Two to tango – A case for dual lobe liver transplantation

Liver Transplantation, 2010

Adult-to-adult living donor liver transplantation (AA-LDLT) has better outcomes when a graft weight to recipient weight ratio (GW/RW) > 0.8 is selected. A smaller GW/RW may result in small-for-size syndrome (SFSS). Portal inflow modulation seems to effectively prevent SFSS. Donor right hepatectomy is associated with greater morbidity and mortality than left hepatectomy. In an attempt to shift the risk away from the donor, we postulated that left lobe grafts with a GW/RW < 0.8 could be safely used with the construction of a hemiportocaval shunt (HPCS). We combined data from 2 centers and selected suitable left lobe living donor/recipient pairs. Since January 2005, 21 patients underwent AA-LDLT with left lobe grafts. Sixteen patients underwent the creation of an HPCS between the right portal vein and the inferior vena cava. The portocaval gradient (portal pressure À central venous pressure) was measured before the unclamping of the shunt and 10 minutes after unclamping. The median actual graft weight was 413 g (range ¼ 350-670 g), and the median GW/RW was 0.67 (range ¼ 0.5-1.0). The portocaval gradient was reduced from a median of 18 to 5 mmHg. Patient survival and graft survival at 1 year were 87% and 81%, respectively. SFSS developed in 1 patient, who required retransplantation. Two patients died at 3 and 10 months from a bile leak and fungal sepsis, respectively. The median recipient bilirubin level and INR were 1.7 mg/dL and 1.1, respectively, at 4 weeks post-transplant. One donor had a bile leak (cut surface). This is the first US series of small left lobe AA-LDLT demonstrating that the transplantation of small grafts with modulation of the portal inflow by the creation of an HPCS may prevent the development of SFSS while at the same time providing adequate liver volume. As it matures, this technique has the potential for widespread application and could positively effect donor safety, the donor pool, and waiting list times. Liver Transpl 16:649-657, Abbreviations: %SLV, percentage of the standard liver volume; AA-LDLT, adult-to-adult living donor liver

Liver Transplantation, 2019

Liver Transplantation, 2013

Adult living donor liver transplantation (aLDLT) is associated with surgical risks for the donor and with the possibility of small-for-size syndrome (SFSS) for the recipient, with both events being of great importance. An excessively small liver graft entails a relative increase in the portal blood flow during reperfusion, and this factor predisposes the recipient to an increased risk of SFSS in the postoperative period, although other causes related to recipient, graft, and technical factors have also been reported. A hemodynamic monitoring protocol was used for 45 consecutive aLDLT recipients. After various hemodynamic parameters before reperfusion were analyzed, a significant correlation between the temporary portocaval shunt flow during the anhepatic phase and the portal vein flow (PVF) after reperfusion of the graft (R 2 ¼ 0.3, P < 0.001) was found, and so was a correlation between the native liver portal pressure and PVF after reperfusion (R 2 ¼ 0.21, P ¼ 0.007). The identification of patients at risk for excessive portal hyperflow will allow its modulation before reperfusion. This could favor the use of smaller grafts and ultimately lead to a reduction in donor complications because it would allow more limited hepatectomies to be performed.

experimental and clinical transplant, 2014

Objectives: Small-sized grafts are associated with high rates of graft failure and small-for-size syndrome. Portal flow is a causative factor for small-for-size syndrome. We sought to evaluate early graft dysfunction in smaller-sized grafts and the study factors responsible for it. Materials and Methods: A total of 450 patients underwent a living-donor liver transplant from January 2010 to June 2013. Fifty-four grafts with graft/recipient's body weight ratio less than 0.8 were included in the study. We used a splenic artery ligation or splenectomy for portal flow modulation if the portal flow after reperfusion was greater than 250 mL/min/100 g. Small-for-size syndrome was defined according to Clavien and Kyushu university definitions. Portal flow was measured with Doppler ultrasound flowmetry. Factors responsible for early graft dysfunction also were analyzed. Results: Six patients out of 54 developed small-for-size syndrome in smaller size group (graft/recipient's body weight ratio < 0.8). There were 28 left lobe grafts and 26 right lobe grafts. Sixteen out of 132 patients from the control group fulfilled the definitions of small-for-size syndrome. There was no statistical significant difference in graft dysfunction between low graft/recipient's body weight ratio group and high graft/recipient's body weight ratio group. On univariate analysis Hepatitis C, Hepatitis B and HCC as etiologies, Model for End-stage Liver diease score, and portal flow achieved statistical significane as factors associated with graft dysfunction (P < .05). On multivariate analysis, only portal flow achieved statistical significance. Conclusions: Lower graft/recipient's body weight ratio graft with portal flow modulation in case of high portal flow is an effective way to increase donor pool and donor safety with low risk of small-for-size syndrome. Portal flow is mainly responsible for small-for-size syndrome or early graft dysfunction.

