Bile duct variations in partial liver transplantations from living-related donors

The aim of this paper was to present anatomic variations of bile ducts and their effect on the perioperative course of living-related donors in partial liver transplantations in children. Liver fragments for partial transplantation were harvested from 41 related donors. Segments II and III were harvested from 35 and segments II, III, and IV from 6 donors. During the procedure, cholangiography through cystic duct was performed revealing a normal anatomy of the bile ducts in 33 (80.5%) cases. The rest of the donors showed anatomic variations. There was only one case of complications related to the bile duct. The intraoperative diagnosis of anatomic variations allowed for safe partial liver harvesting.     

Evaluation of donor's liver regeneration after left lobe harvesting for living-related liver transplantation

BACKGROUND: Computerized tomography-assisted volumetry permits one to estimate the volume of the liver graft as well as to monitor the regeneration in the donor for living- related liver transplantation (LRLT). METHODS: The size of the whole liver and of the segments II, III, and IV was assessed in 64 living-related liver donors by preoperative computerized tomography (CT) volumetry. Segments II and III were harvested in 56 cases; segments II, III, and IV in 8 cases. The remnant liver was assessed by CT volumetry on postoperative days 7 and 30. RESULTS: There was a linear correlation between the calculated volume of the graft and its weight (R = 0.61, P < .04). Postoperative CT volumetry of the liver from a living-related donor showed a different pattern of volume restoration (regeneration index) both at 7 and 30 days among donors who sacrificed segments II and III versus segments II, III, and IV. The mean regeneration indices were significantly higher among donors of segments II, III, and IV compared with donors of segments II and III after 7 and 30 days (P < .05). DISCUSSION: It is possible that the donor liver displays a different pattern of growth due to the alteration in the blood supply to segment IV.     

Liver Regeneration in 120 Consecutive Living-Related Liver Donors

Background

Living-related liver transplantation for pediatric patients has become an acceptable, low-risk treatment option. The aim of this study was to assess the extent of donor liver regeneration.

Materials and Methods

Between October 1999 and January 2008, 120 living-related donors provided 109 grafts consisting of segments II and III and 11 grafts consisting of segments II, III, and IV. Volumetric assessment of the donor liver and selected segments was performed using computed tomography. After procurement every graft was weighed. At 7 and 30 days, as well as 12 months after the operation the donor liver remnant was evaluated for differences in volume.

Results

A significant correlation was observed between the liver graft mass and its volume as assessed by computed tomography (r = 0.781; P < .05). Twelve months after procurement, the average regeneration index was significantly higher among donors of segments II, III, and IV (144 ± 23%) versus donors of segments II and III (114 ± 15%; P < .05).

Conclusion

Liver regeneration after procurement of selected liver segments from living donors is a consistent finding. Computed tomography is an accurate imaging modality to track changes in liver volume. This study showed a positive correlation between the size of the liver graft and the regeneration of the liver remnant in the donor.     

Living-related liver transplantation in children: the 'Parisian' strategy to safely increase organ availability.

