Clinical study on safety of adult-to-adult living donor liver transplantation in both donors and recipients

AIM: To investigate the safety of adult-to-adult living donor liver transplantation (A-A LDLT) in both donors and recipients. METHODS: From January 2002 to July 2006, 50 cases of A-A LDLT were performed at West China Hospital, Sichuan University, consisting of 47 cases using right lobe graft without middle hepatic vein (MHV), and 3 cases using dual grafts (one case using two left lobe, 2 using one right lobe and one left lobe). The most common diagnoses were hepatitis B liver cirrosis, 30 (60%) cases; and hepatocellular carcinoma, 15 (30%) cases in adult recipients. Among them, 10 cases had the model of end-stage liver disease (MELD) with a score of more than 25. Donor screening consisted of reconstruction of the hepatic blood vessels and biliary system with 3-dimension computed tomography and volumetry of whole liver and right liver volume. Various improved surgical techniques were adopted in the procedures for both donors and recipients . RESULTS: Forty-nine right lobes and 3 left lobes (2 left lobe grafts for 1 recipient, 1 left lobe graft for 1 recipient who had received right lobe graft donated by relative living donor) were obtained from 52 living donors. The 49 right lobe grafts, without MHV, weighed 400 g-850 g (media 550 g), and the ratio of graft volume to recipient standard liver volume (GV/SLV) ranged from 31.74% to 71.68% (mean 45.35%). All donors' remnant liver volume was over 35% of the whole liver volume. There was no donor mortality. With a follow-up of 2-52 mo (media 9 mo), among 50 adult recipients, complications occurred in 13 (26%) cases and 4 (8%) died postoperatively within 3 mo. Their 1-year actualsurvival rate was 92%. CONCLUSION: When preoperative CT volumetry shows volume of remnant liver is more than 35%, the ratio of right lobe graft to recipients standard liver volume exceeding 40%, A-A LDLT using right lobe graft without MHV should be a very safe procedure for both donors and recipients, otherwise dual grafts liver transplantation should be considered.     

Donor safety and remnant liver volume in living donor liver transplantation

AIM:To evaluate the relationship between donor safety and remnant liver volume in right lobe living donor liver transplantation(LDLT).METHODS:From July 2001 to January 2009,our liver transplant centers carried out 197 LDLTs.The clinical data from 151 cases of adult right lobe living donors(not including the middle hepatic vein) were analyzed.The conditions of the three groups of donors were well matched in terms of the studied parameters.The donors' preoperative data,intraoperative and postoperative data were calculated for the three groups:Group 1 remnant liver volume(RLV) 35%,group 2 RLV 36%-40%,and group 3 RLV 40%.Comparisons included the different remnant liver volumes on postoperative liver function recovery and the impact of systemic conditions.Correlations between remnant liver volume and post-operative complications were also analyzed.RESULTS:The donors' anthroposomatology data,op-eration time,and preoperative donor blood test indicators were calculated for the three groups.No significant differences were observed between the donors' gender,age,height,weight,and operation time.According to the Chengdu standard liver volume formula,the total liver volume of group 1 was 1072.88 ± 131.06 mL,group 2 was 1043.84 ± 97.11 mL,and group 3 was 1065.33 ± 136.02 mL.The three groups showed no statistically significant differences.When the volume of the remnant liver was less than 35% of the total liver volume,the volume of the remnant had a significant effect on the recovery of liver function and intensive care unit time.In addition,the occurrence of complications was closely related to the remnant liver volume.When the volume of the remnant liver was more than 35% of the total liver volume,the remnant volume change had no significant effect on donor recovery.CONCLUSION:To ensure donor safety,the remnant liver volume should be greater than the standard liver volume(35%) in right lobe living donor liver transplantation.     

