INTRODUCTION:One of the critical factors that influence graft function after live donor liver transplantation is the presence or absence of global or sectorial liver congestion. Many authors advocate for routine middle hepatic vein (MHV) reconstruction because it is often difficult to determine when the MHV or one of its major branches have functional significance. Predictive tests to assess hemodynamic and functional significance of the MHV and its tributaries are still under study.CASE REPORT:We have described a novel intraoperative manipulation and Doppler ultrasonographic evaluation that led to the decision to include the MHV with the right lobe graft.

Orthotopic liver transplantation (OLT) is performed for benign hepatic lesions that are symptomatic, too large to be resected, have a malignant transformation potential, cause debilitating/life-threatening manifestations, or in patients experiencing posthepatectomy acute liver failure. Among benign tumors, polycystic liver disease (PLD) is the most common indication for OLT alone, or combined liver-kidney transplantation. Our 10-year experience with OLT for benign tumors includes two patients with PLD and one with a benign giant fibrous tumor. In this report, we present our experience with OLT for benign liver tumors, commenting on relevant published studies.

Background. Due to the shortage of available cadaveric organs, living donor liver transplantation (LDLT) has been recently applied extensively in adults. The use of the left lobe should be encouraged because of donor safety, but frequently the metabolic requirements of severely cirrhotic patients are great and subsequent graft dysfunction is encountered after transplantation. The importance of increased portal inflow to the graft in previously severely cirrhotic patients and other hemodynamic changes in LDLT using left lobes are still under debate, as are the surgical modulations to correct them. In this study, we have reported an initial series of adult-to-adult LDLT using left lobes, underlining the hemodynamic changes encountered during the transplant and the surgical modulations we applied to correct them.Methods. Eight adult recipients underwent left lobe liver transplantation from living donors. Portal vein pressure and central venous pressure were measured before and after surgical modulation.Results. We encountered four cases of small-for-size syndrome. Two patients were retransplanted; the other two died. Seventy-five percent of our recipients survived and 50% did not require further surgery.Conclusion. Surgical portal inflow modulation should be considered in cases of left lobe liver transplantation between adults.

Introduction. Living donation in adult liver transplantation (LDLTx) is an important resource because of the waiting list growth. We. started a living donor program to overcome the shortage of cadaveric sources.Patients. From May 2001 to May 2003, 36 patients underwent LDLTx: 27 received a right lobe, 8 received a left lobe, and 1 received segments 11 and III.Results. The 1-year actuarial survival rate was 77.7%, with a mean follow-up, in survivors, of 754 +/- 248 days. Eleven of 27 (40.7%) right lobe recipients died. Among left graft recipients, 3 patients died (33%). We undertook retransplantation in 4 cases, because of 2 "small for size" syndrome, 1 late hepatic artery thrombosis, and 1 early portal vein thrombosis. After a period of 797 days, all 36 donors returned to a normal social and working life. Two donors, who underwent right lobe donation, experienced major complications: 1 case of biliary stenosis, treated by stenting, and I case of biliary leak from the cut surface of the liver, requiring laparotomy and abscess drainage. Left lobe donors developed no complications.Conclusions. LDLTx has a learning curve for experienced liver transplantation surgeons. Our last 18 cases showed better survivals than the first 18 (9 deaths vs 5), even if, in the latter group, we transplanted 8 left livers. In our experience, LDLTx of a left liver graft has an increased risk of "small for size syndrome," but patients, both donors and recipients, report improved outcomes.

cRight lobe living liver transplantation is being performed worldwide with increased frequency. Difficult arterial reconstructions are often encountered because of small diameter or discrepancy between arterial stumps. The risk of arterial thrombosis is reported as high as 26%: microsurgical techniques have reduced this rate below 2%, increasing warm ischemia time. We have developed a new branch patch technique in living related liver transplantation using the donor cystic artery to create an enlarged patch anastomosis that enables increase in the vessel’s diameter and therefore greater inflow to the liver. We have followed 8 patients treated with this technique. After more than 1 year (mean follow-up: 636 days) we did not observe any arterial thrombosis by Doppler ultrasound performed every 3 months. The mean resistance index was 0.68 (0.57–0.83–). Three patients died with functional graft without signs of thrombosis. We believe that the cystic artery branch patch technique is feasible in all cases. It is fast (mean time: 6.2 min), it allows a shorter warm ischemia time, and there is no increased risk of thrombosis.

