Simplifying living donor liver transplantation

BACKGROUND:Living donor liver transplantation is a complex surgical operation.Treatment policies and operative techniques evolved in the last two decades.DATA SOURCES:Our center's experience in living donor liver transplantation was reviewed in conjunction with relevant publications in the literature.RESULTS:The surgical techniques and perioperative surgical therapeutics could be modified towards simplicity.Examples include regular inclusion of the middle hepatic vein without compromising the venous outflow...     

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.     

Adult-to-adult living donor liver transplantation.

The present review outlines the principles of living donor liver transplantation, donor workup, procedure and outcomes. Living donation offers a solution to the growing gap between the need for liver transplants and the limited availability of deceased donor organs. With a multidisciplinary team focused on donor safety and experienced surgeons capable of performing complex resection/reconstruction procedures, donor morbidity is low and recipient outcomes are comparable with results of deceased donor transplantation.     

Hepatic vein in living donor liver transplantation

Right lobe living donor liver transplantation (LDLT) is a major development in adult LDLT that has significantly increased the donor pool by providing larger graft size and by decreasing risk of small-for-size graft syndrome. However, right lobe anatomy is complex, not only from the inflow but also from the outflow perspective. Outflow reconstruction is one of the key requirements of a successful LDLT and venous drainage of the liver graft is just as important as hepatic inflow for the integrity of graft function. Outflow complications may cause acute graft failure which is not always easy to diagnose. The right lobe graft consists of two sections and three hepatic venous routes for drainage that require reconstruction. In order to obtain a congestion free graft, several types of vascular conduits and postoperative interventions are needed to assure an adequate venous allograft drainage. This review described the anatomy, functional basis and the evolution of outflow reconstruction in right lobe LDLT.     

Small-for-size syndrome in living donor liver transplantation

When the graft volume is too small to satisfy the recipient's metabolic demand, the recipient may thus experience small-for-size syndrome (SFSS). Because the occurrence of SFSS is determined by not only the liver graft volume but also a combination of multiple negative factors, the definitions of small-for-size graft (SFSG) and SFSS are different in each institute and at each time. In the clinical setting, surgical inflow modulation and maximizing the graft outflow are keys to overcoming SFSS. Accordingly, relatively smaller-sized grafts can be used with surgical modification and pharmacological manipulation targeting portal circulation and liver graft quality. Therefore, the focus of the SFSG issue is now shifting from how to obtain a larger graft from the living donor to how to manage the use of a smaller graft to save the recipient, considering donor safety to be a priority.     

Outcomes of donor evaluation in adult-to-adult living donor liver transplantation

The purpose of donor evaluation for adult-to-adult living donor liver transplantation (LDLT) is to discover medical conditions that could increase the donor postoperative risk of complications and to determine whether the donor can yield a suitable graft for the recipient. We report the outcomes of LDLT donor candidates evaluated in a large multicenter study of LDLT. The records of all donor candidates and their respective recipients between 1998 and 2003 were reviewed as part of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). The outcomes of the evaluation were recorded along with demographic data on the donors and recipients. Of the 1011 donor candidates evaluated, 405 (40%) were accepted for donation. The donor characteristics associated with acceptance (P < 0.05) were younger age, lower body mass index, and biological or spousal relationship to the recipient. Recipient characteristics associated with donor acceptance were younger age, lower Model for End-stage Liver Disease score, and shorter time from listing to first donor evaluation. Other predictors of donor acceptance included earlier year of evaluation and transplant center. CONCLUSION: Both donor and recipient features appear to affect acceptance for LDLT. These findings may aid the donor evaluation process and allow an objective assessment of the likelihood of donor candidate acceptance.     

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.     

