Three-dimensional CT volumetry is useful for size matching in cases of living-related orthotopic liver transplantation.

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.)

In conclusion, the use of a fatty liver graft up to the moderate level can be justified in LDLT, even though ischemia-reperfusion injury tends to be severe in such grafts.

Hypothesis: Few studies have investigated the results of research focused on living-donor adult liver transplantation. Different characteristics between right-and leftlobe grafts have not yet been clarified in living-donor adult liver transplantation. Left-lobe graft remains an important option, even in adult recipients. Setting: A single liver transplantation center with a long history of hepatic resection. Patients: Forty-five donors received left-lobe (n=39) and right-lobe (n=6) grafts. The clinicopathological data for the donor, graft, and recipient were compared. All leftlobe grafts were extended grafts that included the middle hepatic vein, and 24 of the 39 left-lobe grafts included the left caudate lobe. No right-lobe graft included a middle hepatic vein. Results: The postoperative aspartate aminotransferase and total bilirubin values of the donor in the right-lobe graft group were higher, and the postoperative hospital stay was longer than in the left-lobe graft group. Graft weight in the left-lobe graft group was lighter than in the right-lobe graft group (median weight, 450 vs 675 g). The median graft weight divided by the standard liver volume in the left-lobe graft group was 41% (range, 21%-66%), compared with 52% (range, 47%-75%) in the rightlobe graft group. We found no difference in terms of the incidence of postoperative complications between groups. No difference in induced complications of smallfor-size grafts such as intractable ascites and persistent hyperbilirubinemia was evident between groups. The survival rate for grafts at 18 months was 75.0% in the rightlobe graft group compared with 85.6% in the left-lobe group. In the right-lobe graft group, we found a few cases in which a marked poor-perfusion area in the anterior segment caused liver dysfunction. Conclusions: Left-lobe grafts are a feasible option for living-donor adult liver transplantation, and in the case of right-lobe grafts, hepatic venous drainage is one of the most critical problems.

A Roux-en-Y choledochojejunostomy (CDJ) has been the sole method of choice for the reconstruction of the bile duct in living-donor liver transplantation (LDLT) using left-lobe grafts. In this study, we evaluated the feasibility of duct-to-duct (DD) biliary reconstruction in adult-to-adult LDLT using left-lobe grafts. Between October 1996 and October 2001, 46 adult-to-adult LDLTs using the left lobe were performed at our institution. The DD biliary reconstruction (hepaticocholedochostomy) over a T-tube was performed for seven of the last nine recipients (DD group, n=7), whereas the conventional Roux-en-Y CDJ was used for the remaining cases (CDJ group, n=39). The technical problems and the incidence of biliary complications were compared between the groups. Bile leakage developed in only 1 of 7 (14%) in the DD group (leakage from a T-tube exit site), whereas it occurred in 8 of 39 (20%) in the CDJ group. Up to now, no patients from the DD group developed anastomotic stricture, whereas twelve (30.7%) patients from the CDJ group did. Other complications included bleeding from the Roux-en-Y jejunojejunostomy (n=1) and anastomotic occlusion caused by an internal stent (n=1), and both complications were associated with CDJ. In conclusion, DD anastomosis is a simple and viable option for biliary reconstruction in left-lobe LDLTs. A long-term follow-up, especially regarding the incidence of biliary stricture, is thus warranted in such patients.