Shin Hwang

CONGESTION OF RIGHT LIVER GRAFT IN LIVING DONOR LIVER TRANSPLANTATION

Background. Left liver graft from a small donor will not meet the metabolic demands of a larger adult recipient. One solution to this problem is to use a right liver graft without a middle hepatic vein (MHV). However, the need for drainage from the MHV tributaries has not yet been described. Methods. Five right liver grafts without a MHV were transplanted in patients including two hepatitis B virus-cirrhosis, two fulminant hepatic failure and one secondary biliary cirrhosis. The graft weight ranged from 650 to 1000 g, corresponding to 48 to 83% of the standard liver volume of the recipients. Results. Two of five recipients were complicated with severe congestion of the right median sector immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction. One of the patients died of sepsis with progressive hepatic dysfunction 20 days after the operation. Conclusions. Preservation and reconstruction of the MHV tributaries is recommended to prevent congestion of the right liver graft without MHV.

Lessons learned from 1,000 living donor liver transplantations in a single center: how to make living donations safe.

Serious complications have occurred in a considerable proportion of living donors of liver transplants, but data from a single high‐volume center has rarely been available. We analyzed the medical records of donors and recipients of the first 1,000 living donor liver transplants, performed at Asan Medical Center from December 1994 to June 2005, with a focus on donor safety. There were 107 pediatric and 893 adult transplants. The most common diagnoses were biliary atresia in pediatric recipients (63%) and hepatitis B‐associated liver cirrhosis (80%) in adult recipients. Right lobe donors were strictly selected based on liver resection rate and steatosis. From 1,162 living donors, 588 right lobes, 6 extended right lobes, 7 right posterior segments, 464 left lobes, and 107 left lateral segments were obtained. Of these, 837 grafts were implanted singly, whereas 325, along with 1 cadaveric split graft, were implanted as dual grafts into 163 recipients. The 5‐yr survival rates were 84.8% in pediatric recipients and 83.2% in adult recipients. There was no donor mortality, but 3.2% of donors experienced major complications. Until the end of 2001, the major donor complication rate was 6.7%, with most occurring in right liver donors. Since 2002, liver resection exceeding 65% of whole liver volume were avoided except for young donors with no hepatic steatosis, and the donor complication rate has been reduced to 1.3%. In conclusion, a majority of major living donor complications appear to be avoidable through the strict selection of living donor and graft type, intensive postoperative surveillance, and timely feedback of surgical techniques. Selection of right lobe graft should be very prudently considered if the donor right liver appears to be larger than 65% of the whole liver volume. Liver Transpl 12:920–927, 2006.

Liver transplantation for adult patients with hepatocellular carcinoma in Korea: Comparison between cadaveric donor and living donor liver transplantations

Current selection criteria of liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) were derived from the outcomes of cadaveric donor LT (CDLT). We tried to assess the applicability of such criteria to living donor LT (LDLT) through a comparative study between CDLT and LDLT. We analyzed the outcomes of 312 HCC patients who underwent LT at 4 Korean institutions during 1992 to 2002. There were no gross differences of tumor characteristics between CDLT group (n = 75) and LDLT group (n = 237). Overall 3‐year survival rate (3‐YSR) was 61.1% after CDLT and 73.2% after LDLT including 38 cases of perioperative mortality. Comparison of HCC recurrence curves did not reveal any statistical difference between these 2 groups. Patient survival period till 50% mortality after HCC recurrence was 11 months after CDLT and 7 months after LDLT. Significant risk factors for HCC recurrence were alpha‐fetoprotein level, tumor size, microvascular invasion, gross major vessel invasion, bilateral tumor distribution, and histologic differentiation in the LDLT group on univariate analysis, and tumor size, gross major vessel invasion, and histologic differentiation on multivariate analysis. Milan criteria were met in 70.4%: Their 3‐YSR was 89.9% after CDLT and 91.4% after LDLT with exclusion of perioperative mortality. University of California San Francisco criteria were met in 77.7%: Their 3‐YSR was 88.1% after CDLT and 90.6% after LDLT. In conclusion, we think that currently available selection criteria for HCC patients can be applicable to LDLT without change of prognostic power. (Liver Transpl 2005;11:1265–1272.)

Expanded indication criteria of living donor liver transplantation for hepatocellular carcinoma at one large‐volume center

The currently available indication criteria of living donor liver transplantation (LDLT) for patients with hepatocellular carcinoma (HCC) have high prognostic power but insufficient discriminatory power. On the basis of single‐center results from 221 HCC patients undergoing LDLT, we modified the indication criteria for LDLT to expand recipient selection without increasing the posttransplant recurrence of HCC. Our expanded criteria, based on explant pathology, were largest tumor diameter ≤ 5 cm, HCC number ≤ 6, and no gross vascular invasion. One hundred eighty‐six of the 221 HCC patients (84.2%) met our criteria, 10% and 5.5% more than those that met the Milan and University of California at San Francisco (UCSF) criteria, respectively. The overall 5‐year patient survival rates were 76.0% and 44.5% within and beyond the Milan criteria, respectively; 75.9% and 36.4% within and beyond the UCSF criteria, respectively; and 76.3% and 18.9% within and beyond our expanded criteria, respectively. Although these 3 sets of criteria had similar prognostic power, our expanded criteria had the highest discriminatory power. Thus, these expanded criteria for LDLT eligibility of HCC patients broaden the indications for patient selection and can more accurately identify patients who will benefit from LDLT. Liver Transpl 14:935–945, 2008.