Transplantation, 2020

Introduction: Middle hepatic vein (MHV) reconstruction in right lobe is reported to contribute better outcome. Large congestion of anterior section in right lobe graft can be a potential cause of small for size syndrome (SFSS), and releasing this congestion with MHV reconstruction would improve the outcome. Another cause of SFSS is high flow volume of portal vein. Portal vein flow volume (PVFV) over 300 ml/min/100g graft weight (GW) was reported as a cause of SFSS. We report how the MHV reconstruction in right lobe graft contribute to better outcome by analyzing congestion area and portal vein flow volume. Material and method: From February 2017 to December 2018, we had 268 right lobe living donor liver transplantation with MHV reconstruction. MHV was reconstructed with autologous portal vein and consecutive umbilical vein. We classified patients into 4 groups according to PVFV per 100g graft weight, and congestion area ratio (CAR). Group 1 is PFFV < 300ml/m/100g GW, and CAR < 40%, including 83 patients. Group 2 is PF > 300ml/m/100g, and CAR > 40%, including 76 patients. Group 3 is PF < 300ml/m/100g, and CAR < 40%, including 63 patients. Group 4 is PF <300ml/m/100g, and CR <40%, and including 46 patients. As for Small for size syndrome (SFSS), group 1 is considered as low risk, group 2 and 3 are considered as medium risk, and group 4 patients are considered as high risk. We compared patients background, intraoperative data, and postoperative outcome (postoperative complications, SFSS, and survival) among these 4 groups. Results: There was no significant difference in preoperative status among 4 groups. Except for congestion area and portal flow volume, there was no significant difference in intraoperative data. There was no significant difference in postoperative complications, incidence of SFSS. The 2 year survival of each group showed no significant difference among 4 groups. Conclusion: The outcome of medium and high risk groups was equivalent to low risk group. MHV reconstruction release the congestion of anterior section and it also makes tolerate the high portal flow. These factors is considered to make the outcome of medium and high risk group comparable to that of low risk group, and finally the outcome of right lobe living donor liver transplantation result in better outcome.

Liver Transplantation, 2009

Clinical Transplantation, 2007

Liver Transplantation, 2013

Living donor liver transplantation (LDLT), originally used in children with left lateral segment grafts, has been expanded to adults who require larger grafts to support liver function. Most adult LDLT procedures have been performed with right lobe grafts, and this means a significant risk of morbidity for the donors. To minimize the donor risk for adults, there is renewed interest in smaller left lobe grafts. The smaller graft size increases the recipient risk in the form of small-for-size syndrome (SFSS) and essentially transfers the risk from the donor to the recipient. We review the donor and recipient risks of LDLT and pay particular attention to the different types of liver grafts and the use of graft inflow modification to ameliorate the risk of SFSS. Finally, a new metric is proposed for quantifying the recipient benefit in exchange for a specific donor risk.

ccccccccccccccccccccccc

Linen was a major commodity in pre-industrial societies. Despite this material being broadly used among all social ranks of Renaissance Florence, the linen industry has received scant attention by scholars who have instead mostly focused on the manufacture of high-quality woollen and silk cloth. An in-depth study of the household account books of several patrician families dating from the 15th and 16th centuries has allowed me to shed light on the importance of women in processing, exchanging and caring of flaxen fabrics. Drawing on a broad sample of unexplored women’s practical writings, this article will show how these economic activities were not just oriented to self-consumption and domestic use, but were often directed towards local and regional markets. I will also argue that women’s participation in this sector of textile production has been a determining factor allowing them to acquire a complex set of management skills within the household economy.