*Autoimmune Hepatitis (AIH), Primary Biliary Cirrhosis (PBC), Primary Sclerosing Cholangitis (PSC)
Living Donors and Split Livers
Article first published online: 15 OCT 2013
Copyright © 2013 American Association for the Study of Liver Diseases
Special Issue: The 64th Annual Meeting of the American Association for the Study of Liver Diseases: The Liver Meeting 2013
Volume 58, Issue S1, pages 776A–785A, October 2013
How to Cite
(2013), Living Donors and Split Livers. Hepatology, 58: 776A–785A. doi: 10.1002/hep.26860
- Issue published online: 1 OCT 2013
- Article first published online: 15 OCT 2013
A novel protocol for ABO incompatible living donor liver transplantation without graft local infusion and splenectomy
Seung Duk Lee, Seong Hoon Kim, Young-Kyu Kim;
Liver Cancer Center, National Cancer Center, Republic of Korea, Goyang-si, Republic of Korea
Background: Graft local infusion and splenectomy have been established as pivotal strategies in ABO incompatible (ABO-I) living donor liver transplantation (LDLT). However, these procedures are associated with high rates of intraoperative and postoperative complications. Methods: From January 2012 to January 2013, 13 consecutive ABO-I LDLT patients were identified at National Cancer Center, Republic of Korea. Our protocol involved rituximab (300 mg/m2) at preoperative 2 weeks, followed by plasma exchange (target before LDLT: isoagglutinin titer ≤ 1:8), basiliximab (20 mg on operation day and postoperative day 4), and intravenous immune globulin (0.8 g/day at postoperative day 1 and 4) without graft local infusion and splenectomy. Results: The 13 patients (10 males, three females) who underwent transplantation comprised liver cirrhosis (n=3) and hepatocellular carcinoma (n = 10). The median isoagglutinin antibody titer before plasma exchange was 1:32 (range, 1:4 - 1:256). All patients are alive without graft failure. There was no hyperacute rejection and antibody-mediated rejection. Mean duration of hospital stay was 13.2 days. There was no recurrence of hepatitis B virus (0/10 patients), but recurrence of hepatitis C virus (1/1 patient) and one positive CMV antigenemia (1/13 patients) after transplantation. No bacterial and fungal infections were observed. Complications included herpes zoster viral infection in one patient, postoperative bleeding in one patient and extrahepatic biliary stricture in three patients. Conclusions: The new simplified ABO-I LDLT protocol using rituximab, plasma exchange, basiliximab, and intravenous immune globulin without graft local infusion and splenectomy showed good graft outcomes without hyperacute, antibody mediated rejection, and serious infection.
The following people have nothing to disclose: Seung Duk Lee, Seong Hoon Kim, Young-Kyu Kim
Surgical Resection and Liver Transplantation for Hepatocellular Adenoma
Kaitlyn R. Musto, Justin H. Nguyen, Tushar Patel, Denise M. Harnois;
Mayo Clinic, Jacksonville, FL
Hepatocellular adenoma (HA) is a rare benign epithelial tumor. Prognosis of HA is highly variable, but there is a risk of malignant transformation. Current management guidelines (Gut BMJ, 2012- 85; Gastroenterology, 2009–137) for HA in men propose resection regardless of size, and for women (a) resection for HA >5 cm or symptomatic; (b) observation for HA <5 cm with OCP use; (c) if HA <5 cm without OCP use optimal management is undefined; resection or observation may be recommended. If observation, biopsy considered. Our aim was to review the outcomes of HA based on current management guidelines. Methods: A retrospective analysis of patients with HA evaluated at our center between 1999 and 2012 was completed. Demographic information (gender, age, OCP use, BMI), clinical (symptoms, interventions, follow-up), imaging, and pathology (number, size, hemorrhage, malignant change) were examined. Results: 28 patients with HA were identified, 2 males and 26 females. The median age was 39 years (range: 26–65) with median BMI of 30 (range: 19–51). 20 patients underwent surgical resection, 2 had liver transplant, and 6 had no surgical intervention. Of the 6 patients without surgical intervention, 2 presented with biopsy-proven HCC occurring within the adenoma: 1 received chemotherapy (14.9-cm tumor) and the other (6.5-cm tumor) died of unrelated cause. 4 patients had HA with median size of 4.1cm (range: 3–5.6). 1 patient was lost to follow-up, 1 chose another center; 2 remain in observation. 20 patients underwent resection, HA median size was 7.5-cm (range: 3–15cm). On pathological examination, 5 had preoperative hemorrhage and 1 had malignant transformation to HCC. 2 HA's <5 cm were resected for pain. 11 of 18 females had prior history of OCP use. Neither 2 male patients had malignancy but 1 had posthepatectomy liver failure following resection of 14-cm HA. He received a liver transplant a month later but died from central pontine myelinolysis and mul-tiorgan failure. 2 patients underwent liver transplantation as primary management. 1 had an unresectable 10-cm caudate lobe lesion while the other had a 14-cm hepatic mass with congenital absence of portal vein and innumerable smaller HA's. Both underwent liver transplantation with no malignancy in explants.
Conclusion: Malignant transformation occurred in 3 of 28 (10.7%) patients with HA. Current management guidelines are not optimal and do not adequately define individuals with HA at risk of malignancy. Future refinements including the use of molecular profiling may be required to improve management of HA and guide surgical interventions such as resection or transplantation.
The following people have nothing to disclose: Kaitlyn R. Musto, Justin H. Nguyen, Tushar Patel, Denise M. Harnois
A novel segment-oriented liver anatomy based on portal circulation: Comparison with Couinaud's segmental anatomy
Ami Kurimoto, Junichi Yamanaka, Yuichi Kondo, Shinichi Saito, Hideaki Sueoka, Tadamichi Hirano, Yuji Iimuro, Jiro Fujimoto;
Surgery, Hyogo college of Medicine, Hyogo,Nishinomiya, Japan
Background/Aim: Mandatory for liver resection is knowledge of the precise vascular structure and segment-oriented anatomy. Couinaud's classification of liver segment has been widely accepted and used. But, there are many variations in portal vein, especially in the right paramedian sector. Couinaud's classification is not always right during liver resection. We assessed portal branching pattern and perfused area in the right hemiliver, and also evaluated hepatic vein drainage area by using multi-detector computed tomography (MD-CT). Methods: We have reported the clinical implication of pre-operative prediction of liver resection volume by newly developed hepatec-tomy simulation software (Hepatology, 2005). Between 2007 and 2013, 150 patients underwent preoperative dynamic MD-CT, using the three-dimensional (3D) virtual hepatectomy simulation software which was programmed to reconstruct detailed 3D vascular structure and calculate liver volume based on hepatic circulation. Results: The third branches of portal vein of right paramedian sector often diverge into more than three. The volume of each portal branch's perfusion volume was calculated and the portal branch of which perfusion volume less than 10% volume of paramedian sector was excluded from this study. The variation pattern of the portal vein ramification in the right paramedian sector was classified into the following three types; cranio-caudal type (classical Couinaud's segments V and VIII) in 37%, ventro-dorsal type in 30%, and multiple type in 33%. Meanwhile, the analysis showed correlation between hepatic venous drainage and portal inflow pattern. In the cranial section of the cranio-caudal type, volume of draining via middle hepatic vein (MHV) and right hepatic vein (RHV) accounted for 48.6% and 49.9%, respectively. In the caudal section, the draining volume via MHV and RHV accounted for 41.7% and 58.2%, respectively. In ventro-dorsal type, however, draining volume via MHV accounted for 78.7% of the ventral section and draining volume via RHV accounted for 84% of the dorsal section, respectively. Conclusion: Pattern of portal branch ramification and its perfusion area in the right paramedian sector was classified into three types, and perfusion pattern was different from classical Couinaud's segmentation in 63%. Simulation also suggested correlation between the portal branch type and the venous drainage pattern of the right paramedian sector, implying significant impact of preoperative planning on safe and curative hepatectomy in patients with marginal liver function.
