Living-related transplantation of left liver plus caudate lobe

Living-related transplantation of left liver plus caudate lobe

Living-Related Transplantation of Left Liver Plus Caudate Lobe Tadatoshi Takayama, MD, Masatoshi Makuuchi, MD, Keiichi Kubota, MD, Keiji Sano, MD, Yas...

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Living-Related Transplantation of Left Liver Plus Caudate Lobe Tadatoshi Takayama, MD, Masatoshi Makuuchi, MD, Keiichi Kubota, MD, Keiji Sano, MD, Yasushi Harihara, MD, Hideo Kawarasaki, MD

Living-related liver transplantation (LRLT) has been accepted as an effective treatment of choice for pediatric patients1-3 but its feasibility for adult patients is limited because of graft size disparity. Kawasaki and colleagues4 have shown that the donor’s left liver (without the caudate lobe) can be used as a maximal-for-size graft to adults if the ratio of the predicted graft volume (GV) to the recipient’s standard liver volume (SV) is more than one-third. When the graft is too small, auxiliary implantation of the left liver5 or use of the right liver6 can be an option in patients under urgent situations. Recently Miyagawa and colleagues7 reported a patient who received a left liver with caudate lobe graft, but they did not reconstruct the drainage vein of the caudate lobe, which may cause lobe congestion and dysfunction. We report a new technique by which the left liver plus caudate lobe is implanted with complete reconstruction of the vessels relevant to the caudate lobe.

the paracaval portion [segment IX])8 satisfies the requirement.4 The donor undergoes extended left hemihepatectomy including the middle hepatic vein and the caudate lobe. The aberrant left hepatic artery, if present, is dissected up to the celiac axis.9 The left portal vein is isolated at the bifurcation and its transverse portion is left undissected to preserve the caudate lobe branches. After division of the left caval ligament the caudate lobe is liberated from the vena cava with preservation of its thickest drainage vein and division of thin veins of approximately 1 mm in diameter. Under right-sided vascular occlusion2 hepatic parenchymal transection advances along a plane placed 1 cm to the right from the middle hepatic vein and finally is directed to the center of the vena cava; transection behind the hilar plate is continued, taking care to avoid injuring the small vessels of the caudate lobe (Fig. 1). The leftsided liver graft is harvested with division of the vessels at their origin. The recipient receives the graft orthotopically. A cavotomy is made on the vena cava, to which the hepatic venous branch of the caudate lobe (conserved like a Carrel patch) is anastomosed in an end to side fashion (Fig. 2). End to end anastomoses are made between the recipient and graft common trunks of the middle-left hepatic veins, the left portal veins, and the hepatic arteries, respectively (Fig. 3), and the bile is drained into a Roux-en-Y jejunal loop.

METHODS Our procedure for LRLT using a whole left liver with the caudate lobe is described. To be indicated the donor-recipient combination must meet the following criterion: the left liver of the donor shows a GV/SV ratio of ⬍33% on computed tomographic volumetry; addition of the left-sided caudate lobe (Spiegel’s lobe [segment I] and left half of Received September 14, 1999; Revised December 22, 1999; Accepted January 4, 2000. From the Departments of Hepato-Biliary-Pancreatic and Transplantation Surgery (Takayama, Makuuchi, Kubota, Sano, Harihara) and Pediatric Surgery (Kawarasaki), Faculty of Medicine, University of Tokyo, Tokyo, Japan. Correspondence address: Masatoshi Makuuchi, MD, Department of Hepato-Biliary-Pancreatic and Transplantation Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. © 2000 by the American College of Surgeons Published by Elsevier Science Inc.

RESULTS Between 1996 and 1998 we performed LRLT on 45 patients. Of 12 adults, 3 (Child-Pugh scores, 7, 10, and 12 points) underwent this procedure because 635

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Figure 1. Donor left hepatectomy. The thickest hepatic vein of the caudate lobe (shaded portion) is preserved and the aberrant left hepatic artery is dissected up to the celiac axis.

the ratio of GV/SV (333⫾29g/1,060⫾69g) was 31%⫾0.5% (mean⫾SD). Nine patients received the left liver alone (GV/SV, 437⫾100g/1,121⫾ 139g; the ratio, 39%⫾7%). Addition of the caudate lobe (29⫾3g) increased the GV/SV ratio by 3%⫾0.3% and the whole graft volume by 9%⫾ 1%. All of the donors had an uneventful course during and after extended left hepatectomy (blood loss,

Figure 3. Graft implantation. The outflow and inflow of the caudate lobe are maintained completely.

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Figure 2. Recipient hepatic venous reconstruction. The caudate lobe hepatic vein with a caval cuff is anastomosed end-to-side to the vena cava.