Donor quality of life after living donor liver transplantation

BACKGROUND: Quality of life of the donor after living donor liver transplantation has not been evaluated in Brazil yet. AIM: To evaluate the quality of live of the donor after living donor liver transplantation. METHODS: Of a total of 300 liver transplantations, 51 were of living donors. All donors with less than 6 months of follow-up and those who did not want to participate were excluded from the study. The donors answered a questionnaire contained 28 questions about several aspects of donation. Demographic and clinical data from the donors were also evaluated. RESULTS: Thirty-seven donors were included in the study. Thirty-two were first or second degree relatives of the receptor. Only one donor would not donate again. Twenty-two donors (59%) experienced more postoperative pain than they had previously anticipated. Return to regular activities occurred in less than 3 months for 21 donors (57%). Twenty-one donors (57%) referred financial loss with the donation due to expenses with medications, exams, transportation or lost wages. Thirty-three (89%) had no modification or limitation in their lives after donation. The most negative aspects of donation were postoperative pain and the presence of a surgical scar. Most postoperative complications resolved with clinical treatment, but severe or potentially fatal complications occurred in two patients. CONCLUSIONS: Most donors had good recovery and returned to regular activities few months after donation. The most negative aspect of donation was postoperative pain.     

Adult-to-adult living donor liver transplant: UK experience

BACKGROUND: Adult-to-adult living donor liver transplantation (ALDLT) is being adopted widely in the USA and mainland Europe, fueled by the increasing waiting lists for cadaver organs. The present report describes the first UK experience with the procedure in patients from overseas who have the lowest priority for cadaver organ allocation. METHODS: The 16 patients seen over the period November 1998 to March 2002 had end-stage cirrhosis from chronic hepatitis C virus (HCV) or hepatitis B virus (HBV) infection (13 cases), with single instances of cryptogenic cirrhosis, secondary biliary cirrhosis and alcoholic liver disease. Grafts were left lobe in the first two recipients and right lobe in the subsequent 14 recipients, donated by nine sons/daughters and seven brothers/sisters. RESULTS: Twelve of the 16 recipients did well. The four recipients who died had recurrent sepsis; two of these died following hepatic arterial occlusion, and in three major surgical factors were present before transplantation. Serial computed tomography (CT) measurements in the survivors showed regeneration of the grafted lobe with final volumes reaching in each case the calculated standard liver volume for body size. In the donors, liver function tests had returned to normal by day 7-14, with rapid regeneration of the remaining lobe, although the final size attained that estimated before donation in only four donors. CONCLUSIONS: ALDLT, although requiring considerable facilities and organization, can give good results for both recipient and donor. As with cadaver grafts, outcome in the recipient if the larger right lobe is used is dependent on surgical risk factors and the severity of clinical decompensation before transplantation. Measures to ensure the safety of the donors remain the main concern.     

Anatomy of the middle hepatic vein: applications to living donor liver transplantation

BACKGROUND/AIMS: In living donor liver transplantation, right lobe graft without a middle hepatic vein (MHV) results in potential venous congestion in the anterior segment, while transplantation with MHV represents an important ethical issue from the perspective of donor safety. The present study assessed ramification patterns of the MHV and relationships between hepatic venous drainage of the anterior and medial segments, to plan optimal harvesting of the right lobe as a graft. METHODOLOGY: The authors reviewed 102 patients with normal livers who underwent contrast-enhanced multi-detector row CT. RESULTS: The hepatic vein that drained S4sup (V4sup) joined only the left hepatic vein (LHV) in 60 patients (58%), only the MHV in 25 (25%), and both LHV and MHV in 17 (17%). Both V4sup and the hepatic vein that drained S8 (V8) joined the MHV in 42 patients (42%), and V8 joined proximal to V4sup in 18 of these 42 patients. CONCLUSIONS: In donation of a right lobe graft including MHV, preservation of V4sup in the remnant donor liver seems possible in most donors.     

Risks faced by donors of right lobe for living donor liver transplantation

BACKGROUND:Because of the shortage of deceased donors with livers fit for transplantation,living donor liver transplantation(LDLT)is becoming an attractive alternative.Attention should be paid to the donors,especially to those of the right lobe.In this study,we evaluated the risks faced by donors of the right lobe for adult-to-adult LDLT.METHODS:The perioperative data from 105 consecutive living donors of the right lobe performed in West China Hospital from January 2002 to December 2007 were retrospectively...     

