Anatomic variations requiring multiple vascular and biliary anastomosis were more frequently seen in right-lobe living-donor liver transplantation (LDLT) than in left lobes, which was explained by the relative consistency between the left umbilical vein and the liver (1,2). Clinical implications and surgical anatomy of these variations in LDLT, however, has not been studied in detail because of the lack of accumulated experience. Trifurcation of portal venous system, which necessitated dual portal vein anastomosis, occurred in 6.7% of our initial experience with 120 right lobe LDLTs (3). Reconstruction using bifurcation of recipient portal vein is feasible in the right-lobe graft with duplicated portal branches and is not a contraindication of right-lobe LDLT. A relatively high incidence of multiple bile ducts in the patient with trifurcated portal vein was experienced in our series; however, the exact incidence and anatomic relationship have not been analyzed. We report here the incidence of dual portal vein and multiple bile ducts in 321 cases of right-lobe LDLT. Between June 1990 and April 2004, 972 LDLTs were performed for 947 patients at Kyoto University Hospital. Right-lobe LDLT was first adopted in February 1998, and thereafter, 321 patients received right-lobe graft. Portal and biliary anatomy was confirmed by one experienced radiologist using preoperative three- or two-dimensional computed tomography, intraoperative cholangiography, and intraoperative findings. None of the patients were excluded from the potential donation because of portal and biliary anomaly. A total of 295 (91.9%) grafts had bifurcated portal vein, and 26 (8.1%) had trifurcated portal vein. Overall, one hundred twenty-six (39.6%) grafts had multiple bile ducts in the series. One hundred nine of 295 (36.9%) grafts showed single portal vein with multiple bile ducts. Eighteen of 26 (69.2%) grafts showed dual portal vein accompanied with multiple bile ducts. Incidence of multiple bile ducts was significantly higher in the graft with dual portal vein (P=0.001). The anatomic variation in right-lobe grafts was classified into five types based on tributaries from the posterior segment, which was proposed by Nakamura et al. (3) (Fig. 1). The overall incidence of biliary anastomotic leakage and stenosis was 8.4% and 19.5% in our experience with 321 right-lobe LDLTs.FIGURE 1.: Anatomic types of biliary tree in trifurcated portal vein in right-lobe graft defined by tributary from the posterior segment. A, anterior; P, posterior; L, left portal vein; LHD, left hepatic duct.Biliary complications are the most common complications related to LDLT surgery (4). When a dual portal vein anastomosis is required, there may be an increased risk of multiple biliary reconstruction in right-lobe LDLT. An understanding of these frequently encountered variations is vital to avoid surgical complications in right-lobe LDLT. Mureo Kasahara Hiroto Egawa Koichi Tanaka Organ Transplant Unit Kyoto University Hospital Kyoto, Japan Kohei Ogawa Kenji Uryuhara Yasuhiro Fujimoto Yasuhiro Ogura Mikiko Ueda Yasutsugu Takada Koichi Tanaka Department of Transplantation and Immunology Kyoto University Faculty of Medicine Kyoto, Japan
Liver transplantation is a radical surgical therapy for end-stage liver disease. Although in Japan organ transplantation from brain-dead donors (BDD) has been allowed since October 1997, to date, only 29 liver grafts from BDD have been obtained. Thus, most of the liver transplantations carried out use living-donor liver transplantation (LDLT), and BDD liver transplantation is only used in rare cases. In order to carry out LDLT more safely, apheresis (plasmapheresis: PE) plays a major role in our country because of the prevalence of LDLT wherein later re-transplantation is difficult. Thus, because of a limited donor supply and because the needs of patients with end-stage liver disease is critical, use of grafts from ABO-incompatible (ABO-I) donors might be the only available option. From June 1990 to November 2005, 1100 patients underwent 1151 LDLT cases at Kyoto University Hospital. Additionally, 159 LDLT cases (13.8%) received ABO-I living-donor liver grafts. The role of apheresis in ABO-I LDLT is the reduction of antibody titers such as anti-A or anti-B antibody. We carry out preoperative PE as a general rule for ABO-I cases, and the recipient's antibody level against the donor's blood type is decreased to one eighth of the baseline value before LDLT. Until now, baseline immunosuppressive agents included steroids, tacrolimus and cyclophosphamide. At first, splenectomy was carried out during surgery to suppress antibody production, and intraportal (PV) infusion therapy was carried out to control local disseminated intravascular coagulation (DIC) occurring in ABO-I grafts. At that time, three drugs-methylprednisolone, prostaglandin E1 (PGE1), and gabexate mesylate (FOY) were infused continuously for 3 weeks after LDLT. At present, instead of PV infusion therapy, hepatic artery infusion therapy without splenectomy is adopted because of portal thrombosis, and two drugs- methylprednisolone and PGE1- are infused continuously for 3 weeks following LDLT. Recently, we introduced anti-CD20 monoclonal antibody (Rituximab) instead of splenectomy for B cell deletion before ABO-I LDLT. In the present article, we describe the role of apheresis around ABO-I LDLT based on our recent experiences.
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