Tolga Demirbas

Utilization of elderly donors in living donor liver transplantation: When more is less?†

An accepted definition of donor exclusion criteria has not been established for living donor liver transplantation (LDLT). The use of elderly donors to expand the living donor pool raises ethical concerns about donor safety. The aims of this study were (1) the comparison of the postoperative outcomes of living liver donors by age (≥50 versus <50 years) and (2) the evaluation of the impact of the extent of right hepatectomy on donor outcomes. The study group included 150 donors who underwent donor right hepatectomy between October 2004 and April 2009. Extended criteria surgery (ECS) was defined as right hepatectomy with middle hepatic vein (MHV) harvesting or right hepatectomy resulting in an estimated remnant liver volume (RLV) less than 35%. The primary endpoints were donor outcomes in terms of donor complications graded according to the Clavien classification. Group 1 consisted of donors who were 50 years old or older (n = 28), and group 2 consisted of donors who were less than 50 years old (n = 122). At least 1 ECS criterion was present in 74% of donors: 57% had 1 criterion, and 17% had 2 criteria. None of the donors had grade 4 complications or died. The overall and major complication rates were similar in the 2 donor age groups [28.6% and 14.3% in group 1 and 32% and 8.2% in group 2 for the overall complication rates (P = 0.8) and the major complication rates (P = 0.2), respectively]. However, there was a significant correlation between the rate of major complications and the type of surgery in donors who were 50 years old or older. In LDLT, extending the limits of surgery comes at the price of more complications in elderly donors. Right hepatectomy with MHV harvesting and any procedure causing an RLV less than 35% should be avoided in living liver donors who are 50 years old or older. Liver Transpl 17:548–555, 2011.

Hemophagocytic syndrome after living-related liver transplantation

Hemophagocytic syndrome (HPS) is a life-threatening hematological disorder in immunocompromised patients. Although the number of patients with HPS following liver transplantation is scarce the outcome is usually fatal. We report a patient who developed HPS following living-related liver transplantation (LRLT) and was treated successfully by a combination of intravenous (IV) immunoglobulin (Ig) and granulocyte colony-stimulating factor (GCSF).

Living donor liver hilar variations: surgical approaches and implications

BACKGROUND Varied vascular and biliary anatomies are common in the liver. Living donor hepatectomy requires precise recognition of the hilar anatomy. This study was undertaken to study donor vascular and biliary tract variations, surgical approaches and implications in living liver transplant patients. METHODS Two hundred living donor liver transplantations were performed at our institution between 2004 and 2009. All donors were evaluated by volumetric computerized tomography (CT), CT angiography and magnetic resonance cholangiography in the preoperative period. Intraoperative ultrasonography and cholangiography were carried out. Arterial, portal and biliary anatomies were classified according to the Michels, Cheng and Huang criteria. RESULTS Classical hepatic arterial anatomy was observed in 129 (64.5%) of the 200 donors. Fifteen percent of the donors had variation in the portal vein. Normal biliary anatomy was found in 126 (63%) donors, and biliary tract variation in 70% of donors with portal vein variations. In recipients with single duct biliary anastomosis, 16 (14.4%) developed biliary leak, and 9 (8.1%) developed biliary stricture; however more than one biliary anastomosis increased recipient biliary complications. Donor vascular variations did not increase recipient vascular complications. Variant anatomy was not associated with an increase in donor morbidity. CONCLUSIONS Living donor liver transplantation provides information about variant hilar anatomy. The success of the procedure depends on a careful approach to anatomical variations. When the deceased donor supply is inadequate, living donor transplantation is a life-saving alternative and is safe for the donor and recipient, even if the donor has variant hilar anatomy.

Biliary complications after right lobe living donor liver transplantation: a single-centre experience

BACKGROUND Biliary complications that developed after right lobe liver transplantation from living donors were studied in a single centre. METHODS From 2004 to 2010, 200 consecutive living donor right lobe liver transplantations were performed. The database was evaluated retrospectively. Biliary complications were diagnosed according to clinical, biochemical and radiological tests. The number of biliary ducts in the transplanted graft, the surgical techniques used for anastomosis, biliary strictures and bile leakage rates were analysed. RESULTS Of a total of 200 grafts, 117 invloved a single bile duct, 77 had two bile ducts and in six grafts there were three bile ducts. In 166 transplants, the anastomosis was performed as a single duct to duct, in 21 transplants double duct to ducts, in one transplant, three duct to ducts and in 12 transplants as a Roux-en-Y reconstruction. In all, 40 bile leakages (20%) and 17 biliary strictures (8.5%) were observed in 49 patients resulting in a total of 57 biliary complications (28.5%). Seventeen patients were re-operated (12 as a result of bile leakages and five owing to biliary strictures). CONCLUSION Identification of more than one biliary orifice in the graft resulted in an increase in the complication rates. In grafts containing multiple orifices, performing multiple duct-to-duct (DD) or Roux-en-Y anastomoses led to a lower number of complications.

Which Incision Is Better for Living-Donor Right Hepatectomy? Midline, J-Shaped, or Mercedes

Incision-related morbidity for donors is a major concern in living-donor right hepatectomy (LDRH). Open approaches use midline, J-shaped, and Mercedes incisions for LDRH. We retrospectively studied 95 consecutive donors who underwent LDRH between January 2009 and November 2010. They underwent midline (n = 32), J-shaped (n = 28), or Mercedes (n = 35) incisions. We studied resection times, perioperative bleeding, postoperative hospital stay, and postoperative pain assessed by the visual analog scale (VAS) and by analgesic requirements as well as laboratory data and complications. Postoperative analgesic requirements and postoperative VAS scores were significantly lower in the midline group (P < .05) upon univariate but not multivariate analyses. The postoperative complications as well as other parameters were similar between the groups. In conclusion, compared with a J-type shaped or not for Mercedes incision, a donor hepatectomy can be satisfactorily performed via a midline incision by experienced surgeons without increased risk.

