Living donor for liver transplantation

Using 3D Microscope for Hepatic Artery Reconstruction in Living Donor Liver Transplant

Introduction: This study compares the intraoperative process of hepatic artery anastomosis using conventional microscope and novel 3D digital microscope and discusses our technique and operative set-up. Method: A retrospective comparative cohort study with 46 hepatic artery reconstructions in living donor liver transplant patients. Either an operational microscope (control group) or a 3D digital microscope Mitaka Kestrel View II (study group) was used for hepatic artery anastomosis. We then discuss and share our institution’s experience of improving surgical training. Results: Both operation instruments provide effective and comparable results. There was no statistical difference regarding operational objective results between conventional microscope and exoscope. Both instruments have no hepatic artery size limit, and both resulted in complete vessel patency rate. Conclusions: There was no statistical differences regarding hepatic artery anastomosis between microscope and exoscope cohorts. Microsurgeons should perform hepatic artery anastomosis efficiently with the instruments they are most proficient with. Yet, exoscope provided better ergonomics in the operation room and lessened musculoskeletal strain, allowing surgeons to work in a more neutral and comfortable posture while allowing the first assistant to learn and assist more effectively. Using exoscope with micro-forceps and modified tie technique make artery reconstruction easier.

The Landscape of Nondirected Living Liver Donation in the United States

BACKGROUND

Living donor liver transplants (LDLTs) including those from nondirected donors (NDDs) have increased during the past decade, and center-level variations in LDLTs have not yet been described. We sought to quantify changes in the volume of NDD transplants over time and variation in NDD volume between transplant centers. We further examined characteristics of living liver donors and identified factors potentially associated with receiving an NDD liver transplant.

METHODS

Using Scientific Registry of Transplant Recipients data between March 01, 2002, and December 31, 2020, we compared 173 NDDs with 5704 DLDs and 167 NDD recipients with 1153 waitlist candidates.

RESULTS

NDDs increased from 1 (0.4% of LDLTs) in 2002 to 58 (12% of LDLTs) in 2020. Of 150 transplant centers, 35 performed at least 1 NDD transplant. Compared with waitlist candidates, adult NDD recipients were less frequently males (39% versus 62%, P < 0.001), had a lower model for end-stage liver disease (16 versus 18, P = 0.01), and spent fewer days on the waitlist (173 versus 246, P = 0.02). Compared with waitlist candidates, pediatric NDD recipients were younger (50% versus 12% age <2 y, P < 0.001) and more often diagnosed with biliary atresia (66% versus 41%, P < 0.001). Compared with DLDs, NDDs were older (40 versus 35 y, P < 0.001), college educated (83% versus 64%, P < 0.001), White (92% versus 78%, P < 0.001), and more frequently donated left-lateral segment grafts (32.0% versus 14%, P < 0.001).

CONCLUSIONS

Liver NDD transplants continue to expand but remain concentrated at a few centers. Graft distribution favors female adults and pediatric patients with biliary atresia. Racial inequities in adult or pediatric center-level NDD graft distribution were not observed.

Postoperative outcomes of purely laparoscopic donor hepatectomy compared to open living donor hepatectomy: a preliminary observational study

Purpose

To lessen the physical, cosmetic, and psychological burden of donors, purely laparoscopic donor hepatectomy (PLDH) has been proposed as an ideal method for living donors. Our study aimed to prospectively compare the effect of PLDH and 2 other types of open living donor hepatectomy (OLDH) on postoperative pain and recovery.

Methods

Sixty donors scheduled to undergo donor hepatectomy between March 2015 and November 2017 were included. Donors were divided into 3 groups by surgical technique: OLDH with a subcostal incision (n = 20), group S; OLDH with an upper midline incision (n = 20), group M; and PLDH (n = 20), group L. The primary outcomes were postoperative pain and analgesic requirement during postoperative day (POD) 3. Other variables regarding postoperative recovery were also analyzed.

Results

Although pain relief during POD 3, assessed by visual analog scale (VAS) score and analgesic requirement, was similar among the 3 groups, group L showed lower VAS scores and opioid requirements than group M. Moreover, group L was associated with a rapid postoperative recovery evidenced by the shorter hospital length of stay and more frequent return to normal activity on POD 30.

Conclusion

This pilot study failed to verify the hypothesis that PLDH reduces postoperative pain. PLDH did not reduce postoperative pain but showed faster recovery than OLDH.

Prediction of liver remnant regeneration after living donor liver transplantation using preoperative CT texture analysis

PURPOSE

To predict the rate of liver regeneration after living donor liver transplantation (LDLT) using pre-operative computed tomography (CT) texture analysis.

MATERIALS AND METHODS

112 living donors who performed right hepatectomy for LDLT were included retrospectively. We measured the volume of future remnant liver (FLR) on pre-operative CT and the volume of remnant liver (LR) on follow-up CT, taken at a median of 123 days after transplantation. The regeneration index (RI) was calculated using the following equation: [Formula: see text]. Computerized texture analysis of the semi-automatically segmented FLR was performed. We used a stepwise, multivariable linear regression to assess associations of clinical features and texture parameters in relation to RI and to make the best-fit predictive model.

RESULTS

The mean RI was 110.7 ± 37.8%, highly variable ranging from 22.4% to 247.0%. Among texture parameters, volume of FLR, standard deviation, variance, and gray level co-occurrence matrices (GLCM) contrast were found to have significant correlations between RI. In multivariable analysis, smaller volume of FLR (ß - 0.17, 95% CI - 0.22 to - 0.13) and lower GLCM contrast (ß - 1.87, 95% CI - 3.64 to - 0.10) were associated with higher RI. The regression equation predicting RI was following: RI = 203.82 + 10.42 × pre-operative serum total bilirubin (mg/dL) - 0.17 × V_FLR (cm³) - 1.87 × GLCM contrast (× 100).

