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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.
________________________________________________________________
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.
________________________________________________________________
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
________________________________________________________________
Ann Surg. 1997 September; 226(3): 261–270.
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.
________________________________________________________________
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.
________________________________________________________________
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.
________________________________________________________________
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
________________________________________________________________
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.
________________________________________________________________
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.
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