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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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Bekheit M, Grundy L, Salih AK, Bucur P, Vibert E, Ghazanfar M. Post-hepatectomy liver failure: A timeline centered review. Hepatobiliary Pancreat Dis Int 2023; 22:554-569. [PMID: 36973111 DOI: 10.1016/j.hbpd.2023.03.001] [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: 04/11/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection. DATA SOURCES This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black's checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis. RESULTS This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade. CONCLUSIONS Remnant liver volume manipulation is the most consistent preventive measure against PHLF.
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Affiliation(s)
- Mohamed Bekheit
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Institute of Medical Sciences, Medical School, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Hépatica, Integrated Center of HPB Care, Elite Hospital, Agriculture Road, Alexandria, Egypt.
| | - Lisa Grundy
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
| | - Ahmed Ka Salih
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Institute of Medical Sciences, Medical School, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
| | - Petru Bucur
- Department of Surgery, University Hospital Tours, Val de la Loire 37000, France
| | - Eric Vibert
- Centre Hépatobiliaire, Paul Brousse Hospital, 12 Paul Valliant Couturier, 94804 Villejuif, France
| | - Mudassar Ghazanfar
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
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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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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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5
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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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6
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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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7
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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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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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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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10
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Braun HJ, Roberts JP. Current status of left lobe adult to adult living donor liver transplantation. Curr Opin Organ Transplant 2021; 26:139-145. [PMID: 33595983 DOI: 10.1097/mot.0000000000000863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW This review describes the history and current state of left lobe living donor liver transplantation (LDLT). The transplant community continues to face an organ shortage on a global scale, and the expansion of LDLT is attractive because it allows us to provide life-saving liver transplants to individuals without drawing from, or depending on, the limited deceased donor pool. Donor safety is paramount in LDLT, and for this reason, left lobe LDLT is particularly attractive because the donor is left with a larger remnant. RECENT FINDINGS This article reviews the donor and recipient evaluations for left lobe LDLT, discusses small for size syndrome and the importance of portal inflow modification, and reviews recipient outcomes in right lobe versus left lobe LDLT. SUMMARY Left lobe LDLT was the first adult-to-adult LDLT ever to be performed in Japan in 1993. Since that time, the use of both right and left lobe LDLT has expanded immensely. Recent work in left lobe LDLT has emphasized the need for inflow modification to reduce portal hyperperfusion and early graft dysfunction following transplant. Accumulating evidence suggests, however, that even though early graft dysfunction following LDLT may prolong hospitalization, it does not predict graft or patient survival.
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Affiliation(s)
- Hillary J Braun
- Department of Surgery, University of California, San Francisco, California, USA
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11
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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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12
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Allard MA, Akamatsu N, Kokudo T, Kobayashi K, Kaneko J, Ishizawa T, Arita J, Hasegawa K. Clinical Significance of Spontaneous Portosystemic Shunts in Living Donor Liver Transplantation. Liver Transpl 2021; 27:77-87. [PMID: 32416038 DOI: 10.1002/lt.25798] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 03/17/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022]
Abstract
Spontaneous portosystemic shunts (SPSS) are commonly observed in patients undergoing living donor liver transplantation (LDLT); however, their impact on the outcome after transplantation is unclear. We aimed to assess the type, size, and the effects of SPSS on outcomes after LDLT. A total of 339 LDLT recipients in a single institution were included. The type and diameter of the SPSS (splenorenal shunt [SRS], oesogastric shunt, and umbilical shunt) were retrospectively analyzed. A large shunt was defined as having a diameter ≤7 mm. No portal flow modulation was attempted over time. Portal complications were defined as stenosis, thrombosis, or hepatofugal flow requiring any treatment after transplantation. There were 202 (59.0%) patients who exhibited at least 1 large SPSS. Neither the size nor type of SPSS was associated with mortality, morbidity, or liver function recovery. However, the incidence of portal complications was significantly higher in patients with a large SRS (8.6% versus 2.9%; P = 0.04). Multivariate analysis of portal complications revealed 2 independent predictors: pre-LT portal vein thrombosis (PVT) and SRS size. The observed risk among recipients with pre-LT PVT was 8.3% when the SRS was ≤7 mm, but increased to 38.5% when the SRS was >15 mm. The present study suggests that large SPSS do not negatively affect the outcomes after LDLT. However, a large SRS is associated with a higher risk of portal complications, particularly in recipients with pre-LT PVT, for whom intraoperative intervention for SRS should be considered. Otherwise, a conservative approach to SPSS during LDLT seems reasonable.
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Affiliation(s)
- Marc-Antoine Allard
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.,Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, Villejuif, France
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Takashi Kokudo
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kosuke Kobayashi
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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13
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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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14
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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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15
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Lerut JP. Bilateral proficiency over time leads to reduced donor morbidity in living donor hepatectomy. Hepatobiliary Surg Nutr 2020; 9:339-341. [PMID: 32509823 PMCID: PMC7262619 DOI: 10.21037/hbsn.2019.10.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/24/2019] [Indexed: 08/29/2023]
Affiliation(s)
- Jan P Lerut
- Institut de Recherche Expérimentale et Clinique (IREC), Université catholique Louvain (UCL), Brussels, Belgium
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16
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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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17
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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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18
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Tamura K, Tohyama T, Watanabe J, Nakamura T, Ueno Y, Inoue H, Honjo M, Sakamoto K, Takai A, Ogawa K, Takada Y. Preformed donor-specific antibodies are associated with 90-day mortality in living-donor liver transplantation. Hepatol Res 2019; 49:929-941. [PMID: 30991451 DOI: 10.1111/hepr.13352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 03/27/2019] [Accepted: 04/07/2019] [Indexed: 12/19/2022]
Abstract
AIM The impact of donor-specific anti-human leukocyte antigen (HLA) antibodies (DSAs) on living donor liver transplantation (LDLT) is unclear. The aim of this study was to investigate the association between DSAs and short-term outcomes in LDLT recipients, and to clarify the clinical impact of DSAs. METHOD Anti-HLA antibodies were screened in preoperative serum samples taken from 40 liver transplant recipients at Ehime University (Toon, Japan) between August 2001 and July 2015. Screening was carried out using the Flow-PRA method, and DSAs were detected in anti-HLA antibody-positive recipients using the Luminex single-antigen identification test. A mean fluorescence intensity of 1000 was used as the cut-off for positivity. We retrospectively reviewed the clinical courses of patients who were DSA-positive to elucidate early clinical manifestations in LDLT recipients. RESULTS Fifteen (12 female and 3 male) patients (38%) had anti-HLA antibodies. Eight of the 15 anti-HLA antibody-positive patients were positive for DSAs, and all were women. The 90-day survival rate of DSA-positive patients (50%) was significantly lower than that of DSA-negative patients (84.4%) (0.0112; Wilcoxon test). On univariate analysis, the DSA-positive rate was significantly higher in the 90-day mortality group. Postoperatively, the incidence of acute cellular rejection was higher in DSA-positive than DSA-negative patients. Thrombotic microangiopathy developed only in DSA-positive patients. We found no relationship between DSA status and bile duct stricture. CONCLUSION Preformed DSAs could be associated with elevated 90-day mortality in LDLT recipients. Further large-scale studies are required to verify the risk associated with DSAs in LDLT.