CONCLUSION

Volume of FLR and GLCM contrast were independent predictors of RI, showing significant negative correlations. Pre-operative CT with texture analysis can be useful for predicting the rate of liver regeneration in living donor of liver transplantation.

Microvascular Hepatic Artery Anastomosis in Pediatric Living Donor Liver Transplantation: 73 Consecutive Cases Performed by a Single Surgeon

BACKGROUND

Living donor liver transplantation is an important strategy of procuring segmental liver allografts for pediatric patients with liver failure, as suitably sized whole donor organs are scarce. The early pediatric living donor liver transplantation experience was associated with high rates of hepatic artery thrombosis, graft loss, and mortality. Collaboration with microsurgeons for hepatic artery anastomosis in pediatric living donor liver transplantation has decreased rates of arterial complications; however, reported outcomes are limited.

METHODS

A 14-year retrospective review was undertaken of children at the authors' institution who underwent living donor liver transplantation with hepatic artery anastomosis performed by a single microsurgeon using an operating microscope. Data were collected on demographics, cause of liver failure, graft donor, vessel caliber, vessel anastomosis, arterial complications, and long-term follow-up.

RESULTS

Seventy-three children with end-stage liver failure underwent living donor liver transplantation with microvascular hepatic artery anastomosis. The commonest cause for liver failure was biliary atresia (63 percent). A total of 83 end-to-end hepatic artery anastomoses were completed using an operating microscope. Hepatic artery complications occurred in five patients, consisting of three cases of kinked anastomoses that were revised without complications and two cases of hepatic artery thrombosis (3 percent), of which one resulted in graft loss and patient death. Patient survival was 94 percent at 1 year and 90 percent at 5 years.

CONCLUSIONS

Microvascular hepatic artery anastomosis in pediatric patients undergoing living donor liver transplantation is associated with a low hepatic artery complication rate and excellent long-term liver graft function. Collaboration between microsurgeons and transplant surgeons can significantly reduce technical complications and improve patient outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Current Status of Living Donor Liver Transplantation in the United States

Adult-to-adult living donor liver transplantation (LDLT) was introduced in response to the shortage of deceased donor liver grafts. The number of adult living donor transplants is increasing due to improved outcomes and increasing need. Advantages of LDLT include optimization of the timing of transplant, better organ quality, and lower rates of recipient mortality compared to staying on the wait list for deceased donor liver transplant. Donor safety remains the major focus when considering LDLT. Recent advancements have supported the increased use of LDLT to help decrease wait list death and improve long-term survival of transplant recipients.

Outcomes of right-lobe and left-lobe living-donor liver transplantations using small-for-size grafts

AIM

To analyze the outcomes of living-donor liver transplantation (LDLT) using left-lobe (LL) or right-lobe (RL) small-for-size (SFS) grafts.

METHODS

Prospectively collected data of adult patients who underwent LDLT at our hospital in the period from January 2003 to December 2013 were reviewed. The patients were divided into the RL-LDLT group and the LL-LDLT group. The two groups were compared in terms of short- and long-term outcomes, including incidence of postoperative complication, graft function, graft survival, and patient survival. A SFS graft was defined as a graft with a ratio of graft weight (GW) to recipient standard liver volume (RSLV) (GW/RSLV) of < 50%. The Urata formula was used to estimate RSLV.

RESULTS

Totally 218 patients were included for analysis, with 199 patients in the RL-LDLT group and 19 patients in the LL-LDLT group. The two groups were similar in terms of age (median, 53 years in the RL-LDLT group and 52 years in the LL-LDLT group, P = 0.997) but had significantly different ratios of men to women (165:34 in the RL-LDLT group and 8:11 in the LL-LDLT group, P < 0.0001). The two groups were also significantly different in GW (P < 0.0001), GW/RSLV (P < 0.0001), and graft cold ischemic time (P = 0.007). When it comes to postoperative complication, the groups were comparable (P = 0.105). Five patients died in hospital, 4 (2%) in the RL-LDLT group and 1 (5.3%) in the LL-LDLT group (P = 0.918). There were 38 graft losses, 33 (16.6%) in the RL-LDLT group and 5 (26.3%) in the LL-LDLT group (P = 0.452). The 5-year graft survival rate was significantly better in the RL-LDLT group (95.2% vs 89.5%, P = 0.049). The two groups had similar 5-year patient survival rates (RL-LDLT: 86.8%, LL-LDLT: 89.5%, P = 0.476).

CONCLUSION

The use of SFS graft in LDLT requires careful tailor-made surgical planning and meticulous operation. LL-LDLT can be a good alternative to RL-LDLT with similar recipient outcomes but a lower donor risk. Further research into different patient conditions is needed in order to validate the use of LL graft.

Technical aspects for live-donor organ procurement for liver, kidney, pancreas, and intestine

PURPOSE OF REVIEW

This article reviews current strategies for living-donor organ procurement in liver, kidney, pancreas, and intestinal transplant.

RECENT FINDINGS

Here we summarize current open and laparoscopic approaches to living donation of abdominal organs.

SUMMARY

Living donation strategies expand the organ pool in the setting of a significant organ shortage.

Anatomic similarity of the hepatic artery and portal vein according to the donor-recipient relationship

INTRODUCTION

Anatomic variants of the hepatic vasculature are common, so precise preoperative donor evaluation, including variations in the vasculature, is essential. We analyzed the anatomic similarity according to the donor-recipient relationship.

METHODS

Among the cases who underwent living donor liver transplantations from September 2008 to January 2011 we selected 104 cases with clearly defined hepatic artery and portal vein on preoperative computed tomography. They were classified according to Hiatt et al for the hepatic artery and Cheng for the portal vein. We categorized the 104 cases into three groups: parents-child (n=40), sibling (n=24) and no-relation (n=40), for analysis of the concordance of the hepatic artery and portal vein.