The following people have nothing to disclose: Ami Kurimoto, Junichi Yamanaka, Yuichi Kondo, Shinichi Saito, Hideaki Sueoka, Tadamichi Hirano, Yuji Iimuro, Jiro Fujimoto
Utilization Of Living Liver Donors With Positive Thrombophilia Screening: Is It Safe?
Murat Dayangac1, Murat Akyildiz1,2, Necdet Guler1, Onur Yaprak1, Yildiray Yuzer1, Yaman Tokat1, Reyhan Kucukkaya3;
1 Center for Organ Transplantation, Florence Nightingale Hospital, Istanbul, Turkey; 2Department of Gastroenterology, Istanbul Bilim University, Istanbul, Turkey; 3Department of Hematology, Istanbul Bilim University, Istanbul, Turkey
In living donor liver transplantation (LDLT), venous thromboem-bolism (VTE) has appeared as a significant source of morbidity and mortality in donors. Factor V Leiden (FVL) and prothrombin G20210A (FII) mutations are the most common inherited risk factors, which contribute to the occurrence of VTE. The aim of this retrospective cohort study is to assess the safety of utilizing living liver donors with positive thrombophilia screening. Between June 2004 and July 2012, 410 LDLTs were performed in our institution without donor mortality. A retrospective analysis of the first 214 cases revealed that, the two donors (2/214, 0.9%) who developed VTE (1 pulmonary embolism, 1 portal vein thrombosis) after donor hepatectomy had homozygous (HO) FII mutation. In April 2010, we started routine thrombophilia screening during the initial phase of evaluation in all potential donors. In a total of 665 potential donors who underwent screening, the rate of heterozygous (HE) and HO mutations for Factor V Leiden (FVL) and FII were 11.5% and 0.7%, and 4.5% and 0.6%, respectively. All potential donors with HO FVL or HO FII mutations (n=9), and those with double HE FVL-FII mutation (n=4) were eliminated. A total of 23 donors with HE-FVL mutation and 7 donors with HE-FII mutation underwent donor hepatectomy. These 30 donors were given low molecular weight heparin (LMWH) for VTE prophylaxis until they were discharged from the hospital. In a median follow-up of 15.0 (12.0–25.5) months, none of the donors with either HE-FVL or HE-FII mutations had VTE. In the second cohort, four donors (4/196, 2.0%) developed VTE (3 PE and 1 deep vein thrombosis) and were treated with short-term LMWH. Further hematologic work-up of these donors did not reveal any pro-thrombotic disorder. Carriers of HO FVL/FII mutations have significantly increased risk of VTE. Acquired risk factors such as hypercoagulability after partial hepatectomy may further increase the risk. We recommend routine thrombophilia screening during the evaluation of potential living liver donors, and elimination of those with HO FVL/FII mutations. Our results support the utilization of donors with a single HE-FVL or HE-FII mutation, provided that they are given LMWH for VTE prophylaxis.
The following people have nothing to disclose: Murat Dayangac, Murat Akyildiz, Necdet Guler, Onur Yaprak, Yildiray Yuzer, Yaman Tokat, Reyhan Kucukkaya
Results From Live Donor Liver Transplantation When Compared To Recipient Of Deceaed Donors According To Their MELD Score
Yucel Yankol1,2, Luis A. Fernandez2, Nesimi Mecit1, Glen E. Lever-son2, Joshua D. Mezrich2, Bayindir Cimsit1, David Foley2, Turan Kanmaz1, Janet M. Bellingham2, Anthony M D'Alassendro2, Koray Acarli1, Munci Kalayoglu1;
1Organ Transplantation Center, Istanbul Sisli Memorial Hospital, Istanbul, Turkey; 2Department of Surgery Division of Transplantation, University of Wisconsin, Madison, WI
The objective of this study is to accept or reject the hypothesis that both high and low model of end-stage liver disease (MELD) score patients benefit from Live Donor Liver Transplantation (LDLT). The genesis of the study is based on the paucity of many centers in North America that remain reluctant to offer living donor (LDLT) to patients with moderate to high MELD scores. Material and Methods. A total of 764 primary adult liver transplantations, 595 deceased donors liver transplantation (DDLT) and 143 LDLT were performed between both institution between January 1 st 2002 and December 31 st 2012. Patient beyond Milan criteria and neuroendocrine tumors were excluded. Immunosupression and anti-viral therapy was consistent among all groups. Graft Survival and Free of Acute Cellular Rejection (ACR) were assessed by Kaplan Meier method . Differences between curves were tested by Log-rank test. Statistically significant was considered for those values p value < 0.05. The recipients were categorized according to their MELD score into a low (MELD Score ≤15), Moderate (Score 15 to 25) and high (Score >26 to 40). In addition, we compared short-term donor morbidity, graft loss within 30 days, length of hospital stay from initial transplant, biochemical markers of hepatocyte injury and graft function, and first year post-transplant complications including infection, rejection, bleeding, and renal failure. Results: Donor and recipients demographics were comparable between both groups. For low MELD score patient, graft survival and free of ACR were comparable from deceased donors (81.1, 76 and 47%) and living donors (76.8, 72.7 and 78.5%) (p=0.1, 0.2 and 0.001) respectively with the exception of ACR which was lower in the LDLT group. For patients with a moderate MELD score, patient, graft survival and free of ACR were also comparable from deceased donors (81.3, 76 and 47%) and living donors (87.8, 85.7 and 68.1%) (p=0.87, 0.78 and 0.08) respectively. Even in High MELD Score, patient, graft survival and free of ACR rate were very similar for deceased donor (75.6, 71.8 and 44.3%) when compared with LDLT (77.8, 74 and 58%) (p=0.9, 0.6 and 0.6) respectively. Biliary Complications and sepsis were significantly higher in living donors when compared to deceased donors regardless of the MELD Score. Conclusion: LDLT can provide excellent graft function and survival rates in high MELD score recipients and should be widely considered as an option for transplantation.
