how far can we go with suboptimal grafts in ldlt. fumitaka oike and koichi tanaka dept. transplant...

How far can we go with suboptimal grafts in LDLT.

Fumitaka Oike and Koichi Tanaka Dept. Transplant Surgery, Kyoto University, Japan

“Small-for-size syndrome in liver surgery” Symposium

Ghent 2005

Kyoto University 2005Kyoto University 2005 Ghent Ghent

Donor Factors = Suboptimal Graft• Small-for-Size• Graft quality (aged liver, steatotic liver, imperfect outflow)

Recipient Factors• Metabolic load (Pretransplant condition)• Surgical complications• Latent infectious complications• Extrahepatic organ dysfunction

Donor and Recipient Factors Influencing Graft Survival


Prognosis of small-for-size grafts

00

100

50

54321

(%)1.0-3.0%BW

0.8-1.0%BW

< 0.8%BW

移植後年数移植後年数

累積生存率

累積生存率

GRWR ＝ Graft weight / recipient body weight

Small-for-size syndrome

Prolonged cholestasisCoagulopathyMassive ascitesPortal hypertentionGI bleedingRenal DysfunctionSepsis

Years after LDLT

Sur

viva

l rat

e


Mean PV pressure1st week

Mean PV pressure1st week

100100

5050

0000 11 22

100100

5050

0000 11 22

(%)(%) (%)(%)

P<0.01P<0.01 NSNS

PVP<20 (n=80)PVP<20 (n=80)

PVP≥20 (n=18)PVP≥20 (n=18)

PVP≥20 (n=29)PVP≥20 (n=29)

PVP<20 (n=50)PVP<20 (n=50)

Years Years

Pat

ient

sur

viva

lP

atie

nt s

urvi

val

Mean PV pressure2nd week

Mean PV pressure2nd week

Years Years

Portal vein pressure and patient survival


0

2

4

6

8

0 10 20 300

2

4

6

8

0 10 20 3010

12.5

15

17.5

20

0 10 20 3010

12.5

15

17.5

20

0 10 20 30

T.BilT.Bil PT timePT time(sec)(sec)(mg/ml)(mg/ml)

*

**

*

* ** ***

*

***

**

* **** *

***

*

*p<0.01-0.05*p<0.01-0.05 *p<0.01-0.05*p<0.01-0.05

PVP <20 (n=80)PVP ≥20 (n=18)PVP <20 (n=80)PVP ≥20 (n=18)

Portal vein pressure and prolonged cholestasis / prolonged coagulopathy

POD PODKyoto University 2005Kyoto University 2005 Ghent Ghent

5

10

15

20

25

30

010

0020

0030

0040

0050

00

5

10

15

20

25

30

010

0020

0030

0040

0050

00

AscitesAscites

(mmHg)(mmHg)

(ml/50kg)(ml/50kg)

P

VP

PV

P

P<0.0001R=0.556(n=98)

P<0.0001R=0.556(n=98)

Portal vein pressure and ascites


Incidence of positive blood culture ( 3 posttransplant months )

n Bacteremia pPVP < 20 83 27.7% PVP ≥ 20 13 64.0% 0.0153

Portal vein pressure and infection


10

15

20

25

10

15

20

25

P

VP

PV

P

(mmHg)(mmHg)<0.8% of BW (n=8)0.8-1.0% of BW (n=30)≥1.0% of BW (n=64)

<0.8% of BW (n=8)0.8-1.0% of BW (n=30)≥1.0% of BW (n=64)

POD POD

**

**

****

** **

**

** **

*p<0.05-0.01*p<0.05-0.01

14141212101088664422Intra-operativeIntra-operative

Graft size and portal vein pressure


IMV

Antithrombotic catheter

rubber band

PV pressure measurementPV pressure measurement PV flow measurementPV flow measurement

