Living related adult-to-adult liver transplantation: meeting the donor shortage.

Experience in the Cromwell Hospital London, Adult-to-Adult Living Donor Liver Transplantation programme is described with particular reference to the results obtained in the first five recipients. The first two of these received a left lobe graft and the remaining three a right lobe graft. Three sons/daughters, and two siblings were the donors. Four of the five recipients survived and did well. The one recipient who died was a complicated retransplant procedure. The donors showed rapid recovery of liver function with normal tests by the 10th day and with evidence of regeneration on follow-up CT volume evaluation. The value of the procedure for patients who have little chance of obtaining a cadaver organ is undoubted, but critical assessment of the recipient's clinical state is essential if success is to be obtained with a small graft and at all times the safety of the donor must remain of paramount concern, as reports to date indicate instances of donor death in adult programme.     

Extension of organ transplantation: some ethical considerations

The concept of vital organ transplantation is critically analyzed by considering how traditional transplantation modifies the commitment to saving lives. Problems such as those associated with immunosuppression might seem to provide a compelling reason to oppose extension of transplantation to non-lifesaving situations. A closer examination, however, shows that immunosuppression does not present an intractable objection. For some organ transplants, such as the uterus, use of immunosuppression could be limited to the childbearing years. Complexities associated with assessment of quality of life are discussed using the example of hand transplantation. Assessment of success and functionality in a hand transplant is more complicated than it might appear at first. These complications suggest that monitoring and assessment should be a part of any extension of organ transplantation. Informed consent provides a limited, but important, component in justifying extended transplantation. Such justification, however, does not rest on patient autonomy, but on the reasonable prospect of benefit. Transplant programs considering an extension of traditional transplantation should develop formal protocols that include assessment of costs, benefits, quality of life, and the adequacy of informed consent.     

儿童活体和尸体肝移植的临床效果比较

目的 分析和评价儿童活体和尸体肝移植的效果。 方法 回顾性分析 320 例终末期肝病儿童肝移植的预后及影响因素。 根据肝移植手术方式的不同, 将 320 例受者分为活体肝移植组（活体组）252 例和尸体肝移植组（尸肝组）68 例。 活体组所有供者均为 3 代以内的直系亲属; 尸肝组所有供者均为心脏死亡或脑死亡供者。 比较两 组受者术后存活情况和并发症情况。 结果 活体组受者 1、2、3 年的总体存活率分别为 95.1%、93.5%和 93.5%, 尸肝组分别为 92.3%、92.3%和 82.4%, 两组间比较差异无统计学意义（Log-rank χ2=0.69, P=0.41）。 随访期间, 活体组死亡14 例（5.56%）, 其中 8 例死于呼吸系统并发症, 3 例死于多器官功能衰竭, 3 例死于移植肝功能衰竭; 尸肝组死亡 5 例（7.35%）, 其中 1 例死于呼吸系统并发症, 2 例死于多器官功能衰竭, 1 例死于腹腔出血, 1 例死于其他原因。 两组门静脉血栓（PVT）、流出道梗阻、胆道并发症、肺部感染差异无统计学意义（均 P＞ 0.05）, 活体组肝动脉血栓（HAT）比例低于尸肝组（1.98% vs. 10.29%, χ2=10.245, P < 0.01）。 结论 活体肝移植作为治疗终末期肝病的有效手段, 疗效较好。     

边缘供体肝脏在成人肝脏移植中的应用

目的探讨不同边缘供体肝脏在成人肝脏移植中的应用。方法回顾性分析接受边缘供体肝脏的42例患者及供体的一般资料及生存情况。根据风险因子的不同,将所有供体分为E1、E2两组,比较接受两组供体的受体间生存率的异同。结果接受了两组供体的受者其0.5、1、2年生存率无显著性差异(P>0.05)。结论在注意供-受体匹配的情况下,边缘肝脏供体是可以应用的。     