RESULT

Anatomic variations were observed in 25% of donors and 23.1% of recipients in the hepatic artery and 6.7% of donors and 10.6% of recipients in the portal vein. There was no significant difference in the distribution of the type of hepatic vasculature. Identical anatomic variations between donors and recipients were observed in 62.5% of the parent-child; 66.7% of the sibling and 52.5% of no-related group (P=.493) in the hepatic artery and 92.5%, 100%, and 77.5% (P=.014) in the portal vein respectively.

CONCLUSION

There was no similarity in the anatomic variations of the hepatic artery according to the donor-recipient relationship, but a similarity in portal venous anatomy according to the donor-recipient relationship.

Liver transplantation in children using organs from young paediatric donors

Nowadays, most paediatric liver transplant recipients receive a split or other technical variant graft from adult deceased or live donors, because of a lack of available age- and size matched paediatric donors. Few data are available, especially for liver grafts obtained from very young children (<6 years). We analysed all paediatric liver transplantations between 1989 and 2009. Recipients were divided into five groups (1-5) depending on donor age (<1, ≥1 to <6, ≥6 to <16, ≥16 to <45, ≥45 years). Overall, 413 paediatric liver transplantations from deceased donors were performed; 1- and 5-year graft survival rates were 75%, 80%, 78%, 81%, 74% and 75%, 64%, 70%, 67%, 46%, and 1- and 5-year patient survival rates were 88%, 91%, 90%, 89%, 78% and 88%, 84%, 84%, 83%, 63% for groups 1-5, respectively, without significant difference. Eight children received organs from donors younger than 1 year and 45 children received organs from donors between 1 and 6 years of age. Overall, vascular complications occurred in 13.2% of patients receiving organs from donors younger than 6 years. Analysis of our data revealed that the usage of liver grafts from donors younger than 6 years is a safe procedure. The outcome was comparable with grafts from older donors with excellent graft and patient survival, even for donors younger than 1 year.

Imaging evaluation of the liver using multi-detector row computed tomography in micropigs as potential living liver donors

The shortage of organ donors has stimulated interest in the possibility of using animal organs for transplantation into humans. In addition, pigs are now considered to be the most likely source animals for human xenotransplantation because of their advantages over non-human primates. However, the appropriate standard values for estimations of the liver of micropigs have not been established. The determination of standard values for the micropig liver using multi-detector row computed tomography (MDCT) would help to select a suitable donor for an individual patient, determine the condition of the liver of the micropigs and help predict patient prognosis. Therefore, we determined the standard values for the livers of micropigs using MDCT. The liver parenchyma showed homogenous enhancement and had no space-occupying lesions. The total and right lobe volumes of the liver were 698.57 ± 47.81 ml and 420.14 ± 26.70 ml, which are 51.74% and 49.35% of the human liver volume, respectively. In micropigs, the percentage of liver volume to body weight was approximately 2.05%. The diameters of the common hepatic artery and proper hepatic artery were 6.24 ± 0.20 mm and 4.68 ± 0.13 mm, respectively. The hepatic vascular system of the micropigs was similar to that of humans, except for the variation in the length of the proper hepatic artery. In addition, the diameter of the portal vein was 11.27 ± 0.38 mm. In conclusion, imaging evaluation using the MDCT was a reliable method for liver evaluation and its vascular anatomy for xenotransplantation using micropigs.

The dilemma of living liver donor death: to report or not to report?

Living donor liver transplantation has become a life-saving alternative for end-stage liver disease patients who have no chance of receiving a deceased donor organ. On the basis of information available to the medical community, mortality risk for the living donor is reviewed and implications of not reporting donor deaths are discussed.

Death of a living liver donor from illicit drugs

In children with acute hepatic failure, it has been suggested to offer living donor transplantation to all parents when a deceased donor organ can not be provided. Ethically, living related donation is coercive by its very nature, especially in emergencies. We report a 36-year-old woman who died from a drug overdose 57 days after living donor liver resection. The recipient was her 3-year-old son, who experienced acute hepatic failure as a result of acetaminophen intoxication. A deceased donor organ had not become available within 2 days after listing. Was the death of this living donor preventable or unpreventable? Certainly if the mother had decided not to take drugs, she would not have died from an overdose. One could argue that this was her personal choice, and beyond our influence. On the other hand, if we had not performed the surgery, the recipient might have died without receiving a liver transplant in time.

Steatosis as a risk factor in liver surgery

OBJECTIVE

To review present knowledge of the influence of hepatic steatosis in liver surgery as derived from experimental and clinical studies.

SUMMARY BACKGROUND DATA

Hepatic steatosis is the most common chronic liver disease in the Western world, and it is associated with obesity, diabetes, and metabolic syndrome. Fatty accumulation affects hepatocyte homeostasis and potentially impairs recovery of steatotic livers after resection. This is reflected clinically in increased mortality and morbidity after liver resection in patients with any grade of steatosis. Because of the epidemic increase of obesity, hepatic steatosis will play an even more significant role in liver surgery.

METHODS

A literature review was performed using MEDLINE and key words related to experimental and clinical studies concerning steatosis.

RESULTS

Experimental studies show the increased vulnerability of steatotic livers to various insults, attributed to underlying metabolic and pathologic derangements induced by fatty accumulation. In clinical studies, the severity of steatosis has an important impact on patient outcome and mortality. Even the mildest form of steatosis increases the risk of postoperative complications.

CONCLUSIONS

Hepatic steatosis is a major factor determining patient outcome after surgery. Further research is needed to clarify the clinical relevance of all forms and severity grades of steatosis for patient outcome. Standardized grading and diagnostic methods need to be used in future clinical trials to be able to compare outcomes of different studies.