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Affiliation(s)
- Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Taiji Tohyama
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Jota Watanabe
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Taro Nakamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yoshitomo Ueno
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Hitoshi Inoue
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Masahiko Honjo
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Akihiro Takai
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
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19
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Inoue Y, Fujii K, Ishii M, Kagota S, Tomioka A, Hamamoto H, Osumi W, Tsuchimoto Y, Masubuchi S, Yamamoto M, Asai A, Komeda K, Shimizu T, Asakuma M, Fukunishi S, Hirokawa F, Narumi Y, Higuchi K, Uchiyama K. Volumetric and Functional Regeneration of Remnant Liver after Hepatectomy. J Gastrointest Surg 2019; 23:914-921. [PMID: 30264387 DOI: 10.1007/s11605-018-3985-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/19/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Post-hepatectomy liver regeneration is of great interest to liver surgeons, and understanding the process of regeneration could contribute to increasing the safety of hepatectomies and improving prognoses. METHODS Five hundred thirty-eight patients who underwent hepatectomy were retrospectively analyzed. Postoperative outcomes were evaluated, with a focus on the effects of portal vein resection and resected liver volume on remnant liver regeneration in patients with liver tumors. Remnant liver volumes (RLVs) and laboratory data were measured postoperatively using multidetector computed tomography on day 7 and months 1, 2, 5, 12, and 24 after the operation. RESULTS Liver regeneration speed peaked at 1 week postoperatively and gradually decreased. Regeneration with large resections was longer than that with small resections, with the remnant liver regeneration rate being significantly lower in the former at all time points. Remnant liver regeneration plateaued around 5 months postoperatively, when regeneration is almost complete. Up to 1 month postoperatively, laboratory data were significantly worse when more portal veins was resected. After 2 months postoperatively, these data recovered to near normal levels. CONCLUSION The speed and rate of remnant liver regeneration primarily showed a strong correlation with the number of resected portal veins and the amount of removed liver parenchyma. The larger the resection ratio, the longer it took the liver to regenerate. We confirmed that recovery of the liver's functional aspects accompanies recovery of the RLV.
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Affiliation(s)
- Yoshihiro Inoue
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan.
| | - Kensuke Fujii
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Masatsugu Ishii
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Syuji Kagota
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Atsushi Tomioka
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Hiroki Hamamoto
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Wataru Osumi
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Yusuke Tsuchimoto
- Second Department of Internal Medicine, Osaka Medical College Hospital, Takatsuki City, Japan
| | - Shinsuke Masubuchi
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Masashi Yamamoto
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Akira Asai
- Second Department of Internal Medicine, Osaka Medical College Hospital, Takatsuki City, Japan
| | - Koji Komeda
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Tetsunosuke Shimizu
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Mitsuhiro Asakuma
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Shinya Fukunishi
- Second Department of Internal Medicine, Osaka Medical College Hospital, Takatsuki City, Japan
| | - Fumitoshi Hirokawa
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Yoshihumi Narumi
- Department of Radiology, Osaka Medical College Hospital, Takatsuki City, Japan
| | - Kazuhide Higuchi
- Second Department of Internal Medicine, Osaka Medical College Hospital, Takatsuki City, Japan
| | - Kazuhisa Uchiyama
- Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
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20
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Iesari S, Inostroza Núñez ME, Rico Juri JM, Ciccarelli O, Bonaccorsi-Riani E, Coubeau L, Laterre PF, Goffette P, De Reyck C, Lengelé B, Gianello P, Lerut J. Adult-to-adult living-donor liver transplantation: The experience of the Université catholique de Louvain. Hepatobiliary Pancreat Dis Int 2019; 18:132-142. [PMID: 30850341 DOI: 10.1016/j.hbpd.2019.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 02/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Liver transplantation is the treatment for end-stage liver diseases and well-selected malignancies. The allograft shortage may be alleviated with living donation. The initial UCLouvain experience of adult living-donor liver transplantation (LDLT) is presented. METHODS A retrospective analysis of 64 adult-to-adult LDLTs performed at our institution between 1998 and 2016 was conducted. The median age of 29 (45.3%) females and 35 (54.7%) males was 50.2 years (interquartile range, IQR 32.9-57.5). Twenty-two (34.4%) recipients had no portal hypertension. Three (4.7%) patients had a benign and 33 (51.6%) a malignant tumor [19 (29.7%) hepatocellular cancer, 11 (17.2%) secondary cancer and one (1.6%) each hemangioendothelioma, hepatoblastoma and embryonal liver sarcoma]. Median donor and recipient follow-ups were 93 months (IQR 41-159) and 39 months (22-91), respectively. RESULTS Right and left hemi-livers were implanted in 39 (60.9%) and 25 (39.1%) cases, respectively. Median weights of right- and left-liver were 810 g (IQR 730-940) and 454 g (IQR 394-534), respectively. Graft-to-recipient weight ratios (GRWRs) were 1.17% (right, IQR 0.98%-1.4%) and 0.77% (left, 0.59%-0.95%). One- and five-year patient survivals were 85% and 71% (right) vs. 84% and 58% (left), respectively. One- and five-year graft survivals were 74% and 61% (right) vs. 76% and 53% (left), respectively. The patient and graft survival of right and left grafts and of very small (<0.6%), small (0.6%-0.79%) and large (≥0.8%) GRWR were similar. Survival of very small grafts was 86% and 86% at 3- and 12-month. No donor died while five (7.8%) developed a Clavien-Dindo complication IIIa, IIIb or IV. Recipient morbidity consisted mainly of biliary and vascular complications; three (4.7%) recipients developed a small-for-size syndrome according to the Kyushu criteria. CONCLUSIONS Adult-to-adult LDLT is a demanding procedure that widens therapeutic possibilities of many hepatobiliary diseases. The donor procedure can be done safely with low morbidity. The recipient operation carries a major morbidity indicating an important learning curve. Shifting the risk from the donor to the recipient, by moving from the larger right-liver to the smaller left-liver grafts, should be further explored as this policy makes donor hepatectomy safer and may stimulate the development of transplant oncology.
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Affiliation(s)
- Samuele Iesari
- Starzl Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrates 10, 1200 Brussels, Belgium; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | | | - Olga Ciccarelli
- Starzl Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrates 10, 1200 Brussels, Belgium
| | - Eliano Bonaccorsi-Riani
- Starzl Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrates 10, 1200 Brussels, Belgium
| | - Laurent Coubeau
- Starzl Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrates 10, 1200 Brussels, Belgium
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Pierre Goffette
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Chantal De Reyck
- Starzl Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrates 10, 1200 Brussels, Belgium
| | - Benoît Lengelé
- Department of Plastic and Reconstructive Surgery, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Pierre Gianello
- Pôle de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Jan Lerut
- Starzl Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrates 10, 1200 Brussels, Belgium.