The following people have nothing to disclose: Yucel Yankol, Luis A. Fernandez, Nesimi Mecit, Glen E. Leverson, Joshua D. Mezrich, Bayindir Cimsit, David Foley, Turan Kanmaz, Janet M. Bellingham, Anthony M D'Alassendro, Koray Acarli, Munci Kalayoglu
Donor Risk Index and MELD Score Interactions in Graft Survival, How those results compare to Live Donor Liver Transplantation?
Yucel Yankol1,2, Luis A. Fernandez2, Turan Kanmaz1, Glen E. Lever-son2, David Foley2, Bayindir Cimsit1, Joshua D. Mezrich2, Nesimi Mecit1, Janet M. Bellingham2, Anthony M D'Alassendro2, Koray Acarli1, Munci Kalayoglu1;
1Organ Transplantation Center, Istanbul Sisli Memorial Hospital, Istanbul, Turkey; 2Department of Surgery Division of Transplantation, University of Wisconsin, Madison, WI
The present analysis is aimed to assess the role of the Donor Risk Index (DRI) and of the MELD score in predicting the outcome after liver transplantation and compare those results with recipients of equivalent MELD scores that received a living donor liver transplantation (LDLT). Material and Methods. A total of 738 primary adult liver transplantations, 595 deceased donors liver transplantation (DDLT) and 143 were recipients of LDLT were performed between both institution from January 1st 2002 and December 31 st 2012. Patient beyond Milan criteria and neuroendocrine tumors were excluded . Immunosupression and anti-viral therapy was consistent among all groups. The deceased donor cases were divided in three groups according to DRI score : low risk (1–1.6 DRI), moderate risk (1.7–2 DRI) and high risk(>2.0 DRI). The cases were also stratified in 2 classes according to the MELD score .Low MELD Score (between 6–25) and High MELD (between 26 to 40). Results were compared between LDLT with equivalent MELD scores. Patients, Graft Survival and Free of Acute Cellular Rejection (ACR) were assessed by Kaplan Meier method . Differences were tested by Log-rank test. p value < 0.05 was considered to be statistically significant. Results. No differences in patients and graft survival at 5 years were identified for patients with a low MELD score between recipients of LDLT ( 81.7 and 78.2%) compared to recipients of DDLT stratified by low DRI risk (80.7 and 78%), moderate risk (80.5 and 74.1%) and high risk DRI (68.9 and 56.4%) (p= 0.2 and 0.053 ) respectively. Similarly, patients with a low MELD Score have similar rates of ACR . In contrast, for high MELD Score patients and graft survival at 5 years were statistically significantly lower for those that received DDLT and a DRI score of >2 (64.1 and 52%), when compared to a low DRI score (82.5 and 79% ), moderate DRI scores (60 and 56%) and LDLT ( 78 and 74%)(p= 0.04 and 0.01) respectively . The incidence of ACR for the group with a High MELD score was equivalent in all groups . Complications rate were greater in living donors with High and Low MELD Score mostly related to biliary stricture and sepsis. Conclusions. Matching DRI and MELD scores provide a meaningful tool to predict patient and graft survival . High MELD Score patient benefit from receiving organs with low DRI or living donors. This findings allows to stratified donor -recipient pairs and facilitate counseling patients and their potential donors in regards to clinical outcome when live donor liver is an option for transplantation.
The following people have nothing to disclose: Yucel Yankol, Luis A. Fernandez, Turan Kanmaz, Glen E. Leverson, David Foley, Bayindir Cimsit, Joshua D. Mezrich, Nesimi Mecit, Janet M. Bellingham, Anthony M D'Alassendro, Koray Acarli, Munci Kalayoglu
Comparing Outcomes of Roux-En-Y Choledochojejunos-tomy versus Duct-to-Duct Biliary Anastomosis in Liver Transplantation in Primary Sclerosing Cholangitis: A Meta-Analysis
Malcolm M. Wells, Kristopher Croome, Erin Boyce, Natasha Chan-dok;
University of Western Ontario, London, ON, Canada
INTRODUCTION: Roux-en-Y choledochojejunostomy and duct-to-duct anastomosis are two potential methods for biliary reconstruction in liver transplant (LT) for recipients with Primary Sclerosing Cholangitis (PSC). However, there is controversy over which method of biliary reconstruction yields superior clinical outcomes. It has been previously reported that Roux-en-Y loop reconstruction may reduce the incidence of postoperative stricture formation, and improve patient and graft survival when compared with duct-to-duct anastomosis in LT. For this reason, Roux-en Y choledochojejunostomy is historically the default biliary reconstruction technique in the transplant of a PSC recipient. However, some publications have suggested that duct-to-duct anastomosis may be preferable in well-selected patients with native duct preservation as it more effectively restores the normal anatomy and function of the biliary tree, facilitates postoperative access of the biliary tree, and is associated with less operative time and shorter postoperative recovery time. The purpose of this study was to evaluate the clinical outcomes of duct-to-duct biliary anastomosis versus Roux-en-Y choledochojejunostomy in patients undergoing LT for PSC. METHODS: Studies comparing Roux-en-Y choledochojejunostomy versus duct-to-duct anastomosis during LT for PSC were identified based on systematic searches of nine electronic databases and multiple sources of gray literature. RESULTS: The search identified 496 citations, including 7 retrospective series, and 692 patients met eligibility criteria. The use of duct-to-duct anastomosis was not associated with a significant difference in clinical outcomes, including 1-year recipient survival rates (OR 1.02; 95% CI 0.65–1.60; p=0.95), 1-year graft survival rates (OR 1.11; 95% CI 0.72–1.71; p=0.64), risk of biliary leaks (OR of 1.23; 95% confidence interval [CI] 0.59–2.59; p=0.33), risk of biliary strictures (OR 1.99; 95% CI 0.98–4.06; p=0.06), or rate of recurrence of PSC (OR 0.94; 95% CI 0.19–4.78; p=0.94). CONCLUSION: The current evidence presented herein does not support the universal preference of Roux-en-Y choledochojejunostomy for all patients undergoing OLT for PSC, as there is no significance difference in clinical outcomes between well-selected patients who receive duct-to-duct anastomosis versus Roux-en-Y loops. Selection will continue to be made by the surgeon at time of LT with or without pre-LT cholangiography, based on donor and recipient characteristics, but barring other factors such as a diseased common bile duct, our results suggest duct-to-duct anastomosis should be preferred.
