Tailoring the type of donor hepatectomy for adult living donor liver transplantation

Revisiting the Prognostic Influences of Donor-Recipient Size Mismatch in Deceased Donor Liver Transplantation

Background

Liver transplantation (LT) outcomes are influenced by donor-recipient size mismatch. This study re-evaluated the impact on graft size discrepancies on survival outcomes.

Methods

Data from 53 389 adult LT recipients from the United Network for Organ Sharing database (2013-2022) were reviewed. The study population was divided by the body surface area index (BSAi), defined as the ratio of donor body surface area (BSA) to recipient BSA, into small-for-size (BSAi < 0.78), normal-for-size (BSAi 0.78-1.24), and large-for-size (BSAi > 1.24) grafts in deceased donor LT (SFSD, NFSD, and LFSD). Multivariate Cox regression and Kaplan-Meier survival analyses were conducted.

Results

The frequency of size mismatch in deceased donor LT increased over the past 10 y. SFSD had significantly worse 90-d graft survival (P < 0.01), and LFSD had inferior 1-y graft survival among 90-d survivors (P = 0.01). SFSD was hazardous within 90 d post-LT because of vascular complications. Beyond 1 y, graft size did not affect graft survival. LFSD risk within the first year was mitigated with lower model for end-stage liver disease (MELD) 3.0 scores (<35) or shorter cold ischemia time (<8 h).

Conclusions

The negative impacts on donor-recipient size mismatch on survival outcomes are confined to the first year post-LT. SFSD is associated with a slight decrease in 90-d survival rates. LFSD should be utilized more frequently by minimizing cold ischemia time to <8 h, particularly in patients with MELD 3.0 scores below 35. These findings could improve donor-recipient matching and enhance LT outcomes.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

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.

Right Lobe Versus Left Lobe Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Donor and Recipient Outcomes

BACKGROUND

Living donor liver transplantation (LDLT) is an established treatment for advanced liver disease. Whether right lobe (RL) or left lobe (LL) LDLT provides the best outcomes for donors and recipients remains contentious.

METHODS

MedLine, Embase, PubMed, and Cochrane Central were searched to identify studies comparing RL- and LL-LDLT and reporting donor and/or recipient outcomes. Effect sizes were pooled using random-effect meta-analysis. Meta-regressions were used to explore heterogeneity.

RESULTS

Sixty-seven studies were included. RL donors were more likely to experience major complications (relative risk [RR] = 1.63; 95% confidence interval [CI] = 1.30-2.05; I2 = 19%) than LL donors; however, no difference was observed in the risk of any biliary complication (RR = 1.41; 95% CI = 0.91-2.20; I2 = 59%), bile leaks (RR = 1.56; 95% CI = 0.97-2.51; I2 = 52%), biliary strictures (RR = 0.99; 95% CI = 0.43-1.88; I2 = 27%), or postoperative death (RR = 0.51; 95% CI = 0.25-1.05; I2 = 0%). Among recipients, the incidence of major complications (RR = 0.85; 95% CI = 0.68-1.06; I2 = 21%), biliary complications (RR = 1.10; 95% CI = 0.91-1.33; I2 = 8%), and vascular complications (RR = 0.79; 95% CI = 0.44-1.43; I2 = 0%) was similar. Although the rate of small for size syndrome (RR = 0.47; 95% CI = 0.30-0.74; I2 = 0%) and postoperative deaths (RR = 0.62; 95% CI = 0.44-0.87; I2 = 0%) was lower among RL-LDLT recipients, no differences were observed in long-term graft (hazard ratio = 0.87; 95% CI = 0.55-1.38; I2 = 74%) and overall survival (hazard ratio = 0.86; 95% CI = 0.60-1.22; I2 = 44%).

CONCLUSIONS

LL donors experience fewer complications than RL donors, and LL-LDLT recipients had similar outcomes to RL-LDLT recipients. These findings suggest that LL-LDLT offers the best outcomes for living donors and similar outcomes for recipients when measures are taken to prevent small for size syndrome.

The application of magnetic anchoring traction device in assisting donor liver bench surgery in classic orthotopic liver transplantation

Objective

To explore the clinical application of a newly developed magnetic anchoring traction (MAT) system in the liver bench trimming and transplantation surgery.

Background

The conventionally limited space, vision, and exposure have always been a challenge for the quality of surgery in the liver bench trimming due to the fact that the exposure depends largely on the experience of surgeon. To deal with this problem, a MAT system is developed as an alternative support to enhance exposure. The preliminarily experiments on animals verified its feasibility and reliability in the practical use, and its clinical application and effects were examined in the present research.

Methods

A total of 20 DCD (donation of cardiac death) donor livers were collected and divided evenly between the magnetic anchor traction (MAT) assisted group (n = 10) and the manual assisted group (n = 10). The results and quality assessment from experts about the liver bench surgery performed by two groups were examined and compared.

Results

The MAT system can be employed effectively to compete and replace the manual assistance to achieve a better exposure in the liver bench trimming. No statistical difference was found regarding the baseline data between the MAT and the manual groups. In the inferior vena cava and hepatic artery trimming, the MAT group outperformed the manual group remarkably in many aspects. The surgery time for liver bench shortened considerably after a quick grasp of MAT skills by surgeons.

Conclusion

The MAT system provides a more stable, reliable and qualified local exposure in the liver bench surgery, and can preferably be employed to replace the manual assistance in the procedures of liver transplantation.

Hepatic vein in living donor liver transplantation

Right lobe living donor liver transplantation (LDLT) is a major development in adult LDLT that has significantly increased the donor pool by providing larger graft size and by decreasing risk of small-for-size graft syndrome. However, right lobe anatomy is complex, not only from the inflow but also from the outflow perspective. Outflow reconstruction is one of the key requirements of a successful LDLT and venous drainage of the liver graft is just as important as hepatic inflow for the integrity of graft function. Outflow complications may cause acute graft failure which is not always easy to diagnose. The right lobe graft consists of two sections and three hepatic venous routes for drainage that require reconstruction. In order to obtain a congestion free graft, several types of vascular conduits and postoperative interventions are needed to assure an adequate venous allograft drainage. This review described the anatomy, functional basis and the evolution of outflow reconstruction in right lobe LDLT.

Sex differences in postsurgical skeletal muscle depletion after donation of living-donor liver transplantation, although minimal, should not be ignored

Background

Donor safety is the top priority in living-donor liver transplantation. Splenic hypertrophy and platelet count decrease after donor surgery are reported to correlate with the extent of hepatectomy, but other aftereffects of donor surgeries are unclear. In this study, we evaluated the surgical effects of donor hepatectomy on skeletal muscle depletion and their potential sex differences.

