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An adult-to-adult living donor liver transplant using dual left lobe grafts
Surgical technique An adult-to-adult living donor liver transplant using dual left lobe grafts SungGyu Lee, MD, Shin Hwang, MD, KwangMin Park, MD, YoungJoo Lee, MD, DongLak Choi, MD, ChulSoo Ahn, MD, YangWon Nah, MD, KyungSuck Koh, MD, SangHoon Han, MD, SangHoon Park, MD, and PyungChul Min, MD, Seoul, Korea
From the Department of Surgery, Asan Medical Center, Ulsan University Medical School, Seoul, Korea
THE SHORTAGE OF CADAVERIC donor livers has stimulated the development of advanced surgical approaches such as living donor liver transplantation (LDLT), which produces the same results as cadaveric organ replacement. However, insufficient graft size has been a major obstacle to expanding the use of adult-to-adult LDLT when the donor graft is taken only from the left lobe. To successfully expand LDLT to adult recipients, right lobe grafts have been used, but the risk to the donor is still unknown. The safety of right lobectomy varies, depending mainly on the volume of the remaining left lobe.1 Although a donor has a relatively large right lobe that is suitable as a graft for a larger recipient, the remaining left lobe may be too small to maintain a donor’s life in many instances. In this particular circumstance, the donor cannot be accepted to donate the left or right liver for a larger-size recipient. As an alternative, dual left lobe grafts from 2 living donors into 1 recipient can make up for graft size insufficiency and secure the donors’ safety. In this case report, we describe our experience of an adult-to-adult LDLT using dual left lobe grafts from 2 living donors.
disease and LDLT was planned using the left or right liver lobe of his 38-year-old brother (height 178 cm, weight 84.5 kg). The standard liver volume (SLV) of the recipient was calculated to be 1314 mL.2 Volumetric computed tomography (CT) analysis of the donor’s liver showed that his left and right lobe had a volume of 360 mL and 962 mL, respectively; these were 27% and 73%, respectively, of the SLV estimated for the recipient. The left lobe of the donor was too small to meet the metabolic demands of the recipient. The right lobe of the donor was large enough to meet the metabolic demands of the recipient. However, right lobectomy was thought to be dangerous to the donor because the remaining left lobe volume was estimated to be only 26% of his total liver volume. Meanwhile, the 20-year-old daughter of the recipient (height 167 cm, weight 54.4 kg) volunteered to be a potential living donor. Volumetric CT of her liver showed that the left and right lobe had a volume of 200 mL and 537 mL each. Technically, either the right or left lobe would be considered as small-for-size. If a right lobe donation was performed, her remaining left liver lobe volume was calculated to be less than 30% of her total liver volume. Because these 2 donors had a volume disproportion between the right and left lobe, 2 left lobes from each donor were harvested for the sake of the donors’ safety.
CASE REPORT A 48-year-old man (height 177 cm, weight 75.5 kg) with a 17-year history of hepatitis B cirrhosis had repeated spontaneous bacterial peritonitis and intractable ascites develop. He was believed to be in end-stage liver
The first liver graft is orthotopically implanted at the original left position. The second liver graft is heterotopically positioned to the right upper fossa and rotated 180°, bridging the distance between the recipient’s right hepatic vein and the hepatic venous end of the liver graft by means of cadaveric interposition vein graft (Fig 1). This new procedure requires 2 technical modifications during engrafting of the hetrotopic second left lobe graft. The rotation of the heterotopic second liver graft through 180° of sagittal orientation brings the hilar structures into a reversed location.3 That is, the bile duct comes to lie behind the portal vein
Accepted for publication January 7, 2001. Reprint requests: SungGyu Lee, MD, Department of Surgery, Asan Medical Center, Ulsan University Medical School, 388-1 PoongNap Dong, SongPa Ku, Seoul 138-736, Korea. Surgery 2001;129:647-50. Copyright © 2001 by Mosby, Inc. 0039-6060/2001/$35.00 + 0 11/60/114218 doi:10.1067/msy.2001.114218
OPERATIVE PROCEDURE
SURGERY 647
648 Lee et al
Surgery May 2001
Fig 1. Living donor liver transplant using dual left lobe grafts. A, Orthotopically implanted first left lobe graft. B, Heterotopically implanted 180° rotated second left lobe graft.