17例全肝和9例活体肝移植术后感染病原菌分析

目的：通过研究全部以及部分肝移植术后感染的痛原菌分布等特点,探讨肝移植术后抗感染的有效治疗方式。方法：采用26例肝移植患者术后送检的血液经细菌常规培养、真菌培养所分离出的病原菌进行分析。结果：17例全肝移植术后细菌性感染的发生率为94．1％,病原菌中革兰阴性杆菌占72．4％,9例活体肝移植患者感染发生率88．9％,革兰阳性球菌53．99％。结论：肝移植术后常会出现细菌感染,但活体肝移植患者以革兰阳性球菌感染为主,而全肝移植以革兰阴性杆菌为主．本研究认为,相对而言,活体肝移植患者术后感染较易控制。     

活体肝脏移植供者安全性评估

目的 评估供肝手术方式对供体的安全性.方法 86例供体接受了活体肝移植供肝手术:左叶供肝58例(A组);右叶供肝28例(B组).收集并分析供者住院及出院1、3、6个月CT、B超及肝功能随访资料.结果 86例供体手术顺利,康复出院.A、B两组平均手术时间[(7.40±0.88) h vs. (8.00±0.84) h]、平均失血量[(457.41±40.74) ml vs. (518.96±40.74) ml]和平均术后住院时间[(18.62±0.92) d vs. (10.16±0.99) d]均有统计学差异(P<0.05).两组供体肝功能指标可有轻度波动,1周内均恢复正常.CT显示供肝者残留肝恢复至(或超过)正常肝体积的时间:A组6～11个月,B组10～14个月(P<0.05).A、B组术后恢复期分别有30.7%和 32.3%供肝者出现一过性腹部不适、疼痛等;A、B组术后8个月分别有88.5%和85.6%的供肝者恢复术前工作或劳动.结论 健康成人捐献部分肝脏是安全、可行的.     

活体肝移植的临床研究

目的 总结活体肝移植的临床应用.方法 回顾性临床分析75例活体肝移植的临床经验,对活体肝移植的外科技术改进、建立供体安全保障体系和受体预后等问题进行探讨.结果 适应证为良性终末期肝病72例,恶性肿瘤3例.75例供体术后顺利康复,均未出现严重并发症;65例(65/75)受体健在,手术死亡5例(5/75),5例死于远期并发症(5/75).供体右半肝(不包括肝中静脉)21例,扩大右半肝(包括肝中静脉)2例,扩大左半肝(包括肝中静脉)48例,左半肝或左外叶(不包括肝中静脉)4例.术后主要并发症以血管并发症、胆道并发症、细菌及病毒感染和肺部并发症为主.结论 活体肝移植具有供肝来源广泛的优点,适合我国国情,有广阔的临床应用前景.改进活体肝移植技术,建立供体安全保障体系是改善受体预后的关键.     

Candidate selection criteria for living donor liver transplantation

Living donor liver transplantation is a new surgical technique that challenges the assumptions of the current system for allocation of livers for transplantation. Arguments based on justice in the setting of scarcity, and the consequent need for triage, do not apply. The risk to the living donor, an order of magnitude higher than that for kidney donation, raises different ethical concerns related to autonomy, what constitutes an acceptable risk-benefit equation, and who is to decide.     

Review article: adult-to-adult right hepatic lobe living donor liver transplantation

Spurred on by the critical shortage of cadaveric livers, adult-to-adult right hepatic lobe living donor liver transplantation has grown rapidly as a therapeutic option for selected patients. In the USA alone, the number of living donor liver transplantations has increased six-fold in the last 4 years. The therapy can be complex, bringing together a variety of disciplines, including transplantation medicine and surgery, hepatology, psychiatry and medical ethics. Moreover, living donor liver transplantation is still defining itself in the adult-to-adult application. Uniform standards, guidelines and long-term outcomes are yet to be determined. Nevertheless, initial success has been remarkable, and a basic understanding of this field is essential to any physician contemplating options for their liver failure patients. This review covers a range of topics, including recipient and donor selection and outcomes, donor risk, controversies and future issues.     

