- Email: [email protected]
Living donor and split-liver transplantation: an overview
Living Donor and Split-Liver Transplantation: An Overview M. Abouljoud, A. Yoshida, F. Dagher, D. Moonka, and K. Brown
I
N THE UNITED STATES there are almost 18,000 patients currently listed for liver transplantation. The list has been growing every year with the number of transplants performed reaching a plateau at about 5000 annually. Hence, deaths on the waiting list continue at the rate of 10% to 15% and are still underreported. National and local efforts to increase organ donation are continuing, but their impact has leveled off. In addition, current allocation policies continue to make efforts for timely transplantation of critically ill patients. Patients entering the system at an earlier stage of illness are bound to wait until they become more ill to receive a liver, with a higher risk for morbidity and mortality. This is further compounded by demands from patients and their families to find immediate solutions to save their dying family member, coupled with their willingness to donate parts of their organs, in spite of the associated potential risks.
ADVANCES IN SPLIT-LIVER AND LIVING DONATION TECHNIQUES
The crisis in organ shortage for the pediatric liver population has been recognized for many years. The development of liver reduction and splitting techniques has nearly reversed this trend by providing segmental transplants for smaller children. The technique for using segments II and III from living donors has been described as early as 1989.1 This technique was put into clinical application soon thereafter2 with a rapid adoption of this procedure by many programs in different countries.3–5 One-year patient survival has exceeded 80% in most series with 5-year survival of over 70% being reported. This living donor technique was subsequently applied to the cadaver donor as the in situ splitting technique.6,7 Patient survival and graft outcomes in these series matched established cadaver organ transplant outcomes with a caution when using such a procedure for the critically ill recipient. Evidently, the in situ technique has been limited by the time factor with extension of the donor procedure by a minimum of 2 hours. Furthermore, logistics of sharing such organs, donor hospital and procurement issues, and donor hemodynamic stability have limited its maximum potential. Some groups have resorted to the ex situ or bench splitting technique. Although this may solve some of the donor hospital logistics, it definitely prolongs the total ischemia time on the organ and hence organ selection becomes
paramount. The Kings College group has adopted this procedure8 with patient survival rates at 1 and 3 years of 93.5% and 88.1% and graft survival rates of 89.7% and 86.1%, respectively.
RIGHT LOBE LIVING DONOR LIVER TRANSPLANTATION
The procedures described above did not do much to alleviate the shortage of adult livers for adult recipients. Hence, this concept was extended for application into the adult recipient. Earlier experience consisted mostly of left lobe usage, mostly in Japan. This was limited by the size of the lobe and the anatomical challenges presented by the frequent variation in ductal, arterial, and venous anatomy. The first adult–adult right lobe liver transplant was performed in Japan in an unplanned fashion due to anatomical issues.9 This led to attempts by other groups to use the right lobe as a most suitable choice for adult recipients.10 In 1997 the first right-lobe adult–adult liver transplant was done11 and since then this has become the preferred technique by most centers.12–14 The right lobe offered several advantages that included adequate liver mass (mitigating against the risk of small-for-size grafts), less anatomic variations, and larger arterial and bile duct size. The survival of transplant recipients has also been comparable to cadaver transplantation with 1-year patient survival exceeding 85%. However, there is a selection bias as since most centers do not accept critically ill or ventilated patients for this procedure. Technical complications are potentially higher in view of the small artery size, bile duct anastomotic leaks/strictures, and cut-surface leaks. However, with adherence to excellent technique and perfect execution, these complications can occur at acceptable rates. Generally, arterial complications (thrombosis, stenosis) are ⱕ10% and biliary complications (leak, stenosis) are ⬍30%.13,14 The technical aspects of the operation continue to improve, however, as the procedure becomes widely applicable, the quality of execution and outcomes is bound From the Henry Ford Medical Center, Liver Transplant Program, Detroit, Michigan, USA. Address reprint requests to M.S. Abouljoud, Henry Ford Medical Center, 2799 W Grand Blvd, Detroit, MI 48202. E-mail: [email protected]
0041-1345/03/$–see front matter doi:10.1016/j.transproceed.2003.08.067
© 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2772
Transplantation Proceedings, 35, 2772⫺2774 (2003)
LIVING DONOR AND SPLIT LIVER TRANSPLANTATION
