These manoeuvres should improve graft function and survival

M Makuuchi

Y Sugawara

CiteSeerX

Technical progress in living donor liver transplantation
for adults
M Makuuchi and Y Sugawara
Artificial Organ and Transplantation Division, Department of Surgery, University of Tokyo, Tokyo, Japan
Background
Liver transplantation from a living donor (LDLT) was
introduced during the 1990s to overcome the shortage of
donor organs, particularly among children and in those
countries in which cadaveric grafts were seldom available. In
Japan alone, some 1700 LDLTs were performed in the first 12
years with a 5-year survival rate of 70% in adults and an even
higher rate (82%) in children. The major limitation to
successful LDLT is inadequate graft size, which usually
necessitates the use of the whole right liver unless (I) the
caudate lobe is included in a left liver graft, (2) only the right
lateral sector is employed (segments VI and VII) or (3) left
livers from two donors are implanted into one recipient.
Discussion
From a technical standpoint, the main problem with the
various types of LDLT has been the venous reconstruction in
the recipient. For the left-sided graft, the hepatic vein of the
caudate lobe should be re-anastomosed to prevent congestion
of this segment. For the right-sided graft, there has been
uncertainty about the need to reconstruct the middle hepatic
vein (MHV). Implantation is clearly simpler without this
additional step, but there is a risk of dysfunction and sepsis in
the right paramedian sector. Venous congestion in this sector
can be observed during operation, both visually after clamping
the MHV and by ultrasonographic assessment of the direction
of blood flow in the portal vein. These techniques can be used
to determine which patients require bench reconstruction of
MHV tributaries or indeed of the inferior right hepatic vein.
These manoeuvres should improve graft function and survival.
Keywords
middle hepatic vein, congestion, reconstruction
Introduction
Strong and co-workers [1] reported the first successful
liver transplantation from a living donor (LDLT) in 1990.
LDLT is mainly undertaken in an attempt to alleviate the
shortage of donor organs and to decrease deaths among
children awaiting transplants [2]. After the first success-
ful adult LDLT case reported by Hashikura and
colleagues in 1993 [3], however, the number of adult
patients has increased rapidly.
In Western countries, the shortage of grafts for adults
is the main problem as regards liver transplantation [41 •
More than 30 transplantation programmes have per-
formed more than 400 LDLTs for adult patients in the
USA. In Asia, where cadaveric liver transplantation is
seldom performed, LDLT remains the only way to save
the lives of patients with end-stage liver disease.
According to the Japanese Society for Liver Transplanta-
tion, 1718 LDLT procedures were performed at 43
institutions in Japan from 1989 to November 2001.
The 5-year survival rates were 81.5% in children and
69.7% in adults. The outcome in adults was significantly
worse than that in children (p < 0.0001), which indicates
that there are some unsolved problems in adult LDLT.
This report describes recent technical advances in LDLT
for adult patients.
Partial liver grafts: left or right?
The major limitation for LDLT for adults is the adequacy
of the graft size. In initial LDLT, only a left liver graft was
used [5]. Kiuchi and colleagues [6] reported that the
graft, estimated to be 28% of the recipient's standard
liver volume [7], was successfully transplanted in a
patient with primary biliary cirrhosis. Lo and associates
[8] reported that a graft estimated to be 25% of the
recipient standard liver volume was transplanted in a
patient with fulminant hepatic failure. However, some
transplant surgeons suggested that the unsatisfactory
results in adults might be due to undersized grafts, which
might not meet the metabolic demands of the patient
[9]. Accordingly, recent reports indicate that left liver
95
grafts for adult patients have now been almost aban-
doned and right liver grafts are almost always used [10],
Clearly, a right liver graft can help to alleviate the
problem of graft size disparity in adult-to adult LDLT.
We believe that routine use of a right graft cannot be
justified, however, because right hemi-hepatectomy is
not a sufficiently safe form of donor hepatectomy. The
safety of right hepatectomy varies, depending mainly on
the volume of the left liver. We do not perform right
hepatectomy if the volume of the left liver is estimated to
be <30% of the whole liver.
The harvested graft should be down-sized according to
the pre-transplant condition [8] and the disease of the
recipient [11]. A left liver with a caudate lobe graft [12]
can provide an alternative to right liver graft. The
caudate lobe corresponds to only 3-4% of the whole liver
volume. In conjunction with a left liver graft, however,
the caudate lobe provides an 8-12% gain in weight. The
rate of postoperative cholestasis in patients decreases
significantly when using the left liver with the caudate
lobe.
