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Living Donor Liver Transplantation 681work at 2 to 3 months, and a full recovery to normal at3 to 4 months. This report describes our series of 41 Table 2. Recipient Demographicspatients undergoing this procedure and outcomes ofboth donors and recipients. We also focus on the tech- Sex (M/F) 24/17 Age (yr) 45.0 Ϯ 8.6nical aspects of the surgery that have changed during Median waiting time (d) 124this period. Mean LOS (d) 21.5 Ϯ 19.5 Median LOS (d) 12Methods NOTE. Values expressed as number or mean Ϯ SD. Abbreviation: LOS, length of stay.Forty-one cases of adult-to-adult right-lobe LDLT were per-formed at the University of Colorado Health Sciences Centerin Denver, CO, from August 1997 to March 2001. Thefrequency of this operation has increased over time, with 12 Sharing (UNOS) status IIB at time of transplantation. Twocases performed over the past 6 months. Donor demographics recipients were status I with a diagnosis of fulminant hepaticare listed in Table 1. Only one donor was not related to the failure, and 4 transplant recipients were status IIA. Transplantrecipient. Donor age ranged from 19 to 54 years. Details of recipients were evaluated and screened for listing similarly toour donor evaluation are presented elsewhere.8 All donors other liver transplant candidates. After being informed of thepresented on a strictly voluntary basis and were never solic- option for LDLT and only after the recipient and/or donorited. Each donor underwent a thorough physical examination presented voluntarily, further assessment was performed toand laboratory evaluation. Imaging modalities of the donor ensure good candidacy. This included the absence of morbidincluded magnetic resonance angiography and cholangiogra- obesity, limited previous major upper-abdominal surgery,phy in all cases. Conventional angiography was used as a good size matching between the pair, and stricter age criteriaconﬁrmatory test in patients with arterial anomalies, espe- (only 1 of 41 recipients was older than 60 years). Risks andcially when there was a question of more than one artery beneﬁts of surgery for both donor and recipient were method-supplying the right lobe. Absolute liver volume of the right ically explained, including minimal risk for donor mortality.lobe was calculated based on these scans, but the judgment Donor hepatectomy is performed under general anesthe-and experience of the senior transplant physicians were used sia, with a thoracic epidural catheter used for postoperativeto determine adequacy of mass, mainly based on donor and pain management. A right subcostal incision with upper mid-recipient body size, along with the imaging studies. Full psy- line extension similar to that performed on the transplantchological and social evaluations were performed on each recipient is used. Mobilization of the right lobe of the liverdonor, and a stable support system was documented. Liver proceeds, with care focused on leaving the attachments of thebiopsies were performed infrequently; only 3 of the 41 even- left lobe intact to prevent future twisting or torsion. Accessorytual donors underwent a biopsy. Biopsies were not deemed hepatic veins are ligated and divided to free the vena cava.necessary for patients considered to be at low risk for fatty liver Branches greater than 1 cm are preserved. After cholecystec-disease. tomy, an intraoperative cholangiogram is obtained. Vascular Recipient demographics are listed in Table 2. Of the 41 isolation of the right hepatic artery, right portal vein, and righttransplant recipients, 35 were United Network for Organ hepatic vein is then completed. A transection line is marked on the liver with electrocautery. Using electrocautery and ligatures, parenchymal transection proceeds. As our series progressed, the line of transection shifted to run left of and Table 1. Donor Demographics parallel to the middle hepatic vein branch draining segments 5 and 8. This right branch of the middle hepatic vein is left No. of donors 41 intact on the edge of the graft and transected superiorly at its Sex (M/F) 26/15 junction with the middle hepatic vein. The right hepatic bile Mean age (yr) 30.8 Ϯ 11.2 duct is transected, leaving a small cuff so as not to stricture the Mean LOS (d) 6.3 Ϯ 1.6 main hepatic duct. Accessory posterior right-lobe bile ducts Relationship to recipient Son 12 draining to the left hepatic duct are identiﬁed on intraopera- Brother 7 tive cholangiography and also carefully identiﬁed at the tran- Sister 5 section plane, with the remaining left stumps oversewn. Daughter 6 Autologous blood transfusion systems were available for all Wife 2 donor operations. Parenchymal transection is completed, Father 1 leaving both lobes of the liver with intact blood supply. No Other 8 inﬂow occlusion is used. The raw surface of the liver is then NOTE. Values expressed as number or mean Ϯ SD. packed and re-evaluated 20 to 30 minutes after transection to Abbreviation: LOS, length of stay. ensure no detectable bleeding or bile leak is present. The transplant recipient is taken to the operating room
