Adult-to-adult living donor liver transplantation at the Asan Medical Center, Korea.

Between February 1997 and December 2001, 311 adult-to-adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (203), chronic hepatitis C (5), hepatocellular carcinoma (64), alcoholic cirrhosis (9), cryptogenic cirrhosis (4), secondary biliary cirrhosis (5), primary biliary cirrhosis (1), Wilson' s disease (2), autoimmune hepatitis (1), hepatic tuberculosis (1), cholangiocarcinoma (1), fulminant hepatic failure (14) and primary non-function of cadaveric liver graft (1). Of 311 A-A LDLTs, 36 were of medical high urgency, 20 were for acute and subacute hepatic failure, 15 were for hepato-renal syndrome and 1 was for primary non-function. Recipient age ranged from 27 to 64 years. Donor age ranged from 16 to 62 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 175 modified right lobe (MRL), 70 left lobe, 32 right lobe, 20 dual grafts, 10 left lobe plus caudate lobe, three extended right lobe and one posterior segment. In MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and four of 20 were emergency cases. Of 20 dual grafts, 14 received two left lobes, four received a left lobe and a lateral segment, one received a right lobe and a left lobe and one received a lateral segment and a posterior segment. Graft volume ranged from 28% to 83% of the standard liver volume of the recipients. There were 33 (10.6%) in-hospital mortalities (< 4 months) among the 310 patients after 311 A-A LDLTs. Of the 36 patients receiving emergency transplants, 31 survived. These encouraging results justify the expansion of A-A LDLT in coping with increasing demands, even in urgent situations. We have aimed to introduce the establishment of the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome small graft-size syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.

One hundred and eleven liver resections for hilar bile duct cancer.

A positive correlation between absence of residual tumor at resection margins and long-term survival in the treatment of hilar bile duct carcinoma has encouraged some surgeons to use a more radical approach, including liver/portal vein resection and combined pancreatoduodenectomy. However, if liver resection is associated with significant morbidity and mortality, it may not produce any overall benefit. This review was undertaken in an attempt to determine whether liver resection is a safe procedure and whether if has any beneficial effect over that of local bile duct excision alone, in terms of achieving curative resection and long-term survival. The records of 151 patients with hilar bile duct carcinoma surgically treated between June 1989 and December 1997 at the Asan Medical Center, Seoul, were retrospectively analyzed. Surgical resection was possible in 128 patients. The remaining 23 patients had surgical palliative drainage. Local bile duct excision alone was performed in 17 patients. Liver resection for tumor extending to secondary bile ducts or hepatic parenchyma was performed in 111 patients; portal vein resection was necessary in 29 of these 111 patients (26.1%) and pancreatoduodenectomy was combined in 18 patients (16.2%). Seven patients died during hospitalization after liver resection, an operative mortality of 6.3%. Margins of bile duct resection were free of tumor on histologic examination in 4 of the 17 local bile duct excisions, but in 86 of the 111 liver resections. The cumulative survival rate after local bile duct excision was 85.7% at 1 year, 42.9% at 2 years, 21.4% at 3 years, and 0% at 4 years. However, the survival rate after liver resection (excluding operative mortality) was 97.1% at 1 year, 72.8% at 2 years, 55.3% at 3 years, and 24.0% at 5 years. Survival and the percentage of patients with tumor-free resection margins after liver resection were superior to those after local bile duct excision. Resection of hilar bile duct carcinoma offers long-term survival only when surgery is aggressive and includes liver resection.

Regeneration of graft liver in adult-to-adult living donor liver transplantation using a left lobe graft.

Graft size-matching is one of the critical concerns in adult-to-adult living donor liver transplantation (ATALDLT). In this study, we evaluated regeneration of a small-for-size graft less than 50% of the standard liver volume (SLV). We reviewed nine patients of united network of organ sharing (UNOS) status 2 or 3 who had undergone ATALDLT with a left lobe graft. For the comparison of liver regeneration, 20 hepatectomized patients for biliary malignancy were selected as non-transplant control group. In the ATALDLT group, graft size ranged from 30 to 49% of the SLV of recipients and their regeneration rates were 158%, 182%, 200% and 185% after 1,2, 3 and 4 weeks following transplantation, respectively. In the control group, preoperative volume of left lobe to whole liver volume ranged between 40 and 54% and their regeneration rates were 145%, 156%, 163% and 177% after 1,2, 3 and 4 weeks following extended right lobectomy, respectively. There was no statistical difference in regeneration rates between two groups. In the ATALDLT group, serum aspartate aminotransferase showed the median peak level of 198 IU/L on the first postoperative day and it was normalized within one week. Recovery of bilirubin clearance lagged behind rapid volume regeneration by about one week. Two patients died of sepsis. We postulate that the regenerative power of small-for-size grafts from living donors is preserved, although time-lag between volume regeneration and metabolic capability occurs in small-for-size grafts, when the initial graft volume meets metabolic demands during the early postoperative days.

Extracorporeal shockwave lithotripsy of primary intrahepatic stones.

Extracorporeal shockwave lithothripsy (ESWL) was performed in intrahepatic stone patients (n = 18) by Dornier MPL 9,000 with ultrasound guidance. The patients had T-tube (n = 9) or percutaneous transhepatic biliary drainage tube (n = 9). Average treatment session was four and shock-wave numbers were in the range of 3,064 to 12,000 (average 6,288 shocks). Intrahepatic stones were removed completely in 16 patients over a 3 month period by ESWL and combined stone extraction maneuver such as cholangioscopic or interventional radiologic method. Extracorporeal shockwave lithothripsy was very helpful in facilitating extraction of stones in unfavorable locations or located above the severe stricture. In summary, extracorporeal shockwave lithotripsy, followed by percutaneous stone extraction, will provide an improvement in the success rate and duration of treatment required for complete removal of primary hepatolithiasis.