Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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While inflow occlusion techniques such as Pringle's maneuver are accepted methods of reducing bleeding without inducing liver injury during liver surgery, donor hepatectomy for living donor liver transplantation is currently performed without inflow occlusion for fear that injury to the graft may result. We have performed donor hepatectomy for 12 years using selective intermittent inflow occlusion, a technique in which the portion used to form the graft is perfused during hepatectomy. Starting in November 2000, we applied intermittent Pringle's maneuver to donor hepatectomy in 81 cases of living donor liver transplantation. ⋯ Maximum ALT values in the recipients of the total ischemia group was lower, albeit not significantly, than in other groups. Total inflow occlusion can be applied to living donor hepatectomy without causing graft injury. In conclusion, because the transection surface is blood-free, there is decreased risk to the donor during living donor liver transplantation surgery, and surgeons should not hesitate to apply this technique because it contributes to donor safety.
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The standard liver volume (LV) of a recipient is estimated in liver transplantation to determine the minimum LV necessary for the recipient. Simple linear formulas of LV estimation were developed for the Japanese and Caucasian populations. The present study examined the applicability of the reported formulas to the Korean population. ⋯ The Japanese formula produced underestimates for the Korean population (226.9 +/- 289.4 mL), while the Caucasian formula produced random errors (-30.64 +/- 281.5 mL). A better LV estimation formula was established: LV (mL) = 21.585 x BW (kg)(0.732) x BH (cm)(0.225) (adjusted R(2) = 0.59; SE = 275.8 mL). In conclusion, this study indicates that a nonlinear or piecewise linear model is more desirable than a simple linear model for LV estimation in children and adults, because LV / BW and LV / BSA are not constant with age and BSA.
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Comparative Study
Liver transplantation for hepatocellular carcinoma: lessons from the first year under the Model of End-Stage Liver Disease (MELD) organ allocation policy.
We examined the impact of the Model for End-Stage Liver Disease (MELD) organ allocation scheme on 44 patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT) between February 2002 and January 2003, and compared the outcome with 58 patients listed in the 4 years before MELD implementation. Patients undergoing living-donor liver transplantation were excluded. The Kaplan-Meier probabilities for OLT at 3, 6, and up to 8.5 months were 22.5%, 64.0%, and 88.0%, respectively, under MELD versus 17.2%, 24.7%, and 35.8% at 3, 6 and 9 months, respectively, in the pre-MELD group (P =.0006). ⋯ No HCC was found in the explant in 1 patient from each group. In conclusion, the HCC-adjusted MELD system significantly improved the probability of timely OLT, albeit a significant disadvantage for blood group O was evident. Compared with preliminary UNOS data, in which 90% of patients with HCC have received OLT within 3 months, our results reflect the wide regional variation in the impact of MELD.
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Liver transplantation is now an acceptable treatment for small hepatocellular carcinomas in the setting of cirrhosis. Larger tumors in cirrhotic livers and unresectable tumors in noncirrhotic livers (including fibrolamellar hepatocellular carcinomas) may also be indications for transplantation. With the limited number of cadaver grafts available, living donor liver transplant is becoming an option for some of these patients. We describe a method of reconstruction of the recipient inferior vena cava with deceased donor graft in right lobe living donation for fibrolamellar hepatocellular carcinoma.
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Living liver donors for adult liver transplant recipients undergo extensive liver resection. Partial donor hepatectomies may alter postoperative drug metabolism and hemostasis; thus, the risks and the benefits of pain management for this unique patient population may need to be reassessed. The safety and efficacy of combined epidural analgesia and field infiltration in our initial living liver donor group are presented. ⋯ This 2-site approach provided effective, safe, postoperative analgesia for our donors. Universally, coagulopathy ensued, indicating a potentially increased risk for epidural hemorrhage at epidural catheter removal and mandating close postoperative neurologic and laboratory monitoring. Research is needed to advance the understanding of postoperative coagulopathy and hepatic dysfunction in these donors to further optimize their perioperative management, including that of analgesia.