Historical perspective of living donor liver transplantation

Living donor liver transplantation （LDLT） has gone through its formative years and established as a legitimate treatment when a deceased donor liver graft is not timely or simply not available at all. Nevertheless, LDLT is characterized by its technical complexity and ethical controversy. These are the consequences of a single organ having to serve two subjects, the donor and the recipient, instantaneously. The transplant community has a common ground on assuring donor safety while achieving predictable recipient success. With this background, a reflection of the development of LDLT may be appropriate to direct future research and patientcare efforts on this life-saving treatment alternative.     

静脉移植物在成人间活体肝移植中应用的研究

目的研究移植血管在成人间活体右半肝移植（LDLT）中的应用。方法对26例成人间LDLT患者，用大隐静脉重建肝Ⅴ、Ⅷ段肝中静脉粗大属支，及右肝下静脉，用大隐静脉补片修补供体门静脉损伤．狭窄以及肝动脉搭桥。结果利用大隐静咏重建Ⅴ、Ⅷ段肝中静脉粗大属支和右肝下静脉流出道20例，其总的重建率76．9％（20／26），其中重建一支静脉15例，重建两支静脉5例。重建引流的模式和病例数如下：Ⅴ53例，Ⅴ82例，Ⅴ5和Ⅴ83例，V5和右肝下静脉1例，Ⅴ8和右肝下静脉1例，右肝下静脉10例。肝动脉搭桥率11．5％（3／26），肝动脉和腹主动脉间大隐静脉搭桥2例，肝动脉与肝动脉间夫隐静脉搭桥1例。供体门静脉补片1例。所有病例术中和术后随访2～48月，超声检查均未发现血栓，血流通畅。结论自体大隐静脉在LDLT术中重建Ⅴ5、Ⅴ8及右肝下静脉流出道和肝动脉搭桥，能有效预防小肝综合征和动脉并发症。     

Asian contribution to living donor liver transplantation

Although the shortage of brain-dead donor organs is a worldwide problem, the situation is especially serious in Asia because of various cultural and social reasons, and cadaveric organ donation remains below 5 per million population per year. Living donor liver transplantation (LDLT) could provide an alternative for liver graft for patients with acute and chronic end-stage liver disease. This article introduces the important contributions to the development of LDLT by the leading Asian liver transplantation centers. The first successful adult LDLT using a left-lobe graft was reported by Makuuchi et al. from Japan in 1994. To overcome the barrier of graft-size matching for adult patients with use of a left-lobe graft, a trial of adult LDLT using a right-lobe graft with middle hepatic vein was reported with satisfactory outcome by Fan et al. from Hong Kong in 1997. Despite the impressive results of right-lobe LDLT, considerable debate persists concerning donor safety. Lee et al. from Korea initiated modified right-lobe liver grafting with interposition vein grafts to drain anterior segment and two left-lobe liver grafting to overcome graft-size insufficiency and to ensure donor safety in 1999 and 2000, respectively. In addition to technical innovations, indications for liver transplantation have been developed by Asian centers as LDLT activity has increased.     

Bloodstream infection after living donor liver transplantation

There are no detailed studies on the prevalence or clinical magnitude of bloodstream infection (BSI) following living donor liver transplantation (LDLT). The study aimed to assess the incidence and analyze the risk factors for BSI after LDLT. Univariate and multivariate analyses were performed to identify the independent risk factors for postoperative BSI. Postoperatively, 26 episodes of BSI occurred in 21 of 242 studied adult patients by median postoperative d 35. Five patients had primary BSI. The source was unknown in 3 patients and an intravascular catheter in 2. The other 16 patients had secondary BSI. Secondary BSI was caused by surgical site infection in 8 patients, followed by intra-abdominal infection in 5, pneumonia in 2, and both surgical site infection and intra-abdominal infection in 1. The most frequent pathogen isolated was MRSA, which was detected in 4 patients. Surveillance culture detected the same isolates prior to BSI in 14 of 26 (50%) episodes. Diabetes mellitus and serum albumin level less than 2.4 g/dl independently predicted postoperative BSI. Perioperatively, screening for and taking actions against pathogen including MRSA should be performed in LDLT patients.     

