- Email: [email protected]
Living donor liver transplantation
LIVER DONATION
Living Donor Liver Transplantation: Personal Experience T. Kiuchi and K. Tanaka
T
HE ANNUAL NUMBER of living donor liver transplantations (LDLT) at the Kyoto University is increasing steadily. In 1990 a pediatric LDLT program was started; more than 500 pediatric LDLTs were performed from 1990 to 2001. In 1994 the center started an adult LDLT program; 250 adult LDLTs were performed until 2001. The graft selection in LDLT now includes right lobe grafts, posterior segment grafts (S6 ⫹ 7), whole left liver grafts (S1 ⫹ 2 ⫹ 3 ⫹ 4 ⫹ middle hepatic vein, MHV), left lobe grafts (S2 ⫹ 3 ⫹ 4 ⫹ MHV), extended lateral segment grafts (S2 ⫹ 3 ⫹ partial 4), lateral segment grafts (S2 ⫹ 3), and monosegmental grafts.
RIGHT LOBE GRAFT HARVESTING
Systematic right lobe graft harvesting was started in 1998. In 2001, more than 50% of all grafts were right lobe grafts. Nevertheless, problems related with small-for-size graft were not eliminated. Hepatocyte damage due to ischemia, prolonged cholestasis, delayed graft function, and susceptibility to infections are representative symptoms that constitute the “small-forsize syndrome.” Potential cofactors include age; latent diseases; anatomical factors that lead to ischemia, congestion, and necrosis; technical factors like vascular reconstruction and positioning of the graft; and recipient factors like original disease, clinical status, and extrahepatic diseases. Most of anatomical variations are safely managed by technical modifications, but one remaining problem is separate and distant portal veins, especially when they are combined with similar bile duct variants. 0041-1345/03/$–see front matter doi:10.1016/S0041-1345(03)00176-3 950
MIDDLE HEPATIC VEIN RECONSTRUCTION
Inclusion of the MHV in recipients potentially increases the risk to the donor. A CT volumetric study in 25 recipients of right lobe grafts without MHV revealed that regeneration of the whole graft was not affected by the presence of significant drainage vein(s) from the anterior segment to the MHV. The only significant factor for graft regeneration was the graft-to-recipient weight ratio (GRWR). In a group of 19 patients without MHV reconstruction the congestion in the anterior sector (segments 5 and 8) was measured by T2-weighted MR imaging. Fifteen recipients had congestion in one or both anterior segments during the first month after transplantation. The amount of congestion was correlated neither with liver function tests nor graft prognosis. The reconstruction of MHV is indicated in small-for-size right lobe grafts with large MHV drainage and small right hepatic vein or in steatotic or old age donor grafts for highly deteriorated recipients. A sufficient size and appropriate anatomy of the remnant donor liver is essential for right lobe graft harvesting with inclusion of MHV. BILIARY RECONSTRUCTION
The reconstruction of biliary tract in right lobe recipients in the Kyoto program has been primarily Roux-en-Y hepaticojejunostomy in the beginning. By now, most biliary reconFrom the Department of Transplantation and Immunology, Kyoto University Graduate School of Medicine (K.T.) and the Department of Transplant Surgery, Kyoto University Hospital (T.K.), Kyoto, Japan. Address reprint requests to Tetsuya Kiuchi, MD, Department of Transplant Surgery, Kyoto University Hospital, 54 Kawaracho, Shogoin Sakyo-ku, Kyoto 606, Japan. © 2003 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 35, 950 –951 (2003)
PERSONAL EXPERIENCE
structions are duct-to-duct anastomosis. Usage of an anastomotic decompression tube leads to decreased leakage and stenosis complications compared to using a postanastomotic decompression tube. Comparing Roux-en-Y hepaticojejunostomy and duct-to-duct anastomosis, there tend to be more frequent biliary leaks in Roux-en-Y reconstructions and more frequent biliary stenoses in duct-to-duct reconstructions. CONCLUSIONS
There still remains a “small-for-size syndrome” in an exclusive living donor program, although most anatomical vari-
951
ants are acceptable for right lobe grafting. A cavoplasty should be done for right hepatic vein reconstruction to assure compensatory drainage for the MHV, if it is not reconstructed. Congestion in the anterior sector is generally reversible without major sequelae. The regeneration is compensated for by the posterior sector. However, the congestion may affect marginal grafts or recipients. Thus, right lobe harvesting with MHV is indicated for selected cases. A duct-toduct biliary reconstruction is still suboptimal, but there may be a benefit in adult LDLT.
