Tung-Liang Huang

Evaluation of living liver donors.

Preoperative evaluation of donors for living-donor liver transplantation aims to select a suitable donor with optimal graft quality and to ensure donor safety. There are minor variations in the donor selection process among different centers, but the safety of the donor remains central to the entire process. The potential donors are evaluated in a stepwise manner including medical, physical, laboratory, psychosocial, and imaging assessment to disqualify unsuitable donors as early as possible in the evaluation process. The main goal of the imaging study is to provide an accurate picture of liver vascular anatomy and liver volume measurement for surgical guidance or for exclusion of unsuitable donors. All imaging studies can now be obtained using noninvasive modalities, thereby decreasing the risk associated with the donor evaluation process. This article describes the donor selection practice in our center including the details of the imaging evaluation.

Right Lobe Living Donor Liver Transplantation—Addressing the Middle Hepatic Vein Controversy

Objective To describe our approach in the decision-making for taking the middle hepatic vein with the graft or leaving it with the remnant liver in right lobe live donor liver transplantation. Summary Background Data Right lobe living donor liver transplantation has been successfully performed. However, the extent of donor hepatectomy is still a subject of debate and the main considerations in the decision making are graft functional adequacy and donor safety. Methods An algorithm based on donor-recipient body weight ratio, right lobe-to-recipient standard liver volume estimate, and donor hepatic venous anatomy was used to decide the extent of donor hepatectomy. This algorithm was applied in 25 living donor liver transplant operations performed between January 1999 and January 2002. In grafts taken without the middle hepatic vein, anterior segment tributaries draining into it were not reconstructed. Outcomes between right lobe liver transplants with (Group I) and without (Group II) the middle hepatic vein were compared. Results Ten grafts included the middle hepatic vein and 15 did not. The mean graft to recipient standard liver volume ratio was 58% and 64% in Groups I and II, respectively, and the difference was not statistically significant. Donors from both groups had comparable recovery, with 2 complications, 1 from each group, requiring a percutaneous drainage procedure. The recipient outcomes were, likewise, comparable and there was 1 case of structural outflow obstruction in Group I, which required venoangioplasty and stenting. There were 2 recipient mortalities, 1 due to a biliary complication and the other to recurrent hepatitis C. Another patient required retransplantation for secondary biliary cirrhosis. The overall actuarial graft and patient survival rates are 84% and 96%, respectively, at a median follow-up of 16 months. Conclusion Based on certain preoperative criteria, a right lobe graft can be taken with or without the middle hepatic vein with equally successful outcomes in both the donors and recipients. The decision, therefore, of the extent of right lobe donor hepatectomy should be tailored to the particular conditions of each case.

Minimal blood loss living donor hepatectomy.

BACKGROUND Donor hepatectomy with maximal safety while preserving graft viability is of principal concern in living donor liver transplantation. There are compelling reasons for avoiding blood transfusion, even with autologous blood, to avoid the potential risks it imposes on healthy donors. This study aims to describe the surgical technique and clinical outcomes of living donor hepatectomy with minimal blood loss requiring no blood transfusion. METHODS Donor hepatectomy was performed in 30 living donors according to a detailed preoperative imaging study of the vascular and biliary anatomy. Liver parenchymal transection was carried out with strict adherence to a meticulous surgical technique without vascular inflow occlusion to either side of the liver. Pre-, intra-, and postoperative data were gathered, and factors related to blood loss were analyzed retrospectively. RESULTS The intraoperative blood loss ranged from 20 to 300 ml with a mean of 72.0+/-58.9 ml (median, 55 ml), and neither homologous nor autologous blood transfusion was required in any of the donors intra- and postoperatively. All 30 donors were discharged with minimal complications, and remain well at a mean follow-up of 24 months after donation. Excellent graft viability was verified by the fact that all 30 recipients are alive and well with a few manageable complications. The actual graft and patient survival are both 100% at the time of writing. CONCLUSIONS Regardless of the extent of donor hepatectomy, blood loss can and should be kept to a minimum, and living donor hepatectomy without blood transfusion is a realistic objective.

