Long-term results of in situ split-liver transplantation

BACKGROUND: Split-liver transplantation (SLT) offers immediate expansion of the cadaver donor pool. The principal beneficiaries have been adult and pediatric recipients with excellent outcomes. This study analyzed a single-center experience of adult to adult in situ SLT in adult recipients. PATIENTS AND METHODS: Fourteen consecutive adult-to-adult in situ SLT have been performed at our institution since 1998. The extended right lobe comprising segment 1 was transplanted in to adult patients, the left lateral segment, for pediatric transplants. RESULTS: Donors of SLT were significantly younger (P = .03) than those of whole liver transplants. Survival rates of patients receiving a split liver were 83%, 73%, and 73% at 1, 3, and 5 years after the transplant respectively and grafts of 73%, 73%, and 73% for SLT and 76%, 70%, and 66% for whole liver transplants (P = .44). The rate of biliary complication after SLT was 21%, which was comparable to that after whole organ transplantation (17%). The incidence of hepatic artery thrombosis and primary nonfunction was not significantly different between split liver and whole organ transplantation performed during the same time period (7% versus 4.6% P = .67 and 7% versus 2.6% P = .32, respectively). CONCLUSION: This limited single-center experience confirmed that both early and long-term results of SLT are comparable to those of traditional whole liver organ transplantation.     

Hepatic vein reconstruction in ex situ split-liver transplantation

BACKGROUND: Anatomy of the left hepatic vein (LHV) was studied in a series of 53 consecutive cadaveric liver grafts that were divided for transplantation. METHODS: All divisions were performed ex situ and provided a left split graft with only the LHV as the hepatic outflow. The anatomy was categorized into three types: (A) single LHV trunk, (B) two veins closely merging toward the median hepatic vein, or (C) a double outflow. RESULTS: Direct implantation of the graft was performed in type A and was possible in type B after simple plasty of the ostia to create a single orifice. In type C, a venous jump graft could be interposed at bench work to allow direct anastomosis into the recipient. There were no related complications, except one type A case with late outflow obstruction. CONCLUSION: Liver division can be performed safely in liver grafts with variant LHV anatomy, if appropriate techniques for reconstruction are used. Also ex situ liver division has the advantage of allowing a detailed anatomic evaluation before dividing LHV: reconstruction can be performed ex situ, allowing a single-step direct anastomosis in the recipient, thus shortening suturing time.     

Successful segmental auxiliary liver transplantation from a non-heart-beating donor: implications for split-liver transplantation

BACKGROUND: Liver transplantation (LT) using grafts from non-heart-beating donors (NHBDs) has been shown to be a successful practice. Recently reported primary nonfunction rates are similar to those of LT using grafts from brain-dead donors. METHOD: We report the use of an NHBD liver, which was cut into a right-lobe graft and implanted as an auxiliary partial orthotopic liver transplant for acute liver failure in a 11-year-old child. The warm ischemia time was 21 minutes, and the cold ischemia was 8 hours. RESULTS: Initial graft function was excellent, and the child is well, with normal liver function 2 months posttransplant. CONCLUSION: Reduction and splitting of livers from NHBDs for transplantation is a realistic option, provided there is careful selection of the graft.     

Deferred versus prophylactic therapy with gancyclovir for cytomegalovirus in allograft liver transplantation

OBJECTIVE: The aim of this study was to assess the efficacy of deferred versus prophylactic therapy with gancyclovir to prevent cytomegalovirus (CMV) infection or disease in liver transplantation recipients, and to alter the timing of infection or the incidences of acute rejection, chronic rejection, or death. METHODS: We retrospectively studied 89 consecutive liver transplant recipients with a minimum of 1 year follow-up. CMV early antigen detection (pp65) was performed weekly for the first 2 months and thereafter monthly for an additional 10 months. Forty-one recipients were administered prophylactic treatment and (48 recipients) deferred therapy for positive antigenemia. RESULTS: During the first year after transplantation, CMV infection or disease developed in 61% or 12.2% of those treated with prophylactic therapy and 54.1% or 31.3% of those treated with deferred therapy (P = 0.51 or P = 0.032, respectively). The mean time to CMV disease in the prophylactic group was 161 +/- 33 days compared with 82 +/- 27 days for the deferred therapy arm (P < 0.001). Subgroup analysis based on CMV serological status also showed prophylactic treatment significantly diminished CMV disease in the CMV IgG antibody negative group. No patients died in the prophylactic group, and one died in the deferred group (P = 0.54). The incidence of acute rejection episodes was 34% in the prophylactic and 46% in the deferred group (P = 0.26). Chronic rejection was observed in two recipients in the prophylactic group versus one recipient in the deferred arm (P = 0.35). CONCLUSION: Compared with deferred therapy prophylactic therapy with gancyclovir decreased CMV disease and delayed the onset of CMV disease after liver transplantation.     

