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Addeo P, de Mathelin P, Bachellier P. Graft reduction in adult liver transplantation: indications, techniques, and outcomes. J Gastrointest Surg 2024:S1091-255X(24)00431-1. [PMID: 38710440 DOI: 10.1016/j.gassur.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/24/2024] [Accepted: 04/27/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE Graft reduction can be a patient's graft-saving option to avoid large-for-size (LFS) syndrome. This study aimed to summarize the literature on graft reduction in adult liver transplantation and to demonstrate the technique of H67 graft hepatectomy. METHODS The technique, shown in a didactical video, entails an ex situ posterior sectionectomy under hypothermic perfusion. The right hepatic vein is identified, and the transection line follows the right hepatic fissure. The Glissonean pedicles are ligated during parenchymal transection. RESULTS A narrative review of the literature yielded 7 studies. A total of 15 liver grafts were reduced in adult liver transplantations. Most of the reductions were ex situ (11/15 [73.3%]). Graft reduction entailed an H67 sectionectomy in 10 cases and an H23 sectionectomy in 1 case. In situ reduction included 1 right hepatectomy (H5678), 2 H67 sectionectomies, and 1 H23 left lateral sectionectomy. The duration of the ex situ reduction averaged 56 minutes (median: 40.5 minutes; IQR, 33.0-130.0), and the graft weight-to-recipient weight ratio decreased from 3.57% ± 0.40% to 2.70% ± 0.50% after graft reduction. The average cold ischemia time was 390 minutes (IQR, 230-570). There was no liver retransplantation. CONCLUSION Graft reduction in adult liver transplantation may be necessary to avoid LFS syndrome. Graft reduction entailed an H67 sectionectomy in 10 cases and an H23 sectionectomy in 1 case. In situ reduction included 1 right hepatectomy (H5678), 2 H67 sectionectomies, and 1 H23 left lateral sectionectomy.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Pierre de Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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2
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Pu X, He D, Liao A, Yang J, Lv T, Yan L, Yang J, Wu H, Jiang L. A Novel Strategy for Preventing Posttransplant Large-For-Size Syndrome in Adult Liver Transplant Recipients: A Pilot Study. Transpl Int 2022; 35:10177. [PMID: 35185367 PMCID: PMC8842270 DOI: 10.3389/ti.2021.10177] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/24/2021] [Indexed: 12/15/2022]
Abstract
There are two causes of graft compression in the large-for-size syndrome (LFSS). One is a shortage of intra-abdominal space for the liver graft, and the other is the size discrepancy between the anteroposterior dimensions of the liver graft and the lower right hemithorax of the recipient. The former could be treated using delayed fascial closure or mesh closure, but the latter may only be treated by reduction of the right liver graft to increase space. Given that split liver transplantation has strict requirements regarding donor and recipient selections, reduced-size liver transplantation, in most cases, may be the only solution. However, surgical strategies for the reduction of the right liver graft for adult liver transplantations are relatively unfamiliar. Herein, we introduce a novel strategy of HuaXi-ex vivo right posterior sectionectomy while preserving the right hepatic vein in the graft to prevent LFSS and propose its initial indications.
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Affiliation(s)
- Xingyu Pu
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Diao He
- Laboratory of Liver Transplantation, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital of Sichuan University, Chengdu, China
| | - Anque Liao
- Anesthesia and Operating Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Jian Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Tao Lv
- Laboratory of Liver Transplantation, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital of Sichuan University, Chengdu, China
| | - Lunan Yan
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Jiayin Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Hong Wu
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Li Jiang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
- Department of General Surgery, West China TianFu Hospital, Sichuan University, Chengdu, China
- *Correspondence: Li Jiang,
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3
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Reduced-right posterior sector salvage liver transplantation using a moderate steatotic graft from one obese donor after cardiac death. Chin Med J (Engl) 2020; 134:596-598. [PMID: 33652461 PMCID: PMC7929647 DOI: 10.1097/cm9.0000000000001272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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4
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Addeo P, Noblet V, Naegel B, Bachellier P. Large-for-Size Orthotopic Liver Transplantation: a Systematic Review of Definitions, Outcomes, and Solutions. J Gastrointest Surg 2020; 24:1192-1200. [PMID: 31919740 DOI: 10.1007/s11605-019-04505-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND We systematically reviewed the literature on definitions and outcomes of large-for-size (LFS) syndrome in orthotopic liver transplantation (LT). METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Cochrane Library, PubMed, and Embase were searched (January 1990-January 2019) for studies reporting LFS in LT. Primary outcomes were definitions and mortality of LFS LT. RESULTS Eleven studies reporting patients with LFS LT were identified. Four different formulas (graft-to-recipient weight ratio (GRWR), body surface area index (BSAi), donor standardized total liver volume (sTLV)-to-recipient sTLV ratio, and graft weight/right anteroposterior distance (RAP) ratio) with their critical thresholds were found. There were 81 patients (54% women) with a median weight and height of 62.5 kg (range, 40-105 kg) and 165 cm (range, 145-180 cm). The median graft weight was 1772 g (range, 1290-2400 g), and the median GWRW was 2.77% (range, 2.1-4.00%). Graft venous outflow obstruction was described in seven patients (8.6%). At the time of LT, fascial closure was not achieved in 24 patients (29.6%) and the graft size was reduced by a liver resection in three patients (3.7%). Thirteen deaths (16%) were reported in the first 90 postoperative days with two patients undergoing re-transplant. CONCLUSIONS LFS LT remains heterogeneously defined but characterized by high mortality rates despite the use of tailored surgical solutions (graft reduction and open abdomen). A composite definition is proposed in order to better describe LFS clinical syndrome.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Moliere, 67098, Strasbourg, France. .,ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France.