Prevention of de novo hepatitis B virus infection in living donor liver transplantation using hepatitis B core antibody positive donors

Abstract: Exclusion of liver grafts from hepatitis B core antibody (anti‐HBc) positive donors to prevent de novo hepatitis B virus (HBV) infection after liver transplantation is not feasible in areas highly endemic for HBV virus like Taiwan, where approximately 80% of adults are anti‐HBc(+). The efficacy of lamivudine monotherapy to prevent de novo HBV infection after living donor liver transplantation (LDLT) using grafts from anti‐HBc(+) donors remains to be elucidated. From June 1994 to August 2000, LDLT was performed in 42 recipients. Twenty‐four of the 42 donors were anti‐HBc(+) (57%). Pre‐transplant HBV vaccination was given to all recipients irrespective of anti‐HBc status at monthly intervals for 3 months. Until December 1997, eight recipients received liver grafts from anti‐HBc(+) donors without prophylaxis. Since January 1998, prophylaxis with lamivudine monotherapy was given to 16 recipients receiving liver grafts from anti‐HBc(+) donors. De novo HBV infection occurred in three of the eight recipients (37.5%) who did not receive prophylaxis, while none of the 16 recipients given lamivudine developed de novo HBV infection after a mean follow‐up of 25 months. Two of the three recipients with de novo HBV infection were anti‐HBs(–) and one recipient was anti‐HBs(+). Lamivudine was well tolerated, and no side effects were noted. These results suggest that lamivudine monotherapy for recipients receiving anti‐HBc(+) liver grafts is a simple, relatively inexpensive and effective prophylactic regimen for prevention of de novo HBV infection. The additive protection provided by vaccine‐induced or natural immunity is uncertain.

Outflow tract reconstruction in living donor liver transplantation.

Background. Hepatic venous reconstruction is critical in living donor liver transplantation because outflow obstruction may lead to graft dysfunction or loss. We describe our e-perience and analyze outcomes with a technique of creating a single outflow tract using venoplasties of the graft and recipient hepatic veins. Patients and Methods. A retrospective study was done on 38 consecutive living donor liver transplants performed from June 1994 to March 2000. The grafts included 36 left-side grafts and 2 right-side grafts. Nine grafts had multiple hepatic veins and required a venoplasty of two or three hepatic veins to create a single outflow orifice. Triple recipient hepatic venoplasty was performed in 32 patients, double venoplasty in 5 and none in 1. Results. There were four cases of outflow obstruction, three occurring in patients with a double recipient venoplasty. Two of the problems were remedied intraoperatively by adjusting the position of the graft although two were structural in nature and required the insertion of expandable metallic vascular stents. All donors and recipients with their original grafts are alive at a mean follow-up period of 27 months. Conclusion. A triple recipient venoplasty with a matching venoplasty of multiple graft hepatic veins to create a single wide outflow orifice is recommended in living donor liver transplantation using left side grafts.

Living donor liver transplantation for hepatocellular carcinoma: a single-center experience in Taiwan.

Background. Living donor liver transplantation (LDLT) demonstrates certain survival benefits over deceased donor liver transplantation for hepatocellular carcinoma (HCC) but there is no consensus on criteria for the use of LDLT for HCC for hepatocellular carcinoma (HCC) taking into account strategies to improve survival. Methods. Thirty-five patients (89% men) underwent LDLT for HCC. The mean age was 51 years (range, 22–61). The median disease severity scores were B, 11–20, and 2B for Child-Turcotte-Pugh, Model for End-stage Liver Disease, and United Network for Organ Sharing, respectively. The transplant records were retrospectively analyzed. Results. All were within Milan criteria at time of transplantation. A novel approach to downstaging tumors initially beyond the Milan criteria was evaluated using transarterial embolization or percutaneous ethanol injection. Our initial results were encouraging as recipients whose tumors had been downstaged had not had recurrence to date. Seven (20%) patients underwent hepatectomy for HCC before undergoing transplant. The overall mean posttransplant follow-up in this series was 40.3 months (range, 23–75). The overall posttransplant complication rate requiring intervention was 11%. There was only one malignancy recurrence for an overall recurrence rate of 3%. Vascular invasion and small- for-size transplants did not seem to influence tumor recurrence. The nonestimated recipient 1-year, 3-year, and 5-year survivals were 98%, 96%, and 90%, respectively. Conclusion. This review emphasizes the need for early disease recognition and prompt intervention when Milan criteria are met to improve survival from HCC after LDLT.