to differ among centers with varying levels of expertise in liver surgery and transplantation. Toward the effort of establishing a certain set of criteria to ascertain adequate expertise in a transplant center embarking on this project, the American Society of Transplant Surgeons published a white paper that included the following set of center criteria15 that would serve as guidelines. ● The transplant center should give careful consideration to the inherent risks of the procedure to the donor. ● There should be a well-established informed consent process. ● Surgical expertise in liver transplant and hepatobiliary surgery is necessary. ● There should be an existing need for living donation with shortage of cadaver organs in that particular program. ● Adequate resources, personnel and otherwise, should be properly allocated and there should be an ongoing oversight process with periodic review of donor and recipient outcomes. LIVING DONOR OUTCOMES
The liver donation procedure is of significant magnitude and hence a certain set of complications is bound to occur. It is the responsibility of the transplant team to educate the potential donor about possible outcomes, morbidity, and even potential mortality. Hence, there should be a stepwise process that includes informed consent and the assurance of both medical and psychosocial suitability. This process has been well outlined in a recently published consensus statement16 on living donation and is quite helpful for centers considering the initiation of such a program. We have included a copy of the donor consent used at our center and it has been designed around these principles. CONSENT FOR LIVING LIVER DONATION AT HENRY FORD MEDICAL CENTER
The following is a typical consent form that has been generated by the liver transplant staff in collaboration with our psychology and ethics staff. The form is discussed in detail with the potential donor before it is signed. I, , give my permission to Dr and his surgical colleagues to initiate the medical workup for a right liver lobe resection for living donor liver transplantation. In order to be accepted as a candidate for living liver donation, I will consent to the surgeons and physicians from Henry Ford Hospital to perform the following: routine blood work, serology tests for viruses (including hepatitis C, B and HIV or AIDS virus), MRI and possibly ultrasound of the liver, liver biopsy, and arteriogram of the hepatic arteries. The specialists will obtain a separate consent form at the time of liver biopsy and arteriogram and they will explain the risks. I understand that these tests are necessary to determine if the part of my liver to be removed is adequate for transplantation.
2773 I will give consent twice for the organ donation procedure. I am not under any duress by the relatives of the recipient or the transplant team to undergo this operation. I understand that I will undergo laparotomy (opening of the abdomen surgically through an incision) and a portion of my liver (55% to 60%) will be removed and placed in the recipient. I also consent to the extraction of veins from my legs (about 5 to 10 cm) if deemed necessary by the transplant team in order to establish conduits for the recipient operation. If, at the time of laparotomy, there is a finding that in the best judgment of the surgeons would put me at risk, they may stop the operation at that point. After the operation, drains will be placed around the liver and these will be removed in 2 to 4 days; I will be transferred to ICU, possibly intubated on the breathing machine, where I will stay for 24 hours or more. I consent to the use of stored blood or blood products from the blood bank. At the discretion of the surgeons and physicians, I will come off the breathing machine, perhaps in the operating room, and be transferred to a general care unit and then home by about 6 to 7 days after the operation. I understand that potential complications may include: 1. Risk of death. Mortality rates from this operation are not well known; similar procedures performed for liver disease in nonselected patients of all ages result in 1% mortality. 2. Risk of liver failure. The transplant team will evaluate my liver to make sure I have enough liver left to regenerate. However, although rare (⬍0.1%), liver failure may occur and result in the need for liver transplantation. 3. Risk of life-threatening infection resulting from the operation (⬃1%). This may be due to postoperative bleeding, abscess, bile leak, or injury to the bile duct. 4. Risk of blood-borne infection acquired through blood transfusions, if given. 5. Risk of pulmonary embolus from blood clots that can be fatal (⬍1%). 6. Risk of temporary or permanent disability. 7. These complications may require another operation or other treatment to take care of them. I understand that I can withdraw from participation in this procedure at any time prior to the operation. All I need to do is inform any member of the team and this will be taken in full confidentiality. If I change my mind about going ahead with the procedure, a medical excuse will be given and full confidentiality will be assured. In the extreme event that the liver could not be placed in the intended recipient due to intraoperative death or unexpected pathology, I consent for it to be given to another recipient on the waiting list, if possible. Physicians and surgeons at Henry Ford Health System will provide health care needs related to this procedure. A team of surgeons and physicians at Henry Ford Hospital will take care of me after my surgery. My follow-up care will consist of clinic visits, blood work, and a follow-up MRI of the abdomen to assess the regeneration of my liver after hepatectomy (removal of a portion of the liver). I understand Henry Ford Hospital is a teaching facility and therefore agree to the photography of material involving all phases of the procedure and the use of such information for
2774
ABOULJOUD, YOSHIDA, DAGHER ET AL
