活体肝移植小比重供肝受者并发症及生存率的分析

在GRWR<0.8%的15例患者中,1例出现了典型的小肝综合征.两组在术后并发症发生率(X2=0.000,P=1.000)及生存率(X2=0.058,P=0.811)方面差异均无统计学意义,小供肝组流出道的重建情况与其生存率密切相关(X2=6.821,P=0.009).结论 GRWR<0.8%并不是供肝选择的绝对禁忌指标,在保证移植肝流出道通畅的情况下,小供肝可以被考虑.     

Minimum graft size for successful living donor liver transplantation.

BACKGROUND: The extension of living donor liver transplantation to adult recipients is limited by the adequacy of the size of the graft. We evaluate the effect of the graft size on the survival of the recipient in order to establish a clinical guide for the minimum requirement. METHODS: The clinical records of 14 adults and 11 children (body weight 6.1-100 kg) who underwent living donor liver transplantation for chronic or acute liver failure were reviewed. The effect of the graft weight ratio (graft weight divided by standard liver weight of recipient) on graft function and survival was studied. RESULTS: The graft weight ratio ranged from 31 to 203%. The overall graft and patient survival rates were 84% at a median follow-up of 29 months. The survival rate was 95% for recipients with a graft weight ratio >40%, and 40% only for those with a ratio < or =40% (P = 0.016). It was 88% (7/8) when the ratio was >100%, 100% (5/5) when the ratio was 71 to 100%, 100% (7/7) when the ratio was 41 to 70%, and 40% (2/5) only when the ratio was < or =40%. When the graft weight ratio was < or =40%, early graft dysfunction was evident and contributed to the causes of death in three patients. CONCLUSIONS: Preoperative computed tomographic measurement of liver size of a living donor is essential. A graft that represented 40% or less of the recipient's standard liver weight should be regarded as a marginal graft with a lower success rate.     

Small graft for living donor liver transplantation

OBJECTIVE: To evaluate the impact of graft size on recipients in living donor liver transplantation (LDLT) to establish a clinical guideline for the minimum requirement. SUMMARY BACKGROUND DATA: Although the minimum graft size required for LDLT has been reported to be 30% to 40% of graft volume (GV)/standard liver volume (SLV), the safety limit of the graft size was unknown. METHODS: A total of 33 cases of LDLT, excluding auxiliary transplantation, were reviewed with a minimum observation period of 4 months. The 33 patients were divided into three groups according to GV/SLV: medium-size graft group, small-size graft group, and extra-small graft group. The effect of GV/SLV on graft function, graft regeneration, and survival was evaluated. RESULTS: The overall patient survival rate was 94% at a mean follow-up of 15 months with a minimum observation period of 4 months. There were no statistically significant differences in postoperative bilirubin clearance, alanine aminotransferase, prothrombin time, and frequency of postoperative complications among the three groups. One week after transplantation, the regeneration rate (GV at 1 week/harvested GV) in the extra-small and small groups was significantly higher than that of the medium group. The graft and patient survival rates were both 100% in the extra-small group, 75% and 88% in the small group, and 90% and 95% in the medium group. CONCLUSIONS: Small-for-size grafts less than 30% of SLV can be used with careful intraoperative and postoperative management until the grafts regenerate.     

Interpostion vein graft in living donor liver transplantation

In adult-to-adult living donor liver transplantation (LDLT), right lobe grafts without a middle hepatic vein can cause hepatic congestion and disturbance of venous drainage. To solve this problem, various types of interposition vein graft have been used. OBJECTIVES: We used various types of interposition vein grafts for drainage of the paramedian portion of the right lobe in living donor liver transplantation. METHODS: From June 1996 to June 2003, 37 of 176 patients (128 adults, 48 pediatric) who underwent LDLT received vein grafts for drainage of segments V, VIII, or the inferior portion of the right lobe. RESULTS: In 36 adult cases the reconstruction included the inferior mesenteric vein of the donor (n = 14); cadaveric iliac vein stored at cold (4 degrees C) temperature (n = 5); cryopreserved (-180 degrees C) cadaveric iliac vein (n = 10); cryopreserved cadaveric iliac artery (n = 1 case); donor ovarian vein (n = 1); recipient umbilical vein (n = 3); recipient saphenous vein (n = 1); recipient left portal vein (n = 1); recipient left hepatic vein (n = 1). In a pediatric case with malignant hemangioendothelioma that encased and compressed the inferior vena cava, we used an interposition vein graft to replace the inferior vena cava. CONCLUSION: Various types of interposition vein grafts can be used in living donor liver transplantation. Cryopreserved cadaveric iliac vein and artery are useful to solve these drainage problems.     