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21
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Nacif LS, Zanini LY, Sartori VF, Kim V, Rocha-Santos V, Andraus W, Carneiro D'Albuquerque L. Intraoperative Surgical Portosystemic Shunt in Liver Transplantation: Systematic Review and Meta-Analysis. Ann Transplant 2018; 23:721-732. [PMID: 30323164 PMCID: PMC6248172 DOI: 10.12659/aot.911435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Expanded clinical and surgical techniques in liver transplantation can markedly improve patient and graft survival. The main purpose of this study was to evaluate the efficacy of intraoperative portocaval shunts in liver transplantation. Material/Methods Searches were conducted in Cochrane, MEDLINE, and EMBASE databases, and updated in January 2018. The following specific outcomes of interest were defined and evaluated separated using 2 different reviews and meta-analyses for 1) hemi-portocaval shunt (HPCS) and 2) temporary portocaval shunt (TPCS). Comparative studies were analyzed separately for both surgical portocaval shunt modalities. Results Only 1 well-designed randomized controlled trial was found. Most studies were retrospective or prospective. Initially, we found 1479 articles. Of those selected, 853 were from PubMed/MEDLINE, 32 were from Cochrane and 594 were from EMBASE. Our meta-analysis included a total of 3232 patients for all the included studies. Results found that 41 patients with HPCS experienced increased 1-year patient survival (OR 16.33; P=0.02) and increased 1-year graft survival (OR 17.67; P=0.01). The TPCS analysis with 1633 patients found patients had significantly shorter intensive care unit length of stay (days) (P=0.006) and hospital length of stay (P=0.02) and had decreased primary nonfunction (PNF) (OR 0.30, P=0.02) and mortality rates (OR 0.52, P=0.01). Conclusions Intraoperative surgical portosystemic shunt in relation to liver transplantation with TPCS was able to prevent PNF, decrease hospital length of stay and unit care length of stay. Furthermore, in analyzing data for patients with HPCS, we observed increases in the 1-year graft and patient survival rates. More prospective randomized trials are needed to arrive at a more precise conclusion.
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Affiliation(s)
- Lucas Souto Nacif
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Leonardo Yuri Zanini
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vinicius Farina Sartori
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vera Kim
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vinicius Rocha-Santos
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Wellington Andraus
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Luiz Carneiro D'Albuquerque
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
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22
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Bell R, Pandanaboyana S, Upasani V, Prasad R. Impact of graft-to-recipient weight ratio on small-for-size syndrome following living donor liver transplantation. ANZ J Surg 2018; 88:415-420. [DOI: 10.1111/ans.14245] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/23/2017] [Accepted: 08/18/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Richard Bell
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
- Department of Hepatobiliary and Pancreatic Surgery; Auckland City Hospital; Auckland New Zealand
- Department of Surgery; Faculty of Medical and Health Sciences, The University of Auckland; Auckland New Zealand
| | - Vivek Upasani
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
| | - Raj Prasad
- Department of Hepatobiliary and Transplant Surgery; St James University Hospital; Leeds UK
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23
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Nguyen JH, Harnois DM. Allograft Portacaval Shunt in Small-for-Size Liver in Deceased Donor Liver Transplant. Transplant Proc 2018; 50:930-932. [PMID: 29661465 DOI: 10.1016/j.transproceed.2017.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/18/2017] [Accepted: 12/12/2017] [Indexed: 11/30/2022]
Abstract
Portal hyperperfusion is detrimental to small-for-size livers (SFSLs) in liver transplantation. Surgical techniques modulating portal inflow provide the most effective approach to protect the SFSL. In this report, we describe a technique creating an allograft portacaval shunt that effectively attenuates portal inflow without a requirement of extensive surgical dissection in the recipient during the transplantation.
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Affiliation(s)
- J H Nguyen
- Divisions of Transplant Surgery and Transplant Hepatology, Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida.
| | - D M Harnois
- Divisions of Transplant Surgery and Transplant Hepatology, Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida
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24
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Gomez Gavara C, Bhangui P, Salloum C, Osseis M, Esposito F, Moussallem T, Lahat E, Fuentes L, Compagnon P, Ngongang N, Lim C, Azoulay D. Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients. Liver Transpl 2018; 24:505-515. [PMID: 29266668 DOI: 10.1002/lt.24999] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 11/02/2017] [Accepted: 12/03/2017] [Indexed: 02/07/2023]
Abstract
The management of large spontaneous portosystemic shunt (SPSS) during liver transplantation (LT) is a matter of debate. The aim of this study is to compare the short-term and longterm outcomes of SPSS ligation versus nonligation during LT, when both options are available. From 2011 to 2017, 66 patients with SPSS underwent LT: 56 without and 10 with portal vein thrombosis (PVT), all of whom underwent successful thrombectomy and could have portoportal reconstruction. The SPSS were either splenorenal (n = 40; 60.6%), left gastric (n = 16; 24.2%), or mesenterico-iliac (n = 10; 15.1%). Following portoportal anastomosis, the SPSS was ligated in 36 (54.4%) patients and left in place in 30 (45.5%) patients, based on the effect of the SPSS clamping/unclamping test on portal vein flow during the anhepatic phase. Intraoperatively, satisfactory portal flow was obtained in both groups. Primary nonfunction (PNF) and primary dysfunction (PDF) rates did not differ significantly between the 2 groups. Nonligation of SPSS was significantly associated with a higher rate of postoperative encephalopathy (P < 0.001) and major postoperative morbidity (P = 0.02). PVT occurred in 0 and 3 patients in the ligated and nonligated shunt group, respectively (P = 0.08). A composite end point, which included the relevant complications in the setting of SPSS in LT (ie, PNF and PDF, PVT, and encephalopathy) was present in 16 (44.4%) and 22 (73.3%) patients of the ligated and nonligated shunt group, respectively (P = 0.02). Patient (P = 0.05) and graft (P = 0.02) survival rates were better in the ligated shunt group. In conclusion, the present study supports routine ligation of large SPSS during LT whenever feasible. Liver Transplantation 24 505-515 2018 AASLD.
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Affiliation(s)
- Concepcion Gomez Gavara
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Delhi National Capital Region, India
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Michael Osseis
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Francesco Esposito
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Toufic Moussallem
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Liliana Fuentes
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France.,Université Paris-Est Créteil, Créteil, France.,INSERM, U955, Créteil, France
| | - Norbert Ngongang
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France.,Université Paris-Est Créteil, Créteil, France.,INSERM, U955, Créteil, France
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25
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Kim SH, Lee EC, Park SJ. Impact of preserved collateral veins on small-for-size grafts in living donor liver transplantation. Hepatol Res 2018; 48:295-302. [PMID: 29125895 DOI: 10.1111/hepr.13002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/05/2017] [Accepted: 11/06/2017] [Indexed: 12/14/2022]
Abstract
AIM Graft size is a critical issue in living donor liver transplantation (LDLT). We hypothesized that too much portal flow could possibly be diverted into pre-existing collateral veins, alleviating small-for-size syndrome (SFSS) in LDLT. This study evaluated the impact of the preserved collateral veins in the outcomes of LDLT using a small-for-size graft. METHODS For patient safety, a graft-to-recipient weight ratio (GRWR) <0.8% was strictly confined to patients with collateral veins (group A), and the patient group was compared in a 1:3 ratio to a matched group of patients with GRWR ≥0.8% (group B) using propensity score analysis. RESULTS Forty and 120 patients were included in group A and B, respectively. No significant differences in baseline patient characteristics were observed between the two groups except for graft weight and GRWR. The lowest GRWR was 0.4%. The graft portal inflow showed no significant differences for 7 days after graft implantation, ranging from 1668 to 5100 mL/min. Small-for-size syndrome occurred in no patients (0.0%) in group A and in 10 (8.3%) in group B (P = 0.067). Overall survival rates at 1, 3, and 5 years were not different between the two groups (85.0%, 82.5%, and 82.5% vs. 92.5%, 86.7%, and 85.0%, respectively; P = 0.670). CONCLUSION Pre-existing collateral veins saved during surgery may have a reserve buffer for excessive portal flow to obviate SFSS in LDLT.
