Operative mortality for a right lobe (RL) donor in adult living donor liver transplantation (LDLT) is estimated to be as high as 0.5-1%. To minimize the risk to the donor, left lobe (LL)-LDLT might be an ideal option in adult LDLT. The aim of the study was to assess the feasibility of LL-LDLT between adults based on a single-center experience of 107 LL-LDLTs performed over 8 years. The mean graft weight of LL grafts was 452 g, which amounted to 40.5% of the estimated standard liver volume of the recipients. The overall 1-, 3-and 5-year patient survival rates in LL-LDLT were 81.4, 76.9 and 74.7%, respectively, which were comparable to those of RL-LDLT. Twenty-six grafts (24.3%) were lost for various reasons with three losses directly attributable to small-for-size graft syndrome. Post-operative liver function and hospital stay in LL donors were significantly better and shorter than that in RL donors, while the incidence of donor morbidity was comparable between LL and RL donors. In conclusion, LL-LDLT was found to be a feasible option in adult-to-adult LDLT. Further utilization of LL grafts should be undertaken to keep the chance of donor morbidity and mortality minimal.
Graft size problems remain the greatest limiting factor for expansion of living donor liver transplantation (LDLT) to the adult population. The result of adult-to-adult LDLT using the left lobe with special reference to graft size has not been fully evaluated to date. In this study, we evaluated the outcome of adult-to-adult LDLT using the left lobe and also analyze the impact of using small-for-size grafts on outcome. Thirty-six recipients who underwent adult-to-adult LDLT using the left lobe (n ؍ 14) or left lobe plus caudate lobe (n ؍ 22) were included in the study. Variables including preoperative and operative data, patient and graft survival, complications, and causes of graft loss were studied. Furthermore, the incidence of small-for-size syndrome and its impact on graft survival were studied. Mean graft volume (GV) was 420 ؎ 85 g (range, 260 to 620 g), which resulted in 38.2% ؎ 8.1% (range, 22.8% to 53.8%) of the recipient standard liver volume (SLV). Overall 1-year patient and graft survival rates were 85.7% and 82.9%, respectively. Seven grafts were lost. Small-for-size syndrome occurred in 7 of 16 patients (43.8%) with cirrhosis and only 1 of 20 patients (5.0%) without cirrhosis (P ؍ .005). Recipients who developed small-for-size syndrome had inferior graft survival to those who did not (P ؍ .07). In conclusion, adult-to-adult LDLTs were found to be feasible without affecting patient or graft survival. Small-for-size syndrome developed more frequently in patients with cirrhosis. Minimum GV in adult-to-adult LDLT should be 30% less than the recipient's SLV in patients without cirrhosis, whereas 45% less was required in patients with cirrhosis. (Liver Transpl 2003;9:581-586.)
Reconstruction of middle hepatic vein (MHV) tributaries is controversial in right-lobe living donor liver transplantation (LDLT).L iving donor liver transplantation (LDLT) was developed to overcome the shortage of suitably sized organs from cadaveric donors for children and adults with end-stage liver disease. 1 LDLT necessitates a right-lobe graft for adequate liver volume; however, a right-lobe graft without a middle hepatic vein (MHV) potentially has problems of hepatic venous congestion (HVC) caused by deprivation of drainage from the inferior right hepatic vein (IRHV) and MHV tributaries (V5 and V8). 2 -4 Lee et al. 2 reported 2 cases of severe congestion of a graft without MHV; 1 resulted in sepsis due to congestive infarction and the other developed prolonged massive jaundice. We believe that impaired graft congestion venous outflow was the cause of previously unexplained graft failures during our initial experience of LDLT. Surgeons have agreed on the need of MHV reconstruction because of occasional massive congestion, and so there is an interest in criteria for MHV reconstruction. 3 -5 Further, HVC has been realized only after parenchymal transection and temporary arterial clamping of the donor liver; while preoperative prediction of congestion volume (CV) has been difficult. 5 Recently, preoperative liver volumetry and the measurement of the hepatic vein diameter based on the 3-dimensional computed tomography (3D-CT) has resulted in a significantly improved outcomes, compared to the use of 2-dimensional computed tomography. 6,7 Furthermore, Kishi et al. 8 reported that CV could be calculated and predicted applying new 3D-CT software by calculating the volume from the diameter and length of intrahepatic vascular branches. This study aimed to analyze the efficacy and accuracy of predicting CV and graft volume (GV) based on the software and to evaluate the appropriateness of the reconstruction of these tributaries.
Biliary complications, biliary strictures (BS) in particular, continue to be a significant cause of morbidity after LDLT despite technical refinement. In this study, we assessed the incidence of BS and their management in living donor liver transplantation (LDLT) with special reference to the type of biliary reconstruction. A total of 182 LDLTs performed at our institution for either adult (n ؍ 157) or pediatric (n ؍ 25) patients were included in the study. The duct-to-duct (DD) biliary reconstruction was performed for 106 cases, while the conventional Roux-en-Y hepaticojejunostomy (HJ) was utilized for the remaining 76 cases. Overall, BS developed in 46/182 (25.3%) of the cases (DD, 26.4%; HJ, 25.0%). The 1-and 3-year cumulative incidences of BS were 22.9% and 31.9%, respectively, in the DD group, and 15.2% and 29.1%, respectively, in the HJ group (P ؍ not significant). The left-lobe LDLT was more prone to develop BS. Continuous anastomosis tended to be associated with the high incidence of BS in the DD group. The incidence of anastomotic leak was significantly lower in the DD group. Intervention via either precutaneous or endoscopic approach was successful in the majority of cases, although recurrence could occur in some patients. In conclusion, BS was not associated with the type of reconstruction in LDLT. The primary radiological or endoscopic interventions were satisfactory treatments of choice. Technical refinement is an important factor to reduce the incidence of BS. Liver Transpl 12:979-986, 2006.
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