PVF

0.035mm

Measurement of portal vein pressure and flow

15

17.5

20

22.5

25

27.5

0 25 50 75 100 12515

17.5

20

22.5

25

27.5

0 25 50 75 100 125

Pressure

Pressure

P=0.0468ρ=0.567 P=0.0468ρ=0.567

Before anhepatic Before anhepatic

FlowFlow

5

10

15

20

0 100 200 300 400 5005

10

15

20

0 100 200 300 400 500

Pressure

Pressure

NS NS

POD 3 POD 3

Flow(ml/min/100g tissue)

Flow(ml/min/100g tissue)

7.5

10

12.5

15

17.5

20

0 100 200 300 400 5007.5

10

12.5

15

17.5

20

0 100 200 300 400 500

Pressure

(mmHg)

Pressure

(mmHg)

NS NS

POD 1 POD 1

5

7.5

10

12.5

15

17.5

0 250 500 750 10005

7.5

10

12.5

15

17.5

0 250 500 750 1000

Pressure

Pressure

NS NS

PV reflow PV reflow

Portal vein pressure and flow volume


0

5

10

15

20

0

5

10

15

20

PV

gra

ft co

mp

lianc

eP

V g

raft

com

plia

nce

Donor age < 40 (n=7) Donor age ≥ 40 (n=10) Donor age < 40 (n=7) Donor age ≥ 40 (n=10)

*

*

*

* *

*P<0.01-0.05*P<0.01-0.05

(ml/min/100 g tissue/mmHg)(ml/min/100 g tissue/mmHg)

Operation processOperation process

PV reflowPV reflow

Donor age and PV graft compliance


PV

gra

ft co

mp

lianc

eP

V g

raft

com

plia

nce

Operation processOperation process

WIT < 40 min (n=11) WIT ≥ 40 min (n=6) WIT < 40 min (n=11) WIT ≥ 40 min (n=6)

*

**

*

* *

*

*

*P<0.01-0.05*P<0.01-0.05

(ml/min/100 g tissue/mmHg)(ml/min/100 g tissue/mmHg)

0

5

10

15

20

0

5

10

15

20

PV reflowPV reflow

Warm ischemic time and PV graft compliance


Figure 6. Algorithm for the graft selection

Right lobe graft

MHV dominant RHV dominant

GRWR>1.0% GRWR>1.0%GRWR<1.0% GRWR<1.0%

Remnant LV>35%

Remnant LV<35%

Remnant LV<35%

Remnant LV>35%

Remnant LV<35%

Significant V4** No significant V4

Right lobewithout MHV

Right lobewith MHV

Discussion*Right lobewith partial MHV

Right lobewith MHV

Discussion*

Algorithm for the graft selection


Regeneration index for ant. and post. Segments


Wilcoxon signed rank test p=0.007V

olum

e of

the

graf

t

Anterior segment Posterior segment-50

0

50

100

150

200

250

Venous anatomy and graft congestion in anterior segment without MHV

Congestion Score Original Drainage Vein(s) (n) in the 1st Month R>>M RHV>MHV Even RHV<MHV R<<M Segment V (p=0.0175)

0 0 3 2 0 0 1 0 0 1 3 5 2 4 1 3 5 12 3 0 0 0 0 1 Segment VIII (p=0.0172)

0 2 2 0 2 0 1 0 2 3 3 2 2 0 0 3 10 9 3 0 0 0 1 1


RHV vs MHV dominancy Calculation of potential congestive area in right lobe donation by 3D-CT