PURPOSE: The aim of the authors was to report their experience with living related liver transplantation (LRLT) in children, particularly focusing on the safety of the two-center "Parisian" strategy. METHODS: The records of donors and recipients of 26 pediatric living-related donor liver transplantations performed between November 1994 and March 1998 were reviewed retrospectively. Donors were assessed 1 year after transplantation for medical and overall status. RESULTS: Indications for LRLT included biliary atresia (n = 18), Byler's disease (n = 5), alpha-1-antitrypsin deficiency (n = 1), Alagille syndrome (n = 1), and undefined cirrhosis (n = 1). Liver harvesting consisted of either a complete left hepatectomy (n = 14) or left lateral hepatectomy (n = 12) without vascular clamping. The recipient procedure essentially was the same as in split liver transplantation. Mean overall cold ischemia time averaged 140 minutes (range, 90 to 230 minutes). Twenty-four of 26 patients had end-to-end vascular anastomoses without interposition. Biliary reconstruction consisted of a Roux-en-Y choledochojejunostomy in all patients. All recipients except one received cyclosporine A (CSA). Mean donor hospitalization was 8 days (range, 6 to 13) with normalization of all liver function assays by the time of discharge. There were no donor deaths and two postoperative complications (perihepatic fluid collection and bleeding from the wound). One year after donation, the initial 19 donors had resumed their pretransplant status. Two of the children who underwent transplant died. Thirteen of the recipients required reoperation for hepatic artery thrombosis (n = 2), portal vein thrombosis (n = 2), biliary complications (n = 6), fluid collection (n = 3), small bowel perforation (n = 1), and plication for diaphragmatic eventration (n = 1). With mean follow-up of 2 years, 24 of 26 patients are alive and well (patient and graft survival rate, 92%). CONCLUSIONS: LRLT is still controversial, even with minimal and decreasing donor risk. The "Parisian" strategy consists of harvesting the liver in an adult unit by an adult hepatic surgery team. The transplantation is then performed in a pediatric hospital by the pediatric liver transplantation team. The two steps of the procedure allow units specialized in adult surgery, on one hand, and pediatric liver transplantation, on the other hand, to dedicate themselves completely to their respective procedures, improving the safety of the harvest, and alleviating stress for both the medical staff and the families.     

Impact of celiac axis stenosis on living donor hepatectomy

BACKGROUND: Celiac axis stenosis was once cited as a reason for exclusion from living donor liver transplantation. Donor hepatectomy, however, leaves the pancreaticoduodenal artery arcade untouched, and theoretically, celiac axis stenosis has no impact on otherwise possible donors. METHODS: Among 350 consecutive adult living donors of liver transplantation at Tokyo University Hospital, we experienced 11 (3%) donors with celiac axis stenosis or occlusion due to the median arcuate ligament. RESULTS: Harvesting of the right liver was the most common procedure (n = 8), followed by harvesting of segments II and III (n = 2), and left liver (n = 1). The postoperative course was uneventful in all of the donors. CONCLUSIONS: Our results indicate that donor hepatectomy can be safely performed in the presence of significant celiac artery stenosis.     

Lebendspende-Lebertransplantation beim Kind

Liver transplantation is the first-line therapy for children with acute and chronic hepatic failure, metabolic liver diseases and liver tumors. As most of the children with end-stage liver disease are very small in stature the resources of compatible organs of deceased donors are limited. Living liver donation was able to nearly eliminate waiting list mortality with excellent patient and graft survival. As 80% of the pediatric recipients have a body weight <25 kg donation of the left lateral lobe (segments II+III) is sufficient in most of the cases. According to a standardization of the surgical procedures as well as the preoperative, intraoperative and postoperative management donation of the left lateral lobe advanced to a procedure with very low donor morbidity and mortality rates. The complexity of hepatic disease patterns in pediatric patients which often affect other organ systems demand a close cooperation with an experienced pediatric team. Pediatric living donor liver transplantation requires high expertise in liver surgery and split liver transplantation and should therefore only be performed in transplant centers meeting these high qualifications.     

Monosegment Liver Allografts for Liver Transplantation in Infants Weighing Less Than 6 kg: An Initial Indian Experience

BackgroundLiving donor liver transplantation in small infants is a significant challenge. Liver allografts from adults may be large in size. This is accompanied by problems of graft perfusion, dysfunction, and the inability to achieve primary closure of the abdomen. Monosegment grafts are a way to address these issues.MethodsTwo recipients in our cohort weighed less then 6 kg. The prospective left lateral segments from their donors were large for size. Therefore, monosegment 2 liver grafts were harvested. Data regarding the preoperative, intraoperative, and postoperative events in the donor and the recipient were recorded.ResultsWe were able to achieve significant reduction in the sizes of the grafts harvested. The donors underwent surgery and hospital stay uneventfully. The recipients had normal graft perfusion and no graft dysfunction, and we could achieve primary abdominal closure. One recipient had self-limiting bile leak postoperatively.ConclusionsMonosegment 2 liver allografts are safe and effective for use in living donor liver transplantation in small infants weighing less than 6 kg.     