Methods

Among a total of 450 consecutive donor hepatectomies performed from April 2001 through March 2017, 277 donors who completed both preoperative and postoperative (60–119 days postsurgery) evaluation by computed tomography were the subjects of this study. Donors aged 45 years or older were considered elderly donors. Postoperative skeletal muscle depletion was assessed on the basis of the cross-sectional area of the psoas major muscle. Postoperative changes in the spleen volume and platelet count ratios were also analysed to evaluate the effects of major hepatectomy.

Results

The decrease in the postoperative skeletal muscle mass in the overall donor population was slight (99.4 ± 6.3%). Of the 277 donors, 59 (21.3%) exhibited skeletal muscle depletion (i.e., < 95% of the preoperative value). Multivariate analysis revealed that elderly donor (OR:2.30, 95% C.I.: 1.27–4.24) and female donor (OR: 1.94, 95% C.I. 1.04–3.59) were independent risk factors for postoperative skeletal muscle depletion. Stratification of the subjects into four groups by age and sex revealed that the elderly female donor group had significantly less skeletal muscle mass postoperatively compared with the preoperative values (95.6 ± 6.8%), while the other three groups showed no significant decrease. Due to their smaller physical characteristics, right liver donation was significantly more prevalent in the female groups than in the male groups (112/144, 77.8% vs 65/133, 48.9%; p < 0.001). The estimated liver resection rate correlated significantly with the splenic hypertrophy ratio (r = 0.528, p < 0.001) and the extent of the platelet count decrease (r = − 0.314, p < 0.001), but donor age and sex did not affect these parameters.

Conclusion

Elderly female donors have a higher risk of postoperative skeletal muscle depletion. Additionally, female donors are more likely to donate a right liver graft, whose potential subclinical risks include postoperative splenic enlargement and a platelet count decrease.

Long-term outcomes of endoscopic treatment for duct-to-duct anastomotic strictures after living donor liver transplantation

BACKGROUND AND AIMS

The anastomotic biliary stricture is a clinically important complication after living donor liver transplantation (LDLT) with a duct-to-duct anastomosis. Although endoscopic management of post-LDLT biliary strictures using balloon dilation (BD) and plastic stents (PSs) has provided acceptable short-term outcomes, long-term outcomes and prognostic factors for treatment success remain unclear.

METHODS

We included 96 patients with post-LDLT biliary strictures who were endoscopically managed between 2003 and 2016. BD was utilized as a first-line treatment strategy, and PS placement was carried out for refractory cases. Potential prognostic factors for biliary stricture resolution were analysed using logistic regression analyses.

RESULTS

Endoscopic treatment was technically successful in 84 patients (87.5%). The overall rate of biliary stricture resolution was 44.8% (43 of 96 patients) with a median follow-up duration of 90.9 months (interquartile range, 30.9-122.3 months). Bile duct kinking was associated with a lower rate of biliary stricture resolution (odds ratio, 0.33; 95% confidence interval, 0.13-0.87). After successful endoscopic treatment, biliary strictures recurred in 22 patients (57.9%) after BD, and in one patient (4%) after PS treatment.

CONCLUSIONS

Despite a high technical success rate, endoscopic treatment only provided a low rate of resolution of anastomotic biliary strictures among LDLT patients and required prolonged treatment duration. Alternative strategies including the use of a covered metal stent should be evaluated to further improve the treatment outcomes of post-LDLT biliary strictures, particularly in those accompanied by the bile duct kinking.

How Has Virtual Hepatectomy Changed the Practice of Liver Surgery?: Experience of 1194 Virtual Hepatectomy Before Liver Resection and Living Donor Liver Transplantation

OBJECTIVE

To assess how virtual hepatectomy (VH), conducted using surgical planning software, influences the outcomes of liver surgery.

BACKGROUND

Imaging technology visualizes the territories of the liver vessels, which were previously impossible. However, the clinical impact of VH has not been evaluated.

METHODS

From 2004 to 2013, we performed 1194 VHs preoperatively. Outcomes of living donor liver transplantation (LDLT) and hepatectomy for hepatocellular carcinoma (HCC)/colorectal liver metastases (CRLM) were compared between patients in whom VH was performed (VH) and those without VH evaluation (non-VH).

RESULTS

In LDLT, the rate of right liver graft use was higher in the VH (62.1%) than in the non-VH (46.5%) (P < 0.01), which did not increase morbidity of donor surgery. Duration of recipient surgery in the VH in which middle hepatic vein branch reconstruction was skipped was shorter than that in the VH with venous reconstruction. Among HCC patients with impaired liver function, portal territory-oriented resection was conducted more often in the VH than in the non-VH. The 5-year disease-free survival rate for localized HCC was higher in the VH than in the non-VH (37.2% vs 23.9%; P = 0.04). In CRLM, long-term outcomes were similar in the VH and non-VH despite the larger tumor load in the VH.

CONCLUSIONS

VH in LDLT allows double equipoise for the recipient and donor by optimizing decision-making on graft selection and venous reconstruction. VH offers a chance for radical hepatectomy even in HCC patients with impaired liver function and CRLM patients with advanced tumors, without compromising survival.

Living Donor Liver Transplantation: Technical Innovations

Living donor liver transplantation (LDLT) has found a place to serve the end-stage liver disease community as the donor safety and recipient suitability has been elucidated. Donor safety is of paramount importance and transplant programs must continue endeavors to maintain the highest possible standards. At the same time, adequacy of grafts based on recipient clinical status via their model for end-stage liver disease (MELD) score and volumetric studies to achieve a GRBWR >0.8, along with special attention to anatomic tailoring and portal venous flow optimization are necessary for successful transplantation. Technical innovations have improved sequentially the utility and availability of LDLT.

Predictive Factors of Liver Dysfunction After Right Hemihepatectomy for Adult Living Donor Liver Transplantation

BACKGROUND

Living liver donors represent a special group of patients. They are healthy individuals who are exposed to a major surgery, in which the dominant liver proportion is extracted as a graft. Of all potential donor-related morbidities, posthepatectomy liver dysfunction (PHLD) is the most significant as it may be directly related to donor mortality. We aimed to review our data of adult living donor liver transplantation (LDLT) utilizing the right hemiliver grafts to determine the incidence and potential predictors for the development of PHLD, defined according to the International Study Group of Liver Surgery.

METHODS

We reviewed the data of all adult living donors who underwent right hemihepatectomy during the period between May 2004 and 2016.

RESULTS

During the study period, 434 cases underwent right hemihepatectomy for adult LDLT. We divided our cases into 2 groups according to the occurrence of PHLD. A significant lower residual liver volume and percentage were noted in PHLD group. Longer intensive care unit stay and hospital stay, and more postoperative morbidities, were observed in PHLD group. PHLD occurred in 50 cases (11.5%), and most of them were grade A (47 cases [10.8%]). Two cases (0.5%) had grade B requiring diuretic therapy, and 1 case (0.2%) had grade C requiring ultrasound guided tube drainage and surgical exploration finally.

