dual ldlt turkey hwang

Dual-Grafts Dual-Grafts

Living Donor Liver TransplantationLiving Donor Liver Transplantation

Dual-Grafts Dual-Grafts

Living Donor Liver TransplantationLiving Donor Liver Transplantation

Shin Hwang and SungGyu Lee, MD.

Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

What is dual-graft LDLT?

300 gm

400 gm

World first case of dual-graft LDLT in 2000

VideoVideo

Modification of Right Hepatic Vein ReconstructionModification of Right Hepatic Vein ReconstructionIntrahepatic RHVIntrahepatic RHV

Why we perform dual-graft LDLT?

DDLT

Shortage of deceased donor organs

Number of cadaver donors per 1 million population (pmp) in different countries in the year 2000. Data from non-Asian countries were obtained from the Organization National de Transplantes. De Villa VH 2003 TransplantationDe Villa VH 2003 Transplantation

KOREA

11.9 PMP

8% of Korean Population are 8% of Korean Population are HBV-Carrier. HBV-Carrier.

High Prevalence of Cirrhosis and High Prevalence of Cirrhosis and HCCHCC

34

6 68

10

16

30

16

11

4

20 2021

23

0

5

10

15

20

25

30

Cases

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Deceased Donor Liver Transplantation at Asan Medical Center

(1992. 8. 20 - 2006. 12. 31)

CDLT

LDLT

LDLT

Donor safetyDonor safety Graft size matchingGraft size matching

Small-for-Size Liver Graft

acceptable range of Steatosis of Donor’s Liver

Issues in Adult Living-Donor Issues in Adult Living-Donor Partial Liver TransplantationPartial Liver Transplantation

• Donor SafetyDonor Safety

Extent of Donor Hepatectomy

Chronology

LLS LL RL ERL

PediatricLDLT

AdultLDLT

Operation Risk and Extent of Hepatectomy

Donor Risk

Estimated Worldwide Living Liver Donor Mortality

Biliary Biliary 6 % 6 % 7.2% 7.2% 5% 5%

Transfusions Transfusions 4.5% 4.5% 0.5% 0.5% - -

Re-operation Re-operation 4.5% 4.5% 1.1% 1.1% - -

Major infection Major infection 1 % 1 % 0.5% 0.5% 4% 4%

Other Other 10 % 10 % 7 % 7 % 11% 11%

Morbidity Morbidity 14.5% 14.5% 21 % 21 % 15.8%15.8%

Mortality(reported) Mortality(reported) 1(0.2%) 1(0.2%) 0 0 4(0.5%)4(0.5%)

USA ASIA EUROPE USA ASIA EUROPE

Jacques Belghiti. 2003, 92003, 9thth Congress International Liver Transplantation Society

Donor Complications after Living Donor Liver Transplantation

Donor Complications after Living Donor Liver Transplantation

Permissible Extent of Donor HepatectomyRemnant liver volume

35% or 30%35% or 30%of total liver volumeof total liver volume

Each Institutional LDLT rate after Evaluating Recipients and Donors

No. of No. of Rejection Rejection

Patients Patients due to due to

Evaluated Underwent Recipient Donor

LDLT Problems Problems

2000 USA (Colorado )

2004 Hong Kong

2004 Germany (Essen )#

2005 Spain (Villarroel)

2006 Japan (Tokyo )

2006 Korea (AMC)

100 15(15%) 51(51%) 34(34%)

51 21(41%) 0 (0%) 30(59%)

349 111(32%) 183(52%) 55(16%)

121 21(17%) 60(50%) 40(33%)

533 249(47%) 165(31%) 119(22%)

385 230(60%) 69(18%) 86(22%)# Of 700 potential donors, a total of 589(84%) potential donors rejected.

No. of

Patients

Underwent LDLT

15(15%)

21(41%)

111(32%)

21(17%)

249(47%)

230(60%)

To overcome a small-for-size grafts syndromeTo overcome a small-for-size grafts syndrome

• Left-Lobe and Segment 1 liver graft

• Right-Lobe liver graft

• Right-Lobe liver graft with anterior sector drainage

• APOLT

• Dual LDLT

• Left-Lobe and Segment 1 liver graft

• Right-Lobe liver graft

• Right-Lobe liver graft with anterior sector drainage

• APOLT

• Dual LDLT

To overcome the problem of small-for-size graft, Right-Right-LobeLobe (>60% of Total Liver Volume)(>60% of Total Liver Volume) LDLTLDLT has been established to optimize graft-size.

