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UniversitätsKlinikum Essen - AllgemeinchirurgieUniversitätsKlinikum Essen - AllgemeinchirurgieM M 2002M M 2002

M. Malagó and C E. BroelschM. Malagó and C E. Broelsch

Universitätsklinikum Essen, Klinik für Allgemeine Universitätsklinikum Essen, Klinik für Allgemeine und Transplantationschirurgieund Transplantationschirurgie

ADULT LIVING DONOR LIVER TRANSPLANTATION

Right versus Left Grafts


Waiting Time on the List

UNOS: 13,181 patients waitingUNOS: 13,181 patients waiting

5,791 donors5,791 donors

4,450 livers used4,450 livers used

Retrieval rate 60%Retrieval rate 60%


Liver Transplantation Liver Transplantation using Liver Segmentsusing Liver Segments


SPLIT LTXSPLIT LTXTransplantation einer Spenderleber auf zwei EmpfängerTransplantation einer Spenderleber auf zwei Empfänger

Pichlmayr, Langenbecks Arch Chir (1988) 373: 127-130Pichlmayr, Langenbecks Arch Chir (1988) 373: 127-130


The first LDLTs worldwideThe first LDLTs worldwide

S. Raia, S. MiesS. Raia, S. Mies Sao PauloSao Paulo 3.12.19883.12.1988

R. StrongR. Strong Brisbane Brisbane 1989 1989

NagasueNagasue JapanJapan 13.11.198913.11.1989

C.E. Broelsch C.E. Broelsch ChicagoChicago 27.11.198927.11.1989

K. OzawaK. Ozawa KyotoKyoto 15.06.199015.06.1990

M. MakuuchiM. Makuuchi MatsumotoMatsumoto 19.06.199019.06.1990


The first LDLDT The first LDLDT at the University of Chicagoat the University of Chicago

1989 1989


10 YEARS OF PEDIATRIC LIVING DONATION

1,000 liver transplants in 60 centers1,000 liver transplants in 60 centers

WESTWEST EAST EAST

CentersCenters 4545 15 15

N. of casesN. of cases 35%35% 65% 65%


EUROPEAN LIVER TRANSPLANT REGISTRY21 Countries - 125 active Institutions49361 Transplantations - 43826 Patients05/1968 - 06/2002

229

720 8442

1146

169244 126

251

550311

1177

303

1571

2443

427

789

7537

439

8568

Canary islands

32

261


Evolution of the Number of Living Related Liver Transplantations in Europe

Oct. 1991 - Dec. 2000

6 17 27 38 34 3261

51 50 590 31

2 7 5

618

48

124

0

20

40

60

80

100

120

140

160

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Children Adults

170

ELTR 2001ELTR 2001


Evolution of the Number of Centers performing LRLT in Europe

33/115 (29%) Centers

3 48

1115 17

2225

3133

91 92 93 94 95 96 97 98 99 2000

Years

0

4

8

12

16

20

24

28

32


Type of Graft used for LRLTOct. 1991 - Dec. 2000

Left lobe (seg 2,3) : 205 59%

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

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


R Living Donor graftR Living Donor graftR Living Donor graftR Living Donor graft


ETHICSETHICSEquipoise analysisEquipoise analysis

in Living Donor Liver Transplantationin Living Donor Liver Transplantation

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


LTX ESSEN April 1998 – March 2003 n = 483

Split (72)

Living Donor (106)

Standard-Tx (299)

Reduced Size (6)


83

419

rechts linkslinkslateral

LTX ESSEN April 1998 – March 2003 Living donor Tx

n = 106


Left lobe (seg 2,3) : 3 3%

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

6%

Type of Graft used for Adult LRLTOct. 1991 - Dec. 2000

ELTR 2001ELTR 2001


•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 criteria


Donor Evaluation - Anatomy PV individual Segmentation


Donor selection - Anatomy

341 donors for 62 recipients341 donors for 62 recipients

Only 1 rejected for difficult anatomy associatedOnly 1 rejected for difficult anatomy associated

to poor recipient conditions to poor recipient conditions

Zur Anzeige wird der QuickTim e™ Dekom pres s or “Cinepak”

benötigt.

Zur Anzeige w ird der QuickTim e™ Dekom pres s or “C inepak”

benötigt.


