Anaesthesia for living-donor liver transplantation

In Japan, living-donor liver transplantation has long been the only solution for end-stage liver disease. During the past 10 years, 526 cases of living-donor liver transplantation have been performed at Kyoto University Hospital. This report reviews the authors experience of anaesthesia. The most important issue is the safety of the donor. As the percentage of adult recipients has increased, so has the age of donors and because risk for the donor increases with age, careful preoperative evaluation of the donor by the anaesthetist is needed. The principal differences between living-donor liver transplantation and cadaveric donor liver transplantation are surgical technique (the former is always a partial liver transplantation) and viability of the graft (should always be better with a living donor). The major problems concerning the intraoperative management of recipients in living-donor liver transplantation are how to deal with massive blood loss and postreperfusion syndrome.     

Living-donor liver transplantation for situs inversus: 2 case reports

Two cases of living-donor liver transplantation performed in patients with situs inversus are reported. The authors discuss the operative management for a situs inversus recipient to undergo liver transplantation.     

Long-term survival after living-donor liver transplantation for unresectable colorectal metastases to the liver: case report

We present a case of long-term survival of a patient who underwent living-donor liver transplantation for unresectable liver metastases of colon cancer. Two years after left hemicolectomy and subsequent to repeated liver resections, this patient presented with unresectable metastatic disease confined to the liver. She was offered a living-donor liver transplantation, and her husband agreed to be the donor. Five years after transplant, she was alive and recurrence free.     

Steroid-free living-donor liver transplantation in adults

To examine the benefits of steroid avoidance in adult living donor liver transplantation, we compared the clinical courses of nine recipients receiving basiliximab or daclizumab and 13 historical patients who received steroids. The 1-year patient and graft survival and the incidence of acute cellular rejection were similar in both groups. The side effects of immunosuppression tended to be more frequent in the steroid group. Hepatitis C virus (HCV)-RNA levels measured early after transplantation remained suppressed in the steroid-free group. Steroid avoidance was beneficial in the recipients, as both steroid side effects and recurrence of HCV could be avoided.     

Liver regeneration in living-donor liver transplantation

Liver regeneration in living-donor liver transplantation is summarized from the authors' data. In donors, liver function tests recovered to within the normal range 2 weeks after surgery regardless of graft type. At 2 weeks, the volumetric recovery of the remnant liver was 65% and 80% of the original volume in right and left lobe donors, respectively. These results suggest that functional recovery occurs earlier than morphologic restoration in donors. In recipients, the factor that affected the regeneration rate in size 4 weeks after transplantation was only implanted graft size; the rate was greater in patients in whom smaller grafts were implanted. In recipients with a rate of two or more, however, high portal vein pressure and flow were observed. Further, persistent low platelet counts and hyperbilirubinemia were seen in those patients. These results indicate that size enlargement may be caused by engorgement, and functional recovery is not achieved concurrently with morphologic restoration, especially in patients with smaller grafts. In patients with fulminant hepatic failure who receive auxiliary partial orthotopic liver transplantation, sequential histopathologic observations of the diseased liver revealed that liver regeneration initiates from cytokeratin 17-positive ductules and at least 1 year is necessary for complete recovery.     

Thrombotic microangiopathy in living-donor liver transplantation

BACKGROUND: Thrombotic microangiopathy (TMA) is a fatal complication characterized by microvascular occlusive disorder resulting in systemic or intrarenal platelet aggregation, severe thrombocytopenia, and microangiopathic hemolytic anemia. Only sporadic case reports of TMA after cadaveric or living-donor liver transplantation (LDLT) have been described. METHODS: The authors report 10 (5% of the total series) TMA patients after LDLT and review the previously reported cases. TMA was diagnosed on the basis of progressive thrombocytopenia of unknown cause and microangiopathic hemolytic anemia, suggested by sharp elevation of serum lactate dehydrogenase levels and the presence of fractionated erythrocytes in blood smear. RESULTS: Of the 10 patients with TMA, 7 presented with viral hepatitis (2 with hepatitis B and 5 with hepatitis C virus infection) as the cause of end-stage liver disease. Clinical diagnosis of TMA was made at a median interval of 18 days (range, 3-356 days) from the time of transplantation. Conversion of calcineurin inhibitors (CNI) was conducted in nine patients. One patient recovered after CNI conversion alone. Plasma exchange was performed in eight patients. Three patients died. CONCLUSIONS: Immediate treatment of TMA should be initiated by reduction or conversion of CNI followed by plasma exchange. Hepatitis C virus infection might contribute to the high incidence of TMA in LDLT patients.     