Cryopreserved Aortic Quilt Plasty for One-Step Reconstruction of Multiple Hepatic Venous Drainage in Right Lobe Living Donor Liver Transplantation

Hepatic venous outflow should be maintained for the success of living right lobe liver transplantation. In cases when the right hepatic vein is not the dominant venous drainage, the anterior branch of the middle hepatic vein and the accessory hepatic veins should be adequately drained to preserve graft function. One-step reconstruction of the hepatic veins became a preferred technique to create separate outflow for each of the grafts veins. In this report, we have described a quilt plasty technique for 1-step reconstruction of living donor hepatic veins using cadaveric cryopreserved aorta and iliac vein grafts.

Ratio of remnant to total liver volume or remnant to body weight: which one is more predictive on donor outcomes?

BACKGROUND Right lobe donations are known to expose the donors to more surgical risks than left lobe donations. In the present study, the effects of remnant volume on donor outcomes after right lobe living donor hepatectomies were investigated. METHODS The data on 262 consecutive living liver donors who had undergone a right hepatectomy from January 2004 to June 2011 were retrospectively analysed. The influence of the remnant on the outcomes was investigated according to the two different definitions. These were: (i) the ratio of the remnant liver volume to total liver volume (RLV/TLV) and (ii) the remnant liver volume to donor body weight ratio (RLV/BWR). For RLV/TLV, the effects of having a percentage of 30% or below and for RLV/BWR, the effects of values lower than 0.6 on the results were investigated. RESULTS Complication and major complication rates were 44.7% and 13.2% for donors with RLV/TLV of ≤30%, and 35.9% and 9.4% for donors with RLV/BWR of < 0.6, respectively. In donors with RLV/TLV of ≤30%, RLV/BWR being below or above 0.6 did not influence the results in terms of liver function tests, complications and hospital stay. The main impact on the outcome was posed by RLV/TLV of ≤30%. CONCLUSION Remnant volume in a right lobe living donor hepatectomy has adverse effects on donor outcomes when RLV/TLV is ≤30% independent from the rate of RLV/BWR with a cut-off point of 0.6.

A new technique for the reconstruction of complex portal vein anomalies in right lobe living liver donors

Living donor liver right lobe transplantation using donors with variation of the right sectorial portal vein is considered a challenging procedure in terms of the donors safety and the complexity of reconstruction in the recipient. We describe an innovative technique to reconstruct double portal vein orifices via a deceased donor iliac vein graft. The postoperative course of the recipient was uneventful. Doppler ultrasound on the fourth postoperative month revealed equivalent flow in both portal vein branches. Reconstruction of double right portal vein branches using a cryopreserved iliac vein is a valuable technique for utilizing right lobe grafts with challenging portal vein anatomy.

General evaluation of hepatectomy and hepatocellular carcinoma cases.

OBJECTIVE Although the clinical and histopathological findings of hepatocellular carcinoma are well described, there are few national studies. In this study, we aimed to investigate the relationship between these findings in total or partial hepatectomy specimens in our series. MATERIAL AND METHOD We first collected 190 cases of total or partial hepatectomies performed because of hepatocellular carcinoma, cirrhosis or other disorders from the archives of Pathology. After re-examining the histopathological and clinical features such as age, gender and etiology, the relationship between them and serology results were statistically analyzed using the chi square and Multiple Comparison Tests. RESULTS Among 190 cases, there were 168 (88.5%) total and 18 (9.5%) partial hepatectomies and 4 (2%) tumorectomy or metastasectomy cases. After gross and microscopic examination, 170 (89.5%) cases had a diagnosis of cirrhosis, 85 (44.7%) hepatocellular carcinoma, 3 parasitic cyst, 7 metastasis, 1 hepatoblastoma, 1 hepatocellular adenoma, 2 cholangiocarcinoma, 2 Budd Chiari Syndrome, 1 focal nodular hyperplasia, 1 cavernous hemangioma, and 2 acute fulminant hepatitis. Among the hepatocellular carcinoma cases, 53 had Hepatitis B virus, 15 Hepatitis C virus , 3 Hepatitis B virus and Hepatitis C virus, and 3 Hepatitis B virus and Hepatitis delta virus etiology, while 6 were alcoholic and 4 were due to other causes. Among cirrhosis patients, 84 (49.4%) had hepatocellular carcinoma. The male to female ratio of hepatocellular carcinoma cases was 74/11. The mean age was 55 and the median age 56.7. CONCLUSION The results of this study demonstrated that the most common hepatic disorder was cirrhosis due to Hepatitis B virus in the hepatectomy specimens of our series that mostly consisted of total hepatectomies performed for transplantation where 50% had hepatocellular carcinoma.

Donor safety in adult-to-adult living donor liver transplantation.

LIVING DONOR liver transplantation (LDLT) is becoming an important treatment option for adult patients with progressive liver disease, due to the shortage of cadaveric donors. The procedure obviously shortens the waiting time, allowing for a better selection for and ideal timing of transplantation. The key to success of the enterprise depends on donor safety. The major concern is delivering an adequate liver volume to the recipient, on the one hand, while the remaining liver volume determines the donor’s postoperative outcome, on the other hand. Graft size is one important factor to avoid postoperative recipient liver failure. Application of LDLT for adult recipients has increased by using right lobe grafts, a procedure first described by Hashikura et al in 1994. Although a right hepatic lobe consists of about 50% to 60% of the donor’s total hepatic volume, the graft may still be too small for the recipient. In the present study, we analyzed the postoperative course of right lobe donor surgery on the basis of the residual hepatic volume.