However, Right-Lobe Hepatectomy in DonorRight-Lobe Hepatectomy in Donor is not always safe and is associated with a higher risk to Donor, depending on the volume of the remaining Left-LobeLeft-Lobe.

Donor Risks

Extent of Donor Hepatectomy Extent of Donor Hepatectomy Lateral Lateral Left Left Right Right ExtendedExtendedSegment Segment Lobe Lobe Lobe Lobe Right Right Lobe Lobe

Estimated worldwide operative donor mortalityEstimated worldwide operative donor mortalityVancouver Forum Vancouver Forum on September 2005on September 2005 Vancouver Forum Vancouver Forum on September 2005on September 2005

Transplantation . Volume 81, Number 10, May 27, 2006 Transplantation . Volume 81, Number 10, May 27, 2006

After Sept 2005 Korea 1Japan 1 (?)

For the right liver donor, the mortality is up to 0.5%. For the left liver donor, the mortality is 0.1%.

3 left liver 11 right liver

US 1 US 2 Brazil 1 Brazil 2 Germany 1 Germany 1

France 1Japan 1Egypt 1HongKong 1India 1

Donor Donor SafetySafety

• Safe Donation is possible when the esti

mated residual liver volume is > 30 %.• 25% of Potential Donors has a large Right-Lobe

( > 70% of total liver volume)

• More than 60 % Donor Hepatectomy m

ay be risky in > 30% steatotic liver.

IssuesIssues in Adult Living-Donor Partial Liver Transplantationin Adult Living-Donor Partial Liver Transplantation

Donor Safety

acceptable range of Steatosis of Donor’s Liver

Issues in Adult Living-Donor Partial Liver TransplantationIssues in Adult Living-Donor Partial Liver Transplantation

• Small-for-Size Liver GraftSmall-for-Size Liver Graft

Single Left Lobe LDLT

• Even after adoption of Right-Lobe gr

aft, 1/3 of adult recipients still suffer f

rom negative impact of suboptimal G

RWR of less than 1.0 %.• Graft Size < GRWR of 0.8 – 1.0 %

• Steatosis ( + )

• Congestion ( + )

Small-for-Size Liver GraftSmall-for-Size Liver Graft

Issues in Adult Living-Donor Partial Liver Transplantation

• Donor Safety

• Optimal Graft SizeOptimal Graft Size

Prerequisites for Selection of Ideal Donor for Adult

Living Donor Liver Transplantation

Currently, Currently, not more than ⅓ of potential donorsnot more than ⅓ of potential donors are accepted as proper candidate.are accepted as proper candidate.

Each Institutional LDLT rate after Evaluating Recipients and Donors

No. of No. of Rejection Rejection

Patients Patients due to due to

Evaluated Underwent Recipient Donor

LDLT Problems Problems

2000 USA (Colorado )

2004 Hong Kong

2004 Germany (Essen )#

2005 Spain (Villarroel)

2006 Japan (Tokyo )

2006 Korea (AMC)

100 15(15%) 51(51%) 34(34%)

51 21(41%) 0 (0%) 30(59%)

349 111(32%) 183(52%) 55(16%)

121 21(17%) 60(50%) 40(33%)

533 249(47%) 165(31%) 119(22%)

385 230(60%) 69(18%) 86(22%)## Of 700 potential donors, a total of 589(84%) potential donors rejected. Of 700 potential donors, a total of 589(84%) potential donors rejected.

No. of

Patients

Underwent LDLT

15(15%)

21(41%)

111(32%)

21(17%)

249(47%)

230(60%)

Donor-related Problems rejected for LDLTDonor-related Problems rejected for LDLT

ReasonsReasons Number of Number of potential donorpotential donor

ABO incompatible

Significant medical diseases

Small remnant volume in Donor

Small graft size

Viral marker abnormality

Abnormal LFT

Severe fatty change

Anatomical variation

Refusal to donate

6

5

39

4

6

1

14

2

11

total 86 of 385 (22%)

