Salvage dual graft living donor liver transplantation after major hepatectomy

Special Techniques of Liver Transplantation: Living Donor Liver Transplantation With Right Posterior Sector Grafts and Extended Left Lobe Grafts; Auxiliary Partial Orthotopic Liver Transplantation, and Dual-Lobe Liver Transplantation

Living donor liver transplantation (LDLT) constitutes the majority of liver transplants in Asia and advancements in LDLT techniques have expanded the range of allografts beyond the commonly used right lobe (RL). This review provides a comprehensive overview of lesser-known variants of allografts and LDLT techniques which include right posterior sector grafts (RPSG), dual-lobe liver transplantation (DLLT), auxiliary partial orthotopic liver transplantation (APOLT), and extended left lobe grafts with caudate concentrating on the technical aspects, current evidence, and their indications in contemporary practice of LDLT. The first section examines RPSGs, focussing on their potential as an alternative to RL grafts particularly when volumetric studies indicate a larger right posterior sector in donors. It addresses donor selection, surgical techniques, and potential complications. Next, the article explores DLLT, which optimizes graft volume through partial grafts from two donors. The emphasis is on the ethical considerations, surgical challenges, and haemodynamic risks, such as graft atrophy, highlighting the importance of careful donor selection and meticulous planning. The section on APOLT covers its application in treating acute liver failure (ALF) and metabolic liver diseases. The technique's ability to support liver function in ALF while avoiding long-term immunosuppression when the native liver regenerates is discussed, along with patient selection criteria and follow-up requirements. Finally, the review addresses left lobe grafts with caudate used in smaller adults and older children to increase functional graft volume and improve outcomes.

Advocating for a "shift-to-left" in transplant oncology: left grafts, RAPID and dual graft

The extension of liver transplantation to new oncologic indications might exacerbate the shortage of grafts. Living donor liver transplantation (LDLT) may emerge as a viable resource, although its diffusion in the Western world is still very limited. Several groups have advocated for minimizing the impact on donors by reducing the extent of donor hepatectomy, i.e., shifting from right-lobe to left-lobe or left-lateral segment donation ("shift-to-left"). This is particularly relevant when dealing with non-established indications and could make it more acceptable both for potential donors and for the recipients. Left grafts can be transplanted straightforward, despite a higher risk of small-for-size syndrome, or they can be used in the setting of dual-graft LDLT or RAPID procedures, despite technical complexity. This review will expose the most relevant features of each technique, highlighting their strengths and pitfalls and focusing on outcomes. This wide set of tools should be available at high-volume transplant centers, to propose the best technique to adapt to donor-recipient matching.

Dual Graft Living Donor Liver Transplantation for High Acuity Patients: A Single-Center Experience

BACKGROUND

The outcomes of dual graft living donor liver transplantation (DGLDLT) in high acuity patients remain underreported. The objective of this study was to report long-term outcomes from a single center in this select group of patients.

METHODS

This was a retrospective review of patients who underwent DGLDLT between 2012 and 2017 (n = 10). High acuity patients were defined as patients with model for end stage liver disease (MELD) ≥30 or Child Pugh score ≥11. We looked at 90-day morbidity and mortality and 5-year overall survival (OS).

RESULTS

The median MELD score and Child Pugh score were 30 (26.7-35) and 11 (11-11.2). The median recipient weight was 105 (95.2-113.7) and ranged from 82 to 132 kg. Out of 10 patients, 4 (40%) required perioperative renal replacement therapy, and 8 (80%) required hospital admission for optimization. The estimated graft to recipient weight ratio (GRWR) with right lobe graft alone was <0.8 in all patients, between 0.75 and 0.65 in 5 (50%) patients, and <0.65 in 5 (50%) patients. The 90-day mortality was 3/10 (30%), and there were 3/10 (30%) deaths during long-term follow-up. Among 155 high acuity patients, the 1-year OS with standard LDLT, standard LDLT with GRWR <0.8, and DGLDLT was 82%, 76%, and 58%, respectively (P = 0.123). With a median follow-up of 40.6 (1.9-74.4) months, the 5-year OS for DGLDLT was 50%.

CONCLUSION

The use of DGLDLT in high acuity patients should be prudent and low GRWR grafts should be considered a viable alternative in selected patients.

Associating microwave ablation and portal vein ligation for staged hepatectomy for the treatment of huge hepatocellular carcinoma with cirrhosis

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could induce extensive and rapid future liver remnant hypertrophy. However, the morbidity for ALPPS is very high. This paper reports a modified ALPPS (associating microwave ablation and portal vein ligation for staged hepatectomy, AMAPS), which was successfully applied in the treatment of huge hepatocellular carcinoma with cirrhosis, and the procedure of operation was greatly simplified. Hence, AMAPS is feasible and safe in selected patients with primary hepatocellular carcinoma and cirrhosis.

Living donor liver transplantation using dual grafts: Experience and lessons learned from cases worldwide

In living donor liver transplantation (LDLT), insufficient graft volume could result in small-for-size syndrome in recipients, whereas major liver donation predisposes the donor to a high risk of posthepatectomy liver failure. Dual graft LDLT is therefore introduced to obtain combined graft sufficiency. To date, 367 patients have been reported worldwide. We reviewed all the relevant literature, with a special focus on 43 case reports containing enough data to extract and analyze. A simple decision-making algorithm was developed. Dual graft LDLT is indicated when (1) a single donation is unacceptable due to graft-to-recipient size mismatch; (2) the future liver remnant is insufficient in the single donor after major resection; or (3) there is a significant underlying disorder or anatomical variation within the donor liver. The outcome of dual graft LDLT is reported to be comparable with that of single donor LDLT. Unilateral graft atrophy was found in 7 of the 43 patients, predominantly in the right-sided, heterotopic and initially smaller grafts. Technically, the heterotopic implantation and complex vascular reconstruction are the most demanding. Elaborate surgical planning and modification are needed. Ethical concerns about involving a second living donor need to be addressed. In conclusion, dual graft LDLT should be prudently performed in select cases by surgeons of proven expertise when single donation is unacceptable and a second living donor is available. The decision-making criteria need to be standardized. More surgical modification and clinical research are needed.