Strategy for Selective Middle Hepatic Vein Reconstruction in Living Donor Liver Transplantation Using Right Lobe Graft: A Retrospective Observational Study

Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) is a well-recognized complication following liver transplantation (LT), with up to 20% developing this following living donor LT (LDLT). Preventing SFSS involves consideration of factors before the surgical procedure, including donor and recipient selection, and factors during the surgical procedure, including adequate outflow reconstruction, graft portal inflow modulation, and management of portosystemic shunts. International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplant Society of India Consensus Conference was convened in January 2023 to develop recommendations for the prediction and management of SFSS in LDLT. The format of the conference was based on the Grading of Recommendations, Assessment, Development, and Evaluation system. International experts in this field were allocated to 4 working groups (diagnosis, prevention, anesthesia, and critical care considerations, and management of established SFSS). The working groups prepared evidence-based recommendations to answer-specific questions considering the currently available literature. The working group members, independent panel, and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and evidence-based recommendations provided by working group 2 that can be implemented to prevent SFSS in LDLT patients.

Selection of Safe Donors for Living Donor Liver Transplant Using Extended Right Lobe Graft

Extended right lobectomy (ERL) for living donor liver transplant (LDLT) is selectively performed in many transplant centers and has shown excellent recipient outcomes as reported in previous studies. Yet, there is no universally accepted indication for ERL in respect to donor safety. Current study was designed to stratify risk factors of adverse donor outcome after ERL. A total of 79 living donors who underwent ERL for LDLT were included in analysis. Donors were classified as safety and hazard donor groups according to postoperative findings relevant to posthepatectomy liver failure classification by the International Study Group for Liver Surgery. On multivariable analysis, left lateral section volume <20% of total liver volume and nonpreservation of segment 4a venous drainage were the independent risk factors impairing postoperative outcomes. Despite the short-term impairment of liver function in hazard donor groups, all donors recovered and showed satisfactory remnant liver regeneration. However, these findings have implications in establishing selection criteria of donors eligible for ERL donation. In conclusion, LDLT using ERL graft can be safely performed provided so that left lateral section volume/total donor liver is ≥20% besides conventional donor selection criteria. Also, efforts to preserve segment 4a vein must be made in performing ERL graft procurement in LDLT donors.

Successful use of venous graft from native liver with hepatocellular carcinoma during living donor liver transplantation with no impact on recurrence rate: A retrospective cohort study

Introduction

There are still debates regarding using portal vein (PV) from liver with hepatocellular carcinoma (HCC) for vascular reconstruction. This study aimed to assess the feasibility and patency of PV venous graft from an explanted liver with HCC for the reconstruction of the hepatic veins tributaries or PV in living donor liver transplantation (LDLT) and to see if it has any risk on recurrence of HCC.

Patient and methods

We conducted a retrospective study on 81 patients with HCC who underwent LDLT from April 2004 to July 2022.

Results

Venous graft from native liver PV was used for vascular reconstruction in 31 patients as follows; reconstruction of V5 in 7 patients, V8 in 4 patients, V6 in 3 patients, combined V5 and V8 in 4 patients, V6 with V5/V8 in 5 patients, and as Y shape venous graft for 2 PV reconstruction in 8 patients. The implantation of the new conduit PV graft after reconstruction of the anterior sector tributaries was direct to the IVC in 8 patients, and to the common orifice of the left and middle hepatic veins in 12 patients. The 1 month, 3 months, and 1-year overall patency of the venous graft was 93.5%, 90.3%, and 84%, respectively. Nine patients had recurrent HCC. In multivariate analysis, the independent risk factors for HCC recurrence were AFP >400 ng/mL (HR = 1.47, 95% CI: 1.69–2.31, P = 0.01), moderate/poor differentiated tumor (HR = 3.06, 95% CI: 2.58–6.29, P = 0.02), and microvascular invasion (HR = 2.51, 95% CI: 1.05–1.93, P = 0.01). Using a PV venous graft had no risk factor for HCC recurrence (P = 0.9).

Conclusion

The use of PV venous graft of native liver with HCC for venous reconstruction is a feasible and valuable option in LDLT with good patency rates and no risk of HCC recurrence.

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The use of PV venous graft of native liver with HCC for venous reconstruction is a feasible and valuable option in LDLT.

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It has good patency rates and no risk on HCC recurrence.

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The independent risk factors for HCC recurrence in our study were AFP >400 ng/mL, moderate/poor differentiated tumor, and microvascular invasion.