Dual Graft

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Asan Medical Center

Department of Surgery, Division of Hepato-Biliary Surgery and

Liver Transplantation, Ulsan University Medical School, Seoul, Korea

Chul-Soo Ahn, M.DSungGyu Lee, M.D.

From Two Donors To One Recipient

Dual Adult-to-Adult Living-DonorLiver Transplantation:


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Living-Donor Liver Transplantation in Adults:Living-Donor Liver Transplantation in Adults:

RightRightversusversus Left-sided Grafts?Left-sided Grafts?

o or

o or

RecipientRecipient

SafeSafe

HigherHigher

MortalityMortality

AscitesAscites

JaundiceJaundicerare mortalityrare mortality

HigherSuccess LowCholestasis

LeftLeftRightRight


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Even after adoption of Right-Lobe graft, 1/3 of adult re

cipients still suffer from negative impact of suboptimal G

RWR of less than 1.0 %.

DonorDonor SafetySafety

Small-for-Size Liver GraftSmall-for-Size Liver Graft

safe Donation is possible when the estimated residual

liver volume is > 30 %.

25% of Potential Donors has a large Right-Lobe ( > 70% of total liver volume)

More than 60 % Donor Hepatectomy may be risky in > 30%

steatotic liver.

IssuesIssues

in Adult Living-DonorPartial Liver Transplantation


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Minimum-required

Remaining Liver Vol

> 30% of SLV of

> 40% of SLV of

> 30% of total Liver volume of

> 35%of total Liver volu

of

Minimum-required

Graft Volume

recipient

recipient

Donor

Donor

To avoid Small-for-Size Graft and To secure Donor Safetyn LDLT at the Asan Medical Center

A B


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48 year-old male recipient

HBV-LC

Prothrombin time 33%

Total bilirubin 3.1mg/dl

172cm, 70Kg, A+

World First ase

Recipient

Donor 1:younger broth

Donor 2:daughter

> 70%> 70%

> 70%> 70%

360ml360ml

960ml960ml

250ml250ml

527ml527ml

(Mar. 2000)(Mar. 2000)


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226 cases of adult to adult LDLT

using dual grafts

57 (1; Cadaveric graft) 10

39 (6; LS) 2 7

Left lobe Left lob

e

Lateral segment

Left lobe

Lateral segment

Right lobe

Left lobe

Posterior segmen

t Lateral segmentPosterior segmen

t

Left

e

From March, 2000 to December, 2007

111

Lateral se


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Indication of LTIndication of LT

10 20 30 40 50 6010 20 30 40 50 60

188188

HBV-cirrhosisHBV-cirrhosis(62 HCC)(62 HCC)

12 FHF`11 HCV-cirrhosis

(1HCC)7Alcoh

olic

cirrhosis

30 Acute-on-Chronic

Liver Failure

Age DistributioAge Distributio

Male : Female = 194 : 32Male : Female = 194 : 32

( fromMarch, 2000 to December, 2007 )

Demographic Data of 266 Dual LDL

10 Other


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GRWR (%)GRWR (%)MedianMedian 0.98 0.98 0.980.98 0.790.79

MeanMean 0.990.99 0.140.14 0.990.99 0.150.15 0.790.79

RangeRange 0.640.64 1.291.29 0.590.59 1.391.39 0.490.49 11

Recipient Severity

ACLF 13 9 2

CTP 10 31 28

CTP < 10 26 8

Hospital Death 2 3 2

57 Right Lobe 45 Dual 36 Left L

Liver Graft Graft Liver Gr

Liver Graft Size at the year of 2003, AMC

GRWR (%)Median 0.98 0.98 0.79

Mean 0.99 0.14 0.99 0.15 0.79

Range 0.64 1.29 0.59 1.39 0.49 1


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Preop CT shows Massive Ascites (16 liters of ascites

in HBV-Cirrhosis and HCC(male, 53 year)

ACLF, MELD > 30 with H-R syndromeACLF, MELD > 30 with H-R syndrome


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Preop aftertwo left-lobes Dual LDL

Post-Transplant 3 we


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Does Donor Complication

become Twice

Does Recipient Complication

become Twice

Raised Questionsin Dual LDLT

because Two Donors are operated ?

because Vascular and Biliary

Anastomoses are two-folde?