From 2005 April To 2006 April at the Asan Medical Center

Small remnant volume in Donor 39

Severe fatty change 14

Dual LDLT in Asan Medical Center

2

10

3 3 3

15

38

6

22

2

59

13

1

9

1

75

814

7

85

41

4 4

0

10

20

30

40

50

60

70

80

90

1997 1998 1999 2000 2001 2002

Liver Graft Types of 436 Adult LDLT at the Asan Medical Center

MRLRL

ERL

PS

LL

LL+S1

DualDual

881212

3030

23 %23 %

(Feb 1997 – Dec 2002)

Total OLT : 634

Cadaveric LT : 113 (since 1992)

Pediatric LDLT : 85 (since 1994)

2002 Jan - Dec

RL 57RL 57(40.1%)(40.1%)RL 86RL 86

(67.7%)(67.7%)Dual 28Dual 28(22.0%)(22.0%)

Dual 45Dual 45(31.7%)(31.7%)

LL 36LL 36(25.4%)(25.4%)LL 13LL 13

(10.3%)(10.3%)

2003 Jan - Dec

( PS 3 )( PS 3 )

Changing Trends of Liver Grafts Changing Trends of Liver Grafts

in adult LDLT at the AMCin adult LDLT at the AMC

1.1. Major ComplicationMajor ComplicationIntestinal obsructionIntestinal obsruction 11Bile Leakage requiring medial segmentectomyBile Leakage requiring medial segmentectomy 11

2.2. ReoperationReoperation 22 003.3. MortalityMortality 00 00

1. Major Complication1. Major ComplicationBile LeakageBile Leakage requiring drainage requiring drainage 11Bile Duct Stricture Bile Duct Stricture 33Hyperbilirubinemia ( TB Hyperbilirubinemia ( TB 10 mg/dl) 10 mg/dl) 33PVTPVT 22CRFCRF 11Intra-abdominal BleedingIntra-abdominal Bleeding 33Intestinal ObstructionIntestinal Obstruction 22

2. Reoperation2. ReoperationIntra-abdominal BleedingIntra-abdominal Bleeding 33Intestinal ObstructionIntestinal Obstruction 11PVTPVT 11

3. Mortality3. Mortality 00 00

In 311 LDLTs from February 1997 to December 2001In 311 LDLTs from February 1997 to December 2001In 311 LDLTs from February 1997 to December 2001In 311 LDLTs from February 1997 to December 2001

Type of Grafts

97 Left Lobe 213 Right Lobe

Type of Grafts 183 Left Lobe 158 Right Lobe

Donor Morbidity and Mortality in 580 A-A LDLT at the Asan Medical Center, Ulsan University from Feb 1997 to Dec 2003

In 269 LDLTs from January 2002 to December 2003In 269 LDLTs from January 2002 to December 2003In 269 LDLTs from January 2002 to December 2003In 269 LDLTs from January 2002 to December 2003

4.1%4.1% 7.5%7.5%

0%0%2.2%2.2%

adult to adultadult to adult

2006200220012000199919981997199619951994 Year

10

127

7

116

14

91

14

68

13

12

9

24

91132

225000

2003

142

10

203

7

Living Donor Liver Transplantation Living Donor Liver Transplantation Asan Medical CenterAsan Medical Center

PediatricPediatric

20040

50

100

150

200

250

(1994 December - 2006 December)

45

57

812

28Dual LDLT

206

8

2005

2728

Total

112

1,218

Donor Remnant Donor Remnant Liver Liver > 35 %> 35 %

Donor Remnant Donor Remnant Liver > 30 %Liver > 30 %

0

50

100

150

200

250

Pediatric

Adult

2006200220012000199919981997199619951994 Year

10

127

7

116

14

91

14

68

13

12

9

24

91132

225000

2003

142

10

203

7

2004

45

57

812

28

Dual-graft LDLT

206

8

2005

27

28

Total

112

1,218

Dual LDLT at Asan Medical CenterDual LDLT at Asan Medical Center

In DonorIn Donor

Donor Donor Remnant Liver Remnant Liver

< 30% < 30%

Macro-steatosis Macro-steatosis > 30%> 30%

Volume ratioVolume ratio R : L > 2 : 1R : L > 2 : 1

steatosis > 30%steatosis > 30%

In RecipientIn Recipient

GRWR < 0.8 %GRWR < 0.8 %

1. FFor Donor Safety, Left-Lobe and Left-Lobe Dual LDLT.

2. BBecause of marginal Steatotic donor liver, Left-Lobe and Left-Lobe

Dual LDLT.