scientific and teaching purposes. This is intended to further expand our knowledge of this procedure, enhance continuous learning and progress, and improve outcomes. I have been assured that the origin of this photographic documentation will be kept confidential and anonymous. I have carefully considered the risks of this serious operation. I had the opportunity to discuss this major decision with my family and friends. In addition, I have had ample opportunity to question my doctors and the transplant team about further details of the operation and any concerns I have about it. Patient signature Witness signature Physician signature
Date Date Date
The majority of donor complications are of a minor nature and tend to occur less frequently as the expertise of the team becomes more established.17 These range from wound infections to cut-surface bile leaks, bile duct strictures, and bowel obstruction and some may require reoperation.13 Of importance is that deaths and psychosocial morbidity tend to be underreported especially as they impact donor families and their ability to maintain healthy psychosocial dynamics and livelihood. To date, there have been at least five or six deaths among living liver donors from technical complications, perioperative anesthetic recovery, pulmonary embolism, and liver failure. Some could have been prevented with compulsive care, assurance of proper surgical expertise, and better donor selection, but some will always be an act of fate and one has to accept that this can happen and be ready to deal with it at all levels. Recently, a survey of living liver donors from a single center has shed some light on the postdonation recovery and psychosocial outcomes.18 All donors were satisfied with the information provided before donation and none regretted or felt “forced” to donate. Although all donors continue to recommend the procedure, those who had a complication tended to recommend it “as a last resort” instead. Interestingly, as has been our experience, pain and surgical wound issues were reported as being “worse than expected” by one third of the patients. All donors who returned to work were able to resume the same employment activities as before donation, although the return date was over 6 months after the procedure in more than 30% of cases. No donor acquired disability as a result of donation and all those who changed or quit employment did not do so because of the donation procedure.
In summary, living donor liver transplantation is becoming widely practiced and is making a substantial impact on the organ donor shortage. Our efforts toward the maximization of the cadaver donor process should continue in full gear because this resource is not tapped to its fullest extent. Societal involvement is essential as since inefficiency of cadaver donation is being replaced by efforts toward living donation with its inherent risks. Further application of this technique needs to be coupled with adherence to the principles outlined above, keeping in mind that donor health and safety always come first. Lastly, maintenance of ongoing registries on donor and recipient outcomes should be undertaken by societies/organizations in their respective regions with regular reporting and exchange of such valuable information. Such an effort has already been developed in the United States and is underway under a contract from the Department of Health and Human Services. REFERENCES 1. Raia S, Nery JR, Mies S: Lancet 21:497, 1989 2. Strong RW, Lynch SV, Ong TH, et al: N Engl J Med 322:1505, 1990 3. Broelsch CE, Whitington PF, Emond JC, et al: Ann Surg 214:428, 1991 4. Tanaka K, Uemoto S, Tokunaga Y, et al: Ann Surg 217:82, 1993 5. Millis JM, Cronin DC, Brady LM, et al: Ann Surg 232:104, 2000 6. Rogiers X, Malago M, Habib N, et al: Transplantation 59:1081, 1995 7. Goss JA, Yersiz H, Shackleton C, et al: Transplantation 64:871, 1997 8. Desphande RR, Bowles MJ, Vilca-Melendez H, et al: Am Surg 236:248, 2002 9. Yamoka Y, Washida M, Honda K, et al: Transplantation 57:1127, 1994 10. Lo CM, Fan ST, Liu CL, et al: Ann Surg 226:261, 1997 11. Wachs ME, Bak TE, Karrer FM, et al: Transplantation 66:1313, 1998 12. Marcos A, Ham JM, Fisher RA, et al: Liver Transpl 6:296, 2000 13. Miller CM, Gondolesi GE, Florman S, et al: Ann Surg 234:301, 2001 14. Nakamura T, Tanaka K, Kiuchi T, et al: Transplantation 73:1896, 2002 15. American Society of Transplant Surgeons Ethics Committee: Liver Transpl 6:815, 2000 16. Abecassis M, Adams M, Adams P, et al: JAMA 284:2919, 2000 17. Grewal HP, Thistlewaite JR, Loss GE, et al: Ann Surg 228:214, 1998 18. Diaz GC, Renz JF, Mudge C, et al: Ann Surg 236:120, 2002
I
N THE UNITED STATES there are almost 18,000 patients currently listed for liver transplantation. The list has been growing every year with the number of transplants performed reaching a plateau at about 5000 annually. Hence, deaths on the waiting list continue at the rate of 10% to 15% and are still underreported. National and local efforts to increase organ donation are continuing, but their impact has leveled off. In addition, current allocation policies continue to make efforts for timely transplantation of critically ill patients. Patients entering the system at an earlier stage of illness are bound to wait until they become more ill to receive a liver, with a higher risk for morbidity and mortality. This is further compounded by demands from patients and their families to find immediate solutions to save their dying family member, coupled with their willingness to donate parts of their organs, in spite of the associated potential risks.