Living donor liver transplantation--adult donor outcomes: a systematic review

The objective of this study was to evaluate the safety and efficacy of adult-to-adult living donor liver transplantation, specifically donor outcomes. A systematic review, with searches of the literature up to January 2004, was undertaken. Two hundred and fourteen studies provided information on donor outcomes. The majority of these were case series studies, although there were also studies comparing living donor liver transplantation with deceased donor liver transplantation. Both underreporting and duplicate reporting is likely to have occurred, and so caution is required in interpretation of these results. Overall reported donor mortality was 12 to 13 in about 6,000 procedures (0.2%) (117 studies). Mortality for right lobe donors to adult recipients is estimated to be 2 to 8 out of 3,800 (0.23 to 0.5%). The donor morbidity rate ranged from 0% to 100% with a median of 16% (131 studies). Biliary complications and infections were the most commonly reported donor morbidities. Nearly all donors had returned to normal function by 3 to 6 months (18 studies). In conclusion, there are small, but real, risks for living liver donors. Due to the short history of adult-to-adult living donor liver transplantation, the long-term risks for donors are unknown.

The current status of living donor liver transplantation

In response to the critical organ shortage, transplant professionals have utilized living donors in an attempt to decrease the mortality rate associated with waiting on the liver transplant list. Although the surgical techniques were first utilized clinically 15 years ago, application of LDLT has been somewhat limited by the steep learning curve associated with developing a program. Clinical success with LDLT in children was realized early in the experience and application of the techniques to the adult population has occurred more recently. Although transplant centers embark on LDLT with enthusiasm, the safety of the donor must always be at the forefront of the process. Potential donors must come to the decision to donate without pressure from members of the family or transplant team. He/she should also be assigned advocates who constantly promote the donor's best interest. Failure to adhere to strict donor evaluation protocols and standardized operative techniques could result in disastrous consequences.

Evolution of donor morbidity in living related liver transplantation: a single-center analysis of 165 cases

OBJECTIVE

During the last 14 years, living donor liver transplantation (LDLT) has evolved to an indispensable surgical strategy to minimize mortality of adult and pediatric patients awaiting transplantation. The crucial prerequisite to performing this procedure is a minimal morbidity and mortality risk to the healthy living donor. Little is known about the learning curve involved with this type of surgery.

PATIENTS AND METHODS

From January 1991 to August 2003, a total of 165 LDLTs were performed in our center. Of these, 135 were donations of the left-lateral lobe (LL, segments II and III), 3 were of the left lobe (L, segments II-IV), 3 were full-left lobes (FL, segments I-IV), and 24 were of the full-right lobe (FR, segments V-VIII). We divided the procedures into 3 periods: period 1 included the years 1991 to 1995 (LL, n = 49; L, n = 2; FR, n = 1), period 2 covered 1996 to 2000 (LL, n = 47), and period 3 covered 2001 to August 2003 (LL, n = 39; FR, n = 23; FL, n = 3; L, n = 1). Perioperative mortality and morbidity were assessed using a standardized classification. Length of stay in intensive care unit, postoperative hospital stay, laboratory results (bilirubin, INR, and LFTs), morbidity, and the different types of grafts in the 3 different periods were compared.

RESULTS

One early donor death was observed in period 1 (03/07/93, case 30; total mortality, 0.61.%). Since 1991, the perioperative morbidity has continually declined (53.8% vs. 23.4% vs. 9.2%). In period 1, 28 patients had 40 complications. In period 2, 11 patients had 12 complications, and in period 3, 6 patients had 9 complications. Within the first period, 1 donor underwent relaparotomy because of bile leakage. Postoperative hospital stay was 10 days, 7 days, and 6 days, respectively. Donation of the full right lobe, in comparison with that of the left lateral lobe, resulted in a significantly diminished liver function (bilirubin and INR) during the first 5 days after donation but did not increase morbidity. One donor from period 1 experienced late death caused by amyotrophic lateral sclerosis.

CONCLUSIONS

In a single center, morbidity after living liver donation strongly correlates to center experience. Despite the additional risks associated with temporary reduction of liver function, this experience enabled the team to bypass part of the learning curve when starting right lobe donation. Specific training of the surgical team and coaching by an experienced center should be implemented for centers offering this procedure to avoid the learning curve.

Factors that identify survival after liver retransplantation for allograft failure caused by recurrent hepatitis C infection

Hepatitis C virus (HCV) is becoming the most common indication for liver retransplantation (ReLTx). This study was a retrospective review of the medical records of liver transplant patients at our institution to determine factors that would identify the best candidates for ReLTx resulting from allograft failure because of HCV recurrence. The patients were divided into 2 groups on the basis of indication for initial liver transplant. Group 1 included ReLTx patients whose initial indication for LTx was HCV. Group 2 included patients who received ReLTx who did not have a history of HCV. We defined chronic allograft dysfunction (AD) as patients with persistent jaundice (> 30 days) beginning 6 months after primary liver transplant in the absence of other reasons. HCV was the primary indication for initial orthotopic liver transplantation (OLT) in 491/1114 patients (44%) from July 1996 to February 2004. The number of patients with AD undergoing ReLTx in Groups 1 and 2 was 22 and 12, respectively. The overall patient and allograft survival at 1 year was 50% and 75% in Groups 1 and 2, respectively (P = .04). The rates of primary nonfunction and technical problems after ReLTx were not different between the groups. However, the incidence of recurrent AD was higher in Group 1 at 32% versus 17% in Group 2 (P = .04). Important factors that predicted a successful ReLTx included physical condition at the time of ReLTx (P = .002) and Child-Turcotte-Pugh score (P = .008). In conclusion, HCV is associated with an increased incidence of chronic graft destruction with a negative effect on long-term results after ReLTx. The optimum candidate for ReLTx is a patient who can maintain normal physical activity. As the allograft shortage continues, the optimal use of cadaveric livers continues to be of primary importance. The use of deceased donor livers in patients with allograft failure caused by HCV remains a highly controversial issue.

