size syndrome (SFSS): 5 of 39 (12.8%) in group 1 and 21 of 159 (13.2%) in group 2 and none in group 3 (P < 0.001). There were 2 hospital mortalities; otherwise, the remaining patients [24/26 (92.3%)] survive with a functional liver graft. The 5-year graft survival rates were 85.4% versus 87.8% versus 84.7% for group 1, 2, and 3, respectively (P = 0.718). GRWR did not predict worse survivals in multivariable analysis. CONCLUSIONS Graft size in LDLT can be lowered to 0.6% after careful recipient selection, with low incidence of SFSS and excellent outcomes. Accurate graft weight prediction, donor-recipient matching, meticulous surgical techniques, appropriate use of PFM, and vigilant perioperative care is important to the success of such approach.
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Liu S, Moller PW, Kohler A, Hana A, Beldi G, Obrist D, Berger D, Takala J, Jakob SM. Effects of Trendelenburg position and increased airway pressure on hepatic regional blood flow of normal and resected liver. J Appl Physiol (1985) 2020; 128:667-680. [DOI: 10.1152/japplphysiol.00705.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
High portal venous blood flow (Qpv) may contribute to posthepatectomy liver failure. Both Trendelenburg position (TP) and elevated airway pressure (Paw) increase backpressure to venous return and may thereby reduce Qpv. The aim of this study was to evaluate the effects of TP and increased Paw on hepatosplanchnic hemodynamics before and after major liver resection. Arterial and venous blood pressures, Qpv, extrasplanchnic inferior vena cava (Qivc), superior mesenteric (Qsma), hepatic (Qha), and carotid artery blood flows (Qca) were measured in 14 anesthetized and mechanically ventilated pigs in supine and 30° TP during end-expiratory hold at 5 cmH2O positive end-expiratory pressure (PEEP) and during inspiratory hold with Paw of 15, 20, 25, and 30 cmH2O. After major liver resection, the interventions were repeated in seven randomly selected animals. At baseline, TP increased right atrial pressure (Pra) and Qpv but not Qivc or Qsma. With increased Paw in the supine position, Pra increased and all regional blood flows decreased. TP during increasing Paw attenuated the decrease in Qpv, Qsma, and Qivc but not in Qha or Qca. After liver resection, the effects of TP during increasing Paw remained, albeit at higher portal vein pressures. However, TP alone did not increase IVC venous return. Increasing Paw in supine position reduces Qpv and all other regional flows, while the reduction in Qpv is attenuated in TP, suggesting partly preserved liver waterfall or decreased intrahepatic resistance. Liver resection, despite resulting in major intrahepatic blood flow changes, does not fundamentally influence the interaction of increasing Paw and TP on regional perfusion. NEW & NOTEWORTHY In Trendelenburg position (TP), liver blood flow is the only contributor to increased venous return measured in the inferior vena cava (IVC), which attenuates the decreased IVC venous return induced by increasing airway pressure. After liver resection, TP similarly attenuated effects of increasing airway pressure.
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Affiliation(s)
- Shengchen Liu
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Per W. Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Ostra, Gothenburg, Sweden
| | - Andreas Kohler
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anisa Hana
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik Obrist
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Liver Transplantation. THE CRITICALLY ILL CIRRHOTIC PATIENT 2020. [PMCID: PMC7122092 DOI: 10.1007/978-3-030-24490-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.