CONCLUSIONS

We should not underestimate the risks of liver donation surgery, especially when utilizing the right hemiliver graft. Donor safety should be ensured by accurate preoperative volumetric assessment of the remnant liver and remnant liver volume limitations must be strictly followed.

Successful Resection and Vascular Ligation of a Large Hepatic Artery Aneurysm - A Case Report and Literature Review

The occurrence of hepatic artery aneurysms is rare and might be incidentally diagnosed, as the patient remains asymptomatic for a long period of time. However, due to the fact that these lesions are associated with a high risk of developing life threatening complications, such as intraperitoneal rupture, it has been stated that all cases should be submitted to treatment by endovascular or surgical approach. We present the case of a 68-year-old patient, who presented with recurrent upper digestive tract bleedings and was diagnosed with a large aneurysm of the common and the proper hepatic artery, and the gastroduodenal artery. The preoperative angiography revealed an anatomic variation consisting of the common hepatic artery originating from the celiac trunk, and the left hepatic artery originating from the left gastric artery. A percutaneous right portal vein embolization was performed in order to induce hypertrophy of the left lobe and prepare the patient for a right hepatectomy and aneurysmal resection. However, at the time of surgery, after performing the aneurysmal resection and arterial ligation, the vascular supply of the entire liver was efficiently provided by the left hepatic artery and its collaterals. Concluding, hepatic resection was no longer necessary.

Influence of outflow-obstructed liver volume and venous communication development: A three-dimensional volume study in living donors

Living donor liver transplantation using the left liver graft with the middle hepatic vein (MHV) is a well-established procedure. Following such procedures, outflow obstruction occurs in remnant livers. However, the effects of the outflow-obstructed liver volume (LV_Out-Ob ), with or without venous communication development, remain unclear. The aim of the study is to investigate effects of outflow-obstructed regions by focusing on short-term outcomes and remnant liver hypertrophy in left liver procurement donors. Of 532 donors, we collected data from 119 undergoing left liver procurement with the MHV. Postoperative hepatic parameters, venous communication development, and liver hypertrophy were evaluated in 2 donor groups based on LV_Out-Ob . The left liver was procured with the MHV in 119 donors, who formed 2 more groups based on the median LV_Out-Ob : large-outflow-obstruction group (n = 60; LV_Out-Ob  ≥ 263 mL) and small-outflow-obstruction (n = 59; LV_Out-Ob  < 263 mL) group. Postoperative liver function parameters were significantly impaired in the large-outflow-obstruction group compared with the small-outflow-obstruction group. Postoperative venous communication developed in 52 (66.7%) of 78 donors analyzed. Hypertrophy ratios in remnant right livers and right paramedian sectors were significantly higher in the small-outflow-obstruction group than in the large-outflow-obstruction group (P = 0.01 and P = 0.02, respectively). The liver hypertrophy ratio of outflow-obstructed regions was better, especially in small regions developing venous communication (P =  0.001). The postoperative morbidity rate did not differ significantly (P = 0.66). In conclusion, the procurement of the left liver graft with the MHV was safely performed with minimal morbidity by assessing the donor remnant right liver volume with and without outflow obstruction. Attention should be paid that postoperative hepatic parameters and remnant liver hypertrophy were impaired in the remnant livers with large outflow-obstructed regions compared with those with small outflow-obstructed regions. Liver Transplantation 23 1531-1540 2017 AASLD.

Asunaprevir/daclatasvir and sofosbuvir/ledipasvir for recurrent hepatitis C following living donor liver transplantation

AIM

This study aimed to clarify the efficacy and safety of interferon-free therapy using asunaprevir and daclatasvir, or sofosbuvir and ledipasvir for post living donor liver transplantation (LDLT) recipients with hepatitis C virus (HCV).

METHODS

A retrospective cohort study of LDLT recipients with HCV genotype 1b treated with asunaprevir (100 mg twice daily) and daclatasvir (60 mg once daily), or sofosbuvir (400 mg/day) and ledipasvir (90 mg/day) was carried out.

RESULTS

Ten patients without mutations in the area of L31 and Y93 completed the treatment with asunaprevir and daclatasvir. Five of them had end-stage chronic kidney disease, including three hemodialysis patients. Of the 10 patients, nine completed the protocol of 24 weeks; one stopped the treatment due to the development of aortic valve stenosis. All nine patients who completed the 24-week treatment protocol achieved end of treatment response. Nineteen patients received treatment with sofosbuvir and ledipasvir. Of the 19 patients, 18 completed the protocol of 12 weeks; one stopped treatment due to severe interstitial pneumonia. All 18 patients who completed the 12-week treatment protocol achieved end of treatment response. All patients in both treatment groups who completed the regimen and reached 3 months after the end of treatment achieved sustained virological response at 12 weeks after treatment. Liver functions were significantly improved at the end of treatment, and no adverse events were observed.

CONCLUSIONS

Interferon-free therapy using asunaprevir and daclatasvir, or sofosbuvir and ledipasvir, is highly effective for post-LDLT recipients with HCV genotype 1b.

Low Platelet Counts and Prolonged Prothrombin Time Early After Operation Predict the 90 Days Morbidity and Mortality in Living-donor Liver Transplantation

OBJECTIVE

The aim of the study was to investigate the association between platelet count/prothrombin time early after transplant and short-term outcomes among living-donor liver transplant (LDLT) recipients.

BACKGROUND

Postoperative platelet count and prothrombin time-international normalized ratio (PT-INR) were critical biomarkers in LDLT.

METHODS

The study participants consisted of 445 initial LDLT recipients, and perioperative variables, including platelet count and PT-INR, were assessed for their association with severe complications (Clavien-Dindo classification grade IIIb/IV) and mortality within 90 days after operation.

RESULTS

Severe complications and operative mortality occurred in 161 (36%) and 23 patients (5%), respectively. Cox regression analysis revealed that a high body mass index [hazard ratio (HR) 1.2; 95% confidence interval (CI), 1.1-1.4; P = 0.004] and low platelet count on postoperative day (POD)3 (HR 0.88; 95% CI, 0.57-0.97; P < 0.001) were independent predictors for grade IIIb/IV complications after LDLT, whereas high PT-INR on POD5 (HR 1.1; 95% CI, 1.1-1.3; P = 0.021) was the only independent factor for operative mortality. In addtion, the progonostic scoring with low platelet count (<50 × 10/L) and prolonged prothrombin time (PT-INR >1.6) within POD5, 1 point for each, was demonstrated to be useful in predicting the development of Clavien-Dindo grade IIIb/IV/V complications after LDLT (30% for score 0, 46% for score 1, and 72% for score 2: 0 vs 1, P = 0.004; 0 vs 2, P < 0.001; 1 vs 2, P = 0.002).

