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.     

Adult living donor liver transplantation

The number of adult living-donor liver transplantations is rapidly increasing world wide. Donor selection, technical innovation, and postoperative management are important for donor safety. The adequacy of graft size is the major limitation and the most critical issue in adult living-donor liver transplantation. The outcome of this surgery is significantly influenced by the pretransplant patient condition and the original patient disease. Further study is needed to clarify the indications for and timing of living-donor transplantation for adult recipients.     

Monosegmental living donor liver transplantation

BACKGROUND: Living donor liver transplant (LDLT) program has been started from 1990 in Japan, and is still major form of liver transplantation because of the scarcity of cadaveric donor organs. In small infants, implantation of left lateral segment grafts can be a problem because of a large-for-size graft. Until November 2002, we performed 867 transplants for 828 patients (561 children and 306 adults), and 14 cases received monosegment grafts from living donors. METHODS: Fifteen patients, median age 211 days, median weights 5.95 kg, received monosegmental LDLT. The indication for using this technique was infants with an estimated graft-to-recipient weight ratio of over 4.0%. RESULTS: Graft and patient survival is 85.7%. There were no differences in donor operation time and blood loss between monosegmentectomy and left lateral segmentectomy. Segment III grafts were indicated in 13 cases. Two vascular complications were observed (one hepatic artery thrombosis and one portal vein thrombosis). CONCLUSIONS: Monosegental living donor liver transplantation is a feasible option with satisfactory graft survival in small babies with liver failure.     

成人活体肝移植

活体肝移植（LDLT）最初作为一种降低等待做肝移植患者死亡率的方法。日本京都大学LDLT开始于1990年6月,移植例数逐年增加,临床应用范围从小儿扩展到成人。肝脏右叶移植物的应用在LDLT具有重要临床意义,已经成为成人间LDLT标准方法。由于肝脏右叶移植物在LDLT移植后成功应用,近年来成人LDLT例数显著增加,自1990年6月至2005年12月,京都大学附属病院已完成了1140例LDLT手术,其中包括477例成人LDLT手术（年龄大于18岁）。HBV和HCV相关性肝硬化和肝癌是LDLT最常见的适应证,截至2005年12月,随访统计结果表明成人LDLT术后总的5年生存率为69．1％。     

Pediatric living donor liver transplantation

AIM: The aim of this study was to analyze the results of living donor in a pediatric liver transplantation program. PATIENTS: Twenty-six living donor liver transplantations were performed in children from 0.5 to 14.8 years of age. The main indication was biliary atresia (72%) followed by tumors (2 hepatoblastomas and 1 hepatocarcinoma). Left lateral segments were used in 23 (1 transformed into a monosegment), 1 left lobe was used in 1, and right lobes were used in 2. Arterial reconstruction employed saphenous venous grafts in the first 3 cases and end-to-end anastomoses with a microsurgical technique in the following 22 cases. RESULTS: There has been no major morbidity in the donors, with a median hospitalization of 6 days. Four grafts have been lost; 2 in the first 3 cases. In only 1 case, the graft loss was related to the procedure saphenous venous graft thrombosis). Early biliary complications were frequent (23%). Six month, 1 year, and 5 year graft and patient survival rates were 91%, 85%, and 85% and 100%, 96%, and 96%, respectively. CONCLUSIONS: Living donor liver transplantation is an excellent option for transplantation in children.     