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Ikegami T, Kim JM, Jung DH, Soejima Y, Kim DS, Joh JW, Lee SG, Yoshizumi T, Mori M. Conceptual changes in small-for-size graft and small-for-size syndrome in living donor liver transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2019; 33:65-73. [PMID: 35769983 PMCID: PMC9188939 DOI: 10.4285/jkstn.2019.33.4.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 12/29/2019] [Indexed: 01/10/2023] Open
Abstract
Early series in living donor liver transplantation (LDLT) in adults demonstrated a lower safe limit of graft volume standard liver volume ratio 25%–45%. A subsequent worldwide large LDLT series proposed a 0.8 graft recipient weight ratio (GRWR) to define small-for-size graft (SFSG) in adult LDLT. Thereafter, researchers identified innate and inevitable factors including changes in liver volume during imaging studies and graft shrinkage due to perfusion solution. Although the definition of small-for-size syndrome (SFSS) advocated in the 2000s was mainly based on prolonged cholestasis and ascites output, the term SFSS was inadequate to describe clinical manifestations possibly caused by multiple factors. Thus, the term “early allograft dysfunction (EAD),” characterized by total bilirubin >10 mg/dL or coagulopathy with international normalized ratio >1.6 on day 7, has become prevalent to describe graft dysfunction including SFSS after LDLT. Although various efforts have been made to overcome EAD in LDLT, graft selection to maintain an expected GRWR >0.8 and full venous drainage, as well as inflow modulation using splenic artery ligation, have become standard in recent LDLT.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Liver Transplantation and Hepatobiliary and Pancreatic Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - Yuji Soejima
- Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Dong-Sik Kim
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Department of Liver Transplantation and Hepatobiliary and Pancreatic Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | | | - Masaki Mori
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
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Soin AS, Yadav SK, Saha SK, Rastogi A, Bhangui P, Srinivasan T, Saraf N, Choudhary NS, Saigal S, Vohra V. Is Portal Inflow Modulation Always Necessary for Successful Utilization of Small Volume Living Donor Liver Grafts? Liver Transpl 2019; 25:1811-1821. [PMID: 31436885 DOI: 10.1002/lt.25629] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/05/2019] [Indexed: 02/07/2023]
Abstract
Although the well-accepted lower limit of the graft-to-recipient weight ratio (GRWR) for successful living donor liver transplantation (LDLT) remains 0.80%, many believe grafts with lower GRWR may suffice with portal inflow modulation (PIM), resulting in equally good recipient outcomes. This study was done to evaluate the outcomes of LDLT with small-for-size grafts (GRWR <0.80%). Of 1321 consecutive adult LDLTs from January 2012 to December 2017, 287 (21.7%) had GRWR <0.80%. PIM was performed (hemiportocaval shunt [HPCS], n = 109; splenic artery ligation [SAL], n = 14) in 42.9% patients. No PIM was done if portal pressure (PP) in the dissection phase was <16 mm Hg. Mean age of the cohort was 49.3 ± 9.1 years. Median Model for End-Stage Liver Disease score was 14, and the lowest GRWR was 0.54%. A total of 72 recipients had a GRWR <0.70%, of whom 58 underwent HPCS (1 of whom underwent HPCS + SAL) and 14 underwent no PIM, whereas 215 had GRWR between 0.70% and 0.79%, of whom 51 and 14 underwent HPCS and SAL, respectively. During the same period, 1034 had GRWR ≥0.80% and did not undergo PIM. Small-for-size syndrome developed in 2.8% patients. Three patients needed shunt closure at 1 and 4 weeks and 60 months. The 1-year patient survival rates were comparable. In conclusion, with PIM protocol that optimizes postperfusion PP, low-GRWR grafts can be used for appropriately selected LDLT recipients with acceptable outcomes.