CONCLUSIONS

PT-INR above 1.6 and platelet count below 50 × 10/L within POD5 were useful predictors of mortality and severe complications after LDLT.

Splenectomy is not indicated in living donor liver transplantation

Simultaneous splenectomy (SPX) is preferentially performed in living donor liver transplantation (LDLT) to modulate portal flow; increase postoperative platelet count, especially among those with hepatitis C virus (HCV) infection; and modulate the immunologic status in ABO-incompatible cases. The negative effects of the procedure, however, are not well established. Records of 395 LDLTs performed at our institution, including 169 (42.8%) patients with simultaneous SPX and 226 (57.2%) patients with spleen preservation, were reviewed with special reference to the simultaneous SPX cases. The most common indication for SPX was HCV-related disease (n = 114), followed by low preoperative platelet count (n = 52), and other reasons (n = 3). Simultaneous splenectomy did not increase the platelet count in the early postoperative period, but the incidence of reoperation for postoperative hemorrhage was increased, mainly at the SPX site, within the first week. In addition, the operative time, intraoperative blood loss, and incidence of lethal infectious disease were significantly higher in the SPX group, whereas the incidence of small-for-size syndrome was comparable between groups. Finally, SPX was an independent predictor for both postoperative hemorrhage (odds ratio [OR] = 2.451; 95% confidence interval [CI] = 1.285-4.815; P = 0.006) and lethal infectious complication (OR = 3.748; 95% CI = 1.148-14.001; P = 0.03). In conclusion, on the basis of the present findings, we do not recommend simultaneous SPX in LDLT. Liver Transplantation 22 1526-1535 2016 AASLD.

Living donor liver transplantation for hepatocellular carcinoma at the University of Tokyo Hospital

BACKGROUND

Living donor liver transplantation (LDLT) is an established treatment not only for those with end-stage liver disease but for those with hepatocellular carcinoma (HCC) developing in cirrhotic liver. The aim of this study was to present a single-center experience of LDLT for HCC at the University of Tokyo Hospital, Japan.

METHODS

Among 573 liver transplant recipients from January 1996 until the end of 2015, 139 patients have been indicated LDLT for the treatment of HCC, and were the subjects of the present study. We use the expanded criteria for HCC as follows; the number of tumor should be five or less, and the maximum diameter of the tumor should be 5 cm or less, without the distant metastasis nor the vascular invasion (Tokyo criteria, 5-5 rule). We also focused on the identification of the incidental intrahepatic cholangiocarcinoma (ICC) and combined hepatocellular carcinoma/cholangiocarcinoma (cHCC-CC) in liver explants.

RESULTS

The overall 1-, 5-, and 10-year recurrence-free and patient survival rates were 95%, 91%, and 91%, 91%, and 80%, 78%, respectively. The 1-, 3-, and 5-year cumulative recurrence rate was 5%, 6%, and 6% for within Milan, 0%, 8%, and 8% for beyond Milan/within Tokyo, and 33%, 50%, and 50% for beyond Tokyo, respectively, demonstrating the significantly impaired outcome of those beyond Tokyo criteria (P<0.001). The high alpha-fetoprotein (AFP) value (≥400 ng/mL), the high des-gamma-carboxy prothrombin (DCP) value (≥200 mAU/mL) and beyond the Tokyo criteria were proved to be significant predictors for the HCC recurrence, but the size or the type of the partial graft was not associated. Incidental ICC and cHCC-CC were found in one and two patients, respectively, with the size of less than 2 cm in all cases. ICC was not detected in preoperative evaluation but cHCC-CCs were misdiagnosed as HCC preoperatively. All three patients were alive without recurrence with a follow-up period of 2 to 14 years.

CONCLUSIONS

The present results of our institution seem acceptable in terms of the recurrence-free and patient survival. The issues of the expansion of indication, living donor vs. deceased donor for HCC, and liver transplantation (LT) for cholangiocarcinoma are still left to be investigated in future studies.

Use of a Right Lateral Sector Graft in Living Donor Liver Transplantation Is Feasible, but Special Caution Is Needed With Respect to Liver Anatomy

Right lateral sector (RLS) grafting has been introduced to enlarge the potential donor pool for living donor liver transplantation (LDLT); however, evidence of its feasibility is limited. Data from 437 LDLTs carried out between 2000 and 2013 were analyzed retrospectively. LDLTs using a right liver graft (n = 251) were compared with those using a RLS graft (RLSG; n = 28). No donor mortality occurred, and the major complication rates were similar between the two groups. Postoperative liver function preservation was better in the RLSG donors. Concerning the recipients, the mortality and overall survival rates were similar between the two groups. The complication rate for the recipients was higher when more than two arterial or biliary anastomoses were necessary. A systematic literature search identified four reports on LDLT using RLSGs. Among 66 LDLTs, including the present series, there were no cases of donor death, and the rates of major and minor complications in the donors were 6% and 29%, respectively. The major complication and overall mortality rates in the recipients were 29% and 6%, respectively. LDLT using an RLSG is feasible, with an acceptable survival rate among the recipients.

Reconstruction of hepatic venous tributary in right liver living donor liver transplantation: The importance of the inferior right hepatic vein

Special care must be taken in hepatic vein reconstruction to avoid outflow block in living donor liver transplantation (LDLT) with a right liver graft. We have used cryopreserved homologous veins to reconstruct the right hepatic vein (RHV), middle hepatic vein (MHV), MHV tributaries (V5 and V8), and inferior right hepatic vein (IRHV). The reconstruction of V5, V8, and IRHV was based on the estimated congestive volume, calculated by the computed tomography volumetry, to secure the functional graft volume of 40% of the recipient standard liver volume. Among 262 right liver LDLT recipients, the number of reconstructed RHVs, MHVs, V5s, V8s, and IRHVs was 262, 48, 110, 111, and 147, respectively, and the overall patency was 95%, 100%, 36%, 58%, and 86%, respectively. Although the patency of the RHVs and MHVs was satisfactory, that of the V5s, V8s, and IRHVs was suboptimal. Patency of the IRHVs (86%, 126/147) was significantly better than that of both V5s (36%, 40/110) and V8s (58%, 64/111; P < 0.001). In addition, the estimated volume drained by IRHVs was significantly greater than that of V5s and V8s (IRHV, 176 ± 92 mL; V5, 105 ± 49 mL; V8, 127 ± 60 mL; P < 0.001). The patency of IRHV was significantly improved by applying the double inferior vena cava method (93%, 94/101) when compared to the direct anastomosis to vena cava (68%, 25/37; P < 0.001). The IRHV functioned as a main drainage route in cases of an obstructed RHV. In conclusion, reconstruction of the IRHV is recommended, not only to improve the functional reserve of the graft, but also to secure multiple drainage routes of the graft.