Applicability of adult-to-adult living donor liver transplantation

BACKGROUND/AIMS: The applicability of adult-to-adult living donor liver transplantation has not been established yet. We report the first data in a European center of the process leading to this procedure from the first moment the patients were informed about it. METHODS: In phase 1 of the process, 121 adult patients enlisted for cadaveric liver transplantation and their relatives were informed of the technical aspects, advantages and risks of living donor liver transplantation, and the essential criteria for living donation. In phase 2, potential donors identified in phase 1 were evaluated in depth. RESULTS: Twenty-one (17%) patients underwent living donor liver transplantation. This procedure was not performed in 60 patients (50%) for reasons concerning the patients themselves, especially their refusal to receive living donor liver transplantation from a relative (30%). Forty patients (33%) did not undergo living donor liver transplantation for reasons concerning potential donors: donors were not identified (14%), declined the donation (13%), or were refused for technical reasons (6%). The expected waiting time to transplantation was longer in patients who underwent living donor liver transplantation than in those who did not. CONCLUSIONS: The applicability of adult-to-adult living donor liver transplantation is low, mainly because of reasons related to potential recipients.     

Living donor hepatectomy in a pregnant woman

Liver transplantation with a live donor is an effective way to expand the donor pool. Restrictive selection of living donors may assure donor safety but limit the utility of this resource. A 12-month-old recipient with biliary atresia was rapidly deteriorating with hepatic encephalopathy, massive ascites and coagulopathy. Her mother, the only possible living donor, expressed a strong desire to donate part of liver to her baby, although she was found to be pregnant. The donor hepatectomy was then undertaken at 18 weeks of gestation. A left lateral segmentectomy was performed. Her postoperative course was uneventful and she was discharged 7 days after the operation. She gave birth to a healthy term baby without any complications 5 months later. Both recipient and her younger brother are well 12 months after the operation. Despite the limited experience reported herein, pregnancy may no longer be considered an absolute contraindication for live liver donation.     

Surgical experience in splitting donor liver into left lateral and right extended lobes

AIM: To outline the surgical experience with donor liver splitting in split liver transplantation. METHODS: From March 1 to September 1 in 2004, 10 donor livers were split ex situ into a left lateral lobe (segments II and III) and a right extended lobe (segments I, IV-VIII) in Medical School of Hannover, and thereafter split liver transplantation was performed successfully in 19 cases. The average age, weight and ICU staying period of the donors were 32.7 years (15-51 years), 64.5 kg (45-75 kg) and 2.4 d (1-8 d) respectively. RESULTS: The average weight of the whole graft and the left lateral lobe was 1 322.6 g (956-1 665 g) and 281.8 g (198-373 g) respectively, and the average ratio of left lateral lobe to the whole graft was 0.215 (0.178-0.274). The average graft to recipient weight ratio (GRWR) of the left lateral lobe and the right extended lobe reached 2.44% (1.22-5.41%) and 1.73% (1.31-2.30%) respectively. On average it took approximately 105 min (85-135 min) to split the donor liver. Five donor organs showed anatomic variation including the left hepatic vein variation in two cases, the left hepatic artery variation in two cases and the bile duct variation in one case. CONCLUSION: Split liver transplantation has become a mature surgical technique to expand the donor pool with promising results. In the process of graft splitting, close attention needs to be paid to potential anatomic variations, especially to variations of the left hepatic vein, the left hepatic artery, and the bile duct.     