Pediatric euthanasia in Belgium: some ethical considerations

On February 2014, the Belgian Parliament approved the first law on children euthanasia stating that also young children can make the autonomous choice to have their lives terminated. This article reviews the ethical objections to the law. These include the impossibility to gauge the competence of children and their vulnerability, and the fact that euthanasia itself implies that some lives are not worthy of living. The denial of life as a “bonum onticum” reneges the very principles on which civil laws and medical ethics are founded.     

Laryngeal and tracheal transplantation: ethical limitations

Over the last decade, there have been extraordinary developments in the field of transplantation science. As a result, organ transplantation enjoys a success that is unparalleled since its introduction nearly 50 years ago. Progress in the laboratory has translated into less toxic, more effective immunosuppressive therapies that have improved both allograft survival and patient quality of life. Consequently, physicians and their patients look toward a new frontier, the transplantation of non-vital organs. While the transplantation of non-vital organs is technically feasible, as demonstrated by the recent success of a human laryngeal transplant, a variety of ethical concerns must be confronted before tracheal and laryngeal transplantation can be offered to patients as a reconstructive option. When considering the risks and benefits of non-vital organ transplantation, one must consider the immeasurable impact of a procedure on the patient s quality of life. The focus of this article is on quality of life and the role of laryngotracheal transplantation in contemporary medicine.     

Clinical research in the elderly: ethical and methodological considerations

Clinically oriented research in the elderly is of growing interest because of increasing numbers of older persons, the relative lack of research data with this population, and recent Food and Drug Administration mandates to study drugs in the elderly. Studies of young, healthy persons cannot necessarily be extrapolated to the elderly due to changes associated with aging and the increased number of concomitant disease states and medications. Subject recruitment may be more time consuming in finding subjects with the appropriate inclusion criteria and lack of exclusion criteria who are willing to participate. Additional concern must be placed on protecting the subject's rights while allowing autonomous decision making. Likewise, protocols may need to be flexible enough to include persons with concomitant disease and medications.     

活体肝移植肝动脉重建技术与并发症

目的 探讨活体肝移植中肝动脉重建的显微外科技术,以降低肝动脉栓塞的发生率,提高患移植后的生存率。方法 本组24例,其中右半肝活体肝移植6例,左半肝移植16例,左外叶2例;采用显微外科技术行肝动脉吻合。吻合的方式是端端吻合。结果11例肝动脉直径＜2mm,重建肝动脉时间为24～88min。行单支动脉吻合20例,两支动脉吻合4例;2例患术后出现肝动脉血栓形成,均须行再次肝移植后恢复。本组肝动脉血栓的发生率为8．3％。结论 显微外科技术重建肝动脉可减少肝移植术后肝动脉栓塞的发生。     

Emergency adult living donor right lobe liver transplantation for fulminant hepatic failure

Fulminant hepatitis is fatal in most cases and timely liver transplantation is the only effective treatment. This study evaluates the survival outcomes of patients who underwent living-donor liver transplantation (LDLT) using right lobe liver grafts for fulminant liver failure due to hepatitis B infection. Nine cases of adult right lobe LDLT were performed in our department from September 2002 to August 2005 and the clinical and following-up data were reviewed. According to the pre-transplant Child-Pugh-Turcotte classification, the nine patients were classified as grade C. The model for end-stage liver disease (MELD) score of these patients ranged from 16 to 42. The principal complications before transplantation included abnormal renal function, hepatic coma of different degrees and alimentary tract hemorrhage. The main complications after transplantation included pulmonary infection in two cases, acute renal failure in three cases and transplantation-related encephalopathy in one case. No primary failure of vascular or biliary complications occurred. The one-year survival rate was 55.6%. There were no serious complications or deaths in donors. In general, it is extremely difficult to treat fulminant hepatitis by conservative regimen, particularly, in cases with rapid progression. Emergency adult living-donor liver transplantation is an effective treatment for fulminant hepatitis patients and is relatively safe for donors.     