682 Bak et al Figure 1. Donor hepatic vein anastomosis to recipient vena cava.after the donor operation has started and shows no contrain- fused at this point. The recipient right hepatic arterial branchdications to proceeding. No donor operations were aborted in is then spatulated and anastomosed in an end-to-end fashionour series. Two transplant recipients with diagnoses of cancer to the spatulated donor right hepatic artery using a runningunderwent exploratory surgery to ensure that there was no 7-0 vasculature suture. Bile duct reconstruction then pro-extrahepatic spread of disease before the donor operation ceeds. Thirteen of 41 cases were reconstructed in a duct-to-commenced. The recipient native hepatectomy proceeded in duct fashion over an internal stent. The remainder of thesestandard fashion, with extreme care used to ensure adequate reconstructions were performed using a standard Roux-en-Yhepatic artery and portal vein length. The piggyback tech- small-bowel limb anastomosis to the right hepatic duct withnique was also necessarily used in all cases. interrupted 6-0 sutures over an internal stent. Secondary and With the recipient team in the room, the vasculature to occasional tertiary anastomoses were performed to the samethe right lobe of the donor liver is transected and the liver is Roux limb with any signiﬁcant (Ͼ3 mm) accessory bile ducts.passed to the back table. The vascular stumps on the donor are Small accessory bile ducts (Ͻ3 mm), particularly those in athen closed with running monoﬁlament vascular suture. The very posterior position that would be technically difﬁcult tograft is immediately ﬂushed through the portal vein with 1 L reconstruct, are oversewn. Routine abdominal wall closureof heparinized (10,000 U/L) iced saline followed by a second follows in both the donor and recipient. One Jackson-Prattliter of iced saline. No systemic anticoagulation with heparin drain is left in the donor between the hilum and the cutis used in the donor. surface of the liver. The recipient has 2 to 3 drains placed, with The liver is transported to the recipient room, where the 1 drain also along the cut liver surface. The donors recover innative hepatectomy is completed. In most cases, we use a the recovery room and are transferred to the ward. Twenty-complete cross-clamp to allow easy access to the recipient vena three of the recipients went to the surgical intensive care unitcava. No venovenous bypass is used. The recipient middle and postoperatively, and the remainder were transferred to theleft hepatic veins are oversewn, and the right hepatic vein cuff ward from the recovery room.is extended down the anterior surface of the vena cava, creat-ing an oriﬁce to match the right hepatic vein size on the donorgraft. The right hepatic vein is anastomosed to the caval open- Resultsing with a running 5-0 vascular suture (Fig. 1). The recipientportal vein is then anastomosed to the right portal vein oriﬁce All 41 donors are alive, well, and have returned tousing a running 6-0 vascular suture. The right lobe is reper- normal predonation activity. Donor complications are
Living Donor Liver Transplantation 683listed in Table 3. Of 41 donors, 2 required nonautolo-gous blood transfusions (5%). One of these was for alarge hemothorax secondary to a central venous catheterplaced preoperatively by the anesthesia department.The second was in a patient whose hematocrit de-creased on postoperative day 2 and stabilized after 2units of packed red blood cells were administered.Three patients had postoperative bile leaks. Two ofthese patients were returned to the operating room andunderwent direct repair of a leaking bile duct stumpwithin 3 days of the hepatectomy. One of these stumpswas the cystic duct, whereas the other was the righthepatic duct stump. The other patient was treated con-servatively with percutaneous drainage, resulting in res- Figure 2. Donor aspartate aminotransferase (AST) (s)olution of the leak from the cut liver surface. One large and alanine aminotransferase (ALT) (}) levels versusincisional hernia was repaired in a patient who returned postoperative day.to lifting concrete bags 2 weeks after her surgery. OneJackson-Pratt drain was retrieved surgically after itsnapped