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Living related right lobe liver transplantation at Ankara University
Living Related Right Lobe Liver Transplantation at Ankara University S. Ersoz, M.A. Yerdel, K. Karayalc¸in, and E. Anadol
T
HE unique surgical anatomy of the liver allows it to be separated into independent anatomic units that can be transplanted. With the recent surgical innovations, livingrelated right lobe liver transplantation (LDRLT) is becaming the main source of organ supply for adult recipients in countries with a shortage of cadaver donors.
courses with an early survival rate of 100% (first 3 months) under tacrolimus and steroid immunosuppression. One patient required biliary dilatation at 4 months after transplantation. Although the follow-up is short, all recipients have normal liver function tests and are at home.
PATIENTS
LDRLT seems to be a very important treatment option, especially in countries with a shortage of cadaveric donors. Teams experienced in hepatic and transplantation surgery can achieve excellent initial results with minimum donor morbidity.1–3 Temporary portocaval shunts to decrease bowel edema seem to be helpful to achieve hemostasis after hepatectomy. We are even planning to use venovenous bypass through the inferior mesenteric vein in order to minimize bowel edema with continuous portal decompression. We believe that performing the anastomosis to a nonedematous small bowel is of utmost importance. Despite every effort, hepatic artery thrombosis seems to be inevitable following LDRLT.4,5 Microsurgical assistance is of great help when available. Small and/or multiple bile ducts are another concern in the procedure. Despite every effort, we are hardly satisfied with the anatomosis in all cases. Using meticulous technique and surgical loops will aid the surgeon.
At Ankara University Medical School, we performed 5 LDRLT in the last 16 months. Two of the donors were mothers, 2 were sisters, and 1 was a cousin. The donors were 44, 45, 46, 36, and 23 years old. The volumes of the right lobe grafts were 810, 860, 980, 650, and 1,000 mL. Four grafts had 2 bile ducts while the third one had 3. All grafts had single right hepatic vein and right hepatic artery, while 1 graft had separate anterior and posterior portal branches that required a cadaveric iliac vein graft for reconstruction. One donor received only autologous blood transfusion, while the last case was performed without any transfusion. The average donor heterologus blood transfusion was 1,150 mL for the other 3 donors. One donor experienced a transfusion reaction, with serious intravascular hemolysis that required plasma exchange. None of the donors experienced a surgical complication. The recipient ages were 22, 23, 35, 36, and 27 years. Etiology for recipient cirrhosis were Wilson’s disease, autoimmune hepatitis, and hepatitis B (3 cases). After recipient hepatectomy with preservation of the vena cava, hepatic veins were oversewn and right hepatic veins were anastomosed directly to a separate incision on the vena cava. No accessory hepatic veins or posterior hepatic vein anastomoses were done. Hepatic artery anastomoses were done under 2.5 loop magnification. One patient required an infrarenal aorto-hepatic artery saphenous vein interposition graft. In 4 patients, temporary end-to-side portocaval anastomoses were constructed for portal decompression using the right branch of the portal vein. Bile ducts were anastomosed to a Roux-Y limb over an external stent.
RESULTS
One patient’s hepatic artery thrombosed at 48 hours after surgery. Emergency revascularization was performed via an infrarenal aortic graft. Because of increasing bilirubin levels, a cadaveric retransplantation was performed. This patient and 4 other recipients had smooth postoperative
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 2159 (2002)
DISCUSSION
REFERENCES 1. Fujita S, Il-Deok Kim, Uryuhara K, et al: Transpl Int 13:333, 2000 2. Greval HP, Thistlethwaite JR, Loss GE, et al: Ann Surg 228:214, 1998 3. Malago M, Rogiers X, Burdelski M, et al: Transplant Proc 26:3620, 1994 4. Kiuchi T, Tanaka K: Acta Chir Belg 100:279, 2000 5. Asakura T, Ohkohchi N, Orii T, et al: Transplant Proc 32:2250, 2000 From Ankara University Medical School, Department of Surgery, Ankara, Turkey. Address reprint requests to S. Ersoz, Ankara University Medical School, Department of Surgery, Ankara, Turkey.