BACKGROUND:Cardiac complications represent a cause of morbidity and mortality after liver transplantation among patients with familial amyloid polyneuropathy (FAP), especially for the non-VAL30MET variant types.METHODS:We retrospectively evaluated 11 recipients from a nonendemic area including 90.9% affected by FAP variants. Preoperative cardiovascular symptoms were present in 81% of patients. An intraoperative pacemaker was placed prophylactically in 90.9% of all recipients. Since tacrolimus has been reported in the international literature to display cardiac toxicity, we evaluated the influence of intraoperative prophylactic pacing and rapid postoperative weaning from tacrolimus, mainly allowed by thymoglobulin on the occurrence of posttransplantation cardiac complications.RESULTS:One patient received a combined heart-liver transplant, another, living donor liver transplantation. We did not observe any significant intraoperative cardiac complications. Postoperatively, the pacemaker was removed from all patients but 1. Five patients received tacrolimus and steroids; a subsequent, second group of 6 patients (54.5%) was treated with thymoglobulin followed by tacrolimus. At discharge the mean tacrolimus level was 10.6 ng/mL, whereas after 1 month it was 7.5 ng/mL. We observed a case of acute cellular rejection before discharge, which was successfully treated with intravenous steroids and OKT3. After a mean follow-up of 17.4 months (range, 1-31), 2 patients had died (18.1%): 1 due to sepsis and another, to MI. Two recipients experienced cardiac complications (18.1%), namely, the patient who died due to an myocardial infarction and a second one with a tachyarrhythmia, which was treated successfully with beta-blockers and amiodarone.CONCLUSION:Prophylactic pacing and rapid weaning from immunosuppression are still associated with a significant rate of postoperative cardiac complications.

Technical aspects in living-related liver transplantation are still under debate: the main pitfall is the arterial reconstruction due to the small diameter and the discrepancy between stumps, with a subsequent increased risk of arterial thrombosis. The gold standard is the microsurgical technique, that reports the lowest risk of thrombosis, but it is a time consuming procedure requiring a long training. Our method of choice reconstructing hepatic artery in right lobe is the use of the cystic artery as a branch patch with the recipient hepatic artery by loop magnification, saving time and with a low incidence of hepatic artery thrombosis.

Clamping of the portal triad accomplishes complete inflow occlusion. This maneuver is commonly used during liver surgery to minimize blood loss but is not widely used in living donors undergoing resection for liver transplantation. We compared outcomes in living donors who underwent resection with and without inflow occlusion. We reviewed data on 2 nonsimultaneous living liver donor cohorts. The first 20 donors (group 1) underwent resection without inflow occlusion. In the next 15 donors (group 2), inflow occlusion was used during parenchymal transection, using cycles of 10-15 minutes occlusion and 6 minutes reperfusion. In donors, we recorded type of resection; ischemia times; blood loss; transfusions; peak ALT, AST, bilirubin, and INR in the first 5 days; hospital length of stay (LOS), and major complications. In recipients, we recorded peak ALT. In group 1, 19 of 20 donors underwent right hepatectomy. In group 2, 8 donors underwent right hepatectomy, and 7 donors had left lobectomies. Total ischemic time ranged from 16-49 minutes (mean, 31 +/- 9 minutes). In group 1, two donors received a total of 5 U of allogeneic blood. In group 2, no donor required transfusion. Mean peak ALT was significantly higher in group 1 (521 +/- 336 U/L) than group 2 (322 +/- 162 U/L; P = 0.03). Mean INR was significantly higher in group 1 (1.8 +/- 0.2) vs. group 2 (1.5 +/- 0.2; P = 0.001). There were 4 major complications in group 1 (incisional hernia, transient liver failure, biliary stricture, and biliary leak) and no major intraoperative or postoperative complications in group 2. Mean LOS was significantly longer in group 1 (7.9 +/- 2.9 days) than group 2 (6.2 +/- 1.1 days; P = 0.04). Mean peak ALT in recipients trended lower in group 2. In conclusion, inflow occlusion was associated with reduced blood loss and less ischemic injury to hepatic remnants in the donors and the grafts in the recipients. These benefits were associated with a diminished incidence of major complications and shorter LOS. Inflow occlusion should be an essential part of living donor hepatectomy.