Vein reconstruction in left side graft
Takayama and associates [13] emphasised the impor-
tance of short hepatic vein reconstruction. The hepatic
vein of the caudate lobe can be resected on the cuff of the
vena cava, which resembles a Carrel's patch. In the
recipient operation, reconstruction of the caudate
hepatic vein is performed first. The trunk of the left
hepatic vein (LHV) and middle hepatic vein (MHV) of
the recipient and the graft are then anastomosed.
Recently, a new technique [14] was described by which
the left liver plus caudate lobe was implanted with
complete reconstruction of a short hepatic vein. This
technique is applicable when the orifice of the short
hepatic vein is located near those of the LHV and MHV.
According to the cast study by Couinaud [15], 69%
(66/96) of caudate lobes have a single vein and 20% have
two. Most of the veins (91%, 115/126) enter directly into
the vena cava. That study indicated that one or two veins
of the caudate lobe should be reconstructed to prevent
venous congestion of the caudate lobe. To estimate the
success of reconstruction of the caudate hepatic vein,
computed tomography (CT) was performed 1 month
after the operation. Regeneration of the left liver and the
caudate lobe was comparable to that of the left liver [16].
Vein reconstruction in right side graft
A right liver graft without the MHV trunk is now
commonly used. In the initial reports of LDLT using this
type of right liver graft, the MHV tributaries were not
reconstructed [17-19]. Lee and colleagues [20] empha-
sised the necessity of MHV reconstruction in this type of
graft. They noted that the graft could develop severe
congestion of the right paramedian sector because
hepatic venous outflow of the right paramedian sector
drains mostly into the MHV. Such congestion can cause
severe graft dysfunction and septic complications.
MHV drainage into the recipient's venous system can
be reconstructed by means of vein grafts. This technique
provides a functioning liver mass comparable to an
extended right liver graft. Some transplant teams now
seem to recognise the value of reconstruction of the
MHV tributaries. Cattral and associates [21] reported a
case of reconstruction using the recipient's left portal
branch. Ghobrial and colleagues [22] reported a venous
variant with a small right hepatic vein and large MHV
branch and proposed that MHV reconstruction should
be performed in such cases. Lee and colleagues [23]
recently reported a series of 42 adult recipients. All
sizeable (>5mm in diameter) MHV tributaries were
preserved during donor hepatectomy and were recon-
structed with the recipient's autogenous interposition
vein grafts at the surgical bench. Serial Doppler ultra-
sonography revealed a patent interposition vein graft in
38 of 42 recipients until 30 days post-transplant. In these
38 recipients, no evidence of congestion in the right
paramedian sector was recognised on enhanced CT,
while the procedure provided enough functioning liver
mass-comparable to an extended right liver graft.
Criteria for MHV reconstruction
It remains unclear whether all modified right liver grafts
without the MHV trunk require MHV reconstruction.
Lee and colleagues [20] emphasised aggressive recon-
struction of MHV under any circumstances. However,
most of the initial cases [10, 17, 18] using a modified
right liver graft seemed to achieve successful results
without MHV reconstruction.
Sano and associates [24] proposed clear criteria for
MHV reconstruction. Hepatic venous congestion in the
right paramedian sector was investigated intraoperatively
96
after parenchyma transection. First, liver surface dis-
coloration in the right paramedian sector was observed
after simultaneous clamping of MHV tributaries and the
right hepatic artery for 5 min. Next, intraoperative
Doppler ultrasonography was performed after declamping
only the hepatic artery. If the portal flow of the
paramedian sector was hepatofugal, this confirmed that
the area was congested. All of the examinations for
checking venous congestion can be completed in 10
minutes in experienced hands.
If the congested area is dominant, based on the
clamping test or ultrasonography, we have proceeded
with bench reconstruction of MHV tributaries. The
necessity of inferior right hepatic vein reconstruction was
determined using the same criteria. MHV tributaries
were reconstructed under these criteria in our series [25].
Reconstruction was performed in 18 of 30 grafts, and all
the grafts had an uneventful functional recovery. As our
experience of MHV reconstruction under the criteria has
been limited, the feasibility must be confirmed in a larger
number of cases in the future.