供体特异性调节性T细胞在肝移植免疫耐受中的意义

免疫耐受是器官移植的终极目标。尽管目前对于移植术后免疫耐受的探索很多,但大多处于试验阶段,应用于临床的方案甚少。对调节性 T细胞诱导免疫耐受的研究较为透彻,但供体特异性调节性 T细胞因其比例较低、制备困难,在移植免疫中的研究相对较少。本文从调节性 T细胞的共性、供体特异性调节性 T细胞的抑制功能、体外培养技术、胸腺移植等方面出发,总结供体特异性调节性 T 细胞在近年的研究热点,以期为临床研究提供新思路。     

Drug studies in women of childbearing age: ethical and methodological considerations

Despite a recognized need for the inclusion of women of childbearing age in drug studies, many such studies include only men. This practice is due mainly to the added risk of teratogenicity and to cyclic variations in the menstrual phase and hormonal state. The methodological and ethical problems associated with drug studies in women are demonstrated by a discussion of a proposed study using lithium, a widely used drug that has been shown to have a teratogenic effect in animals and in women with bipolar affective disorder when taken chronically. Practical considerations and solutions for drug studies in women in general are suggested.     

Preliminary experience in adult-to-adult living donor liver transplantation in a single center in China

The aim of this paper is to report the authors’ experience in performing adult-to-adult living donor liver transplantation (LDLT) by using a modified technique in using grafts of the right lobe of the liver. From January 2002 to September 2006, 56 adult patients underwent LDLT using right lobe grafts at the West China Hospital, Sichuan University Medical School, China. All patients underwent a modified operation designed to improve the reconstruction of the right hepatic vein (RHV) and the tributariers of the middle hepatic vein (MHV) by interposing a vessel graft, and by anastomosing the hepatic arteries and bile ducts. There were no severe complications or deaths in all donors. Fifty-two (92.8%) recipients survived the operations. Among the 56 recipients, complications were seen in 15 recipients (26.8%), including hepatic vein stricture (one case), small-for-size syndrome (one case), hepatic artery thrombosis (two cases), intestinal bleeding (one case), bile leakage (two cases), left subphrenic abscess (one case), renal failure (two cases) and pulmonary infection (five cases). Within three months after transplantation, four recipients (7.14%) died due to small-for-size syndrome (one case), renal failure (one case) and multiple organ failure (two cases). All patients underwent direct anastomoses of the RHV and the inferior vena cava (IVC), and in 23 cases, reconstruction of the right inferior hepatic vein was also done. In 24 patients, the reconstruction of the tributaries of the MHV was also done by interposing a vessel graft to provide sufficient venous outflow. Trifurcation of the portal vein was seen in nine cases. Thus, veno-plasty or separate anastomoses were performed. The graft and recipient body weight ratios (GRWR) were between 0.72% and 1.43%, and in three cases it was <0.8%. The graft weight to recipient standard liver volume ratios (GV/SLV) were between 31.86% and 71.68%, among which four cases had <40%. No “small-for-size syndrome” occurred. With modification of the surgical technique, especially in the reconstruction of the hepatic vein to provide sufficient venous outflow, living donor liver grafts in adults using the right lobe of the liver can become a relatively safe procedure and prevent the “small-for-size syndrome”.     

Reducing biliary complications in adult-to-adult living donor liver transplantation using right lobe graft: experience of 124 cases

The aim of this paper is to summarize our experience of using right lobe liver grafts to reduce biliary complications in adult-to-adult (A-A) living donor liver transplantation (LDLT). From January 2002 to October 2007, 124 adult patients underwent living donor liver transplantation using right lobe grafts at the West China Hospital, Sichuan University Medical School, China. There was no death in all donors. Biliary reconstruction for 178 hepatic duct orifices from 124 donor grafts was performed which included 106 reconstructions of duct-to-duct anastomoses and 72 cholangiojejunostomy. Nine recipients had biliary complications including six bile leakages (four from the anastomotic site and two from the cut surface of the liver graft) and three biliary strictures. With the improved techniques for biliary reconstruction, we have achieved good results in 124 recipients of A-A LDLT. We ascribe our success to the introduction of microsurgical techniques and the use of fixed operators which help in decreasing the biliary complications of LDLT.