Live donor liver transplantation: staging hepatectomy in a Jehovah's Witness recipient

Orthotopic liver transplantation (OLT) is usually associated with significant blood loss and frequently requires the usage of blood products. OLT has been offered sparingly in Jehovahs Witness (JW) patients because of their refusal to accept blood products for religious reasons. Several innovations have made surgery safer in these patients. These include the pre-operative use of erythropoietin to increase red cell mass, the use of intraoperative cell salvage and acute normovolemic hemodilution, and judicious postoperative blood testing. Thoughtful perioperative decision-making and careful surgical techniques remain the cornerstone to a successful outcome. We report our experience in a two-stage hepatectomy done for a JW patient who underwent live donor liver transplant from his mother, also a JW, without blood transfusion. The recipient had an unusually enlarged left lateral segment of the liver which was densely adherent to the spleen. Removing these adhesions in the presence of significant portal hypertension would have resulted in considerable blood loss. This was successfully avoided by leaving this portion of the liver attached to the spleen while proceeding with the hepatectomy. The right lobe of the liver from the donor was then implanted uneventfully. Two weeks later the remaining segment of the recipient liver was removed without incident. The two-stage procedure was life-saving in this JW patient.     

Posterior spinal fusion without blood replacement in Jehovah's Witnesses

Posterior spinal fusion without blood replacement is a formidable procedure that most orthopedic surgeons are reluctant to attempt. This procedure has been performed without transfusions on 19 patients, all of whom were Jehovah's Witnesses. The operations were performed over four spinal segments at a time and were planned so that the procedure could be terminated when 10% of the patient's estimated total blood volume had been lost. Allogeneic donor bone was used to minimize blood loss whenever this was acceptable to the patient. The procedure was associated with a high incidence of pseudarthrosis, all cases of which occurred when allogeneic bone was used. No deaths or life-threatening complications were encountered. Thus, posterior spinal fusion can be performed in Jehovah's Witnesses without transfusion, but the procedure should be conducted only by the experienced spinal surgeon.     

Total hip arthroplasty in Jehovah's Witnesses without blood transfusion

One hundred patients who were Jehovah's Witnesses underwent total hip replacement without transfusion, of which eighty-nine procedures were performed under hypotensive anesthesia. Of these eighty-nine patients, sixty-five had not had previous hip surgery and sustained an average intraoperative blood loss of 450 milliliters. This was a 43 per cent reduction in blood loss as compared with a control group of patients, who were not Jehovah's Witnesses and who had total hip replacement under normotensive anesthesia. Twenty-four of the eighty-nine patients who were Jehovah's Witnesses and had had previous hip surgery underwent total hip arthroplasty under hypotensive anesthesia and sustained an average intraoperative blood loss of 680 milliliters, which was 30 per cent less than that of similar matched controls who were operated on under normotensive anesthesia. The postoperative blood loss in the patients who had had hypotensive anesthesia was not increased compared with that in the controls. Eleven Jehovah's Witnesses who were not candidates for hypotensive anesthesia had a total hip replacement under normotensive techniques. Factors other than hypotensive anesthesia that aided in reducing blood loss were careful surgical technique, meticulous hemostasis, and well planned surgery. There were six complications, one of which was possibly related to hypotensive anesthesia, and no deaths.     

Live donor liver transplantation for acute liver failure

BACKGROUND: Acute liver failure (ALF) carries a high mortality unless urgent orthotopic liver transplantation (OLT) is performed on time. Live donors are utilized to treat this irreversible condition first in pediatric cases and then in adults. Herein, we aimed to report our experience with live donors for ALF in a country of a deceased donor organ donation rate is only 1.5 per million people. METHODS: Among the 245 live donor liver transplantations (LDLT) performed from June 1999 to December 2005, 14 of them (6%) were performed for ALF in 8 pediatric and 6 adult cases. Right lobes were harvested for the adult cases whereas left lateral segments were harvested for pediatric cases, except one child transplanted with a right lobe graft. The etiology of the disease was; acute hepatitis B in four cases, hepatitis A in three cases, Wilson disease two cases, autoimmune hepatitis in two cases, and was unknown in three cases. RESULTS: Three-year graft and patient survival is 79% for these series. Five of the six adult patients and six of the eight pediatric cases survived after transplantation. There was not any donor mortality or major morbidity. CONCLUSIONS: LDLT offers a safe and effective modality of treatment for ALF for both pediatric and adult patients to overcome the problem of organ shortage especially in countries where the chance of receiving an organ from a deceased donor is low.     