Dual grafts
Lee and associates [29] recently reported an innovative
technique in LDLT, which could make up for graft size
insufficiency and secure the donor's safety. Left liver
grafts were harvested from two living donors, which were
then implanted into one recipient. This procedure may
be indicated in a particular situation. Donors should have
a large right liver while the remaining left liver is too
small to maintain life. The recipient is in the advanced
stage of liver disease and needs >40% of the standard
liver volume. The risks for the recipient and donors are
also doubled in this procedure, although the results of the
reported cases were quite satisfactory in their series of 17
patients [30]. The procedure should be limited to specific
circumstances from the point of view of economic cost
and medical labour: three operating theatre rooms and
three surgical teams are required for the techique.
The Kyoto group [31 ] implanted dual grafts in one
patient; so far, no other groups have reported experience
of dual grafts.
Right lateral sector graft
A right lateral sector graft (segments VI and VII
according to Couinaud's nomenclature for liver segmen-
tation) was devised recently [26]. The details of the
harvesting technique are as follows. Occlusion of the
right paramedian and left branches of the portal veins
and hepatic arteries reveal the demarcation line on the
liver surface. The dissection plane is 5 mm to the left of
the right portal fissure. Liver transection is performed
using a Kelly clamp under occlusion of the right
paramedian branches of the portal veins and hepatic
arteries. The right lateral bile duct is then identified by
intraoperative cholangiography before liver transection.
The procedure is indicated when the right liver is
>70% of the estimated volume of the whole donor liver
and the estimated right lateral sector volume is greater
than that of the left liver [27]. Recent volumetric
analysis [28] of donors revealed that 72% had a larger
right lateral sector than a left liver with caudate lobe
when the volume of the right liver was estimated to be
>70% of the whole.
Conclusions
A right liver graft seems to alleviate the small-for-size
problem in LDLT for adults. The procedure imposes
greater surgical risk for living donors and is associated
with an increased mortality rate. The patients who truly
need a right liver graft should be selected using evidence-
based criteria. Secure hepatic vein reconstruction is one
of the most crucial factors in the recipient [32]. To
obtain satisfactory functional reserve of the hemi-liver
graft, aggressive vein reconstruction using our criteria is
required.
Acknowledgements
This work was supported by a grant-in-aid for scientific
research from the Ministry of Education, Culture, Sports,
Science and Technology of Japan, Public Trust Fund for
the Promotion of Surgery, Welfide Medical Research
Foundation, Mitsui Life Social Welfare Foundation, and
a grant-in-aid for research on human genome, tissue
engineering, food biotechnology, health sciences re-
search grants, Ministry of Health, Labor and Welfare of
Japan.
97
References
1 Strong RW, Lynch SV, Ong TH, Matsunami H, Koido Y,
Balderson GA. Successful liver transplantation from a
living donor to her son. N Engl J Med 1990;322: 1505-7.
2 Tanaka K, Inomata Y. Present status and prospects of
living-related liver trasnplantation. J Hep Bil Pancr Surg
1997;4:51-70.
3 Hashikura Y, Makuuchi M, Kawasaki S, et al. Successful
living-related partial liver transplantation to an adult
patient. Lancet 1994;343:1233-4.
4 Cronin DC, 2nd, Millis JM, Siegler M. Transplantation of
liver grafts from living donors into adu l t s - too much, too
soon. N Engl J Med 2001;344:1633-7.
5 Kawasaki S, Makuuchi M, Matsunami H, et al. Living
related liver transplantation in adults. Ann Surg
1998;227:269-74.
6 Kiuchi T, Kasahara M, Uryuhara K, et al. Impact of graft
size mismatching on graft prognosis in liver transplanta-
tion from living donors. Transplantation 1999;67:321-7.
7 Urata K, Kawasaki S, Matsunami H, et al. Calculation of
child and adult standard liver volume for liver transplan-
tation. Hepatology 1995;21:1317-21.
8 Lo CM, Fan ST, Liu CL, et al. Minimum graft size for
successful living donor liver transplantation. Transplanta-
tion 1999;68:1112-16.
9 Sugawara Y, Makuuchi M, Takayama T, et al. Small-for-
size grafts in living-related liver transplantation. J Am Coll
Surg 2001;192:510-13.
10 Marcos A, Fisher RA, Ham JM, et al. Right lobe living
donor liver transplantation. Transplantation 1999;68:798-
803.