Preoperative Imaging Evaluation of Potential Living Liver Donors: Reasons for Exclusion From Donation in Adult Living Donor Liver Transplantation

Accurate pretransplant evaluation of a potential donor in living donor liver transplantation (LDLT) is essential in preventing postoperative liver failure and optimizing safety. The aim of this study was to investigate the reasons for exclusion from donation of potential donors in adult LDLT. From September 2003 to June 2006, 266 potential donors were evaluated for 215 recipients: 220 potential donors for 176 adult recipients; 46 for 39 pediatric recipients. Imaging modalities including Doppler ultrasound, computerized tomography (CT), and magnetic resonance (MR) angiography provided vascular evaluation and MR cholangiopancreatography to evaluate biliary anatomy. Calculation of liver volume and assessment of steatosis were performed by enhanced and nonenhanced CT, respectively. In the adult group, only 83 (37.7%) potential donors were considered suitable for LDLT. Of the 137 unsuitable potential donors, 36 (26.2%) candidates were canceled because of recipient issues that included death of 15 recipients (10.9%), main portal vein thrombosis (8%), recipient condition beyond surgery (5%), and no indication for liver transplantation due to disease improvement (2%). The remaining 101 (73.8%) candidates who were excluded included steatosis (27.7%), an inadequate remnant volume (57.4%), small-for-size graft (8.9%), HLA-homozygous donor leading to one-way donor-recipient HLA match (3%), psychosocial problems (4%), as well as variations of hepatic artery (4%), portal vein (1%), and biliary system anatomy (5%). Anatomic considerations were not the main reason for exclusion of potential donors. An inadequate remnant liver volume (< 30%) is the crucial point for the adult LDLT decision.

Efficacy and Safety of Preoperative Lobar or Segmental Ablation via Transarterial Administration of Ethiodol and Ethanol Mixture for Treatment of Hepatocellular Carcinoma: Clinical Study

Abstract. Transarterial embolization (TAE) using various thrombotic substances for unresectable hepatocellular carcinoma (HCC) performed on many patients has resulted in a better survival rate. We evaluated the efficacy and clinical safety of using an Ethiodol–ethanol mixture as the embolizer for treatment of HCC and the possibility of a surgical approach for inoperable tumors after TAE. Twenty patients with HCC who underwent TAE and tumor resection were included in the study. Initially, eight had increased retention rate of indocyanine green dye via intravenous injection (0.5 mg/kg) at 15 minutes (ICGR15), and six had an insufficient residual volume that precluded them from undergoing tumor resection. TAE was performed by slowly infusing the mixture of Ethiodol and ethanol into the artery supplying the tumor until dual hepatic artery and portal vein embolization was achieved. Serum levels of alanine aminotransferase increased after embolization, but all biochemistry studies reverted to normal within 2 weeks. A decreased tumor size (n= 15), improved ICG (n= 8), and increased volume of the nonembolized lobe (n= 10) were noted. The operations performed were right lobectomy (n= 11), extended right lobectomy (n= 3), left lobectomy (n= 2), extended left lobectomy (n= 2), and wedge resection (n= 2), which included patients who did not want to undergo major hepatectomy. Complete tumor necrosis was found in seven cases. All patients survived with no associated complications. The 1-year survival rate was 95%. Transarterial Ethiodol and ethanol administration creating dual hepatic artery and portal vein embolization was a safe and efficacious method for treating HCC. It effectively decreases tumor size, causes compensatory hepatic hypertrophy, and improves the ICGR15, which allows a wider range of patients to undergo liver surgery and achieve better survival.