Live donor liver transplantation.

With ever-increasing demand for liver replacement, supply of organs is the limiting factor and a significant number of patients die while waiting. Live donor liver transplantation has emerged as an important option for many patients, particularly small pediatric patients and those adults that are disadvantaged by the current deceased donor allocation system. Ideally there would be no need to subject perfectly healthy people in the prime of their lives to a potentially life-threatening operation to procure transplantable organs. Donor safety is imperative and cannot be compromised regardless of the implication for the intended recipient. The evolution of split liver transplantation is the basis upon which live donor transplantation has become possible. The live donor procedures are considerably more complex than whole organ decreased donor transplantation and there are unique considerations involved in the assessment of any specific recipient and donor. Donor selection and evaluation have become highly specialized. The critical issue of size matching is determined by both the actual size of the donor graft and the recipient as well as the degree of recipient portal hypertension. The outcomes after live donor liver transplantation have been at least comparable to those of deceased donor transplantation. Nevertheless, all efforts should be made to improve deceased donor donation so as to minimize the need for live donors. Transplant physicians, particularly surgeons, must take responsibility for regulating and overseeing these procedures.     

Live donor liver transplantation in adults

Live donor liver transplantation (LDLT) was initiated in 1988 for children recipients. Its application to adult recipients was limited by graft size until the first right liver LDLT was performed in Hong Kong in 1996. Since then, right liver graft has become the major graft type. Despite rapid adoption of LDLT by many centers, many controversies on donor selection, indications, techniques, and ethics exist. With the recent known 11 donor deaths around the world, transplant surgeons are even more cautious than the past in the evaluation and selection of donors. The need for routine liver biopsy in donor evaluation is arguable but more and more centers opt for a policy of liberal liver biopsy. Donation of the middle hepatic vein (MHV) in the right liver graft was considered unsafe but now data indicate that the outcome of donors with or without MHV donation is about equal. Right liver LDLT has been shown to improve the overall survival rate of patients with chronic liver disease, acute or acute-on-chronic liver failure and hepatocellular carcinoma waiting for liver transplantation. The outcome of LDLT is equivalent to deceased donor liver transplantation despite a smaller graft size and higher technical complexity.     

Live donor nephrectomy for kidney transplantation

The number of patients with end-stage renal disease is increasing substantially every year around the world. Renal transplantation is the best treatment option to improve survival and quality of life. Although the numbers of living, related and deceased transplant donors has also increased, this growth is insufficient to keep up with the expansion rate of the renal failure population. The introduction of laparoscopic donor nephrectomy has gained widespread acceptance by physicians and patients, and seems to be better than open donor nephrectomy in terms of reduced postoperative pain, quick recovery and improved cosmetic outcomes. Evidence strongly suggests that graft survival is similar in recipients of kidneys from living related and unrelated donors. Fortunately, this information has raised awareness of the suitability of potential live, unrelated donors, including spouses, friends, or even anonymous donors. In this Review we touch on sociological aspects of living related kidney transplantation and review the available and proposed methods of increasing the live donor pool, including organ exchange and desensitization protocols for ABO-incompatible and cross-match-positive donor pairs.     