3. TTo avoid a small-for-size graft in a Large-sized Recipient,

RightRight-Lobe and Left-Lobe Dual L

DLT.

Indication of Indication of Dual LDLT

First more favorable Donor Second Donor stand-by

Laparotomy

Single graft sufficient

Right Lobe Transplant

Single graftinsufficient

Dual graftsDual grafts TransplantTransplant

Decision process for Dual LDLT

56 (1; Cadaveric graft) 10

35 (5; Lateral segment) 2 6

Left lobe Left lobe

Lateral segment

Left lobe

Right lobe

Left lobePosterior segment Lateral segment

Posterior segment

Left lobe

96

Lateral segment

Lateral segment

From February 1997 (from March 2000) to December 2006 at the Asan Medical Center

Various kinds of 205 dual living donor liver transplantation among 1218 adult living donor liver transplantation.

Two Left Lobes harvest

Immoderate Right Lobe harvest

Sum of Two Left-Lobes volume is near

equivalent to a Right-Lobe volume.

0

Background for Background for Two Left-Liver Lobes Two Left-Liver Lobes LDLTLDLT

To provide Adequate Graft size

Safety of Dual-Graft DonorsDonor Risk Comparison

• More than 60 % Donor Hepatectomy may be risky in > 30% steatotic liver.

• Safe Donation is possible when the estimated residual liver volume is > 30 %.

ST Fan; 2000 Arch Surgery

• 25% of Potential Donors has a large Right-Lobe ( > 70% of total liver volume).

M Makuuchi; 2002 Liver Transplantation

For Donor Safety, Dual Left-Lobe and Left-Lobe LDLT can be applicable when Volume ratio of Right and Left Lobe is greater than 2:1 or when a potential Donor has Marginal Donor Liver( > 30% steatosis)

Background for Combination Background for Combination

of of Two Left-Liver LobesTwo Left-Liver Lobes

Background for Combination ofBackground for Combination ofa Right-Liver and a Left-Liver Lobesa Right-Liver and a Left-Liver Lobes

• Even after adoption of Right-Lobe graft, 1/3 of adult recipients still suffer from negative impact of suboptimal GRWR of less than 1.0 %.

K Tanaka; 2001 Current Opinion in Organ Transplantation

To avoid a small-for-size Graft, Dual Right-Lobe and Left-Lobe LDLT can be applicable for a Large-Sized Recipient.

After 2 monthsAfter 2 months

LL graft

RL graft

Dual LDLT using Right and Left lobe grafts

RecipientRecipient 90 Kg, 188 cm, HBV-LC90 Kg, 188 cm, HBV-LC

mRL 570 gmRL 570 g(GRWR 0.63)(GRWR 0.63)

F/38 wife 161cm, 51kgF/38 wife 161cm, 51kg

LL 380 gLL 380 g(GRWR 0.42)(GRWR 0.42)

GRWR = 1.05GRWR = 1.05

Right lobe as modified RL graft

Recipient 90 Kg, 188 cmRecipient 90 Kg, 188 cmHBV-LCHBV-LC

V8V8

V8V8

V5V5

V5V5 i-RHVi-RHV

LL 380 gmLL 380 gmmRL 570 gmmRL 570 gm

F/38F/38

M/29M/29

GRWR = 1.05GRWR = 1.05

Dual LDLT using RPS and LLS grafts

POD # 7

Posterior Segment Donor Lateral Segment Donor

RHV

RPSRPS

LLSLLS

Dual LDLT using RPS and LLS grafts

VideoVideo

Ethics of Liver Transplantation with Living Donors.

Singer PA, Siegler M, Whitington PF, et al

N Engl J Med 1989; 321:620-622N Engl J Med 1989; 321:620-622.

MHVMHV

RHVRHV IRHVIRHV

MHV tributary MHV tributary Draining S5 and S6Draining S5 and S6

A potential donor donated his Left Lateral Segment

instead of Left Lobe with MHV?

A potential donor donated his Left Lateral Segment

instead of Left Lobe with MHV?

Even in left-lobe LDLT, the possibility of donor mortality isreal, and at least one such death has been reported

V5

Preop CT Preop CT POD#7 CTPOD#7 CT

Donor Left Lobectomy

Does Donor Complication become Twice

Does Recipient Complication become Twice

Dose Competition between two grafts occur

as APOLT ?