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Affiliation(s)
- Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang-si, Korea
| | - Eung Chang Lee
- Center for Liver Cancer, National Cancer Center, Goyang-si, Korea
| | - Sang Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang-si, Korea
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26
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Nguyen JH, Harnois DM. Incidence and Outcome of Small-for-Size Liver Grafts Transplanted in Adult Recipients. Transplant Proc 2018; 50:198-201. [PMID: 29407308 DOI: 10.1016/j.transproceed.2017.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/08/2017] [Accepted: 12/04/2017] [Indexed: 02/04/2023]
Abstract
Small-for-size liver transplantation (SFS-LT) carries high morbidity and mortality after transplantation. SFS-LT is usually associated with living-donor or deceased-donor split LT; however its incidence and outcome are poorly defined in adult LT recipients who receive whole grafts (WLT). In this study, we retrospectively reviewed our cohort of 3,106 deceased-donor LT in adult recipients. We found that among the 31 split LTs, 11 (35.5%) were SFS. In contrast, there only 1.08% of the whole-graft transplants (31 out of 2,868) were SFS. Although less common, SFS-WLT is associated with poorer long-term outcome of both graft and patient survivals.
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Affiliation(s)
- J H Nguyen
- Divisions of Transplant Surgery and Transplant Hepatology, Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida.
| | - D M Harnois
- Divisions of Transplant Surgery and Transplant Hepatology, Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida
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27
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Abstract
OBJECTIVE A principal aim of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study was to study hepatic blood flow and effect of portal flow modulation on graft outcomes in the setting of increasing use of smaller and left lobe grafts. METHODS Recipients of 274 living donor liver transplant were enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study, including 233 (85.0%) right lobes, 40 (14.6%) left lobes, and 1 (0.5%) left lateral section. Hepatic hemodynamics were recorded after reperfusion. A total of 57 portal flow modulations were performed on 52 subjects. RESULTS Modulation lowered portal pressure in 68% of subjects with inconsistent effects on hepatic arterial and portal flow. A higher rate of graft dysfunction was observed in modulated vs. unmodulated subjects (31% vs. 18%; P = 0.03); however, graft survival in modulated subjects was not different from unmodulated subjects at 3 years. CONCLUSIONS These results suggest the need for a study using a prespecified portal flow modulation protocol with defined indications to better define the effects of these interventions.
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Abstract
Living donor liver transplantation (LDLT) has been increasingly embraced around the world as an important strategy to address the shortage of deceased donor livers. The aim of this guideline, approved by the International Liver Transplantation Society (ILTS), is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT. Recommendations were developed from an analysis of the National Library of Medicine living donor transplantation indexed literature using the Grading of Recommendations Assessment, Development and Evaluation methodology. Writing was guided by the ILTS Policy on the Development and Use of Practice Guidelines (www.ilts.org). Intended for use by physicians, these recommendations support specific approaches to the diagnostic, therapeutic, and preventive aspects of care of living donor liver transplant recipients. Compared to cadaveric liver transplantation, live donor LT (LDLT) is challenged by ethical, medical and surgical considerations, many of which are still unresolved. The aim of this guideline is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT.
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29
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Patterns of Early Allograft Dysfunction in Adult Live Donor Liver Transplantation: The A2ALL Experience. Transplantation 2017; 100:1490-9. [PMID: 27326811 DOI: 10.1097/tp.0000000000001240] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Early allograft dysfunction (EAD) after living donor liver transplantation (LDLT) has often been attributed to inadequate graft size, and termed small-for-size syndrome. Early allograft dysfunction definitions include a variable constellation of findings, including hyperbilirubinemia, coagulopathy, encephalopathy, and ascites formation. Among putative causes of EAD after LDLT are excessive portal pressure and/or flow. Our objective was to evaluate patterns of EAD after LDLT. METHODS In this study, 631 LDLT recipients were monitored for complications, EAD (defined by postoperative day 7 bilirubin >10 mg/dL or international normalized ratio >1.6), and graft failure. Approximately 200 had portal venous and arterial pressure and flow measurements before and after LDLT. Portal inflow modification (splenic artery ligation, hemiportocaval shunt, or splenectomy) was performed at the discretion of the operating surgeon. Associations between EAD and recipient, donor, and transplant factors were examined using multivariable logistic regression. RESULTS Risk of EAD was associated with left lobe grafts, lower graft weight among left lobes, higher preoperative bilirubin, higher portal reperfusion pressure, higher donor age, and higher donor body mass index. The risk of graft loss within the first 90 days was 5.2 times higher for recipients with EAD versus those without EAD (P < 0.001). CONCLUSIONS Early allograft dysfunction can be defined using postoperative day 7 laboratory values that are highly predictive of early graft failure within 90 days. Risk factors associated with EAD after LDLT include: graft type and size, preoperative bilirubin, portal reperfusion pressure, donor age, and donor body mass index.
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30
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Reddy MS, Rela M. Portosystemic collaterals in living donor liver transplantation: What is all the fuss about? Liver Transpl 2017; 23:537-544. [PMID: 28073180 DOI: 10.1002/lt.24719] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/18/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023]
Abstract
Portosystemic collaterals are a common finding in patients with cirrhosis undergoing liver transplantation. Recently, there has been a renewed interest regarding their significance in the setting of living donor liver transplantation (LDLT) due to concerns of graft hypoperfusion or hyperperfusion and its impact on early posttransplant outcomes. Presence of these collaterals has greater significance in the LDLT setting when compared with the deceased donor liver transplantation setting as dictated by the difference in the physiology of partial liver grafts. We discuss current thinking of portal flow dynamics and the techniques for dealing with this clinical problem. Liver Transplantation 23 537-544 2017 AASLD.