Long‐term incidence, risk factors, and management of biliary complications after adult living donor liver transplantation

A considerable proportion of adult living donor liver transplantation (LDLT) recipients experience biliary complication (BC), but there are few reports regarding BC based on long‐term studies of a large LDLT population. The present study examined BC incidence, risk factors and management using single‐center data from 259 adult patients (225 right liver and 34 left liver grafts) between 2000 and 2002. The mean follow‐up period was 46 ± 14 months. Biliary reconstruction included single duct‐to‐duct anastomosis (DD, n = 141), double DD (n = 19), single hepaticojejunostomy (HJ, n = 67), double HJ (n = 28), and combined DD and HJ (n = 4). There were 12 episodes of anastomotic bile leak and 42 episodes of anastomotic stenosis in 50 recipients. Most leaks occurred within the first month, whereas stenosis occurred over 3 yr. Most stenoses were successfully treated using radiological intervention. Cumulative 1‐, 3‐, and 5‐yr BC rates were 12.9%, 18.2%, and 20.2%, respectively. BC occurred much more frequently in right liver grafts compared to left liver grafts (P = 0.024). Stenosis‐free survival curves for right liver graft recipients were similar for all reconstruction groups. When right liver graft recipients with single biliary reconstructions were grouped according to graft duct size and type of biliary reconstruction, DD involving a small‐sized duct (less than 4 mm in diameter) was found to be a BC risk factor (P = 0.015), whereas HJ involving such duct sizes was not found to be associated with a higher risk (P = 0.471). In conclusion, close surveillance for BC appears necessary for at least the first 3 yr after LDLT. We found that most BC could be successfully controlled using radiological intervention. In terms of anastomotic stenosis risk, HJ appears a better choice than DD for right liver grafts involving ducts less than 4 mm in diameter. Liver Transpl 12:831–838, 2006.

Modified right liver graft from a living donor to prevent congestion.

Background. Right liver grafts without middle hepatic vein (MHV) drainage reconstruction resulted in severe congestion of the anterior segment (AS) in our early experience of adult-to-adult living donor liver transplantation (LDLT). However, a detailed strategy for preventing such congestion or the necessity of MHV reconstruction has not been discussed in LDLT using a right lobe graft. Methods. From July 1997 to February 1998, two of five right lobe grafts without MHV drainage reconstruction were complicated with severe congestion of the AS. Thereafter, 42 adult recipients who received right liver grafts with sizable MHV tributaries underwent the reconstruction of MHV drainage. All sizable (>5 mm in diameter) MHV tributaries were preserved during donor hepatectomy and were reconstructed with the recipient’s autogenous interposition vein grafts at the bench surgery. The reconstructed vein grafts of this modified right lobe graft were anastomosed to the stump of the MHV and/or left hepatic vein of the recipient after graft revascularization. Results. Serial Doppler ultrasonography, which was regularly checked until 30 days posttransplant, revealed the patent interposition vein graft in 38 of 42 recipients (patency rate 90.5%). In these 38 recipients, no evidence of congestion in the AS was recognized on enhanced computed tomography, while providing enough functioning liver mass comparable to an extended right lobe graft. Also, congestion-related graft injury, such as an infarct of the AS, was not observed in these recipients. Conclusions. Our early experience indicated the necessity of MHV drainage reconstruction in right lobe grafts, which do not have MHV trunk in certain instances. However, preoperatively, it is difficult to predict the degree of AS congestion of the right liver graft without MHV drainage reconstruction. We suggest aggressive reconstruction of MHV drainage tributaries of the AS, under the circumstances that sizable MHV tributaries are encountered, to prevent possible congestion-related complications.

Salvage living donor liver transplantation after prior liver resection for hepatocellular carcinoma

Salvage liver transplantation has been performed for recurrent hepatocellular carcinoma (HCC) or deterioration of liver function after primary liver resection. Because prior liver resection per se is an unfavorable condition for living donor liver transplantation (LDLT), we assessed the technical feasibility of LDLT after prior hepatectomy, and we compared the outcome of salvage LDLT with that of primary LDLT in HCC patients. Of 342 patients with HCC, 17 (5%) underwent salvage LDLT, with 5 having undergone prior major liver resection and 12 prior minor resection. During salvage LDLT, 12 patients received right lobe grafts, 3 received left lobe grafts, and 2 received dual grafts. There was 1 incident (5.9%) of perioperative mortality. Recipient operation time was not prolonged in patients undergoing salvage LDLT, but bleeding complications occurred more frequently than in patients undergoing primary LDLT. Overall survival rates after salvage LDLT were similar to those after primary LDLT, especially when the extent of recurrent tumor was within the Milan criteria. These results indicate that every combination of prior hepatectomy and living donor liver graft is feasible for patients undergoing salvage LDLT, and the acceptable extent of HCC for salvage LDLT is equivalent to that for primary LDLT. Liver Transpl 13:741–746, 2007.