Right lobe graft in living donor liver transplantation

BACKGROUND: For the sake of donor safety in living donor liver transplantation (LDLT), the left lobe is currently being used most often for the graft. However, size mismatch has been a major obstacle for an expansion of the indication for LDLT to larger-size recipients, because a left lobe graft is not safe enough for them. METHODS: In 1998, LDLT using a right lobe graft was introduced and performed on 26 recipients to overcome the small-for-size problem. The right lobe, which does not include the middle hepatic vein of the donor, was used. Initially, indication for right lobe LDLT was basically defined as an estimated left lobe graft volume/recipient body weight ratio (GRWR) of <0.8%, which was later raised to <1.0%. RESULTS: All the donors recovered from the operation without persistent complications. Two donors with transient bile leakage were successfully treated with a conservative approach. A right lobectomy resulted in more blood loss (337+/-175 ml), and a longer operative time (6.67+/-0.85 hr) than a lateral segmentectomy, but not a left lobectomy. Grafts with a GRWR >0.8% were implanted in all recipients, except for two, who received relatively smaller right lobes (GRWR of 0.68% and 0.66%). In one of these two, the right lobe from the donor was used as the orthotopic auxiliary graft. Postoperative transitory increases in total bilirubin and aspartate transaminoferase for right lobe donors were higher than those for the left lateral segmentectomy. Nineteen recipients (73.1%) were successfully treated with this procedure. The causes of death were not specific for right lobe LDLT, except for one patient with a graft that had multiple hepatic venous orifices. These multiple and separate anastomoses of the hepatic veins caused an outflow block as a result of a positional shift of the graft, which finally led to graft loss. CONCLUSION: Our experience suggests that right lobe grafting is a safe and effective procedure, resulting in the expansion of the indication for LDLT to large-size recipients. How to deal with the possible variation in the anatomy of the right lobe graft should be given attention throughout the procedure.     

Congestion of right liver graft in living donor liver transplantation

BACKGROUND: Left liver graft from a small donor will not meet the metabolic demands of a larger adult recipient. One solution to this problem is to use a right liver graft without a middle hepatic vein (MHV). However, the need for drainage from the MHV tributaries has not yet been described. METHODS: Five right liver grafts without a MHV were transplanted in patients including two hepatitis B virus-cirrhosis, two fulminant hepatic failure and one secondary biliary cirrhosis. The graft weight ranged from 650 to 1,000 g, corresponding to 48 to 83% of the standard liver volume of the recipients. RESULTS: Two of five recipients were complicated with severe congestion of the right median sector immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction. One of the patients died of sepsis with progressive hepatic dysfunction 20 days after the operation. CONCLUSIONS: Preservation and reconstruction of the MHV tributaries is recommended to prevent congestion of the right liver graft without MHV.     

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

A major concern regarding adult living donor liver transplantation is graft-size disparity. The right liver graft is now commonly used, which might impose a risk on the donors. In selected cases, the left liver with caudate lobe and right lateral sector graft might alleviate the problem without increasing the risk to donors.     

活体右半肝供体的安全性

目的 探讨活体右半肝供体的安全性。方法 对2002年1月至2005年6月施行的13例活体右半肝移植中供体的资料进行回顾性研究。不阻断入肝血流,在肝中静脉右侧,用超声刀离断肝组织得到右半供肝。通过计算得到标准肝体积及残余左半肝的比例。结果 右半供肝切取术平均失血490ml,平均输血440ml。围手术期平均输入人血白蛋白85g。1例供体门静脉分为3支,2例供体右后与右前胆管汇入左肝管,1例左外与左内胆管先后与右肝管汇合成肝总管,术中处理恰当,门静脉左干血流及左肝管胆汁引流保持通畅。2例供肝轻度脂肪变。术后第1天肝功能均有不同程度损害,但术后1周恢复到接近正常水平。术后并发症包括1例腹腔内出血,2例切口脂肪液化和1例乳糜漏。所有供体恢复好并回到原工作岗位。结论 只要保证左半肝血管与胆管通畅,残余肝体积在30％以上及手术对残余肝无大的损伤,右半供肝切取是安全的。     