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Affiliation(s)
- Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Gleneagles Global Hospital, Chennai, India
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Gleneagles Global Hospital, Chennai, India.,National Foundation for Liver Research, Chennai, India.,Institute of Liver Studies, King's College Hospital, London, UK
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31
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Goldaracena N, Echeverri J, Selzner M. Small-for-size syndrome in live donor liver transplantation-Pathways of injury and therapeutic strategies. Clin Transplant 2017; 31. [PMID: 27935645 DOI: 10.1111/ctr.12885] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2016] [Indexed: 12/14/2022]
Abstract
Due to the severe organ shortage and the increasing gap between the supply and demand for donor grafts, live donor liver transplantation (LDLT) has become an accepted and alternative technique for the expansion of the donor pool. However, donor safety and good recipient outcomes must be balanced regarding risk stratification and decision-making within this patient population. Small-for-size syndrome (SFSS) is one of the complications encountered after LDLT, thus increasing the burden of optimizing donor graft selection and effective treatments during its occurrence. A graft-to-recipient weight ratio (GRWR) <0.8 predisposes the graft to SFSS. However, other factors may induce this complication even without a graft-to-patient size mismatch. Several strategies to prevent this complication include portal vein flow and liver outflow modulation, as well as pharmacological treatment. Also, as an entity with a multifactorial etiology, outcomes vary between right-lobe, left-lobe, and posterior-lobe donation among series encountered in the literature. In this review, we analyze the pathophysiology and classification of this complication, the state-of-the-art on management of SFSS, and the outcomes regarding the best treatment strategy on this patient population.
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Affiliation(s)
- Nicolas Goldaracena
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Juan Echeverri
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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32
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Graft inflow modulation in adult-to-adult living donor liver transplantation: A systematic review. Transplant Rev (Orlando) 2016; 31:127-135. [PMID: 27989547 DOI: 10.1016/j.trre.2016.11.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 11/29/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Small-for-size syndrome (SFSS) has an incidence between 0 and 43% in small-for-size graft (SFSG) adult living donor liver transplantation (LDLT). Portal hypertension following reperfusion and the hyperdynamic splanchnic state are reported as the major triggering factors of SFSS. Intra- and postoperative strategies to prevent or to reduce its onset are still under debate. We analyzed graft inflow modulation (GIM) during adult LDLT considering the indications, efficacy of the available techniques, changes in hemodynamics and outcomes. MATERIALS AND METHODS A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central. Treatment outcomes including in-hospital mortality and morbidity, re-transplantation rate, 1-, 3-, and 5-year patient overall survival and 1-, 3-, and 5-year graft survival rates, hepatic artery and portal vein flows and pressures before and after inflow modulation were analyzed. RESULTS From 563 articles, 12 studies dated between 2003 and 2014 fulfilled the selection criteria and were therefore included in the study. These comprised a total of 449 adult patients who underwent inflow modulation during adult-to-adult LDLT. Types of GIM described were splenic artery ligation, splenectomy, meso-caval shunt, spleno-renal shunt, portocaval shunt, and splenic artery embolization. Mortality and morbidity ranged between 0 and 33% and 17% and 70%, respectively. Re-transplantation rates ranged between 0% and 25%. GIM was associated with good survival for both graft and recipients, reaching an 84% actuarial rate at 5 years. Through the use of GIM, irrespective of the technique, a statistically significant reduction of PVF and PVP was obtained. CONCLUSIONS GIM is a safe and efficient technique to avoid or limit portal hyperperfusion, especially in cases of SFSG, decreasing overall morbidity and improving outcomes.
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Ikegami T, Yoshizumi T, Sakata K, Uchiyama H, Harimoto N, Harada N, Itoh S, Nagatsu A, Soejima Y, Maehara Y. Left lobe living donor liver transplantation in adults: What is the safety limit? Liver Transpl 2016; 22:1666-1675. [PMID: 27540888 DOI: 10.1002/lt.24611] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 08/01/2016] [Indexed: 12/29/2022]
Abstract
Small-for-size syndrome (SFSS) is the most significant cause of graft loss after living donor liver transplantation (LDLT), especially after left lobe (LL) LDLT in adults. The safety limit of applying LL-LDLT in adults without severe SFSS with a high rate of lethality needs to be determined. A total of 207 LL-LDLTs in adults since September 2005 were evaluated to analyze the risk factors for severe SFSS, defined as a serum total bilirubin concentration of ≥20.0 mg/dL after LDLT. Although there were no significant differences in cumulative graft survival after LDLT between medium grafts (graft volume [GV] to standard liver volume [SLV] ratio ≥ 40.0%), small grafts (35.0% ≤ GV/SLV < 40.0%), and extra small grafts (GV/SLV < 35.0%), patients with severe SFSS showed a significantly lower 5-year graft survival rate than those without (42.9% versus 94.3%, respectively; P < 0.001). Multivariate analysis for severe SFSS after LL-LDLT showed that donor age of ≥48 years (P = 0.01), Model for End-Stage Liver Disease (MELD) score of ≥ 19 (P < 0.01), and end portal venous pressure of ≥19 mm Hg (P = 0.04) were the significant and independent factors for severe SFSS after LL-LDLT. Within such high-risk subgroups of patients with a donor age of ≥48 years or MELD score of ≥ 19 before LDLT, operative blood loss volume of ≥8.0 L was a risk factor for severe SFSS. LL-LDLT in adults could be indicated and provide acceptable outcomes for the combinations of donors aged < 48 years and recipients with a MELD score of <19. Smaller grafts might yield acceptable outcomes in appropriately selected donor-recipient combinations. Liver Transplantation 22 1666-1675 2016 AASLD.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhito Sakata
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hideaki Uchiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 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
| | - Akihisa Nagatsu
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuji Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Fukazawa K, Nishida S. Size mismatch in liver transplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:457-66. [PMID: 27474079 DOI: 10.1002/jhbp.371] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 06/24/2016] [Indexed: 12/20/2022]
Abstract
Size mismatch is an unique and inevitable but critical issue in live donor liver transplantation. Unmatched metabolic demand of recipient as well as physiologic mismatch aggravates the damage to liver graft, inevitably leading to graft failure on recipient. Also, an excessive resection of liver graft for better recipient outcome in live donor liver transplant may jeopardize the healthy donor well-being and even put donor life in danger. There is a fine balance between resected graft volume required to meet the recipient's metabolic demand and residual graft volume required for donor safety. The obvious clinical necessity of finding that balance has prompted a clinical need and promoted the improvement of knowledge and development of management strategies for size-mismatched transplants. The development of the size-matching methodology has significantly improved graft outcome and recipient survival in live donor liver transplants. On the other hand, the effect of size mismatch in cadaveric transplants has never been observed as being so pronounced. The importance of matching of the donor recipient size has been unrecognized in cadaveric liver transplant. In this review, we attempt to summarize the current most updated knowledge on the subject, particularly addressing the definition and complications of size-mismatched cadaveric liver transplant, as well as management strategies.