Small-for-size syndrome in LDLT is associated with graft exposure to excessive portal perfusion. Prevention of graft overperfusion in LDLT can be achieved through intraoperative modulation of portal graft inflow. We report a successful LDLT utilising the left lobe with a GV/SLV of only 20%. A 43 year-old patient underwent to LDLT at our institution. During the anhepatic phase a porto-systemic shunt utilizing an interposition vein graft anastomosed between the right portal branch and the right hepatic vein was performed. After graft reperfusion splenectomy was also performed. Portal vein pressure, portal vein flow and hepatic artery flow were recorded. A decrease of portal vein pressure and flow was achieved, and the shunt was left in place. The recipient post-operative course was characterized by good graft function. Small-for-size syndrome by graft overperfusion can be successfully prevented by utilizing inflow modulation of the transplanted graft. This strategy can permit the use of left lobe in adult-to-adult living donor liver transplantation.

The risks and benefits of adult-to-adult living donor liver transplantation need to be carefully evaluated. Anesthetic management includes postoperative epidural pain relief, however, even patients with a normal preoperative coagulation profile may suffer transient postoperative coagulation derangement. This study explores the possible causes of postoperative coagulation derangement after donor hepatectomy and the possible implications on epidural analgesia. Thirty donors, American Society of Anesthesiology 1, with no history of liver disease were considered suitable for the study. A thoracic epidural catheter was inserted before induction and removed when laboratory values were as follows: prothrombin time (PT) > 60%, activated partial thromboplastin time < 1.24 (sec), and platelet count > 100,000 mmfpound (mm'). Standard blood tests were evaluated before surgery, on admission to the recovery room, and daily until postoperative day (POD) 5. The volumes of blood loss and of intraoperative fluids administered were recorded. Coagulation abnormalities observed immediately after surgery may be related mostly to blood loss and to the diluting effect of the intraoperative infused fluids, although the extent of the resection appears to be the most important factor in the extension of the PT observed from POD 1. In conclusion, significant alterations in PT and platelet values were observed in our patients who underwent uncomplicated major liver resection for living donor liver transplantation. Because the potential benefits of epidural analgesia for liver resection are undefined according to available data, additional prospective randomized studies comparing the effectiveness and safety of intravenous versus epidural analgesia in this patient population should be performed.

Key Points 1. Ethical principles and informed consent standards should be implemented for all living donors.2. Institutions that perform living donor transplantation should provide an independent donor advocate to ensure that informed consent standards and ethical principles are applied to the practice of all live organ donor transplantation.3. A database of health outcomes for all live donors should be established and funded through and under the auspices of the US Department of Health and Human Services.4. Serious consideration should be given to the establishment of a separate resource center for living donors and their families.5. The present preference in Organ Procurement and Transplantation Network allocation policy, given to previous living organ donors who subsequently need a kidney, should be extended so that any living organ donor would be given preference as a candidate for any organ transplant, should one become needed.6. A process should be established to verify qualifications of a center to perform living donor liver or lung transplantation.