Factors affecting graft survival after living donor liver transplantation

Living donor liver transplantation (LDLT) has been considered as an alternative option to resolve the shortage of cadaveric donor organs, despite the ethical aspects of the donor procedure. The objective of this study was to analyze the risk factors affecting graft survival in LDLT. From June 1996 to December 2002, 141 patients who underwent LDLT were retrospectively analyzed. Graft survival rates were 82.5%, 80%, 77.3%, and 77.3% at 6 months, 1 year, 3 years, and 5 years, respectively. The factors influencing graft survival in univariate analysis were graft-to-recipient body weight ratio (GRWR) less than 0.8% (P = .0009), intraoperative transfusion of more than six packed RBC units in addition to the use of cell saver amounts (P = .0001), left lobe grafts in adults causing small-for-size situations (P = .0135), and donor age (P = .0472). The multivariate analysis demonstrated that GRWR less than 0.8% (P = .002) and intraoperative transfusion of more than six packed RBC units (P = .014) were independent factors that decreased graft survival rates. The graft selection of greater than 0.8% of GRWR and reduction of intraoperative RBC transfusion improve graft survival.     

Noninvasive evaluation of graft steatosis in living donor liver transplantation

BACKGROUND: Hepatic steatosis affects graft function as well as postoperative recovery of donors in living donor liver transplantation. Liver macrovesicular steatosis in living donors was assessed using quantitative X-ray computed tomography (CT) analysis and histological examination of intraoperative liver biopsy. METHODS: A total of 266 living donors with complete pretransplant CT data and intraoperative "time 0" biopsy were included in the study. Liver biopsy specimen obtained during donor operation was examined for macrovesicular steatosis and was classified as none; mild (<30%); moderate (30%-60%); or severe (>60%). Liver-to-spleen CT attenuation values ratio (L/S ratio) on noncontrast-CT was evaluated for its usefulness as an index of hepatic steatosis in comparison with other parameters including body mass index (BMI) and serum liver function tests (gamma-glutamyl transpeptidase, alanine aminotransferase, aspartate aminotransferase, cholinesterase, and total cholesterol) using receiver operating characteristic (ROC) analysis. RESULTS.: Histological grade of macrovesicular steatosis was none in 198 patients (74.4%), mild in 50 (18.8%), moderate in 15 (5.7%), and severe in 3 (1.1%). The median L/S ratios for the respective histological grades were 1.20 (range: 1.00-1.46), 1.12 (0.83-1.37), 1.01 (0.74-1.21), and 0.90 (0.70-0.99) (P<0.0001). The ROC curve for L/S ratio was located closest to the upper left corner, and the area under the curve of L/S ratio was significantly larger than that of any other preoperative variables. CONCLUSION: L/S ratio calculated from preoperative CT can be a useful tool to discriminate hepatic macrovesicular steatosis. Based on the present results, the optimal cut-off value for L/S ratio to exclude more than moderate steatosis would be 1.1.     

Donor graft outflow venoplasty in living donor liver transplantation.

Hepatic venous outflow reconstruction is a key to successful living donor liver transplantation (LDLT) because its obstruction leads to graft dysfunction and eventual loss. Inclusion or reconstruction of most draining veins is ideal to ensure graft venous drainage and avoids acute congestion in the donor graft. We developed donor graft hepatic venoplasty techniques for multiple hepatic veins that can be used in either right- or left-lobe liver transplantation. In left-lobe grafts, venoplasty consisting of the left hepatic vein and adjacent veins such as the left superior vein, middle hepatic vein, or segment 3 vein is performed to create a single, wide orifice without compromising outflow for anastomosis with the recipient's vena cava. In right lobe graft where a right hepatic vein (RHV) is adjacent with a significantly-sized segment 8 vein, accessory RHV, and/or inferior RHV, venoplasty of the RHV with the accessory RHV, inferior RHV, and/or segment 8 vein is performed to create a single orifice for single outflow reconstruction with the recipient's RHV or vena cava. Of 35 venoplasties, 2 developed hepatic venous stenoses which were promptly managed with percutaneous interventional radiologic procedures. No graft was lost due to hepatic venous stenosis. In conclusion, these techniques avoid interposition grafts, are easily performed at the back table, simplify graft-to-recipient cava anastomosis, and avoid venous outflow narrowing.     

Postoperative hyperbilirubinemia and graft outcome in living donor liver transplantation.