off during its removal. One idiosyncratic med- setting was consistent with poor graft function based onication reaction caused donor lethargy that resolved worsening laboratory values and a deteriorating clinicalpostoperative day 3. Also, a temporary neuropraxia picture. Ultrasound evaluation showed patent vesselsoccurred in the dominant hand of one donor. All 41 with no evidence of venous obstructions. Venous con-donors are alive, well, and have returned to normal gestion was conﬁrmed on gross inspection and micro-activity. scopic analysis of the explanted liver. One retransplan- Postoperative laboratory values are shown in Figure tation was performed for hepatic artery thrombosis2. Aspartate aminotransferase and alanine aminotrans- postoperative day 12. The fourth retransplantation wasferase levels peaked postoperative day 3, with a return to performed for a persistent bile leak that 2 surgicalnormal by day 7. Serum bilirubin levels peaked slightly repairs failed to resolve. This patient underwentlater. Mean hospital stay for donors was 6.3 days. retransplantation postoperative day 50 and died of sep- Forty-one right-lobe adult-to-adult LDLTs have sis 4 weeks after retransplantation. The second of the 3been completed using this technique. Thirty-eight of deaths occurred 15 months posttransplantation because41 recipients (93%) are alive and well, with a mean of uncontrolled chronic rejection, whereas the thirdfollow-up of 9.6 months. Thirty-six of 41 grafts are death was in a patient who developed multiple strokesfunctioning, for a graft survival rate of 88%. Four on postoperative day 1 and died of a cardiac arrest onpatients required retransplantation with cadaveric postoperative day 5.grafts (9.8%). All 4 of these retransplantations occurred Forty-four percent of transplant recipients under-in our initial 11 cases, initiating several technical adjust- went multiple bile duct reconstructions, with onements described next. Two retransplantations were per- patient requiring 3 bile duct anastomoses. Overall bili-formed for hepatic dysfunction resulting from hepatic ary complication rates were 34%. This includes 3 anas-venous outﬂow obstruction. These were performed tomotic leaks treated surgically (1 duct-to-duct, 2postoperative days 14 and 5. In both cases, the clinical Roux-en-Y). Three patients developed postoperative strictures. The ﬁrst occurred in a duct-to-duct anasto- mosis, which was converted to a Roux. The other 2 strictures were in patients with Roux limb anastomoses, Table 3. Donor Complications and these were successfully treated with percutaneous transhepatic cholangioplasty. Nine patients developed Bile leak, reoperation 2 cut surface leaks; 6 patients were treated with prolonged Bile leak, external drainage 1 drainage and 3 patients underwent reoperation. Eight Incisional hernia, surgical repair 1 Neuropraxia, transient 1 of the 9 leaks resolved; the exception was the patient Drain retrieval, reoperation 1 who died after retransplantation. Hemothorax from venous access 1 Four patients required a second hepatic vein anasto- mosis because of an accessory hepatic vein greater than
684 Bak et al1 cm. One of these patients had 2 accessory hepatic the right hepatic vein system.15 Since moving our tran-veins. Three patients underwent 2 portal venous anas- section plane in this manner, we have not experiencedtomoses without complications. outﬂow problems causing graft dysfunction. Another venous drainage issue is that of accessory hepatic veins draining into the vena cava. Previous series of right-lobeDiscussion transplants have reported reanastomosis of any acces-Our results suggest that adult-to-adult LDLT using a sory vein greater than 5 mm.16 We have been moreright hepatic lobe graft is a safe and effective operation selective in our series, and of the 41 grafts, have per-for people requiring liver transplantation when careful formed accessory venous anastomoses in only 4donor and recipient screening is performed. Graft and patients. We routinely reconstruct accessory veinspatient survival rates in our series are equal to our cur- greater than 0.8 to 1 cm.rent cadaveric transplantation results. Donor safety is of Arterial anatomy is often quite variable in bothutmost importance for this procedure, and although donor and recipient. Most commonly, the major rightthere have been reported donor complications and hepatic artery of the donor graft can be directly anasto-deaths,5,14 our series shows excellent donor outcomes mosed to the recipient artery at either the bifurcation ofwith 100% survival and return to normal activity. the right and left branches or a bifurcation patch created Despite these