Introduction. In cadaveric or segmental liver transplantation, accurate assessment of graft volume is desirable but not always easy to achieve based on donor morphometric data. We sought to establish a simple, reliable formula for accurate prediction of liver volume.Methods. Data from 1,413 cadaveric adult and pediatric liver donors were analyzed using simple and multiple regression analysis. Liver weight (LW) was plotted against age, height, body weight (BW), body surface area (BSA) or body mass index (BMI); a formula was developed using simple regression: LW (g) = 772 (g/m(2)) x BSA, r = 0.73, P < .01. For donors with BSA less than or equal to1.0, a pediatric factor (PF) of 1.0 was included, resulting in the formula: LW (g) = 772 (g/m(2)) x BSA - 38PF, r = 0.73, P < .01. We then applied our formula on 5 published formulae to estimate LW of our donors.Results. Among donors with BSA >1.0, there was no significant difference between the actual and the estimated mean LW as calculated by the new formula. For pediatric donors, there was no significant difference between estimated and actual mean liver weight with any formula. When the new formula was applied, the difference between the actual and the estimated liver weight was acceptable (<20%) in 1040 (73.6%) cases. In all races, there was no significant difference between actual and estimated mean liver weight as calculated by this formula.Conclusion. A simple formula to calculate liver weight in donors with BSA >1.0 is: LW 772 x BSA, and for donors with BSA less than or equal to1.0: Liver Weight 772 x BSA - 38.

Five "contaminations", where faeces containing Trichostrongylus colubriformis eggs were deposited on pasture and serially recovered, were used to compare the rate of decline of faecal mass and larval development. In the first three contaminations, faeces from a common source were deposited on swards of browntop (Agrostis capillaris cv Grasslands Muster), ryegrass (Lolium perenne cv Grassland Nui), white clover (Trifolium pratense cv Grassland Tahora), or onto bare ground in the late spring, summer or autumn. The last two contaminations were done on the north facing aspect or south facing aspect of hill country pastures in summer and autumn. Number of free-living nematodes (first- and second-stage larvae (L(1) and L(2)) and soil dwelling nematodes) and third stage larvae (L(3)) recovered from faeces were counted. In spring there was a significant (P<0.01) effect of sward type on the mass of faeces remaining, with greatest mass remaining on browntop and ryegrass 28 days later, and less on bare ground and white clover. In summer there were more (P<0.05) faeces remaining on browntop than on other herbages which had little faeces remaining and which did not differ one from another. In autumn there was a rapid decline in faecal mass. All faeces were gone from white clover and ryegrass swards by day 10 and from browntop and bare ground by day 14. The number of free-living nematodes did not differ markedly between seasons, ranging from 5 to 8.5% of eggs deposited. The number of L(3) recovered was low in spring ( approximately 0.4% of eggs deposited) and did not differ between swards. In summer, more (P<0.05) L(3) were recovered from faeces deposited on swards of ryegrass and white clover than from bare ground or browntop. Most L(3) were recovered from days 7 to 14 ( approximately 1.3% of eggs deposited). In the autumn, low numbers of L(3) were recovered from browntop on day 3 and ryegrass on day 7 (0.2% of eggs deposited) with virtually no L(3) recovered from faeces placed on white clover or bare ground. There were significant (P<0.001) effects of aspect on the amount of faecal mass remaining in both summer and autumn with less faeces remaining on the south facing aspect than on the north. This was particularly evident during the summer when virtually all of the faeces were intact on the north facing aspect but only 40% was remaining on the south on day 28. In the autumn, while faeces were completely gone from both aspects by day 28 but there were less (P<0.05) faeces remaining on the south facing aspect from days 3 to 18 than from the north. There was no aspect effect in either season on the number of free-living nematodes recovered which averaged 8-11% of eggs deposited. In both seasons a greater number of L(3) were recovered from faeces on the south facing aspect than on the north, particularly 3-10 days after faecal deposition. In summer the rise in L(3) recovered in faeces was more rapid on south facing aspect than on the north but both attained a maximum level of approximately 4% of eggs deposited. In autumn on day 3 there was a rapid rise on south facing aspect to approximately 21% of eggs deposited followed by a gradual decline on day 10 while on the north facing aspect numbers of L(3) recovered only attained 10% of eggs deposited.

Right lobe liver transplantation is a relatively new and technically challenging method of living donor transplantation. Integrity of the hepatic venous anastomosis is crucial for successful transplantation. We describe the use of intraoperative Doppler sonography to diagnose stenosis of the hepatic vein anastomosis, with associated compromise of venous drainage and graft perfusion.