The following people have nothing to disclose: Malcolm M. Wells, Kristopher Croome, Erin Boyce, Natasha Chandok
Change of Growth Patterns in Glycogen Storage Disease Type I After Portocaval Shunt or Liver Transplantation
YoungRok Choi1, Nam-Joon Yi1,2, Jae Sung Ko3, Jin Soo Moon3, Tae Yoo1, Sukwon Suh1, Jeong-moo Lee1, Kwang-Woong Lee1, Kyung-Suk Suh1;
1Surgery, Seoul National University Hospital, Seoul, Republic of Korea; 2Pediatric Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea; 3Pediatrics and Adolescent Medicine, Seoul National University Hospital, Seoul, Republic of Korea
[Background] Glucose storage diseases (GSD) show growth retardation, but there are a few reports about the growth pattern and the effect of portocaval shunt (PCS) and liver transplantation (LT) for GSD patients. This study aims to analyze the change of physical growth and 2nd sexuality after PCS or/and LT in GSD type I. [Patients and Methods] We reviewed retrospectively 56 patients (M : F=38 : 18) with GSD type I between 1975 and 2013. Among them, 13 underwent LT (at median 14 year-old, range 9–21, LT group) and 17 with PCS (10, 4–12, PCS group). Their data were compared with the normal data of CDC & WHO and the height standard deviation scores (Z-scores) and its annual differences (delta Z-score) were calculated and presented. And a modified delta Z-score (m-delta Z-score) was defined an annual difference between Z-score of operation group and the cross-sectional median Z-score of non-operation group. [Results] Regardless of height at birth, Z score for their height was sharply decreased to less than zero within 4 years in all patients. After operations, there was a spurt of height in the postoperative period. The median Z-score was −3.1 in LT group and −2.7 in PCS group at the time of operations. They caught up growth up to Z=−0.25 at postoperative 4 years in LT group and to Z=−0.6 at postoperative 6 years in PCS group. Delta Z-score were +0.4 and +0.6 respectively in the postoperative 1st year after LT or PCS. Then delta Z-score decreased annually. The m-delta Z-scores changed to positive values 2 years later after PCS or LT, relatively to the median Z-score of non-op group (Figure 1). [Conclusions] Patients with GSD type I showed a growth spurt after LT or PCS and caught up growth 2 years later. Although they did not reach at level of Z-score=0, they overcame the general growth pattern of non-operation group in GSD type I. And we are waiting the result about their final height after following a growth period.
The annual m-delta Z-score for height before & after PCS or LT in GSD type I
The following people have nothing to disclose: YoungRok Choi, Nam-Joon Yi, Jae Sung Ko, Jin Soo Moon, Tae Yoo, Sukwon Suh, Jeong-moo Lee, Kwang-Woong Lee, Kyung-Suk Suh
Assessment of ISGLS definition of posthepatectomy liver failure with hepatocellular carcinoma patients
Kenji Fukushima, Takumi Fukumoto, Kaori Kuramitsu, Masahiro Kido, Atsushi Takebe, Motofumi Tanaka, Tomoo Itoh, Yonson Ku;
Kobe University, Kobe, Japan
Background: Posthepatectomy liver failure (PHLF) is a major complication after hepatectomy. As there was no standardized definition, the International Study Group of Liver Surgery (ISGLS) defined PHLF as increased international normalized ratio and hyperbilirubinemia on or after postoperative day 5, and graded its severity based on required clinical management. We evaluated the impact of the ISGLS definition of PHLF on hepatocellular carcinoma (HCC) patients. Methods: ISGLS definition of PHLF was retrospectively assessed with 210 consecutive HCC patients who underwent curative hepatectomy at our facility from January 2005 to December 2010. The median follow-up period after hepatectomy was 35.2 months. Results: Thirty-nine (18.6%) patients fulfilled the ISGLS definition of PHLF. Mortality, hospital stay, and morbidity excluding PHLF increased with higher grades of PHLF (P < .001). Overall survival (OS) rates at 1, 3, and 5 years in patients with/without PHLF were 69.1/93.5, 45.1/72.5, 45.1/57.8%, respectively (P = .002). Recurrence-free survival (RFS) rates at 1, 3, and 5 years in patients with/without PHLF were 40.9/65.9, 15.7/38.3, 15.7/20.3%, respectively (P = .003). Multivariate analysis revealed that PHLF was significantly associated with both OS (P = .047) and RFS (P = .019). Extent of resection (P < .001), intraoperative blood loss (P = .002), and fibrosis stage (P = .040) were identified as independent risk factors for developing PHLF. Conclusion: The ISGLS definition of PHLF was associated with OS and RFS in HCC patients, and long-term survival will be improved by reducing the incidence of PHLF.
The following people have nothing to disclose: Kenji Fukushima, Takumi Fukumoto, Kaori Kuramitsu, Masahiro Kido, Atsushi Takebe, Motofumi Tanaka, Tomoo Itoh, Yonson Ku
Do Liver Transplant (LT) Candidates with and without Potential Live Donors (LD) Differ? A Large, Retrospective, Single Center Analysis of Demographic, Clinical and Psychosocial Factors
Rania N. Rabie1,2, Arastoo Mokhtari2, Mark Cattral2, Anand Ghanekar2, David Grant2, Paul Greig2, Gary Levy2, Leslie Lilly2, Ian McGilvray2, Markus Selzner2, Nazia Selzner2, Eberhard L. Renner2;
1Department of Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada; 2Multi-Organ Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
Adult to adult live donor liver transplantation (LDLT) offers excellent post-LT outcomes and reduces wait-list mortality. However, only a proportion of LT candidates have a potential LD. We hypothesize that potentially modifiable differences exist between LT candidates for whom at least one potential LD steps forward and those for whom not. Methods: We retrospectively extracted prospectively collected, a priori specified demographic, clinical and psychosocial variables from electronic charts and standardized social work assessments of all adults (ages 18–75) newly listed for LT in our program between Jan 1st, 2009 to Dec 31st, 2011. Patients listed for multi-organ transplants were excluded. All patients in our program are systematically informed about the option of LDLT. A potential LD was defined as an individual submitting a health questionnaire to our LD program. Unpaired t- and Chi-squared tests were used for group comparisons, as appropriate, and a p value < 0.05 was regarded as statistically significant. Results: In 87% of all patients newly listed during the study period, a complete data set was available; these 491 patients form the basis of this analysis. 245 (50%) of these patients had at least one potential LD step forward. Demographic LT candidate factors significantly associated with a potential LD included younger mean age (52.2±0.7 vs. 54.4±0.7 years, p=0.03), Caucasian ethnicity (82% vs. 74%, p=0.02) and English mother tongue (77% vs. 65%, p<0.001). Female LT candidates were not statistically significantly more likely to have a potential LD step forward although a trend was observed (33% vs. 26%, p=0.06). As detailed in Table 1, liver disease etiology and more advanced liver impairment (MELD, Child-Pugh class) were also significantly associated with the presence of a LD. However, the presence of hepatoma, employment status, professional skill level, dependence on income support by the provincial disability program, and a history of recreational drug use or smoking did not differ in LT candidates with and without potential LD (data not shown). Conclusion: There are defined differences between LT candidates with and without at least one potential LD. A better understanding of the factors underlying these differences may help to improve access for all LT candidates to LDLT.