Does ACR become doubled and develop unilaterally or bilaterally ?

because Bilateral Vascular and Biliary Anastomoses have to be performed ?

Raised QuestionsRaised Questions in Dual LDLT in Dual LDLT

because Two Donors are operated ?

EarlyEarlywound seroma 20wound infection 4

intraabdominal hematoma 3

arm paresthesia 1

transient bile leak 6pleural effusion 5

subcapsular hematoma of liver 1

bile leak & catheter drainage 1

Re-exploration 1(Medial Segmentectomy for cut-surface

bile leak after Lateral Segmentectomy)

Mortality 0

LateLate 00

(1 deceased donor)Donor Complication in 409 living donors

205 Dual A-A LDLTs from March 2000 to December 2006

10%10%

0.2%0.2%

A B

C D

Living donor of Re-operation

16

31

67

84

16

0

10

20

30

40

50

60

70

80

90

10 20 30 40 50 60 70 year 10 20 30 40 50 60 70 year

Age Distribution

Male : Female = 180 : 25

( from March 21, 2000 to December 31, 2006 )

Patients Demographic Data of 205 Dual LDLT

Indications

Hepatitis BHepatitis Bvirus-virus-

associated associated cirrhosiscirrhosis(n = 174)(n = 174)

Alcoholic cirrhosis(n = 7)

HCV-associated cirrhosis(n = 10)

Fulminant hepatic failure(n = 11)

Wilson disease (n = 1)

Budd-Chiari syndrome (n = 1)

Primary sclerosing cholangitis (n = 1)

Re-explorations 13

Unilateral Liver Graft Removal 2

In-Hospital Mortality 13 (6.3%)

Graft Loss within 1 year 17 (8.3%)

Patient Loss within 1 year 16 (7.8%)

Recipient Outcome in 205 patients

205 Dual A-A LDLTs from March 2000 to December 2006

Long-term Results of 100 Dual LDLT Long-term Results of 100 Dual LDLT

using Two Left-Liver Graftsusing Two Left-Liver Grafts

Long-term Results of 100 Dual LDLT Long-term Results of 100 Dual LDLT

using Two Left-Liver Graftsusing Two Left-Liver Grafts

From March 2000 to May 2004

8989HBV-cirrhosisHBV-cirrhosis

(27 HCC)(27 HCC)

12 Acute-on-ChronicLiver Failure

6 FHF`4 HCV-cirrhosis

(1 HCC)1 Alcoholic cirrhosis

41 (1; Cadaveric graft) 8

Left lobe Left lobe

Lateral segment

Left lobe

51

Follow-up Period: from 35 months to 85 months

Lateral segment

Lateral segment

100 Dual LDLTs 100 Dual LDLTs using 2 Left-Liver Graftsusing 2 Left-Liver Grafts 100 Dual LDLTs 100 Dual LDLTs using 2 Left-Liver Graftsusing 2 Left-Liver Grafts

GRWR (%)GRWR (%)MedianMedian 0.98 0.98 0.98 0.98 0.790.79MeanMean 0.99 0.99 0.14 0.14 0.99 0.99 0.150.15 0.79 0.79 0.14 0.14RangeRange 0.64 0.64 1.29 1.29 0.59 0.59 1.391.39 0.49 0.49 1.151.15

Right-Lobe Dual Two Left-Lobe

Liver Graft Left-Lobe Grafts Liver

Graft

Comparison of Liver Graft SizeComparison of Liver Graft Size

GRWR (%)GRWR (%)

Median 0.98 0.95 0.79

Mean 0.98 0.14 0.95 0.15 0.79 0.14

Range 0.64 1.29 0.59 1.25 0.49 1.15

Re-exploration 1(Medial Segmentectomy for cut-surface

bile leak after Lateral Segmentectomy)

100 Two Left-Lobes A-A LDLTs from March 2000 to May 2004

Major Donor Complication in 199 living donorsMajor Donor Complication in 199 living donorsMajor Donor Complication in 199 living donorsMajor Donor Complication in 199 living donors(1 deceased donor)

Technical Complications in 100 recipients

Unilateral Graft Atrophy 14 right-sided graft 10 left-sided graft 4

Unilateral Graft Removal by HAT 2Biliary Complication 32

Acute Rejection in 15/100 Dual A-A LDLTAcute Rejection in 15/100 Dual A-A LDLT

ACR was not doubled.

