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MR imaging in living donor evaluation: a comprehensive imaging examination
654A
AASLD ABSTRACTS
HEPATOLOGYOctober 2001
1927
1928
DONOR MORBIDITY ASSOCIATED W I T H RIGHT LOBECTOMY FOR LIVING DONOR LIVER TRANSPLANTATION TO ADULT RECIPIENTS:
MR IMAGING IN LIVING DONOR EVALUATION: A COMPREHENSIVE IMAGING EXAMINATION. Sander S Florman, Jeffrey Goldman, Leona Kim-
A SYSTEMATIC REVIEV¢. Kimberly L Beavers, Roshan Shrestha, University of North Carolina, Chapel Hill, NC Specific Aim: To determine donor morbidity associated with right lobectomy for living donor liver transplantation to adult recipients through a systematic review of the published literature. Data Sources: All Engfish-language reports on living donors for living donor liver transplantation. MEDLINE (1995 to April 2001) was searched using the MeSH terms living donors and liver transplantation. Limits were set for human only and English language only. Bibliographies of retrieved references were cross-checked to identify additional reports. 202 reports were obtained. Study Selection: Population studies, consecutive, and non-consecutive series were included. All studies reported at least one of the following outcomes specific to living donors of right lobes to adult recipients: surgical and hospital complications, length of hospital stay, readmissions, recovery time, return to pre-donation occupation, health-related quality of life, or mortality. Data Extraction: The abstracts of relevant articles were independently reviewed against predetermined criteria and appropriate articles were retrieved. Study design and results were summarized in evidence tables. Summary statistics of combined data were performed when possible. Data Synthesis: 11 studies met the inclusion criteria. Data on donor morbidity associated with right lobectomy is limited. On the basis of reported data, morbidity associated with living donor right lobectomy ranges from 0 % to 50%. Summing the number of events and the denominators from each individual study gives an overall crude morbidity rate of 26.4%. Conclusions: Evidence for morbidity associated with right lobectomy donation for living donor liver transplantation is variable. Acceptable, and transportable definitions of morbidity, and better methods for observing and measuring outcomes are necessary to understand and potentially improve morbidity. Further reports should contain more detail regarding complications.
Schluger, Mount Sinai Medical Center, New York, NY Introduction: Early in our experience with evaluation of volunteers for living liver donation, we used computed tomography, angiography and endoscopic retrograde cholangiography to evaluate hepatic anatomy and volumes, vascular anatomy and the biliary system. Later, as an alternative to these invasive studies, we used only magnetic resonance imaging (MRI) with angiography (MRA), venography (MRV), and cholangiography (MRC). We report here our experience with our more recent approach. Methods: Between 7/00 and 5/01, potential living donors were evaluated with MRI to assess vascular and bfliary anatomy. In our program, radiologic studies are done once the potential donors have cleared a medical and psychosocial evaluation. MRI imaging was performed on a 1.5T GE CVi scanner. Imaging included: axial in and out of phase gradient echo images for assessment of fatty infiltration of the liver, axial and coronal ssfse MRCP images, pre and post contrast dynamic 3DT1W GRE images after the administration of IV gadolineum (Berlix) in the arterial and venous phase. Intravenous Teslascan (a hepatobilliary agent) was then administered and 3DT 1W GRE images were obtained through the biliary system after a delay of 20 minutes. Images were then postprocessed on an AW (GEMS) workstation using 3D and volume rendering software. All images were then reviewed jointly by a radiologist and surgeon. Results: Thirty-two potential donors eventually proceeded with donation. Their arterial anatomy was found intraoperatively to correspond to the MRI findings 100%. Three potential donors were excluded based on the MRI findings of portal-venous anomalies. The first had a meandering left portal vein in his right lobe. The second had segment IV (left lobe) portal venous drainage to the right portal vein. In the third, a right anterior portal vein originated from the left main portal vein. Conclusions: MRI is a useful noninvasive comprehensive examination for the imaging evaluation of living related donors undergoing evaluation for living related liver donation. MR depiction of the arterial and hepatic venous anatomy correlated well with the intra-operative findings. Careful analysis of the portal anatomy using three dimensional post-processing proved most important in excluding patients who were not suitable surgical candidates. Close interactions between the surgical and radiologic teams was necessary to best utilize the 3D information for pre-operative planning.