Donor evaluation and hepatectomy for living-donor liver transplantation

In the past decade, considerable technical advances have been accomplished in living-donor liver transplantation (LDLT). The procedure has become accepted globally as a standard modality for the treatment of end-stage liver disease and hepatocellular carcinoma in both pediatric and adult populations. During the period of this procedure’s development, however, tragedy has occurred. Serious morbidity and even mortality have been experienced and reported in live donors. The transplant community has been very much aware of its responsibilities toward live donor care, and much effort has been made to improve and secure the overall outcomes of donors. Unlike in deceased-donor liver transplantation (DDLT), opportunity or chance plays a lesser role in the availability of an organ for LDLT. Judgment calls are often made by individuals; therefore, the evaluation process includes social and ethical aspects not encountered among the usual indications for hepatobiliary surgical disease. Thus, the selection of live donors should be made from a wider perspective compared with that for conventional patient care. The approach to selecting live donors may vary slightly between the West, where a large number of DDLTs are performed daily, and the Far East, where they are much less frequent. However, the recognition that the transplant community has a responsibility to provide care to living donors is common. This review provides an overview of the current donor evaluation and surgical procedures involved in LDLT, with the recognition that an open and educated debate is key to ensuring public confidence and maintaining ethical standards in the field.     

Successful living-donor liver transplantation and retransplantation with cavoportal hemitransposition: a case report

An 11-month-old female infant underwent living-donor liver transplantation for secondary biliary cirrhosis 8 months after Kasai operation. The portal vein was hypoplastic, and its diameter was only 4 mm at the level of the splenomesenteric confluence. End-to-end anastomosis of the recipient suprarenal vena cava to the graft portal vein (a left lateral section from the patient's mother) was performed. An end-to-side portocaval shunt with the recipient portal vein was constructed to mitigate portal hypertension. The early postoperative course was relatively uneventful. However, persistent hepatitis caused by infection with Cytomegalovirus and chronic rejection resulted in progressive hepatic dysfunction. Nine months after the initial operation, a living-donor retransplantation (a left lateral section from the patient's grandmother) was performed. One month after retransplantation, severe acute rejection that eventually required OKT3 treatment developed. The patient was in excellent health until 4 months after retransplantation, when another acute rejection episode (for which she was successfully treated) developed. Cavoportal hemitransposition should be included in the armamentarium of the transplant surgeon for the management of extensive portal system thrombosis and portal vein hypoplasia. An additional shunt may be useful in mitigating portal hypertension.     

Monosegmental living-donor liver transplantation for infantile hepatic hemangioendothelioma

Infantile hepatic hemangioendothelioma (IHHE) is a rare vascular tumor that presents before the age of 6 months. The patients with IHHE suffer from high-output congestive heart failure caused by major arteriovenous fisutulas in the liver, which leads to respiratory compromise and results in a high mortality rate despite medical treatments. A case of 4-month-old baby with liver failure caused by IHHE is reported. The baby received an urgent liver transplantation from a living donor. A monosegmental graft was used to mitigate graft-to- recipient size mismatching. The surgical procedure of monosegmental living donor liver transplantation also is discussed.     

Small-for-size graft in adult living-donor liver transplantation

In the era of living donor liver transplantation (LDLT), graft size is related to recipient prognosis. This study was performed to compare the clinical outcomes according to the graft-to-recipient weight ratio (GRWR) in adult LDLT. Seventy-nine adult patients who had undergone LDLT between June 1997 and June 2002 were retrospectively analyzed. The patients were divided into two groups according to the GRWR (group I, GRWR < 0.8%, n = 11; group II, GRWR > or = 0.8%, n = 68). The mean follow-up period was 19.4 (range 1 to 48) months. The recipients were 62 men (78.5%) and 17 women (21.5%) of mean age 45.2 (range 18 to 63) years. The overall patient survival rates were 74.7% at 1 year and 70.7% at 2 years. The patient survival rate in group I was 54.6% at 1 year and 40.9% at 2 years, whereas that in group II was 77.9% at 1 year and 75.3% at 2 years, showing a significant difference (P = .03). There were no significant differences in postoperative total bilirubin, transaminase enzyme level, prothrombin time (INR), portal vein flow on Doppler sonography, amount of ascites through the drain, complications, or acute rejection rates between the two groups. In conclusion, the minimum acceptable graft size in an adult-to-adult LDLT is GRWR of 0.8%. This study suggests that careful postoperative management and/or technical modifications during surgery are necessary, because small-for-size grafts (GRWR < 0.8%) result in lower patient survival rates.     