Bilateral

Unilateral

Percutaneous BxPercutaneous Bx Transjugular BxTransjugular Bx

Severe Acute RejectionPolymorphous portal inflammation (+)Polymorphous portal inflammation (+)Bile duct inflammation (+)Bile duct inflammation (+)Endothelialitis (+)Endothelialitis (+)

Severe Acute RejectionPolymorphous portal inflammation (+)Polymorphous portal inflammation (+)Bile duct inflammation (+)Bile duct inflammation (+)Endothelialitis (+)Endothelialitis (+)

Rt. side graft

Hepatic Vein Congestion &Mild Acute Rejection Hepatocyte necrosis and apoptosisHepatocyte necrosis and apoptosiswithout portal inflammationwithout portal inflammation

Hepatic Vein Congestion &Mild Acute Rejection Hepatocyte necrosis and apoptosisHepatocyte necrosis and apoptosiswithout portal inflammationwithout portal inflammation

Lt. side graftPost-OP 6th day

Different Severity of Acute Rejection between Grafts

Biliary Complications in 100 Two Left-Lobe LDLT : 32% (32/100): 32% (32/100) Leakage 3%Leakage 3% ( 3/100) Stricture 31%Stricture 31% (31/100) 2323/100 in Left-sided graft (H-JH-J) 1414/100 in Right-sided graft (D-DD-D)

Rt. Graft stricture Lt. Graft stricture

Pro

po

rtio

ns

of

cu

mu

lati

ve

s

urv

iva

l

Posttransplant months

HJ

DD

Biliary complication-free survivalafter single RL graft implantation

UNOS GRWR cause survival UNOS GRWR cause survival Status (%) status (%)

1 2a 0.94 PPortal PPyemia of 12days 4 2b 0.88 Intraabdominal 12 days

Left-sided Hemorrhage Left Lobe Graft, → MI→ MIIIntestinal GGangrene

2 2a 0.89 IIntracranial 52 days 5 2a 1.00 Intracranial 5 days

Hemorrhage Hemorrhage, AR

3 3 0.80 PPortal Flow 14 days 6 2a 0.89 Massive Hemorrhagic steal Necrosis of Liver 10

daysGraft → Liver Failure→ Liver Failure

7 2a 1.01 Bile Leak, Sepsis 70 days

Cause of 7 In-hospital mortality in In-hospital mortality in 100 Two-Left Lobes LDLT100 Two-Left Lobes LDLT

0

10

20

30

40

50

60

2000 2001 2002 2003 2004

In-hospital mortalityIn-hospital mortality

Annual dual LDLT

Nu

mb

er o

f cas

esN

um

be

r of ca

ses

In-Hospital Mortality of Recipients who underwent Dual A-A LDLT at the Asan Med

ical Center, Ulsan University

881212

2828

4545

5757

11

22

11

44

00

I 0 % ( 0 / 7 )

2a 20.7 % ( 6 / 29)

2b 1.1 % ( 1 / 91)

3 4.3 % ( 1 / 23)

Total 5.3 % ( 8 /150)

I 7 ( 4.7 %)

2a 29 (19.3 %)

2b 91 (60.7 %)

3 23 (15.3 %) Emergency LDLT 7 Urgent LDLT 29 Elective LDLT 114

PreTransplant status and In-Hospital Mortality of 150 PatiePreTransplant status and In-Hospital Mortality of 150 Patients after Dual LDLTsnts after Dual LDLTs

UNOS statusUNOS status In-Hospital Mortality In-Hospital Mortality

Re-explorations Re-explorations 66UnilateralUnilateral Liver Graft Removal Liver Graft Removal 22

In-Hospital MortalityIn-Hospital Mortality 77Graft Loss within 1 yearGraft Loss within 1 year 1111Patient Loss within 1 yearPatient Loss within 1 year 1111

Recipient Outcome in 100 patientsRecipient Outcome in 100 patientsRecipient Outcome in 100 patientsRecipient Outcome in 100 patients

100 Two Left-Lobes Dual A-A LDLTs from March 2000 to May 2004

100806040200

1.11.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

( Median follow-up : 42 months )