Living donor liver transplantation: Eastern experiences

BACKGROUND: The techniques of living donor liver transplantation (LDLT) developed rapidly in the 1990s to compensate for a severe deficiency in the availability of liver grafts from cadaveric donors for the treatment of patients with end-stage liver disease. This tendency was particularly prominent in East Asia, as brain-death donors have remained largely unavailable for a variety of reasons. Thanks to refinements in surgical technique and postoperative management for LDLT, the cumulative total of LDLTs in East Asian countries has exceeded 2000 and, importantly, donor mortality has yet to be encountered. Moreover, indications for LDLT have been successfully expanded from paediatric to adult cases, following the introduction of right lobe graft. The significance of LDLT under conditions of limited opportunities for cadaveric liver transplantation, as experienced in these countries, differs significantly from that seen with the numerous opportunities for cadaveric donors in Europe and the USA. This review describes not only the experiences of East Asia, but also the specific differences from Western countries, such as indications, graft size issues and ABO blood type combinations, to shed light on the future of liver transplantation.     

Endoscopic management of postoperative biliary complications in donors for living donor liver transplantation.

BACKGROUND & AIMS: Biliary leakage and stricture are serious complications that occur in donors whose liver is resected for living donor transplantation. We assessed the usefulness of endoscopic nasobiliary drainage and endoscopic biliary stenting, respectively, in repairing biliary leakage and stricture. METHODS: Between July 1999 and December 2001, a total of 276 donors underwent liver resection (left side, 118; right side, 158) for living donor transplantation at Kyoto University Hospital. Seven (2.5%) donors developed biliary leakage, which required endoscopic nasobiliary drainage; 3 of these donors also had biliary stricture. RESULTS: All 7 patients who developed biliary leakage were the right-lobe donors. Endoscopic retrograde cholangiography identified the site of the biliary leakage in all 7 of the donors. In 6 of these donors, the biliary leakage resolved within an average of 15 days after an endoscopic nasobiliary drainage tube was placed. In the seventh donor, the biliary leakage resolved after percutaneous transhepatic biliary drainage was performed. Three patients developed biliary stricture that required endoscopic biliary stenting. The angles between common hepatic duct and the left hepatic duct were more acute in patients with stricture than in those without stricture (62 degrees vs. 119 degrees). CONCLUSIONS: Biliary complications requiring endoscopic treatment developed exclusively in donors for right-lobe living donor transplantation. Endoscopic retrograde cholangiography is a favorable modality for diagnosing and treating postoperative biliary complications in donors for living donor liver transplantation.     

Comparison of pre-operative exams and per-operative findings in living donor liver transplantation

BACKGROUND: Success in living donor liver transplantation is associated to donor vascular and biliar anatomy. AIM: Compare pre-operative and per-operative findings in living liver donors related to portal vein, hepatic artery, bile duct and hepatic venous drainage anatomy. METHODS: Donors charts of living donor liver transplants done at Clinics Hospital of the Federal University of Paraná, Curitiba, PR, Brazil, were reviewed between March 1998 and August 2005. On the pre-operative period the anatomy was analysed through: celiac and mesenteric arteriography of the hepatic artery and portal vein (venous phase); magnetic resonance imaging of the venous drainage, portal vein and bile duct. Normality was determined based on data of the literature. Pre-operative findings were compared to per-operative findings. RESULTS: Portal vein and hepatic artery were studied in 44 patients, 16 females and 28 males, mean age of 33 years old. In 8 cases the left liver lobe was used to pediatric receptor, in 36 cases the right liver lobe was used to adult receptor. Bile duct anatomy was studied in 37 cases and venous drainage in 32. Over all, the findings related to pre-operative and per-operative anatomy were not coincident in 36.36% of the cases. In the case of hepatic artery, they were not coincident in 11.36%, in the case of the portal vein in 9.1%, in the case of the venous drainage in 9.37% and in the case of the bile duct in 21.6%. CONCLUSION: The pre-operative and per-operative findings related to vascular and bile duct donor anatomy are frequently different in living donor liver transplantation.     

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.     

