مخاطر نقل الكبد الجزئي

نقل الكبد من الأحياء - Living Donor Liver Transplantation

 

 

مقالات اجنبية التى تظهر الحقائق التى يخفيها اطباء نقل الاعضاء حول نقل الكبد الجزئى من الاحياء :-

- اعتراف الاطباء بانهم تحــــولوا منذ عام 1994 الى استئـــصال الفص الايمــن من الكـــبد ( 65% ) من المتبرع بدلاً من الفص الايسر من الكبد (35% ) لانه اكبر حجماً ويحقق نتائج جيدة للمتلقى ( دون اى اعتبار لمصلحة المتبرع والخطر الذى يتعرض له):

 

 


World J Gastroenterol. 2007 Feb 14;13(6):955-9


Clinical study on safety of adult-to-adult living donor liver transplantation in both donors and recipients.
Liu B, Yan LN, Wang WT, Li B, Zeng Y, Wen TF, Xu MQ, Yang JY, Chen ZY, Zhao JC, Ma YK, Liu JW, Wu H.


Liver Transplantation Division, Department of Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.


AIM: To investigate the safety of adult-to-adult living donor liver transplantation (A-A LDLT) in both donors and recipients. METHODS: From January 2002 to July 2006, 50 cases of A-A LDLT were performed at West China Hospital, Sichuan University, consisting of 47 cases using right lobe graft without middle hepatic vein (MHV), and 3 cases using dual grafts (one case using two left lobe, 2 using one right lobe and one left lobe). The most common diagnoses were hepatitis B liver cirrosis, 30 (60%) cases; and hepatocellular carcinoma, 15 (30%) cases in adult recipients. Among them, 10 cases had the model of end-stage liver disease (MELD) with a score of more than 25. Donor screening consisted of reconstruction of the hepatic blood vessels and biliary system with 3-dimension computed tomography and volumetry of whole liver and right liver volume. Various improved surgical techniques were adopted in the procedures for both donors and recipients. RESULTS: Forty-nine right lobes and 3 left lobes (2 left lobe grafts for 1 recipient, 1 left lobe graft for 1 recipient who had received right lobe graft donated by relative living donor) were obtained from 52 living donors. The 49 right lobe grafts, without MHV, weighed 400 g-850 g (media 550 g), and the ratio of graft volume to recipient standard liver volume (GV/SLV) ranged from 31.74% to 71.68% (mean 45.35%). All donors' remnant liver volume was over 35% of the whole liver volume. There was no donor mortality. With a follow-up of 2-52 mo (media 9 mo), among 50 adult recipients, complications occurred in 13 (26%) cases and 4 (8%) died postoperatively within 3 mo. Their 1-year actual survival rate was 92%. CONCLUSION: When preoperative CT volumetry shows volume of remnant liver is more than 35%, the ratio of right lobe graft to recipients standard liver volume exceeding 40%, A-A LDLT using right lobe graft without MHV should be a very safe procedure for both donors and recipients, otherwise dual grafts liver transplantation should be considered.

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Surgery. 2006 Nov;140(5):749-55. Epub 2006 Aug 7.
Small remnant liver volume after right lobe living donor hepatectomy.
Ibrahim S, Chen CL, Wang CC, Wang SH, Lin CC, Liu YW, Yang CH, Yong CC, Concejero A, Cheng YF.


Liver Transplant Program, Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan.


BACKGROUND: Right lobe living donor liver transplantation has become a viable option for adult patients with end-stage liver disease, however, the safety of the donor is of paramount importance. One of the key factors in donor safety is ensuring adequate donor remnant liver volume. METHODS: We retrospectively examined donors who had less than 30% remnant liver volume after right graft procurement. Eighty-six right lobe living donor transplants were carried out in Chang Gung Memorial Hospital, Kaohsiung Medical Center, from January 1999 to December 2004. RESULTS: Eight donors had less than 30% remnant liver volume (Group 1) after graft procurement and 78 donors had remnant liver volume greater than 30% (Group 2). There were no differences in donor characteristics, types of graft, operative parameters, and post-operative liver and renal function as well as liver volume at 6 months post-donation between the 2 groups. The graft weight obtained in Group 1 donors was significantly greater compared with that from Group 2 (P<.005). The overall donor complication rate was 6.98%, and all the complications occurred among group 2 donors. CONCLUSIONS: The judicious use of donors with less than 30% remnant liver volume is safe as a last resort.