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Affiliation(s)
- Kyota Fukazawa
- Division of Transplantation, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, Washington 98195, USA.
| | - Seigo Nishida
- Division of Liver and Gastrointestinal Transplant, Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
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Kurihara T, Yoshizumi T, Yoshida Y, Ikegami T, Itoh S, Harimoto N, Ninomiya M, Uchiyama H, Okabe H, Kimura K, Kawanaka H, Shirabe K, Maehara Y. Graft selection strategy in adult-to-adult living donor liver transplantation: When both hemiliver grafts meet volumetric criteria. Liver Transpl 2016; 22:914-22. [PMID: 26953726 DOI: 10.1002/lt.24431] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/05/2016] [Accepted: 02/10/2016] [Indexed: 12/20/2022]
Abstract
To ensure donor safety in living donor liver transplantation (LDLT), the left and caudate lobe (LL) is the preferred graft choice. However, patient prognosis may still be poor even if graft volume (GV) selection criteria are met. Our aim was to evaluate the effects of right lobe (RL) donation when the LL graft selection criteria are met. Consecutive donors (n = 135) with preoperative LL graft volumetric GV/standard liver volume (SLV) of ≥35% and RL remnant of ≥35% were retrospectively studied. Patients were divided into 2 groups: LL graft and RL graft. Recipient's body surface area (BSA), Model for End-Stage Liver Disease (MELD) score, and the donor's age were higher in the RL group. The donor's BSA and preoperative volumetric GV/SLV of the LL graft were smaller in the RL group. The predicted score (calculated using data for graft size, donor age, MELD score, and the presence of portosystemic shunt, which correlated well with graft function and with 6-month graft survival) of the RL group, was significantly lower if the LL graft were used, but using the actual RL graft improved the score equal to that of the LL group. Six-month and 12-month graft survival rates did not differ between the 2 groups. In patients with a poor prognosis, a larger RL graft improved the predicted score and survival was equal to that of patients who received LL grafts. In conclusion, graft selection by GV, donor age, and recipient MELD score improves outcomes in LDLT. Liver Transplantation 22 914-922 2016 AASLD.
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Affiliation(s)
- Takeshi Kurihara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Yoshida
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toru Ikegami
- 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
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mizuki Ninomiya
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hideaki Uchiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirohisa Okabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Kimura
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirofumi Kawanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Clinical Research Institute, Beppu Medical Center, Beppu, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Fukazawa K, Nishida S, Pretto EA, Vater Y, Reyes JD. Detrimental graft survival of size-mismatched graft for high model for end-stage liver disease recipients in liver transplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:406-413. [DOI: 10.1002/jhbp.355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Kyota Fukazawa
- Division of Transplantation, Department of Anesthesiology and Pain Medicine; University of Washington School of Medicine; 1959 NE Pacific Street Seattle WA 98195 USA
| | - Seigo Nishida
- Division of Liver and Gastrointestinal Transplant, Department of Surgery; University of Miami Miller School of Medicine and Jackson Memorial Hospital; Miami Florida USA
| | - Ernesto A. Pretto
- Division of Solid Organ Transplantation, Department of Anesthesiology, Perioperative Medicine and Pain Management; University of Miami Miller School of Medicine; Miami Florida USA
| | - Youri Vater
- Division of Transplantation, Department of Anesthesiology and Pain Medicine; University of Washington School of Medicine; 1959 NE Pacific Street Seattle WA 98195 USA
| | - Jorge D. Reyes
- Division of Transplantation, Department of Surgery; University of Washington School of Medicine; Seattle Washington USA
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Kinaci E, Kayaalp C. Portosystemic Shunts for “Too Small-for-Size Syndrome” After Liver Transplantation: A Systematic Review. World J Surg 2016; 40:1932-40. [DOI: 10.1007/s00268-016-3518-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Marubashi S, Nagano H, Eguchi H, Wada H, Asaoka T, Tomimaru Y, Tomokuni A, Umeshita K, Doki Y, Mori M. Minimum graft size calculated from preoperative recipient status in living donor liver transplantation. Liver Transpl 2016; 22:599-606. [PMID: 26684397 DOI: 10.1002/lt.24388] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/10/2015] [Accepted: 12/01/2015] [Indexed: 02/07/2023]
Abstract
Small-for-size graft syndrome is an inevitable complication in living donor liver transplantation (LDLT). We hypothesized that graft weight (GW) measured after graft procurement is one of the variables predicting postoperative graft function. A total of 138 consecutive recipients of adult-to-adult LDLT between March 1999 and October 2014 were included in this study. We investigated the factors associated with small-for-size-associated graft loss (SAGL) to determine the GW required for each patient. Both preoperatively assessed and postoperatively obtained risk factors for SAGL were analyzed in univariate and multivariate logistic regression analysis. Twelve (8.8%) of the transplant recipients had SAGL. In multivariate logistic regression analyses using preoperatively assessed variables, the preoperative Model for End-Stage Liver Disease (MELD) score (P < 0.001) and actual GW/recipient standard liver volume (SLV) ratio (P = 0.008) were independent predictors of SAGL. The recommended graft volume by preoperative computed tomography volumetry was calculated as SLV × (1.616 × MELD + 0.344)/100/0.85 (mL) [MELD ≥ 18.2], or SLV × 0.35 (mL) [MELD < 18.2]. The required allograft volume in LDLT can be determined by the preoperative MELD score of the recipient, and patients with higher MELD scores require larger grafts or deceased donor whole liver transplant to avoid SAGL. Liver Transplantation 22 599-606 2016 AASLD.
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Affiliation(s)
- Shigeru Marubashi
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hiroaki Nagano
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hiroshi Wada
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Tadafumi Asaoka
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshito Tomimaru
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Akira Tomokuni
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Koji Umeshita
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuichiro Doki
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masaki Mori
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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Kim JH. Effects of portal hyperperfusion on partial liver grafts in the presence of hyperdynamic splanchnic circulation: hepatic regeneration versus portal hyperperfusion injury. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.2.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Jong Hae Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
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41
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The outcomes of pediatric living donor liver transplantation using small-for-size grafts: experience of a single institute. Pediatr Surg Int 2016; 32:363-8. [PMID: 26786017 DOI: 10.1007/s00383-016-3859-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE We aimed to evaluate patients who had undergone pediatric LDLT with small-for-size graft (SFSG) and identify risk factors of graft failure to establish a preoperative graft selection strategy. METHODS The data was collected retrospectively. SFSG was used in 14LDLTs (5.7%) of 245 LDLTs performed between May 2001 and March 2014. The mean patient age and body weight at LDLT were 12.6 ± 2.0 years and 40.5 ± 9.9 kg, respectively. The graft type was left lobe in six patients, left + caudate lobe in seven patients, and posterior segment in one patient. RESULTS The graft survival rates in SFSG and non-SFSG groups were 78.9 and 93.1%, respectively (p = 0.045). In the univariate analysis, bleeding volume during LDLT were an independent risk factors for graft failure (p = 0.011). Graft failure was caused by sepsis in all three patients and occurred at a median of 70 postoperative days 70 (range 14-88 days). Among them, two cases showed high preoperative PELD/MELD score (PELD; 19.4 and MELD; 22, respectively). CONCLUSIONS Pediatric LDLT using SFSG had poor outcome and prognosis, especially when it accompanies the surgical infectious complications with preoperative high PELD/MELD scores.