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EarlyEarly

wound seroma 18wound infection 4

intraabdominal hematoma 3

arm paresthesia 1

transient bile leak 5pleural effusion 4

bile leak & catheter drainage 1

Re-exploration 1(Medial Segmentectomy for cut-surface

bile leak after Lateral Segmentectomy)

Mortality 0

LateLate 00

150DualA-A LDLTsfromMarch 2000 toDecember, 2004

Donor Complication in 299 living donors(1 deceased donor)


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Unilateral Graft Atrophy 10 ( 6 Right-

in Left-Liver Lobe and 4 Left-si

Left-Liver LobeCombination

Unilateral Graft HAT and 2

Graft Removal

HV Stenting for HV outflow Occlusion 19

PV Stenting for uneven inflow to Each Liver Graft 3

Biliary Stricture (Early and Late) 49 ( 24.3 % )Biliary Lekage 11 ( 5.45% )

Dual-Graft related post-operative Complication and

Procedure in 202Recipients

DualA-A LDLTsfrom

March, 2000 to December, 2006


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LL graftLL graft

LLS graftLLS graft

Atrophy and hypoperfusionof the right-sided graft

CompetitionCooperation

5 months post-LDLT2 months post-LDLT

Does Competitive Liver Regeneration

between both Grafts Develop

in Dual LDLT like APOLT ?

Liver Grafts Regeneration


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Right-sided Left Lobe Liver Graft

patic Vein Obstruction at posttransplant 3 month


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Pre-Stenting Post-Stenting

RA : 4 mmHg

HV : 16 mmHg

RA : 6 mmHg

HV : 7 mmHg


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Recovery of Right-sided Left Lobe Liver Graft

fter Hepatic Vein Stenting


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Incidence

29 of 202 (14.4 %)

27 were responded to

Pulsed Steroid Therapy

2 died of Refractory AR

Biopsy from both grafts

: 22 simultaneous occurrence

of AR

( 7 unilateral AR)

Acute Rejection after Dual A-A LDL


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I 11 ( 5.4 %)

2a 38 (18.9 %)

2b 98 (48.5 %)

3 55 (27.2 %)

I 18.1 % ( 2 /1

2a 15.8 % ( 6 /

2b 1 % ( 1 / 9

3 5.4 % ( 3 / 5

Total 5.9 % ( 12/2Emergency LDLT 9Urgent LDLT 33Elective LDLT 160

PreTransplant status and In-Hospital Mortal

of 202 Patients after Dual LDLTs

UNOS status In-Hospital Mortality


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UNOS GRWR cause survival UNOS GRWR cause s

Status (%) status (%)

1 2a 0.94 Portal Pyemia of 12days 7 2a 0.89 Massive HemorrhagicLeft Graft, Necrosis of LiverIntestinal Gangrene GraftLiver Failure

2 2a 0.89 Intracranial 52 days 8 2a 1.01 Bile Leak, Sepsis

Hemorrhage

3 2a 1.15 Refractory 37 days 9 1 1.00 Sepsis

Rejection Poor graft function

4 3 0.80 Portal Flow 14 days 10 1 1.24 Intestinal ischemic

Steal necrosis

5 2b 0.88 Intraabdominal abscess 12 days 11 3 1.65 Intracranial Hemorrhge

6 2a 1.00 intracranial 5 days 12 3 0.92 Biliary Sepsis

Hemorrhage, AR

Cause of

In-hospital mortality


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Re-explorationsRe-explorations 1313

UnilateralUnilateralLiver Graft RemovalLiver Graft Removal 22

In-Hospital MortalityIn-Hospital Mortality 12 12

Graft Loss within 1 yearGraft Loss within 1 year 1616

Patient Loss within 1 yearPatient Loss within 1 year 1515

Recipient Outcome in 202 patients

202DualA-A LDLTsfromMarch 2000 toDecember, 2006


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Dual LDLTDual LDLT

T200520042003200220012000199919981997 Year

205

27

201

55

142

44

123

27

91

8

116

12

1682412

000

2006

28

228

24

276

Living Donor Liver Transplantation

Asan Medical CenterAsan Medical Center

Adult LDLTLDLT

2007

(1997 March - 2007 December)


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Annual dual LDLTAnnual dual LDLT

Numbe

rofcases

Numbe

rofcases

In-Hospital Mortality who underwent Dual A-A LD

at the Asan Medical Center, Ulsan University

88

1122

11

4400

In hospital mortality

11 33

5555

4444

88 1212

2727 2727 2828


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Summary1. From March 21, 2000 toDecember 31, 2007, 225Dual A-A LDL

e performed among 1484A-A LDLTs(from Feb 1998 to Dec 20

ensure Donor Safetyand toavoid a small-for-size graft syndrome.

2. Major Donor Complication was lower than a single Right-Lobe

3. Acute Rejection developed in 14.4% and usually respondedto

pteroid therapy.

4. Although Dual LDLT is a complex procedure,

was 5.9% comparable to a single graft LDLT. Mortality was initi

high (20.7%) in UNOS 2a patients,but with increasing experience

UNOS 2a patients shows the good results.

5. Incidence and severity of long-term complications were almostr to a single graft LDLT.

in-hospital mor


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Dual Graft

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