New-onset diabetes mellitus developing in Asian adult living donor liver transplant recipients: a single-center experience

BACKGROUND

New-onset diabetes mellitus (NODM) after liver transplantation is a common complication with a potentially negative impact on patient outcome.

METHODS

To evaluate the incidence of NODM and its impact on Asian adult living donor liver transplant (LDLT) recipients, we investigated 369 adult LDLT cases in our institute.

RESULTS

Preoperative diabetes mellitus (DM) was diagnosed in 38 (9 %) patients. NODM was observed in 128/331 (38 %) patients, 56 (44 %) with persistent NODM and 72 (56 %) with transient NODM. The mean interval between LDLT and the development of NODM was 0.6 ± 1.8 (range 0-1.4) months. Multivariate analyssis revealed that older age, being male and having a higher body mass index were independent risk factors among recipients for developing NODM, while hepatitis C virus infection was not a significant risk factor, and DM had no impact on patient outcome.

CONCLUSIONS

Although the long-term effect of DM on outcome remains to be investigated, the presence of DM after liver transplant, whether it was NODM or preexisting DM, had no impact on LDLT recipients' outcomes in mid-term.

Outcomes of adult-to-adult living donor liver transplantation in 321 recipients

We conducted a retrospective investigation in order to clarify whether selecting the type of liver graft had an impact on outcomes of adult-to-adult living donor liver transplantation (AALDLT). Data from the medical records of the donors and the recipients of 321 consecutive cases of AALDLT performed between April 2004 and March 2014 were retrospectively analyzed. Our general criteria for selecting the type of liver graft was that a left graft was preferentially selected when the estimated volume of the left graft was ≥35% of the standard liver volume of the recipient, and that a right graft was selected only when the estimated remnant liver volume of the donor was ≥35% of the total liver volume. In this series, 177 left grafts, 136 right grafts, and 8 posterior grafts were used. The left grafts tended to have 2 or more arteries, whereas the right grafts tended to have 2 or more bile duct orifices. The graft survival curves and the incidences of severe complications were comparable between the AALDLT using right grafts and the AALDLT using left grafts. The preoperative estimation of graft size hardly enabled us to predict severe posttransplant complication. Moreover, small-for-size graft syndrome occurred regardless of the estimated graft volumes. Instead, donor age was a significant risk factor for small-for-size graft syndrome. In conclusion, left grafts should be more aggressively used for the sake of donors' safety. The use of hepatic grafts from older donors should be avoided if possible in order to circumvent troublesome posttransplant complications.

A new formula for calculating standard liver volume for living donor liver transplantation without using body weight

BACKGROUND & AIMS

The standard liver volume (SLV) is widely used in liver surgery, especially for living donor liver transplantation (LDLT). All the reported formulas for SLV use body surface area or body weight, which can be influenced strongly by the general condition of the patient.

METHODS

We analyzed the liver volumes of 180 Japanese donor candidates and 160 Swiss patients with normal livers to develop a new formula. The dataset was randomly divided into two subsets, the test and validation sample, stratified by race. The new formula was validated using 50 LDLT recipients.

RESULTS

Without using body weight-related variables, age, thoracic width measured using computed tomography, and race independently predicted the total liver volume (TLV). A new formula: 203.3-(3.61×age)+(58.7×thoracic width)-(463.7×race [1=Asian, 0=Caucasian]), most accurately predicted the TLV in the validation dataset as compared with any other formulas. The graft volume for LDLT was correlated with the postoperative prothrombin time, and the graft volume/SLV ratio calculated using the new formula was significantly better correlated with the postoperative prothrombin time than the graft volume/SLV ratio calculated using the other formulas or the graft volume/body weight ratio.

CONCLUSIONS

The new formula derived using the age, thoracic width and race predicted both the TLV in the healthy patient group and the SLV in LDLT recipients more accurately than any other previously reported formulas.

Hemostatic status in liver transplantation: association between preoperative procoagulants/anticoagulants and postoperative hemorrhaging/thrombosis

The delicate rebalanced hemostatic status of liver transplant recipients may lead to both hemorrhagic and thrombotic tendencies in this population. The aim of this study was to investigate the association between pretransplant procoagulants/anticoagulants and posttransplant bleeding and thrombosis among living donor liver transplant recipients. The study subjects were 403 consecutive recipients with chronic liver disease. Perioperative variables, including preoperative values for procoagulants and anticoagulants, were assessed to determine their association with posttransplant hemorrhaging and thrombosis. There were 35 hemorrhagic complications (9%) and 21 thrombotic complications (5%). In logistic regression analyses, a higher Model for End-Stage Liver Disease score (P = 0.01) and a lower fibrinogen value (P < 0.001) were independently associated with hemorrhaging, whereas only a lower protein C value (P < 0.001) was independently associated with thrombosis. In a receiver operating characteristic analysis, a low preoperative protein C value (with the most accurate cutoff value being 25%) was a reliable predictor of thrombotic complications after liver transplantation (area under the curve = 0.921, P < 0.001, sensitivity = 0.9, specificity = 0.8). In conclusion, the decreases in both procoagulants and anticoagulants in liver transplant recipients may additively result in a delicate hemostatic balance and predispose patients to both hemorrhagic and thrombotic complications. A lower preoperative protein C value (<25%) was demonstrated to be a significant and reliable predictor of postoperative thrombotic complications in liver transplant recipients.

Adult right living-donor liver transplantation with special reference to reconstruction of the middle hepatic vein

Two hundred fifty-three consecutive living-donor liver transplant recipients with a right liver graft (RLG) were divided into three groups: an extended right liver graft (ERLG) group (n = 47) in which the middle hepatic vein (MHV) trunk was included in the graft, a modified right liver graft (MRLG) group (n = 114) in which the MHV tributaries were reconstructed with cryopreserved homologous veins and a simple RLG group (n = 92) in which the MHV tributaries were sacrificed. The volume of the anterior sector was significantly impaired in the RLG group compared to the other two groups, whereas the volume of the posterior sector was significantly improved in the RLG group, indicating that the impaired anterior sector regeneration by MHV deprivation was compensated by the posterior sector regeneration. The regeneration rate of the anterior sector was highest in the ERLG group (92%), moderate in the MRLG group (71%) and lowest in the RLG group (52%). The whole graft regeneration rate of the ERLG group was significantly higher than that of the other two groups. Poor regeneration, however, was not correlated with delayed functional recovery or long-term outcome. Short-term, the patency of reconstructed MHV tributaries was over 90%, but occlusion occurred frequently over the long-term, especially in V5.