First two cases of living related liver transplantation with complicated anatomy of blood vessels in Beijing

AIM: Living related liver transplantation (LRLT) has been developed in response to the paediatric organ donor shortage. Though it has been succeeded in many centers worldwide, the safety of the donor is still a major concern, especially in donors with anatomy variation. We succeeded in performing the first two cases of living related liver transplantation with complicated anatomy of blood vessels as a way to overcome cadaveric organ shortage in Beijing. METHODS: Two patients, with congenital liver fibrosis and congenital biliary atresia were performed with living donor liver transplantation in our hospital and then followed up from November 12 to December 13, 2001. The two living donors, mother and father, were healthy aged 34 and 35 years. One right lobe (segment V, VI, VII, VIII) and one left lateral lobe (segment II and III) were used. The grafts weighed 394 g and 300 g. The ratio of graft weight to the standard liver volume (SLV) of donors was 68% and 27%. The graft weight to recipient body weight ratio was 3.2% and 4.4%. The graft weight to recipient estimated standard liver mass (ESLM) ratio was 63% and 85%. The two donors had complicated blood vessel variation. RESULTS: Two patients undergone living donor liver transplantation had good results. Abnormal liver function with high bilirubin level appeared in a few days after operation, but liver function returned to normal one month after operation with bilirubin level almost decreased to near normal. No bleeding, thrombosis, infection and bile leakage occurred. One had an acute rejection and recovered. The two donors recovered in two weeks. One had slight fever because of a little collection in abdomen and recovered after paracentesis and drainage. CONCLUSION: Living donor liver transplantation has been proved to be a good way that offers a unique opportunity of getting a timely liver graft as a response to shortage of pediatric donors, though it could be a technically difficult operation if there is anatomical variation.     

Temporal changes in the stiffness of the remnant liver and spleen after donor hepatectomy as assessed by acoustic radiation force impulse: A preliminary study

Aim: Virtual touch tissue quantification (VTTQ) is an implementation of ultrasound acoustic radiation force impulse imaging that provides numerical measurements of tissue stiffness. We have evaluated the temporal changes of the remnant liver and spleen after living donor hepatectomy with special reference to the differences between right and left liver donation. Methods: Nineteen living donors who received right lobectomy (small remnant liver [SRL] group; n = 7) or extended left and caudate lobectomy (large remnant liver [LRL] group; n = 12) were enrolled. They underwent measurement of liver and spleen VTTQ before and after donor surgery. Results: Virtual touch tissue quantification of the remnant liver increased postoperatively until postoperative day (POD) 3–5, and the values in the SRL group were significantly higher than those in the LRL group at POD 3–9. The values of the spleen also increased after donor surgery and the values in the SRL group were significantly higher than those in the LRL group at POD 3–14. A significant positive correlation between postoperative maximum value of VTTQ and postoperative maximum total bilirubin levels was observed. In liver transplant recipients, there was a significant positive correlation between preoperative spleen VTTQ and the corresponding actual portal venous pressure that was measured at the time of transplant surgery. Conclusion: Stiffness of the remaining liver and spleen in the smaller remnant liver group became harder than that in the larger remnant liver group. Perioperative measurement of liver and spleen VTTQ seems to be a useful means for assessing the physiology of liver regeneration.     

Following up of liver transplantation using dual left grafts from living donors--one case

Living donor liver transplantation (LDLT) using right lobe graft was advocated to treat adult patients who could not receive a timely cadaveric graft. The major limitation of adult-to-adult LDLT using right lobe graft is the safety of the donors. Adult-to-adult LDLT using dual left grafts was performed for one patient with end-stage liver disease in our division. Both donors and recipient underwent a full recovery from the operation without persistent complications. Two left dual grafts from two living donors can help alleviate the pressure of organ shortage, prevent the small-for-size problem and yet secure the safety of the donors.     

3D-multidetector CT angiography in the evaluation of potential donors for living donor lung transplantation