| | - Vincent Noblet
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France
| | - Benoit Naegel
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Moliere, 67098, Strasbourg, France
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5
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Kim YM, Kwak BJ, Shim DJ, Kwon YK, Yoon YC. In Situ Left Lateral Sectionectomy in Deceased Donor Liver Transplantation: Could This Be Another Solution for a Large-for-Size Graft? A Case Report. Transplant Proc 2019; 51:3116-3119. [PMID: 31587814 DOI: 10.1016/j.transproceed.2019.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/09/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Large-for-size (LFS) graft should be avoided when performing an adult deceased donor liver transplantation (DDLT) as it is associated with abdominal compartment syndrome, severe graft injury, and primary graft nonfunction. When inadvertently facing with LFS graft intraoperatively, the most commonly reported approach has been a surgical reduction of the right lobe despite its technical difficulty in addition to ongoing coagulopathy after graft reperfusion. We report a case where we performed a left lateral sectionectomy instead of a right lobe modification. CASE REPORT A 44-year-old 58.4 kg female patient was admitted with drug-induced acute hepatic failure and underwent an emergency DDLT. The donor was a 51-year-old 60.0 kg man. At the time of procurement, the liver was noted to be hypertrophic. The estimated graft/recipient weight ratio was 3.49%. After completing the vascular and bile duct anastomosis, the abdomen could not be closed due to its large graft size. Because of the hypertrophic left lateral lobe and ongoing coagulopathy, we decided to perform an in situ left lateral sectionectomy rather than right posterior sectionectomy or right hemihepatectomy. The next day, the liver function failed to improve, and the patient's blood pressure began to decline gradually. Computed tomography showed severe inferior vena cava (IVC) compression by the graft, and the patient underwent transjugular IVC stent placement. Soon after, the patient's blood pressure improved and liver function gradually normalized. The patient was discharged uneventfully on postoperative day 45. CONCLUSION Under specific conditions, in situ left lateral sectionectomy is a solution for unexpected LFS graft during DDLT.
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Affiliation(s)
- Yu Mi Kim
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bong Jun Kwak
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Jae Shim
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Kyong Kwon
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Young Chul Yoon
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Allard MA, Lopes F, Frosio F, Golse N, Sa Cunha A, Cherqui D, Castaing D, Adam R, Vibert E. Extreme large-for-size syndrome after adult liver transplantation: A model for predicting a potentially lethal complication. Liver Transpl 2017; 23:1294-1304. [PMID: 28779555 DOI: 10.1002/lt.24835] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 06/14/2017] [Accepted: 07/09/2017] [Indexed: 02/07/2023]
Abstract
There is currently no tool available to predict extreme large-for-size (LFS) syndrome, a potentially disastrous complication after adult liver transplantation (LT). We aimed to identify the risk factors for extreme LFS and to build a simple predictive model. A cohort of consecutive patients who underwent LT with full grafts in a single institution was studied. The extreme LFS was defined by the impossibility to achieve direct fascial closure, even after delayed management, associated with early allograft dysfunction or nonfunction. Computed tomography scan-based measurements of the recipient were done at the lower extremity of the xiphoid. After 424 LTs for 394 patients, extreme LFS occurred in 10 (2.4%) cases. The 90-day mortality after extreme LFS was 40.0% versus 6.5% in other patients (P = 0.003). In the extreme LFS group, the male donor-female recipient combination was more often observed (80.0% versus 17.4%; P < 0.001). The graft weight (GW)/right anteroposterior (RAP) distance ratio was predictive of extreme LFS with the highest area under the curve (area under the curve, 0.95). The optimal cutoff was 100 (sensitivity, 100%; specificity, 88%). The other ratios based on height, weight, body mass index, body surface area, and standard liver volume exhibited lower predictive performance. The final multivariate model included the male donor-female recipient combination and the GW/RAP. When the GW to RAP ratio increases from 80, 100, to 120, the probability of extreme LFS was 2.6%, 9.6%, and 29.1% in the male donor-female recipient combination, and <1%, 1.2%, and 4.5% in other combinations. In conclusion, the GW/RAP ratio predicts extreme LFS and may be helpful to avoid futile refusal for morphological reasons or to anticipate situation at risk, especially in female recipients. Liver Transplantation 23 1294-1304 2017 AASLD.