Hepatocellular Carcinoma Downstaging in Liver Transplantation

BACKGROUND Hepatocellular carcinoma (HCC) is the leading malignant tumor in Taiwan. The majority of HCC patients are diagnosed in late stages and therefore in eligible for potentially curative treatments. Locoregional therapy has been advocated as an effective treatment for patients with advanced HCCs. PURPOSE The aim of this study was to evaluate the outcomes of HCC downstaged patients after locoregional therapy to allow eligibility for liver transplantation. METHODS AND MATERIALS From January 2004 to June 2010, 161 patients with HCCs underwent liver transplantation including 51 (31.6%) who exceeded the University of California-San Francisco (UCSF) who had undergone successful locoregional therapy to be downstaged within these criteria. Among the downstaged patients, 48 (94.1%) underwent transarterial embolization; 7 (13.8%), percutaneous ethanol injection; 24 (47.1%), radiofrequency ablation; 15 (29.4%), surgical resection, and 34 (66.7%), combined treatment. RESULTS The overall 1- and 5-year survival rates of all HCC patients (n=161) were 93.2% and 80.5%. The overall 1- and 5-year survival rates of downstaged (n=51) versus non-downstaged (n=110) subjects were 94.1% versus 83.7% and 92.7% versus 78.9%, respectively (P=.727). There are 15 (9.2%) HCC recurrences. The overall 1- and 5-year tumor-free rates of all HCC patients were 94.8% and 87.2%. The overall 1- and 5-year tumor-free rates between downstaged versus non-downstaged patients were 93.9% and 90.1% versus 95.2% and 86.0%, respectively (P=.812). CONCLUSION Patients with advanced HCC exceeding the UCSF/Milan criteria can be downstaged to fit the criteria using locoregional therapy. Importantly, successfully downstaged patients who are transplanted show excellent tumor-free and overall survival rates, similar to fit-criteria group.

Outcome of living donor liver transplantation for glycogen storage disease.

GLYCOGEN storage diseases (GSD) are inherited disorders in which the amount and/or structure of glycogen in body tissues are abnormal. GSD I (von Gierke disease) is caused by a deficiency of glucose 6-phosphatase activity in the liver, kidney, and intestinal mucosa with glycogen overloading in these organs. The clinical manifestations are seizures, systemic acidosis, hyperlipidemia, hyperuricemia, and growth retardation. Without effective treatment, long-term complications occur, including gout, osteoporosis, short stature, and hepatic adenomas. GSD III (Cori disease) is caused by a deficiency of glycogen debranching enzyme activity and characterized with limit dextrin-like glycogen accumulated in both liver and muscle in most patients. Hepatomegaly, hypoglycemia, hyperlipidemia, and growth retardation are the main manifestations in children; while liver cirrhosis and /or hepatocellular carcinoma may occur later. Great progress in the management of GSD I and III has been made recently. For patients affected with GSD I, nocturnal nasogastric feeding of glucose or orally administered uncooked cornstarch is effective. With early diagnosis and initiation of treatment, normal growth and development may be expected. Some patients are free of long-term complications. Treatment of GSD III consists of highprotein diet, and frequent high carbohydrate meals for patients with hypoglycemia. Nocturnal gastric feeding or cornstarch supplements comprise effective therapy. However, some patients with GSD do not respond to diet therapy and may need frequent intravenous glucose infusions and even parenteral nutrition to maintain metabolic homeostasis. Liver transplantation (LT) is considered to correct the metabolic defects and the deleterious complications of GSD. LT for GSD I and III was first reported, respectively, by Malatack et al in 198 and by Superina et al in 1989. We present five cases of GSD (four GSD Ia; one GSD III), which were treated by living donor liver transplantation (LDLT) in our institution. These patients were unresponsive to medical therapy or developed serious complications of GSD. In this study we investigate the outcome of these children after LDLT for GSD. PATIENTS AND METHODS