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ADULT LIVING DONOR LIVER
TRANSPLANTATION
Right versus Left Grafts

M. Malagó and C E. Broelsch
Universitätsklinikum Essen, Klinik für Allgemeine
und Transplantationschirurgie
M M 2002 UniversitätsKlinikum Essen - Allgemeinchirurgie

Waiting Time on the List
UNOS: 13,181 patients waiting
5,791 donors
4,450 livers used

Retrieval rate 60%

Liver Transplantation
using Liver Segments


SPLIT LTX
Transplantation einer Spenderleber auf zwei Empfänger
Pichlmayr, Langenbecks Arch Chir (1988) 373: 127-130


The first LDLTs worldwide
S. Raia, S. Mies Sao Paulo 3.12.1988

R. Strong Brisbane 1989

Nagasue Japan 13.11.1989

C.E. Broelsch Chicago 27.11.1989

K. Ozawa Kyoto 15.06.1990

M. Makuuchi Matsumoto 19.06.1990


The first LDLDT
at the University of Chicago
1989


10 YEARS OF PEDIATRIC
LIVING DONATION
1,000 liver transplants in 60 centers
WEST EAST
Centers 45 15
N. of cases 35% 65%

EUROPEAN LIVER TRANSPLANT REGISTRY
21 Countries - 125 active Institutions
49361 Transplantations - 43826 Patients 303 439
05/1968 - 06/2002 1146

427
251 1177
8568 229
2443 7537
261
1571 126
9244 789 32
5503 16
11
720 8442

Canary islands

Evolution of the Number of Living Related
Liver Transplantations in Europe
Oct. 1991 - Dec. 2000 124
170
160

140

120 Children Adults
100 48

80
6
60 18

2 7 5
40
1 61
20 0 3 50 59
38 51
6 27 34 32
17
0
ELTR 2001
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Evolution of the Number of Centers
performing LRLT in Europe
32 33/115 (29%) Centers
33
28
31
24

20 25
22
16
17
12
15
11
8 8
4 3 4
0
91 92 93 94 95 96 97 98 99 2000
Years

Type of Graft used for LRLT
Oct. 1991 - Dec. 2000

Right liver (5,6,7,8) : 153
37%

Left lobe (seg 2,3) : 205
Left liver (seg 2,3,4) : 58 59%
14% ELTR 2001


R Living Donor graft


ETHICS
Equipoise analysis
in Living Donor Liver Transplantation

Singer, Lantos, Whitington, Broelsch, Siegler Clin Res 1988:539-45


LTX ESSEN April 1998 – March 2003
n = 483
Reduced Size (6)
Living Donor (106)

Split (72)

Standard-Tx (299)


LTX ESSEN April 1998 – March 2003
Living donor Tx
n = 106
19
4
rechts
links
linkslateral

83


Type of Graft used for Adult LRLT
Oct. 1991 - Dec. 2000

Left lobe (seg 2,3) : 3
3%
Right liver (seg 5,6,7,8) : 108
Left liver (seg 2,3,4) : 8
91%
6%

ELTR 2001


Donor criteria
•Liver biopsy: steatosis
• > 20% contraindication
• 10-20% diet and control
• < 10% depending on % Res.
•Volumetry
• % Resection 60- 65%
• GRBWR >0.8
• Rest DBWR >0.8


Donor Evaluation - Anatomy
PV individual Segmentation


Donor selection - Anatomy
341 donors for 62 recipients
Only 1 rejected for difficult anatomy associated
to poor recipient conditions

Zur Anzeige w ird de r Qu ickTim e ™
Zur Anzeige w ird der QuickTim e™ D e kom pres s or “C inepa k”
D ekom pres s or “C inepak” be nötigt.
benötigt.


Costs of the evaluation of donors

A d u lt s C h ild r en

n° C os t s n ° C os t s

Total donors rejected 395 377.362 € 39 55.578 €
Initial screening 76 760 € 4 40 €
During evaluation 196 215.706 € 25 26.995 €
Recipient contraind. 123 160.896 € 10 25.583 €

Total donors accepted 69 313.812 € 19 86.412 €


MORTALITY in Living Liver Donors

Total 7 / 3000 (0,023%) Asia? Other Countries?
(5 Deaths discussed in public)
Pediatric 2 / 1200
Adult 5 / 1800

Reasons
2 Failures of the selection process
3 Management – surgical ?
2 Anaphylaxys - casuality ?
Small rest donor liver
3/7 donors overweight


Lobe grafting Live Donor
Increased donor risk ?
Recipient refusal
Technical difficulty
Blood loss
Right better than Left


RESULTS DONOR EVALUATION
PEDIATRIC ADULT

Potential Donors 58 464
Potential Recipients 42 206
Ratio D/R 1,4 2,3
Excluded 67% 85%
Accepted 33% 15%