0041-1345/02/$–see front matter PII S0041-1345(02)02889-0 2159
T
HE unique surgical anatomy of the liver allows it to be separated into independent anatomic units that can be transplanted. With the recent surgical innovations, livingrelated right lobe liver transplantation (LDRLT) is becaming the main source of organ supply for adult recipients in countries with a shortage of cadaver donors.
courses with an early survival rate of 100% (first 3 months) under tacrolimus and steroid immunosuppression. One patient required biliary dilatation at 4 months after transplantation. Although the follow-up is short, all recipients have normal liver function tests and are at home.
PATIENTS
LDRLT seems to be a very important treatment option, especially in countries with a shortage of cadaveric donors. Teams experienced in hepatic and transplantation surgery can achieve excellent initial results with minimum donor morbidity.1–3 Temporary portocaval shunts to decrease bowel edema seem to be helpful to achieve hemostasis after hepatectomy. We are even planning to use venovenous bypass through the inferior mesenteric vein in order to minimize bowel edema with continuous portal decompression. We believe that performing the anastomosis to a nonedematous small bowel is of utmost importance. Despite every effort, hepatic artery thrombosis seems to be inevitable following LDRLT.4,5 Microsurgical assistance is of great help when available. Small and/or multiple bile ducts are another concern in the procedure. Despite every effort, we are hardly satisfied with the anatomosis in all cases. Using meticulous technique and surgical loops will aid the surgeon.
At Ankara University Medical School, we performed 5 LDRLT in the last 16 months. Two of the donors were mothers, 2 were sisters, and 1 was a cousin. The donors were 44, 45, 46, 36, and 23 years old. The volumes of the right lobe grafts were 810, 860, 980, 650, and 1,000 mL. Four grafts had 2 bile ducts while the third one had 3. All grafts had single right hepatic vein and right hepatic artery, while 1 graft had separate anterior and posterior portal branches that required a cadaveric iliac vein graft for reconstruction. One donor received only autologous blood transfusion, while the last case was performed without any transfusion. The average donor heterologus blood transfusion was 1,150 mL for the other 3 donors. One donor experienced a transfusion reaction, with serious intravascular hemolysis that required plasma exchange. None of the donors experienced a surgical complication. The recipient ages were 22, 23, 35, 36, and 27 years. Etiology for recipient cirrhosis were Wilson’s disease, autoimmune hepatitis, and hepatitis B (3 cases). After recipient hepatectomy with preservation of the vena cava, hepatic veins were oversewn and right hepatic veins were anastomosed directly to a separate incision on the vena cava. No accessory hepatic veins or posterior hepatic vein anastomoses were done. Hepatic artery anastomoses were done under 2.5 loop magnification. One patient required an infrarenal aorto-hepatic artery saphenous vein interposition graft. In 4 patients, temporary end-to-side portocaval anastomoses were constructed for portal decompression using the right branch of the portal vein. Bile ducts were anastomosed to a Roux-Y limb over an external stent.
RESULTS
One patient’s hepatic artery thrombosed at 48 hours after surgery. Emergency revascularization was performed via an infrarenal aortic graft. Because of increasing bilirubin levels, a cadaveric retransplantation was performed. This patient and 4 other recipients had smooth postoperative
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 2159 (2002)
DISCUSSION
REFERENCES 1. Fujita S, Il-Deok Kim, Uryuhara K, et al: Transpl Int 13:333, 2000 2. Greval HP, Thistlethwaite JR, Loss GE, et al: Ann Surg 228:214, 1998 3. Malago M, Rogiers X, Burdelski M, et al: Transplant Proc 26:3620, 1994 4. Kiuchi T, Tanaka K: Acta Chir Belg 100:279, 2000 5. Asakura T, Ohkohchi N, Orii T, et al: Transplant Proc 32:2250, 2000 From Ankara University Medical School, Department of Surgery, Ankara, Turkey. Address reprint requests to S. Ersoz, Ankara University Medical School, Department of Surgery, Ankara, Turkey.
0041-1345/02/$–see front matter PII S0041-1345(02)02889-0 2159