Jessica Walter

Long-term Outcome of Split Liver Transplantation Using Right Extended Grafts in Adulthood: A Matched Pair Analysis

Objective:Shortage of suitable organs led to the development of alternative techniques in liver transplantation. Split liver transplantation (SLT) is well established in pediatric patients. SLT is not completely accepted in adult recipients due to potential increased risk of complications. Despite satisfying results of short-term outcome, there is a leak on information of the long-term outcome. Therefore, we compared the outcome after transplantation of the right extended liver lobe with whole liver transplantation (WLT) using a matched pairs analysis. Patients and Methods:From the period of January 1993 to February 2005, 70 SLT recipients were matched with 70 WLT recipients of whole livers. Matching criteria were: 1) indication for transplantation, 2) United Network for Organ Sharing (UNOS) status, 3) recipient age, 4) donor age, 5) cold ischemic time, and 6) year of transplantation. The outcome was analyzed retrospectively. Results:Mean follow-up was 36 months. The 2- and 5-year patient survival rates after SLT and WLT were 86.3% and 82.6%, and 78.4% and 75.6%, respectively (log rank, P = 0.2127). Two- and 5-year graft survival rates were 77.3% and 77.3% after SLT and 71.9% and 65.8% after WLT, respectively (log rank, P = 0.3822). The total biliary complication rate was 11.4% in the SLT group versus 10.0% in the WLT group in the short-term course, while it was 8.5% after SLT and 10.0% after WLT in the long-term course. We did not observe significant differences between the groups in term of short- and long-term morbidity. Conclusion:Transplantation of the right extended lobe deriving from left lateral splitting of deceased donor livers is followed by the same long-term patient and graft survival, which is known from WLT. There were no differences in the complication rates even in long-term outcome implementing that SLT does not put the adult recipient to an increased early and late risk. Transplantation of the extended right liver lobe provides a safe and efficient procedure in adult patients to expand the number of available grafts.

The first two cases of living donor liver transplantation using dual grafts in Europe

The major limitation in adult‐to‐adult living donor liver transplantation (LDLT) is an adequate graft size with special regard to the safety of the donor. Only 20% of the evaluated donors are suitable to donate the right liver, depending mainly on the critical remnant liver volume. We report 2 cases of adult‐to‐adult LDLT using dual grafts. In the first case we implanted a left lateral lobe together with a left lobe; in the second case we used a left lateral and a right lobe. Dual graft LDLT solves the problem of graft‐size insufficiency and avoids critical right lobectomy in the donor. This procedure can be safely performed and opens up the possibility of LDLT to even more families in the Western world. Liver Transpl 13:149–153, 2007.

Overcoming the portal steal phenomenon in auxiliary partial orthotopic liver transplantation by modulation of the venous outflow of the native liver.

The main drawback of auxiliary partial orthotopic liver transplantation (APOLT) is the competition of the portal flow between the graft and the native liver, leading to graft failure. In two patients with Crigler‐Najjar syndrome type I, the intrahepatic resistance of the native liver was increased by occluding the recipients middle hepatic vein during parenchymal transection, leading the portal flow towards the graft. This new surgical technique could encourage centers to recommence APOLT. (Liver Transpl 2005;11:1140–1143.)

Invasive aspergillosis caused by Aspergillus terreus in a living donor liver transplant recipient successfully treated by caspofungin.

Invasive aspergillosis is one of the most severe complications after liver transplantation characterised by early dissemination of disease and high mortality. Recent data show that the prognosis is diminishing even further when Aspergillus terreus, a strain resistant to standard treatment with amphotericin, is isolated. We report a high risk liver transplant recipient with multiple co‐morbidities including renal failure and allograft dysfunction in whom pulmonary aspergillosis due to A. terreus was successfully treated by the echinocandin antifungal agent caspofungin.

The accuracy of estimations of liver volume

The accurate measurement of the standard liver volume (SLV) is important with respect to the estimation of an adequate graft size for partial liver transplantation, such as split liver transplantation or living donor liver transplantation (LDLT). A major objective is to prevent the occurrence of the syndrome that has been designated small-for-size liver syndrome. This syndrome concerns not only the graft size but also complications, such as prolonged cholestasis, coagulopathy, portal hypertension, and ascites. The syndrome leads to impaired graft survival. The numerous equations that are available and have been applied to calculate SLV make comparisons of the results of different relevant studies complicated. One of the best known equations for calculating SLV is the one attributed to Urata that was published in 1995:

Current status of hepatic transplantation

n extensive knowledge of hepatic anatomy is required for the transplant urgeon. For explantation and implantation of the whole liver graft, the nterest is focused on the hilar structures placed in the gastroduodenal igament, with the proper hepatic artery located ventromedially, the ommon bile duct running ventrolaterally, and the main portal vein orsally, and also the extrahepatic course of the hepatic veins. Despite ew variations, venous drainage into the inferior vena cava (IVC) consists f the right hepatic vein and the common trunk arising from the onfluence of the left and middle hepatic vein. Regarding segmental liver transplantation, a closer examination of the unctional and intrahepatic anatomy of the liver is recommended. The egmentation of the liver was primarily described by Couinaud in 1957 nd forms the basis of splitting a liver graft. The 8 described segments are ased on the vertical division of the liver by the 3 hepatic veins in portal ectors and the horizontal segmenting by the portal pedicles. Functionlly, the main portal fissure divides the liver along the line of Cantlie in he right (segments V-VIII) and left hemiliver (segments I-IV), which are upplied by the right and left hepatic artery and portal vein, respectively. egarding the contribution of the liver volume, the right hemiliver generally rovides two thirds and the left lobe one third of the total liver volume, which ypically represents at least 2% to 2.7% of the body weight. he Left Liver Lobe (Segments I-IV)