Liver transplantation with monosegments. Technical aspects and outcome: a meta-analysis.

The shortage of organ donors for low-weight liver transplant recipients, especially small children, has led to the development of new surgical techniques to increase the donor pool. Almost all of these techniques use the left lateral segment (Couinaud's segments II and III), but even this graft could be too large for children under 10 kg, and further reduction could be necessary. Few articles address the issue of monosegmental liver transplantation. Available articles are with small sample sizes or even case reports, which makes it difficult to draw conclusions about indication and outcome for monosegmental grafts. A search of the MEDLINE databases using the terms "Liver Transplantation" and "Monosegmental" or "Monosegments" limited to title or abstract with publication in the English language was conducted. The data from each study were selected and analyzed, regarding donor status (living or cadaveric), donor weight, surgical techniques used in left lateral further reduction, recipient indication for liver transplantation, age and recipient weight, graft-to-recipient body weight ratio, segment utilized, type of abdominal closure, postoperative complications, and survival. Seven publications were identified from 1995 to 2004 and fulfilled the criteria. A total of 27 pediatric patients who received a monosegment transplant were identified, median age 211 days (range, 27 to 454 days) and median weight 4.6 kg (range, 2.45 to 7.4 kg). Segment III was utilized in 21 (78%) and segment II in 6 (22%). Patient survival was 85.2%. In conclusion, monosegment liver transplantation appears to be a satisfactory option for infants weighing less than 10 kg who require a liver transplant.     

Surgical strategy in abdominal organs retrieval from elderly donors

BACKGROUND: There are no literature data on surgical problems that can be encountered during harvesting of grafts from elderly donors. The aim of our study was to report our experience during liver harvesting from donors over 70 years old and during transplantations of these grafts. METHODS: From April 1986 to December 2001, 686 OLT in 599 patients were performed at the Liver Transplant Unit of the S. Orsola Hospital in Bologna. In particular we harvested 68 livers from donors with mean age of 75.4+/-4.5 years (range 70-87). The cause of brain death was a spontaneous cerebral haemorrhage in 58 cases and trauma in 10 cases. Thirteen donors were previously submitted to cardiovascular surgery. Three subjects had an abdominal aorta aneurysm 5, 6 and 7 cm large respectively, involving the iliac arteries, not diagnosed before the harvesting procedure. In 60 donors atherosclerosis was present. RESULTS: Out of 68 transplanted patients with donor over 70 years of age we observed 13 arterial complications (19.1%): 7 hepatic artery thrombosis, 3 hepatic artery stenosis, 1 iliac graft thrombosis, 1 splenic artery stump rupture and 1 hepatic artery rupture both leading to fatal hemoperitoneum. A primary non-function occurred in 4 cases treated with retransplantation. The 1- and 3-year graft survival was 74 and 56.2%, respectively; the 1 and 3-years patient survival was 85.8 and 72.5% respectively. CONCLUSIONS: Harvesting technique from old donors is not so different from standard procedure: however it is fundamental surgeon's experience to optimize organ retrieval from these donors.     

Split Liver Transplantation for Two Adult Recipients: An Initial Experience

The shortage of cadaver donor livers has been most severe for adult patients. Split liver transplantation is one method to expand the donor pool, but to have a significant impact on the waiting list, it needs to be applied for 2 adult recipients. We split livers from 6 cadaver donors, and transplanted 12 adult recipients. All splits were performed in situ with transection through the midplane of the liver, resulting in a right lobe and a left lobe graft. Mean donor age was 19.7 years; mean donor weight was 79.1 kg. Mean recipient age was 41.5 years. Mean weight of right lobe recipients was 89 kg; left lobe recipients, 60 kg. All donors were hemodynamically stable and had normal liver function tests. Mean operative time for the procurement was 7.4 h. Average blood loss during the transection of the liver was 490 mL. Mean GW/ RW ratio for all recipients was 0.87%; right lobe recipients, 0.86%; and left lobe recipients, 0.88%. With mean follow-up of 9.3 months, patient and graft survival rates were both 83.3%. There were 2 deaths: 1 after hepatic artery thrombosis (HAT) and subsequent multiorgan failure; the other after HAT, a liver retransplant, and subsequent gram-negative sepsis. The remaining 10 recipients are doing well. We observed no cases of primary nonfunction. Other complications included bile leak and/or stenosis (n = 3), bleeding from the Roux loop (n = 1), bleeding after percutaneous biopsy (n = 1), and incisional hernia (n = 1). In conclusion, split liver transplantation, using 1 cadaver liver for 2 adult recipients, can be performed successfully. Crucial to success is proper donor and recipient selection.     