results, it should be stressed that a at the branch of the cystic artery. We attempt to maxi-learning curve exists with this procedure: as experience mize right hepatic arterial length in the recipient butand level of comfort increased, so did our overall success stay extraparenchymal in this dissection. On donorrates. The four retransplantations described during our workup, a replaced right hepatic artery is not a contra-early experience led us to 2 important technical indication; this frequently makes the operation techni-changes. Speciﬁcally, our signiﬁcant changes during cally easier because of a longer length of graft artery. Inthis procedure have been improvements in graft hepatic this situation, an angiogram is often obtained to assessvenous outﬂow and the understanding of the need for whether this right branch off the superior mesentericintraoperative cholangiography to help show and artery is completely replaced or whether it is an acces-reconstruct accessory right bile ducts. sory branch. This allows us to conclude whether a sec- In our early experience, we transected the liver to the ond arterial anastomosis is required. We have studiedright of the middle hepatic vein, even if the middle arterial ﬂow postoperatively with duplex ultrasonogra-hepatic vein contributed drainage to segments 5 and 8. phy on a daily basis through postoperative day 5.Using this technique, 2 transplant recipients had severe Patients are started on 81 mg of acetylsalicylic acidgraft congestion and poor function requiring retrans- when a stable postoperative hematocrit is present. Toplantation. Their clinical picture was consistent with date, we have had one hepatic artery thrombosis, whichpoor graft function despite ultrasound evaluation show- is similar in incidence to our cadaveric recipient popu-ing patent vessels and no obstruction. We now believe lation, and concerns of greater thrombosis rates causedthat primary nonfunction of these grafts is very by smaller vessels have not been realized. Arterial anas-unlikely, and if the postoperative clinical course mimics tomoses are performed with 3.5 ϫ loupe magniﬁcationthis picture, it is likely caused by a technical issue. These with a running monoﬁlament 7-0 vascular suture. In 2cases prompted us to change our plane of transection to cases, the donor right hepatic artery bifurcated intothe left. The right branch of the middle hepatic vein is anterior and posterior branches that encircled the com-preserved with the right-lobe graft and ligated superi- mon bile duct. In the ﬁrst instance, the anterior branchorly at its junction with the main middle hepatic vein. was small and therefore was ligated. In the second case,We believe this prevents disruption of collateral drain- both arteries were of equal size. The anterior artery wasage between the right hepatic vein and the right branch transected at the time of graft removal to free it from theof the middle hepatic vein. We do not believe it is bile duct and was then repaired, with an end-to-endnecessary to connect this middle hepatic vein branch to anastomosis performed on the back table.the cava using a jump graft. When the graft is reper- Portal vein inﬂow has been adequate in all patients.fused, this right branch of the middle hepatic vein is Direct end-to-end anastomosis of the donor right por-well decompressed, presumably by collaterals in the tal vein to the right branch or common portal vein ofgraft. It has been our experience and also recently the recipient was performed in all but 3 cases. In thesereported that postoperative ultrasound examination of cases, there were 2 separate major portal veins to thethe graft drainage shows reversal of ﬂow in the right right lobe. In 1 of these, 2 anastomoses were performed;middle hepatic vein branch ultimately emptying into one each to the right and left branches of the recipient
Living Donor Liver Transplantation 685portal vein. In the other 2 cases, the graft veins were very internal stent. In addition, Roux drainage is performedclose to each other, with liver parenchyma providing a in cases of a single bile duct when there is concern aboutcommon back wall, and the donor had a large native tension or blood supply. We do not use t-tubes or otherportal system. A single anastomosis of the donor veins external biliary drainage catheters. Biliary complica-to the native portal vein branch was performed. tions have occurred in 34% of transplant recipients. A preoperative ultrasound showed one transplant This is similar to rates previously reported in livingrecipient to have a thrombosed portal vein, with patent donor liver surgery.17-19 Most of our leaks (60%) havesplenic and superior