Spontaneous disappearance of intracranial arteriovenous malformation after living-donor liver transplantation: a case report

In this report, the authors describe a 35-year-old male whose intracranial arteriovenous malformation (AVM) spontaneously disappeared about 2 years after successful living-donor liver transplantation for alcohol-induced liver cirrhosis. Preoperative screening MRI revealed intracranial arteriovenous malformation (AVM) around the midbrain. Cerebral angiography demonstrated that the AVM was fed by the paramedian mesencephalic arteries and was drained via the vein of Galen. He successfully underwent living-donor liver transplantation, and his postoperative course was uneventful. Follow-up MRI and MRA revealed spontaneous disappearance of the AVM 27 months after surgery. The authors discuss precisely the underlying mechanism of this rare phenomenon, based on thorough literature review.     

Application of endovascular stapler in living-donor liver transplantation

We used an endovascular stapler in recipients of living-donor liver transplantation (LDLT). Hepatic veins were transected in 10 recent LDLTs (6 right-lobe and 4 left-lobe grafts), and the portocaval shunt was transected in 5 of these 10 LDLTs. Median operative time with the vascular stapler was 861 minutes (range 675 to 932), whereas the median time to liver explantation was 292 minutes (range 200 to 461) (both with P < or = .05 vs vascular stapler use). To our knowledge, this is the first report on the use of an endovascular stapler device in LDLT.     

Incidental appendectomy in donors undergoing hepatectomy for living-donor liver transplantation

Background

The aim of this study was to investigate the morbidity associated with appendectomy in living liver donors undergoing hepatectomy.

Methods

The medical records of 338 donors who underwent hepatectomies for living-donor liver transplantation between 2008 and 2010 were reviewed retrospectively. The patients were divided into 2 groups on the basis of appendectomy: patients in group A (n = 126) received incidental appendectomies in conjunction with donor hepatectomy, and those in group B (n = 212) underwent hepatectomy alone.

Results

No significant difference in age, gender, or body mass index was found between groups. The wound infection rate (P = .037) and length of hospital stay (P = .0038) were higher in group A than in group B. Intraoperative findings in 126 donors in group A were subserosal (n = 4), retrocecal (n = 6), or hard nodular (n = 11) appendix; hyperemic appendix with edema (n = 9); appendix length ≥8 cm (n = 18); and palpable fecalith (n = 78). Histopathologic examination of appendix specimens revealed lymphoid hyperplasia with a fecalith (n = 32), fecalith only (n = 32), acute appendicitis (n = 20), normal anatomy (n = 18), fibrous obliteration (n = 9), lymphoid hyperplasia (n = 9), Enterobius vermicularis (n = 3), appendiceal neuroma (n = 1), carcinoid tumor (n = 1), and mucoceles (n = 1).

Conclusion

Although incidental appendectomy increased the wound infection rate and length of hospital stay, this procedure is necessary for the prevention of potential complications due to appendicitis when the exploration of the ileocecal region in patients undergoing donor hepatectomy reveals one or more of the following: appendix length ≥8 cm; dropsical, hyperemic, subserosal, nodular, and/or retrocecal appendix; and/or palpable fecaloma.     

Indication for splenectomy in the era of living-donor liver transplantation

Although end-stage liver disease (ESLD) is often associated with splenomegaly and thrombocytopenia, splenectomy is not necessary in liver transplantation (OLT) except in special situations. In this paper, we examined the indications for splenectomy in the era of living-donor living transplantation. Six of 46 patients underwent splenectomies. Among them, one received a cadaveric graft. Three splenectomies were performed at 6, 7, and 44 days after OLT because of a huge spleen, massive ascites, or impaired liver function. The other two patients received simultaneous splenectomy during OLT to prevent rejection of ABO-incompatible grafts with a positive anti-T-cell test; and one, for postoperative therapy of hepatitis C. All six patients had a good response to splenectomy. We concluded that splenectomy may be indicated for recipients with severe thrombocytopenia, small-for-size syndrome, ABO incompatibility with positive anti-T/B-cell tests and post-OLT therapy for hepatitis C.     

Total hepatectomy and liver transplantation as a two-stage procedure for toxic liver: case reports

Total hepatectomy with temporary portocaval shunt was employed as a bridging procedure before liver transplantation, in the setting of fulminant hepatic failure with "toxic liver syndrome"; acute, severe, and extensive liver necrosis associated with cardiovascular shock and acute renal failure with or without respiratory failure. This procedure sought to improve metabolic acidosis and hemodynamic instability related to advanced liver necrosis. The aim of this study was to report our experience with three patients who underwent total hepatectomy and protocaval shunt, followed by liver transplantation (two-stage procedure).     

Biliary complications in recipients of living-donor liver transplantation

The key points of the management of biliary complications in recipients of living-donor liver transplantation are described. The characteristics of these complications are somewhat different from those in deceased-donor liver transplantation, mainly due to the technical difficulties. Appropriate prevention, diagnosis, and treatment are essential for successful transplants, to avoid the development of secondary biliary cirrhosis when complication occurs.