|Potential Living Donor(s) (n=245)||No Potential Living Donor(s) (n=246)||P value|
|Etiology (%) Alcohol Hepatitis C Hepatitis B AIH/PBC/PSC* Non-Alcoholic Fatty Liver Disease Cryptogenic Other||18317 221039||2336148 83 8||<0.001|
|MELD Score (%)<1111 -1516–2021 -2526 - 30 > 30||1837251046||3029211145||0.04|
|Child-Pugh Class (%) A/B/C||13/46/41||27/44/29||<0.001|
Eberhard L. Renner - Advisory Committees or Review Panels: Vertex Canada, Novartis Canada, Novartis, Astellas Canada, Roche Canada, Gambroi; Speaking and Teaching: Novartis Canada, Astellas Canada, Roche Canada
The following people have nothing to disclose: Rania N. Rabie, Arastoo Mokhtari, Mark Cattral, Anand Ghanekar, David Grant, Paul Greig, Gary Levy, Leslie Lilly, Ian McGilvray, Markus Selzner, Nazia Selzner
Usefulness of expanded selection criteria incorporating biological marker for liver transplantation for hepato-cellular carcinoma
Toshimi Kaido, Kohei Ogawa, Akira Mori, Yasuhiro Fujimoto, Takashi Ito, Koji Tomiyama, Shinji Uemoto;
Hepato-Biliary-Pancre-atic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
Background: We previously proposed expanded selection criteria for liver transplantation (LT) for hepatocellular carcinoma (HCC), the Kyoto criteria, involving a combination of tumor number ≤lO, maximal diameter of each tumor <5 cm, and serum des-gamma-carboxy prothrombin levels <400 mAU/mL, and we have used these criteria since January 2007. In the present study, the usefulness of the criteria was prospectively as well as retrospectively validated. Methods: Two hundred patients with HCC who underwent living donor LT (LDLT) at our institute between February 1999 and February 2012 were enrolled in this study. Overall survival and the recurrence rate were investigated in patients classified according to the Kyoto criteria and the Milan criteria. Tumor biological aggressiveness, including microvascular invasion and histological differentiation, according to the criteria was also examined. Results: The median follow-up period was 98 (range 12–168) months. The 5-year overall survival rate for patients within the Kyoto criteria (82%) was significantly higher than that for patients exceeding them (42%) (P < 0.001). The 5-year recurrence rate for patients within the Kyoto criteria (4%) was significantly lower than that for patients exceeding them (51%) (P < 0.001). The 5-year overall survival rate for patients within the Milan criteria (76%) did not differ significantly from that for patients exceeding them (65%) (P = 0.300). The 5-year recurrence rate was significantly lower for patients within the Milan criteria (5%) than for patients exceeding them (30%) (P < 0.001). Intention-to-treat analysis of the 62 patients who underwent LDLT after implementation of the Kyoto criteria showed that the 5-year overall survival rate and the recurrence rate were 82% and 6%, respectively. In patients with Child-Pugh C (n=91), the 5-year overall survival rate and the recurrence rate for patients exceeding the Milan and within the Kyoto criteria rate were 94% and 7%, respectively. The incidence of microvascular invasion and poorly differentiated HCC were significantly lower in patients within the Kyoto criteria than in patients exceeding the Kyoto criteria (P < 0.001 and P = 0.010, respectively). In contrast, the incidence of poorly differentiated HCC did not differ significantly between patients within and exceeding the Milan criteria (P = 0.146). Conclusions: The Kyoto criteria incorporating biological marker are simple and useful expanded criteria for LDLT for HCC and could help achieve favorable outcomes.
The following people have nothing to disclose: Toshimi Kaido, Kohei Ogawa, Akira Mori, Yasuhiro Fujimoto, Takashi Ito, Koji Tomiyama, Shinji Uemoto
Usefulness of 99mTc-GSA scintigraphy on preoperative evaluation of liver function for hepatectomy
Motofumi Tanaka, Takumi Fukumoto, Masahiro Kido, Atsushi Takebe, Kaori Kuramitsu, Hisoka Kinoshita, Shohei Komatsu, Kenji Fukushima, Takeshi Urade, Shinichi So, Yonson Ku;
Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
Background: The accurate evaluation of preoperative liver function is essential to prevent postoperative liver failure, especially in patients with cirrhotic liver. In addition to conventional examination of liver function such as Child-Pugh score and indocya-nine green (ICG) test, 99mTc-diethylenetriamine pentaacetic acid galactosyl human serum albumin (99mTc-GSA) scintigraphy has been expected to be more quantitative modality. However, it still remains unclear whether this modality is helpful to decide the indication of hepatic resection. Methods: From 2005 to 2012, 247 patients with hepatic resection for hepatocellular carcinoma who underwent 99mTc-GSA scintigraphy preoperatively were enrolled in this study. Heart and liver ROIs were drawn manually to cover cardiac blood pool and entire liver, respectively. The blood clearance index was calculated by dividing the radioactivity in the heart ROI at 15 min postinjec-tion by that of the heart ROI at 3 min (HH15). The receptor index of liver was calculated by dividing the radioactivity of the liver ROI by the sum of that of the liver and heart ROIs at 15 min postinjection (LHL15). The parameters of scintigraphy; HH15, LHL15, VLmg (amount of 99mTc-GSA accumulation), GSA index (LHL15/HH15) were analyzed on the correlation with liver function and fibrosis. Moreover, in cases of right (n=69) or left (n=29) hemihepatectomy, the predictor of pos-thepatectomy liver failure (PHLF) defined by ISGLS was also analyzed. Results: The number of Child-Pugh A and B was 213 and 34, respectively. HH15 and LHL15 were significantly associated with ICG-R15 (r=0.51; P<0.0001, r=−0.58; P<0.0001). When cut-off value of HH15 and LHL15 was defined as 0.60 and 0.91 according to institutional criteria, the abnormal group of HH15 and LHL15 had significantly lower albumin (P<0.001, 0.001) and lower thrombocyte (P<0.001, 0.001). When both of HH15 and LHL15 were abnormal, the rate of fibrosis score 3 or 4 in resected liver tissue was 74%. In analysis of patients with hemihepatectomy (n=98), mortality rate was 2% (2/98) and PHLF was occurred in 41 % (40/98). The values of remnant liver LHL15, remnant liver GSA index, and remnant liver VLmg calculated by multiplying the 99mTc-GSA count rate of remnant liver were significantly associated with PHLF incidence (P<0.001, 0.001, 0.001, respectively), whereas other conventional parameters such as albumin, INR, and ICG test had no association with PHLF. Conclusions: 99mTc-GSA scintigraphy can estimate preoperative liver function and fibrosis grade. This modality has a possibility to predict PHLF after hemihepatectomy.
The following people have nothing to disclose: Motofumi Tanaka, Takumi Fukumoto, Masahiro Kido, Atsushi Takebe, Kaori Kuramitsu, Hisoka Kinoshita, Shohei Komatsu, Kenji Fukushima, Takeshi Urade, Shinichi So, Yonson Ku
Is There A Role For MELD In Adult Living Donor Liver Transplantation?
