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Bang, Kim, Wang, Kim, Sim, and Hu: The Feasibility of Right Posterior Sector Graft in the Adult Living Donor Liver Transplantation
Original Article

J Korean Soc Transplant 2015;29(3):148-159.

Published online: 10 September 2015

DOI: https://doi.org/10.4285/jkstn.2015.29.3.148

The Feasibility of Right Posterior Sector Graft in the Adult Living Donor Liver Transplantation

Jun-Bae Bang, M.D., Bong-Wan Kim, M.D., Hee-Jung Wang, M.D., Tae-Gyu Kim, M.D., Joohyun Sim, M.D., Xu-Guang Hu, M.D.

1Department of Liver Transplantation and Hepatobiliary Surgery, Ajou University School of Medicine, Suwon, Korea

Corresponding author: Bong-Wan Kim, Department of Liver Transplantation and Hepatobiliary Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeong-tong-gu, Suwon 16499, Korea Tel: 82-31-219-5200, Fax: 82-31-219-5755 E-mail: drbwkim@ajou.ac.kr

Received 8 September 2015       Revised 8 September 2015       Accepted 9 September 2015

Copyright © the Korean Society for Transplantation, 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

The aim of this study is to evaluate the feasibility of living donor liver transplantation (LDLT) using an right posterior sector (RPS) graft selected by liver volumetry of living donors.

Methods

From April 2008 to August 2014, 132 LDLTs were performed in our hospital. Of these, 20 recipients (15.1%) received an RPS graft. Perioperative data of LDLTs using an RPS graft were analyzed retrospectively.

Results

Mean of the Model for End-stage Liver Disease score of the 20 recipients was 12.1±6.2. The mean right liver volume was 72.4%±3.1% of total liver volume (TLV) and the mean volume of RPS was 38.2%±5.3% of TLV. Anatomical anomalies were found in the portal vein (PV) of 14 donors (70%), in the hepatic artery of one donor (5%), and bile duct of seven donors (35%). All donors were discharged with normal liver function. Two donors (10%) developed bile leakage after RPS donation. None of the recipients experienced complication associated with hepatic artery and PV anastomosis. One recipient had in-hospital mortality due to pneumonia. The remaining 19 recipients were discharged with good graft function. Four recipients (20%) developed biliary stricture and one (5%) had a liver abscess during follow-up.

Conclusions

The RPS donor had a high incidence of abnormal anatomy of PV. LDLT using an RPS graft might have high incidence of biliary complications. We think that selection of an RPS graft from a donor with an inappropriately large right lobe volume could expand the donor pool and be a feasible option in LDLT.

Keywords: Liver transplantation, Living donors, Right posterior sector

References

1). Gali B, Rosen CB, Plevak DJ. Living donor liver transplantation: selection, perioperative care, and outcome. J Intensive Care Med. 2012; 27:71–8.
2). Campos BD, Botha JF. Strategies to optimize donor safety with smaller grafts for adult-to-adult living donor liver transplantation. Curr Opin Organ Transplant. 2012; 17:230–4.
crossref
3). Barr ML, Belghiti J, Villamil FG, Pomfret EA, Sutherland DS, Gruessner RW, et al. A report of the Vancouver Forum on the care of the live organ donor: lung, liver, pancreas, and intestine data and medical guidelines. Transplantation. 2006; 81:1373–85.
crossref
4). Kim BW, Xu W, Wang HJ, Park YK, Lee K, Kim MW. Volumetry-based selection of right posterior sector grafts for adult living donor liver transplantation. Liver Transpl. 2011; 17:1046–58.
crossref
5). Yoshizumi T, Ikegami T, Kimura K, Uchiyama H, Ikeda T, Shirabe K, et al. Selection of a right posterior sector graft for living donor liver transplantation. Liver Transpl. 2014; 20:1089–96.
crossref
6). Hori T, Kirino I, Uemoto S. Right posterior segment graft in living donor liver transplantation. Hepatol Res. Epub. 2015 Jan 6. DOI:. http://dx.doi.org/10.1111/hepr.12469.
7). Hwang S, Lee SG, Lee YJ, Park KM, Kim KH, Ahn CS, et al. Donor selection for procurement of right posterior segment graft in living donor liver transplantation. Liver Transpl. 2004; 10:1150–5.
crossref
8). Sugawara Y, Makuuchi M, Takayama T, Mizuta K, Kawarasaki H, Imamura H, et al. Liver transplantation using a right lateral sector graft from a living donor to her granddaughter. Hepatogastroenterology. 2001; 48:261–3.
9). Kyoden Y, Tamura S, Sugawara Y, Akamatsu N, Matsui Y, Togashi J, et al. Biliary complications in right lateral sector graft live donor liver transplantation. Transpl Int. 2008; 21:332–9.
crossref
10). Marubashi S, Dono K, Nagano H, Kobayashi S, Takeda Y, Umeshita K, et al. Biliary reconstruction in living donor liver transplantation: technical invention and risk factor analysis for anastomotic stricture. Transplantation. 2009; 88:1123–30.
crossref
11). Leelaudomlipi S, Sugawara Y, Kaneko J, Matsui Y, Ohkubo T, Makuuchi M. Volumetric analysis of liver segments in 155 living donors. Liver Transpl. 2002; 8:612–4.
crossref
12). Sugawara Y, Makuuchi M, Takayama T, Imamura H, Kaneko J. Right lateral sector graft in adult living-related liver transplantation. Transplantation. 2002; 73:111–4.
13). Stange BJ, Glanemann M, Nuessler NC, Settmacher U, Steinmuller T, Neuhaus P. Hepatic artery thrombosis after adult liver transplantation. Liver Transpl. 2003; 9:612–20.