Sequential preoperative ipsilateral hepatic vein embolization after portal vein embolization to induce further liver regeneration in patients with hepatobiliary malignancy.

Objective:To assess the effect of ipsilateral hepatic vein embolization (HVE) performed after portal vein embolization (PVE) on liver regeneration. Summary Background Data:PVE induces shrinkage of the embolized lobe and compensatory enlargement of the non-embolized lobe, but it does not always induce sufficient liver regeneration. There was no effective method to accelerate liver regeneration in addition to PVE yet. Methods:During a 1-year study period, preoperative HVE were performed on 12 patients who had shown limited liver regeneration after PVE awaiting right hepatectomy. The right hepatic vein was embolized with multiple coils after insertion of vena cava filters or vascular plugs. Results:No HVE procedure-related complications occurred, but embolization of the wrong hepatic vein trunk occurred in 1 patient. The increase in blood liver enzymes after HVE was comparable with that after PVE alone. In 9 patients who underwent hepatectomy, the proportions of future liver remnant volume to total liver volume were 34.8% ± 1.5% before PVE, 39.7% ± 0.6% 1 to 2 weeks after PVE, 44.2% ± 1.1% 2 weeks after HVE, and 64.5% ± 6.2% 1 week after right hepatectomy. Cirrhotic livers showed lower regeneration rates following HVE after PVE and 1 patient underwent hepatectomy 17 months after HVE. Immunohistochemistry showed that apoptosis occurred more in the liver area affected by both PVE and HVE than in that affected by PVE alone. Conclusions:Preoperative sequential application of PVE and HVE seems to be safe and effective in facilitating contralateral liver regeneration by inducing more severe liver damage than PVE alone.

Toward 300 liver transplants a year.

The technical success of cadaveric whole-size liver transplantation and better immunosuppressive drugs has extended the application of this life-saving procedure to include patients with irreversible acute and chronic liver diseases. However, because of the scarcity of cadaveric liver grafts, living-donor liver transplantation (LDLT) has emerged as an alternative to cadaveric-donor liver transplantation (CDLT), especially in Asia. In Korea, 8% of the population are hepatitis B virus (HBV) carriers, and the resultant HBV cirrhosis, with or without hepatocellular carcinoma (HCC), is common in the 40- to 60-year-old generation. Accordingly, many patients require orthotopic liver transplantation (OLT). In 1992, we started performing CDLTs in the Asan Medical Center. In 1994, the first successful pediatric LDLT was performed in Korea, on a 9-monthold infant with biliary atresia. In 1997, the first successful adult LDLT was performed in our department, using a left lobe, on a 37-year-old patient with HBV cirrhosis associated with HCC. Even after the first successful right-lobe LDLT, we faced the obstacle of anterior segment congestion of a right-lobe graft, and initiated reconstruction of the middle hepatic venous tributaries of a right-lobe graft in 1998. In 1999, we performed more than 100 OLTs a year. Insufficient graft size has hindered the expansion of adult LDLT, when the remaining left-lobe of potential donors is too small to assure donor safety. Dual two-left-lobe graft LDLT (transplanting from two donors into one recipient) was developed in 2000 to solve graft-size insufficiency and minimize donor risk. More than 200 OLTs a year have been performed since 2004, while broadening the indications for adult LDLT to near complete obstruction of the portal vein, with the application of intraoperative portography (IOP) and portal vein stenting. In 2007, 320 LTs were performed, including 276 adult LDLTs, 10 pediatric LDLTs, and 34 CDLTs (including 7 adult and 1 pediatric split-liver transplant). There has been no donor mortality in LDLT. With technical refinement and advanced perioperative care, the in-hospital mortality of recipients has dropped to 4%: attributed to the dedication of our liver transplantation team members.

The effect of donor weight reduction on hepatic steatosis for living donor liver transplantation

Hepatic steatosis is often associated with overweight, so we tried body‐weight reduction in potential living donors with fatty liver and/or obesity to alleviate hepatic steatosis. We advised to reducing the body weight by 5% for 9 potential living donors showing hepatic steatosis of 25–95% on initial percutaneous needle biopsy (PCNB). They lost 5.9 ± 2.0% of the initial body weight during 2–6 months and their body mass index changed from 25.3 ± 3.8 to 23.7 ± 3.4. Total amount of hepatic steatosis changed significantly from 48.9 ± 25.6% to 20.0 ± 16.2% before and after weight reduction. The proportional reduction in microvesicular steatosis was more obvious than in macrovesicular fatty changes. Six right lobe and 3 left lobe grafts were procured uneventfully from these 9 donors. All donors recovered uneventfully, and all 9 recipients survived more than 15 months to date. In conclusion, we think that short‐term weight reduction of living donors will be helpful to alleviate excessive hepatic steatosis, especially in microvesicular type and can contribute to expand the pool of marginal living donors. (Liver Transpl 2004;10:721–725.)