Graft hyperperfusion in small-for-size grafts (SFSG) is considered the main causal factor of small-for-size syndrome (SFSS). We compared SFSG with a graft-torecipient body ratio ≤0.8, with and without graft inflow modulation (GIM) by means of a hemi-portocaval shunt (HPCS). Thirteen patients underwent adult-toadult living donor liver transplantation (AALDLT): G1, n = 5 [4 right livers (RL) and 1 left liver (LL)] without GIM, and G2, n = 8 (4 RL and 4 LL) with GIM. In G2 patients, portal vein flow (PVF) was significantly reduced by HPCS: 190 ± 70 mL/min/100 g liver in G2 vs. 401 ± 225 ml/min in G1 (p = 0.002). One-and 6-month post-transplantation graft volume/standard liver volume (GV/SLV) ratio was of 72% and 79.5% in G1; 80% and 101% in G2 (p = ns). SFSS was observed in three G1 recipients (who were retransplanted), but in none of the G2 patients. At 1-year, patient and graft survival was respectively of 40% and 20% in G1, 87.5% and 75% in G2 (p = 0.024 and 0.03).It is concluded that drastic reduction of PVF by means of HPCS improves overall patient and graft survival by averting the occurrence of SFSS. Graft inflow modulation through HPCS reduces the risk of complications when transplanting SFSG in adult recipients.

ABO-incompatible (ABO-I) liver transplantation is a controversial issue because of the generally less favorable outcome as compared to compatible transplants. Encouraging results have been shown by the introduction of new strategies to reduce posttransplant-specific hemagglutinin (HA) titers with plasmapheresis, reinforced immunosuppression (IS), and the use of splenectomy. We describe a new protocol consisting of daclizumab (DAC) induction, mycophenolate mofetil (MMF)/tacrolimus (TAC)/steroids without splenectomy. Five recipients (mean age of 47 Ϯ 14 yr) undergoing ABO-I living donor liver transplantation (LDLT) were included in this protocol. Immunoadsorbent columns (Glycosorb ABO) were used for antigenspecific immunoadsorption (ASI). The median follow-up was 18.5 Ϯ 10.5 months. ASI was very efficient in lowering HA titers (mean log 2 immunoglobulin [Ig] M [IgM] and IgG values before and after ASI were 5.9 Ϯ 2.8 and 1.2 Ϯ 1.4 [P ϭ 0.0038] and 6.5 Ϯ 2.3 and 1.1Ϯ 1.9, respectively [P ϭ 0.0001]). Persisting low HA titers were observed over time. No sepsis nor cytomegalovirus infection episodes were recorded. Acute cellular rejection (ACR) occurred in 1 recipient responding to steroid pulse therapy. Two grafts were lost in 2 patients due to technical failure during the first postoperative month. We conclude that ASI using Glycosorb ABO, quadruple immunosuppression including DAC and MMF provide high efficiency to lower HA titers over time, avoiding the need for splenectomy. ABO-I LDLT can be performed with this adapted IS protocol. Liver Transpl 12: 1412Transpl 12: -1417Transpl 12: , 2006 See Editorial on Page 1324Liver transplantation across ABO barriers is a controversial issue. The risks for severe acute rejection episodes, vascular thrombosis, and bile duct necrosis are high and predict the outcome. Indeed, early reports showed 1-yr graft survival of 66% or 2-yr graft survival of 30% for ABO-I liver transplants compared to 76% for compatible procedures. The global 5-yr graft survival rate was not higher than 20%. [1][2][3] Since the role of preformed complement-fixing hemagglutinin (HA) has been demonstrated in mediating hyperacute or severe rejection, several therapeutic protocols were proposed to decrease HA titers when crossing ABO barriers. [4][5][6] These protocols were based principally on plasma exchange and reinforced immunosuppression (IS) with antithymocyte globulin, OKT 3 induction, or cyclophos-

Long-term results of organ transplantation are still limited by serious side effects of immunosuppressive drugs. A major issue, therefore, is to elaborate novel therapeutic protocols allowing withdrawal or minimization of immunosuppressive therapy after transplantation. We report on 3 patients prospectively enrolled in an original protocol designed to promote graft acceptance in living donor liver transplantation, using posttransplant conditioning with high doses of antithymocyte globulin followed by injection of donor-derived stem cells. In 2 patients, early immunosuppression withdrawal was possible, without subsequent graft deterioration. In these 2 cases, in vitro studies showed indices of immunological tolerance as assessed by specific hyporesponsiveness to donor alloantigens in mixed lymphocytes culture. In the third patient, acute rejection rapidly occurred after discontinuation of immunosuppression, and minimal immunosuppression has to be maintained during long-term followup. In this case, a clearly distinct immunoreactive profile was observed as compared to tolerant patients, as no specific modulation of the antidonor response was observed in vitro. Of note, no macrochimerism could be detected in any of the 3 patients during the follow-up. In conclusion, these clinical observations demonstrated that, despite the absence of macrochimerism, donor stem cells infusion combined with recipient conditioning may allow early immunosuppression withdrawal or minimization after liver transplantation. Liver Transpl 12:1523Transpl 12: -1528Transpl 12: , 2006

Split liver transplantation with eRLG according to the patient-oriented allocation policy can be performed under emergency or urgent care circumstances with acceptable morbidity and adequate long-term survival.

BackgroundLaparoscopic left lateral sectionectomy (LLS) has gained popularity in its use for benign and malignant tumors. This report describes the evolution of the authors’ experience using laparoscopic LLS for different indications including living liver donation.MethodsBetween January 2004 and January 2009, 37 consecutive patients underwent laparoscopic LLS for benign, primary, and metastatic liver diseases, and for one case of living liver donation. Resection of malignant tumors was indicated for 19 (51%) of the 37 patients.ResultsAll but three patients (deceased due to metastatic cancer disease) are alive and well after a median follow-up period of 20 months (range, 8–46 months). Liver cell adenomas (72%) were the main indication among benign tumors, and colorectal liver metastases (84%) were the first indication of malignancy. One case of live liver donation was performed. Whereas 16 patients (43%) had undergone a previous abdominal surgery, 3 patients (8%) had LLS combined with bowel resection. The median operation time was of 195 min (range, 115–300 min), and the median blood loss was of 50 ml (range, 0–500 ml). Mild to severe steatosis was noted in 7 patients (19%) and aspecific portal inflammation in 11 patients (30%). A median free margin of 5 mm (range, 5–27 mm) was achieved for all cancer patients. The overall recurrence rate for colorectal liver metastases was of 44% (7 patients), but none recurred at the surgical margin. No conversion to laparotomy was recorded, and the overall morbidity rate was 8.1% (1 grade 1 and 2 grade 2 complications). The median hospital stay was 6 days (range, 2–10 days).ConclusionsLaparoscopic LLS without portal clamping can be performed safely for cases of benign and malignant liver disease with minimal blood loss and overall morbidity, free resection margins, and a favorable outcome. As the ultimate step of the learning curve, laparoscopic LLS could be routinely proposed, potentially increasing the donor pool for living-related liver transplantation.