活体肝移植的供肝处理技巧

目的 探讨活体肝移植术供肝的选择，切取和修整，方法 1997至2001年期间，第四军医大学西京医院共完成活体肝移植术3例。其中2例是儿童活体肝移植术，另1例是成人辅助性原位活体肝移植术，供肝切取均为左外叶，供者术中作必要的肝周韧带游离和肝门解剖，超声刀切取供肝，不阻断肝脏血流。结果 供者手术时间为5-6.5h，失血量为200-400ml，无并发症发生。目前所有的供者肝功能均正常。恢复正常的工作和生活。结论 左肝外叶切除对供者是非常安全的。一般无手术并发症发生。     

Right lateral sector graft in adult living-related liver transplantation.

BACKGROUND: A major concern regarding adult living-related liver transplantation (LRLT) is graft-size disparity. The authors report their experience with LRLT using the right lateral sector. PATIENTS AND METHODS: Between January 2000 and April 2001, 32 adult-to-adult LRLTs were performed at our institution. Of these, six patients received a right lateral sector (RLS, segments VI and VII according to Couinaud's nomenclature for liver segmentation) graft. The right liver was over 70% of the estimated volume of the whole donor liver. The estimated RLS volume was greater than that of the left liver, which was over 40% of the recipient's standard liver volume. RESULTS: The postoperative course was uneventful in all donors. All of the patients survived the operation. Three patients were complicated with bile leakage from the dissection plane of the graft. Four patients suffered from acute rejection. CONCLUSIONS: RLS graft obtained by this procedure may be useful for overcoming borderline graft-recipient size differences and expanding the donor pool.     

liver portion transplantation from living donor: pilot clinical experience

The unique in Russia experience of 35 liver transplantations since 1990 has revealed benefits of the method and quite encouraging results with 81% survival of the recipients. But the extreme shortage of cadaveric donor organs followed by more than 60 per cent mortality in waiting list and absence of any real facilities to improve the situation dictate the living related donation to become a considerable alternative. Totally 12 living related liver transplant procedures were performed with no morbidity in donors. In 7 donors the routine surgical technique of harvesting were used to get left lateral segment in five and whole left lobe in two cases. The unique twin-to-twin liver left lobe donation with no consequent immunosuppression was observed in this series. New special technique of living donor surgery was successfully developed for liver right lobe harvesting. The living related liver right lobe replacement was used in 5 cases and appeared to become a real compensation of donor organs shortage for elder children with body weight more than 20 kg and adults.     

Live donor liver transplantation for acute liver failure

BACKGROUND: Acute liver failure (ALF) carries a high mortality unless urgent orthotopic liver transplantation (OLT) is performed on time. Live donors are utilized to treat this irreversible condition first in pediatric cases and then in adults. Herein, we aimed to report our experience with live donors for ALF in a country of a deceased donor organ donation rate is only 1.5 per million people. METHODS: Among the 245 live donor liver transplantations (LDLT) performed from June 1999 to December 2005, 14 of them (6%) were performed for ALF in 8 pediatric and 6 adult cases. Right lobes were harvested for the adult cases whereas left lateral segments were harvested for pediatric cases, except one child transplanted with a right lobe graft. The etiology of the disease was; acute hepatitis B in four cases, hepatitis A in three cases, Wilson disease two cases, autoimmune hepatitis in two cases, and was unknown in three cases. RESULTS: Three-year graft and patient survival is 79% for these series. Five of the six adult patients and six of the eight pediatric cases survived after transplantation. There was not any donor mortality or major morbidity. CONCLUSIONS: LDLT offers a safe and effective modality of treatment for ALF for both pediatric and adult patients to overcome the problem of organ shortage especially in countries where the chance of receiving an organ from a deceased donor is low.     