The management of coagulopathy and blood loss in liver surgery

Liver surgery has long been associated with massive perioperative blood loss and high rates of postsurgery morbidity and mortality. Recent advances in our knowledge of hepatic segmental anatomy have led to the evolution of liver resection, and a growing awareness of the coagulopathy present in cirrhotic patients has produced a greater understanding of the factors influencing surgical hemostasis. This review will examine the risk factors for perioperative hemorrhage in liver disease patients, and will describe current pharmacological, surgical, and radiological methods available for controlling bleeding and achieving effective hemostasis during liver resection and orthotopic liver transplantation (OLT). The potential role of recombinant factor VIIa (rFVIIa) in providing safe hemostasis during such procedures will also be explored. Today, due to careful monitoring and correction of coagulopathy, improved surgical techniques, and judicious patient selection, liver surgery is no longer a high-risk specialty with an unfavorable risk profile, but a safe and widely practiced procedure.

Outcome after pediatric liver transplantation impact of living donor transplantation on cost

OBJECTIVE

To compare the direct health care cost of living donor liver transplantation (LDLT) with that of cadaver donor liver transplantation (CDLT) in children and identify predictors of cost.

STUDY DESIGN

All 16 children who underwent LDLT from January 1997 through January 2002 at Cincinnati Children's Hospital Medical Center comprised the study population. They were matched for age, diagnosis, and nutritional status with 31 children who received CDLT during the same era. A historic cohort analysis was performed.

RESULTS

There was no difference in the 1-year mortality rates between both groups. Costs associated with graft retrieval contributed 15.3% and 31% of the initial transplant cost for LDLT and CDLT, respectively. Mean cost of care in the first year was 60.3% higher for LDLT than CDLT (P=.01). Multivariate analysis identified biliary complications and insurance status as predictors of cost for initial transplantation (R(2)=0.57), whereas biliary complications and pediatric end stage liver disease scores were identified as predictors of cost of care in the first year after transplantation (R(2)=0.77).

CONCLUSIONS

The comprehensive cost of LDLT in the first year after transplantation is higher than cadaveric transplantation. This must be balanced against the time spent and care needs of patients on the waiting list.

The impact of cyclosporine on the development of immunosuppressive therapy for pediatric liver transplantation

Since the introduction of cyclosporine into pediatric liver transplantation remarkable progress in patient and graft survival has been observed: survival rates 60%; acute (60%), steroid-resistant (22%) and chronic rejection (4%); infections (60%); and side effects (20%). Individualization of cyclosporine therapy complements the development of new immunosuppressive agents such as tacrolimus, mycophenolate mofetil, and sirolimus for specific indications. The ultimate goal of transplantation to achieve immunotolerance a waits future progress.

Right living donor liver transplantation: an option for adult patients: single institution experience with 74 patients

OBJECTIVE

To present an institutional experience with the use of right liver grafts in adult patients and to assess the practicability and efficacy of this procedure by analyzing the results.

SUMMARY BACKGROUND DATA

Living donor liver transplantation (LDLT) for the pediatric population has gained worldwide acceptance. In the past few years, LDLT has also become feasible for adult patients due to technical evolution in hepatobiliary surgery and increased experience with reduced-size and split-liver transplants. Nevertheless, some graft losses remain unexplained and are possibly due to unrecognized venous outflow problems.

METHODS

From April 1998 to September 2002, we performed 74 right LDLTs (segments 5-8). The 74 donors were selected from 474 candidates according to standard protocol. The median age of the donors was 35 years (range 18-58 years) and 51 years (range 18-64 years) in recipients. Standard and extended indications for transplantation were considered. Over the period reported, technical modifications in the bile duct anastomosis (duct-to-duct, end-to-end, or end-to-side) and a new graft implantation technique that provides maximized venous outflow, leading to outcome improvement, were developed.

RESULTS

64.9% of patients had liver cirrhosis and 35.1% had malignancy. While 44 donors (59.5%) presented an uneventful postoperative course, 27% minor (pleural effusion, pneumonia, venous thrombosis, wound infection, incisional hernia) and 13.5% major (biliary leakage, death of a donor due to unrecognized hereditary liver disease, and consecutive liver insufficiency) complications were documented. In recipients, 23% biliary complications and 6.8% hepatic artery thrombosis occurred. The overall patient and graft survival rate after 1 year was 79.4% and 75.3%, respectively. In cases with extended indication, the patient survival rate was 74% and the graft survival rate 68% at 12 months. Using technical modifications in the last 10 recipients, including 2 critically decompensated cirrhotics, the survival rate was 100% at a median follow-up of 3.5 months.

CONCLUSIONS

In our transplant program, living donor liver transplantation has become a standard option in the adult patient population. The critical issue of this procedure is donor morbidity. Technical improvements in the harvesting and implantation of right grafts can also offer hope to patients with challenging forms of end-stage liver disease or malignant liver tumors.

History of pediatric liver transplantation. Where are we coming from? Where do we stand?

