Ann Liver Transplant.  2021 May;1(1):48-57. 10.52604/alt.21.0010.

Living donor liver transplantation-associated retransplantation in adult patients

• Moon DB
• Hwang S
• Ahn CS
• Ha TY
• Song GW
• Jung DH
• Park GC

• KMID: 2560852
• DOI: http://doi.org/10.52604/alt.21.0010

Abstract

Adult-to-adult living donor liver transplantation (LDLT) has been established as a successful alternative to help solve the serious shortage problem of deceased donor (DD) grafts. LDLT-associated retransplantation has been much less frequently performed than DD liver transplantation-associated retransplantation due to lower incidence of primary nonfunction, advance in surgical technique for LDLT, and organ shortage for retransplantation. Common causes of retransplantation include immunologic rejection, primary nonfunction or severe dysfunction, biliary complications, recurrence of primary disease and vascular complications. LD-associated retransplantation can be classified into three types according to the sequences of the grafts used: LD-to-LD, LD-to-DD, and DD-to-LD because different surgical techniques should be considered according to the different sequences. They are also re-classified into two types according to the retransplantation timing: early and late. The most typical type of LDLT-associated retransplantation is early LD-to-DD retransplantation. Any cause of early graft failure can be indicated for this type of retransplantation if a DD organ is available. For early LD-to-LD retransplantation, the type of second liver graft and hepatic arterial inflow source should be considered prudently. Early DD-to-LD retransplantation has been usually applied to primary non-function of the first DD liver graft. Late LD-to-LD or DD-to-LD retransplantation is not recommended because of heavy adhesion and anatomical distortion. The outcome of LDLT-associated retransplantation appears to be inferior to that of DDto-DD retransplantation. There are several technical limitations. Procurement of a LD liver graft with long vascular stumps is not allowed. Thus, alternative methods of vascular reconstruction are often required, which have high technical difficulty. Furthermore, the timing of retransplantation is usually suboptimal, given the shortage of DD and LD grafts and the urgency involved with the failing first liver graft. Fundamental requirements for improving retransplantation results include expanding the donor pool and having a proper timing of retransplantation.

Keyword

Living donor; Deceased donor; Graft failure; Chronic rejection; Primary nonfunction

Figure

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  Figure 1 Posttransplant findings of severe early graft dysfunction following living donor liver transplantation using a modified right liver graft. The liver graft shows extensive parenchymal infarct (A, B) with intact inflow and outflow vessels (C). The explant liver shows massive coagulative necrosis (D).

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  Figure 2 Intraoperative photographs showing heavy adhesion around the liver graft. First living donor liver transplantation using a modified right liver graft was performed 7 years (A) and 5 years (B) before.

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  Figure 3 Schematic illustration showing various sources of the hepatic artery inflow used for living donor liver transplantation using a right liver graft. RGEA indicates the right gastroepiploic artery.

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  Figure 4 Intraoperative photographs showing the retrogastric running course (A) of the isolated right gastroepiploic artery and its anastomosis with the right hepatic artery of the graft (B). Arrows indicate the right gastroepiploic artery.

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  Figure 5 Images showing preparation of the recipient inferior vena cava (IVC) for deceased whole liver retransplantation after initial living donor liver transplantation. (A) The failed liver graft is completely removed and the supra- and infrahepatic IVC stumps are deeply clamped. (B) Relatively long IVC stumps are left. (C) The hepatic vein stumps at the suprahepatic IVC stump are unified to be suitable for anastomosis.

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  Figure 6 Intraoperative photograph showing deep total clamping of the retrohepatic inferior vena cava.

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  Figure 7 Schematic illustration showing early retransplantation using a modified right liver graft after deceased donor whole liver transplantation. The interposed vessels originated from the deceased donor (DD) graft included the retrohepatic inferior vena cava (IVC), main portal vein (PV) and hepatic artery (HA). RHV, V5 and V8 indicate the right hepatic vein, segment V hepatic vein and segment VIII hepatic vein, respectively.