and the hepatic artery. That would make the future hepaticojejunostomy of the second liver graft difficult in a limited area after portal vein anastomosis is established. Therefore, the first technical modification is that the bile duct is reconstructed by ductto-duct anastomosis followed by the ventrally lying portal vein anastomosis (Fig 1). The left lobe graft is always too small to replace the portion of the right lobe of the recipient’s resected liver. Consequently, the noticeable distance between the recipient’s right hepatic vein and the hepatic venous end of the liver graft will be developed after hilar vessel reconstruction. Bridging a distance between both hepatic venous ends by means of an interposition vein graft is the second technical modification (Fig 1). In the recipient operation, both the right and left branch of the portal vein and the hepatic artery are dissected free from the surrounding tissue as peripherally as possible to obtain maximal length for future bilateral vascular anastomoses. The bile duct is similarly dissected to the level of the hilum, dividing the right and left hepatic duct separately. To preserve the arterial blood supply of the proximal hepatic duct, care must be taken to ensure that the right hepatic artery crossing behind the common bile duct is not dissected. Venovenous bypass (Biopump, BioMedicus, Inc) is set up by cannulating the left portal vein, femoral vein, and axillary vein. A total hepatectomy to preserve the inferior vena cava is performed, while the suprahepatic and retrohepatic vena cava just below the insertion of hepatic veins are clamped. Before implanting liver grafts, the caval end of the cryopreserved cadaveric cavoiliac interposition vein graft is approximated to the recipient’s right hepatic vein with 5-0 continuous Prolene sutures. The first left lobe graft (actual
weight, 400 g) is orthotopically implanted in the usual manner. First, a hepatic vein anastomosis is made. A portal cannula for venovenous bypass is removed, followed by anastomosis between the graft’s and the left branch of the recipient’s portal vein. Now, a large bulldog vascular clamp is applied to the interpositioned cavo-iliac vein graft to prevent the escape of caval blood flow after recirculation of the first liver graft. Vena caval vascular clamps are removed and reperfusion of the liver graft is allowed by releasing the vascular clamp on the main trunk of portal vein. The portal vascular clamp is reapplied to the right branch of the recipient’s portal vein. Next, the 180° rotated second liver graft (actual weight, 270 g) is located in the right upper hepatic fossa. First, the bile duct of the second liver graft is directly anastomosed to the right hepatic duct of the recipient over an externalized Silastic (Dow Corning Corp, Midland, Mich) stent tube with 6-0 interrupted Prolene sutures. The stent tube is brought out through the left hepatic duct orifice of the recipient. The remaining hole of its orifice is oversewn by 5-0 continuous Prolene sutures, securely holding the stent tube by tying. The portal vein of the liver graft is anastomosed to the right branch of the recipient’s portal vein. Then, the hepatic vein of the liver graft is anastomosed to the iliac end of the interpositioned cavo-iliac vein graft, while the redundant length of vein graft is excised to keep the vein graft from buckling. In this case, the length of the remaining interposition vein graft was 3 cm. Then, the second liver graft is reperfused, and hepatic artery anastomoses of both liver grafts are performed under microscopy. A tissue expander filled with saline solution (250 mL in this case) is inserted underneath the second liver graft to relieve
Lee et al 649
Surgery Volume 129, Number 5
undue tension on hilar anastomosis (Fig 1). Finally, a Roux-en-Y hepaticojejunostomy of the first liver graft is performed over a small internalized stent. The operation time in the recipient was 15 hours, and the operative blood loss was less than 9 units of packed red blood cells. The cold ischemic time of the first and second liver graft was 40 and 60 minutes, respectively. Immunosuppression was the same as that of a single graft transplant. Postoperative liver function was satisfactory, and there were no specific complications related to this particular surgical technique. A daily-reduced tissue expander was completely removed on operative day 13. The patient was discharged on postoperative day 25 without an episode of rejection. A postoperative follow-up CT scan of the patient demonstrated the balanced regeneration of both liver grafts (Fig 2). DISCUSSION In an adult-to-adult LDLT, liver graft size has been one of the most important factors determining a successful outcome. To avoid postoperative liver failure, the graft to be implanted should not be too small. Recently, the number of right lobe implantations is increasing in many institutes to overcome the limitation of the small-for-size graft.4,5 However, because the donor’s safety takes precedence to the recipient’s outcome, the remaining liver volume of the donor should not be less than 30% of his total liver volume.5 If a donor has a relatively large right lobe that is suitable as a graft for an adult recipient while the remaining left lobe is too small to maintain his life, this donor cannot be accepted to donate his left or right liver for a larger-size recipient. This new procedure using dual left lobe grafts from 2 living donors is indicated in this particular situation and can expand the application of an adult-to-adult LDLT despite the limitation of a left lobe being the available largest graft. To justify placing 2 donors at risk, the combined risk must be less than the risk to 1 donor. Therefore, if the sum of 2 left lateral segment grafts will exceed the minimum required volume of the recipient (> 50% of SLV), the left lateral segment has to be used instead of the left lobe graft because the donor’s risk for left lobectomy is apparently higher than for left lateral segmentectomy. The same operative principle can be applied to the cadaveric split liver transplant if dual left lobe or lateral segment grafts from 2 donors are transplanted to an adult recipient, while the remaining right-sided grafts are used for another 2 adult recipients. In fact, among our initial 3 experiences from March to June 2000, one patient simultane-
A
B
C Fig 2. Postoperative follow-up CT scan of the recipient demonstrated the balanced regeneration of both liver grafts. A, CT scan taken 5 days after transplant showed that the second left lobe graft in right upper abdomen was still small and supported by a tissue expander bag. B, CT scan taken 2 weeks after transplant showed the rapid regeneration of both grafts. C, CT scan taken 2 months after transplant showed that 2 regenerated left lobe grafts were in the shape of normal liver.