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Affiliation(s)
- Arvinder Singh Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Sanjay Kumar Yadav
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Sujeet Kumar Saha
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Thiagarajan Srinivasan
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Narendra S Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Sanjeev Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Vijay Vohra
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
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Response to the Comment on "Somatostatin as Inflow Modulator in Liver-transplant Recipients With Severe Portal Hypertension: A Randomized Trial". Ann Surg 2019; 271:e122. [PMID: 31714314 DOI: 10.1097/sla.0000000000003675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Comprehensive Characterization of a Porcine Model of The "Small-for-Flow" Syndrome. J Gastrointest Surg 2019; 23:2174-2183. [PMID: 30734180 DOI: 10.1007/s11605-019-04130-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/16/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The term "Small-for-Flow" reflects the pathogenetic relevance of hepatic hemodynamics for the "Small-For-Size" syndrome and posthepatectomy liver failure. We aimed to characterize a large-animal model for studying the "Small-for-Flow" syndrome. METHODS We performed subtotal (90%) hepatectomies in 10 female MiniPigs using a simplified transection technique with a tourniquet. Blood tests, hepatic and systemic hemodynamics, and hepatic function and histology were assessed before (Bas), 15 min (t-15 min) and 24 h (t-24 h) after the operation. Some pigs underwent computed tomography (CT) scans for hepatic volumetry (n = 4) and intracranial pressure (ICP) monitoring (n = 3). Postoperative care was performed in an intensive care unit environment. RESULTS All hepatectomies were successfully performed, and hepatic volumetry confirmed liver remnant volumes of 9.2% [6.2-11.2]. The hepatectomy resulted in characteristic hepatic hemodynamic alterations, including portal hyperperfusion, relative decrease of hepatic arterial blood flow, and increased portal pressure (PP) and portal-systemic pressure gradient. The model reproduced major diagnostic features including the development of cholestasis, coagulopathy, encephalopathy with increased ICP, ascites, and renal failure, hyperdynamic circulation, and hyperlactatemia. Two animals (20%) died before t-24 h. Histological liver damage was observed at t-15 min and at t-24 h. The degree of histological damage at t-24 h correlated with intraoperative PP (r = 0.689, p = 0.028), hepatic arterial blood flow (r = 0.655, p = 0.040), and hepatic arterial pulsatility index (r = 0.724, p = 0.066). All animals with intraoperative PP > 20 mmHg presented liver damage at t-24 h. CONCLUSION The present 90% hepatectomy porcine experimental model is a feasible and reproducible model for investigating the "Small-for-Flow" syndrome.
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Dili A, Bertrand C, Lebrun V, Pirlot B, Leclercq IA. Hypoxia protects the liver from Small For Size Syndrome: A lesson learned from the associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure in rats. Am J Transplant 2019; 19:2979-2990. [PMID: 31062475 DOI: 10.1111/ajt.15420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 02/07/2023]
Abstract
Portal hyperperfusion and "dearterialization" of the liver remnant are the main pathogenic mechanisms for Small For Size syndrome (SFSS). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces rapid remnant hypertrophy. We hypothesized a similar increase in portal pressure/flow into the future liver remnant in ALPPS and SFSS-setting hepatectomies. In a rodent model, ALPPS was compared to SFSS-setting hepatectomy. We assessed mortality, remnant hypertrophy, hepatocyte proliferation, portal and hepatic artery flow, hypoxia-induced response, and liver sinusoidal morphology. SFSS-hepatectomy rats were subjected to local (hepatic artery ligation) or systemic (Dimethyloxalylglycine) hypoxia. ALLPS prevented mortality in SFSS-setting hepatectomies. Portal hyperperfusion per liver mass was similar in ALLPS and SFSS. Compared to SFSS, efficient arterial perfusion of the remnant was significantly lower in ALPPS causing pronounced hypoxia confirmed by pimonidazole immunostaining, activation of hypoxia sensors and upregulation of neo-angiogenic genes. Liver sinusoids, larger in ALPPS, collapsed in SFSS. Induction of hypoxia in SFSS reduced mortality. Hypoxia had no impact on hepatocyte proliferation but contributed to the integrity of sinusoidal morphology. ALPPS hemodynamically differ from SFSS by a much lower arterial flow in ALPPS's FLR. We show that the ensuing hypoxic response is essential for the function of the regenerating liver by preserving sinusoidal morphology.