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Liver Transpl. 2006 Feb;12(2):201-6.
Outcome of donors with a remnant liver volume of less than 35% after right hepatectomy.
Cho JY, Suh KS, Kwon CH, Yi NJ, Lee HH, Park JW, Lee KW, Joh JW, Lee SK, Lee KU.


Department of Surgery, Seoul National University College of Medicine, Chongno-gu, Seoul, Korea.


To overcome the barrier of size match, right lobe graft has been widely used in living donor liver transplantation (LDLT). We assessed donor outcome, with a focus on remnant liver volume (RLV) after right hepatectomy based on the experiences of 2 LDLT centers, as a means of guiding the establishment of safe RLV limits for donor right hepatectomy. Between January 2002 and December 2003, a consecutive 146 liver donors who underwent right hepatectomy with at least 12 months of follow-up were enrolled in this study. Donors were grouped into 2 groups according to RLV: group 1 (n = 74), <35% (range, 26.9-34.9) and group 2 (n = 72), > or = 35% (35.0-46.8). No donors died or suffered a life-threatening complication. Mean peak serum postoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (IU/L) levels were 219.5 +/- 79.9 and 231.5 +/- 83.3 in group 1 and 210.3 +/- 81.6 and 225.8 +/- 93.0 in group 2 (P = 0.497 and 0.699), respectively. Mean peak serum total bilirubin (TB) (mg/dL) level in group 1 (3.4 +/- 1.6) was higher than in group 2 (2.8 +/- 1.4; P = 0.023). Overall 23 (15.8%) major morbidities, 10 in group 1 (13.5%) and 13 in group 2 (18.1%), occurred according to Clavien's system (P = 0.939). These included bleeding (n = 3 in group 1 and n = 6 in group 2; P = 0.282), ileus (n = 3 and 1; P = 0.324), biliary leakage (n = 4 and 4; P = 0.968), and pneumonia (n = 0 and 2; P = 0.149). Minor morbidities were also comparable in the 2 groups. In conclusion, the outcome of donors with an RLV of <35% was not different from that of donors with an RLV of > or = 35%, with the exception of transient cholestasis. Therefore, a remnant RLV of <35% does not appear to be a contraindication for right liver procurement in living donors. Copyright 2006 AASLD

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Ann Surg. 1997 September; 226(3): 261270.
Adult-to-adult living donor liver transplantation using extended right lobe grafts.
C M Lo, S T Fan, C L Liu, W I Wei, R J Lo, C L Lai, J K Chan, I O Ng, A Fung, and J Wong


Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.


Abstract
OBJECTIVE: The authors report their experience with living donor liver transplantation (LDLT) using extended right lobe grafts for adult patients under high-urgency situations. SUMMARY BACKGROUND DATA: The efficacy of LDLT in the treatment of children has been established. The major limitation of adult-to-adult LDLT is the adequacy of the graft size. A left lobe graft from a relatively small volunteer donor will not meet the metabolic demand of a larger recipient.

METHODS: From May 1996 to November 1996, seven LDLTs, using extended right lobe grafts, were performed under high-urgency situations. All recipients were in intensive care units before transplantation with five having acute renal failure, three on mechanical ventilation, and all with hepatic encephalopathy. The median body weight for the donors and recipients was 58 kg (range, 41-84 kg) and 65 kg (range, 53-90 kg), respectively. The body weights of four donors were less than those of the corresponding recipients, and the lowest donor-to-recipient body weight ratio was 0.62:1. The extended right lobe graft was chosen because the left lobe volume was <40% of the ideal liver mass of the recipient.

RESULTS: Median blood loss for the donors was 900 mL (range, 700-1600 mL) and hospital stay was 19 days (range, 8-22 days). Homologous blood transfusion was not required. Two donors had complications (one incisional hernia and one bile duct stricture) requiring reoperation after discharge. All were well with normal liver function 5 to 10 months after surgery. The graft weight ranged from 490 g to 1140 g. All grafts showed immediate function with normalization of prothrombin time and recovery of conscious state of the recipients. There was no vascular complication, but six recipients required reoperation. One recipient died of systemic candidiasis 16 days after transplantation and 6 (86%) were alive with the original graft at a median follow-up of 6.5 months (range, 5-10 months).