Impact of early reoperation following living-donor liver transplantation on graft survival

BACKGROUND

The reoperation rate remains high after liver transplantation and the impact of reoperation on graft and recipient outcome is unclear. The aim of our study is to evaluate the impact of early reoperation following living-donor liver transplantation (LDLT) on graft and recipient survival.

METHODS

Recipients that underwent LDLT (n = 111) at the University of Tokyo Hospital between January 2007 and December 2012 were divided into two groups, a reoperation group (n = 27) and a non-reoperation group (n = 84), and case-control study was conducted.

RESULTS

Early reoperation was performed in 27 recipients (24.3%). Mean time [standard deviation] from LDLT to reoperation was 10 [9.4] days. Female sex, Child-Pugh class C, Non-HCV etiology, fulminant hepatitis, and the amount of intraoperative fresh frozen plasma administered were identified as possibly predictive variables, among which females and the amount of FFP were identified as independent risk factors for early reoperation by multivariable analysis. The 3-, and 6- month graft survival rates were 88.9% (95%confidential intervals [CI], 70.7-96.4), and 85.2% (95%CI, 66.5-94.3), respectively, in the reoperation group (n = 27), and 95.2% (95%CI, 88.0-98.2), and 92.9% (95%CI, 85.0-96.8), respectively, in the non-reoperation group (n = 84) (the log-rank test, p = 0.31). The 12- and 36- month overall survival rates were 96.3% (95%CI, 77.9-99.5), and 88.3% (95%CI, 69.3-96.2), respectively, in the reoperation group, and 89.3% (95%CI, 80.7-94.3) and 88.0% (95%CI, 79.2-93.4), respectively, in the non-reoperation group (the log-rank test, p = 0.59).

CONCLUSIONS

Observed graft survival for the recipients who underwent reoperation was lower compared to those who did not undergo reoperation, though the result was not significantly different. Recipient overall survival with reoperation was comparable to that without reoperation. The present findings enhance the importance of vigilant surveillance for postoperative complication and surgical rescue at an early postoperative stage in the LDLT setting.

Living donor liver transplantation for non-alcoholic steatohepatitis: A single center experience

AIM

The number of patients referred for liver transplantation (LT) with non-alcoholic steatohepatitis (NASH) continues to increase, but information about living donor liver transplantation (LDLT) for NASH is scarce. We conducted this study to document the details of LDLT for NASH in a Japanese LT center.

METHODS

Among all LDLT recipients in our institution from March 1996 to March 2013 (n = 425), we identified seven patients that underwent LDLT for NASH.

RESULTS

Of all the seven recipients, most of the patients (86%) were obese. The median follow-up period post-LDLT was 5.3 years. All were alive at the last follow-up. Recurrent NASH was detected in one patient (14%), and no recurrent hepatic steatosis was detected among the remaining six recipients on prospectively performed ultrasonography. No significant comorbidities were observed following donor surgery among the respective living donors during the follow-up period. We also retrospectively reviewed 22 patients with NASH-related end-stage liver disease (ESLD) who were evaluated but rejected for LDLT during the same period. The reasons for rejection for LDLT were presumably associated with the nature of NAFLD/NASH in either potential recipients or donors.

CONCLUSION

The post-transplant outcome of LDLT for NASH-related ESLD in our institution was feasible, although the sample size was small. Further studies in a larger patient cohort are warranted to investigate the long-term outcome of LDLT for NASH, both for recipients and living donors.

Selection of a right posterior sector graft for living donor liver transplantation

Right posterior sector (RPS) grafts have been used to overcome graft size discrepancies, the major concern of living donor liver transplantation. Previous studies have reported the volumetry-based selection of RPS grafts without anatomical exclusion. We reviewed our data and established selection criteria for RPS grafts. The procurement of RPS grafts [conventional (n = 3) and extended (n = 5)] was performed for 8 of 429 recipients at our center. Extended RPS grafts contained the drainage area of the right hepatic vein. The mean graft weight (GW) according to 3-dimensional computed tomography volumetry was 488 g, and the GW/standard liver weight (SLW) ratio was 42.6%. The mean actual GW was 437 g, and the GW/SLW ratio was 38.4%. One donor exhibited standard bifurcation of the right portal vein (PV) and the left PV, and 2 donors exhibited trifurcation of the left PV, the right anterior portal vein (APV), and the posterior PV. The remaining 5 donors exhibited APV branching from the left PV, which is the most suitable anatomy for RPS grafts. Two recipients died of sepsis or small-for-size graft syndrome. One underwent retransplantation because of an intractable bile leak and fibrosing cholestatic hepatitis. Intractable bile duct (BD) stenosis developed in 4 of the 6 survivors. In conclusion, with the significant complications and potential concerns associated with RPS grafts, these grafts should be used very rarely and with extreme caution. Donors with the standard bifurcation of the PV and the posterior BD running through the dorsal side of the posterior PV are not suitable candidates for RPS grafts. Extended RPS graft procurement is recommended for easier parenchymal transection.

Remnant growth rate after portal vein embolization is a good early predictor of post-hepatectomy liver failure

BACKGROUND

After portal vein embolization (PVE), the future liver remnant (FLR) hypertrophies for several weeks. An early marker that predicts a low risk of post-hepatectomy liver failure can reduce the delay to surgery.

STUDY DESIGN

Liver volumes of 153 patients who underwent a major hepatectomy (>3 segments) after PVE for primary or secondary liver malignancy between September 1999 and November 2012 were retrospectively evaluated with computerized volumetry. Pre- and post-PVE FLR volume and functional liver volume were measured. Degree of hypertrophy (DH = post-FLR/post-functional liver volume - pre-FLR/pre-functional liver volume) and growth rate (GR = DH/weeks since PVE) were calculated. Postoperative complications and liver failure were correlated with DH, measured GR, and estimated GR derived from a formula based on body surface area.

RESULTS

Eligible patients underwent 93 right hepatectomies, 51 extended right hepatectomies, 4 left hepatectomies, and 5 extended left hepatectomies. Major complications occurred in 44 patients (28.7%) and liver failure in 6 patients (3.9%). Nonparametric regression showed that post-embolization FLR percent correlated poorly with liver failure. Receiver operating characteristic curves showed that DH and GR were good predictors of liver failure (area under the curve [AUC] = 0.80; p = 0.011 and AUC = 0.79; p = 0.015) and modest predictors of major complications (AUC = 0.66; p = 0.002 and AUC = 0.61; p = 0.032). No patient with GR >2.66% per week had liver failure develop. The predictive value of measured GR was superior to estimated GR for liver failure (AUC = 0.79 vs 0.58; p = 0.046).