ADVANCES IN SPLIT-LIVER AND LIVING DONATION TECHNIQUES
The crisis in organ shortage for the pediatric liver population has been recognized for many years. The development of liver reduction and splitting techniques has nearly reversed this trend by providing segmental transplants for smaller children. The technique for using segments II and III from living donors has been described as early as 1989.1 This technique was put into clinical application soon thereafter2 with a rapid adoption of this procedure by many programs in different countries.3–5 One-year patient survival has exceeded 80% in most series with 5-year survival of over 70% being reported. This living donor technique was subsequently applied to the cadaver donor as the in situ splitting technique.6,7 Patient survival and graft outcomes in these series matched established cadaver organ transplant outcomes with a caution when using such a procedure for the critically ill recipient. Evidently, the in situ technique has been limited by the time factor with extension of the donor procedure by a minimum of 2 hours. Furthermore, logistics of sharing such organs, donor hospital and procurement issues, and donor hemodynamic stability have limited its maximum potential. Some groups have resorted to the ex situ or bench splitting technique. Although this may solve some of the donor hospital logistics, it definitely prolongs the total ischemia time on the organ and hence organ selection becomes
paramount. The Kings College group has adopted this procedure8 with patient survival rates at 1 and 3 years of 93.5% and 88.1% and graft survival rates of 89.7% and 86.1%, respectively.
RIGHT LOBE LIVING DONOR LIVER TRANSPLANTATION
The procedures described above did not do much to alleviate the shortage of adult livers for adult recipients. Hence, this concept was extended for application into the adult recipient. Earlier experience consisted mostly of left lobe usage, mostly in Japan. This was limited by the size of the lobe and the anatomical challenges presented by the frequent variation in ductal, arterial, and venous anatomy. The first adult–adult right lobe liver transplant was performed in Japan in an unplanned fashion due to anatomical issues.9 This led to attempts by other groups to use the right lobe as a most suitable choice for adult recipients.10 In 1997 the first right-lobe adult–adult liver transplant was done11 and since then this has become the preferred technique by most centers.12–14 The right lobe offered several advantages that included adequate liver mass (mitigating against the risk of small-for-size grafts), less anatomic variations, and larger arterial and bile duct size. The survival of transplant recipients has also been comparable to cadaver transplantation with 1-year patient survival exceeding 85%. However, there is a selection bias as since most centers do not accept critically ill or ventilated patients for this procedure. Technical complications are potentially higher in view of the small artery size, bile duct anastomotic leaks/strictures, and cut-surface leaks. However, with adherence to excellent technique and perfect execution, these complications can occur at acceptable rates. Generally, arterial complications (thrombosis, stenosis) are ⱕ10% and biliary complications (leak, stenosis) are ⬍30%.13,14 The technical aspects of the operation continue to improve, however, as the procedure becomes widely applicable, the quality of execution and outcomes is bound From the Henry Ford Medical Center, Liver Transplant Program, Detroit, Michigan, USA. Address reprint requests to M.S. Abouljoud, Henry Ford Medical Center, 2799 W Grand Blvd, Detroit, MI 48202. E-mail: [email protected]
0041-1345/03/$–see front matter doi:10.1016/j.transproceed.2003.08.067
© 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2772
Transplantation Proceedings, 35, 2772⫺2774 (2003)
LIVING DONOR AND SPLIT LIVER TRANSPLANTATION
to differ among centers with varying levels of expertise in liver surgery and transplantation. Toward the effort of establishing a certain set of criteria to ascertain adequate expertise in a transplant center embarking on this project, the American Society of Transplant Surgeons published a white paper that included the following set of center criteria15 that would serve as guidelines. ● The transplant center should give careful consideration to the inherent risks of the procedure to the donor. ● There should be a well-established informed consent process. ● Surgical expertise in liver transplant and hepatobiliary surgery is necessary. ● There should be an existing need for living donation with shortage of cadaver organs in that particular program. ● Adequate resources, personnel and otherwise, should be properly allocated and there should be an ongoing oversight process with periodic review of donor and recipient outcomes. LIVING DONOR OUTCOMES
