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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
B
P
B
P
B
P
B
P
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%
Steatosis : 70% Macro : 55% Micro : 15%
Steatosis : 50% Macro : 30% Micro : 20%
Steatosis : 50% Macro : 30% Micro : 20%
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