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  Figure 8 Schematic illustration showing late retransplantation using a modified right liver graft after living donor liver transplantation. The right hepatic vein (RHV) stump is newly made with vein patch venoplasty. The portal vein (PV) is interposed with a large-caliber vein graft. The right gastroepiploic artery (RGEA) is used for hepatic artery (HA) reconstruction.

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  Figure 9 Intraoperative photograph showing an aorto-hepatic jump graft during retransplantation using a modified right liver graft. Arrow indicates an interposed iliac artery homograft.

Reference

References

1. Braun HJ, Grab JD, Dodge JL, Syed SM, Roll GR, Schwab MP, et al. 2020; Retransplantation after living donor liver transplantation: data from the adult to adult living donor liver transplantation study (A2ALL). Transplantation. [Epub ahead of print]. DOI: 10.1097/TP.0000000000002783. PMID: 31107823. PMCID: PMC7087460.

2. Kuramitsu K, Fukumoto T, Egawa H, Ohdan H, Umeshita K, Uemoto S, et al. 2020; A multicenter Japanese survey assessing the long-term outcomes of liver retransplantation using living donor grafts. Transplantation. 104:754–761. DOI: 10.1097/TP.0000000000002958. PMID: 31568214.

3. Lerner SM, Markmann J, Jurim O, Busuttil RW. 2005; Retransplantation. In: Busuttil RW, Klintmalm GB, eds. Transplantation of the liver. 2nd ed. Philadelphia:. Saunders,. 767–775. DOI: 10.1016/B978-0-7216-0118-2.50056-2.

4. Busuttil RW, Farmer DG, Yersiz H, Hiatt JR, McDiarmid SV, Goldstein LI, et al. 2005; Analysis of long-term outcomes of 3200 liver transplantations over two decades: a single-center experience. Ann Surg. 241:905–916. discussion 916-918. DOI: 10.1097/01.sla.0000164077.77912.98. PMID: 15912040. PMCID: PMC1357170.

5. Olthoff KM, Merion RM, Ghobrial RM, Abecassis MM, Fair JH, Fisher RA, et al. A2ALL Study Group. 2005; Outcomes of 385 adult-to-adult living donor liver transplant recipients: a report from the A2ALL Consortium. Ann Surg. 242:314–323. discussion 323-325. DOI: 10.1097/01.sla.0000179646.37145.ef. PMID: 16135918. PMCID: PMC1357740.

6. Hwang S, Lee SG, Lee YJ, Park KM, Choi DN, Ahn CS, et al. 2002; A case of primary non-function following adult-to-adult living donor liver transplantation. Hepatogastroenterology. 49:1412–1414.

7. Colombani PM, Lau H, Prabhakaran K, Maley W, Wise B, Schwarz K, et al. 2000; Cumulative experience with pediatric living related liver transplantation. J Pediatr Surg. 35:9–12. DOI: 10.1016/S0022-3468(00)80004-4.

8. Sugawara Y, Makuuchi M. 2004; Advances in adult living donor liver transplantation: a review based on reports from the 10th anniversary of the adult-to-adult living donor liver transplantation meeting in Tokyo. Liver Transpl. 10:715–720. DOI: 10.1002/lt.20179. PMID: 15162463.

9. Moon DB, Lee SG. 2004; Adult-to-adult living donor liver transplantation at the Asan Medical Center. Yonsei Med J. 45:1162–1168. DOI: 10.3349/ymj.2004.45.6.1162. PMID: 15627313.

10. Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, Song GW, et al. 2013; Liver retransplantation for adult recipients. Korean J Hepatobiliary Pancreat Surg. 17:1–7. DOI: 10.14701/kjhbps.2013.17.1.1. PMID: 26155206. PMCID: PMC4304506.

11. Ahn CS, Lee SG, Hwang S, Moon DB, Ha TY, Lee YJ, et al. 2005; Anatomic variation of the right hepatic artery and its reconstruction for living donor liver transplantation using right lobe graft. Transplant Proc. 37:1067–1069. DOI: 10.1016/j.transproceed.2005.01.068. PMID: 15848624.