Living Donor Liver Transplantation: Personal Experience T. Kiuchi and K. Tanaka
T
HE ANNUAL NUMBER of living donor liver transplantations (LDLT) at the Kyoto University is increasing steadily. In 1990 a pediatric LDLT program was started; more than 500 pediatric LDLTs were performed from 1990 to 2001. In 1994 the center started an adult LDLT program; 250 adult LDLTs were performed until 2001. The graft selection in LDLT now includes right lobe grafts, posterior segment grafts (S6 ⫹ 7), whole left liver grafts (S1 ⫹ 2 ⫹ 3 ⫹ 4 ⫹ middle hepatic vein, MHV), left lobe grafts (S2 ⫹ 3 ⫹ 4 ⫹ MHV), extended lateral segment grafts (S2 ⫹ 3 ⫹ partial 4), lateral segment grafts (S2 ⫹ 3), and monosegmental grafts.
RIGHT LOBE GRAFT HARVESTING
Systematic right lobe graft harvesting was started in 1998. In 2001, more than 50% of all grafts were right lobe grafts. Nevertheless, problems related with small-for-size graft were not eliminated. Hepatocyte damage due to ischemia, prolonged cholestasis, delayed graft function, and susceptibility to infections are representative symptoms that constitute the “small-forsize syndrome.” Potential cofactors include age; latent diseases; anatomical factors that lead to ischemia, congestion, and necrosis; technical factors like vascular reconstruction and positioning of the graft; and recipient factors like original disease, clinical status, and extrahepatic diseases. Most of anatomical variations are safely managed by technical modifications, but one remaining problem is separate and distant portal veins, especially when they are combined with similar bile duct variants. 0041-1345/03/$–see front matter doi:10.1016/S0041-1345(03)00176-3 950
MIDDLE HEPATIC VEIN RECONSTRUCTION
Inclusion of the MHV in recipients potentially increases the risk to the donor. A CT volumetric study in 25 recipients of right lobe grafts without MHV revealed that regeneration of the whole graft was not affected by the presence of significant drainage vein(s) from the anterior segment to the MHV. The only significant factor for graft regeneration was the graft-to-recipient weight ratio (GRWR). In a group of 19 patients without MHV reconstruction the congestion in the anterior sector (segments 5 and 8) was measured by T2-weighted MR imaging. Fifteen recipients had congestion in one or both anterior segments during the first month after transplantation. The amount of congestion was correlated neither with liver function tests nor graft prognosis. The reconstruction of MHV is indicated in small-for-size right lobe grafts with large MHV drainage and small right hepatic vein or in steatotic or old age donor grafts for highly deteriorated recipients. A sufficient size and appropriate anatomy of the remnant donor liver is essential for right lobe graft harvesting with inclusion of MHV. BILIARY RECONSTRUCTION
The reconstruction of biliary tract in right lobe recipients in the Kyoto program has been primarily Roux-en-Y hepaticojejunostomy in the beginning. By now, most biliary reconFrom the Department of Transplantation and Immunology, Kyoto University Graduate School of Medicine (K.T.) and the Department of Transplant Surgery, Kyoto University Hospital (T.K.), Kyoto, Japan. Address reprint requests to Tetsuya Kiuchi, MD, Department of Transplant Surgery, Kyoto University Hospital, 54 Kawaracho, Shogoin Sakyo-ku, Kyoto 606, Japan. © 2003 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 35, 950 –951 (2003)
PERSONAL EXPERIENCE
structions are duct-to-duct anastomosis. Usage of an anastomotic decompression tube leads to decreased leakage and stenosis complications compared to using a postanastomotic decompression tube. Comparing Roux-en-Y hepaticojejunostomy and duct-to-duct anastomosis, there tend to be more frequent biliary leaks in Roux-en-Y reconstructions and more frequent biliary stenoses in duct-to-duct reconstructions. CONCLUSIONS
There still remains a “small-for-size syndrome” in an exclusive living donor program, although most anatomical vari-
951
ants are acceptable for right lobe grafting. A cavoplasty should be done for right hepatic vein reconstruction to assure compensatory drainage for the MHV, if it is not reconstructed. Congestion in the anterior sector is generally reversible without major sequelae. The regeneration is compensated for by the posterior sector. However, the congestion may affect marginal grafts or recipients. Thus, right lobe harvesting with MHV is indicated for selected cases. A duct-toduct biliary reconstruction is still suboptimal, but there may be a benefit in adult LDLT.