1929
1930
PORTAL HYPERTENSION AFTER SIZE MISMATCH ADULT LIVING RELATED DONOR LIVER TRANSPLANTATION: REDUCTION OF EXCESSIVE PORTAL PRESSURE BY SPLENECTOMY. Yoshinobu Sato, Satoshi
TIPS IS N O T A CONTRAINDICATION FOR ADULT LIVING DONOR LIVER TRANSPLANTATION. Mohamed Wehbe, Devon John, Glyn Morgan,
Yamamoto, Hideki Nakatsuka, Takaoki Watanabe, Niigata Univ Sch of Medicine, Niigata Japan; Katsuyoshi Hatakeyama, Niigata Uinv, Niigata Japan (aim) Size mismatch is most important obstacle in adult living related donor liver transplantation (ALRDLT). We have reported that acute elevated portal hypertension, refecting wall shear stress of portal vein become a trigger of liver regeneration following partial hepatectomy and excessive shear stress induce liver injury after massive hepatectomy. We have also reported that splenic arterial ligation and splenectomy prevented liver injury by reduction of excessive portal hypertension after major hepatectomy in hepatocellular carcinoma patients with cirrhosis. In this study, we investigated the relation between posttransplant portal hypertension and graft size mismatch in ALRDLT. (Materials and Methods) We examined 15 patients transplanted between March 1999 and April 2001. These patients divided into three group, group I ;(graft volume / recipient body weight (GV/RBW) ratio :>1.0), group II; GV/RBW ratio < 1.0, and group III; recent cases measured portal pressure after ALRDLT and controlled portal pressure below 25cmH20). The patients of group III were given an intraportal administration of prostaglandin E1 and insuline after operation. The liver function and posttranplanted portal pressure were examined. Results: Peak T.Bfl level after ALRDLT were 7.6-+3.3mg/ dl, 17.4 -+12.9mg/dl,9.3 -+4.0mg/dl respectively. Peak GPT level were 466 -+402 IU/I ,166 ~ 105 IU/1,and 1 7 9 - 99 IU/1 respectively. In postoperative hyperbillirubinemia, direct billirubin was dominant especially in group II ( GV/RBW ratio < 1.0). Interestingly, patient performed auxiliary partial orthotopic liver transplantation due to metabolic disease had not portal hypertension (11cmH20) and the direct billirubin did not increase. The portal pressure of three patients after ALRDLT elevated above 30cmH20 despite of right lobe graft and splenectomy underwent in these patients. The portal pressure after splenectomy decreased below 25cmH20. Postoperative courses in splenectomized patients were uneventful. On the other hand, the portal pressure of the patient whose GV/RBW ratio was 0.55 was 19.5 cmH20 after ALRDLT. (Conclusion) There was discrepancy between posttransplanted portal pressure and GV/RBW ratio. The measurement of portal pressure after ALRDLT might be very useful for recognition of its discrepancy. The splenectomy or splenic arterial ligation reduced excessive portal hypertensioon after ALRDLT and might prevent liver injury. The liver injury due to excessive portal pressure might include the damage of transport of direct bifirubin.
Thomas Diflo, Fadi Dagher, Hillel Tobias, Lewis Teperman, NYU Medical Center, New York, NY Adult living donor liver transplantation (LDLT) is being performed with increasing frequency. Cirrhotic patients may require a transjugular intrahepatic portasystemic shunt (TIPS) procedure as a bridge to liver transplantation. The stent stimulates neo-intimal growth that may predispose to portal or hepatic vein thrombosis or to weakening at the point of an anastomosis. TIPS had been considered a possible relative contraindicafion to adult LDLT. Between 9/1/ 1999 and 11/15/2000,16 patients underwent LDLT at our institution. Of these, five patients had a TIPS performed prior to transplantation. The patients were divided into two groups: TIPS patients (n=5) and non-TIPS patients (n= 11). Veno-venous bypass was performed in all recipients. The recipient's right hepatic vein was taken flush with the cava and the donor's right hepatic vein was taken flush with the parenchyma. This technique serves to minimize torsion and/or outflow obstruction at the anastomosis. Accessory hepatic veins greater than 1 cm were reimplanted. The donor's right portal vein was anastomosed to the recipient's right or main portal vein. The TIPS was removed within the explanted liver four times and in one instance small pieces had to be removed from the portal vein. All patients underwent doppler ultrasonography of the hepatic and portal vein anastomosis after transplantation. Both groups were comparable by age (range 41- 62 years) and the etiology of liver failure, with hepatitis C cirrhosis being the most common (56%). Post-operatively, no thrombotic complications occurred in either group. The cold ischemia time (CIT), operative time and number of packed cell units transfused during the operative procedure were compared in Table 1. These preliminary results show that about one third of our patients had TIPS prior to adult LDLT. The transplant procedure may be performed safely in this group of recipients with no added risk. No thrombotic complications occurred at the hepatic or portal venous anastomosis. TIPS is not a contraindication for Adult LDLT. Table 1 CIT Operative Time