ously received the left lobe graft from a living donor at the orthotopic left position and the left lateral segmental graft from a cadaveric donor at the heterotopic right position. Although LDLT using dual left lobe grafts is technically complex and elaborate, this procedure can solve the problems related to the small-for-size graft and expand indication of LDLT and split-liver transplant for an adult recipient.
650 Lee et al
Surgery May 2001
REFERENCES 1. Sugawara Y, Makuuchi M. Technical advances in livingrelated liver transplantation. J Hepatobiliary Pancreat Surg 1999;6:245-53. 2. Park KM, Lee SG, Lee YJ, Nam CW, Choi KM, Nam CH, et al. Adult-to-adult living donor liver transplantation at Asan Medical Center. Transplant Proc 1999; 31:456-8. 3. Ringe B, Pichlmayr R, Burdelski M. A new technique of
hepatic vein reconstruction in partial liver transplantation. Transplant Int 1988;1:30-5. 4. Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP. Surgical management of anatomical variations of the right lobe in living donor liver transplantation. Ann Surg 2000;6:824-31. 5. Inomata Y, Uemoto S, Asonuma K, Egawa H, Kiuchi T, Fujita S, et al. Right lobe graft in living donor liver transplantation. Transplantation 2000;69:258-64.
Acknowledgment—cont’d (Continued from page 644) Gottrup, Finn Copenhagen World Healing Center Herfarth, Christian University of Heidelberg Idezuku, Yasuo Saitama Medical School Ikeda, Yoshifumi Teikyo University School of Medicine Izbicki, Jakob R. Universitats-Krankenhaus Eppendorf Jacobs, Danny O. St. Joseph’s Hospital Kawarada, Yoshifumi Mie University School of Medicine Kendrick, Michael Mayo Clinic Knechtle, Stuart J. University of Wisconsin Hospital Krag, David University of Vermont Law, Simon The University of Hong Kong/Queen Mary Hospital Libsch, Karen Mayo Clinic Mack, Eberhard A. University of Wisconsin-Madison Makuuchi, Hiroyasa Tokai University School of Medicine McFadden, David W. West Virginia University/Robert C. Byrd Health Sciences Center Moreno-Gonzalez, Enrique Hospital Doce de Octubre Moulton, Steven Boston Medical Center Muluk, Satish University of Pittsburgh Murr, Michel M. University of South Florida/Tampa General Hospital
Norton, Jeffrey A. VA Medical Center, San Francisco Nyberg, Scott L. Mayo Clinic Pemberton, John H. Mayo Clinic Peters, Jeffrey H. USC Healthcare Consultation Center Poon, Ronnie T. The University of Hong Kong/Queen Mary Hospital Sellke, Frank W. Beth Israel Deaconess Medical Center Soper, Nathaniel J. Washington University School of Medicine Souba, Wiley W. Hershey Medical Center Steele, Glenn D., Jr University of Chicago/Pritzker School of Medicine Stentovich, Stephen M. Boston Medical Center Sumpio, Bauer E. Yale University School of Medicine Thompson, Jon S. University of Nebraska Medical Center Torosian, Michael H. Fox Chase Cancer Center Tsiotos, Greg Greece Wade, Terrance P. Lincoln Surgical Associates Weigel, Ronald J. Stanford University School of Medicine Wong, John The University of Hong Kong/Queen Mary Hospital Zenilman, Michael E. Albert Einstein College of Medicine Zyromski, Nicholas Mayo Clinic
From the Department of Surgery, Asan Medical Center, Ulsan University Medical School, Seoul, Korea
