Impact of localized ascites after pediatric living donor liver transplantation: report of three cases
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Living donor liver transplantation (LDLT) has become one of the most exciting and controversial aspects of liver transplantation in recent years. It's exciting because it offers an alternative to the deceased donor waiting lists with long waiting times, potential mortality, and impaired quality of life. It's controversial because of the real risks in the donor and the potential for inferior outcomes in the recipient due to the use of a reduced sized graft. Initial concerns for the recipient focused on poor outcomes for patients with very advanced liver disease undergoing LDLT—i.e., prior United Network for Organ Sharing status 2A or high model for end-stage liver disease (MELD) cases. More recent research has focused on issues of relative rates and severity of recurrence of hepatitis C and hepatocellular carcinoma following LDLT and deceased donor liver transplantation (DDLT). Since hepatitis C (HCV) is the most common indication for liver transplantation in the United States, the issue of recurrent HCV in LDLT is of critical importance. Some early reports have shown earlier and more severe recurrence of hepatitis C following LDLT compared to deceased donor controls.1-3 Our group showed that though the overall recurrence rate was not different between living donor and deceased donor recipients, severe recurrence including cholestatic HCV occurred more frequently in our living donor recipients.4 Most of these studies were limited by the lack of long-term outcome or protocol biopsies. LDLT, living donor liver transplantation; MELD, model for end-stage liver disease; DDLT, deceased donor liver transplantation; HCV, hepatitis C virus. Recently, Russo et al. analyzed the Scientific Registry of Transplant Recipients (SRTR) registry and demonstrated that patient and graft survival were similar for HCV patients undergoing living donor or deceased donor transplant.5 However, since it was a database study, they could not examine the severity of histologic recurrence in the 2 groups, only the rates of graft failure. In this issue of Liver Transplantation, Shiffman et al. present a comparison between recipients of living donor and deceased donor transplants for chronic HCV with up to 4 years of follow-up using protocol biopsies to reliably grade the severity of graft recurrence.6 Similar to the data of Russo et al., they show no difference in either graft or patient survival. More importantly, there was no difference seen in either hepatic inflammation or fibrosis between the 2 groups during follow-up. In contrast to prior studies, there is actually a trend toward less fibrosis in living donor liver transplant recipients in the later years, with stabilization of the fibrosis progression in these grafts. This is very important data and the most rigorous single-center report to date. The strengths of the Shiffman et al. data include the relatively long follow-up in their cohort and, most importantly, the fact that they did annual protocol biopsies regardless of the presence of liver function test abnormalities. Many of the prior studies can be critiqued by the absence of protocol biopsies, which are necessary for a truly unbiased comparison of histology between living donor and deceased donor HCV-positive recipients. In the absence of protocol biopsies, biopsy rates in the two groups may be systematically different due to higher levels of alanine aminotransferase and or alkaline phosphatase particularly in the early time points posttransplant in living donor patients either due to regeneration or to unrecognized biliary tract disease. However, some caution is required in interpreting the data. First, as with all single-center studies, the sample size is relatively small, with 23 living donor recipients versus 53 deceased donor recipients. Thus, especially at the later time points, the number of patients who were available for biopsy is small this therefore limits statistical significance, and raises the question of the possibility of a Type II error. A second concern is the differences in the baseline characteristics of the population 2 cohorts and whether these differences could confound the results. Among deceased donor transplant recipients there were more males, non-whites, and alcohol use than among LDLT recipients. This supports the work of our group showing similar clinical and demographic differences in patients who did and did not have potential donors for LDLT.7 As mentioned earlier, the donor age was significantly different among living donor recipients (38.4 vs. 56 years). There were also differences in the immunosuppressive regimens used, with tacrolimus used in a higher proportion of living donor than deceased donor recipients. We are not provided data on how the choice of calcineurin inhibitor was made in the 2 groups. It would have been preferable to analyze the data controlling for calcineurin inhibitor used, since this variable is the only one that differed and is at the clinicians discretion. However, the groups are too small to perform meaningful multivariate analysis and prior data does not clearly support any significant differences in histology of recurrent HCV based on the calcineurin inhibitor used. Importantly, steroid regimens were similar, and the differences in baseline immunosuppression did not lead to statistically different rejection rates, though the rejection rate was slightly higher in the deceased donor transplant patients, including 2 patients who received thymoglobulin, both of whom developed severe recurrent hepatitis C with bridging fibrosis. What are the potential reasons for a difference in the severity of HCV recurrence in LDLT compared to DDLT? Hepatic regeneration has the potential to lead to higher rates of hepatitis C replication, which could potentiate recurrence of hepatitis C. This risk has to be balanced against the younger donor age and the absence of steatosis in most LDLT grafts, as well as the improved physiologic state of the potential recipient. Finally, where does the data leave us relative to our patients? The more recent reports, particularly those that used stringent methods and protocol biopsies, have not shown any worse outcomes for hepatitis C when one compares living donor and deceased donor transplants.4, 5, 6 The data of Shiffman et al. support similar outcomes or even a potential long-term benefit with stabilization of fibrosis in LDLT recipients. Given the decrease in waiting list mortality with LDLT, there are no data to support avoiding LDLT for hepatitis C–positive candidates. Hepatitis C cirrhosis patients should be treated like other diagnoses when considering LDLT, and a decision should be made on the relative risks and benefits of transplantation versus waiting for the individual based on MELD score and physiologic condition, taking into account both quality of life and the availability of each donor source in the local region. Further multicenter data from the National Institutes of Health Living Donor Liver Transplant Cohort Study (A2ALL) will provide more data and is awaited. In the interim, this paper provides an important guidepost for our therapeutic decision-making.