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Affiliation(s)
- Alexandra Dili
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium.,Department of Surgery, Centre Hospitalier Universitaire UCLouvain-Namur, Yvoir, Belgium
| | - Claude Bertrand
- Department of Surgery, Centre Hospitalier Universitaire UCLouvain-Namur, Yvoir, Belgium
| | - Valérie Lebrun
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
| | - Boris Pirlot
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
| | - Isabelle A Leclercq
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
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Vinayak N, Ravi M, Ankush G, Rashmi B, Prashantha R, Parul G, Anurag S. Dual graft living donor liver transplantation - a case report. BMC Surg 2019; 19:149. [PMID: 31640624 PMCID: PMC6805583 DOI: 10.1186/s12893-019-0606-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 09/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Living donor liver transplantation (LDLT) has emerged as an equally viable option to deceased donor liver transplant for treating end stage liver disease patients. Optimising the recipient outcome without compromising donor safety is the primary goal of LDLT. Achieving the adequate graft to recipient weight ratio (GRWR) is important to prevent small for size syndrome which is an uncommon but potentially lethal complication of LDLT. Case presentation Here we describe a case of successful dual lobe liver transplant for a 32 years old patient with ethanol related end stage liver disease. A right lobe graft without middle hepatic vein and another left lateral sector graft were transplanted successfully. Recipient and both donors recovered uneventfully. Conclusion Dual lobe liver transplant is a feasible strategy to achieve adequate GRWR without compromising donor safety.
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Affiliation(s)
- Nikam Vinayak
- Institute of Liver Diseases, HPB Surgery and Transplantation, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Room No- 202, 2nd Floor, Mumbai, Maharashtra, 400012, India.
| | - Mohanka Ravi
- Institute of Liver Diseases, HPB Surgery and Transplantation, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Room No- 202, 2nd Floor, Mumbai, Maharashtra, 400012, India
| | - Golhar Ankush
- Institute of Liver Diseases, HPB Surgery and Transplantation, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Room No- 202, 2nd Floor, Mumbai, Maharashtra, 400012, India
| | - Bhade Rashmi
- Institute of Liver Diseases, HPB Surgery and Transplantation, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Room No- 202, 2nd Floor, Mumbai, Maharashtra, 400012, India
| | - Rao Prashantha
- Institute of Liver Diseases, HPB Surgery and Transplantation, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Room No- 202, 2nd Floor, Mumbai, Maharashtra, 400012, India
| | - Gadre Parul
- Institute of Liver Diseases, HPB Surgery and Transplantation, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Room No- 202, 2nd Floor, Mumbai, Maharashtra, 400012, India
| | - Shrimal Anurag
- Institute of Liver Diseases, HPB Surgery and Transplantation, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Room No- 202, 2nd Floor, Mumbai, Maharashtra, 400012, India
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Golriz M, Lemekhova A, Khajeh E, Ghamarnejad O, Al-Saeedi M, Strobel O, Hackert T, Müller-Stich B, Schneider M, Berchtold C, Tinoush P, Mayer P, Chang DH, Weiss KH, Hoffmann K, Mehrabi A. Evaluation of the role of transhepatic flow in postoperative outcomes following major hepatectomy (THEFLOW): study protocol for a single-centre, non-interventional cohort study. BMJ Open 2019; 9:e029618. [PMID: 31604785 PMCID: PMC6797302 DOI: 10.1136/bmjopen-2019-029618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Liver resection is the only curative treatment for primary and secondary hepatic tumours. Improvements in perioperative preparation of patients and new surgical developments have made complex liver resections possible. However, small for size and flow syndrome (SFSF) is still a challenging issue, rendering patients inoperable and causing postoperative morbidity and mortality. Although the role of transhepatic flow in the postoperative outcome has been shown in small partial liver transplantation and experimental studies of SFSF, this has never been studied in the clinical setting following liver resection. The aim of this study is to systematically evaluate transhepatic flow changes following major liver resection and its correlation with postoperative outcomes. METHODS AND ANALYSIS The TransHEpatic FLOW (THEFLOW) study is a single-centre, non-interventional cohort study, and aims to enrol 50 patients undergoing major hepatectomy (defined as hemihepatectomy or extended hepatectomy based on the Brisbane classification) with or without prior chemotherapy. The portal venous flow, hepatic artery flow and portal venous pressure are measured before and after each resection. All patients are followed-up for 3 months after the operation. During each evaluation, standard clinical data, posthepatectomy liver failure and overall morbidity and mortality will be recorded. THEFLOW study was initiated on 25 March 2018 and is expected to progress for 2 years. ETHICS AND DISSEMINATION This protocol study received approval from the Ethics Committee of the University of Heidelberg (registration number: S576/2017). The results of this study will be published in a peer-reviewed journal, and will also be presented at medical meetings. TRIAL REGISTRATION NUMBER NCT03762876.