Ratio of V5+8 volume

> 40% : MHV dominant

< 40% : RHV dominant

V5+8

Total right lobe



Right lobe graft



Remnant LV>35%

Remnant LV<35%

Remnant LV<35%

Remnant LV>35%

Remnant LV<35%



Right lobewith MHV


Right lobewith MHV

Discussion*



IMPACT OF VENOUS CONGESTION OF ANTERIOR SECTORright lobe graft without reconstruction of V5&V8

uneventful

15 y/o female Wilson disease

Graft: 1.341.34%BW

25 y/o female PSC

Graft: 0.950.95%BW

56 y/o female HBV-cirrhosis

Graft: 0.980.98%BW

massive ascites massive ascitesprolonged cholestasis



Right lobe graft



Remnant LV>35%

Remnant LV<35%

Remnant LV<35%

Remnant LV>35%

Remnant LV<35%



Right lobewith MHV


Right lobewith MHV

Discussion*



Safety criteria for remnant liver volume

Remnant liver ratio

> 35% : safe

30% ~ 35% : marginal

30% > : risky

Remnant liver ratio =

estimated whole liver volume - estimated graft volume

estimated whole liver volume



Right lobe graft



Remnant LV>35%

Remnant LV<35%

Remnant LV<35%

Remnant LV>35%

Remnant LV<35%



Right lobewith MHV


Right lobewith MHV

Discussion*



Evaluation of potential congestive area after right lobectomy with MHV (3D-simulation)

Regional volume of V4 showed significant, the proximal side of the MHV should be left in the donor to reduce the risk of venous congestion in segment 4.

the potential congestive area


Figure 4. The types of middle hepatic vein reconstruction with / without interposition vein graft.

• A. Y-shaped portal vein graft (n=13)

• B. I-shaped vein graft (n=10)

• C. Direct anastomosis (n=12)

• D. Patch graft (n=1)

• E. Venoplasty (n=4)

A

B C D

E


RHV

MHV

A

Plasty to one whole B

Patch graft to anterior wall C

D

Modified MHV reconstruction – Plasty with RHV using patch graft to anterior wall

PODPOD

IntraOpeIntraOpe

PVP PVP

10

12

14

16

18

20

10

12

14

16

18

20

**

3311 55 77 99 1111 1313

**

**

**

**

******

**

**

SAL (n=9)Non-SAL (n=86)SAL (n=9)Non-SAL (n=86)

(mmHg)(mmHg)

*P<0.01-0.05*P<0.01-0.05

PV reflow PV reflow

Splenic artery ligation in adult LDLT


Years after LTxYears after LTx11 2200

00

5050

100100(%)(%)

Gra

ft s

urvi

val

Gra

ft s

urvi

val

SAL (n=9) (PVP < 20 in all cases)GRWR: 0.79-1.28 (0.93)%

SAL (n=9) (PVP < 20 in all cases)GRWR: 0.79-1.28 (0.93)%

Non-SAL (n=18)PVP ≥ 20, GRWR: 0.73-1.43 (1.02)%

Non-SAL (n=18)PVP ≥ 20, GRWR: 0.73-1.43 (1.02)%

Non-SAL (n=68)PVP < 20, GRWR: 0.76-2.02 (1.12)%

Non-SAL (n=68)PVP < 20, GRWR: 0.76-2.02 (1.12)%

P<0.01P<0.01

Optimal outflow reconstruction and porto-caval shunt


RHV

MHV

IRHV

PC shunt (LPV-IVC)

plus SPLENECTOMY GRWR 0.49

RPV

Summary

1. There is a correlation between the portal vein pressure and small-for-size syndrome.

2. Suboptimal graft (aged donor, long warm ischemic time) shows poor graft tolerability for portal inflow (poor compliance).

3. To obtain the maximum functional graft volume along with the maximum donor safety, the algorithm for the selection of donor operation is useful.

4. To obtain the optimal outflow reconstruction of MHV and RHV, a modified technique using an anterior patch graft has been introduced.

5. With the use of the modification of portal inflow (splenic artery ligation,

permanent portocaval shunt), “very small-for-size” transplantation might be possible. (Return to adult left lobe transplant safe for the recipient and safe for the donor ?) Kyoto University 2005Kyoto University 2005 Ghent Ghent

how far can we go with suboptimal grafts in ldlt. fumitaka oike and koichi tanaka dept. transplant...

Documents

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ghent slide

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right lobe donation

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steatotic liver