Living-donor liver transplant using the right hepatic lobe without the right hepatic vein: solving the drainage problem

Factors Affecting Intraoperative Blood Transfusion Requirements during Living Donor Liver Transplantation

Background: Intraoperative blood transfusion (IOBT) during liver transplantation (LT) has negative outcomes, and it has been shown that an increasing number of these procedures may no longer require IOBT. Regarding living donor liver transplantation (LDLT), the literature on the pre-transplant predictors of IOBT is quite heterogeneous and deficient. In this study, we reviewed our experience of IOBT among a homogenous cohort of adult right-lobe LDLTs. Methods: We conducted a retrospective analysis of prospectively collected data on adult LDLT recipients between January 2018 and October 2023. Two groups were constructed (No-IOBT vs. IOBT) for the exploration of pre- and intraoperative predictors of IOBT using univariate and multivariate analyses. An ROC curve analysis was applied to identify possible cut-offs. The one-year post-LDLT overall survival was compared using the Kaplan-Meier method. A p-value < 0.05 was considered statistically significant. Results: A total of 219 adult LDLT recipients were enrolled. The No-IOBT (n = 56) patients were mostly males (p = 0.016), with higher preoperative levels of HGB (p < 0.001), fibrinogen (p = 0.005), and albumin (p = 0.007) and a lower incidence of pre-transplant upper abdominal surgery (p = 0.017), portal vein thrombosis (p = 0.04), hepatorenal syndrome (p = 0.015), and ascites (p = 0.02) than the IOBT group (n = 163). The No-IOBT group had a shorter anhepatic phase (p = 0.002) and received fewer intravenous crystalloids (p = 0.001). In the multivariate analysis, the pre-transplant HGB (p < 0.001), fibrinogen (p < 0.001), and albumin (p = 0.04) levels were independent predictors of IOBT, showing the following cut-offs in the ROC curve analysis: HGB ≤ 11.5 (AUC: 0.800, p < 0.001), fibrinogen ≤ 125 (AUC: 0.638, p = 0.0024), and albumin ≤ 3.6 (AUC: 0.663, p = 0.0002). These were significantly associated with the No-IOBT group. The one-year overall survival of the No-IOBT and IOBT groups was 100% and 83%, respectively (p = 0.007). Conclusions: IOBT during LDLT is associated with inferior outcomes. The increased need of IOBT during LT can be predicted by evaluating serum levels of hemoglobin, albumin and fibrinogen before liver transplantation.

Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplant: Single Center Experience

OBJECTIVES

In this study, we share our approach for care of patients with hepatic venous outlet obstruction after living-donor liver transplant.

MATERIALS AND METHODS

We retrospectively examined the demographic, clinical, and radiologic data of 35 patients who developed hepatic venous outlet obstruction after living-donor liver transplant. Patients were subgrouped on the basis of onset (8 patients with early onset [< 30 days posttransplant] and 27 patients with late onset [≥ 30 days posttransplant]) and postoperative survival (24 survivors, 11 nonsurvivors).

RESULTS

Patients ranged in age from 1 to 61 years (24 adults and 11 children). All adult patients had undergone right lobe living-donor liver transplant. In the pediatric group, 8 had undergone left lateral segment and 3 had undergone left lobe living-donor liver transplant. Nineteen adult patients and all 11 pediatric patients underwent hepatic venous reconstruction, with all procedures based on common large-opening drainage models using various vascular graft materials. Development of hepatic venous outlet obstruction occurred at mean posttransplant day 233 ± 298.5 in the adult patients and mean posttransplant day 139 ± 97.8 in the pediatric patients. After development of obstruction, the patients underwent 1-6 sessions (1.5 ± 1.1 sessions) of balloon angioplasty. After the first balloon angioplasty procedure, 25% of the adults and 36.3% of the pediatric patients developed recurrence. The early-onset and late-onset subgroups showed statistically significant differences in serum albumin (P = .01), underlying causes (P < .001), time from transplant to obstruction (P = .02), and time from transplant to last visit (P = .02). The survivor and nonsurvivor subgroups showed statistically significant differences in total bilirubin (P = .03) and time from transplant to last visit (P = .03).