Live donor adult liver transplantation using right lobe grafts: donor evaluation and surgical outcome

HYPOTHESIS: Live donor adult liver transplantation (LDALT) is a safe and efficacious treatment for patients with end-stage liver disease. DESIGN: Case-control study. SETTING: Hepatobiliary surgery and liver transplantation unit. PATIENTS: From December 10, 1998, through April 10, 2000, a single team performed 15 LDALT procedures with 2 simultaneous living donor kidney transplants. During this period, 66 potential donors were screened and evaluated. INTERVENTIONS: Potential donors were evaluated with 3-dimensional helical computed tomographic scan, including volume renderings for hepatic lobar volume, vascular anatomy, virtual resection planes, and morphologic features. Suitable donors undergo complete medical and psychiatric evaluation and preoperative arteriography. MAIN OUTCOME MEASURES: Donor demographics, evaluation data, operative data, hospital length of stay, and morbidity. RESULTS: A total of 38 men (58%) and 28 women (42%) were evaluated with 15 donors participating in LDALT. Two additional donors provided kidney grafts for simultaneous transplantation at the time of LDALT. Thirty-two donors (48%) were rejected for either donor or recipient reasons, and 10 patients (15%) elected not to participate after initial screening. Three-dimensional volume renderings by helical computed tomographic scan predicted right lobe liver volume within 92% of actual graft volume. Donor morbidity, including all complications, was 67% with no mortality. Residual liver regenerated to approximately 70% of initial volume within 1 week and 80% within 1 month after surgery. CONCLUSIONS: Donor evaluation is an important component of LDALT. Significant donor morbidity is encountered even with careful selection. To minimize donor morbidity, groups considering initiating living donor programs should have expertise in hepatic resection and vena cava preservation using the "piggyback" technique during liver transplantation.     

Blood transfusion and Jehovah's Witnesses revisited: Implications for surgeons

The refusal of blood transfusion and blood products is becoming more common. Jehovah's Witnesses are notably known to be deeply convicted in this doctrine. Doctors are bound in their practice by codes of ethics as to their professional conduct. When it comes to lifesaving situations where transfusion is absolutely needed, a conflict arises between the doctor's professional duty to save lives and the right of autonomy of the patient to his body. This article discusses the background of this conflict, suggested solutions, the legal precedents and how the authorities can help to handle this difficult dilemma for the frontline clinician, with specific reference to the existing situation in Hong Kong.     

Avoiding blood products during liver transplantation

Liver transplantation is a major surgical procedure usually requiring large amount of blood products (red cells, platelets, fresh-frozen plasma). We developed a multidisciplinary transfusion-free protocol for liver transplantation in Jehovah's witnesses who refuse the use of blood products but accept organ transplantation. Between September 1998 and November 2004, 9 of 29 Jehovah's witnesses evaluated for liver transplantation were transplanted after medical preparation. None of these patients received any blood product during the surgical procedure. This experience may be beneficial for the entire liver transplantation population, as excessive transfusion has been linked to increased morbidity and mortality in liver transplantation.     

Association of Anaesthetists: anaesthesia and peri-operative care for Jehovah's Witnesses and patients who refuse blood

There are approximately 8.5 million Jehovah's Witnesses and around 150,000 live in Great Britain and Ireland. Based on their beliefs and core values, Jehovah's Witnesses refuse blood component transfusion (including red cells, plasma and platelets). They regard non-consensual transfusion as a physical violation. Consent to treatment is at the heart of this guideline. Refusal of treatment by an adult with capacity is lawful. The reasons why a patient might refuse transfusion and the implications are examined. The processes and products that are deemed acceptable or unacceptable to Jehovah's Witnesses are described. When a team is faced with a patient who refuses transfusion, a thorough review of the clinical situation is advocated and all options for treatment should be explored. After discussion, a plan should then be made that is acceptable to the patient and appropriate consent obtained. When agreement cannot be reached between the doctor and the patient, referral for a second opinion should be considered. When the patient is a child, the same strategy should be used but on occasion the clinical team may have to obtain legal help.     