The liver donation procedure is of significant magnitude and hence a certain set of complications is bound to occur. It is the responsibility of the transplant team to educate the potential donor about possible outcomes, morbidity, and even potential mortality. Hence, there should be a stepwise process that includes informed consent and the assurance of both medical and psychosocial suitability. This process has been well outlined in a recently published consensus statement16 on living donation and is quite helpful for centers considering the initiation of such a program. We have included a copy of the donor consent used at our center and it has been designed around these principles. CONSENT FOR LIVING LIVER DONATION AT HENRY FORD MEDICAL CENTER
The following is a typical consent form that has been generated by the liver transplant staff in collaboration with our psychology and ethics staff. The form is discussed in detail with the potential donor before it is signed. I, , give my permission to Dr and his surgical colleagues to initiate the medical workup for a right liver lobe resection for living donor liver transplantation. In order to be accepted as a candidate for living liver donation, I will consent to the surgeons and physicians from Henry Ford Hospital to perform the following: routine blood work, serology tests for viruses (including hepatitis C, B and HIV or AIDS virus), MRI and possibly ultrasound of the liver, liver biopsy, and arteriogram of the hepatic arteries. The specialists will obtain a separate consent form at the time of liver biopsy and arteriogram and they will explain the risks. I understand that these tests are necessary to determine if the part of my liver to be removed is adequate for transplantation.
2773 I will give consent twice for the organ donation procedure. I am not under any duress by the relatives of the recipient or the transplant team to undergo this operation. I understand that I will undergo laparotomy (opening of the abdomen surgically through an incision) and a portion of my liver (55% to 60%) will be removed and placed in the recipient. I also consent to the extraction of veins from my legs (about 5 to 10 cm) if deemed necessary by the transplant team in order to establish conduits for the recipient operation. If, at the time of laparotomy, there is a finding that in the best judgment of the surgeons would put me at risk, they may stop the operation at that point. After the operation, drains will be placed around the liver and these will be removed in 2 to 4 days; I will be transferred to ICU, possibly intubated on the breathing machine, where I will stay for 24 hours or more. I consent to the use of stored blood or blood products from the blood bank. At the discretion of the surgeons and physicians, I will come off the breathing machine, perhaps in the operating room, and be transferred to a general care unit and then home by about 6 to 7 days after the operation. I understand that potential complications may include: 1. Risk of death. Mortality rates from this operation are not well known; similar procedures performed for liver disease in nonselected patients of all ages result in 1% mortality. 2. Risk of liver failure. The transplant team will evaluate my liver to make sure I have enough liver left to regenerate. However, although rare (⬍0.1%), liver failure may occur and result in the need for liver transplantation. 3. Risk of life-threatening infection resulting from the operation (⬃1%). This may be due to postoperative bleeding, abscess, bile leak, or injury to the bile duct. 4. Risk of blood-borne infection acquired through blood transfusions, if given. 5. Risk of pulmonary embolus from blood clots that can be fatal (⬍1%). 6. Risk of temporary or permanent disability. 7. These complications may require another operation or other treatment to take care of them. I understand that I can withdraw from participation in this procedure at any time prior to the operation. All I need to do is inform any member of the team and this will be taken in full confidentiality. If I change my mind about going ahead with the procedure, a medical excuse will be given and full confidentiality will be assured. In the extreme event that the liver could not be placed in the intended recipient due to intraoperative death or unexpected pathology, I consent for it to be given to another recipient on the waiting list, if possible. Physicians and surgeons at Henry Ford Health System will provide health care needs related to this procedure. A team of surgeons and physicians at Henry Ford Hospital will take care of me after my surgery. My follow-up care will consist of clinic visits, blood work, and a follow-up MRI of the abdomen to assess the regeneration of my liver after hepatectomy (removal of a portion of the liver). I understand Henry Ford Hospital is a teaching facility and therefore agree to the photography of material involving all phases of the procedure and the use of such information for