CONCLUSIONS

Common large-opening reconstruction minimizes hepatic venous outlet obstruction development after living-donor liver transplant. Balloon angioplasty and/or stenting is almost always the first option in the care of this complication.

Is right lobe liver graft without main right hepatic vein suitable for living donor liver transplantation?

BACKGROUND

Since the first living donor liver transplantation (LDLT) was performed by Raia and colleagues in December 1988, LDLT has become the gold standard treatment in countries where cadaveric organ donation is not sufficient. Adequate hepatic venous outflow reconstruction in LDLT is essential to prevent graft congestion and its complications including graft loss. However, this can be complex and technically demanding especially in the presence of complex variations and congenital anomalies in the graft hepatic veins.

CASE SUMMARY

Herein, we aimed to present two cases who underwent successful right lobe LDLT using a right lobe liver graft with rudimentary or congenital absence of the right hepatic vein and describe the utility of a common large opening drainage model in such complex cases.

CONCLUSION

Thanks to this venous reconstruction model, none of the patients developed postoperative complications related to venous drainage. Our experience with venous drainage reconstruction models shows that congenital variations in the hepatic venous structure of living liver donors are not absolute contraindications for LDLT.

Management of the middle hepatic vein in right lobe living donor liver transplantation: A meta-analysis

Living donor liver transplantation (LDLT) is a curative treatment for end stage liver disease. It is advantageous due to the shortage of deceased donors. However, in LDLT, whether the middle hepatic vein (MHV) should be preserved in donors remains controversial. We conducted searches in Pubmed, Embase, Cochrane Library, Web of Science, Ovid, and Google Scholar using the key words "living donor liver transplantation" and "middle hepatic vein". Due to ethical issues, there were no randomized control trails focusing on MHV in LDLT. The majority of reports were retrospective studies. We examined the reference lists to identify related investigations. Google Scholar was then used to obtain full texts. Nine observational studies were analyzed. There were no significant differences in liver function (WMD, -5.51; P=0.12) and complications (RR, 0.98; P=0.89) in donors with or without MHV. However, the liver function in recipients was greatly improved after LDLT with MHV (WMD, -78.32; P=0.01). No definite conclusion was obtained in terms of the liver regeneration indices between LDLT with or without MHV. It was conclude that grafts with MHV in LDLT favor recipient outcomes and do not harm the living donor if a careful preoperative evaluation is performed.

Expectations from imaging for pre-transplant evaluation of living donor liver transplantation

Living donor liver transplant (LDLT) is a major surgical undertaking. Detailed pre-operative assessment of the vascular and biliary anatomy is crucial for safe and successful harvesting of the graft and transplantation. Computed tomography (CT) and magnetic resonance imaging (MRI) are currently the imaging modalities of choice in pre-operative evaluation. These cross-sectional imaging techniques can reveal the vascular and biliary anatomy, assess the hepatic parenchyma and perform volumetric analysis. Knowledge of the broad indications and contraindications to qualify as a recipient for LDLT is essential for the radiologist reporting scans in a pre-transplant patient. Similarly, awareness of the various anatomical variations and pathological states in the donor is essential for the radiologist to generate a meaningful report of his/her observations. CT and MRI have largely replaced invasive techniques such as catheter angiography, percutaneous cholangiography and endoscopic retrograde cholangiopancreatography. In order to generate a meaningful report based on these pre-operative imaging scans, it is also mandatory for the radiologist to be aware of the surgeon’s perspective. We intend to provide a brief overview of the common surgical concepts of LDLT and give a detailed description of the minimum that a radiologist is expected to seek and report in CT and MR scans performed for LDLT related evaluation.