Murat Dayangac1, MuratAkyildiz1,2, Necdet Guler1, Levent Oklu1, Yildiray Yuzer1, Yaman Tokat1;
1Center for Organ Transplantation, Florence Nightingale Hospital, Istanbul, Turkey; 2Department of Gastroenterology, Istanbul Bilim University, Istanbul, Turkey
Results from the A2ALL study demonstrated significant survival advantage for patients with MELD scores <15 associated with receipt of living donor liver transplantation (LDLT). However, there is still controversy regarding the benefit of LT in adult candidates with low MELD scores. In this retrospective analysis of 364 adult patients, who underwent right lobe LDLT between January 2005 and July 2012, we examined the impact of pre-LT unadjusted MELD score on post-LT outcome. Patients were divided into four MELD categories: MELD<10 (n=46), MELD between 10–19 (n=216), MELD between 20–29 (n=86), and MELD>30 (n=16) (Table). The median waiting time was 24.5 (16–48) days and the median follow-up was 25 (12–49) months. Perioperative mortality was significantly correlated with pre-LT MELD score (p<0.001, Pearson r=0.196) and showed a significant difference between the groups (ANOVA, p=0.001). A significant correlation was found with further analysis using smaller subsets: for MELD scores of 6–10, 11–15, 16–20,21–25, and >25, perioperative mortality was 3.2%, 6.2%, 9.1%, 18.0%, and 27.5%, respectively (ANOVA, p<0.001). The 1-and 3-year patient survival was the highest in low-MELD group, however, the difference did not reach statistical significance (Wilcoxon, p=0.1). In LDLT, pre-LT disease severity is an important factor for post-LT patient survival. Our results suggest that candidates with low MELD scores have a significantly lower risk of dying after LDLT. To select appropriate candidates for LDLT, donor risk must be balanced by a reasonable chance of success in the recipient. To justify the risk incurred by the donor, timing of LT should be done to achieve the lowest post-LT mortality.
Clinical features of 364 adult LDLT recipients
|MELD<10 (n=46)||MELD=1O-19 (n=216)||MELD=20–29 (n=86)||MELD>30 (n=16)||P value|
|Hepatocellular carcinoma (%)||69.9||25.5||12.8||6.3||<0.001†|
|Blood transfusion (units)||3.6±5.5||5.5±6.3||6.7±6.0||6.1±4.5||0.6t|
|Recipient hospital stay (days)||18.4±6.9||I9.9±11.7||21.0±12.8||21.2±11.6||0.6t|
|Perioperative mortality (%)||2.2||7.9||17.4||31.3||0.001†|
|1 -year survival (%)||91.1||82.8||77.5||62.5||0.1 +|
|3-year survival (%)||83.8||77.5||77.5||62.5||0.1 +|
The following people have nothing to disclose: Murat Dayangac, Murat Akyildiz, Necdet Guler, Levent Oklu, Yildiray Yuzer, Yaman Tokat
Effectiveness of Percutaneous and Endoscopic Therapy for Biliary Strictures and Leaks after Liver Transplantation in Children
Nicholas Fidelman1, Andrew Lee1, Robert Kerlan1, John P. Roberts2;
1Department of Radiology, University of California San Francisco, San Francisco, CA; 2Department of Surgery, University of California San Francisco, San Francisco, CA
Purpose: To determine the effectiveness of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following liver transplantation in children. Material and Methods: Retrospective analysis of 38 consecutive pediatric patients (18 girls, mean age at transplant 5.9 years) treated at our institution from 1997 to 2010 for biliary leak and/or biliary stricture following liver transplantation (29 deceased donor liver transplants, 9 living related liver transplants) was performed. Six patients had a choledochocholedochostomy while the rest had a Roux-en-Y hepaticojejunostomy biliary anastomosis. Patients with a hepaticojejunostomy anastomosis were managed by a percutaneous approach (percutaneous tran-shepatic biliary drain placement followed by balloon dilation of the stricture), whereas endoscopic approach was feasible in 8 of the patients with choledochocholedochostomy. 32 patients had a stricture at the biliary anastomosis, while 6 patients had an anastomotic leak. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment (<30% residual stenosis) and/or correction of the biliary leak. Results: After an average of 9.1 years of follow-up, non-surgical management was clinically successful for 4 patients (67%) with a biliary leak and for 25 patients (78%) with a stricture. Surgical revision of the anastomosis was eventually required in 3 patients with a leak, and long-term clinical success was achieved in 3 patients (50%). For patients that had developed a biliary stricture, surgical revision was ultimately required in 14 patients, with 7 patients proceeding straight to surgery and 7 patients requiring surgical revision after recurrent stricture developed a median of 2.2 months of initial drain removal. Long-term clinical success was achieved in 18 patients (56%) with a biliary stricture. Patients that had long-term failure (n=14) were compared to patients with long-term success (n=18) and were found to have lower median age at transplantation (p=0.09), lower median age at stricture diagnosis (p=0.03), and had a choledochojejunostomy biliary anastomosis (p=0.05). Conclusions: Percutaneous and endoscopic management of biliary strictures and leaks after liver transplantation in children is associated with a durable result in approximately 50% of patients. Younger age at transplant is associated with lower patency rate. If biliary complications develop at a younger age, they are less likely to be successfully treated by non-surgical approaches.
The following people have nothing to disclose: Nicholas Fidelman, Andrew Lee, Robert Kerlan, John P. Roberts
Neutrophil-lymphocyte ratio and serum C-reactive protein predict overall and recurrence free survival after liver transplantation in patients with hepatocellular carcinoma
Dong Goo Kim;
Surgery, Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Republic of Korea
Purpose: Although the Milan criteria have been accepted as standard selection criteria for liver transplantation (LT) candidates with hepatocellular carcinoma (HCC), many transplant centers have accepted some extended criteria and focus on the patient selection. The purpose of this study is to evaluate whether neurtophil-lymhocyte ratio (NLR) and C-reactive protein (CRP) predict survival of patients with HCC who undergo LT. Methods: From October 2000 to November 2011, 224 patients underwent living donor liver transplantation (LDLT) for HCC at our institution. Results: 37 patients (16.5%) experienced HCC recurrence during the study period. The 5 yrs disease free survival (DFS) and overall survival (OS) were 81.6% and 76.6% respectively. In multivariate analysis, DFS and OS were significantly related to AFP > 100 (P=0.017, P=0.048), maximal tumor size > 5cm (P<0.001, P=0.001), NLR >6 (P=0.049, P=0.003), CRP >1.0 (P=0.010, P<0.001). The patients with NLR <6 or CRP <1.0 were significantly better DFS and OS than the patients with NLR >6 or CRP >1.0, especially in beyond Milan criteria group. The scoring system with NRL and CRP were correlated with prediction of DFS and OS. Conclusion: Preoperative NLR and CRP are useful biomarkers for predicting DFS and OS, especially in beyond Milan criteria. Combined with the Milan criteria, NLR and CRP may be new selection criteria for LDLT candidates with HCC.