Fig. 1.
Right posterior sector (RPS) graft contours (dots) on axial computed tomography images. (A) Right hepatic vein (RHV) was the key border of RPS graft (arrow), (B) RHV (arrow), (C) Right posterior portal vein (arrow).
jkstn-29-148f1.tif
Fig. 2.
The flow chart of graft selection in the adult living donor liver transplantation. The graft was selected by the ratio of left lode volume (LLV)/total liver volume (TLV). The right lobe (RL) or extended right lode (ERL) donation was considered when the LLV/TLV greater than 35%. The left lobe (LL) donation was considered when the LLV/TLV less than 35% and LLV ＞0.8% of graft to recipient body weight ratio (GRWR). The right posterior sector (RPS) graft donation was primarily considered when LLV/TLV less than 30%, right posterior sector volume (RPSV) was greater than LLV, and RPSV ＞0.8% of GRWR. Also, the RPS graft was considered when RPSV ＞ LLV among the candidate with 30%∼35% of LLV/TLV (dashed line). ① Primary consideration. ② Secondary consideration. Abbreviation: MS, macrovesicular steatosis.
jkstn-29-148f2.tif
Fig. 3.
A operation field of RPS graft procurement. (A) Hilar dissection for identifying the right posterior hepatic artery (arrow) and portal vein (arrowhead). (B) The surface marking for parenchymal transection was drawn along the ischemic demarcation. (C) A radiopaque marker for intraoperative cholangiography was located after parenchymal transection. (D) Wide graft outflow with a venous patch was made in the back-table.
jkstn-29-148f3.tif
Fig. 4.
Anatomical right posterior hepatic artery (PHA) variations according to preoperative three-dimensional computed tomography. (A) The right PHA was early branching (EB) from right hepatic artery (HA), (B) The right PHA was late branching from right HA, (C) The right PHA was branching from gastroduodenal artery.
jkstn-29-148f4.tif
Fig. 5.
The mean value of the post-hepatectomy serum laboratory tests for the donors. (A) Total bilirubin, (B) prothrombin time-international normalized ratio (PT-INR), (C) alanine transaminase (ALT), (D) aspartate aminotransferase (AST).
jkstn-29-148f5.tif
Fig. 6.
Postoperative computed tomography (CT) scans of a donor. (A) A CT scan on postoperative day 7 showed a congested area (arrows) in the remnant liver, (B) Three months after the operation, congested area disappeared and regeneration of remnant liver was seen.
jkstn-29-148f6.tif
Fig. 7.
The mean value of the post-transplant serum laboratory tests for the recipients. (A) Total bilirubin, (B) prothrombin time-international normalized ratio (PT-INR), (C) alanine transaminase (ALT), (D) aspartate aminotransferase (AST).
jkstn-29-148f7.tif
Fig. 8.
Severe liver abscess was developed in the right posterior sector graft in case 13th recipient who had performed Roux-en-Y hepaticojejunostomy.
jkstn-29-148f8.tif
Table 1.
Recipients and donors’ profiles of the right posterior sector graft living donor liver transplantation
Case No. Age/sex Primary diseases Donor age/sex MELD score CTP score Recipient operation time (m) Donor operation time (m) Cold ischemia (m) Warm ischemia (m)
1 50/M HBV, Klatskin tumor 18/M 14 5 750 430 55 40
2 39/F HCV 38/F 13 7 660 360 190 55
3 46/M HBV, HCC 33/F 9 9 1,060 450 180 30
4 38/M Alcoholic LC 18/M 31 11 1,160 387 355 65
5 56/F HBV 31/M 16 10 620 394 177 55
6 60/F HBV 45/M 12 6 755 489 105 90
7 55/M HBV, HCC 25/M 6 5 760 450 115 80
8 54/F HBV, HCC 42/M 13 6 620 320 45 40
9 45/M HBV, HCC 42/M 12 6 630 365 80 35
10 52/M HBV, HCC 23/M 8 5 502 349 55 37
11 43/F HBV, HCC 39/F 6 5 487 403 65 25
12 41/F HBV, HCC 41/M 6 5 605 452 95 30
13 57/M HBV, HCC 39/M 8 6 775 412 137 33
14 65/M HBV, HCC 35/M 7 5 570 465 95 35
15 60/M HBV 28/M 11 7 494 454 100 45
16 54/M HBV, HCC 27/M 8 5 700 364 155 45
17 35/F Alcoholic LC 33/M 14 6 730 388 115 25
18 54/F Alcoholic LC 22/M 17 9 580 397 95 40
19 51/M Alcoholic LC 19/M 23 5 750 421 60 69
20 42/F HBV, HCC 48/M 7 5 580 465 85 35