Costs of the evaluation of donors

A du lt s C h ildr 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

TotalTotal 7 / 3000 (0,023%) 7 / 3000 (0,023%) Asia? Other Countries?Asia? Other Countries? ((5 Deaths discussed in public)

PediatricPediatric 2 / 12002 / 1200AdultAdult 5 / 18005 / 1800

Reasons Reasons 2 Failures of the selection process2 Failures of the selection process3 Management – surgical ?3 Management – surgical ?2 Anaphylaxys - casuality ?2 Anaphylaxys - casuality ?Small rest donor liverSmall rest donor liver3/7 donors overweight3/7 donors overweight



Lobe grafting Live DonorLobe grafting Live DonorIncreased donor risk ?Increased donor risk ?Recipient refusalRecipient refusalTechnical difficultyTechnical difficultyBlood loss Blood loss Right better than LeftRight better than Left


RESULTS DONOR EVALUATION

PEDIATRIC ADULT

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

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


Right Liver Left-L L ateral liver TOTALTot.Pot .Dono rs 333 52 385Pot . Recipient s 172 37 209Don ors S tep 1- 5 145 (10 0%) 23( 10 0%) 168(100% )

STEP 1 48( 33 ,2%) 14( 61 %) 62( 37 %)Bl ood g ro up 27 6 33Vi ru s s er ol ogy 16 8 24Medica lco mor bi dity 2 0 2Fea r 3 0 3

STEP 2 89( 61 ,3%) 5(2 2% ) 94( 56 %)Volumet ry 54 2 56Psych ological 15 1 16Hist ology 15 0 15Live r an atom y 1 0 1Soc ial 2 1 3Medica lco mor bi dity 2 1 3

STEP 3 3(2 %) 3(1 3% ) 6(3 ,5%)Medica lco mor bi dity 2 2 4Fea r 1 1 2

STEP 4 5(3 ,5%) 1(4 %) 6(3 ,5%)Psych ological 4 0 4Hist ology 1 0 1Medica lco mor bi dity 0 1 1

STEP 5 0 0 0

DONOR EVALUATIONEssen 385 potential liver donors


SMALL-FOR-SIZE LTXSMALL-FOR-SIZE LTX• Hepatocellullar mass

• Minimal volume?• Hepatocellullar function

• How to evaluate? Artificial liver support• Regeneration

• How to modulate - maximize?•

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


LDLT in ADULTS: Right vs. Left graftLDLT in ADULTS: Right vs. Left graft

Frontal approachFrontal approachRight graftRight graft

Lateral approachLateral approach Left or right graftLeft or right graft

““Download” of the waiting listDownload” of the waiting list


Eurotransplant - DESLD Eurotransplant - DESLD Decompensated End-Stage Liver DiseaseDecompensated End-Stage Liver Disease

T2 23% of the listT2 23% of the listT2 32% MortalityT2 32% Mortality


Decompensated End-Stage Liver DiseaseDecompensated End-Stage Liver DiseaseSurvivalSurvival

0

,2

,4

,6

,8

1

Survival

0 5 10 15 20 25 30 35 40 45Time [months]

Cum. Survival (non c)Cum. Survival (c)

Patient survival 57Patient survival DESLD (c) vs non-DESLD (non c)Patient survival DESLD (c) vs non-DESLD (non c)


0

,2

,4

,6

,8

1

Cum. Survival

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

Cum . Survival (C/>=0,85)

Cum . Survival (C/<0,85)

Cum . Survival (A+B/>=0,85)

Cum . Survival (A+B/<0,85)

patient survival Child C vs Child A+B and GW BR <0.85 vs >0.85

Graft - Patient MatchGraft - Patient MatchSFS and disease severitySFS and disease severity

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


Resection TechniqueVariations

EXTENDED R ( + MHV) “SUPRAHEPATIC HEPATECTOMY”


Hepatic VeinsHepatic VeinsMedial sector venousMedial sector venous

congestioncongestion


0,00,10,20,30,40,50,60,70,80,91,0

(x10

0)%

0 6 12 18months

old technique new technique

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

Right LDT: Technical improvements

old technique new technique

0,00,10,20,30,40,50,60,70,80,91,0

(x10

0)%

0 6 12 18months


0

10

20

30

Donors

Wee

ks

Beginning to work Physically fully recovered

Duration of recovery after living Duration of recovery after living related liver transplantationrelated liver transplantation

LIVER DONOR: OUTCOMES


Lobe grafting CAD donorLobe grafting CAD donorLiver volumeLiver volumeTechnical difficultyTechnical difficultyRecipient refusal Recipient refusal Right better than LeftRight better than Left


• VolumetryGRWR > 1 % especially for L graft!!

• Biopsy: Fat infiltration> 20 % Contraindication10-15% R extended - Left Lateral Split< 10% optimal condition to R-L split

• Vascular and biliar anatomy

Split Liver TransplantationGRAFT PARAMETERS


Both donor and recipient must have adequate liver volumes ->GBWR 0.8RBWR 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

LDLT in ADULTS: Right vs. Left graftLDLT in ADULTS: Right vs. Left graftRequirementsRequirements

Zur Anzeige wird der QuickTime™ Dekompressor “Cinepak”

benötigt.


Adult LD LTXAdult LD LTX Conclusion

Right better than Left in the WestRight better than Left in the WestSeverity of disease shall be taken into Severity of disease shall be taken into account calculating graft volumesaccount calculating graft volumesR Hepatectomy R Hepatectomy Challenging, Major procedureChallenging, Major procedure

Contained riskContained risk Cadaveric & Split remain cornerstoneCadaveric & Split remain cornerstoneRecipent management crucialRecipent management crucial


Fert unda nec regiturFert unda nec regitur

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