Evaluation of Living Donor Liver Transplantation: Causes for Exclusion

The decision to perform organ donation surgery involves a series of risks for the live donor including death. The aim of this study was to evaluate exclusion criteria for living donor liver transplantation, as well as to identify the rate of exclusion in each of the 3 process phases according to the Live Donor Evaluation Protocol for adult and child recipients. From December 2001 to December 2007, we evaluated 223 donors among whom 142 were excluded in various phases. The data were statistically evaluated. Among the 142 excluded donors, 113 (79.6%) had an adult recipient. The elimination rates for adult recipients were as follows: 68 cases in phase I, 41 cases in phase II, and 4 cases in phase III. Concerning child recipients, 29 (20.4%) donors were excluded: 17 in phase I, and 12 in phase II. Concerning adult recipients, sons and daughters were the largest part of the excluded donors, with withdrawal as the principal reason for exclusion followed by recipient death. Regarding child recipients the parents represented the largest number of excluded donors due to withdrawal followed by abnormal blood test results. Thus, 36.5% of potential donors were effective donors.     

The concept and technique of the split liver in clinical transplantation

Extreme scarcity of small pediatric donors makes a search necessary for technical variants to benefit infants and small children from the larger group of potential adolescent and adult donors. Three such technical variants are available for orthotopic transplantation. The reduced-size graft allows a weight ratio between donor and recipient of up to 4 to 6. The segmental graft allows transplantation of segments of livers from adult donors into infants and small children of up to a weight ratio of 8 to 9. The technique of the split liver, whereby one single donor liver is divided in such a way as to obtain two viable grafts for transplantation into two different recipients, is the most recent technical variant used to increase the flexibility of liver replacement and maximize the use of the donor liver pool. We report herein our two first cases of split liver with transplantation in four different recipients, with two long-term survivors. The described technique can also be useful in urgent adult transplantation.     

Analysis of postsurgical complications in 75 living liver transplantation donors

Seventy-five living donor liver hepatectomies were performed at our transplantation center between April 1990 and December 2004. We collected the data from patient charts, files, and the Baskent University Liver Registry. There were 39 male and 36 female donors (mean age, 35.1 +/- 9.3 years). We have performed 29 (38.6%) left hepatic lobectomies, 18 (24%) left lateral segmentectomies, 26 (34.6%) right lobectomies, and two (2.6%) donors had simultaneous living donor nephrectomy plus left lobe hepatectomy. The mean remnant liver volume was 598 +/- 168 cm(3) (range, 410-915 cm(3)). The mean percentage of remnant liver for the donor was 55.2%. Mean postoperative hospital stay was 10 +/- 4.4 days. After surgery, there was no mortality or reoperation. We saw 15 (20%) postsurgical complications in 14 donors. Intra-abdominal collection was seen in five (6.6%) patients. Biliary leak was seen in four patients. Portal vein thrombosis was seen in one patient, and a pulmonary embolus developed in one liver donor. Patient safety must be the primary focus in living-donor liver transplantation. These donors face significant risks, including substantial morbidity and death. More experience, improved surgical techniques, and meticulous donor evaluation will help minimize morbidity and mortality for both living liver donors and recipients.     