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Affiliation(s)
- Marc-Antoine Allard
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France.,Université Paris-Sud, Orsay, France.,INSERM 935, Villejuif, France
| | - Felipe Lopes
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France
| | - Fabio Frosio
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France
| | - Nicolas Golse
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France.,Université Paris-Sud, Orsay, France
| | - Antonio Sa Cunha
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France.,Université Paris-Sud, Orsay, France
| | - Daniel Cherqui
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France.,Université Paris-Sud, Orsay, France.,INSERM 785, Paris, France
| | - Denis Castaing
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France.,Université Paris-Sud, Orsay, France.,INSERM 785, Paris, France
| | - René Adam
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France.,Université Paris-Sud, Orsay, France.,INSERM 935, Villejuif, France
| | - Eric Vibert
- Digestive Surgery and Liver Transplantation, Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France.,Université Paris-Sud, Orsay, France.,INSERM 785, Paris, France
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7
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Nagatsu A, Yoshizumi T, Ikegami T, Harimoto N, Harada N, Soejima Y, Taketomi A, Maehara Y. In Situ Posterior Graft Segmentectomy for Large-for-Size Syndrome in Deceased Donor Liver Transplantation in Adults: A Case Report. Transplant Proc 2017; 49:1199-1201. [PMID: 28583557 DOI: 10.1016/j.transproceed.2017.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Large-for-size syndrome (LFSS) is controversial in pediatric living donor liver transplantation patients and is associated with a poor graft outcome. Similar situations in deceased donor liver transplantation (DDLT) in adults have not been reported frequently, and there are no official guidelines worldwide. Deceased donation is extremely limited in Japan, and when a larger liver is allocated for a very sick small recipient in Japan, transplantation with a plan to address LFSS might be necessary. The patient is a 58-year-old female patient who had acute liver failure with coma. The graft-recipient weight ratio (GRWR) was 2.74%. Although the graft was enlarged by reperfusion, the intraoperative Doppler ultrasound, performed after reperfusion, showed sufficient graft in-flow and out-flow. However, when the liver graft was situated appropriately into the right phrenic space supported by the rib cage and diaphragm, the blood flow in the hepatic vein and portal vein was significantly reduced. Graft blood flow did not improve without removing it from the right subphrenic space. Therefore, we decided to perform an in situ graft posterior segmentectomy, so that the graft right lobe was properly accommodated in the patient's right subphrenic space. After the segmentectomy of the graft, an intraoperative Doppler sonogram showed significantly improved blood flow. LFSS could be a significant operative challenge in adult DDLT, especially in areas with limited chances of DDLT. In situ posterior segmentectomy in the demarcated area could be a solution for treating patients with LFSS.
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Affiliation(s)
- A Nagatsu
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of General Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - T Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - N Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - N Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Y Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - A Taketomi
- Department of General Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Y Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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8
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Fukazawa K, Nishida S. Size mismatch in liver transplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:457-66. [PMID: 27474079 DOI: 10.1002/jhbp.371] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 06/24/2016] [Indexed: 12/20/2022]
Abstract
Size mismatch is an unique and inevitable but critical issue in live donor liver transplantation. Unmatched metabolic demand of recipient as well as physiologic mismatch aggravates the damage to liver graft, inevitably leading to graft failure on recipient. Also, an excessive resection of liver graft for better recipient outcome in live donor liver transplant may jeopardize the healthy donor well-being and even put donor life in danger. There is a fine balance between resected graft volume required to meet the recipient's metabolic demand and residual graft volume required for donor safety. The obvious clinical necessity of finding that balance has prompted a clinical need and promoted the improvement of knowledge and development of management strategies for size-mismatched transplants. The development of the size-matching methodology has significantly improved graft outcome and recipient survival in live donor liver transplants. On the other hand, the effect of size mismatch in cadaveric transplants has never been observed as being so pronounced. The importance of matching of the donor recipient size has been unrecognized in cadaveric liver transplant. In this review, we attempt to summarize the current most updated knowledge on the subject, particularly addressing the definition and complications of size-mismatched cadaveric liver transplant, as well as management strategies.
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Affiliation(s)
- Kyota Fukazawa
- Division of Transplantation, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, Washington 98195, USA.
| | - Seigo Nishida
- Division of Liver and Gastrointestinal Transplant, Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
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