Adult-to-Adult Living Donor Liver Transplantation at the Asan Medical Center, Korea

Abstract

Between February 1997 and December 2001, 311 adult-to-adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (203), chronic hepatitis C (5), hepatocellular carcinoma (64), alcoholic cirrhosis (9), cryptogenic cirrhosis (4), secondary biliary cirrhosis (5), primary biliary cirrhosis (1), Wilson' s disease (2), autoimmune hepatitis (1), hepatic tuberculosis (1), cholangiocarcinoma (1), fulminant hepatic failure (14) and primary non-function of cadaveric liver graft (1). Of 311 A-A LDLTs, 36 were of medical high urgency, 20 were for acute and subacute hepatic failure, 15 were for hepato-renal syndrome and 1 was for primary non-function. Recipient age ranged from 27 to 64 years. Donor age ranged from 16 to 62 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 175 modified right lobe (MRL), 70 left lobe, 32 right lobe, 20 dual grafts, 10 left lobe plus caudate lobe, three extended right lobe and one posterior segment. In MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and four of 20 were emergency cases. Of 20 dual grafts, 14 received two left lobes, four received a left lobe and a lateral segment, one received a right lobe and a left lobe and one received a lateral segment and a posterior segment. Graft volume ranged from 28% to 83% of the standard liver volume of the recipients. There were 33 (10.6%) in-hospital mortalities (< 4 months) among the 310 patients after 311 A-A LDLTs. Of the 36 patients receiving emergency transplants, 31 survived. These encouraging results justify the expansion of A-A LDLT in coping with increasing demands, even in urgent situations. We have aimed to introduce the establishment of the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome small graft-size syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.

Evaluation of standard liver volume formulae for Chinese adults

“…The ALV calculated from the volume of the graft and the ratio of the RLV to the total LV on CT (%) was 1050.10 ± 107.41 mL. The Heinemann, Urata, Vauthey, and Lee formulae significantly overestimated the LV (P < 0.01), while the Fan formula significantly underestimated the LV (P < Urata et al [7] 1995 ESLV = 706.2 × BSA + 2.4 CT Volumetry (Japanese, 96) Heinemann et al [8] 1999 ESLV = 1072.8 × BSA -345.7 Autopsy (Caucasian 1332) Vauthey et al [9] 2002 LV = 18.51 × BW + 191.8 CT volumetry (Western, 292) Lee et al [5] 2006 ESLV = 691 × BSA + 95 LDLT (Korea, 311) Fan et al [4] 2000 0.05). There was no significant difference between ALV and ELV using the Chengdu formula ( Figure 2).…”

“…The formulae of Heinemann et al [8] , Urata et al [7] , Vauthey et al [9] , Lee et al [5] , and Fan et al [4] in addition to our own formula [6] were used to determine the estimated SLV (ESLV) of our donor livers. The previously reported for mulae are shown in Table 1.…”

“…Accurate estimation of the standard liver volume (SLV) of the living donor and recipient is crucial. Overestimation of the donor's SLV may result in excessive hepatic resection leading to liver failure, while underestimation of the recipient's SLV may result in small-for-size graft syndrome [1][2][3][4][5] . Since 2001, our transplant centers have carried out 212 LDLTs.…”

Outcome after living donor liver transplantation: A comprehensive retrospective analysis of the risk factors for morbidity, mortality and graft failure in a tertiary care center

“…In Kyoto University, several techniques are being explored and innovated in an attempt to ameliorate the impact of small-for-size syndrome. These procedures include, auxiliary partial orthotopic living donor liver transplantation (APOLT) [35], but it has a lot of complications and dual liver grafts [36,37], but it needs the presence of two available donors which is not always feasible. Other procedures included the middle hepatic vein (MHV) to the right lobe graft which may not add liver volume but can improve the graft function by prevention of the congestion of the anterior segment [38].…”

Adult living donor transplants-which portion of the liver to use?

“…Almost every portion of the liver has been used, including the left lateral segment, left lobe (with or without the caudate lobe), right lobe, and extended right lobe; even dual left-lobe grafts from two separate donors have been used. 1 In deciding which portion is best, donor safety is of primary importance: the risk to the donor must be minimized as much as possible. However, the risk to the donor must be balanced by the benefit to the recipient.…”