mesenteric veins. This LDLT was been raw surface leaks. These are usually managed con-delayed until a cadaveric donor iliac vein of compatible servatively with external drainage if the patient is clini-blood type was available to use as a jump graft. At cally stable. These usually occur while the surgicalsurgery, a successful thrombectomy allowed for ade- drains are still in place. Our experience has been thatquate inﬂow and no vascular graft was used. To date in these will spontaneously seal, allowing for drain re-our series, we have not had to use an arterial or venous moval. If the patient shows signs of uncontrolled leak-graft for reconstruction; however, we routinely repeat age, such as pain or increasing bilirubin levels, they arean ultrasound examination of the recipient 1 week treated surgically. Biliary leak rates are slightly greater inbefore surgery to rule out portal vein thrombosis. The the Roux-drained patients, but this is likely inﬂuenceduse of a recipient saphenous vein graft may be required by the fact that this group includes patients with mul-in a setting in which the right lobe has 2 arterial inﬂows, tiple duct drainage.i.e., an accessory right branch as opposed to a totally Postoperative management of living donor liverreplaced system. transplant recipients has been similar to that of recipi- The second change in technique is in regard to our ents of cadaveric grafts. Overall, 56% of recipients wentbiliary management. Magnetic resonance cholangio- to the intensive care unit postoperatively. Thisgraphy (MRC) imaging is used as preoperative screen- decreased to 40% in the second half of our series as ouring of donor biliary anatomy. This has proven to be a level of comfort with these cases has increased. Anrelatively accurate assessment of major biliary struc- increase in frequency of surveillance ultrasonography istures. In our early cases, a transplant recipient experi- performed, but this has not shown greater thrombosisenced a bile leak from an accessory posterior duct that rates. Hospital length of stay averaged 21.5 days for thehad not been recognized on the MRC or at the original transplant recipients. We believe that this is lengtheneddonor surgery. Despite reoperation and oversewing, the somewhat because of the increase in biliary complica-leak persisted, eventually leading to retransplantation, tions compared with our cadaveric transplant recipientssepsis, and death. We have since instituted routine and a less predictable decrease in postoperative liverintraoperative cholangiography and have identiﬁed and function test results, leading to a heightened vigilancereconstructed accessory bile ducts in 44% of our right- for potential complications and rejection. However,lobe grafts. On one occasion, a patient underwent 2 graft and patient survival rates ultimately are equal toaccessory biliary reconstructions. Identiﬁcation and cadaveric results.drainage of this important posterior branch has pre- These results must be viewed cautiously becausevented biliary complications in a signiﬁcant number of candidates are carefully selected for LDLT and in gen-right-lobe grafts, and we have not performed a retrans- eral are not the sickest liver transplant recipients. Weplantation for a biliary complication since. In 2 believe that the optimal candidates for this procedureinstances, we have oversewn a small (Ͻ3 mm) posterior are patients who are UNOS status IIB and have a goodright duct, avoiding reconstruction. Neither of these 2 donor available. Status III patients should rarelycases had a leak or signs of cholangitis in this small undergo transplantation until more experience has beenundrained biliary section of hepatic parenchyma. These gained to justify the risk to the donor. The use of LDLTsmaller ducts are usually located in a more posterior is especially valuable in the patient population who haslocation than the previously mentioned accessory duct, a suspicion for or proven small hepatocellular carci-which is signiﬁcant and is reconstructed. noma (status IIB), but would unlikely be able to receive Biliary reconstruction is performed with chole- a cadaveric graft before their cancer progressed to adochocholedochostomy when possible. The need for nontransplantable stage. The role of this procedure asRoux limb drainage is obvious in the case of primary palliation for large hepatocellular cancers is still beingsclerosing cholangitis or when multiple anastomoses debated. Our center has not performed this proceduremust be performed, and these are performed to separate on a patient who would otherwise not be a candidate foropenings of the intestinal limb, each over an individual a cadaveric graft.
