AIM: To investigate middle hepatic vein (MHV) management in adult living donor liver transplantation and safer remnant volumes (RV). METHODS: There were 59 grafts with and 12 grafts without MHV (including 4 with MHV-5/8 reconstructions). All donors underwent our five-step protocol evaluation containing a preoperative protocol liver biopsy Congestive vs non-congestive RV, remnant-volume-bodyweight ratios (RVBWR) and postoperative outcomes were evaluated in 71 right graft living donors. Dominant vs non-dominant MHV anatomy in total liver volume (d-MHV/TLV vs nd-MHV/TLV) was constellated with large/small congestion volumes (CV-index). Small for size (SFS) and non-SFS remnant considerations were based on standard cutoff -RVBWR and RV/TLV. Non-congestive RVBWR was based on non-congestive RV. RESULTS: MHV and non-MHV remnants showed no significant differences in RV, RV/TLV, RVBWR, total bilirubin, or INR. SFS-remnants with RV/TLV < 30% and non-SFS-remnants with RV/TLV ≥ 30% showed Prospective Study Radtke A et al. Liver failure in live donors of right grafts 6009 May 21, 2015|Volume 21|Issue 19| WJG|www.wjgnet.com no significant differences either. RV and RVBWR for non-MHV (n = 59) and MHV-containing (n = 12) remnants were 550 ± 95 mL and 0.79 ± 0.1 mL vs 568 ± 97 mL and 0.79 ± 0.13, respectively (P = 0.423 and P = 0.919. Mean left RV/TLV was 35.8% ± 3.9%. Non-MHV (n = 59) and MHV-containing (n = 12) remnants (34.1% ± 3% vs 36% ± 4% respectively, P = 0.148. Eight SFS-remnants with RVBWR < 0.65 had a significantly smaller RV/TLV than 63 non-SFS-remnants with RVBWR ≥ 0.65 [SFS: RV/TLV 32.4% (range: 28%-35.7%) vs non-SFS: RV/TLV 36.2% (range: 26.1%-45.5%), P < 0.009. Six SFS-remnants with RV/TLV < 30% had significantly smaller RVBWR than 65 non-SFS-remnants with RV/TLV ≥ 30% (0.65 (range: 0.6-0.7) vs 0.8 (range: 0.6-1.27), P < 0.01. Two (2.8%) donors developed reversible liver failure. RVBWR and RV/TLV were concordant in 25%-33% of SFS and in 92%-94% of non-SFS remnants. MHV management options including complete MHV vs MHV-4A selective retention were necessary in n = 12 vs n = 2 remnants based on particularly risky congestive and non-congestive volume constellations. CONCLUSION: MHV procurement should consider individual remnant congestive-and non-congestive volume components and anatomy characteristics, RVBWR-RV/TLV constellation enables the identification of marginally small remnants.

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Acute hepatitis A (AHA) involves severe CD8 T cell-mediated liver injury. Here we showed during AHA, CD8 T cells specific to unrelated viruses became activated. Hepatitis A virus (HAV)-infected cells produced IL-15 that induced T cell receptor (TCR)-independent activation of memory CD8 T cells. TCR-independent activation of non-HAV-specific CD8 T cells were detected in patients, as indicated by NKG2D upregulation, a marker of TCR-independent T cell activation by IL-15. CD8 T cells derived from AHA patients exerted innate-like cytotoxicity triggered by activating receptors NKG2D and NKp30 without TCR engagement. We demonstrated that the severity of liver injury in AHA patients correlated with the activation of HAV-unrelated virus-specific CD8 T cells and the innate-like cytolytic activity of CD8 T cells, but not the activation of HAV-specific T cells. Thus, host injury in AHA is associated with innate-like cytotoxicity of bystander-activated CD8 T cells, a result with implications for acute viral diseases.

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A considerable proportion of adult living donor liver transplantation (LDLT) recipients experience biliary complication (BC), but there are few reports regarding BC based on long-term studies of a large LDLT population. The present study examined BC incidence, risk factors and management using single-center data from 259 adult patients (225 right liver and 34 left liver grafts) between 2000 and 2002. The mean follow-up period was 46 Ϯ 14 months. Biliary reconstruction included single duct-to-duct anastomosis (DD, n ϭ 141), double DD (n ϭ 19), single hepaticojejunostomy (HJ, n ϭ 67), double HJ (n ϭ 28), and combined DD and HJ (n ϭ 4). There were 12 episodes of anastomotic bile leak and 42 episodes of anastomotic stenosis in 50 recipients. Most leaks occurred within the first month, whereas stenosis occurred over 3 yr. Most stenoses were successfully treated using radiological intervention. Cumulative 1-, 3-, and 5-yr BC rates were 12.9%, 18.2%, and 20.2%, respectively. BC occurred much more frequently in right liver grafts compared to left liver grafts (P ϭ 0.024). Stenosis-free survival curves for right liver graft recipients were similar for all reconstruction groups. When right liver graft recipients with single biliary reconstructions were grouped according to graft duct size and type of biliary reconstruction, DD involving a small-sized duct (less than 4 mm in diameter) was found to be a BC risk factor (P ϭ 0.015), whereas HJ involving such duct sizes was not found to be associated with a higher risk (P ϭ 0.471). In conclusion, close surveillance for BC appears necessary for at least the first 3 yr after LDLT. We found that most BC could be successfully controlled using radiological intervention. In terms of anastomotic stenosis risk, HJ appears a better choice than DD for right liver grafts involving ducts less than 4 mm in diameter. Liver Transpl 12: 831-838, 2006. © 2006 AASLD. Received October 19, 2005 accepted November 29, 2005. Patient survival rates for living donor liver transplantation (LDLT) to adult recipients became favorable due to innovative surgical techniques that have overcome the anatomical limitations associated with such partial liver grafts. However, a high incidence of biliary complication (BC) remains the most intractable problem associated with LDLT.