Little information is available on the characteristics and clinical significance of serum bilirubin level early after liver transplantation. The aim of this study was to clarify the risk factors for early graft loss and to assess the significance of postoperative hyperbilirubinemia as a predictor of graft outcome in living donor liver transplantation (LDLT). We retrospectively analyzed perioperative parameters in 68 patients who underwent LDLT. Graft loss within 1 year post-LDLT was confirmed in 9 patients (13.4%). Univariate analysis of risk factors showed that preoperative Model for End-Stage Liver Disease score, donor age, postoperative peak serum bilirubin level (p-BIL) within 28 days after LDLT, and surgical complications were significant determinants of early graft loss (<1 year post-transplant). Multivariate analysis identified p-BIL (odds ratio = 1.170, 95% confidence interval = 1.030-1.329, P = 0.016) as the only independent predictor of early graft loss. The incidence of such loss was high in patients with p-BIL over 27.0 mg/dL (area under the receiver operating characteristic curve = 0.988). In conclusion, serum bilirubin level is a useful predictor of short-term (<1 year) graft outcome and for considering retransplantation in a timely fashion.     

Vein reconstruction in modified right liver graft for living donor liver transplantation

OBJECTIVE: To report the authors' experience with hepatic vein reconstruction and plasty in living donor liver transplantation for adult patients. SUMMARY BACKGROUND DATA: A right liver graft without the middle hepatic vein (MHV) trunk (modified right liver graft) can cause severe congestion of the right paramedian sector. However, the need for MHV reconstruction has not been fully recognized. METHODS: From June 2000 to December 2001, 30 adult patients received a modified right liver graft. Major MHV tributaries were preserved and reconstructed under the authors' criteria. Plasty of recipient hepatic veins for a wide outflow orifice was performed when necessitated. The regeneration of paramedian and lateral sectors of the grafts was examined by computed tomography 1 and 3 months after the operation. RESULTS: MHV tributaries were reconstructed in 18 grafts. Plasty of recipient hepatic veins was performed in 15 patients. All patients survived the operation. The regeneration of paramedian and lateral sectors was equivalent. CONCLUSIONS: A modified right liver graft can provide satisfactory surgical results if hepatic vein reconstruction and plasty are performed using the present techniques.     

Safety of donor in adult-to-adult living donor liver transplantation using right lobe graft

BACKGROUND: The growing gap between the number of patients awaiting liver transplantation and available organs has continued to be the primary issue facing the transplant community. To overcome the waiting list mortality, living donor liver transplantation has become an option, in which the greatest concern is the safety of the donor, especially in adult-to-adult living donor liver transplantation (A-A LDLT) using a right lobe liver graft. OBJECTIVE: We evaluated the safety of donors after right lobe liver donation for A-A LDLT performed in our center. METHODS: From January 2002 to March 2006, 26 patients underwent A-A LDLT using right lobe liver grafts in our center. Seven donors were men and 19 were women (range, 19-65 years; median age, 38 years). The right lobe liver grafts were obtained by transecting the liver on the right side of the middle hepatic vein without interrupting the vascular blood flow. The mean follow-up time for these donors was 9 months. RESULTS: These donor residual liver volumes ranged from 30.5% to 60.3%. We did not experience any donor mortality. Two cases (7.69%) experienced major complications: intra-abdominal bleeding and portal vein thrombosis in one each and three (11.54%), minor ones: wound steatosis in two, and transient chyle leak in one. All donors were fully recovered and returned to their previous occupations. CONCLUSIONS: A-A LDLT using a right lobe liver graft has become a standard option. The donation of right lobe liver for A-A LDLT was a relatively safe procedure in our center.     

Transhepatic biliary catheterization before graft implant in living donor liver transplantation

AIM: Despite the evolution in surgical technique, the biliary anastomosis remains the technical Achilles' heel of liver transplantation, especially in living donor liver transplantation. Interventional radiology or endoscopic procedures constitute the most common options to treat complications from the biliary anastomosis. We report a novel technique to prevent biliary complications following the transplant. METHODS: During the donor procedure a wire guide was introduced in the severed duct, left or right, in retrograde fashion. The liver surface was then perforated and the wire guide exposed. A 4F catheter was then attached to the wire guide and pulled into the bile duct passing through the end-to-end duct-to-duct anastomosis or hepaticojejunostomy. RESULTS: This technique was performed in six living donor grafts: one right lobe, two left lobes, and three left lateral segments. All patients had no complications from the stent placement, biliary strictures, or leaks. One developed a hepatic artery thrombosis on the posttransplant day 14 with no major biliary complications.     

Impact of non-congestive graft size in living donor liver transplantation: new indicator for additional vein reconstruction in right liver graft.