686 Bak et al In conclusion, LDLT is a safe and effective proce- 9. Sindhi R, Rosendale J, Mundy D, Taranto S, Baliga P, Reubendure for well-selected patients. We report a large series A, et al. Impact of segmental grafts on pediatric liver transplan- tation—A review of the United Network for Organ Sharingof right-lobe grafts with similar graft and patient sur- Scientiﬁc Registry Data (1990-1996). J Pediatr Surg 1999;34:vival statistics to our cadaveric transplant recipients. 107-110.Donor safety has been maintained throughout the 10. Emond JC, Renz JF, Ferrell LD, Rosenthal P, Lim RC, Robertsseries. This procedure will continue to grow in impor- JP, et al. Functional analysis of grafts from living donors. Anntance in the national transplant community as a way to Surg 1996;224:544-552.alleviate some of the pressure of growing waiting lists 11. Belghiti J, Hiramatsu K, Benoist S, Massault P, Sauvanet A, Farges O. Seven hundred forty-seven hepatectomies in theand stagnant cadaveric donor availability. 1990s: An update to evaluate the actual risk of liver resection. J Am Coll Surg 2000;191:38-46.References 12. Fujita S, Kim ID, Uryuhara K, Asonuma K, Egawa H, Kiuchi T, et al. Hepatic grafts from live donors: Donor morbidity for 470 1. Broelsch CE, Whitington PF, Emond JC, Heffron TG, This- cases of live donation. Transpl Int 2000;13:333-339. tlethwaite JR, Stevens L, et al. Liver transplantation in children 13. Fan ST, Lo CM, Liu CL, Yong BH, Chan JK, Ng IO. Safety of from living related donors: Surgical techniques and results. Ann donors in live donor liver transplantation using right lobe grafts. Surg 1991;214:428-437. Arch Surg 2000;135:336-340. 2. Broelsch CE, Burdelski M, Rogiers X, Gundlach M, Knoefel 14. Grewal HP, Thistlewaite JR, Loss GE, Fisher JS, Cronin DC, WT, Langwieler T, et al. Living donor for liver transplantation. Siegal CT, et al. Complications in 100 living liver donors. Ann Hepatology 1994;20(suppl 1, part 2):49S-55S. Surg 1998;228:214-219. 3. Kawasaki S, Makuuchi M, Matsunami H, Hashikura Y, Ikegami 15. Kaneko T, Kaneko K, Sugimoto H, Inoue S, Hatsuno T, Sawada T, Nakazawa Y, et al. Living related liver transplantation in adults. Ann Surg 1998;227:269-274. K, et al. Intrahepatic anastomosis formation between the hepatic 4. Todo S, Furukawa H, Jin MB, Shimamura T. Living donor liver veins in the graft liver of the living related liver transplantation: transplantation in adults: Outcome in Japan. Liver Transpl Observation by Doppler ultrasonography. Transplantation 2000;6(suppl 2):S66-S72. 2000;70:982-985. 5. Broelsch CE, Malago M, Testa G, Gamazo CU. Living donor 16. Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP. liver transplantation in adults: Outcome in Europe. Liver Single center analysis of the ﬁrst 40 adult-to-adult living donor Transpl 2000;6(suppl 2):S64-S65. liver transplants using the right lobe. Liver Transpl 2000;6:296- 6. Wachs ME, Bak TE, Karrer FM, Everson GT, Shrestha R, 301. Trouillot TE, et al. Adult living donor liver transplantation using 17. Marcos A, Fisher RA, Ham JM, Shiffman ML, Sanyal AJ, Luke- a right hepatic lobe. Transplantation 1998;66:1313-1316. tic VA, et al. Right lobe living donor liver transplantation. Trans- 7. Annual Report of the US Scientiﬁc Registry for Organ Trans- plantation 1999;68:798-803. plantation and the Organ Procurement and Transplantation 18. Cronin D, Alonso E, Piper J, Newell K, Bruce D, Woodle P, et Network—Transplant Data 1988-2000. UNOS, Richmond, al. Biliary complications in living donor liver transplantation. VA, and the Division of Transplantation, Bureau of Health Transplant Proc 1997;29:419-420. Resources and Services Administration, US Department of 19. Testa G, Malego M, Valentin-Gamazo C, Lindell G, Broelsch Health and Human Services, Rockville, MD, 2000. CE. Biliary anastomosis in living related liver transplantation 8. Trotter JF. Selection of donors and recipients for living donor using the right lobe: Techniques and complications. Liver liver transplantation. Liver Transpl 2000;6(suppl 2):S52-S58. Transpl 2000;6:710-714.