Terlipressin versus placebo in living donor liver transplantation

<正>To the Editor:Terlipressin is a long-acting synthetic analogue of vasopressin,demonstrating several potential benefits in the context of living donor liver transplantation (LDLT).During the recipient hepatectomy,terlipressin reduces the portal flow.Consequently,it may mitigate the extent of bowel congestion following portal vein clamping.By decreasing portal hyperperfusion and hypertension,it protects the graft from further injury and improves renal blood flow.All the above described be...     

Postoperative management for donor safety in living related donor liver transplantation

BACKGROUND/AIMS: Living related donor liver transplantation must hold on in absolute donor safety. Nevertheless, the risks to the donors are increased because of the use of right lobe for size mismatch. Therefore the intensive management for donor operation can hardly be overestimated. In this study, we investigated the utility of prostaglandin E1, methylprednisolone and C-tube in the postoperative management for donor operation based on our understanding of the mechanisms of liver injury after massive hepatectomy. METHODOLOGY: Outcome of the thirteen donors, whose right lobe was removed (right lobe group: 7 cases) or the left lobe only (3 cases) and left lobe plus caudate lobe (3 cases) (left lobe group: 6 cases) from 1999 March to 2000 August, for living related liver transplantation were evaluated. Indication for right lobe living related liver transplantation was basically defined as an estimated left lobe volume/recipient body weight ratio (GVBW ratio) of < 0.8% (range: 0.65-1.4, right lobe group: 1.05 +/- 0.18, left lobe group: 0.89 +/- 0.16). RESULTS: The donors recovered from the operation without the differentiation between right and left lobe group. There were no significant differences in the operative time, the operative hemorrhage, the hospital stays and the postoperative liver function in the two groups. They had no bile leakage and no serious complications. We experienced the left lobe donor who suffered from a cholangitis without any infection and he recovered by the administration of prostaglandin E1 and steroid. They improved bile secretion and bilirubinemia. Eleven recipients (84.6%) were successfully treated. The two causes of death were the sepsis (right lobe) and brain hemorrhage (left lobe). CONCLUSIONS: The current series of right lobe donation was able to show successful results as well as left lobe donation by the postoperative management with steroid, prostaglandin E1 and C-tube drainage based on our understanding of liver injury after massive hepatectomy in the adult-to-adult living donor liver transplantation.     

Anatomical keys and pitfalls in living donor liver transplantation

The surgery of living donor liver transplantation is more technically challenging than cadaveric whole liver transplantation and liver resection for the treatment of various pathological conditions. It requires a thorough understanding of the intra- and extra-hepatic anatomical relationships between the portal vein, hepatic artery, biliary tract, and hepatic vein, and also their respective contributions to liver physiology. Although a precise understanding of general anatomical principles is the key to correctly performing living donor liver transplantation procedures, anatomic anomalies are often present, and the means of detecting them and the surgical methods of coping with them represent technical challenges. In this monograph, we describe the anatomical keys and pitfalls of living donor liver transplantation surgery based on our own experience with more than 1800 hepatectomies, and 150 living donor liver transplantations. We also elaborate on techniques of selective intermittent vascular occlusion and their teleological and practical background.     

Biliary complications in right lobe living donor liver transplantation

Living donor liver transplantation is an alternative to deceased donor liver transplantation in the face of insufficient deceased donor liver grafts. Unfortunately, the incidence of biliary complication after living donor liver transplantation is significantly higher than that after deceased donor liver transplantation using grafts from non-cardiac-death donations. The two most common biliary complications after living donor liver transplantation are bile leakage and biliary anastomotic stricture. Early treatment with endoscopic and interventional radiological approaches can achieve satisfactory outcomes. If treatment with these approaches fails, the salvage measure for prompt rectification will be surgical revision, which is now seldom performed. This paper also discusses risk factors in donor biliary anatomy that can affect recipients.