A review of current status of living donor liver transplantation

Abstract

Living donor liver transplantation (LDLT) has become an inevitable procedure in Asia due to its shortage of deceased donor under the influence of the religion and native cultures. Through a broad variety of experience, LDLT has been evolved and extended its indication. Although there have been many surgical and ethical efforts to prevent donor risk, concerns of donor's safety still are remaining questions due to its strict selection criteria. Therefore, dual grafts LDLT or ABO incompatible (ABO-I) LDLT may be effective means in its application and safety aspect. Many Asian LDLT centers have pointed out the useful extended criteria of LDLT for hepatocellular carcinoma (HCC), but the applicability of extended criteria should be validated and standardized by worldwide prospective studies based on the Milan criteria. Recent struggling efforts have been reported to surmount extensive portal vein thrombosis and Budd-Chiari syndrome which were previously contraindicated to LDLT. There is no doubt that LDLT is a surely complicated therapy to be performed successfully and requires devoted efforts by surgeons and co-workers. Nonetheless, comprehensive increasing understandings of partial graft LT and improvements of surgical techniques with challenges to obstacles in LDLT will make its prosperity with satisfactory outcomes.

Keywords: Living donor; current status; liver transplantation; surgical technique.

Figure 1

(A) Postoperative CT revealed retrohepatic IVC stenosis with thrombosis extending to the infrarenal IVC: it was caused by the intention of long stump at graft side during the procurement of the right hepatic vein in right lobe donation; (B) intraoperative cavogram showed resolved IVC stenosis without thrombosis after thrombectomy with cavoplasty. CT, computed tomography; IVC, inferior vena cava.

Figure 2

(A) On the postoperative CT was noted mild intrahepatic ductal dilatation with suspicious of multifocal strictures and wall thickenings in ABO-I adult LDLT using right lobe graft; (B) postoperative cholangiogram through the external biliary stent showed multifocal stenosis with peripherally dilated intrahepatic ducts. CT, computed tomography; ABO-I, ABO incompatible; LDLT, living donor liver transplantation.

Figure 3

(A) Postoperative CT revealed intrahepatic ductal dilatation at right anterior section in right lobe LDLT with duct-to-duct biliary anastomosis; (B) endoscopic retrograde cholangiogram showed biliary anastomosis site stricture (in B₁). After crossing over stricture site with balloon dilatation (in B₂), two biliary stents were inserted (in B₃). CT, computed tomography; LDLT, living donor liver transplantation.

Figure 4

(A) Postoperative CT revealed suspicious right hepatic vein stenosis in right lobe LDLT; (B) doppler ultrasonography showed that the flow pattern of RHV was monophasic; (C) on hepatic venography, pressure gradient between RHV and IVC was over 6 mmHg (C₁). After RHV stenting (C₂), pressure gradient was solved. CT, computed tomography; LDLT, living donor liver transplantation; RHV, right hepatic vein; IVC, inferior vena cava.

Figure 5

(A) Preoperative CT showed extensive PVT with sizable portosystemic collaterals; (B) in spite of PV thrombectomy in RL LDLT, IOCP showed no portal flow owing to portal flow steal via portosystemic shunts (B₁). After PV stenting with balloon dilatation (B_2,3) and coil embolizations of remaining collaterals (B_4,5), restoration of PV flow to the graft was made with good patency (B₆). CT, computed tomography; PVT, portal vein thrombosis; LDLT, living donor liver transplantation; IOCP, intraoperative cineportography.