THE SHORTAGE OF CADAVERIC donor livers has stimulated the development of advanced surgical approaches such as living donor liver transplantation (LDLT), which produces the same results as cadaveric organ replacement. However, insufficient graft size has been a major obstacle to expanding the use of adult-to-adult LDLT when the donor graft is taken only from the left lobe. To successfully expand LDLT to adult recipients, right lobe grafts have been used, but the risk to the donor is still unknown. The safety of right lobectomy varies, depending mainly on the volume of the remaining left lobe.1 Although a donor has a relatively large right lobe that is suitable as a graft for a larger recipient, the remaining left lobe may be too small to maintain a donor’s life in many instances. In this particular circumstance, the donor cannot be accepted to donate the left or right liver for a larger-size recipient. As an alternative, dual left lobe grafts from 2 living donors into 1 recipient can make up for graft size insufficiency and secure the donors’ safety. In this case report, we describe our experience of an adult-to-adult LDLT using dual left lobe grafts from 2 living donors.
disease and LDLT was planned using the left or right liver lobe of his 38-year-old brother (height 178 cm, weight 84.5 kg). The standard liver volume (SLV) of the recipient was calculated to be 1314 mL.2 Volumetric computed tomography (CT) analysis of the donor’s liver showed that his left and right lobe had a volume of 360 mL and 962 mL, respectively; these were 27% and 73%, respectively, of the SLV estimated for the recipient. The left lobe of the donor was too small to meet the metabolic demands of the recipient. The right lobe of the donor was large enough to meet the metabolic demands of the recipient. However, right lobectomy was thought to be dangerous to the donor because the remaining left lobe volume was estimated to be only 26% of his total liver volume. Meanwhile, the 20-year-old daughter of the recipient (height 167 cm, weight 54.4 kg) volunteered to be a potential living donor. Volumetric CT of her liver showed that the left and right lobe had a volume of 200 mL and 537 mL each. Technically, either the right or left lobe would be considered as small-for-size. If a right lobe donation was performed, her remaining left liver lobe volume was calculated to be less than 30% of her total liver volume. Because these 2 donors had a volume disproportion between the right and left lobe, 2 left lobes from each donor were harvested for the sake of the donors’ safety.
CASE REPORT A 48-year-old man (height 177 cm, weight 75.5 kg) with a 17-year history of hepatitis B cirrhosis had repeated spontaneous bacterial peritonitis and intractable ascites develop. He was believed to be in end-stage liver
The first liver graft is orthotopically implanted at the original left position. The second liver graft is heterotopically positioned to the right upper fossa and rotated 180°, bridging the distance between the recipient’s right hepatic vein and the hepatic venous end of the liver graft by means of cadaveric interposition vein graft (Fig 1). This new procedure requires 2 technical modifications during engrafting of the hetrotopic second left lobe graft. The rotation of the heterotopic second liver graft through 180° of sagittal orientation brings the hilar structures into a reversed location.3 That is, the bile duct comes to lie behind the portal vein
Accepted for publication January 7, 2001. Reprint requests: SungGyu Lee, MD, Department of Surgery, Asan Medical Center, Ulsan University Medical School, 388-1 PoongNap Dong, SongPa Ku, Seoul 138-736, Korea. Surgery 2001;129:647-50. Copyright © 2001 by Mosby, Inc. 0039-6060/2001/$35.00 + 0 11/60/114218 doi:10.1067/msy.2001.114218
OPERATIVE PROCEDURE
SURGERY 647
648 Lee et al
Surgery May 2001
Fig 1. Living donor liver transplant using dual left lobe grafts. A, Orthotopically implanted first left lobe graft. B, Heterotopically implanted 180° rotated second left lobe graft.