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Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Anastasia Lemekhova
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Beat Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Parham Tinoush
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Philipp Mayer
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - De-Hua Chang
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Karl Heinz Weiss
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Department of Gastroenterology and Hepatology, University of Heidelberg, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Ma KW, Wong KHC, Chan ACY, Cheung TT, Dai WC, Fung JYY, She WH, Lo CM, Chok KSH. Impact of small-for-size liver grafts on medium-term and long-term graft survival in living donor liver transplantation: A meta-analysis. World J Gastroenterol 2019; 25:5559-5568. [PMID: 31576100 PMCID: PMC6767984 DOI: 10.3748/wjg.v25.i36.5559] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/27/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Small-for-size grafts (SFSGs) in living donor liver transplantation (LDLT) could optimize donor postoperative outcomes and also expand the potential donor pool. Evidence on whether SFSGs would affect medium-term and long-term recipient graft survival is lacking.
AIM To evaluate the impact of small-for-size liver grafts on medium-term and long-term graft survival in adult to adult LDLT.
METHODS A systematic review and meta-analysis were performed by searching eligible studies published before January 24, 2019 on PubMed, EMBASE, and Web of Science databases. The primary outcomes were 3-year and 5-year graft survival. Incidence of small-for-size syndrome and short term mortality were also extracted.
RESULTS This meta-analysis is reported according to the guidelines of the PRISMA 2009 Statement. Seven retrospective observational studies with a total of 1821 LDLT recipients were included in the meta-analysis. SFSG is associated with significantly poorer medium-term graft survival. The pooled odds ratio for 3-year graft survival was 1.58 [95% confidence interval 1.10-2.29, P = 0.014]. On the other hand, pooled results of the studies showed that SFSG had no significant discriminatory effect on 5-year graft survival with an odds ratio of 1.31 (95% confidence interval 0.87-1.97, P = 0.199). Furthermore, incidence of small-for-size syndrome detected in recipients of SFSG ranged from 0-11.4% in the included studies.
CONCLUSION SFSG is associated with inferior medium-term but not long-term graft survival. Comparable long-term graft survival based on liver graft size shows that smaller grafts could be accepted for LDLT with appropriate flow modulatory measures. Close follow-up for graft function is warranted within 3 years after liver transplantation.
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Affiliation(s)
- Ka Wing Ma
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | | | | | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Wing Chiu Dai
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | | | - Wong Hoi She
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, Hong Kong, China
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Yoshizumi T, Mori M. Portal flow modulation in living donor liver transplantation: review with a focus on splenectomy. Surg Today 2019; 50:21-29. [PMID: 31555908 PMCID: PMC6949207 DOI: 10.1007/s00595-019-01881-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/08/2019] [Indexed: 01/10/2023]
Abstract
Small-for-size graft (SFSG) syndrome after living donor liver transplantation (LDLT) is the dysfunction of a small graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. It is a serious complication of LDLT and usually triggered by excessive portal flow transmitted to the allograft in the postperfusion setting, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. These conditions may be attenuated with portal flow modulation. Attempts have been made to control excessive portal flow to the SFSG, including simultaneous splenectomy, splenic artery ligation, hemi-portocaval shunt, and pharmacological manipulation, with positive outcomes. Currently, a donor liver is considered a SFSG when the graft-to-recipient weight ratio is less than 0.8 or the ratio of the graft volume to the standard liver volume is less than 40%. A strategy for transplanting SFSG safely into recipients and avoiding extensive surgery in the living donor could effectively address the donor shortage. We review the literature and assess our current knowledge of and strategies for portal flow modulation in LDLT.