12. Ahn CS, Hwang S, Moon DB, Song GW, Ha TY, Park GC, et al. 2012; Right gastroepiploic artery is the first alternative inflow source for hepatic arterial reconstruction in living donor liver transplantation. Transplant Proc. 44:451–453. DOI: 10.1016/j.transproceed.2012.01.057. PMID: 22410041.

13. Wei WI, Lam LK, Ng RW, Liu CL, Lo CM, Fan ST, et al. 2004; Microvascular reconstruction of the hepatic artery in live donor liver transplantation: experience across a decade. Arch Surg. 139:304–307. DOI: 10.1001/archsurg.139.3.304. PMID: 15006889.

14. Hwang S, Lee SG, Sung KB, Park KM, Kim KH, Ahn CS, et al. 2006; Long-term incidence, risk factors, and management of biliary complications after adult living donor liver transplantation. Liver Transpl. 12:831–838. DOI: 10.1002/lt.20693. PMID: 16528711.

15. Itabashi Y, Hakamada K, Narumi S, Toyoki Y, Totsuka E, Umehara Y, et al. 2000; A case of living-related partial liver transplantation using the right gastroepiploic artery for hepatic artery reconstruction. Hepatogastroenterology. 47:512–513.

16. Yao FY, Saab S, Bass NM, Hirose R, Ly D, Terrault N, et al. 2004; Prediction of survival after liver retransplantation for late graft failure based on preoperative prognostic scores. Hepatology. 39:230–238. DOI: 10.1002/hep.20005. PMID: 14752842.

17. Burton JR Jr, Sonnenberg A, Rosen HR. 2004; Retransplantation for recurrent hepatitis C in the MELD era: maximizing utility. Liver Transpl. 10(10 Suppl 2):S59–S64. DOI: 10.1002/lt.20259. PMID: 15382221.

18. Burton JR Jr, Rosen HR. 2005; Liver retransplantation for hepatitis C virus recurrence: a survey of liver transplant programs in the United States. Clin Gastroenterol Hepatol. 3:700–704. DOI: 10.1016/S1542-3565(05)00158-8.

19. Zimmerman MA, Ghobrial RM. 2005; When shouldn't we retransplant? Liver Transpl. (11 Suppl 2):S14–S20. DOI: 10.1002/lt.20599. PMID: 16237729.

20. Schnitzler MA, Woodward RS, Brennan DC, Whiting JF, Tesi RJ, Lowell JA. 2001; The economic impact of preservation time in cadaveric liver transplantation. Am J Transplant. 1:360–365. DOI: 10.1034/j.1600-6143.2001.10412.x. PMID: 12099381.

21. Totsuka E, Fung JJ, Lee MC, Ishii T, Umehara M, Makino Y, et al. 2002; Influence of cold ischemia time and graft transport distance on postoperative outcome in human liver transplantation. Surg Today. 32:792–799. DOI: 10.1007/s005950200152. PMID: 12203057.

22. Nakamura N, Nishida S, Neff GR, Vaidya A, Levi DM, Kato T, et al. 2005; Intrahepatic biliary strictures without hepatic artery thrombosis after liver transplantation: an analysis of 1,113 liver transplantations at a single center. Transplantation. 79:427–432. DOI: 10.1097/01.TP.0000152800.19986.9E. PMID: 15729168.

23. Schlitt HJ, Meier PN, Nashan B, Oldhafer KJ, Boeker K, Flemming P, et al. 1999; Reconstructive surgery for ischemic-type lesions at the bile duct bifurcation after liver transplantation. Ann Surg. 229:137–145. DOI: 10.1097/00000658-199901000-00018. PMID: 9923811. PMCID: PMC1191619.

24. Shimada M, Ijichi H, Yonemura Y, Harada N, Shiotani S, Ninomiya M, et al. 2004; Is graft size a major risk factor in living-donor adult liver transplantation? Transpl Int. 17:310–316. DOI: 10.1111/j.1432-2277.2004.tb00448.x. PMID: 15221124.

25. Kiuchi T, Tanaka K, Ito T, Oike F, Ogura Y, Fujimoto Y, et al. 2003; Small-for-size graft in living donor liver transplantation: how far should we go? Liver Transpl. 9:S29–S35. DOI: 10.1053/jlts.2003.50198. PMID: 12942476.