肝脏血管解剖与活体肝移植供者选择

目的 研究肝脏血管解剖对选择活体肝移植供者的影响.方法 总结分析312名健康成年人接受活体供肝移植供者评估的临床资料,其中男性278名,女性34名,年龄18～63岁,平均年龄29.3岁.所有受评估者均接受CT强化检查,并进行三维血管重建,观察肝脏血管走行,从而归纳出血管解剖对活体肝移植供者选择的影响.并观察其术后效果.结果 312名受评估者中,肝中动脉起源于肝左动脉的有218名(占69.9%).起源于肝右动脉的有89名(占28.5%),直接起源于肝总动脉的有5名(占1.6%).受评估者具有变异动脉的共有78名(占25%),其中具有副肝左动脉29名,具有副肝右动脉10名,具有替代肝左动脉29名,具有替代肝右动脉38人,其中多人同时具有两支变异动脉.门静脉的分型依据京都大学分型标准,门静脉I型有265名(占84.9%),Ⅱ型有25名(占8%),Ⅲ型有16名(占5.1%),Ⅳ型有6名(占2%),未发现门静脉V型者.Ⅳ段肝静脉汇入肝中静脉的有88名(占28.2%),汇入肝左静脉的为7名(占2.2%),汇入肝中静脉和肝左静脉的共有217名(占69.6%).共有221名受评估者具有右下静脉(占70.8%),其中89例具有两支及两支以上右下静脉.最终有194名受评估者作为肝移植供者接受了手术.结论 肝动脉具有较高的变异率;有Ⅰ～Ⅲ型门静脉者均可作为活体肝移植供者的选择条件;准确了解供肝血管解剖及正确的手术设计是保证活体肝移植供、受者手术成功的先决条件.     

腹腔镜活体肝移植供肝切取术的临床应用进展

活体肝移植的开展不仅扩大了供者数量,有效缓解器官捐献不足,也降低了患者等待肝移植期间的病死率。近年来,随着腹腔镜技术和器械的不断发展,腹腔镜供肝切取术在活体肝移植领域的应用日益广泛,也是该领域的研究热点之一,其具有创伤小、疼痛少、供者术后恢复迅速且心理负担小等优点。但由于其对供者筛选严格、操作复杂、学习曲线长,目前仍然只在少数移植中心得以开展。本文从腹腔镜活体肝移植供肝切取术的发展历史与现状、具体术式及存在的问题与挑战进行介绍,展望腹腔镜供肝切取术的未来发展方向,为促进其在活体肝移植中的进一步发展,改善活体肝移植预后提供参考。     

Live donor partial liver harvest for canine liver transplantation: development of an innovative technique for surgical training and research

Abstract. Purpose. Most models of canine segmental liver transplantation use about 40% of the total liver volume including the left lateral and medial segments, an approach which is associated with some shortcomings. First, during live donor harvest, a necrotic segment requiring further resection is unavoidable after removal of the donor segments; and second, to harvest the left lobe, two dissection planes must be used. This creates some technical bias and limitations in designing a canine research model. Herein, we report a new technique of harvesting up to 70% of the liver in dogs. Methods: The right medial and quadrate segments, the left lobe, and the papillary process of the caudate lobe were resected and harvested for transplantation. We divided the middle hepatic vein to enable a single parenchymal dissection between the right medial and lateral segments and no perfusion defect was seen. Using this technique, we performed orthotopic autoauxiliary transplantation (n= 6) and orthotopic alloauxiliary transplantation (n= 5) in dogs. Results: All dogs transplanted with an autograft were alive at the completion of surgery. All donor dogs providing 70% of the liver volume for allografts were alive 1 week after surgery, and all five allograft recipient dogs were alive 48 h after surgery, at which point they were killed. Conclusions: This novel experimental technique of partial living donor liver transplantation using about 70% of the liver allows for easier harvest and effective live donor partial liver transplantation. Moreover, the fact that division of the liver parenchyme can be done without leaving a necrotic segment shows the possibilities for various research models of ischemic-reperfusion injury. This technique allows us to divide the liver in situ, then subject the right segment of the liver to various insults or remedies for comparison. Received: December 11, 2000 / Accepted: March 5, 2002