UnitsTransfused
TIPS (n=5)
Non-TIPS(n=11)
p-value
153rain +_78rain 586rnin + 46rnin 4,0 +_0.7
189rain _+75rain 667rnin _+.93min 4.4 + 1.4
0,39 NS 0,1 t NS 0.57 NS
AASLD ABSTRACTS
HEPATOLOGYOctober 2001
1927
1928
DONOR MORBIDITY ASSOCIATED W I T H RIGHT LOBECTOMY FOR LIVING DONOR LIVER TRANSPLANTATION TO ADULT RECIPIENTS:
MR IMAGING IN LIVING DONOR EVALUATION: A COMPREHENSIVE IMAGING EXAMINATION. Sander S Florman, Jeffrey Goldman, Leona Kim-
A SYSTEMATIC REVIEV¢. Kimberly L Beavers, Roshan Shrestha, University of North Carolina, Chapel Hill, NC Specific Aim: To determine donor morbidity associated with right lobectomy for living donor liver transplantation to adult recipients through a systematic review of the published literature. Data Sources: All Engfish-language reports on living donors for living donor liver transplantation. MEDLINE (1995 to April 2001) was searched using the MeSH terms living donors and liver transplantation. Limits were set for human only and English language only. Bibliographies of retrieved references were cross-checked to identify additional reports. 202 reports were obtained. Study Selection: Population studies, consecutive, and non-consecutive series were included. All studies reported at least one of the following outcomes specific to living donors of right lobes to adult recipients: surgical and hospital complications, length of hospital stay, readmissions, recovery time, return to pre-donation occupation, health-related quality of life, or mortality. Data Extraction: The abstracts of relevant articles were independently reviewed against predetermined criteria and appropriate articles were retrieved. Study design and results were summarized in evidence tables. Summary statistics of combined data were performed when possible. Data Synthesis: 11 studies met the inclusion criteria. Data on donor morbidity associated with right lobectomy is limited. On the basis of reported data, morbidity associated with living donor right lobectomy ranges from 0 % to 50%. Summing the number of events and the denominators from each individual study gives an overall crude morbidity rate of 26.4%. Conclusions: Evidence for morbidity associated with right lobectomy donation for living donor liver transplantation is variable. Acceptable, and transportable definitions of morbidity, and better methods for observing and measuring outcomes are necessary to understand and potentially improve morbidity. Further reports should contain more detail regarding complications.
Schluger, Mount Sinai Medical Center, New York, NY Introduction: Early in our experience with evaluation of volunteers for living liver donation, we used computed tomography, angiography and endoscopic retrograde cholangiography to evaluate hepatic anatomy and volumes, vascular anatomy and the biliary system. Later, as an alternative to these invasive studies, we used only magnetic resonance imaging (MRI) with angiography (MRA), venography (MRV), and cholangiography (MRC). We report here our experience with our more recent approach. Methods: Between 7/00 and 5/01, potential living donors were evaluated with MRI to assess vascular and bfliary anatomy. In our program, radiologic studies are done once the potential donors have cleared a medical and psychosocial evaluation. MRI imaging was performed on a 1.5T GE CVi scanner. Imaging included: axial in and out of phase gradient echo images for assessment of fatty infiltration of the liver, axial and coronal ssfse MRCP images, pre and post contrast dynamic 3DT1W GRE images after the administration of IV gadolineum (Berlix) in the arterial and venous phase. Intravenous Teslascan (a hepatobilliary agent) was then administered and 3DT 1W GRE images were obtained through the biliary system after a delay of 20 minutes. Images were then postprocessed on an AW (GEMS) workstation using 3D and volume rendering software. All images were then reviewed jointly by a radiologist and surgeon. Results: Thirty-two potential donors eventually proceeded with donation. Their arterial anatomy was found intraoperatively to correspond to the MRI findings 100%. Three potential donors were excluded based on the MRI findings of portal-venous anomalies. The first had a meandering left portal vein in his right lobe. The second had segment IV (left lobe) portal venous drainage to the right portal vein. In the third, a right anterior portal vein originated from the left main portal vein. Conclusions: MRI is a useful noninvasive comprehensive examination for the imaging evaluation of living related donors undergoing evaluation for living related liver donation. MR depiction of the arterial and hepatic venous anatomy correlated well with the intra-operative findings. Careful analysis of the portal anatomy using three dimensional post-processing proved most important in excluding patients who were not suitable surgical candidates. Close interactions between the surgical and radiologic teams was necessary to best utilize the 3D information for pre-operative planning.
