S. Hwang

Seventeen adult-to-adult living donor liver transplantations using dual grafts.

THE MAJOR limitation of adult-to-adult living donor liver transplantation (A-A LDLT) is the adequacy of the graft size. It has been known that 50% of the standard liver volume of the recipient is the minimum liver graft volume required to provide adequate functional hepatocytes. A left lobe from a relatively small volunteer donor will not meet the metabolic demands of a larger recipient. The possible solutions to this problem are to increase the extent of resection in the donor by harvesting the right lobe of the liver, which accounts for 60% to 70% of the total liver mass, to apply an auxiliary partial orthotopic liver transplantation (APOLT), or to implant dual grafts into one recipient. The right lobe harvest in the donor is not always safe, depending mainly on the volume of the remaining left lobe. Even though the donor has sufficiently large right lobe that is adequate as a graft for an adult recipient, the remaining left lobe may be too small to produce a threat to donor safety in many occasions. In this instance, the donor cannot be allowed to donate either side of the liver lobe for a large-size adult recipient. As an alternative, dual left lobe or left lateral segment from two living donors can solve the problem of graft-size insufficiency and guarantee donor safety. Furthermore, if the large-size recipient requires a bigger graft liver volume than the volume of the sum from two potential living donors’ left lobes, and if the right lobe harvested from one of two potential donors seems to be safe, one right lobe and one left lobe from two donors can be transplanted into a single recipient to avoid a small-forsize graft problem. The present study aims to introduce the usefulness of dual-graft A-A LDLT by review of our single-center experience.

Hepatic venous congestion in living donor liver transplantation: Preoperative quantitative prediction and follow‐up using computed tomography

Hepatic venous congestion (HVC) has not been assessed quantitatively prior to hepatectomy and its resolving mechanism has not been fully analyzed. We devised and verified a new method to predict HVC, in which HVC was estimated from delineation of middle hepatic vein (MHV) tributaries in computed tomography (CT) images. The predicted HVC was transferred to the right hepatic lobes of 20 living donors using a paper scale, and it was compared with the actual observed HVC that occurred after parenchymal transection and arterial clamping. The evolution of HVC from its emergence to resolution was followed up with CT. Volume proportions of the predicted and observed HVC were 31.7 ± 6.3% and 31.3 ± 9.4% of right lobe volume (RLV) (P = .74), respectively, which resulted in a prediction error of 3.8 ± 3.7% of RLV. We observed the changes in the HVC area of the right lobes both in donors without MHV trunk and in recipients with MHV reconstruction. After 7 days, the HVC of 33.5 ± 7.7% of RLV was changed to a computed tomography attenuation abnormality (CTAA) of 28.4 ± 5.3% of RLV in 12 donor remnant right lobes, and the HVC of 29.1 ± 11.5% of RLV was reduced to a CTAA of 9.3 ± 3.2% of RLV in 7 recipient right lobe grafts with MHV reconstruction. There was no parenchymal regeneration of the HVC area in donor remnant livers during first 7 days. In conclusion, we believe that this CT‐based method for HVC prediction deserves to be applied as an inevitable part of preoperative donor evaluation. The changes in CTAA observed in the right lobes of donors and recipients indicate that MHV reconstruction can effectively decrease the HVC area. (Liver Transpl 2004;10:763–770.)

Correlation of blood-free graft weight and volumetric graft volume by an analysis of blood content in living donor liver grafts

ASSESSMENT OF GRAFT SIZE is an essential step for living donor liver transplantation (LDLT). Preoperative evaluation by computed tomogram (CT) or magnetic resonance volumetry of living donor livers has been a routine procedure for matching graft sizes. Liver grafts are also weighed at the back table during the operation. At this time, there is usually a significant discrepancy between the graft volume from preoperative volumetry (volumetric graft volume) and the real graft weight. This difference can be caused by inaccurate volumetric measurement from improper CT images with some respiratory movement; its possibility cannot be negligible because even high-speed CT machines require breath-holding of about 20 seconds. Another possible cause can be the differences between the measurement plane of liver parenchyma used for volumetry and the real transection plane of the liver. However, neither the exact parenchymal transection along the preoperative measurement plane nor the repeated measurement of volumetry along the real transection plane after donor operation makes the volumetric graft volume exactly match the graft weight. Another possible cause is blood content itself in the graft, in which the graft weight measured at the back table is usually blood-free. We have measured the amount of blood in the grafts and analyzed the correlation between volumetric graft volume and graft weight. This observation may serve as an interchangeable bridge over blood-free graft weight and blood-filled graft volume.

Preoperative evaluation of biliary anatomy of donor in living donor liver transplantation by conventional nonenhanced magnetic resonance cholangiography

Detailed preoperative evaluation of the biliary anatomy of the donor in living donor liver transplantation (LDLT) can minimize postoperative morbidity in the recipient and maximize safety for the donor. We prospectively evaluated the diagnostic accuracy and clinical usefulness of nonenhanced conventional magnetic resonance cholangiography (MRC) for depicting the biliary anatomy of LDLT donors. MRC and intraoperative cholangiography (IOC) examinations of 111 donors were performed between August 2005 and February 2006. We observed the classical branching pattern of the biliary system in 67 subjects (60.4%), with the remaining 44 subjects (39.6%) showing anatomical variations. MRC showed accurate anatomy of the biliary system, using IOC as the reference standard, in 98 (88.3%) subjects. MRC had a sensitivity in differentiating normal from variant anatomy of 95.5%, specificity of 95.2%, a positive predictive value of 96.8% and a negative predictive value of 93.3%. The agreement between MRC and IOC findings, as evaluated by κ‐value (0.865) was statistically significant (P < 0.001). In conclusion, the diagnostic accuracy of conventional nonenhanced MRC is sufficient for this method to be used for the preoperative evaluation of biliary anatomy in LDLT donor candidates.

Successful Experiences of ABO-Incompatible Adult Living Donor Liver Transplantation In a Single Institute: No Immunological Failure in 10 Consecutive Cases

ABO-incompatible (ABOi) adult living donor liver transplantation (ALDLT) is a feasible therapeutic option for countries with a scarcity of deceased donors. This report presents our initial experiences in ABOi ALDLT in 10 patients between December 2008 and September 2009. The mean age of recipients was 48.5 ± 5.7 years (range, 40-54 years). The mean Model for End-stage Liver-Disease score was 13.9 ± 4.0 (range, 9-22). All patients were administered preoperative rituximab once and plasma exchanges according to the hemagglutinin titer. The spleen was preserved in all cases. For local infusion therapy, hepatic arterial infusion was performed in 9 patients and portal vein infusion in 1 subject. The 10 patients experienced no in-hospital mortality. At a mean follow-up period of 31.8 ± 2.9 months (range, 4.1-34.9 months), 1 patient has died (postoperative month 4 due to sepsis following a biliary stricture. The 3-month patient and graft survivals were 100%, and 1- and 2-year survivals, 90.0%. There was no episode of antibody-mediated rejection. The promising results of our initial experience may have been due to the use of preoperative rituximab and the good preoperative conditions of the patients.