CONCLUSIONS: When performed by a team with experience in hepatectomy and transplantation, LDLT, using an extended right lobe graft, can achieve superior results. The technique extends the success of LDLT from pediatric recipients to adult recipients and opens a new donor pool for adults to receive a timely graft of adequate function.

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Am J Surg. 2005 Jul;190(1):87-97
How much liver resection is too much?
Mullin EJ, Metcalfe MS, Maddern GJ.


University of Adelaide, Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia 5011, Australia.


BACKGROUND: Hepatic failure occurring after liver resection carries a poor prognosis and is a complication dreaded by surgeons. Inadequate reserve in the remaining parenchyma leads to a steady decrease in liver function, inability to regenerate, and progression to liver failure. For this reason, many methods to quantify functional hepatic reserve have been developed.

METHODS: This article reviews the main methods used in the assessment of hepatic reserve in patients undergoing hepatectomy and their use in operative decision making.

RESULTS: A range of methods to categorically quantify the functional reserve of the liver have been developed, ranging from scoring systems (such as the Child-Pugh classification) to tests assessing complex hepatic metabolic pathways to radiological methods to assess functional reserve. However, no one method has or is ever likely to emerge as a single measure with which to dictate safe limits of resectability.

CONCLUSIONS: In the future, the role of residual liver function assessment may be of most benefit in the routine stratification of risk, thus enabling both patient consent to be obtained and surgical procedure to be performed, with full information and facts regarding operative risks. However, there is no one single test that remains conclusively superior.

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Am J Transplant. 2005 Nov;5(11):2605-10.
Small-for-size syndrome after partial liver transplantation: definition, mechanisms of disease and clinical implications.
Dahm F, Georgiev P, Clavien PA.


Department of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland.


Widespread application of cadaveric split or living donor liver transplantation bears considerable potential to increase the pool of available organs and thus alleviate the problem of organ shortage. Although splitting of a cadaveric liver into two grafts for adult recipients can be performed successfully, sufficient function of undersized grafts is a major concern. To minimize the risk for living donors, transplant surgeons aim at procuring the least necessary liver volume, also leading to potentially small grafts. When small partial grafts are unable to meet the functional demands, the recipients can develop a so-called small-for-size syndrome (SFSS). There is currently limited data on the pathogenesis of SFSS, with clinical studies mainly focusing on portal hyperperfusion. Additional aspects include graft-related factors such as functional and regenerative capacity, as well as recipient-related factors, such as overall health status and severity of cirrhosis. However, there is currently no consensus on the definition of SFSS. We propose a novel definition, based on simple clinical criteria, which divides the syndrome into either nonfunction or dysfunction of a small graft after the exclusion of other causes. This definition should ease comparability of future clinical trials, and thus improve understanding of the pathogenesis of SFSS.

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Liver Transpl. 2006 Jan;12(1):24-30.

Living donor liver transplantation--adult donor outcomes: a systematic review.
Middleton PF, Duffield M, Lynch SV, Padbury RT, House T, Stanton P, Verran D, Maddern G.


Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S), Royal Australasian College of Surgeons, SA.


The objective of this study was to evaluate the safety and efficacy of adult-to-adult living donor liver transplantation, specifically donor outcomes. A systematic review, with searches of the literature up to January 2004, was undertaken. Two hundred and fourteen studies provided information on donor outcomes. The majority of these were case series studies, although there were also studies comparing living donor liver transplantation with deceased donor liver transplantation. Both underreporting and duplicate reporting is likely to have occurred, and so caution is required in interpretation of these results. Overall reported donor mortality was 12 to 13 in about 6,000 procedures (0.2%) (117 studies). Mortality for right lobe donors to adult recipients is estimated to be 2 to 8 out of 3,800 (0.23 to 0.5%). The donor morbidity rate ranged from 0% to 100% with a median of 16% (131 studies). Biliary complications and infections were the most commonly reported donor morbidities. Nearly all donors had returned to normal function by 3 to 6 months (18 studies). In conclusion, there are small, but real, risks for living liver donors. Due to the short history of adult-to-adult living donor liver transplantation, the long-term risks for donors are unknown

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Transpl Int. 2005 Aug;18(8):915-22.
Donor outcome and liver regeneration after right-lobe graft donation.
Yokoi H, Isaji S, Yamagiwa K, Tabata M, Sakurai H, Usui M, Mizuno S,
Uemoto S.