The following people have nothing to disclose: Dong Goo Kim
Impact of tumor staging, microvascular invasion, and MELD score on the survival benefit of liver transplantation in resectable HCC
Alessandro Vitale1, Teh Ia Huo2, Alessandro Cucchetti3, Antonio Daniele Pinna3, Yun Hsuan Lee2, Umberto Cillo1;
1Liver Transplant Unit, University of Padova, Padova, Italy; 2Department of Medicine, Taipei Veterans General Hospital, Taipei,, Taipei, Taiwan; 3Liver and Multi-organ Transplantation Unit, St. Orsola Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
Background. There are no studies measuring the impact of tumor morphological staging, microvascular invasion (mVI), and model-for-end-stage-liver-disease (MELD) score on the benefit of liver transplantation (LT) over hepatic resection (HR) for hepatocellular carcinoma (HCC). Methods. Exclusion criteria: very large (>10 cm) tumours, macrovascular invasion and extra-hepatic metastases. Study population: 1106 HCC cir-rhotic patients undergoing HR from one Eastern (n=424) and two Western (n=682) surgical units. We identified 3 tumor stages: I (within Milan, n=806), II (beyond Milan within Up-to-7, n=123), III (beyond Milan and Up-to-7, n=177). Patient survival observed after HR by proportional hazard regression model was compared to that predicted after LT by the Metroticket calculator. The benefit obtainable from LT compared to resection was analyzed in relationship with staging, mVI, and MELD using Monte Carlo simulation. Results. MELD score had the most important effect on transplant benefit independently form tumor characteristics: mean 5-year LT benefit was −2.22 months (95% CI, −2.45 - −1.98) for patients with MELD score < 10, and 6.32 months (95% CI, 6.08–6.60) for those with MELD > 10. mVI significantly decreased LT benefit only in patients staged I-II with MELD < 10; this subgroup had already a negative benefit independently from mVI, however. Staging significantly increased LT benefit only in patients with MELD > 10 with a stage III tumor; this subgroup had an unacceptable 5-year post-LT survival (<50%), however. Conclusion. From a transplant benefit perspective, MELD score is the only variable with the potential to influence the therapeutic decision between LT and HR.
Umberto Cillo - Grant/Research Support: Novartis, Bayer, Astellas
The following people have nothing to disclose: Alessandro Vitale, Teh Ia Huo, Alessandro Cucchetti, Antonio Daniele Pinna, Yun Hsuan Lee
Persistent Decrease in Platelet Count in Living Right Liver Donors
Shi Lam, See-Ching Chan;
Surgery, Queen Mary Hospital, Hong Kong SAR, China
Background The natural history of donor recovery after hepa-tectomy remained unclear. Long-term data on donor physiological alterations remained scarce. Platelet count reflected the joint effect of hemostasis, thrombopoeisis and splenic sequestration. Its persistent decrease after donor hepatectomy provided insight into the donor recovery process. Our study aims to investigate for the clinical factors associated with the persistently decreased platelet count after living donor right hepatectomy. Methodology From October 2003 to December 2009, 1 75 right liver living donor liver transplants were performed in our center. Liver volume, graft weight and laboratory parameters up to 2 years follow-up were analyzed. Donors are grouped into those with >20% drop in platelet count (Group A) and < 20% drop (Group B)Factors associated with platelet drop are analyzed. Results Mean age of the donors were 34.4 years. 67% of the donors were female. The mean total liver volume and right liver graft volume were 11 10.6 ± 178.4 cc and 710.9 ± 125.4 cc respectively. The platelet level at 2 years was significantly lower than pre-operative (212.9 ± 47.8 x 10^9/L vs 259.3 ± 54.8 x 10^9/L, p < 0.001). The mean percentage drop in platelet level was 17.1 ± 14 %. With comparable demographics, donors in Group A were significantly different to Group B with regard to: percentage remnant volume (p = 0.012), graft weight-to-liver volume ratio (p < 0.001) and peak post-operative ALT level (p = 0.067). The percentage drop in platelet count at 2 years was correlated to the graft weight-to-liver volume ratio with a R^2 = 0.046. Summary Our findings signified that after hepatectomy, subclinical hyperslenism may persist in the donors. Correlation between extend of hepatectomy and magnitude of drop in platelet count at 2 years was first shown.
The following people have nothing to disclose: Shi Lam, See-Ching Chan
Liver Stiffness in Living Donors with "Normal" Liver Histology
Ayman Al Sebaey1, Naglaa A. Allam1, Khalid A. Alswat2, Imam Waked1;
1hepatology, National Liver Institute, Menoufeya, Egypt; 2King Saud University, Riyadh, Saudi Arabia
Background: Several studies have investigated liver stiffness by transient elastography measured by fibroscan in healthy populations, but very few included subjects with liver biopsy. The stiffness of the liver with "normal" histology needs further assessment. Aim: To define the stiffness of the normal liver using transient elastography in donors with normal liver histology undergoing evaluation for living related liver transplantation. Methods: Fibroscan was performed in 50 healthy living liver donors (16 females, age 28.4 ±5.9 years) who were being evaluated for liver donation for their relatives. All had normal liver blood tests, were negative for hepatitis B or C virus infection, and had normal liver and abdominal ultrasound. None had diabetes, hypertension, renal impairment, heart disease, or BMI >30 kg/m2. All subjects had normal liver histology on liver biopsy. They all donated part of their liver with successful outcome. Results: Liver stiffness ranged from 1.8 to 7.1kPa (mean 4.3 ± 1.2kPa). Liver stiffness measurements were not significantly different between men (4.4 ±1.1 kPa) and women (3.9 ± 1.3kPa) (p=0.14), and did not correlate with age (p=0.85). Stiffness values were significantly lower in subjects with BMI <26 kg/m2 than in those with BMI > 26 kg/m2(4 ±1.07 kPa vs.4.6 ±1.2kPa, p=0.046).This group of healthy liver donors with "normal" liver histology indicate that the 5th and 95th percentiles of normal liver stiffness would be between 2.6 and 6.8kPa with a median of 4kPa. Conclusion:Healthy liver donors with normal liver histology have median liver stiffness of 4 kPa. Stiffness values did not significantly change with age or gender, but increased with increase of BMI, even with normal liver histology.