2774
ABOULJOUD, YOSHIDA, DAGHER ET AL
scientific and teaching purposes. This is intended to further expand our knowledge of this procedure, enhance continuous learning and progress, and improve outcomes. I have been assured that the origin of this photographic documentation will be kept confidential and anonymous. I have carefully considered the risks of this serious operation. I had the opportunity to discuss this major decision with my family and friends. In addition, I have had ample opportunity to question my doctors and the transplant team about further details of the operation and any concerns I have about it. Patient signature Witness signature Physician signature
Date Date Date
The majority of donor complications are of a minor nature and tend to occur less frequently as the expertise of the team becomes more established.17 These range from wound infections to cut-surface bile leaks, bile duct strictures, and bowel obstruction and some may require reoperation.13 Of importance is that deaths and psychosocial morbidity tend to be underreported especially as they impact donor families and their ability to maintain healthy psychosocial dynamics and livelihood. To date, there have been at least five or six deaths among living liver donors from technical complications, perioperative anesthetic recovery, pulmonary embolism, and liver failure. Some could have been prevented with compulsive care, assurance of proper surgical expertise, and better donor selection, but some will always be an act of fate and one has to accept that this can happen and be ready to deal with it at all levels. Recently, a survey of living liver donors from a single center has shed some light on the postdonation recovery and psychosocial outcomes.18 All donors were satisfied with the information provided before donation and none regretted or felt “forced” to donate. Although all donors continue to recommend the procedure, those who had a complication tended to recommend it “as a last resort” instead. Interestingly, as has been our experience, pain and surgical wound issues were reported as being “worse than expected” by one third of the patients. All donors who returned to work were able to resume the same employment activities as before donation, although the return date was over 6 months after the procedure in more than 30% of cases. No donor acquired disability as a result of donation and all those who changed or quit employment did not do so because of the donation procedure.
In summary, living donor liver transplantation is becoming widely practiced and is making a substantial impact on the organ donor shortage. Our efforts toward the maximization of the cadaver donor process should continue in full gear because this resource is not tapped to its fullest extent. Societal involvement is essential as since inefficiency of cadaver donation is being replaced by efforts toward living donation with its inherent risks. Further application of this technique needs to be coupled with adherence to the principles outlined above, keeping in mind that donor health and safety always come first. Lastly, maintenance of ongoing registries on donor and recipient outcomes should be undertaken by societies/organizations in their respective regions with regular reporting and exchange of such valuable information. Such an effort has already been developed in the United States and is underway under a contract from the Department of Health and Human Services. REFERENCES 1. Raia S, Nery JR, Mies S: Lancet 21:497, 1989 2. Strong RW, Lynch SV, Ong TH, et al: N Engl J Med 322:1505, 1990 3. Broelsch CE, Whitington PF, Emond JC, et al: Ann Surg 214:428, 1991 4. Tanaka K, Uemoto S, Tokunaga Y, et al: Ann Surg 217:82, 1993 5. Millis JM, Cronin DC, Brady LM, et al: Ann Surg 232:104, 2000 6. Rogiers X, Malago M, Habib N, et al: Transplantation 59:1081, 1995 7. Goss JA, Yersiz H, Shackleton C, et al: Transplantation 64:871, 1997 8. Desphande RR, Bowles MJ, Vilca-Melendez H, et al: Am Surg 236:248, 2002 9. Yamoka Y, Washida M, Honda K, et al: Transplantation 57:1127, 1994 10. Lo CM, Fan ST, Liu CL, et al: Ann Surg 226:261, 1997 11. Wachs ME, Bak TE, Karrer FM, et al: Transplantation 66:1313, 1998 12. Marcos A, Ham JM, Fisher RA, et al: Liver Transpl 6:296, 2000 13. Miller CM, Gondolesi GE, Florman S, et al: Ann Surg 234:301, 2001 14. Nakamura T, Tanaka K, Kiuchi T, et al: Transplantation 73:1896, 2002 15. American Society of Transplant Surgeons Ethics Committee: Liver Transpl 6:815, 2000 16. Abecassis M, Adams M, Adams P, et al: JAMA 284:2919, 2000 17. Grewal HP, Thistlewaite JR, Loss GE, et al: Ann Surg 228:214, 1998 18. Diaz GC, Renz JF, Mudge C, et al: Ann Surg 236:120, 2002