11 Ben-Haim M, Emre S, Fishhein TM, et al. Critical graft
size in adult-to-adult living donor liver transplantation:
impact of the recipient's disease. Liver Transpl 2001;7:
948-53.
12 Miyagawa S, Hashikura Y, Miwa S, et al. Concomitant
caudate lobe resection as an option for donor hepatect-
omy in adult living related liver transplantation. Trans-
plantation 1998;66:661-3.
13 Takayama T, Makuuchi M, Kubota K, Sano K, Harihara
Y, Kawarasaki H. Living-related transplantation of left
liver plus caudate lobe. J Am Coll Surg 2000;190:6.35-8.
14 Sugawara Y, Makuuchi M, Kaneko J, Ohkubo T, Matsui
Y, Imamura H. New venoplasty technique for the left liver
plus caudate lobe in living donor liver transplantation.
Liver Transpl 2002;8:76-7.
15 Couinaud C. The paracaval segments of the liver. J Hep
Bil Pancr Surg 1994;2:145-9.
16 Sugawara Y, Makuuchi M, Takayama T. Left liver plus
caudate lobe graft with complete re-vascularization.
Surgery 2002; 132:348-52.
17 Yamaoka Y, Washida M, Honda K, et al. Liver
transplantation using a right lobe graft from a living
related donor. Transplantation 1994:57:1127-30.
18 Wachs M, Bak T, Karrer F, et al. Adult living donor liver
transplantation using a right hepatic lobe. Transplantation
1998:66:1313-16.
19 Marcos A, Ham JM, Fisher RA, et al. Surgical manage-
ment of anatomical variations of the right lobe in living
donor liver transplantation. Ann Surg 2000;231:824-31.
20 Lee S, Park K, Hwang S, et al. Congestion of right liver
graft in living donor liver transplantation. Transplantation
2001:71:812-4.
21 Cattral MS, Greig PD, Muradali D, et al. Reconstruction
of middle hepatic vein of a living-donor right lobe liver
graft with recipient left portal vein. Transplantation
2001;71:1864-6.
22 Ghobrial RM, Hsieh CB, Lerner S, et al. Technical
challenges of hepatic venous outflow reconstruction in
right lobe adult living donor liver transplantation. Liver
Transpl 2001;7:551-5.
23 Lee SG, Min Park K, Hwang S, et al. Modified right liver
graft from a living donor to prevent congestion.
Transplantation 2002;74:54-9.
24 Sano K, Makuuchi M, Miki K, el al. Evaluation of hepatic
venous congestion: proposed indication criteria for
hepatic vein reconstruction. Ann Surg 2002;236:241-7.
25 Sugawara Y, Makuuchi M, Sano K, et al. Vein
reconstruction in modified right liver graft for living
donor liver transplantation. Ann Surg:(in press).
26 Sugawara Y, Makuuchi M, Takayama T, et al. Liver
transplantation using a right lateral sector graft from a
living donor to her granddaughter. Hepatogastroenterology
2001;48:26i-3.
27 Sugawara Y, Makuuchi M, Takayama T, Imamura H,
Kaneko J. Right lateral sector graft in adult living-related
liver transplantation. Transplantation 2002;73:111-14.
28 Leelaudomlipi S, Sugawara Y, Kaneko J, Matsui Y,
Ohkubo T, Makuuchi M. Volumetric analysis of liver
segments in 155 living donors. Liver Transpl 2002;8:612-
14.
29 Lee SG, Hwang S, Park KM, et al. An adult-to-adult
living donor liver transplant using dual left lobe grafts.
Surgery 2001 ;129:647-50.
30 Lee SG, Hwang S, Park KM, et al. Seventeen adult-to-
adult living donor liver transplantations using dual grafts.
Transplant Proc 2001;33:3461-3.
31 Kaihara S, Ogura Y, Kasahara M, Oike F, You Y, Tanaka
K. A case of adult-to-adult living donor liver transplanta-
tion using right and left lateral lobe grafts from 2 donors.
Surgery 2002;131:682-4.
32 Sugawara Y, Makuuchi M. Expectations and limitations
in adult-to-adult living-related liver transplantation.
Asian J Surg 2001;24:5-6.
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Technical progress in living donor liver transplantation for adults

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Technical progress in living donor liver transplantation for adults

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