26. Ito T, Kiuchi T, Yamamoto H, Oike F, Ogura Y, Fujimoto Y, et al. 2003; Changes in portal venous pressure in the early phase after living donor liver transplantation: pathogenesis and clinical implications. Transplantation. 75:1313–1317. DOI: 10.1097/01.TP.0000063707.90525.10. PMID: 12717222.

27. Marcos A, Orloff M, Mieles L, Olzinski A, Sitzmann J. 2001; Reconstruction of double hepatic arterial and portal venous branches for right-lobe living donor liver transplantation. Liver Transpl. 7:673–679. DOI: 10.1053/jlts.2001.26568. PMID: 11510010.

28. Lee SG, Hwang S, Kim KH, Ahn CS, Park KM, Lee YJ, et al. 2003; Approach to anatomic variations of the graft portal vein in right lobe living-donor liver transplantation. Transplantation. 75(3 Suppl):S28–S32. DOI: 10.1097/01.TP.0000047028.97031.66. PMID: 12589136.

29. Lee SG, Park KM, Hwang S, Kim KH, Choi DN, Joo SH, et al. 2002; Modified right liver graft from a living donor to prevent congestion. Transplantation. 74:54–59. DOI: 10.1097/00007890-200207150-00010. PMID: 12134099.

30. Hwang S, Lee SG, Park KM, Kim KH, Ahn CS, Lee YJ, et al. 2004; Hepatic venous congestion in living donor liver transplantation: preoperative quantitative prediction and follow-up using computed tomography. Liver Transpl. 10:763–770. DOI: 10.1002/lt.20178. PMID: 15162471.

31. Chan SC, Lo CM, Liu CL, Wong Y, Fan ST, Wong J. 2004; Tailoring donor hepatectomy per segment 4 venous drainage in right lobe live donor liver transplantation. Liver Transpl. 10:755–762. DOI: 10.1002/lt.20114. PMID: 15162470.

32. Hwang S, Lee SG, Choi ST, Moon DB, Ha TY, Lee YJ, et al. 2005; Hepatic vein anatomy of the medial segment for living donor liver transplantation using extended right lobe graft. Liver Transpl. 11:449–455. DOI: 10.1002/lt.20387. PMID: 15776411.

33. Vivarelli M, Cavallari A, Buzzi M, Conte R. 2004; Successful arterial revascularization in liver transplantation using a cryopreserved arterial allograft. Transplantation. 77:792. DOI: 10.1097/01.TP.0000114592.04652.8B. PMID: 15021853.

34. Kuang AA, Renz JF, Ferrell LD, Ring EJ, Rosenthal P, Lim RC, et al. 1996; Failure patterns of cryopreserved vein grafts in liver transplantation. Transplantation. 62:742–747. DOI: 10.1097/00007890-199609270-00007. PMID: 8824470.

35. Settmacher U, Steinmüller T, Luck W, Eisele R, Theruvath T, Heise M, et al. 2003; Complex vascular reconstructions in living donor liver transplantation. Transpl Int. 16:742–747. DOI: 10.1111/j.1432-2277.2003.tb00234.x. PMID: 12827234.

36. Lee SS, Kim TK, Byun JH, Ha HK, Kim PN, Kim AY, et al. 2003; Hepatic arteries in potential donors for living related liver transplantation: evaluation with multi-detector row CT angiography. Radiology. 227:391–399. DOI: 10.1148/radiol.2272012033. PMID: 12676969.

37. Postma R, Haagsma EB, Peeters PM, van den Berg AP, Slooff MJ. 2004; Retransplantation of the liver in adults: outcome and predictive factors for survival. Transpl Int. 17:234–240. DOI: 10.1111/j.1432-2277.2004.tb00436.x. PMID: 15170527.

38. Yoo HY, Maheshwari A, Thuluvath PJ. 2003; Retransplantation of liver: primary graft nonfunction and hepatitis C virus are associated with worse outcome. Liver Transpl. 9:897–904. DOI: 10.1053/jlts.2003.50176. PMID: 12942450.