The history of pediatric liver transplantation cannot be dissociated from one man, Thomas E. Starzl, whose pioneer efforts contributed more than anyone else to what has become a routinely successful clinical procedure. During the pre-cyclosporine era, the pediatric experience was confined nearly exclusively in Denver: first attempt in 1963, first success with survival beyond one year in 1967, cumulative experience with 84 pediatric cases in the pre-cyclosporine era (1967-1979) with a 2-year patient survival rate of 30%. The stampede for the development of other liver transplant centers came with the introduction of cyclosporine in the early eighties. Besides Pittsburgh, seven centers (Brussels, Cambridge and Hanover in Europe; Boston, Dallas, UCLA, Minneapolis in USA) had performed up to 1986 at least 20 pediatric liver transplants each with a long-term (>1 year) patient survival rate ranging between 57% and 83%. At the moment, a long-term patient survival rate in excess of 90% in elective patients -including infants - is commonly obtained in experienced centers. The shortage of size matched liver donors which was responsible for a high death rate on the cadaveric waiting list stimulated the development or technical innovations based on the segmental anatomy of the liver: reduced ('cutdown') liver graft, split graft and living liver transplantation. Challenging technical aspects in the recipient have been solved in order to reduce the incidence of surgical complications like outflow obstruction, arterial and portal thrombosis, and biliary problems. The indications of liver transplantation have been refined; regarding biliary atresia, which is the most frequent indication, a consensus has developed to propose a sequential strategy with a single attempt at hepatoportoenterostomy followed, when it fails, by liver transplantation. Some contra-indications accepted in the past are not currently valid with better understanding of the pathophysiology and/or increased clinical experience; such is the case of the hepatopulmonary syndrome. A major progress in preoperative management has been achieved through a multidisciplinary approach, particularly regarding nutrition and control of portal hypertension-related bleeding and ascites. Perioperatively, liver transplantation has derived benefit from the expertise of anesthetists managing babies with serious conditions and increased experience of the transplant surgeons regarding the knowledge of all the technical modalities, good strategy, technical skills and meticulous control of bleeding. It is well-recognized that children require more immunosuppression than adults. As in adults, the first breakthrough came with the introduction of cyclosporine which more than doubled the one-year patient survival rate. The next advance during the last decade was afforded by FK 506 - Tacrolimus which allows steroid withdrawal with the first year post-transplant in most patients. Besides its efficacy in reducing the incidence of rejection and absence of cosmetic side-effects, the steroid-sparing effect of Tacrolimus is of utmost importance to preserve the growth potential of children. The use of OKT-3 both for induction and treatment of rejection has been abandoned nearly universally because its use, cumulated with other immunosuppressants, resulted in a high incidence of lymphoproliferative disorder. In contrast, anti-IL2-receptor monoclonal antibodies, will most likely gain an increasing place in induction, with the availability of chimeric or humanized preparations. The side-effects of immunosuppression can endanger both the quality of life and the life expectancy; they are a special source of concern in pediatric recipients whose survival can be expected to be more than a few decades. Children would benefit most from the development of a marker able to identify the patients who have developed graft acceptance, allowing complete wearing of immunosuppression. Also they would benefit most from research protocols of tolerance induction. Since the vast majority of liver-transplanted children will have a reasonably normal life expectancy, the focus should be switched to their long-term rehabilitation and the assessment of their quality of life when they reach adulthood.

Analysis of donor risk in living-donor hepatectomy: the impact of resection type on clinical outcome

The progressive shortage of liver donors has mandated investigation of living-donor transplantation (LDT). Concerns about increasing risk to the donor are evident, but the impact of the degree of parenchymal loss has not been quantified. We analyzed clinical and biological variables in 45 LDT performed by our team over 2years to assess risks faced in adult LDT. All donors are alive and well with complete follow-up through to February 2001. When the three operations were compared, right hepatectomy (RH) was significantly longer in terms of anesthesia time and blood loss compared with left hepatectomy (LH) and left lobectomy (LL). Donor remnant liver was significantly reduced after RH compared with LH and LL. There were significant functional differences as a consequence of the remnant size, measured by an increase in peak prothrombin time after RH. RH for adults represents a markedly different insult from pediatric donations in terms of parenchymal loss and early functional impairment. Left hepatectomy donation offers modest advantage over right lobes but seems to confer substantial technical risk for a small gain in graft size. Unless novel strategies are developed to enhance liver function of the LH graft in the adult recipient, right lobe donation will be necessary for adult LDT.

Potential living liver donors: evaluation with an all-in-one protocol with multi-detector row CT

Multi-detector row computed tomography was performed for the preharvest evaluation of 14 potential living liver donors. Both a biliary contrast agent and a conventional iodinated contrast agent were administered intravenously. This protocol included acquisition of three subsequent scans and allowed accurate assessment of the hepatic parenchymal morphology and volumetrics and a detailed analysis of the biliary and vascular anatomies.

Anatomical variations and surgical strategies in right lobe living donor liver transplantation: lessons from 120 cases

BACKGROUND

Anatomical variations in right liver lobe are common. However, clinical implications and surgical management of these variations in living donor liver transplantation have not been analyzed systematically.

METHODS

Surgical anatomy of vascular and biliary structures in 120 right lobe grafts were reevaluated by reviewing the results of preoperative (computerized tomography and Doppler ultrasonography) and intraoperative (cholangiography) imaging as well as surgical findings. The data were analyzed in relation to surgical management of anatomical variations.

RESULTS

The incidence of variants leading to multiple portal vein anastomoses was 7.5%. The incidence of dual right hepatic veins was 0.8%; 30% of the grafts had significant accessory hepatic veins (>5 mm) and 13.9% of these were multiple. All of them were successfully reconstructed with technical modifications including venoplasty and venous grafts, except for two cases with multiple intraparenchymal portal vein branches to the anterior segment. The incidence of dual hepatic arteries was 1.7%, but only one of them was reconstructed without negative sequelae. The incidence of variants potentially leading to multiple bile duct anastomoses was 35.0%, and eventually 39.2% of the grafts had multiple orifices. With a variety of techniques including ductoplasty, hepaticohepaticostomy, and biliary stent, total incidence of leakage and stenosis was 10.8% and 9.2%, respectively. Although ductoplasty, internal stent or no stenting, seemed to be associated with increased risk of complications, anatomical variants, multiple bile ducts, and duct-to-duct reconstruction did not bear a significant risk.

CONCLUSIONS

Anatomical variations of vascular and biliary structures in right lobe grafts are common. However, most can be managed safely with technical modifications. Only cases with intraparenchymal origin of the anterior portal vein(s) may form a relative contraindication, especially when combined with similar biliary variants. Otherwise, intraoperative assessment of biliary anatomy was enough for successful management. Detailed and precise assessment of vascular and biliary anatomy is vital for appropriate surgical management.

Attitudes regarding organ donation from non-heart-beating donors

PURPOSE

To determine the attitudes toward organ donation from non-heart-beating cadaver donors in a sample of the general public and health care workers.