Even in patients with cirrhosis, pure LRH is not less safe than the traditional open approach. The oncological outcomes of HCC were also comparable between the two groups. In selected patients, pure LRH for HCC appears to represent a viable alternative to ORH.

Large vein allografts are suitable for middle hepatic vein (MHV) reconstruction, but their supply is often limited. Although polytetrafluoroethylene (PTFE) grafts are unlimitedly available, their long-term patency is relatively poor. We intended to enhance the clinical usability of PTFE grafts for MHV reconstruction during living donor liver transplantation (LDLT). Two sequential studies were performed. First, PTFE grafts were implanted as inferior vena cava replacements into dogs. Second, in a 1-year prospective clinical trial of 262 adults undergoing LDLT with a modified right lobe, MHV reconstruction with PTFE grafts was compared with other types of reconstruction, and the outcomes were evaluated. In the animal study, PTFE grafts induced strong inflammatory reactions and luminal thrombus formation, but the endothelial lining was well developed. In the clinical study, the reconstruction techniques were revised to make a composite PTFE graft with an artery patch on the basis of the results of the animal study. MHVs were reconstructed with cryopreserved iliac veins (n ¼ 122), iliac arteries (n ¼ 43), aortas (n ¼ 13), and PTFE (n ¼ 84), and these reconstructions yielded 6-month patency rates of 75.3%, 35.2%, 92.3%, and 76.6%, respectively. The overall 6-month patency rates for the iliac vein and PTFE grafts were similar (P ¼ 0.92), but the 6-month patency rates with vein segment 5 were 51.0% and 34.7%, respectively (P ¼ 0.001). The overall graft and patient survival rates did not differ among these 4 groups. In conclusion, ringed PTFE grafts combined with small vessel patches showed high patency rates comparable to those of iliac vein grafts; thus, they can be used for MHV reconstruction when other sizable vessel allografts are not available. Liver Transpl 18:955-965, 2012. V C 2012 AASLD.Received December 6, 2011; accepted March 19, 2012.Middle hepatic vein (MHV) reconstruction with an interposition vessel graft has been established as a standard procedure for living donor liver transplantation (LDLT) with a right lobe graft when the donor's MHV trunk is preserved in the donor's remnant liver.Materials used to date for this type of venous vascular reconstruction have included various types of homologous and autologous vessel grafts. [1][2][3][4][5] The recent increase in the number of adult LDLT procedures and the relatively limited number of vessel allografts have Abbreviations: CT, computed tomography; GRWR, graft-to-recipient weight ratio; IVC, inferior vena cava; LDLT, living donor liver transplantation; MELD, Model for End-Stage Liver Disease; MHV, middle hepatic vein; PTFE, polytetrafluoroethylene; V5, hepatic vein branch segment 5; V8, hepatic vein branch segment 8.

Right lobe living-donor liver transplantation (LDLT) is often not attempted in donors with anomalous portal venous branching (APVB). The authors describe their experience with portal vein (PV) reconstruction in 17 cases of APVB in right lobe LDLT. From July 1997 to December 2001, 214 right liver LDLT were performed at the Asan Medical Center. Seventeen of the donors had APVB and successfully underwent right lobectomy. The APVB were type II (trifurcation) in nine cases, type III (independent posterior segmental branching from main PV trunk) in seven, and unclassified in one. All 17 donors and recipients are alive, with good liver function. In type II APVB, the donor PV branches were obtained with separate openings that were joined as a common orifice at the back table in two, with a discoid-patch single opening in four, and with one common opening in three. In type III APVB, the donor PV were divided with two openings in four and with a discoid-patch single opening in three. The discoid-patch defect in the remnant PV was repaired with a vein patchplasty in two donors and resected with end-to-end anastomosis in five. However, one donor developed portal vein thrombosis (PVT) that was managed successfully by re-exploration and insertion of a metallic vascular stent. Of the four type III APVB obtained with two separate PV openings, the first two liver grafts were each reconstructed as double PV anastomoses. One of them required re-exploration because of PVT. In the two succeeding cases, a Y-graft interposition technique using a cryopreserved cadaveric iliac vein or the recipient's own portal confluence was successfully applied. To minimize the risk of PVT in donors with APVB, discoid-patch excision followed by repair with vein patchplasty or segmental resection should be avoided. Individual division of the PV branches creating two separate openings instead is recommended. To decrease the recipient's risk of PVT, interposition Y-graft venous reconstruction at the back table is superior to double PV anastomoses.