and the hepatic artery. That would make the future hepaticojejunostomy of the second liver graft difficult in a limited area after portal vein anastomosis is established. Therefore, the first technical modification is that the bile duct is reconstructed by ductto-duct anastomosis followed by the ventrally lying portal vein anastomosis (Fig 1). The left lobe graft is always too small to replace the portion of the right lobe of the recipient’s resected liver. Consequently, the noticeable distance between the recipient’s right hepatic vein and the hepatic venous end of the liver graft will be developed after hilar vessel reconstruction. Bridging a distance between both hepatic venous ends by means of an interposition vein graft is the second technical modification (Fig 1). In the recipient operation, both the right and left branch of the portal vein and the hepatic artery are dissected free from the surrounding tissue as peripherally as possible to obtain maximal length for future bilateral vascular anastomoses. The bile duct is similarly dissected to the level of the hilum, dividing the right and left hepatic duct separately. To preserve the arterial blood supply of the proximal hepatic duct, care must be taken to ensure that the right hepatic artery crossing behind the common bile duct is not dissected. Venovenous bypass (Biopump, BioMedicus, Inc) is set up by cannulating the left portal vein, femoral vein, and axillary vein. A total hepatectomy to preserve the inferior vena cava is performed, while the suprahepatic and retrohepatic vena cava just below the insertion of hepatic veins are clamped. Before implanting liver grafts, the caval end of the cryopreserved cadaveric cavoiliac interposition vein graft is approximated to the recipient’s right hepatic vein with 5-0 continuous Prolene sutures. The first left lobe graft (actual
weight, 400 g) is orthotopically implanted in the usual manner. First, a hepatic vein anastomosis is made. A portal cannula for venovenous bypass is removed, followed by anastomosis between the graft’s and the left branch of the recipient’s portal vein. Now, a large bulldog vascular clamp is applied to the interpositioned cavo-iliac vein graft to prevent the escape of caval blood flow after recirculation of the first liver graft. Vena caval vascular clamps are removed and reperfusion of the liver graft is allowed by releasing the vascular clamp on the main trunk of portal vein. The portal vascular clamp is reapplied to the right branch of the recipient’s portal vein. Next, the 180° rotated second liver graft (actual weight, 270 g) is located in the right upper hepatic fossa. First, the bile duct of the second liver graft is directly anastomosed to the right hepatic duct of the recipient over an externalized Silastic (Dow Corning Corp, Midland, Mich) stent tube with 6-0 interrupted Prolene sutures. The stent tube is brought out through the left hepatic duct orifice of the recipient. The remaining hole of its orifice is oversewn by 5-0 continuous Prolene sutures, securely holding the stent tube by tying. The portal vein of the liver graft is anastomosed to the right branch of the recipient’s portal vein. Then, the hepatic vein of the liver graft is anastomosed to the iliac end of the interpositioned cavo-iliac vein graft, while the redundant length of vein graft is excised to keep the vein graft from buckling. In this case, the length of the remaining interposition vein graft was 3 cm. Then, the second liver graft is reperfused, and hepatic artery anastomoses of both liver grafts are performed under microscopy. A tissue expander filled with saline solution (250 mL in this case) is inserted underneath the second liver graft to relieve
Lee et al 649
Surgery Volume 129, Number 5
undue tension on hilar anastomosis (Fig 1). Finally, a Roux-en-Y hepaticojejunostomy of the first liver graft is performed over a small internalized stent. The operation time in the recipient was 15 hours, and the operative blood loss was less than 9 units of packed red blood cells. The cold ischemic time of the first and second liver graft was 40 and 60 minutes, respectively. Immunosuppression was the same as that of a single graft transplant. Postoperative liver function was satisfactory, and there were no specific complications related to this particular surgical technique. A daily-reduced tissue expander was completely removed on operative day 13. The patient was discharged on postoperative day 25 without an episode of rejection. A postoperative follow-up CT scan of the patient demonstrated the balanced regeneration of both liver grafts (Fig 2). DISCUSSION In an adult-to-adult LDLT, liver graft size has been one of the most important factors determining a successful outcome. To avoid postoperative liver failure, the graft to be implanted should not be too small. Recently, the number of right lobe implantations is increasing in many institutes to overcome the limitation of the small-for-size graft.4,5 However, because the donor’s safety takes precedence to the recipient’s outcome, the remaining liver volume of the donor should not be less than 30% of his total liver volume.5 If a donor has a relatively large right lobe that is suitable as a graft for an adult recipient while the remaining left lobe is too small to maintain his life, this donor cannot be accepted to donate his left or right liver for a larger-size recipient. This new procedure using dual left lobe grafts from 2 living donors is indicated in this particular situation and can expand the application of an adult-to-adult LDLT despite the limitation of a left lobe being the available largest graft. To justify placing 2 donors at risk, the combined risk must be less than the risk to 1 donor. Therefore, if the sum of 2 left lateral segment grafts will exceed the minimum required volume of the recipient (> 50% of SLV), the left lateral segment has to be used instead of the left lobe graft because the donor’s risk for left lobectomy is apparently higher than for left lateral segmentectomy. The same operative principle can be applied to the cadaveric split liver transplant if dual left lobe or lateral segment grafts from 2 donors are transplanted to an adult recipient, while the remaining right-sided grafts are used for another 2 adult recipients. In fact, among our initial 3 experiences from March to June 2000, one patient simultane-
A
B
C Fig 2. Postoperative follow-up CT scan of the recipient demonstrated the balanced regeneration of both liver grafts. A, CT scan taken 5 days after transplant showed that the second left lobe graft in right upper abdomen was still small and supported by a tissue expander bag. B, CT scan taken 2 weeks after transplant showed the rapid regeneration of both grafts. C, CT scan taken 2 months after transplant showed that 2 regenerated left lobe grafts were in the shape of normal liver.