696⫾285 mL; transection plane, 82⫾6 cm2; peak bilirubin value, 1.3⫾0.2 mg/dL). During isolation of the caudate lobe its thickest drainage vein (3⫾ 0.5 mm in diameter) was identified and preserved. In implantation the caudate lobe hepatic vein with a caval cuff (6⫾2 mm in length; 7⫾2 mm in orifice) was reconstructed at a site 25⫾15 mm below the middle-left hepatic venous trunk (taking 24⫾ 10 minutes), and other reconstructions were performed in the usual manner. After reperfusion the grafts were totally normal in firmness and appearance and showed satisfactory blood flow on Doppler ultrasonography. All the recipients recovered with no signs of liver failure. At 1 month the implanted livers had regenerated proportionally to 2.4⫾0.3-fold the original volume, with no abnormality of the caudate lobe, on CTs (Fig. 4). DISCUSSION For LRLT between adults the side of the liver better suited for the graft remains an issue of debate. The criterion for the minimum graft size has been defined as a GV/SV ratio of 33%, which is usually achieved by a left liver graft.4 Surgeons can consider the use of a right liver graft when the left liver is small, but this means that a functioning liver mass of more than two-thirds would be removed at the risk of the living donor. The donor morbidity rate in right liver series has been reported to be higher than that in left liver series (29% versus 0%) with a high peak bilirubin level (4.4⫾3.3 mg/dL versus

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1.7 ⫾ 1.1 mg/dL), although there was no difference in the recipient mortality rate (14% versus 15%).4,6 We support the preferential use of the left-sided liver as the maximal-for-size graft even for adult patients. Based on this policy adult LRLT is unlikely to be feasible in patients in whom the left liver GV/SV ratio is about 30%.4 In an attempt to increase graft volume we have designed a procedure in which the left liver plus caudate lobe graft is implanted with complete revascularization. Up to now the caudate lobe has been left to atrophy in the donor, possibly because of not only its small volume but also the technical difficulty. In the present series this addition helped to increase the whole graft volume by 9%⫾1%, suggesting its clinical value. Extended left hepatectomy including the caudate lobe was accomplished without raising the surgical risk to the donor. We recommend the use of our technique in cases of graft-recipient “borderline” size matching. In our previous series this contribution to hepatic mass would be of benefit in 3 donors who had been rejected for donation because of the small left livers. The advantage needs to be further clarified in comparison with a group receiving the left liver alone. A graft that fails to meet the criterion, even with addition of the caudate lobe, can be too small to support the recipient’s life.10 We consider that right lobe grafting is an option only on such occasions, although it remains questionable whether the benefit of recipients can outweigh the extra risk to living donors. Our method involves no distinct technical difficulty. In donor hepatectomy the transection plane was much flatter and narrower than that of conventional caudate lobe-sparing left hepatectomy. All of the small branches to and from the caudate lobe had to be preserved: care was taken to dissect the portal and biliary bifurcations as minimally as possible, from where most of the caudate branches would originate,8 and to conserve the thickest drainage vein to the vena cava. In recipient operation we first reconstructed the caudate lobe hepatic vein based on a finding of cast analysis8 that it functions as the main drain into the cava in 90% of subjects. In others who have no such thick vein the drainage can be through the left hepatic vein. Although Miyagawa and colleagues7 sacrificed the vein, the reconstruction was not difficult or time-consuming because elongation with a caval cuff ensured a

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Figure 4. CT showing the proportional regeneration of the implanted liver. Arrowhead indicates the hepatic vein of the caudate lobe.

sufficient length and orifice for anastomosis. The portal vein could be reconstructed as usual despite the shorter anastomotic stalk of the graft left portal vein caused by caudate branch preservation. The fact that both the left liver and the caudate lobe appeared normal during operation suggests that favorable blood flow maintained the function and that they were not exposed to an excessive portal pressure. In all cases this has been confirmed by the absence of caudate lobe abnormality and by the proportional regeneration of the implanted liver on followup imaging. The left liver plus caudate lobe graft can be of use in adult LRLT if the GV/SV ratio is ⬍33%, expanding the indication with no additional risk to the living donor. Complete revascularization shown here warrants full graft viability. References 1. Broelsch CE, Whitington PF, Emond JC, et al. Liver transplantation in children from living related donors: surgical techniques and results. Ann Surg 1991;214:428–439. 2. Makuuchi M, Kawasaki S, Noguchi T, et al. Donor hepatectomy for living related partial liver transplantation. Surgery 1993;113: 395–402. 3. Tanaka K, Inomata Y. Present status and prospects of livingrelated liver transplantation. J Hep Bil Pancr Surg 1997;4:51– 70. 4. Kawasaki S, Makuuchi M, Matsunami H, et al. Living related liver transplantation in adults. Ann Surg 1998;227:269–274. 5. Bismuth H, Azoulay D, Samuel D, et al. Auxiliary partial orthotopic liver transplantation for fulminant hepatitis: the Paul Brousse experience. Ann Surg 1996;224:712–726. 6. Lo CM, Fan ST, Liu CL, et al. Adult-to-adult living donor liver transplantation using extended right lobe grafts. Ann Surg 1997; 226:261–270.

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7. Miyagawa S, Hashikura Y, Miwa S, et al. Concomitant caudate lobe resection as an option for donor hepatectomy in adult living related liver transplantation. Transplantation 1998;66:661– 663. 8. Couinaud C. The paracaval segments of the liver. J Hep Bil Pancr Surg 1994;2:145–151.

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9. Takayama T, Makuuchi M, Kawarasaki H, et al. Hepatic transplantation using living donors with aberrant hepatic artery. J Am Coll Surg 1997;184:525–528. 10. Emond JC, Renz JF, Ferrell LD, et al. Functional analysis of grafts from living donors: implications for the treatment of older recipients. Ann Surg 1996;224:544–554.