MATERIALS AND METHODS

A moderator-administered questionnaire was completed by members of the general public, recruited randomly from a professional consumer research group's database, and health care workers recruited from the same database, family practice clinics, and local hospitals. Two primary scenarios were tested: (1) patient in coma, not going to survive intensive care unit (ICU), and (2) patient lapsing in and out of consciousness, lifetime institutional care.

RESULTS

Sixty members of the general public and 68 health care workers completed the questionnaire. The majority of both groups were aware life support could be withdrawn in Scenario 1, however, significantly fewer were aware life support could also be withdrawn in Scenario 2 (83% general public vs 34% general public, P <.001 and 94% health care workers vs 78% health care workers, P =.012). Uncertainty in prognosis was cited as the primary concern. The issue of organ donation was directly linked with withdrawal of life support. The majority of both groups believed that organ donation would be permissible if further life support were deemed to be not in the patient's best interest because of poor short-term prognosis (94% health care workers and 98% general public for Scenario 1 and 87% health care workers and 81% general public for Scenario 2). The greatest difficulty arose in defining futility of care. Expected quality of life, patient's and family's values, opinions, and religious beliefs were felt to be most important in determining decisions regarding futility and withdrawal of life support. Physician beliefs and values were felt to influence decisions more than they should.

CONCLUSIONS

Both the general public and health care workers support the use of non-heart-beating cadaver donors once a decision has been made to withdraw life support. However, both groups raised concerns regarding how the decision to withdraw life support is made.

One hundred nine living donor liver transplants in adults and children: a single-center experience

OBJECTIVE

To summarize the evolution of a living donor liver transplant program and the authors' experience with 109 cases.

SUMMARY BACKGROUND DATA

The authors' institution began to offer living donor liver transplants to children in 1993 and to adults in 1998.

METHODS

Donors were healthy, ages 18 to 60 years, related or unrelated, and ABO-compatible (except in one case). Donor evaluation was thorough. Liver biopsy was performed for abnormal lipid profiles or a history of significant alcohol use, a body mass index more than 28, or suspected steatosis. Imaging studies included angiography, computed tomography, endoscopic retrograde cholangiopancreatography, and magnetic resonance imaging. Recipient evaluation and management were the same as for cadaveric transplant.

RESULTS

After ABO screening, 136 potential donors were evaluated for 113 recipients; 23 donors withdrew for medical or personal reasons. Four donor surgeries were aborted; 109 transplants were performed. Fifty children (18 years or younger) received 47 left lateral segments and 3 left lobes; 59 adults received 50 right lobes and 9 left lobes. The average donor hospital stay was 6 days. Two donors each required one unit of banked blood. Right lobe donors had three bile leaks from the cut surface of the liver; all resolved. Another right lobe donor had prolonged hyperbilirubinemia. Three donors had small bowel obstructions; two required operation. All donors are alive and well. The most common indications for transplant were biliary atresia in children (56%) and hepatitis C in adults (40%); 35.6% of adults had hepatocellular carcinoma. Biliary reconstructions in all children and 44 adults were with a Roux-en-Y hepaticojejunostomy; 15 adults had duct-to-duct anastomoses. The incidence of major vascular complications was 12% in children and 11.8% in adult recipients. Children had three bile leaks (6%) and six (12%) biliary strictures. Adult patients had 14 (23.7%) bile leaks and 4 (6.8%) biliary strictures. Patient and graft survival rates were 87.6% and 81%, respectively, at 1 year and 75.1% and 69.6% at 5 years. In children, patient and graft survival rates were 89.9% and 85.8%, respectively, at 1 year and 80.9% and 78% at 5 years. In adults, patient and graft survival rates were 85.6% and 77%, respectively, at 1 year.

CONCLUSION

Living donor liver transplantation has become an important option for our patients and has dramatically changed our approach to patients with liver failure. The donor surgery is safe and can be done with minimal complications. We expect that living donor liver transplants will represent more than 50% of our transplants within 3 years.

Adult-to-adult live donor liver transplantation: a short-term clinicopathologic study

With the success of pediatric live donor liver transplantation (LDLT) and the continued shortage of cadaveric donors, adult-to-adult LDLT has been performed at some centers, including ours. We performed a detailed histologic review of all liver specimens obtained from 9 adult recipients at and after LDLT and correlated these findings with the patients' course and outcome. Five patients had histologic evidence of biliary tract pathology; 3 of 5 required surgical or radiologic intervention. The other 2 had clinically insignificant biliary disease. Diffuse hepatocytic hemorrhagic necrosis secondary to massive portal blood flow after portal venous revascularization resulted in graft failure and retransplantation in a single patient with severe preoperative portal hypertension. Two perioperative deaths were caused by sepsis and multiorgan failure (day 25) and generalized thrombosis related to factor V Leiden (day 6). The preoperative diagnosis, presence of portal vein thrombosis in the native liver, postoperative cholangiopathy, and subcapsular hemorrhagic necrosis in donor liver wedge biopsies did not affect the short-term outcome. In conclusion, biliary tract pathology is common after adult-to-adult LDLT but does not negatively affect graft or patient survival. Infrequent but catastrophic vascular complications related to portal hemodynamics or thrombosis can result in graft loss and/or patient death.

[Living donor liver transplantation in adults. Initial results]

AIM

To analyze the preliminary results of the implementation of a living donor liver transplantation program.

PATIENTS AND METHOD

Between March and September 2000 we performed 7 living donor liver transplantations using the right hepatic lobe. The donors were 5 men and 2 women with a mean age of 39.3 11.5 years. Three donors were genetically related (daughter, mother, son). The mean relative liver volume transplanted was 58.8 2.5%. The mean age of the recipients was 50.4 16.5 years. Six patients presented hepatitis C virus-induced cirrhosis and one presented familial amyloidotic polyneuropathy.