ously received the left lobe graft from a living donor at the orthotopic left position and the left lateral segmental graft from a cadaveric donor at the heterotopic right position. Although LDLT using dual left lobe grafts is technically complex and elaborate, this procedure can solve the problems related to the small-for-size graft and expand indication of LDLT and split-liver transplant for an adult recipient.
650 Lee et al
Surgery May 2001
REFERENCES 1. Sugawara Y, Makuuchi M. Technical advances in livingrelated liver transplantation. J Hepatobiliary Pancreat Surg 1999;6:245-53. 2. Park KM, Lee SG, Lee YJ, Nam CW, Choi KM, Nam CH, et al. Adult-to-adult living donor liver transplantation at Asan Medical Center. Transplant Proc 1999; 31:456-8. 3. Ringe B, Pichlmayr R, Burdelski M. A new technique of
hepatic vein reconstruction in partial liver transplantation. Transplant Int 1988;1:30-5. 4. Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP. Surgical management of anatomical variations of the right lobe in living donor liver transplantation. Ann Surg 2000;6:824-31. 5. Inomata Y, Uemoto S, Asonuma K, Egawa H, Kiuchi T, Fujita S, et al. Right lobe graft in living donor liver transplantation. Transplantation 2000;69:258-64.
Acknowledgment—cont’d (Continued from page 644) Gottrup, Finn Copenhagen World Healing Center Herfarth, Christian University of Heidelberg Idezuku, Yasuo Saitama Medical School Ikeda, Yoshifumi Teikyo University School of Medicine Izbicki, Jakob R. Universitats-Krankenhaus Eppendorf Jacobs, Danny O. St. Joseph’s Hospital Kawarada, Yoshifumi Mie University School of Medicine Kendrick, Michael Mayo Clinic Knechtle, Stuart J. University of Wisconsin Hospital Krag, David University of Vermont Law, Simon The University of Hong Kong/Queen Mary Hospital Libsch, Karen Mayo Clinic Mack, Eberhard A. University of Wisconsin-Madison Makuuchi, Hiroyasa Tokai University School of Medicine McFadden, David W. West Virginia University/Robert C. Byrd Health Sciences Center Moreno-Gonzalez, Enrique Hospital Doce de Octubre Moulton, Steven Boston Medical Center Muluk, Satish University of Pittsburgh Murr, Michel M. University of South Florida/Tampa General Hospital
Norton, Jeffrey A. VA Medical Center, San Francisco Nyberg, Scott L. Mayo Clinic Pemberton, John H. Mayo Clinic Peters, Jeffrey H. USC Healthcare Consultation Center Poon, Ronnie T. The University of Hong Kong/Queen Mary Hospital Sellke, Frank W. Beth Israel Deaconess Medical Center Soper, Nathaniel J. Washington University School of Medicine Souba, Wiley W. Hershey Medical Center Steele, Glenn D., Jr University of Chicago/Pritzker School of Medicine Stentovich, Stephen M. Boston Medical Center Sumpio, Bauer E. Yale University School of Medicine Thompson, Jon S. University of Nebraska Medical Center Torosian, Michael H. Fox Chase Cancer Center Tsiotos, Greg Greece Wade, Terrance P. Lincoln Surgical Associates Weigel, Ronald J. Stanford University School of Medicine Wong, John The University of Hong Kong/Queen Mary Hospital Zenilman, Michael E. Albert Einstein College of Medicine Zyromski, Nicholas Mayo Clinic