Notes!!!
Time of Evaluation 24 hrs – 4 Weeks
Evaluation Costs : ca. 4000 Euro


DONOR EVALUATION
Essen 385 potential liver donors
Right Liver Left LL atera li ver
- l TOTAL
Tot Po .Don r
. t o s 333 52 385
Po . Recipien s
t t 172 37 209
Do orsS tep 1 5
n - 145 (1 0%)
0 23 1 0%)
( 0 168(100 )
%

STE P 1 48 3 ,2%
( 3 ) 14 6 %
( 1 ) 62 3 %
( 7 )
B oo g r up
l d o 27 6 33
V r ss e o og
i u r l y 16 8 24
Medic la
c m r b dity
o o i 2 0 2
Fe r
a 3 0 3

STE P 2 89 6 ,3%
( 1 ) 5( 2 )
2 % 94 5 %
( 6 )
Vo lume r t y 54 2 56
P y h olo gic al
sc 15 1 16
His olo gy
t 15 0 15
Liv r a ato y
e n m 1 0 1
S c ia
o l 2 1 3
Medic l
a
c m r b dity
o o i 2 1 3

STE P 3 3( %)
2 3( 3 )
1 % 6( ,5%)
3
Medic l
a
c m r b dity
o o i 2 2 4
Fe r
a 1 1 2

STE P 4 5( ,5%)
3 1( %)
4 6( ,5%)
3
P y h olo gic al
sc 4 0 4
His olo gy
t 1 0 1
Medic l
a
c m r b dity
o o i 0 1 1

STEP 5 0 0 0


SMALL-FOR-SIZE LTX
• Hepatocellullar mass
• Minimal volume?
• Hepatocellullar function
• How to evaluate? Artificial liver support
• Regeneration
• How to modulate - maximize?
• Infection -> prophylaxis

Kyoto: 46 % Graft surv for GBWR < 0.8
Kyoto: 46 % Graft surv for GBWR < 0.8

LDLT in ADULTS: Right vs. Left graft
“Download” of the waiting list

Frontal approach
Right graft

Lateral approach
Left or right graft

Eurotransplant - DESLD
Decompensated End-Stage Liver Disease
T2 23% of the list
T2 32% Mortality


Decompensated End-Stage Liver Disease
Survival
Patient survival DESLD (c) vs non-DESLD (non c)
Patient survival 57

1

l ,8
a
v
i ,6
v Cum . Survival (c)
r Cum . Survival (non c)
u,4
S

,2

0

0 5 10 15 20 25 30 35 40 45
Tim e [m onths]


Graft - Patient Match
SFS and disease severity
patient survival Child C vs Child A+B and GW BR <0.85 vs >0.85

l 1
a
v Cum . Survival (A+B/<0,85)
i
v,8
r
u Cum . Survival (A+B/>=0,85)
S ,6
.
m Cum . Survival (C/<0,85)
u,4
C
Cum . Survival (C/>=0,85)
,2

0

0 5 10 15 20 25 30 35
Tim e [m onths]

Kiuchi 0,8% Transplantation 1998
Ben Haim 0,85% Liver Tr. 2001


Resection Technique
Variations
EXTENDED R ( + MHV)
“SUPRAHEPATIC HEPATECTOMY”


Hepatic Veins
Medial sector venous
congestion


Right LDT: Technical improvements

1,0
0,9 1,0
0,8 0,9
(x100)%

0,8

(x100)%
0,7
0,6 0,7
0,5 0,6
0,4 0,5
0,4
0,3 0,3
0,2 0,2
0,1 0,1
0,0 0,0
0 6 12 18 0 6 12 18
months months
old technique new technique old technique new technique

Malagó M, Testa G, Frilling A el al in press


LIVER DONOR: OUTCOMES
Duration of recovery after living
related liver transplantation
30

20
We e k s

10

0
Donor s

Beginning to work Physically fully recovered


Lobe grafting CAD donor
Liver volume
Technical difficulty
Recipient refusal
Right better than Left


Split Liver Transplantation
GRAFT PARAMETERS
• Volumetry
GRWR > 1 % especially for L graft!!

• Biopsy: Fat infiltration
> 20 % Contraindication
10-15% R extended - Left Lateral Split
< 10% optimal condition to R-L split

• Vascular and biliar anatomy


LDLT in ADULTS: Right vs. Left graft
Requirements
Both donor and recipient must have adequate liver volumes ->
GBWR 0.8
RBWR 0.8 or 0.7 with normal histology, young donor

Vascular and biliary anatomy with their anomalies must be known so
to properly plan the resection in the donor and anastomoses in the
recipient

Zur A eige wird der Q
nz uickTime™
Dekompressor “Cinepak”
benötigt.


Adult LD LTX
Conclusion
Right better than Left in the West
Severity of disease shall be taken into
account calculating graft volumes
R Hepatectomy Challenging, Major procedure
Contained risk
Cadaveric & Split remain cornerstone
Recipent management crucial


Fert unda nec regitur


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