Bh Yong

Determinants of Hospital Mortality of Adult Recipients of Right Lobe Live Donor Liver Transplantation

Objective: To define the technical factors that might contribute to hospital mortality of recipients of right lobe live donor liver transplantation (LDLT) so as to perfect the design of the operation. Summary Background Data: Right lobe LDLT has been accepted as one of the treatments for patients with terminal hepatic failure, but the design and results of the reported series vary and the technical factors affecting hospital mortality have not been known. Methods: The data of 100 adult-to-adult right lobe LDLT performed between 1996 and 2002 were prospectively collected and retrospectively analyzed. All grafts except one contained the middle hepatic vein, which was anastomosed to the recipient middle/left hepatic vein in the first 84 recipients and directly into the inferior vena cava (with the right hepatic vein in form of venoplasty) in the subsequent 15 patients. Venovenous bypass was used routinely in the first 29 patients but not subsequently. Results: Eight patients died within the same hospital admission for liver transplantation. There was no hospital mortality in the last 53 recipients. Comparison of data of patients with or without hospital mortality showed that graft weight/body weight ratio, graft weight/estimated standard liver weight ratio, technical error resulting in occlusion/absence of the middle hepatic vein, use of venovenous bypass, the lowest body temperature recorded during surgery, the volume of intraoperative blood transfusion, fresh frozen plasma, and platelet infusion were significantly different between the two groups. However, the pretransplant intensive care unit status of the recipients, cold and warm ischemic time of the graft, and occurrence of biliary complications were not. By multivariate analysis, low body temperature recorded during operation, low graft weight/estimated standard liver weight ratio (≤0.35), and the middle hepatic vein occlusion were independent significant factors in determining hospital mortality. Conclusions: To achieve a uniformly successful right lobe LDLT, the right lobe graft must contain a patent middle hepatic vein. With a completely patent middle hepatic vein, a graft size of >35% of the estimated standard graft weight may be sufficient for recipient survival. Hypothermia, which predisposes to coagulopathy and is enhanced by the use of venovenous bypass and massive blood, and blood product transfusion must be avoided.

Live-donor liver transplantation for acute-on-chronic hepatitis B liver failure.

Background. The survival results of patients demonstrating acute-on-chronic liver failure and undergoing live-donor liver transplantation (LDLT) have been reported to be poor. This study evaluates the survival outcomes of patients who underwent LDLT using right-lobe liver grafts for acute-on-chronic hepatitis B liver failure. Methods. The study comprised 32 patients who demonstrated acute-on-chronic hepatitis B liver failure with mean (± standard error of mean) Model for End-Stage Liver Disease scores of 36±1.8. The mean preoperative intensive care unit stay was 2.4 days. LDLT using a right-lobe liver graft including the middle hepatic vein was performed in all patients. Oral lamivudine 100 mg daily was used for hepatitis B prophylaxis. Results. The patients received liver grafts that were 52%±2% of the estimated standard liver weight. Hospital mortality occurred in two patients, and two other patients died on follow-up. At a median follow-up of 23 months, both patient and graft survival rates were 88%. The survival results were not different from those of 49 patients who underwent right-lobe LDLT for elective conditions during the same study period (graft survival=82%, P =0.55; patient survival=84%, P =0.75). Two (6.3%) patients developed hepatitis B virus DNA breakthrough 47 and 53 months, respectively, after transplantation, but they remained well after treatment with adefovir. Conclusion. Right-lobe LDLT is an effective therapeutic option for patients with acute-on-chronic hepatitis B liver failure. It results in satisfactory survival outcomes comparable to those in patients undergoing LDLT for elective conditions.

Right lobe living donor liver transplantation with or without venovenous bypass

Venovenous bypass was considered necessary to maintain haemodynamic stability and avoid splanchnic and retroperitoneal congestion during the anhepatic phase of liver transplantation. It was essential for right lobe living donor liver transplantation (LDLT) in which the inferior vena cava needed to be cross‐clamped to construct wide and short hepatic vein anastomoses. However, many complications related to venovenous bypass have been reported. This study aimed to determine whether venovenous bypass was necessary for right lobe LDLT.

Causes of hospital death in patients undergoing liver transplantation

Background The hospital mortality rate of liver transplantation is about 10%. The aim of this study was to identify the major factors that predispose to these deaths. Method and results Twelve of the first 90 patients (13%) who underwent liver transplantation at this hospital died within the same admission. Univariate analysis of the preoperative and intraoperative parameters showed that the volume of blood and blood product transfusion was the major factor related to hospital death. Conclusions Massive bleeding during liver transplantation predisposed to severe sepsis, organ failure and brain infarction. Reduction of bleeding and thus of the volume of blood and blood products transfused should be the primary goal to improve the results of liver transplantation.

Operative outcomes of adult-to-adult right lobe live donor liver transplantation: A comparative study with cadaveric whole-graft liver transplantation in a single center

OBJECTIVE To evaluate and compare the operative and survival outcomes of patients who underwent right lobe live donor liver transplantation (RLDLT) and cadaveric whole-graft liver transplant (CWLT) recipients in a single institution. SUMMARY BACKGROUND DATA Current data suggest that RLDLT has an inferior graft survival outcome when compared with CWLT. PATIENTS AND METHODS A prospective study was performed on 180 consecutive adult patients who underwent primary liver transplantation from January 2000 to February 2004. The operative and survival outcomes of RLDLT (n = 124) were compared with those of CWLT (n = 56). RESULTS Fifty-five (44%) and 16 (29%) patients were on high-urgency list in the RLDLT group and the CWLT group, respectively (P = 0.045). The preoperative Model for End-Stage Liver Disease scores were comparable in both groups. The waiting time for liver transplantation was significantly shorter in the RLDLT group. The graft weight to estimated standard liver weight ratio was significantly lower in the RLDLT group. The postoperative hospital stay and hospital mortality were comparable in the RLDLT group (1.6%) and the CWLT group (5.4%). Thirty-one (25%) patients in the RLDLT group and 3 (5%) patients in the CWLT group developed biliary stricture on follow-up (P = 0.002). At a median follow-up of 27 months, the actuarial graft and patient survival rates were 88% and 90%, respectively, in the RLDLT group, and both were 84% in the CWLT group. CONCLUSION RLDLT results in favorable operative outcomes comparable with those of CWLT. However, there is a significantly higher incidence of biliary stricture associated with RLDLT.