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How far can we go with suboptimal grafts in LDLT.

Ghent 2005. “Small-for-size syndrome in liver surgery” Symposium. How far can we go with suboptimal grafts in LDLT. Fumitaka Oike and Koichi Tanaka Dept. Transplant Surgery, Kyoto University, Japan. Kyoto University 2005 Ghent.

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How far can we go with suboptimal grafts in LDLT.

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  1. Ghent 2005 “Small-for-size syndrome in liver surgery” Symposium How far can we go with suboptimal grafts in LDLT. Fumitaka Oike and Koichi Tanaka Dept. Transplant Surgery, Kyoto University, Japan Kyoto University 2005Ghent

  2. Donor and Recipient Factors Influencing Graft Survival • 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 Kyoto University 2005Ghent

  3. Prognosis of small-for-size grafts GRWR＝Graft weight / recipient body weight Small-for-size syndrome Prolonged cholestasis Coagulopathy Massive ascites Portal hypertention GI bleeding Renal Dysfunction Sepsis Survival rate Years after LDLT Kyoto University 2005Ghent

  4. Mean PV pressure 1st week Mean PV pressure 2nd week 100 100 (%) (%) PVP<20 (n=50) PVP<20 (n=80) PVP≥20 (n=29) Patient survival 50 50 PVP≥20 (n=18) P<0.01 NS 0 0 0 2 0 2 1 1 Years Years Portal vein pressure and patient survival Kyoto University 2005Ghent

  5. T.Bil PT time (mg/ml) (sec) * PVP <20 (n=80) PVP ≥20 (n=18) * * * * * * * * * * * * * * * * * * * * * * * * * *p<0.01-0.05 *p<0.01-0.05 Portal vein pressure and prolonged cholestasis / prolonged coagulopathy POD POD Kyoto University 2005Ghent

  6. (mmHg) P<0.0001 R=0.556 (n=98) PVP (ml/50kg) Ascites Portal vein pressure and ascites Kyoto University 2005Ghent

  7. Portal vein pressure and infection Incidence of positive blood culture ( 3 posttransplant months ) n Bacteremia p PVP < 20 83 27.7% PVP ≥ 20 13 64.0% 0.0153 Kyoto University 2005Ghent

  8. <0.8% of BW (n=8) 0.8-1.0% of BW (n=30) ≥1.0% of BW (n=64) (mmHg) * * * * * * * PVP * * *p<0.05-0.01 14 2 4 8 10 12 6 Intra- operative POD Graft size and portal vein pressure Kyoto University 2005Ghent

  9. PV pressure measurement PV flow measurement Antithrombotic catheter rubber band 0.035mm PVF IMV Measurement of portal vein pressure and flow

  10. PV reflow Before anhepatic P=0.0468 ρ=0.567 NS Pressure Pressure POD 3 POD 1 NS NS Pressure (mmHg) Pressure Flow (ml/min/100g tissue) Flow Portal vein pressure and flow volume Kyoto University 2005Ghent

  11. Donor age < 40 (n=7) Donor age ≥ 40(n=10) Donor age and PV graft compliance (ml/min/100 g tissue/mmHg) * * * * * PV graft compliance PV reflow *P<0.01-0.05 Operation process Kyoto University 2005Ghent

  12. WIT < 40 min (n=11) WIT ≥ 40 min (n=6) Warm ischemic time and PV graft compliance (ml/min/100 g tissue/mmHg) * * * * * * * * PV graft compliance PV reflow *P<0.01-0.05 Operation process Kyoto University 2005Ghent

  13. 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 Discussion* Right lobe with partial MHV Right lobe with MHV Discussion* Right lobe with MHV Right lobe without MHV Algorithm for the graft selection Figure 6. Algorithm for the graft selection Kyoto University 2005Ghent

  14. 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 Discussion* Right lobe with partial MHV Right lobe with MHV Discussion* Right lobe with MHV Right lobe without MHV Algorithm for the graft selection Figure 6. Algorithm for the graft selection Kyoto University 2005Ghent

  15. Wilcoxon signed rank test p=0.007 250 200 150 Volume of the graft 100 50 0 -50 Anterior segment Posterior segment Regeneration index for ant. and post. Segments Kyoto University 2005Ghent

  16. Congestion Scor e Original Drainage V ein(s) (n) in the 1st Month R>>M RHV>MHV Even RHV<MHV R<<M Segment V ( =0.0175) p 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 ( =0.0172) p 0 2 2 0 2 0 1 0 2 3 3 2 2 0 0 3 10 9 3 0 0 0 1 1 Venous anatomy and graft congestion in anterior segment without MHV Kyoto University 2005Ghent

  17. V5+8 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 Total right lobe Kyoto University 2005Ghent

  18. 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 Discussion* Right lobe with partial MHV Right lobe with MHV Discussion* Right lobe with MHV Right lobe without MHV Algorithm for the graft selection Figure 6. Algorithm for the graft selection Kyoto University 2005Ghent

  19. 25 y/o female PSC Graft: 0.95%BW 56 y/o female HBV-cirrhosis Graft: 0.98%BW 15 y/o female Wilson disease Graft: 1.34%BW massive ascites prolonged cholestasis uneventful massive ascites IMPACT OF VENOUS CONGESTION OF ANTERIOR SECTOR right lobe graft without reconstruction of V5&V8 Kyoto University 2005Ghent

  20. 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 Discussion* Right lobe with partial MHV Right lobe with MHV Discussion* Right lobe with MHV Right lobe without MHV Algorithm for the graft selection Figure 6. Algorithm for the graft selection Kyoto University 2005Ghent

  21. 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 Kyoto University 2005Ghent

  22. 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 Discussion* Right lobe with partial MHV Right lobe with MHV Discussion* Right lobe with MHV Right lobe without MHV Algorithm for the graft selection Figure 6. Algorithm for the graft selection Kyoto University 2005Ghent

  23. Evaluation of potential congestive area after right lobectomy with MHV (3D-simulation) the potential congestive area 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. Kyoto University 2005Ghent

  24. Figure 4. The types of middle hepatic vein reconstruction with / without interposition vein graft. B C D A • 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) E Kyoto University 2005Ghent

  25. Patch graft to anterior wall C A RHV MHV B D Plasty to one whole Modified MHV reconstruction – Plasty with RHV using patch graft to anterior wall

  26. (mmHg) SAL (n=9) Non-SAL(n=86) PVP * * * * * * * * * * PV reflow *P<0.01-0.05 3 5 7 9 11 13 1 IntraOpe POD Splenic artery ligation in adult LDLT 100 (%) Non-SAL (n=68) PVP < 20, GRWR: 0.76-2.02 (1.12)% SAL (n=9) (PVP < 20 in all cases) GRWR: 0.79-1.28 (0.93)% Graft survival 50 Non-SAL (n=18) PVP ≥ 20, GRWR: 0.73-1.43 (1.02)% P<0.01 0 0 1 2 Years after LTx Kyoto University 2005Ghent

  27. Optimal outflow reconstruction and porto-caval shunt GRWR 0.49 plus SPLENECTOMY RHV MHV PC shunt (LPV-IVC) IRHV RPV Kyoto University 2005Ghent

  28. 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 2005Ghent

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