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Affiliation(s)
- Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Matsushima H, Fujiki M, Sasaki K, Rotroff DM, Sands M, Bayona Molano MDP, Aucejo F, Diago Uso T, Eghtesad B, Miller C, Quintini C, Hashimoto K. Predictive Value of Hepatic Venous Pressure Gradient for Graft Hemodynamics in Living Donor Liver Transplantation. Liver Transpl 2019; 25:1034-1042. [PMID: 30980599 DOI: 10.1002/lt.25471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 03/08/2019] [Indexed: 02/07/2023]
Abstract
The hepatic venous pressure gradient (HVPG) measurement is known to correlate with the severity of portal hypertension in patients with liver cirrhosis. This retrospective study investigated the clinical value of preoperative measurement of HVPG in patients who underwent adult-to-adult living donor liver transplantation (LDLT) and its predictive value for hepatic hemodynamics after graft reperfusion. For this study, 75 patients who underwent adult-to-adult LDLT were divided into 2 groups (HVPG <16 mm Hg or HVPG ≥16 mm Hg) to investigate the correlation between preoperative HVPG and characteristics and surgical outcomes of the patients, including portal vein flow (PVF) and hepatic artery flow (HAF) after graft reperfusion. In total, 35 (46.7%) patients had an HVPG ≥16 mm Hg. These patients had significantly higher international normalized ratio values, serum creatinine levels, and Model for End-Stage Liver Disease scores compared with the 40 patients with HVPG <16 mm Hg. They also had higher rates of variceal bleeding, encephalopathy, and intractable ascites as well as lower serum albumin levels and platelet counts compared with those patients with HVPG <16 mm Hg. Portal inflow modulation (PIM) was frequently performed in the patients with HVPG ≥16 mm Hg compared with those with HVPG <16 mm Hg. No significant differences in surgical outcomes after LDLT were found between these 2 groups except for postoperative ascites. Preoperative HVPG showed a positive correlation with PVF and a negative correlation with HAF after graft reperfusion (false discovery rate [FDR] P = 0.08 and FDR P = 0.08, respectively). In linear regression analyses, preoperative HVPG was independently associated with PVF after graft reperfusion. In conclusion, our findings indicate that preoperative HVPG is associated with hepatic hemodynamics after graft implantation in LDLT. HVPG as a routine preoperative evaluation may be helpful for surgical planning of PIM.
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Affiliation(s)
- Hajime Matsushima
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel M Rotroff
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Mark Sands
- Department of Radiology, Cleveland Clinic, Cleveland, OH
| | | | - Federico Aucejo
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Porcine model for the study of liver regeneration enhanced by non-invasive 13C-methacetin breath test (LiMAx test) and permanent portal venous access. PLoS One 2019; 14:e0217488. [PMID: 31150446 PMCID: PMC6544243 DOI: 10.1371/journal.pone.0217488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/13/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction Despite advances in perioperative management and surgical technique, postoperative liver failure remains a feared complication after hepatic resection. Various supportive treatment options are under current discussion, but lack of structured evaluation. We therefore established a porcine model of major liver resection to study regeneration after partial hepatectomy in a reliable and well-defined pre-clinical setting. Methods Major hepatectomy was performed on seven minipigs with the intention to set up a non-lethal but relevant transient impairment of liver function. For steady postoperative vascular access (e.g. for blood withdrawal, measurement of venous pressure), permanent catheters were implanted into the internal jugular and portal veins, respectively. Animals were followed up for 30 days; clinical and laboratory results were recorded in detail. Monitoring was enhanced by non-invasive determination of the maximum liver function capacity (LiMAx test). Results and conclusions The established porcine model appeared suitable for evaluation of postoperative liver regeneration. Clinical characteristics and progression of liver function impairment as well as subsequent recovery were comparable to courses known from surgery in humans. Laboratory parameters (e.g. liver enzymes, bilirubin, INR, coagulation factor II) showed relevant derangements during postoperative days (POD) 0 to 3 followed by normalization until POD 7. Application of the LiMAx test was feasible in minipigs, again showing values comparable to humans and kinetics in line with obtained laboratory parameters. The exteriorized portal vein catheters enabled intra- and postoperative monitoring of portal venous pressures as well as easy access for blood withdrawal without relevant risk of postoperative complications.
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