Addition of the middle hepatic vein (MHV) or reconstruction of its tributaries to increase noncongestive graft volume is expected to improve graft function in right liver living donor liver transplantation (LDLT). However, the relationship between noncongestive graft volume and graft function after transplantation has not been clarified and definitive criteria for the reconstruction of MHV tributaries have yet to be established. We analyzed 29 right liver LDLT cases. The noncongestive graft weight was calculated as the total weight of the graft regions drained by hepatic veins reconstructed without postoperative occlusion. We calculated the noncongestive graft-to-recipient weight ratio (ncGRWR) by comparing it to the GRWR. Indocyanine green (ICG) clearance results on days 1 and 3 were significantly correlated with ncGRWR, but not with GRWR. Patients were then divided into 2 groups based on ncGRWR: lower than the median (L-ncGRWR group) and above the median (H-ncGRWR group). ICG clearance in the H-ncGRWR group was significantly better on days 1 and 3. For a different analysis, the patients were again divided into 2 groups, those with and without prolonged cholestasis after transplantation. ncGRWR was significantly lower in patients with prolonged cholestasis, and 7 of 9 patients with an ncGRWR value lower than 0.65 suffered from prolonged cholestasis. Our results demonstrated that the noncongestive volume of a right liver graft has a significant association with early graft function. Further, ncGRWR can play a key role in preoperative determination for additional vein reconstruction of MHV tributaries. When the estimated ncGRWR value with reconstruction of only the right hepatic vein (RHV) (+ inferior right hepatic vein [IRHV]) is less than 0.65, additional vein reconstruction of MHV tributaries should be planned.     

Effect of intraportal infusion to improve small for size graft injury in living donor adult liver transplantation

The most important problem in the living donor adult liver transplantation (LDALT) is a small for size graft. Although a right lobe graft is used in many cases in order to avoid small for size graft, for a donor, the risk has few in left lobe graft. We evaluate the effect of an intraportal infusion treatment to the small for size graft. One hundred and twelve patients who underwent LDALT were studied. The graft weight recipient standard liver volume ratio (GV/SLV) of these patients were 50% or less. We divided the patients into following two groups; infusion group (n = 53) and control group (n = 59). For the infusion group, 16 G double lumen catheter was inserted into portal vein and nafamostat mesilate (protease inhibitor which stabilize coagulofibrinolytic state; 200 mg/day), prostaglandin E(1) (vasodilator and hepatoprotective effect; 500 microg/day) and thromboxane A(2) synthetase inhibitor (vasodilator and anticoagulant effect; 160 mg/day) were administrated continuously for 7 days. Small-for-size graft syndrome was defined as bilirubin >10 mg/dl and ascites >1000 cc on postoperative day (POD) 14. Comparison examination of a background factors and postoperative bilirubin and amount of ascites was carried out. The mean GV/SLV did not have the difference at 39.1% of infusion group, and 38.3% of control group (P = 0.58). By the control group, 15 patients (25.4%) were small-for-size graft syndrome, however, there was only two (3.8%) small-for-size graft syndrome in infusion group (P = 0.04). The bilirubin levels of infusion and control group on 7 and 14 POD were 9.9 and 7.8 vs. 9.5 and 10.5 mg/dl, respectively. The amount of ascites of infusion group on 7 and 14 POD were 870 and 430 cc, respectively. On the contrary, in control group, the amount of ascites on 7 and 14 POD were 1290 and 1070 cc, respectively. Bilirubin levels and the amount of ascites on 7 and 14 POD were lower in the patients with infusion group then those with control group. There were no differences between infusion group and control group in age, sex and Child's classification. The intraportal infusion had an effect in prevention of hyperbilirubinemia and loss in quality of excessive ascites in the patients with small for size graft. This was suggested to be what is depended on the improvement of the microcirculation insufficiency considered one of the causes of small-for-size graft syndrome.     

Risk factors for graft dysfunction after adult-to-adult living donor liver transplantation

The aim of this study was to investigate the risk factors for graft dysfunction after adult-to-adult living donor liver transplantation (LDLT). Thirty-nine adults with chronic cirrhosis underwent LDLT between 1999 and 2004. Their postoperative courses were uneventful with no vascular or bile duct complications early after LDLT, except one mild hepatic artery stenosis. The preoperative MELD scores were significantly higher in the failed graft group (n=5) than the functioning graft group (n=34; P=.004), while the graft liver weight/standard liver volume ratio was similar between these groups. We concluded that a high preoperative MELD score was associated with postoperative graft failure and that graft size had little impact on graft outcome. Although large grafts would seem intuitively more suitable for sick recipients, we did not show a benefit among this cohort; the MELD score was the best predictor, a finding that is also most consistent with donor safety.