MonthsMonths

Cu

mu

lati

ve S

urv

ival

Cu

mu

lati

ve S

urv

ival

Actuarial survival1 YSR = 89%2 YSR = 86%3 YSR = 86%5 YSR = 85%

Actuarial survival1 YSR = 89%2 YSR = 86%3 YSR = 86%5 YSR = 85%

Graft SurvivalGraft SurvivalGraft SurvivalGraft Survival

LL graftLL graft

LLS graftLLS graft

Atrophy and hypoperfusion of the right-sided graft

Liver Grafts Regeneration Liver Grafts Regeneration Liver Grafts Regeneration Liver Grafts Regeneration

Competition Competition CooperationCooperation

5 months post-LDLT2 months post-LDLT

After 2 months

LL graft

LLS graft

Cooperative RegenerationCooperative Regeneration

Cooperative RegenerationCooperative Regeneration

After 2 months

Competitive RegenerationCompetitive Regeneration

After 5 months

Severely decreased hepatic uptake in the right-sided graft

Atrophy and hypoperfusion of the right-sided graft

Competitive

Cooperative Competitive

Rt. Graft atrophy(10 cases)(10 cases)

Good regeneration(84 cases)(84 cases)

Lt. Graft atrophy(4 cases)(4 cases)

(?) (?)

Liver Graft Regeneration

Use of Fatty Liver in Liver Transplantation

Steatosis Deceased donor LT Living Partial LT

Mild yes many controversy (< 30%) between 20% and 30%

Moderate yes or no usually no(30% < 60% )

Severe absolutely no absolutely no( 60%)

Also, There is still a big controversy about Micro-and macro-stea

totic Liver Proportion.

Pre-op Bx 80 % fat Post LT Bx 5% fat at 14th day

Resolution of Severe Graft Steatosis following Dual-Graft Living Donor Liver TransplantationDB Moon et al, Asan Medical center, Liver transplantation 12:1156-1160, 2006

Steatosis : 70% Macro : 55% Micro : 15%




Right-sided graft

Preoperative biopsyPreoperative biopsy

Left-sided graft

Severely Steatotic Grafts in Two Severely Steatotic Grafts in Two Left Lobes LDLTLeft Lobes LDLT

Severely Steatotic Grafts in Two Severely Steatotic Grafts in Two Left Lobes LDLTLeft Lobes LDLT

Pre-OP in Donor

PO 1 week PO 2 week

Post-Transplant in Recipient

PO 2nd day

Serial Changes of Liver Graft with Severe SteatosisSerial Changes of Liver Graft with Severe Steatosis

No fatty changeNo fatty changeMild portal inflammation with minimal interface hepatitisMild bile duct damage & proliferation

No fatty changeNo fatty changeMild portal inflammation with minimal interface hepatitisMild bile duct damage & proliferation

70% Fatty change70% Fatty changeMacrovesicular 40%, Microvesicular 30%Mild portal inflammation

70% Fatty change70% Fatty changeMacrovesicular 40%, Microvesicular 30%Mild portal inflammation

Post-Transplant 24th dayPost-Transplant 24th dayIntra-operative biopsy Intra-operative biopsy

of liver graftof liver graft

Change of Severe Steatotic Liver Graft in RecipientChange of Severe Steatotic Liver Graft in Recipient

Left-sided GraftLeft lobe : 320 gmFatty change : 40%

Left-sided GraftLeft lobe : 320 gmFatty change : 40%

Post-Transplant 7th day Post-Transplant 11th month

Dual Living-Donor Liver Transplant by using Gilbert Disease Donors

Right-sided GraftLeft lobe : 250 gmFatty change : 10%

Right-sided GraftLeft lobe : 250 gmFatty change : 10%

UNOS 2a (Male, 56) , MELD score 61HBV-Cirrhosis, Hepato-Renal SyndromeTB 47.8 mg/dL BUN/Cr 169 / 11.5 mg/dL PT 13.4 %

UNOS 2a (Male, 56) , MELD score 61HBV-Cirrhosis, Hepato-Renal SyndromeTB 47.8 mg/dL BUN/Cr 169 / 11.5 mg/dL PT 13.4 %

Although Operative Procedure is complex,

Dual Grafts LDLT overcomes the limitationthe limitation

encountered in Single Graft LDLT as the as the

inadequate graft size and the donor risk,inadequate graft size and the donor risk,

by implanting two suboptimal partial grafts

into one recipient. In addition, it increases

the live donor pool in adult LDLT.

ConclusionConclusion

dual ldlt turkey hwang

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