Preoperative helical computerized tomography estimation of donor liver volume

BACKGROUND: The purpose of this study was to evaluate the accuracy of spiral computed tomography (CT) and 3-D imaging models in measuring total and segmental liver volume in potential living donors. METHODS: A prospective study was undertaken to assess the correlation between the volumes of potential donor livers determined via helical CT and the actual volumes measured during operation in 150 donor candidates. Left-lateral segment (S2,3) or left-lobe (S2,3,4) transplantation was performed in 36 cases with 96 right-lobe liver transplants (S5,6,7,8). Ten donor candidates were refused owing to inadequate liver volumes, and 8 for other reasons. RESULTS: The regression analysis model showed a significant correlation between the preoperative CT estimates of graft volume and intraoperative weight measurement of harvested grafts in living liver donors (F: 5525.37; P < .05); 97.7% of changes in CT volume were explained by differences in graft mass (R2: 0.977). CONCLUSION: Preoperative estimation of segmental volumes of the donor liver is necessary to avoid donor-recipient size disparity, thereby preventing hepatic failure of donors after harvesting. It has a major impact on donor selection and type of surgical management. The accuracy of helical CT was high to determine total and segmental liver volumes.     

Living donor liver transplantation in children: Should the adult donor be operated on by an adult or pediatric surgeon? Experience of a single pediatric center

Background/Purpose

Living donor liver transplantation has become a cornerstone for the treatment of children with end-stage hepatic dysfunction, especially within populations or countries with low rates of organ utilization from deceased donors. The objective is to report our experience with 185 living donors operated on by a team pediatric surgeons in a tertiary center for pediatric liver transplantation.

Methods

Retrospective analysis of medical records of donors of hepatic grafts for transplant undergoing surgery between June 1998 and March 2013.

Results

Over the last 14 years, 185 liver transplants were performed in pediatric recipients of grafts from living donors. Among the donors, 166 left lateral segments (89.7%), 18 left lobes without the caudate lobe (9.7%) and 1 right lobe (0.5%) were harvested. The donor age ranged from 16 to 53 years, and the weight ranged from 47 to 106 kg. In 10 donors, an additional graft of the donor inferior mesenteric vein was harvested to substitute for a hypoplastic recipient portal vein. The transfusion of blood products was required in 15 donors (8.1%). The mean hospital stay was 5 days. No deaths occurred, but complications were identified in 23 patients (12.4%): 9 patients experienced abdominal pain and severe gastrointestinal symptoms and 3 patients required reoperations. Eight donors presented with minor bile leaks that were treated conservatively, and 3 patients developed extra-peritoneal infections (1 wound collection, 1 phlebitis and 1 pneumonia). Eight grafts (4.3%) showed primary dysfunction resulting in recipient death (3 cases of fulminant hepatitis, 1 patient with metabolic disease, 1 patient with Alagille syndrome and 3 cases of biliary atresia in infants under 1 year old). There was no relation between donor complications and primary graft dysfunction (P = 0.6).

Conclusions

Living donor transplantation is safe for the donor and presents a low morbidity. The donor surgery may be performed by a team of trained pediatric surgeons.     

Efficacy of PGI2 analog in preventing ischemia reperfusion damage of liver grafts from living donors

In living-related transplantation, warm ischemia/reperfusion damage (IRD) of liver grafts is inevitable during harvesting. In this study, we investigated the effects of prostacyclin (PGI₂) on IRD of liver grafts in the rat liver transplant model. Donor rats underwent 30-min warm ischemia of part of the liver (right lateral and medial lobes). After 10 min of reflow, the ischemic partial livers were flushed with Ringer's lactate and immediately transplanted into untreated recipients. Donor animals were divided into two groups: group I received vehicle, and group II received PGI₂ analog OP-41483 (OP, 500 ng/kg per min, i. v.) during the donor operation. One-week survival was studied and cellular adenine nucleotide levels of donor livers were assayed by high-performance liquid chromatography (HPLC). Donor treatment with PGI₂ analog group II significantly improved 1-week survival (86%), in comparison with the controls group I (25%). The levels of total adenine nucleotides (TAN, μmol/g dry wt) of the grafts just before implailtation were well maintained by PGI2 treatment (12.22), as compared with the controls (10.36). In summary, PGI2 treatment of the donor maintained high energy metabolism of the liver graft after IRD and improved the survival of recipients after transplantation. Our study suggested that PGI₂ treatment of donors improves viability in liver grafts from living donors thus and increases graft availability for transplantation.