First Department of Surgery, School of Medicine, Mie University, Mie, Japan. yokoi288@clin.medic.mie-u.ac.jp


Sufficiently detailed information on donor safety and the liver regeneration process following right-lobe living donation has been unavailable, so we evaluated donor outcome and liver regeneration in 13 males and 14 females (39.0 +/- 14.8 years old) who provided 27 right-lobe grafts without the middle hepatic vein. Preoperative total liver volume (TLV), graft volume, and postoperative changes in residual liver volume (RLV) were measured by volumetric computed tomography. Histological steatosis of the liver was graded as none, minimal (< or =10%), and mild (11-30%). The median follow-up period was 337 days. Estimated graft volume and actual graft weight were linearly correlated (Y = 177.85 + 0.795X, R(2) = 0.812, P < 0.0001). Graft-to-recipient weight ratio was 1.08 +/- 0.19%. Four donors had postoperative complications, but they resolved in response to conservative treatment. Postoperative hospital stay was 15.2 +/- 5.5 days. Peak liver enzyme values were significantly higher in donors with mild steatosis (n = 7) than without steatosis (n = 16) (P < 0.05). Donor RLV was 40.8 +/- 6.6% of original TLV at surgery, 79.8 +/- 12.0% by 6 months, and 97.2 +/- 10.8% by 12 months. At 3 months the liver of the older donors (> or =50 years) had grown significantly more slowly than in younger donors (70.4 +/- 9.2% vs. 79.3 +/- 9.6%, P = 0.0391). In conclusion, right hepatectomy without middle hepatic vein of living donors is a safe procedure with acceptable morbidity, and the residual liver regenerated to its preoperative size by 1 year. However, meticulous care should be taken in donors with liver steatosis and aged donors.

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Liver Transpl. 2004 Nov;10(11):1428-31
One-year morbidity after donor right hepatectomy.
Rudow DL, Brown RS Jr, Emond JC, Marratta D, Bellemare S, Kinkhabwala M.
Center for Liver Disease and Transplantation, New York Presbyterian Hospital, New York, NY 10032, USA. dl349@columbia .edu


Live donors are becoming an increasingly important source of donor organs in liver transplantation; however, long-term functional aspects of recovery from donor right hepatectomy are unknown. We analyzed donor outcomes at 1-year follow-up. We performed a single-center retrospective analysis of 70 right hepatectomy donors. Six-week and 1-year postoperative follow-up results were compared to preoperative baseline values. Ultrasonography was performed in all donors at 6 weeks and as clinically indicated. All donors were alive and well at the end of the study period. Of 66 right hepatic donors, only 22 (32%) were fully compliant with a 1-year follow-up visit. All those not compliant were contacted by phone. All complications except 1 (late finding of portal vein thrombosis) occurred in the perioperative (90-day) period. The incidence of bile leak was 4.3%, incisional hernia 20%, and autologous transfusion 1.0%. There were no aborted procedures. In those compliant with full 1-year follow-up, total bilirubin, aspartate aminotransferase, and alanine aminotransferase were normal in 97%. A total of 5 donors were noted to have persistence of asymptomatic thrombocytopenia beyond the perioperative period (90 days). These were investigated with Doppler sonography. Sonography was unremarkable in 3 of the 5, while 2 had abnormal findings: splenomegaly alone in 1, and splenomegaly with portal vein thrombosis in the other. Magnetic resonance angiography was performed in both, and the patient with portal vein thrombosis underwent endoscopy, which failed to reveal varices. Neither has clinical portal hypertension. Both remain asymptomatic albeit with stable thrombocytopenia. In conclusion, the majority of complications after donor right hepatectomy occur in the perioperative period. Later findings may include asymptomatic thrombocytopenia, with an incidence possibly as high as 23%, though the significance of this finding remains uncertain. Larger-scale studies are needed to confirm the true incidence and clinical significance of persistent thrombocytopenia in the donor hepatectomy population. Strategies to improve compliance with 1-year follow-up visits need to be developed.