RESULTS

Three complications occurred in the donors: 1 slight infection and 2 biliary fistulae. Graft function was adequate in all recipients and there were three acute rejections. Four biliary leakages occurred of which two required reoperation. None of the patients developed vascular thrombosis. Two recipients died, 53 and 72 days after the operation, with a correctly functioning graft.

CONCLUSION

Living donor liver transplantation constitutes a necessary complement to the current cadaveric donor program to increase the number of patients who can benefit from this treatment, which may represent 10% of the activity of our center. The technical complexity of this procedure is much greater than that of cadaveric transplantation. The right hepatic lobe provides sufficient hepatic mass for most adult recipients.

Accuracy of volumetric measurements after virtual right hepatectomy in potential donors undergoing living adult liver transplantation

OBJECTIVE

The purpose of this study was to evaluate accuracy for determining the total and lobar liver volumes using a multidetector CT scanner in potential donors undergoing living adult right lobe liver transplantation.

SUBJECTS AND METHODS

Fifty-two adult donors underwent CT using a multidetector scanner after IV injection of 180 mL of contrast material. For volumetric determination, portal venous phase images were acquired at 60 sec. Hand-tracing was used to isolate the entire liver, and a curved hepatectomy plane was then identified in a manner simulating the surgical incision. Two observers performed hand-tracing of the entire liver to calculate total liver volume, and of the right lobe to calculate expected graft volume.

RESULTS

The mean volume of the entire liver, right lobe, and left lobe was 1807 mL, 990 mL, and 817 mL, respectively, for observer 1, and 1788 mL, 1007 mL, and 781 mL, respectively, for observer 2. There was significant agreement between the two observers in determining total and lobar liver volumes (r = 0.996, 0.977, and 0.965 for total, right lobe, and left lobe volumes, respectively; p< 0.0001). There was no statistically significant difference between the two observers in measuring total or lobar liver volumes (p< 0.0001). There was significant agreement between right lobe volume measured by each observer and graft weight obtained in 14 donors at surgery (r = 0.898 and 0.879, for observers 1 and 2, respectively; p <0.001).

CONCLUSION

Total and lobar volume determinations after virtual right hemihepatectomy provides accurate and reproducible information that is critical in selecting potential living liver donors.

Impact of multidetector CT on donor selection and surgical planning before living adult right lobe liver transplantation

OBJECTIVE

This study was performed to document the impact of multidetector multiphase CT in facilitating patient selection and surgical planning in potential donors being evaluated for living adult right lobe liver transplantation.

SUBJECTS AND METHODS

Forty consecutive potential donors were included in the study. There were 26 men and 14 women, (age range, 18-57 years; mean, 37 years) We performed CT using a multidetector scanner, after IV injection of 180 mL of contrast material at 5 mL/sec. Arterial phase images were acquired at 18 sec (collimation, 1.25 mm; table speed, 7.5) and portal phase images, at 60 sec (collimation, 2.5 mm; table speed, 15). Postprocessing was performed on a commercially available workstation. CT data included dual-energy assessment of liver parenchyma for fatty infiltration; depiction of arterial, portal venous, and hepatic venous anatomy and identification of important vascular variants; and determination of total and lobar liver volume.

RESULTS

Of the 40 potential liver donors evaluated, 15 patients (37.5%) were excluded on the basis of CT findings, with most exclusions a result of portal vein anomalies (n = 8). Fatty infiltration resulted in four exclusions (10%), and small liver volume resulted in three exclusions (7.5%).

CONCLUSION

Multidetector multiphase CT provided comprehensive parenchymal, vascular, and volumetric preoperative evaluation of potential donors undergoing living adult right lobe liver transplantation. This information had a major impact on patient selection because it was used to stratify patients. It allowed the surgeons to plan their surgical approach, and this planning may reduce postoperative complications.

Improved graft survival of pediatric liver recipients transplanted with pediatric-aged liver donors

BACKGROUND

Improving graft survival after liver transplantation is an important goal for the transplant community, particularly given the increasing donor shortage. We have examined graft survivals of livers procured from pediatric donors compared to adult donors.

METHODS

The effect of donor age (<18 years or > or =18 years) on graft survivals for both pediatric and adult liver recipients was analyzed using data reported to the UNOS Scientific Registry from January 1, 1992 through December 31, 1997. Graft survival, stratified by age, status at listing, and type of transplant was computed using the Kaplan-Meier method. In addition, odds ratios of graft failure at 3 months, 1 year, and 3 years posttransplant were calculated using a multivariate logistic regression analysis controlling for several donor and recipient factors. Modeling, using the UNOS Liver Allocation Model investigated the impact of a proposed policy giving pediatric patients preference to pediatric donors.

RESULTS

Between 1992 and 1997 pediatric recipients received 35.6% of pediatric aged donor livers. In 1998 the percent of children dying on the list was 7.4%, compared with 7.3% of adults. Kaplan-Meier graft survivals showed that pediatric patients receiving livers from pediatric aged donors had an 81% 3-year graft survival compared with 63% if children received livers from donors > or =18 years (P<0.001). In contrast, adult recipients had similar 3-year graft survivals irrespective of donor age. In the multivariate analysis, the odds of graft failure were reduced to 0.66 if pediatric recipients received livers from pediatric aged donors (P<0.01). The odds of graft failure were not affected at any time point for adults whether they received an adult or pediatric- aged donor. The modeling results showed that the number of pediatric patients trans planted increased by at most 59 transplants per year. This had no significant effect on the probability of pretransplant death for adults on the waiting list. Waiting time for children at status 2B was reduced by as much as 160 days whereas adult waiting time at status 2B was increased by at most 20 days.

CONCLUSION

A policy that would direct some livers procured from pediatric- aged donors to children improves the graft survival of children after liver transplantation. The effect of this policy does not increase mortality of adults waiting. Such a policy should increase the practice of split liver transplantation, which remains an important method to increase the cadaveric donor supply.