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Anatomical and Surgical Basis for Adult Living Donor Liver Transplantation with the Right Liver Lobe
Abstract Liver transplantation is now a standard procedure for the treatment of end stage liver diseases. Since 1968 until 2012, a number of 113,627 liver transplantations were performed in Europe, in 28 countries and 153 institutions. Despite these impressive figures the waiting list is growing every year. Transplant surgeons were preoccupied to find new ways to increase the donor pool. Among them: reduced size liver transplantation, split liver technique and more recently living donor liver transplantation. At first in the early `90, living donor liver transplantation was used for pediatric patients because the left lateral hepatic segments were harvested. This graft is too small for the metabolic demands of an adult patient. So the next step was the harvesting of the right liver lobe from the donor and transplantation to adult patients. Living donor liver transplantation has gained fast a wide acceptance but there are a few issues to discuss. The main concern is about the donor safety which is a healthy person undergoing major surgery with potential risks. Also the surgical technique evolved due to a better understanding of the anatomy and physiology of the liver and the right liver graft. We discuss here the anatomical and surgical basis for living donor liver transplantation with the right liver lobe.
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Familial hypobetalipoproteinemia (FHBL) is one of the causes of nonalcoholic steatohepatitis (NASH) and a codominant disorder. Patients heterozygous for FHBL may be asymptomatic, although they demonstrate low plasma levels of low-density lipoprotein (LDL) cholesterol and apolipoprotein B. Here we report a nonobese 54-year-old man with decompensated liver cirrhosis who underwent living donor liver transplantation with his son as the donor. Low albuminemia and refractory ascites persisted after transplantation. A biopsy specimen obtained 11 months after liver transplantation revealed severe steatosis and fibrosis, and recurrent NASH was diagnosed on the basis of pathological findings. Both the patient's and donor's laboratory tests demonstrated low LDL cholesterol and apolipoprotein levels. Because mutations in messenger RNAs of microsomal triglyceride transfer protein and apolipoprotein B genes were excluded neither in the recipient nor in the donor, both were clinically diagnosed as being heterozygous for FHBL. We successfully treated the recipient with heterozygous FHBL–induced recurrent NASH after liver transplantation using our diet and exercise programs. Liver Transpl 15:806–809, 2009. © 2009 AASLD.
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Objective To assess the value of MSCT in the evaluation of the anatomy and variation of hepatic veins for living donor liver transplantation(LDLT)donors and the significance of vessel variation in surgical operation.Methods A total of 238 subjects who wanted to be the donors of LDLT underwent MSCT plain and enhanced examination,and the hepatic veins were evaluated.Results Among all 238 subjects,according to Nakamura's classification of hepatic veins,164 were type Ⅰ,60 were type Ⅱ,14 were type Ⅲ.The left hepatic vein(LHV)shared a common trunk with the middle one in 167 subjects.Branches of Ⅷ going along the cross section and diameter larger than 5 mm were detected in 105 subjects.The Ⅳ segment veins drained into MHV in 68,into LHV in 7 subjects.Right inferior hepatic vein with diameter larger than 3 mm was found in 108 subjects,while the distance between RHV and IRHV were larger than 4 cm in 55 subjects.Conclusion MSCT can offer details and exact information about the donors pre-operation,and is an important non-invasive method for the evaluation of hepatic veins of potential LDLT donors.