经辐照的同种异体血管在肝移植中的应用

目的研究经辐照的同种异体大隐静脉在肝移植中替代门静脉移植后其形态学和免疫学的改变。方法研究分为经辐照的同种异体大隐静脉移植组（n=11）（A组）、新鲜同种异体大隐静脉移植组（n=9）（B组）和新鲜自体大隐静脉移植组（n=14）（C组）进行大隐静脉移植。于移植后1周、2周、1个月、2个月、3个月5个时间点用彩色多普勒超声和免疫组织化学法观察移植大隐静脉的通畅情况及形态学变化,同时观察移植早期CD4^＋、CD8^＋T细胞浸润情况。结果A组大隐静脉无组织学改变,肉眼观察外形无明显变化。移植后3个月3组移植大隐静脉的通畅例数分别为9例、3例和12例。A组和C组移植后2周,移植的大隐静脉内膜出现内皮细胞,移植后2个月,血管内膜的内皮细胞覆盖完整;B组移植早期有淋巴细胞和炎性细胞浸润及明显的大隐静脉结构破坏,移植大隐静脉内膜未见内皮细胞覆盖;A组早期CD4^＋、CD8^＋T细胞比例明显低于B组,略高于C组。结论经辐照的同种异体大隐静脉符合理想的血管移植物的条件,同时具有较弱的抗原性,术后检测CD4^＋、CD8^＋T细胞的变化可作为同种异体血管移植后急性免疫排斥反应的免疫学监测指标。     

Postprandial hypotension in patients with compression of the celiac trunk

One of the causes of the development of postprandial hypotension is thought to be impaired vegetative nervous regulation of arterial pressure. Patients with the syndrome of the celiac trunk compression also have signs of dysautonomy. The investigation performed has shown that syndrome of the celiac trunk compression is often combined with postprandial hypotension. Patients with such combination much more often have complains associated with asthenia and dysfunction of the autonomous nervous system. After operative treatment of patients with the celiac trunk compression (decompression of the celiac trunk) the frequency of symptoms of postprandial hypotension and clinical manifestations of asthenia and dysautonomy become less often in such patients.     

Compression syndrome of the celiac trunk

Compression syndrome of the celiac trunk or Dunbar's syndrome is usually caused by an overly large medial arcuate ligament of the diaphragm. Symptoms are postprandial periumbilical pain, the pathogenesis of which, in spite of abundant collateralization of the celiac trunk, has not yet been clarified. The diagnosis should be established by elimination via lateral aortography. Therapy consists of incision of the ligament, creation of a aorto-celiac bypass, or reinsertion of the celiac trunk. Treatment, however, is successful in only 41% of the operated patients.     

The main hepatic anatomic variations for the purpose of split-liver transplantation