Abbreviations: MELD, model for end-stage liver disease; CTP, Child-Turcotte-Pugh; HBV, hepatitis B virus; HCV, hepatitis C virus; HCC, hepatocellular carcinoma; LC, liver cirrhosis.

Table 2.
Operative measurements of the right posterior sector graft
Case No. Graft weight (g) Actual GRWR (%) PV branching type Graft hepatic arteries (n) Diameter of hepatic artery in graft (mm) Length of hepatic artery in graft (mm) Origin of right posterior hepatic artery Graft bile ducts (n) Graft bile duct diameter (mm) Origin of right posterior hepatic duct Biliary reconstruction
1 500 0.83 II 1 2 15 RHA-EB 1 5 LHD RYHJ
2 608 0.94 I 1 2 10 RHA-LB 1 3 LHD DDA
3 571 1.10 III 1 4 10 RHA-EB 1 4 CHD DDA
4 520 0.81 III 2 3/1 10/5 RHA-LB 1 3 RHD DDA
5 590 1.15 III 1 2 15 GDA 1 4 CHD DDA
6 470 0.76 II 1 1.5 10 RHA-LB 2 3/3 RHD DDA
7 450 0.55 I 1 3 10 RHA-LB 1 3 RHD DDA
8 680 1.15 III 1 2 20 RHA-EB 1 5 RHD DDA
9 540 0.72 I 2 1 10 RHA-LB 1 2 RHD DDA
10 470 0.69 II 1 2 20 RHA-LB 1 3.5 LHD DDA
11 620 1.05 I 2 2/1.5 10/10 RHA-LB 1 4 CHD DDA
12 490 0.93 I 1 2.5 20 RHA-LB 1 3.5 RHD DDA
13 460 0.66 I 1 3 25 RHA-LB 2 4/4 RHD RYHJ
14 560 1.67 III 1 2 15 RHA-LB 2 3/4 RHD DDA
15 660 0.73 II 1 2 20 RHA-LB 1 2.5 RHD DDA
16 415 0.78 III 1 1 6 RHA-LB 1 2.5 RHD DDA
17 480 0.93 II 1 2 5 RHA-LB 1 3 LHD DDA
18 530 1.14 III 1 2 15 RHA-EB 1 4 RHD DDA
19 425 0.59 III 1 1 20 RHA-EB 1 1.5 RHD DDA
20 635 1.20 III 1 2.5 25 RHA-LB 1 5 RHD DDA
Abbreviations: GRWR, graft recipient weight ratio; PV, portal vein; RHA, right hepatic artery; EB, early branching; LHD, left hepatic duct; RYHJ, roux en Y hepaticojejunostomy; LB, late branching; DDA, duct to duct anastomosis; CHD, common hepatic duct; RHD, right hepatic duct; GDA, gastroduodenal artery.
Table 3.
Clinical outcomes of the recipients after the right posterior sector graft living donor liver transplantation
Case No. Postoperative complications or cause of death Outcomes (postoperative day or year)
1 Tumor recurrence Dead (3.5 yr)
2 Biliary stricture Alive (6.8 yr)
3 – Alive (6.8 yr)
4 Postoperative bleeding Alive (6.3 yr)
5 Acute cellular rejection Alive (6.3 yr)
6 Biliary stricture Alive (5.9 yr)
7 Acute cellular rejection, biliary stricture Alive (5.8 yr)
8 Acute cellular rejection Alive (5.4 yr)
9 – Alive (5.3 yr)
10 – Alive (5.2 yr)
11 – Alive (5.2 yr)
12 Gastric cancer Dead (3 yr)
13 Acute cellular rejection, liver abscess Dead (140 day)
14 – Alive (4.6 yr)
15 Acute cellular rejection Alive (3.5 yr)
16 Biliary stricture Alive (3.1 yr)
17 – Alive (1.1 yr)
18 – Alive (1 yr)
19 Pneumonia, sepsis Dead (14 day)
20 – Alive (0.5 yr)
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