INTRODUCTION: In living donor lung transplant, donor lobectomies from 2 donors provide right and left lower lobes for transplantation. In the past, routine evaluation of pulmonary anatomy was not performed preoperatively. Intraoperatively, surgeons were often forced to sacrifice the lingular artery or right middle lobe segmental artery to obtain an adequate arterial cuff for safe reimplantation. This study was performed to evaluate the utility of preoperative 3D-multidetector CT angiography (3D-MDCTA) as a noninvasive method of assessing pulmonary arteries to improve donor selection and surgical planning for living lung donors. SUBJECTS AND METHODS: Five potential lung donors for 2 recipients were included in the study. CT scanning with 4 channel multidetector-row CT was performed, using a modified pulmonary embolism protocol. Post-processing was performed using volume rendering techniques on a commercially available workstation. RESULTS: 3D-MDCT demonstrated that there are a number of variations in pulmonary arterial anatomy and that ideal anatomy was seldom encountered. Comparison of different donors determined which lower lobes were most favorable for transplantation. Surgery confirmed the accuracy of 3D-MDCTA. There were no pulmonary arterial complications, and no vessels were sacrificed. CONCLUSION: Safely explanting lower lobes from living donors for lung transplantation poses challenges not encountered in harvesting cadaveric donors or performing lobectomies for malignancy. 3D-MDCTA of pulmonary arteries can noninvasively delineate the often-complex pulmonary anatomy, which may assist in donor selection as well as reduce donor intraoperative and postoperative vascular complications.     

Urgent adult-to-adult right lobe living donor liver transplantation for acute liver failure; a single center experience from Turkey

BACKGROUND/AIMS: Acute liver failure is a fatal condition unless an urgent liver transplantation is performed. In countries like Turkey, because of limited availability of cadaveric allografts, living donors could be used as an organ source for acute liver failure. We report our single center experience. METHODOLOGY: Six adult-to-adult right lobe living donor liver transplantations have been performed for those patients admitted with fulminant liver failure between September 2000 and April 2004. RESULTS: The age of the patients ranged between 19 and 54 years. Etiology was fulminant hepatitis B in 4 patients, Wilson's disease in 1 patient, and unknown in 1 patient. Five of 6 patients survived and are currently alive and well with a mean 30 (2-46) months follow-up. None of the survivors had neurological sequela. One patient died because of sepsis 2 months after transplantation. There was no donor mortality. CONCLUSIONS: Adult-to-adult right lobe living donor liver transplantation seems to be an effective and safe option for patients with fulminant liver failure, especially in countries with a limited number of available cadaveric donors.     

Living donor liver transplantation: issues regarding left liver grafts

BackgroundThe necessity of widening the indications for living donor liver transplantation (LDLT) has been emphasised. Clarification of the advantages and limitations of using a left liver graft for LDLT in adults is essential for donor safety.MethodsBetween June 1990 and November 2002, 185 patients underwent LDLT at Shinshu University Hospital, Japan. In 97 of these, the graft comprised the left liver with or without the left portion of the caudate lobe. The peri-hepatectomy profiles of the donors, significance of left liver grafts, postoperative courses of the donors and recipients, and survival of the recipients were investigated.ResultsAll the donors recovered well and returned to a normal lifestyle. None required banked-blood transfusion or repeat surgery, and postoperative liver function tests had satisfactory results. The cold ischaemic time for the graft was 127±54 minutes. The graft volumes (GVs) ranged from 230 to 625 ml, and GV/standard liver volume (SV) ratios varied from 22% to 65%, at the time of transplantation. Although 85% of the liver grafts had GV/SV ratios <50%, no patient developed immediate postoperative liver failure. Patient survival rates were 89%, 84% and 84% at 1, 3 and 5 years, respectively.DiscussionAlthough LDLT using a left liver graft imposes potential postoperative complications (a small liver is more vulnerable to injury, and recipients of small grafts are at higher risk of complications during recovery), such grafts have yielded acceptable results in adult LDLT, with minimal burden to the donors.     

Adult-to-adult living donor liver transplantation

Adult-to-adult living donor liver transplantation has become the subject of a great deal of attention over the last few years. Until the use of the donor right lobe was introduced and demonstrated to be relatively safe, it was not possible to offer this alternative to conventional transplantation to most adults. Recent clinical work has focused on the results of these procedures in both donors and recipients, perfecting surgical techniques for right-lobe transplantation, streamlining donor evaluation protocols, and containing costs. This overview summarizes many of the recent publications and presentations in the field of adult-to-adult living donor liver transplantation.