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Hepatic Diseases
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1The Institute of Liver Disease and TransplantationGlobal Hospitals and Health CityChennaiIndia 2Institute of Liver StudiesKing's College HospitalLondonUnited Kingdom *Address reprint requests to Ashwin Rammohan, M.D., The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Cheran Nagar, Chennai 600100, India. Telephone: +91 9884173583; FAX: +91‐44‐25289595; Email: [email protected]
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Chan, Albert C. Y.*,1; Chok, Kenneth S. H.1; Sin, Sui Ling1; Dai, Wing Chiu1; Cheung, Tan To1; Chan, See Ching1; Lo, Chung Mau1 Author Information
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Hepatopulmonary syndrome (HPS) is a progressive, debilitating complication of end-stage liver disease. In contrast to the well-established reversal of HPS after deceased donor liver transplantation (DDLT), little has been written about the natural course of HPS after the newer procedure of living donor liver transplantation (LDLT). We describe HPS in a small series of 4 liver transplant recipients (2 DDLT; 2 LDLT) at a single center. Before transplantation, these 4 patients had a mean shunt fraction of 23.6 ± 14.3% and a mean PaO2 of 58.5 ± 11.3 mm Hg. All 4 patients used supplemental oxygen before transplantation. Sixteen weeks after transplantation, all 4 patients had normalized or improved shunt fraction and PaO2. These patients regained normal pulmonary function within a few months, despite the period of hepatic regeneration after LDLT. In conclusion, both DDLT and LDLT are associated with rapid and dramatic reversal of HPS. (Liver Transpl 2004;10:529–533.)
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Laparoscopically harvested left lateral section (LLS) grafts have drawbacks regarding the size of the graft left hepatic vein (LHV) orifice although they have the merit of cosmetics concerning the donor's wound. We present a case of pediatric living donor liver transplantation (LDLT) using a laparoscopically harvested LLS graft and describe the refined surgical techniques for graft LHV venoplasty with a circumferential vein patch. The patient was a 46-month-old boy with marked growth retardation who was diagnosed with progressive familial intrahepatic cholestasis type 2. The donor was his 25-year-old mother. The LLS graft weighed 285 g. A circumferential patch of external iliac vein homograft was attached to the graft LHV orifice after incisions were made at the medial wall of the LHV trunk and superficial LHV branch, which made the graft LHV orifice much larger. The recipient's hepatic vein orifice was also enlarged by unifying the three hepatic vein orifices. Other surgical procedures followed the standard LDLT operation. This patient recovered uneventfully and has been doing well for 1 year. In conclusion, our incision-and-patch venoplasty to enlarge the graft outflow vein orifice was beneficial for reducing the risk of hepatic vein outflow obstruction in LDLT using a laparoscopically harvested LLS graft.
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Donor safety is the first consideration in living related liver transplantation. Left hemihepatectomy including the middle hepatic vein is a reasonable donor procedure for obtaining a large graft for living related liver transplantation. This procedure, however, needs to be modified in donors with hepatic venous variation. While carrying out donor hepatectomy, we encountered two cases showing a variant form of hepatic venous drainage comprising a thick middle hepatic vein draining segment 6 of the liver. This variation made it necessary to preserve the middle hepatic vein in the donor liver remnant. Failure to recognize such a variant would result in congestion in the remaining right liver of the donor. To guarantee donor safety, evaluation of the drainage area of the corresponding hepatic vein is a matter of great importance in donor hepatectomy.
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Background Venous compromise is still the most common cause of free flap failure. The need of a second venous anastomosis to prevent free flap failure is controversial. It is proposed that the use of dual venous anastomoses reduces venous compromise. However, some surgeons suggest that dual venous drainage reduces venous blood flow causing a potential risk of thrombosis. Objective This study aimed to compare the frequency of reexploration secondary to venous thrombosis in free flap surgeries in reconstruction of soft tissue defects with 1-vein versus 2-vein anastomosis. Materials and Methods We performed a retrospective cohort study including 298 flaps. In 180 of these patients, 2-vein anastomosis was done, and in 118, 1-vein anastomosis was done. The study was conducted at Aga Khan University Hospital from January 2017 to December 2018. Results The number of venous anastomosis was not associated with flap survival. The group with dual anastomosis required more frequent reexploration as compared with 1 venous anastomosis group (8% vs 1.7%). Outcome and salvage rate were better in the 2-vein group as compared with the 1-vein group (64% vs 50%). Conclusion There is no difference in flap survival in single or dual venous anastomosis, but we have noticed higher reexploration rates in the 2-vein group. However, outcome is better in the 2-vein group.
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