Imam Waked - Speaking and Teaching: Hoffman L Roche, Merck, Bayer, BMS
The following people have nothing to disclose: Ayman Al Sebaey, Naglaa A. Allam, Khalid A. Alswat
The Impact Of High Pre-Transplant MELD Score On Live Donor Liver Transplant Outcome
Almoutaz Hahim1, Talaat Z. Ibrahim Mahmoud1, Abeer Ibrahim1, Khaled Attallah1, Faisal A. Abaalkhail1, Waleed K. Al-Hamoudi2, Mohamed Al Sebayel1, Hussien Elsiesy1;
1Liver Transplant, KFSHRC, Riyadh, Saudi Arabia; 2king Saud University, Riyadh, Saudi Arabia
Background: Since the New York State Committee on Quality Improvement in Living Liver Donation prohibited live liver donation for potential recipients with Model for End-stage Liver Disease (MELD) scores greater than 25 back in 2002. There has been few studies evaluating the risk and complications of living donor liver transplant with High MELD >25, the western experience have shown that it does not increase mortality post transplant while several Asian studies have shown increase 3 months mortality and complications Aim: To compare outcome of living donor liver transplant in patients with high MELD score versus those with low MELD and evaluate the impact on patient and graft survival. Methods: The charts of 160 adult live donor liver recipients from 2004–2012 were reviewed retrospectively and divided into 2 groups. Group A were patients who had MELD <25 while Group B included patients with MELD>25 Results: Of 160 live donor performed, Group A (MELD<25) included 143 patients, and group B (MELD>25) had 17 patients in total. Out of the 17 patients transplanted in Group B, 6 have died since the transplant (35% mortality) and 3 of the 6 died within the 1 st 6 months (2 of sepsis, 1 primary graft non-function requiring re-transplantation also died of sepsis). In Group A, 22 out of 143 patients transplanted with MELD<25 died during the same period (15.4% mortality) Conclusion: In our cohort, there was more than two fold increase in mortality between the 2 groups with half the deaths occurring during the first 6 month due to sepsis. Live donor liver transplant for patients with high MELD score seems to carry an increase risk of sepsis and mortality post-transplant.
Hussien Elsiesy - Speaking and Teaching: ROCHE, BMS, JSK
The following people have nothing to disclose: Almoutaz Hahim, Talaat Z. Ibrahim Mahmoud, Abeer Ibrahim, Khaled Attallah, Faisal A. Abaalkhail, Waleed K. Al-Hamoudi, Mohamed Al Sebayel
3 -Dimentional (3D) Print of Liver for Preoperative Planning in Live Donor Liver Transplantation
Nizar N. Zein1, Ibrahim A. Hanouneh1, Paul Bishop2, Maggie H. Samaan1, Bijan Eghtesad3, Cristiano Quintini3, Charles M. Miller3, Lisa M. Yerian4, Ryan Klatte5;
1Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 2Vas-cular imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH; 3Hepato-pancreato-biliary & Transplant Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 4Anatomic Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH; 5Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
Ensuring the safety of donors and the recipients in live donor liver transplantation (LDLT) is critical. Pre-operative identification of the vascular and biliary anatomy with 3D printing may allow for better pre-operative surgical planning and avert unnecessary surgery in patients with potentially unsuitable anatomy and thereby decreasing the complications of surgery. The aims of our study were to establish anatomical precision and volumetric accuracy of 3D printed model of donors and recipients undergoing LDLT. Herein, we developed a protocol and successfully 3D printed synthetic livers with its complex network of vascular and biliary structures that replicate the native livers of six consecutive patients who underwent LDLT. Using intra-operative assessments as the reference standard, we demonstrated identical anatomical landmarks in the 3D printed models and native livers (Figure).The geometric characteristics of the two livers (3D printed and native livers) were identical. These include length [95% CI: −0.17 (−1.2, 0.91)], width [95% CI: 0.33 (−0.05, 0.71)], height [95% CI: 0.17 (−0.08, 0.41)], diameter of main portal vein [95% CI: −0.08 (−0.30, 0.14)], diameter of right hepatic vein [95% CI: −0.04 (−0.23, 0.15)] and diameter of left hepatic vein [95% CI: 0.13 (−0.15, 0.40)]. Additionally, using the liquid displacement means for measuring the volume of the native's liver as the gold standard, the 3D liver model provided more accurate measurements of the liver volume than pre-operative CT [95% CI: 28.8 (−73.9, 131.6)]. In conclusion, we present successful reproduction of human livers using 3D printing technology. These highly accurate simulations may have a number of unique applications in surgical planning and medical educations.
Bijan Eghtesad - Grant/Research Support: Genzyme (Sanofi)
The following people have nothing to disclose: Nizar N. Zein, Ibrahim A. Hanouneh, Paul Bishop, Maggie H. Samaan, Cristiano Quintini, Charles M. Miller, Lisa M. Yerian, Ryan Klatte
Back flow thrombectomy and PIHP for the treatment of multiple bilobular HCC with Vp4 PVTT
Takumi Fukumoto, Kaori Kuramitsu, Masahiro Kido, Atsushi Takebe, Motofumi Tanaka, Hisoka Kinoshita, Shohei Komatsu, Yonson Ku;
Kobe University, Kobe, Japan
(Background) We have previously reported the efficacy of dual treatment, which is consisted of reductive hepatectomy and percutaneous isolated hepatic perfusion (PIHP), for patients with advanced HCC. However these patients are frequently complicated with Vp4 portal vein tumor thrombus (PVTT), and conventional en bloc resection is not always feasible. To overcome this situation, we have developed back flow thrombectomy (BFT) technique. For right hemihepatectomy with Vp4 PVTT, which reached to the contralateral left second portal branch, the portal trunk should be at first clamped at the superior border of the pancreas. After one transverse venotomy at an appropriate site of the right portal branch, tumor thrombus is extracted by forceps and scissors using suction devices. Of particular note, the vascular clamp at the left first portal branch should be avoided because it may split PVTT and enhance portal vein embolization with fragmented tumor thrombus. Instead, back flow pressure in the portal system generated by BFT technique should be kept throughout the thrombectomy procedure. This pressure eases effective extraction of both micro- and macroscopic cancer nests liberated to the blood stream and avoid the migration into the future remnant liver. (Methods) Until the end of 2011, 43 multiple bilobular HCC patients with Vp4 were performed reductive hepatectomy with tumor thrombectomy. In 22 of 43 patients, BFT techniques were used. Sixteen of 23 patients had PVTT in the contralateral second portal branch. Seventeen of 43 patients were not performed PIHP because of economical reason, extrahepatic metastases, aggressive tumor progression, hepatic dysfunction, infectious complications or unfavorable conditions after surgery. (Results) Patency of portal vein at thrombectomy site of all/BFT patients 3 and 6 months after hepatectomy were 92%/90% and 87%/86%, respectively. The median OS of all 43 patients was 14 months and the 1 and 3-year OS rate was 55.5% and 19.1% respectively. In 26 patients who could undergo PIHP as second treatment, the median OS was 17 months and the 1 and 3-year OS rate was 69.2% and 23.1% respectively. (Conclusions) Tumor thrombectomy by BFT technique allows multidisciplinary treatment for patients with PVTT. An impressively increased survival rate achieved by additional PIHP supports the dual treatment strategy for multiple bilobular HCC patients with Vp4 PVTT.
The following people have nothing to disclose: Takumi Fukumoto, Kaori Kuramitsu, Masahiro Kido, Atsushi Takebe, Motofumi Tanaka, Hisoka Kinoshita, Shohei Komatsu, Yonson Ku