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

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 Donor and Recipient Factors Influencing Graft Survival Kyoto University 2005 Ghent

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 Years after LDLT Survival rate Kyoto University 2005 Ghent

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

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

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

Incidence of positive blood culture ( 3 posttransplant months ) n Bacteremia p PVP < % PVP ≥ % Portal vein pressure and infection Kyoto University 2005 Ghent

PVP (mmHg) <0.8% of BW (n=8) % of BW (n=30) ≥1.0% of BW (n=64) <0.8% of BW (n=8) % of BW (n=30) ≥1.0% of BW (n=64) POD * * * * * * * * * * * * * * * * * * *p< Intra- operative Intra- operative Graft size and portal vein pressure Kyoto University 2005 Ghent

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

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

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

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

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

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

Regeneration index for ant. and post. Segments Kyoto University 2005 Ghent Wilcoxon signed rank test p=0.007 Volume of the graft Anterior segmentPosterior segment

Venous anatomy and graft congestion in anterior segment without MHV Kyoto University 2005 Ghent

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 V5+8 Total right lobe Kyoto University 2005 Ghent

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

I MPACT OF V ENOUS C ONGESTION OF A NTERIOR S ECTOR right lobe graft without reconstruction of V5&V8 uneventful 15 y/o female Wilson disease 1.34 Graft: 1.34%BW 25 y/o female PSC 0.95 Graft: 0.95%BW 56 y/o female HBV-cirrhosis 0.98 Graft: 0.98%BW massive ascites prolonged cholestasis Kyoto University 2005 Ghent

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

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 2005 Ghent

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

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

Figure 4. The types of middle hepatic vein reconstruction with / without interposition vein graft. 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) A BCD E Kyoto University 2005 Ghent

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

POD IntraOpe PVP * * * * * * * * * * * * * * * * * * * * SAL (n=9) Non-SAL (n=86) SAL (n=9) Non-SAL (n=86) (mmHg) *P< PV reflow Splenic artery ligation in adult LDLT Kyoto University 2005 Ghent Years after LTx (%) Graft survival SAL (n=9) (PVP < 20 in all cases) GRWR: (0.93)% SAL (n=9) (PVP < 20 in all cases) GRWR: (0.93)% Non-SAL (n=18) PVP ≥ 20, GRWR: (1.02)% Non-SAL (n=18) PVP ≥ 20, GRWR: (1.02)% Non-SAL (n=68) PVP < 20, GRWR: (1.12)% Non-SAL (n=68) PVP < 20, GRWR: (1.12)% P<0.01

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

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 2005 Ghent