1929
1930
PORTAL HYPERTENSION AFTER SIZE MISMATCH ADULT LIVING RELATED DONOR LIVER TRANSPLANTATION: REDUCTION OF EXCESSIVE PORTAL PRESSURE BY SPLENECTOMY. Yoshinobu Sato, Satoshi
TIPS IS N O T A CONTRAINDICATION FOR ADULT LIVING DONOR LIVER TRANSPLANTATION. Mohamed Wehbe, Devon John, Glyn Morgan,
Yamamoto, Hideki Nakatsuka, Takaoki Watanabe, Niigata Univ Sch of Medicine, Niigata Japan; Katsuyoshi Hatakeyama, Niigata Uinv, Niigata Japan (aim) Size mismatch is most important obstacle in adult living related donor liver transplantation (ALRDLT). We have reported that acute elevated portal hypertension, refecting wall shear stress of portal vein become a trigger of liver regeneration following partial hepatectomy and excessive shear stress induce liver injury after massive hepatectomy. We have also reported that splenic arterial ligation and splenectomy prevented liver injury by reduction of excessive portal hypertension after major hepatectomy in hepatocellular carcinoma patients with cirrhosis. In this study, we investigated the relation between posttransplant portal hypertension and graft size mismatch in ALRDLT. (Materials and Methods) We examined 15 patients transplanted between March 1999 and April 2001. These patients divided into three group, group I ;(graft volume / recipient body weight (GV/RBW) ratio :>1.0), group II; GV/RBW ratio < 1.0, and group III; recent cases measured portal pressure after ALRDLT and controlled portal pressure below 25cmH20). The patients of group III were given an intraportal administration of prostaglandin E1 and insuline after operation. The liver function and posttranplanted portal pressure were examined. Results: Peak T.Bfl level after ALRDLT were 7.6-+3.3mg/ dl, 17.4 -+12.9mg/dl,9.3 -+4.0mg/dl respectively. Peak GPT level were 466 -+402 IU/I ,166 ~ 105 IU/1,and 1 7 9 - 99 IU/1 respectively. In postoperative hyperbillirubinemia, direct billirubin was dominant especially in group II ( GV/RBW ratio < 1.0). Interestingly, patient performed auxiliary partial orthotopic liver transplantation due to metabolic disease had not portal hypertension (11cmH20) and the direct billirubin did not increase. The portal pressure of three patients after ALRDLT elevated above 30cmH20 despite of right lobe graft and splenectomy underwent in these patients. The portal pressure after splenectomy decreased below 25cmH20. Postoperative courses in splenectomized patients were uneventful. On the other hand, the portal pressure of the patient whose GV/RBW ratio was 0.55 was 19.5 cmH20 after ALRDLT. (Conclusion) There was discrepancy between posttransplanted portal pressure and GV/RBW ratio. The measurement of portal pressure after ALRDLT might be very useful for recognition of its discrepancy. The splenectomy or splenic arterial ligation reduced excessive portal hypertensioon after ALRDLT and might prevent liver injury. The liver injury due to excessive portal pressure might include the damage of transport of direct bifirubin.
Thomas Diflo, Fadi Dagher, Hillel Tobias, Lewis Teperman, NYU Medical Center, New York, NY Adult living donor liver transplantation (LDLT) is being performed with increasing frequency. Cirrhotic patients may require a transjugular intrahepatic portasystemic shunt (TIPS) procedure as a bridge to liver transplantation. The stent stimulates neo-intimal growth that may predispose to portal or hepatic vein thrombosis or to weakening at the point of an anastomosis. TIPS had been considered a possible relative contraindicafion to adult LDLT. Between 9/1/ 1999 and 11/15/2000,16 patients underwent LDLT at our institution. Of these, five patients had a TIPS performed prior to transplantation. The patients were divided into two groups: TIPS patients (n=5) and non-TIPS patients (n= 11). Veno-venous bypass was performed in all recipients. The recipient's right hepatic vein was taken flush with the cava and the donor's right hepatic vein was taken flush with the parenchyma. This technique serves to minimize torsion and/or outflow obstruction at the anastomosis. Accessory hepatic veins greater than 1 cm were reimplanted. The donor's right portal vein was anastomosed to the recipient's right or main portal vein. The TIPS was removed within the explanted liver four times and in one instance small pieces had to be removed from the portal vein. All patients underwent doppler ultrasonography of the hepatic and portal vein anastomosis after transplantation. Both groups were comparable by age (range 41- 62 years) and the etiology of liver failure, with hepatitis C cirrhosis being the most common (56%). Post-operatively, no thrombotic complications occurred in either group. The cold ischemia time (CIT), operative time and number of packed cell units transfused during the operative procedure were compared in Table 1. These preliminary results show that about one third of our patients had TIPS prior to adult LDLT. The transplant procedure may be performed safely in this group of recipients with no added risk. No thrombotic complications occurred at the hepatic or portal venous anastomosis. TIPS is not a contraindication for Adult LDLT. Table 1 CIT Operative Time
UnitsTransfused
TIPS (n=5)
Non-TIPS(n=11)
p-value
153rain +_78rain 586rnin + 46rnin 4,0 +_0.7
189rain _+75rain 667rnin _+.93min 4.4 + 1.4
0,39 NS 0,1 t NS 0.57 NS