CONCLUSIONS

Both DH and GR after PVE are strong predictors of post-hepatectomy liver failure. Growth rate might be a better guide for the optimum timing of liver resection than static volumetric measurements. Measured volumetrics correlated with outcomes better than estimated volumetrics.

Anatomy of the liver: an outline with three levels of complexity--a further step towards tailored territorial liver resections

The vascular anatomy of the liver can be described at three different levels of complexity according to the use that the description has to serve. The first--conventional--level corresponds to the traditional 8-segments scheme of Couinaud and serves as a common language between clinicians from different specialties to describe the location of focal hepatic lesions. The second--surgical--level, to be applied to anatomical liver resections and transplantations, takes into account the real branching of the major portal pedicles and of the hepatic veins. Radiological and surgical techniques exist nowadays to make full use of this anatomy, but this requires accepting that the Couinaud scheme is a simplification, and looking at the vascular architecture with an unprejudiced eye. The third--academic--level of complexity concerns the anatomist, and the need to offer a systematization that resolves the apparent contradictions between anatomical literature, radiological imaging, and surgical practice. Based on the real number of second-order portal branches that, although variable averages 20, we submit a system called the "1-2-20 concept", and suggest that it fits best the number of actual--as opposed to idealized--anatomical liver segments.

Evaluation methods for pretransplant oncologic markers and their prognostic impacts in patient undergoing living donor liver transplantation for hepatocellular carcinoma

Tumor markers [alpha-fetoprotein (AFP) or des-gamma-carboxyprothrombin (DCP)] and neutrophil/lymphocyte ratio (NLR) reportedly correlate with long-term outcomes for hepatocellular carcinoma (HCC). However, no standardized method has been established for evaluating the pretransplant data. One hundred and twenty-four patients who underwent living donor liver transplantation (LDLT) were retrospectively reviewed. The best predictive parameters for tumor recurrence were maximum values for AFP or DCP and 90-day mean values for NLR, respectively, and multivariate analysis confirmed these values were correlated with tumor recurrence. However, receiver operating characteristic analysis revealed that discriminative powers were sufficient only in maximum AFP [area under the curve (AUC) 0.88, P < 0.001] and maximum DCP (AUC 0.76, P < 0.001), while mean NLR was less predictive (AUC 0.62, P = 0.20). When incorporating AFP and DCP to the Tokyo criteria (≤5 tumors with each tumor ≤ 5 cm), the presence of at least two of the following factors: (i) beyond the Tokyo criteria, (ii) AFP>250 ng/ml, and (iii) DCP > 450 mAu/ml (>450 ng/ml), was correlated with a worse 5-year disease-free survival rate (20.0% vs. 96.8%, P < 0.001) and 5-year overall survival rate (20.0% vs. 84.0%, P < 0.001). The prognosis of patients undergoing LDLT for HCC strongly relies on maximum AFP or DCP values before transplantation, while the prognostic impact of NLR is limited.

Role of 6-month abstinence rule in living donor liver transplantation for patients with alcoholic liver disease

AIM

Although alcoholic liver disease (ALD) is an accepted indication for liver transplantation (LT), there are several controversial issues. The aim of this study is to examine the applicability of the 6-month abstinence rule prior to LT and to evaluate the results in living donor LT for patients with ALD.

METHODS

A retrospective study of 102 patients with ALD referred for LT was performed. Clinical data, including alcohol consumption history, were analyzed. A period of abstinence from drinking alcohol of at least 6 months was strictly required.

RESULTS

Among 102 patients, 21 abstained from drinking for at least 6 months. Of these, 13 patients (12%) underwent LT, five patients (5%) recovered without LT and three patients (3%) were listed for deceased donor LT. LT was not indicated for the remaining 81 patients (80%). Eight patients died within 6 months of referral to our program. The Child-Pugh score was higher in these eight patients than in the 21 who achieved 6-month abstinence, although the alcohol consumption history variables did not significantly differ between the two groups. The 5-year overall survival rates after LT in 13 patients with ALD (91%) were similar to those in 387 non-ALD patients (83%). The rate of alcohol consumption relapse after LT was 8% (n = 1/13).

CONCLUSION

Living donor LT for patients with ALD who complied with the 6-month abstinence rule provides sufficient survival benefit with good compliance, compensating for the potential risks to the donors.

Totally laparoscopic full left hepatectomy for living donor liver transplantation in adolescents and adults

In recent years different minimal access strategies have been designed in order to perform living donor liver surgery for adult recipients with less morbidity. Techniques involve shortening the length of the incision with or without previous laparoscopic mobilization of the liver. Herein we present two cases of totally laparoscopic living donor left hepatectomy, with and without removal of the middle hepatic vein, respectively. We describe in detail the anatomical and technical aspects of the procedure focusing on relevant points to enhance safety.

Portal uptake function in veno-occlusive regions evaluated by real-time fluorescent imaging using indocyanine green

BACKGROUND & AIMS

Although recent advances in preoperative imaging have enabled accurate estimation of the regional liver volume with venous occlusion, the extent of functional decrease in such regions remains unclear. In this study, the portal uptake function in postoperative veno-occlusive regions and non-veno-occlusive regions was evaluated by intraoperative fluorescent imaging after intravenous injection of indocyanine green (ICG).

METHODS

In 22 liver resection patients and 23 recipients and 18 donors of liver transplantation, fluorescent intensity on the remnant liver or the liver graft was evaluated in real time following intravenous injection of ICG (0.0025 mg per 1 ml of remnant liver volume).

RESULTS

Plateau ICG concentrations were significantly lower in the veno-occlusive regions (C(VO)) than in the non-veno-occlusive regions (C(Non)) in liver resection patients (median [range], 0.75 [0.29-2.0]μg/ml vs. 3.0 [0.46-6.4]μg/ml, p<0.001), donors (0.69 [0.29-1.9]μg/ml vs. 2.4 [0.46-6.4]μg/ml, p<0.001), and recipients (0.75 [0.34-1.8]μg/ml vs. 1.8 [0.54-6.4]μg/ml, p<0.001). Distributions of the C(VO)/C(Non) and the ratio of the hepatic uptake rate constant in the veno-occlusive regions to that in non-veno-occlusive regions were both around 40% (mean ± standard deviation, 0.36 ± 0.17 and 0.42 ± 0.16, respectively). When the functional remnant liver volume was calculated as a sum of non-veno-occlusive regions and veno-occlusive regions multiplied by C(VO)/C(Non), its ratio to the total liver volume was correlated with the improved postoperative/preoperative ratio of prothrombin time.