Adult-adult living donor liver transplantation

After the first report from Denver in 1998 of a successful liver transplant in an adult using the right lobe from a living donor, the procedure was rapidly adopted by many transplant centers as a potential solution to the critical shortage of donor livers. By the end of 2000, when the National Institutes of Health held a Consensus Conference on Adult-Adult Living Donor Transplantation (AALDT), a substantial body of literature had already developed and many of the associated technical and medical pitfalls had been defined. The exponential expansion of the procedure came to a dramatic halt in January 2002 when the death of a donor occurred at Mount Sinai Hospital—the busiest AALDT center in the United States. This led to a widespread reassessment of the risks inherent in right lobe donation. Yet, the problem that drove the development of this controversial technique—the dire shortage of organs for transplantation—still persists. After a 50% drop in the number of AALDT procedures performed in the United States in 2002 compared with 2001, centers are regrouping and approaching AALDT with renewed interest, albeit with heightened awareness of the attendant risks. On November 2, 2002, a state-of-the-art symposium on AALDT was held in Boston, MA, under the combined auspices of the American Hepatico-Pancreato-Biliary Association and the American Association for the Study of Liver Diseases. This article comprises the presentations at the symposium on three subjects of critical importance concerning AALDT. These include advances in surgical technique, candidate selection, and hepatic regeneration; each subject is acknowledged by an expert in the field. Presented at 2002 AHPBA/AASLD Surgical Forum, Boston, MA, November, 2002.     

Different kinetics of donor cell populations after isolated liver and combined liver/small bowel transplantation

Abstract Spontaneous tolerance induction after liver transplantation also supports additional transplants, e. g. a small bowel graft, from the same donor (tolerogenic effect). Chimerism serves as a possible explanation of this phenomenon. Isolated liver (LTx) and combined liver/small bowel transplantation (LSBTx) are compared. LSBTx and LTx were performed in the BN → LEW rat strain combination without immunosuppression. Parenchymal damage during rejection was monitored by sequential standard histology. Donor/recipient populations were identified and further differentiated for immunhistochemical single and double staining. A small number of donor specific leukocytes can be detected on all days in host organs (microchimerism). A significantly larger donor leukocyte population survives long‐term in the sinusoids of liver (graft chimerism). Sinusoidal donor leukocytes survive rejection and recover in number after tolerance induction. Rejection of liver allografts and infiltration by host leukocytes are more pronounced after LSBTx than after LTx. Accordingly, during rejection a steeper decline of sinusoidal donor leukocytes is observed after LSBTx and recovery after tolerance induction is not as marked. Microchimerism apparently plays no significant role in either transplantation model. The number of sinusoidal donor leukocytes, however, mirrors closely host immune responses.     

Progress in living donor liver transplantation

Living donor liver transplantation (LDLT) has the capacity to reduce the current discrepancy between the number of patients on the transplant waiting list and the number of available organ donors. For pediatric patients, LDLT has clearly reduced the number of waiting list deaths, providing compelling evidence for an increase in LDLT programs. This review discusses many of the recent advances in LDLT.     

The safety of donor in living donor small bowel transplantation – an analysis of four cases

Abstract:  Intestinal transplantation using living-related donors could potentially reduce the severity of rejection responses against this highly immunogenic organ by better tissue matching and shorter cold ischemia duration, compensating for the shortage of donor grafts. The purpose of this study is to assess the safety of donors receiving living donor small bowel transplantation (LDSBT) in our hospital by reviewing the risk of operations and absorbing capability recovering retrospectively based on the parameters, such as body weight loss, blood loss, blood transfusion, operation time, duration of hospitalization, complications, and d -xylose tolerance test. After a follow-up period (mean 72 months, range: 48–96 months) of four cases of donors performed LDSBT in Xijing Hospital of digestive diseases dated from May 1999 to September 2003, no complication occurred. Therefore, pre-operation angiography, meticulous management of operation and accurate post-operation monitoring were particularly necessary to guarantee the safety of donors.     

Internal hernia of the small bowel after right-lobe live donor liver transplantation

Internal hernia of small bowel is an uncommon but potentially fatal complication of liver transplantation. We report on four patients in whom internal hernia of small bowel occurred after right-lobe live donor liver transplantation (LDLT). Three patients had small bowel herniation with volvulus around the Roux-en-Y loop whereas the other patient had herniation through the mesenteric window of transverse mesocolon after hepaticojejunostomy for biliary reconstruction. Based on clinical and radiologic findings, early diagnosis was made in all cases. All patients survived following surgical reduction of the hernia and closure of the mesenteric defect without bowel resection. Transplant surgeons should be aware of this serious complication so that early diagnosis and appropriate operative intervention can be made. The complication can be avoided with duct-to-duct biliary reconstruction or meticulous closure of all mesenteric defects with non-absorbable suture materials after hepaticojejunostomy in patients undergoing right-lobe LDLT.     