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Uemura T, Wada S, Kaido T, Mori A, Ogura Y, Yagi S, Fujimoto Y, Ogawa K, Hata K, Yoshizawa A, Okajima H, Uemoto S. How far can we lower graft-to-recipient weight ratio for living donor liver transplantation under modulation of portal venous pressure? Surgery 2016; 159:1623-1630. [PMID: 26936527 DOI: 10.1016/j.surg.2016.01.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 12/24/2015] [Accepted: 01/23/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Smaller size grafts for living donor liver transplantation (LDLT) can enhance donor safety and expand donor availability. We previously reported that modulation of portal venous pressure (PVP) was key for successful LDLT with small grafts, and that it actively lowered graft-to-recipient weight ratio (GRWR) for adult-to-adult LDLT. This retrospective study investigated the outcome of LDLT using small grafts with PVP modulation. METHOD This study analyzed 221 adult LDLT patients between March 2008 and December 2013 and divided them into 3 groups based on GRWR: large (L), GRWR ≥ 0.8% (n = 154), medium (M), ≥ 0.7% GRWR < 0.8% (n = 38); and small (S) GRWR < 0.7% (n = 29). Donor and recipient factors, PVP, pressure gradient between PVP and central venous pressure (CVP), occurrence of small for size syndrome (SFSS), ascites, and posttransplant laboratory data were compared across the 3 groups. Patient and graft survival were compared using Kaplan-Meier methods. RESULTS There was no difference in patient or graft survival between the 3 groups. Amount of posttransplant ascites and posttransplant International Normalized Ratio were similar, but the S and M groups had more prolonged cholestasis. SFSS was identified in 17%, 13%, and 13% in the S, M, and L groups, respectively (P = NS). Patients with a final PVP of ≤15 mmHg had better survival than patients with a final PVP of >15 mmHg (P < .001). Multivariate analysis showed that donor age >40 years old, final PVP of >15 mmHg, and pressure gradient of PVP-CVP >5 mmHg were risk factors for inferior patient survival. CONCLUSION We achieved satisfactory outcomes in LDLT with GRWR as low as 0.6% using PVP modulation. Thus, we currently set a lower limit of GRWR at 0.6% while protecting donor safety and expanding donor availability.
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Affiliation(s)
- Tadahiro Uemura
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Seidai Wada
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akira Mori
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuhiro Ogura
- Department of Transplantation Surgery, Nagoya University, Nagoya city, Aichi, Japan
| | - Shintaro Yagi
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuhiro Fujimoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kohei Ogawa
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Yoshizawa
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Du Z, Zhou Y, Lu X, Li L, Lu C, Li L, Li B, Bu H, Yang J, Shi Y. Octreotide prevents liver failure through upregulating 5'-methylthioadenosine in extended hepatectomized rats. Liver Int 2016; 36:212-22. [PMID: 25944273 DOI: 10.1111/liv.12863] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/01/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS Insufficient liver regeneration and hepatocyte injury caused by excessive portal perfusion are considered to be responsible for post-hepatectomy liver failure (PLF) or small-for-size syndrome in living-donor liver transplantation. Somatostatin can decrease portal vein pressure (PVP) but simultaneously inhibits liver regeneration. This interesting paradox motivated us to investigate the outcome of PLF in response to somatostatin treatment. METHODS Rats receiving extended partial hepatectomy (90% PH) were treated with octreotide, a somatostatin analogue, or placebo. Animal survival, serum parameters and hepatic histology were evaluated. Metabolomic analysis was performed to investigate the effect of octreotide on hepatocyte metabolism. RESULTS Despite significantly inhibiting early regeneration, octreotide application noticeably improved the hepatic histology, liver function and survival after PH but did not decrease the PVP level. Metabolomic analysis exhibited that octreotide profoundly and exclusively altered the levels of five metabolites that participate in or closely associate with the methionine cycle, a biochemical reaction that uniquely produces S-adenosylmethionine (SAMe), an active methyl residual donor for methyltransferase reactions. Among these metabolites, 5'-methylthioadenosine (MTA), a derivate of SAMe, increased three-fold and was found independently improve the hepatic histology and reduce inflammatory cytokines in hepatectomized rats. CONCLUSIONS Octreotide exclusively regulates the methionine cycle reaction and augments the MTA level in hepatocytes. MTA prominently protects hepatocytes against shear stress injury and reduces the secondary inflammation, thereby protecting rats from PLF.
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Affiliation(s)
- Zhenggui Du
- Laboratory of Pathology, West China Hospital, Sichuan University, Chengdu, China.,Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, China.,Department of Thyroid and Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yongjie Zhou
- Laboratory of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Xufeng Lu
- Laboratory of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Changli Lu
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Li
- Laboratory of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Bu
- Laboratory of Pathology, West China Hospital, Sichuan University, Chengdu, China.,Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiayin Yang
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yujun Shi
- Laboratory of Pathology, West China Hospital, Sichuan University, Chengdu, China
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Xu Y, Chen H, Yeh H, Wang H, Leng J, Dong J. Living donor liver transplantation using dual grafts: Experience and lessons learned from cases worldwide. Liver Transpl 2015; 21:1438-48. [PMID: 26336078 DOI: 10.1002/lt.24315] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/20/2015] [Accepted: 08/24/2015] [Indexed: 01/10/2023]
Abstract
In living donor liver transplantation (LDLT), insufficient graft volume could result in small-for-size syndrome in recipients, whereas major liver donation predisposes the donor to a high risk of posthepatectomy liver failure. Dual graft LDLT is therefore introduced to obtain combined graft sufficiency. To date, 367 patients have been reported worldwide. We reviewed all the relevant literature, with a special focus on 43 case reports containing enough data to extract and analyze. A simple decision-making algorithm was developed. Dual graft LDLT is indicated when (1) a single donation is unacceptable due to graft-to-recipient size mismatch; (2) the future liver remnant is insufficient in the single donor after major resection; or (3) there is a significant underlying disorder or anatomical variation within the donor liver. The outcome of dual graft LDLT is reported to be comparable with that of single donor LDLT. Unilateral graft atrophy was found in 7 of the 43 patients, predominantly in the right-sided, heterotopic and initially smaller grafts. Technically, the heterotopic implantation and complex vascular reconstruction are the most demanding. Elaborate surgical planning and modification are needed. Ethical concerns about involving a second living donor need to be addressed. In conclusion, dual graft LDLT should be prudently performed in select cases by surgeons of proven expertise when single donation is unacceptable and a second living donor is available. The decision-making criteria need to be standardized. More surgical modification and clinical research are needed.
