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 Kyoto University 2005 Ghent Ghent
Ghent 2005. “Small-for-size syndrome in liver surgery” Symposium. How far can we go with suboptimal grafts in LDLT. Fumitaka Oike and Koichi Tanaka Dept. Transplant Surgery, Kyoto University, Japan. Kyoto University 2005 Ghent. - PowerPoint PPT Presentation
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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 2005Kyoto University 2005 Ghent Ghent
Kyoto University 2005Kyoto University 2005 Ghent Ghent
Figure 6. Algorithm for the graft selection
Right lobe graft
MHV dominant RHV dominant
GRWR>1.0% GRWR>1.0%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 lobewithout MHV
Right lobewith MHV
Discussion*Right lobewith partial MHV
Right lobewith MHV
Discussion*
Algorithm for the graft selection
Kyoto University 2005Kyoto University 2005 Ghent 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 2005Kyoto University 2005 Ghent 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
B C D
E
Kyoto University 2005Kyoto University 2005 Ghent 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
PODPOD
IntraOpeIntraOpe
PVP PVP
10
12
14
16
18
20
10
12
14
16
18
20
**
3311 55 77 99 1111 1313
**
**
**
**
******
**
**
SAL (n=9)Non-SAL (n=86)SAL (n=9)Non-SAL (n=86)
(mmHg)(mmHg)
*P<0.01-0.05*P<0.01-0.05
PV reflow PV reflow
Splenic artery ligation in adult LDLT
Kyoto University 2005Kyoto University 2005 Ghent Ghent
Years after LTxYears after LTx11 2200
00
5050
100100(%)(%)
Gra
ft s
urvi
val
Gra
ft s
urvi
val
SAL (n=9) (PVP < 20 in all cases)GRWR: 0.79-1.28 (0.93)%
SAL (n=9) (PVP < 20 in all cases)GRWR: 0.79-1.28 (0.93)%
Non-SAL (n=18)PVP ≥ 20, GRWR: 0.73-1.43 (1.02)%
Non-SAL (n=18)PVP ≥ 20, GRWR: 0.73-1.43 (1.02)%
Non-SAL (n=68)PVP < 20, GRWR: 0.76-2.02 (1.12)%
Non-SAL (n=68)PVP < 20, GRWR: 0.76-2.02 (1.12)%
P<0.01P<0.01
Optimal outflow reconstruction and porto-caval shunt
Kyoto University 2005Kyoto University 2005 Ghent 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 2005Kyoto University 2005 Ghent Ghent