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Minimally Invasive Living Donor Hepatectomy

Although over 6000 people receive a liver transplant in the United States each year, more than 16,000 patients are listed. The growing gap between the demand and supply for liver grafts is one of the biggest challenges in liver transplantation. Despite enormous effort to increase the pool of deceased donor organs, more than 2000 patients die on the waiting list each year. An absolute imperative to…

Small-for-Size Syndrome

Split-liver transplantation and living donor liver transplantation (LDLT) in adult patients are now recognized as established treatments for end-stage liver disease. During the early days of adult LDLT, left lobe (LL) LDLT was the only option, although LL grafts constitute only 30% to 50% of the whole-liver volume ( Fig. 55-1 ). Subsequently the effect of a relatively “small” partial graft (as compared with whole-liver graft)…

Biliary and Vascular Reconstruction in Living Donor Transplantation

The bile ducts and vascular conduits of the harvested grafts from living donors are incomplete, thin, and short. The biliary and vascular reconstruction of living donor transplantation is therefore too technically demanding to perform by simple extrapolation of the techniques on whole-liver transplantation. Hepatic veins are often multiple (middle hepatic vein tributaries and inferior right hepatic veins of the right liver grafts or short hepatic veins…

Split Liver Transplantation for Two Adult Recipients

Orthotopic liver transplantation has now become the gold standard treatment for end-stage liver disease. However, the ongoing shortage of suitable livers, together with progressively longer waiting lists, prevents many patients from being transplanted; this has led to a significant waiting list mortality rate at most centers. Using livers from living donors is one way to increase the supply of liver grafts but carries with it the…

Split Liver Transplantation for Pediatric and Adult Recipients

Pediatric liver transplantation has driven technical innovations in surgery over the past 25 years. Early successful liver transplantation relied on the use of size-matched whole-liver grafts. This requirement tended to exclude small children of less than 10 kg from liver transplantation because of the lack of donors and the higher rate of technical complications such as hepatic artery thrombosis. In addition, as increasing numbers of children…

Adult Living Donor Left Hepatectomy and Recipient Operation

In 1993 the first successful adult-to-adult living donor liver transplantation was performed using a left liver graft. Until then, liver transplantations from living donors had been performed only for pediatric recipients. Because of the overwhelming shortage of liver grafts from deceased donors to meet the demand, the number of adult living donor liver transplantation has increased dramatically throughout the world. Recipients’ poor prognosis in adult living…

Adult Living Donor Right Hepatectomy and Recipient Operation

Living donor liver transplantation (LDLT) has emerged to relieve the global shortage of deceased donor liver grafts. After the first success in a child was reported by Strong et al of Brisbane in 1990, significant advancements in various fields have been achieved that allow dramatic growth and a wider application of this lifesaving operation. Among these, the advent of adult right liver LDLT, which overcomes the restriction…

Living Donor Transplantation in Children

History and Significance of Pediatric Living Donor Liver Transplantation The first living donor liver transplantation (LDLT) in the world was performed in Brazil by Raia in December 1988, but the recipient did not survive long. The first successful LDLT was reported by Strong et al in 1990. The recipient was a Japanese boy who received a left lateral segment from his mother. Unfortunately, chronic rejection developed a…

Imaging Techniques for Partial Grafting

Preoperative imaging plays a crucial role in optimizing outcomes and minimizing risks involved with partial liver grafting. The primary goals of imaging are to understand donor vascular and biliary anatomy, identify variant anatomy, assess hepatic segmental volumes, and exclude underlying hepatobiliary pathological conditions. Donors with inadequate liver volume, detectable pathology, or anatomical variations that may require extensive vascular or biliary reconstruction may not be selected for…

Anesthesia for Liver Transplantation

Liver transplantation is a very successful and effective treatment for many different disorders of the liver. Improved techniques in surgery, anesthetic management, donor organ procurement, preservation, immunosuppression, and perioperative care have resulted in many centers reporting a 1-year survival rate for some recipient groups of nearly 90%. Increasing survival rates have led to the performance of a greater number of liver transplants and to broadened indications…

Recipient Hepatectomy and Grafting

According to conventional clinical and surgical standards of the early 1960s, removal of a diseased liver and replacing it with a working, undamaged one was a concept that, although visionary and sound, had a low probability of being successfully executed. Only because of the technical brilliance and stubborn perseverance of Thomas E. Starzl did the experiment continue and slowly develop into the refined surgical procedure that…

Principles of Liver Preservation

Liver preservation is one of the most important components of liver transplantation because the efficacy of preservation has an enormous impact on the posttransplant outcome. Especially in wide geographical regions with national organ sharing, liver preservation allows organs to travel great distances. The evolution of organ transplantation was mainly related to the introduction of new immunosuppressive drugs such as cyclosporine, but the development of effective preservation…

The Donor Operation

The expeditious assessment and recovery of cadaver organs without surgical injury will always be the central mission of the donor surgeon; however, the current climate of organ scarcity has placed increasing demands upon the donor surgeon that require enhanced skill and experience to routinely perform these procedures so as to extract the maximal potential from the existing cadaver donor pool. Organ procurement organizations (OPOs) have responded…

Donation After Cardiac Death

Donation after cardiac death (DCD), formerly referred to as non–heart-beating donation , has become the fastest-growing source of transplant organs in the United States over the past decade, bringing full circle the history of organ donation. This chapter reviews the history, ethics, practice guidelines, surgical techniques, clinical outcomes, and challenges of DCD liver transplantation, focusing on the controlled subgroup of DCDs. Profound disparity in supply and…

Extended Criteria Donors

The disparity between supply and demand of organs for transplantation continues to grow, and the organ shortage has made it necessary to liberalize acceptance criteria to include donors beyond traditional criteria. These donors collectively are known as extended criteria donors . (ECDs) In the past, an “ideal” donor was defined as age less than 40 years, trauma as the cause of death, donation after brain death…

Donor Selection and Management

It is estimated that each year in the United States approximately 20,000 potential brain-deceased donors are not properly identified as such; furthermore, of those unquestionably opting to donate lifesaving organs, 17% to 25% of donors are lost due to errors in management. With the persistent disparity of donor organsrelative to patients awaiting liver transplantation (LT), the full potential impact of liver transplantation has gone unrealized due…

Portopulmonary Hypertension and Hepatopulmonary Syndrome

Pulmonary disease is common in patients with end-stage liver disease, and as many as 50% to 70% of patients with end-stage liver disease complain of shortness of breath. The differential diagnosis includes obstructive airway disease, infection, fluid retention with hydrothorax, and decreased lung capacities secondary to ascites. Other conditions such as α 1 -antitrypsin deficiency and cystic fibrosis can affect both the lung and liver. This…

Management of Portal Hypertensive Hemorrhage

Portal hypertension is most commonly a manifestation of underlying liver parenchymal disease and worsens with increasing severity of cirrhosis. It is responsible for complications, such as the development of varices and variceal hemorrhage, among chronic liver disease patients and often portends the need for liver transplantation. Fifty percent of patients with cirrhosis have gastroesophageal varices, and approximately one third of these patients will go on to…

Nutritional Aspects of Transplantation in Adults

The Role of the Liver in Nutrient Metabolism The liver is a key organ in the metabolism of nutrients. The high metabolic activity of the liver accounts for approximately 20% to 30% of the body’s oxygen consumption and energy expenditure. Liver dysfunction induces a catabolic state accompanied by increased energy expenditure; elevated serum insulin, glucagon, epinephrine, and cortisol concentrations; and insulin resistance. Because the liver is…