CONCLUSIONS

Portal uptake function in veno-occlusive regions is approximately 40% of that in non-veno-occlusive regions. Intraoperative ICG-fluorescent imaging enables real-time evaluation of the extent of the functional decrease in veno-occlusive regions, enhancing accurate estimation of the hepatic functional reserve for determining the surgical indications and procedures.

Living-donor liver transplantation for autoimmune hepatitis and autoimmune hepatitis-primary biliary cirrhosis overlap syndrome

AIM

  Recurrent autoimmune hepatitis (AIH) following liver transplantation has been reported in 20-30% of cases, mainly of Western populations. The aim of this study was to review our experience of living-donor liver transplantation (LDLT) in Japanese patients with AIH.

METHODS

  Among 375 adult (age ≥18 years) LDLT performed at our center between 1996 and 2010, 16 (4.2%) were for patients with AIH (n = 12) or AIH-primary biliary cirrhosis overlap syndrome (n = 4). The patient and donor characteristics and post-transplantation course were reviewed.

RESULTS

  All recipients were female with a median age of 48 years (range, 21-58). Low-dose methylprednisolone and calcineurin inhibitors were continued in all patients. Acute cellular rejection occurred in 10 (63%), which was more frequent than in our overall series of 28.5% (107/375 cases). Overall survival rate was 81.2% at 5 years. At the end of the follow up (median, 6.0 years [range, 0.1-9.6]), 13 patients were alive with normal liver function tests (aspartate transaminase, 18 ± 5 IU/mL; alanine transaminase, 16 ± 8 IU/mL). None of the survivors exhibited liver function test results suspicious for recurrent AIH, which might indicate liver biopsy.

CONCLUSION

  Survival after LDLT for AIH and overlap syndrome was excellent and there was no evidence of clinical recurrence. The recurrence rate of AIH after liver transplantation may differ among countries, and requires further investigation.

Magnetic compression anastomosis for bile duct stenosis after donor left hepatectomy: a case report

Magnetic compression anastomosis (MCA) provides a minimally invasive treatment creating a nonsurgical, sutureless enteric anastomosis in conjunction with an interventional radiologic technique by using 2 high-power magnets. Recently, the MCA technique has been applied to bile duct strictures after living donor liver transplantation or major hepatectomy. Herein we described use of MCA for bile duct stenosis 5 months after donor left hepatectomy in a 24-year-old man who presented with a stricture at the porta hepatis and intrahepatic bile duct dilatation. Unsuccessful transpapillary biliary drainage and balloon dilatation through a percutaneous transhepatic biliary drainage (PTBD) route led to the MCA. A 4-mm-diameter cylindrical samarium-cobalt (Sm-Co) daughter magnet with a long nylon wire was placed at the superior site of the obstruction through the PTBD route. A 5-mm-diameter Sm-Co parent magnet with an attached nylon handle was endoscopically inserted into the common bile duct and placed at the inferior site of obstruction. The 2 magnets were attracted, sandwiching the stricture and establishing a reanastomosis. In conclusion, the MCA technique was a unique procedure for choledochocholedochostomy in a patient with bile duct stenosis after donor hepatectomy.

Clinical significance of right hepatectomy along the main portal fissure on donors in living donor liver transplantation

There might be discordance between inter-lobar borders of the main portal fissure (MPF) using the middle hepatic vein (MHV) and of the portal segmentation. Forty-five living donors who underwent right hepatectomy for the adult recipients from 2007 to 2011 in a tertiary hospital were retrospectively analyzed. The donors were classified into conventional right hepatectomy along the MPF (cRL group, n = 26) and modified right hepatectomy along right-side shifted transection plane from the MPF (mRL group, n = 19). The cRL donors had higher postoperative peak level of INR (1.84 vs. 1.62; P = 0.022), and bilirubin (3.37 mg/dl vs. 2.74 mg/dl; P = 0.065) than the mRL donors. cRL donors experienced greater depression of platelet count (144 per nL vs. 168 per nL; P = 0.042) and enlargement of splenic volume (52% vs. 37%; P = 0.025) than mRL donors for 7 days after hepatectomy. The regeneration of the left lateral sector was more accelerated in the cRL donors than the mRL donors for postoperative 3 months (148% vs. 84%; P = 0.015). There were no differences in the post-transplant graft function, incidence of complications, and graft survival rates between the two groups of recipients (P > 0.05). This study suggests that the conventional right hepatectomy along the MHV might increase donor risk by reducing parenchymal liver volume of the segment IV.

Posttransplant mortality risk assessment for adult-to-adult right-lobe living donor liver recipients with benign end-stage liver disease

OBJECTIVE

A model for living donor liver transplantation (LDLT) outcomes, in concert with pretransplant disease severity assessment, would facilitate informed decision-making on both sides considering donation and transplantation. So far, however, few of studies have focused on models specifically for adult-to-adult right-lobe LDLT recipients with benign end-stage liver diseases. Therefore, we aimed to develop such a prognostic model based on easily obtainable and objective pretransplant characteristics.

METHODS

With data retrospectively collected on 120 recipients, we used Cox proportional-hazards regression to analyze six donor characteristics and 33 pretransplant recipient variables for correlation with posttransplant mortality. In both a modeling set and a prospective validation set with 30 recipients, the performances of the new Cox model, MELD, and MELD-Na+ were assessed by measuring both calibration ability and discriminative power with the Hosmer-Lemeshow test and receiver operating characteristic analysis, respectively.

RESULTS

By univariate and multivariate analysis, donor age, serum total bilirubin, creatinine, and HBV-DNA level were significantly associated with posttransplant mortality. The Cox model, employing these four variables, yielded good calibration ability in the modeling set χ² = 2.465, p = 0.653) and the validation set χ² = 2.836, p = 0.586), and high discriminative power in the modeling set (c-statistic = 0.826, p = 0.001) and validation set (c-statistic = 0.816, p = 0.028). The calibration ability and discriminative power of MELD and MELD-Na+ in both sets were poor.

CONCLUSIONS

The newly derived Cox model was valuable in posttransplant mortality risk assessment for adult-to-adult right-lobe LDLT recipients with benign end-stage liver diseases.

A new procedure for temporary auxiliary partial liver transplantation using living donor graft for patients with familial amyloid polyneuropathy

To introduce duct-to-duct biliary anastomosis to conventional temporary auxiliary partial orthotopic liver transplantation (APOLT) using living donor graft for patients with familial amyloid polyneuropathy, we modified the conventional APOLT procedure in a manner characterized by the use of the recipient's common hepatic duct for biliary reconstruction and the preservation of the right posterior section alone for the certain placement of a tube into the corresponding biliary tree for external biliary drainage (modified APOLT). This procedure was performed in 3 patients without biliary complications. No complications associated with the external drainage tube occurred. Here we report the techniques and results for this new procedure.