One Hundred Nine Living Donor Liver Transplants in Adults and Children: A Single-Center Experience

Abstract

ObjectiveTo summarize the evolution of a living donor liver transplant program and the authors' experience with 109 cases. Summary Background DataThe authors' institution began to offer living donor liver transplants to children in 1993 and to adults in 1998. MethodsDonors were healthy, ages 18 to 60 years, related or unrelated, and ABO-compatible (except in one case). Donor evaluation was thorough. Liver biopsy was performed for abnormal lipid profiles or a history of significant alcohol use, a body mass index more than 28, or suspected steatosis. Imaging studies included angiography, computed tomography, endoscopic retrograde cholangiopancreatography, and magnetic resonance imaging. Recipient evaluation and management were the same as for cadaveric transplant. ResultsAfter ABO screening, 136 potential donors were evaluated for 113 recipients; 23 donors withdrew for medical or personal reasons. Four donor surgeries were aborted; 109 transplants were performed. Fifty children (18 years or younger) received 47 left lateral segments and 3 left lobes; 59 adults received 50 right lobes and 9 left lobes. The average donor hospital stay was 6 days. Two donors each required one unit of banked blood. Right lobe donors had three bile leaks from the cut surface of the liver; all resolved. Another right lobe donor had prolonged hyperbilirubinemia. Three donors had small bowel obstructions; two required operation. All donors are alive and well. The most common indications for transplant were biliary atresia in children (56%) and hepatitis C in adults (40%); 35.6% of adults had hepatocellular carcinoma. Biliary reconstructions in all children and 44 adults were with a Roux-en-Y hepaticojejunostomy; 15 adults had duct-to-duct anastomoses. The incidence of major vascular complications was 12% in children and 11.8% in adult recipients. Children had three bile leaks (6%) and six (12%) biliary strictures. Adult patients had 14 (23.7%) bile leaks and 4 (6.8%) biliary strictures. Patient and graft survival rates were 87.6% and 81%, respectively, at 1 year and 75.1% and 69.6% at 5 years. In children, patient and graft survival rates were 89.9% and 85.8%, respectively, at 1 year and 80.9% and 78% at 5 years. In adults, patient and graft survival rates were 85.6% and 77%, respectively, at 1 year. ConclusionLiving donor liver transplantation has become an important option for our patients and has dramatically changed our approach to patients with liver failure. The donor surgery is safe and can be done with minimal complications. We expect that living donor liver transplants will represent more than 50% of our transplants within 3 years.The shortage of cadaveric organs for liver transplantation has limited our ability to provide this life-saving therapy.

Liver organ allocation for hepatocellular carcinoma: Are we sure?

“…This supposition is underscored by a recent publication from the Mount Sinai transplant program that reports that 35.6% of their adult recipients of living donation had HCC. 26 As stated in the American Society of Transplant Surgeons' Position Paper on Adult-toAdult Living Donor Liver Transplantation, "Living donor surgery remains the only area of medicine and surgery in which a major operation is performed on an individual for whom it is not medically indicated." 27 Accordingly, living-donor transplantation should be performed only when a cadaveric donor is unavailable, not because the HCC was too advanced to allow the potential recipient to receive additional points on the waiting list (i.e., a cadaveric donor liver).…”

Split-Liver Transplantation: A Review

“…Graft sharing between centers is infrequent: the ASTS survey reported a 5% incidence of graft sharing between five centers, Yersiz et al have reported sharing three left lateral segment and 22 right trisegment grafts (27) (70). While a 'learning curve' was not assayed by the ASTS survey, it certainly exists as demonstrated in liver living-donation (50,75). The unequal distribution of experience, coupled with a required 'learning curve', forecast that greater information sharing must occur prior to SLT achieving a larger role in alleviating the current organ crisis.…”

Live Donors in Liver Transplantation

“…Biliary complications, either bile leak or stricture at the anastomotic site or cut edge of the transected liver were reported in 15% -60% of recipients in early, single center reports [21][22][23][24] . Stenting the biliary anastomosis has been used to attempt to reduce the rate of bile leaks and strictures, but it is of unproven benefit.…”