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Affiliation(s)
- Yinzhe Xu
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, Haidian, Beijing, China.,Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hao Chen
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, Haidian, Beijing, China
| | - Heidi Yeh
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hongguang Wang
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, Haidian, Beijing, China
| | - Jianjun Leng
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, Haidian, Beijing, China
| | - Jiahong Dong
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, Haidian, Beijing, China.,Beijing Tsinghua Changgung Hospital, Tsinghua University Medical Center, Changping, Beijing, China
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45
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Samstein B, Klair T. Living Donor Liver Transplantation: Donor Selection and Living Donor Hepatectomy. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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46
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Diaz G, Levitsky J, Oniscu G. Meeting report of the 2014 joint international congress of the International Liver Transplantation Society, Liver Intensive Care Group of Europe, and European Liver and Intestinal Association. Liver Transpl 2015; 21:991-1000. [PMID: 25857840 DOI: 10.1002/lt.24144] [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: 02/11/2015] [Accepted: 03/30/2015] [Indexed: 01/13/2023]
Abstract
The 2014 Annual Meeting of the International Liver Transplantation Society was held in London, England. This was the 20th meeting of the Society and was marked by a joint meeting including the European Liver and Intestinal Association as well as the Liver Intensive Care Group of Europe. The meeting included symposia, invited lectures, debates, oral presentations, and posters. The principal themes were living donation, expanding the deceased donor pool, machine preservation, and new oral therapies for hepatitis C virus. This report highlights the scientific discussions of this meeting.
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Affiliation(s)
- Geraldine Diaz
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Josh Levitsky
- Department of Gastroenterology and Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gabriel Oniscu
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Hamza AR, Krasniqi AS, Srinivasan PK, Afify M, Bleilevens C, Klinge U, Tolba RH. Gut-liver axis improves with meloxicam treatment after cirrhotic liver resection. World J Gastroenterol 2014; 20:14841-14854. [PMID: 25356044 PMCID: PMC4209547 DOI: 10.3748/wjg.v20.i40.14841] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 06/07/2014] [Accepted: 06/26/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To investigate the effect of meloxicam on the gut-liver axis after cirrhotic liver resection.
METHODS: Forty-four male Wistar rats were assigned to three groups: (1) control group (CG); (2) bile duct ligation with meloxicam treatment (BDL + M); and (3) bile duct ligation without meloxicam treatment (BDL). Secondary biliary liver cirrhosis was induced via ligature of the bile duct in the BDL + M and BDL groups. After 2 wk, the animals underwent a 50% hepatectomy. In the BDL + M group 15 min prior to the hepatectomy, one single dose of meloxicam was administered. Parameters measured included: microcirculation of the liver and small bowel; portal venous flow (PVF); gastrointestinal (GI) transit; alanine aminotransferase (ALT); malondialdehyde; interleukin 6 (IL-6), transforming growth factor beta 1 (TGF-β1) and hypoxia-inducible factor 1 alpha (HIF-1α) levels; mRNA expression of cyclooxigenase-2 (COX-2), IL-6 and TGF-β1; liver and small bowel histology; immunohistochemical evaluation of hepatocyte and enterocyte proliferation with Ki-67 and COX-2 liver expression.
RESULTS: Proliferative activity of hepatocytes after liver resection, liver flow and PVF were significantly higher in CG vs BDL + M and CG vs BDL group (P < 0.05), whereas one single dose of meloxicam ameliorated liver flow and proliferative activity of hepatocytes in BDL + M vs BDL group. COX-2 liver expression at 24 h observation time (OT), IL-6 concentration and mRNA IL-6 expression in the liver especially at 3 h OT, were significantly higher in BDL group when compared with the BDL + M and CG groups (P < 0.01, P < 0.001, P < 0.01, respectively). Liver and small bowel histology, according to a semi quantitative scoring system, showed better integrity in BDL + M and CG as compared to BDL group. ALT release and HIF-1α levels at 1 h OT were significantly higher in BDL + M compared to CG and BDL group (P < 0.001 and P < 0.01, respectively). Moreover, ALT release levels at 3 and 24 h OT were significantly higher in BDL group compared to CG, P < 0.01. GI transit, enterocyte proliferative activity and number of goblet cells were in favor of meloxicam treatment vs BDL group (P < 0.05, P < 0.001, P < 0.01, respectively). Additionally, villus length were higher in BDL + M as compared to BDL group.
CONCLUSION: One single dose of meloxicam administered after cirrhotic liver resection was able to cause better function and integrity of the remaining liver and small bowel.
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Wang H, Ikegami T, Harada N, Yoshizumi T, Soejima Y, Uchiyama H, Yamashita YI, Itoh S, Harimoto N, Kawanaka H, Shirabe K, Maehara Y. Optimal changes in portal hemodynamics induced by splenectomy during living donor liver transplantation. Surg Today 2014; 45:979-85. [PMID: 25080864 DOI: 10.1007/s00595-014-0999-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 07/07/2014] [Indexed: 02/07/2023]
Abstract
PURPOSES The purpose of this study was to evaluate the impact of splenectomy in adult-to-adult living donor liver transplantation (LDLT). METHODS Adult-to-adult LDLTs (n = 276) were divided into those with simultaneous splenectomy during LDLT (Splenectomy group, n = 154) and those without (Non-Splenectomy group, n = 122). RESULTS In the Splenectomy group, splenectomy decreased the portal venous pressure from 24.0 to 19.1 mmHg (p < 0.001). At the end of surgery, the portal venous pressure was significantly lower and the graft compliance was significantly higher in the Splenectomy group compared with the Non-Splenectomy group. The graft portal venous flow was also better in the Splenectomy group (y = 625-5.1x; r (2) = 0.08, p < 0.01) than in the Non-Splenectomy group (y = 470-2.9x; r (2) = 0.04, p = 0.03). Fourteen days after LDLT, the total bilirubin and ascites output were lower in the Splenectomy group than in the Non-Splenectomy group. Among the patients with hepatitis C, splenectomy was associated with a significantly higher rate of a sustained viral response (59.4 vs. 35.9%, p = 0.020) than was noted in those without splenectomy (n = 39). There were no patients with post-splenectomy sepsis under vaccination. CONCLUSIONS By decreasing the portal pressure and increasing the graft vascular compliance, splenectomy conferred better graft outcomes in adult-to-adult LDLT.
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Affiliation(s)
- Huanlin Wang
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
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EXP CLIN TRANSPLANTExp Clin Transplant 2014; 12. [DOI: 10.6002/ect.2013.0272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Small-for-size syndrome in living-donor liver transplantation using a left lobe graft. Surg Today 2014; 45:663-71. [PMID: 24894564 DOI: 10.1007/s00595-014-0945-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/12/2014] [Indexed: 12/14/2022]
Abstract
In living-donor liver transplantation with a left lobe graft, which can reduce the burden on the donor compared to right lobe graft, the main problem is small-for-size (SFS) syndrome. SFS syndrome is a multifactorial disease that includes aspects related to the graft size, graft quality, recipient factors and even technical issues. The main pathophysiology of SFS syndrome is the sinusoidal microcirculatory disturbance induced by shear stress, which is caused by excessive portal inflow into the smaller graft. The donor age, the presence of steatosis of the graft and a poor recipient status are all risk factors for SFS syndrome. To resolve SFS syndrome, portal inflow modulation, splenectomy, splenic artery modulation and outflow modulation have been developed. It is important to establish strict criteria for managing SFS syndrome. Using pharmacological interventions and/or therapeutic approaches that promote liver regeneration could increase the adequate outcomes in SFS liver transplantation. Left lobe liver transplantation could be adopted in Western countries to help resolve the organ shortage.
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