活体肝移植的术前评估

随着外科技术的发展进步,活体肝移植的生存率不断提高,外科医生在活体肝移植手术前的评估工作与过去相比也更谨慎、细致.近年来,彩超、CT、MRI等先进影像学手段和肝穿刺活检等检查方法在评估工作中的普遍应用,使外科医生能更清楚地了解患者病情、供肝功能情况和内部解剖结构.本文就国内外对活体肝移植术前评估方法的研究进展做一综述.     

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.     

Renal impairment after living donor liver transplantation

BACKGROUND: There are few reports of postoperative renal impairment after living donor liver transplantation (LDLT). METHODS: We reviewed 246 LDLT recipients to examine the effects of postoperative renal impairment on the results of LDLT. RESULTS: The incidence of renal impairment and the requirements for postoperative renal replacement therapy were 29% and 9%, respectively. Intraoperative blood loss (P<.0001) and preoperative serum creatinine (P=.0002) were significant independent risk factors for the development of early renal dysfunction. Patients who required renal replacement therapy had a lower survival rate (P=.01). CONCLUSIONS: We identified the risk factors for postoperative renal impairment, providing useful metrics to establish a treatment strategy for high risk liver transplant patients.     

Donor age in living donor liver transplantation

BACKGROUND: We sought to elucidate the influence of donor age in living donor liver transplantation (LDLT) using either left lobe (LL) or right lobe (RL) grafts. METHODS: Recipients (n = 232) were categorized as: group O/LL (LL, donor age >50, n = 20); group Y/LL (LL, donor age < or =50, n = 140); Group O/RL (RL, donor age >50, n = 12); and group Y/RL (RL, donor age < or =50, n = 61). We compared post-LDLT graft functions. RESULTS: Among LL LDLT, the incidence of small-for-size syndrome was significantly greater for group O/LL compared with group Y/LL (60.0% vs 16.3%, P < .01). However, the cumulative 5-year graft survivals were 73.8% in group O and 76.7% in group Y without substantial difference. In RL LDLT, the post-LDLT morbidity and mortality were similar for group O/RL and group Y/RL. CONCLUSION: Partial liver grafts, even though LL grafts, from older donors can be used safely with caution in LDLT.     

Right lobe living donor liver transplantation.

BACKGROUND: The shortage of livers for transplantation has prompted transplant centers to seek alternatives to conventional cadaveric liver transplantation. Left lateral segmentectomy from living donors has proven to be a safe operation for the donor with excellent results in the pediatric population. Left lobectomy, conceived to supply more tissue, still provides insufficient liver mass for an average size adult patient. Right lobectomy could supply a graft of adequate size. METHODS: Donors were considered only after recipients were listed according to United Network for Organ Sharing (UNOS) criteria. Donor evaluation included liver biopsy, magnetic resonance imaging, and celiac and mesenteric angiography. The donor operation consisted of a right lobectomy uniformly performed throughout the series as described herein. RESULTS: Twenty-five right lobe living donor liver transplants were performed between adults, with no significant complications in donors. Recipient and graft survival was 88%, with three recipient deaths secondary to uncontrolled sepsis in patients at high risk for liver transplant; all three had functioning grafts. CONCLUSIONS: Right lobe living donor liver transplantation poses challenges that require a meticulous surgical technique to minimize morbidity in the recipient. Right lobectomies for living donation can be performed safely with minimal risk to both donor and recipient although providing adequate liver mass for an average size adult patient.