BACKGROUND/AIMS: Variant hepatic anatomy must be recognized and appropriately managed during split-liver transplantation to ensure complete vascular and biliary supply to both grafts. The aim of this study was to demonstrate the importance of an assessment of the hepatic anatomical structures for the purpose of split-liver transplantation. MATERIAL AND METHODS: Human cadaveric livers (n = 60) were obtained during routine autopsies. The cadavers and the livers had to comply with the following requirements: (1) minimum age 18 years, (2) no liver pathology expected from medical history, and (3) no liver pathology noted at autopsy. Resections were carried out en bloc with liver, celiac trunk, left gastric artery, lesser omentum, superior mesenteric artery, and head of the pancreas. The main anatomical structures of the liver as hepatic artery, portal vein, biliary tree, and hepatic veins were dissected and correlated hepatic segments for the application of liver splitting. RESULTS: The right the median, and the left hepatic veins were unique, with in 59 (98.3%), 53 (88.3%) and 46 (76.3%) cases, respectively. The portal vein trunk divided into right and left branches in 59 (98.3%) cases. A median branch appeared in 9 (15.2%) cases and no bifurcation of the portal vein occurred in 1 (1.6%) case. The right and left hepatic ducts were multiple in 47 (78.3%) and 57 (95%) cases, respectively, however, the median, hepatic duct was unique in 16 (26.6%) cases. Examining the intrahepatic distribution of the right hepatic duct, we found 4 branches in 28 (59%) cases (segments V, VI, VII, and VIII) 2 branches in 11 (23%) cases, (segments V and VI) and 2 branches in 8 (17%) cases (segments VII and VIII). Fifty-seven cadavers had multiple left hepatic ducts. The intrahepatic dissection showed that the distribution of the major branches were toward hepatic segments II and III. Three separate branches of the left hepatic duct were found in 11 (19%) cases (segments II, III, and IV). Two intrahepatic ducts coming from hepatic segments V and VI drained separately into the left intrahepatic biliary tree in 1 (2%) case. The arterial supply of the liver was by right and left hepatic artery with only 9 (15%) cases there being median hepatic artery. The right hepatic artery, coming from the superior mesenteric artery, was present in 15 (25%) cases and a left hepatic artery originating from the left gastric artery in only 2 (3.3%) cases. The left hepatic artery had 2 exceptional origins, in 1 (1.6%) case coming directly from the abdominal aorta and in the other from the superior mesenteric artery. The right and left hepatic artery was accessory, in 11 (18.3%) and 2 (3.3%) cases, respectively. The right hepatic artery was dominant in 4 (6.6%) cases. The median hepatic artery was directed to segment IV in 6 (10%) cases and to segment II and III in 3 (4.9%) cases. CONCLUSION: The study showed that the technique of controlled liver splitting for transplantation in 2 recipients is an acceptable method to increase the number of liver allografts. The anatomical and technical details of the splitting procedure are critical for the success of this technique. Good graft function and avoidance of complications depend on each graft having an intact arterial and portal blood supply as well as biliary and venous drainage from all retained liver segments. The absence of a bifurcation of the portal vein is a rare anomaly and would certainly contraindicate a partition.     

Arterial reperfusion in human orthotopic liver transplantation by anastomosis of the celiac trunk to the right or left hepatic artery of the recipient

Fifteen orthotopic liver transplants were performed from 23 April 1986 to June 1987 in 14 patients (age range 3-56 years). In 12 transplants, extracorporeal bypass was used. The installation was effected by suprahepatic and infrahepatic cava-caval and portaportal anastomoses. Arterial anastomosis was realized after reperfusing the graft through the vena porta. In 13 transplants the donor celiac trunk was anastomosed to the receptor's right hepatic artery. In one ten year-old girl, the donor celiac trunk was anastomosed to the left hepatic artery. In one patient who underwent retransplantation for rejection, the donor organ had two separate hepatic arteries and the right and left hepatic arteries were respectively anastomosed to the right and primitive hepatic arteries of the receptor. All patients were followed up periodically by Doppler echography and trimethyl-Br IDA 99 mTc scan, which, consistently confirmed the permeability of the anastomosis and dependent vessels, and the good perfusion and function of the grafts, which were free of infarcted areas. Three patients died at 30 and 31 days and postmortem studies demonstrated vascular permeability. Angiography was performed in one patient, evidencing a good vascular caliber in the hepatic arteriography.     

Living related liver transplantation from donors with the left-sided gallbladder/portal vein anomaly

The presence of a left-sided gallbladder poses a unique challenge for living related liver donation. Associated anomalies include segment IV atrophy, absence of portal vein bifurcation, and abnormal intrahepatic portal branches to segments II and III. The complex is rare, but is more frequent in Japan. Of 379 living related liver transplants from our institution, the complex has been encountered on four occasions (incidence: 1.1%), and we herein review our experience. Anomalies were identified preoperatively (by computed tomography and ultrasound) in all instances. One donor was turned down because there was no common portal trunk to segment II and III branches. Three donors underwent successful retrieval using a modified technique. There were no complications in the donors or recipients relating to the complex. Thus, living related liver retrieval can be achieved safely in the presence of the left-sided gallbladder/portal anomaly complex, but technical modifications are required.