Randomized trial on extended versus modified right lobe grafts in living donor liver transplantation

Abstract

Despite advances in the practice of living donor liver transplantation (LDLT), the optimum surgical approach with respect to the middle hepatic vein (MHV) in right lobe LDLT remains undefined. We designed a randomized trial to compare the early postoperative outcomes in recipients and donors between extended right lobe grafts (ERGs; transection plane was maintained to the left of MHV and division of MHV performed beyond the segment VIII vein) and modified right lobe grafts (MRGs; transection plane was maintained to the right of MHV; the segment V and VIII drainage was reconstructed using a conduit of recipient portal vein). Eligible patients (n = 86) were prospectively randomized into the ERG arm (n = 43) and the MRG arm (n = 43) at the beginning of donor hepatectomy. The primary endpoint considered in this equivalence trial was patency of the MHV or the reconstructed "neo-MHV" in the recipient. The secondary endpoints included biochemical parameters, postoperative complications, mortality in recipients as well as donors and volume regeneration of remnant liver in donors, measured at 2 months. The patency of the MHV was comparable in the ERG and MRG arms (90.7% versus 81.4%; difference, 9.3%; 95% confidence interval [CI], -5.8 to 24.4; z score, 1.245; P = 0.21). Volume regeneration of the remnant liver in donors was significantly better in the MRG arm (111.3% versus 87.3%; mean difference, 24%; 95% CI, 14.6-33.3; P < 0.001). The remaining secondary endpoints in donors and recipients were similar between the 2 arms. To conclude, MRG with reconstructed neo-MHV has comparable patency to native MHV in ERG and confers equivalent graft outflow in the recipient. Furthermore, it allows better remnant liver regeneration in the donor at 2 months. Liver Transplantation 24 888-896 2018 AASLD.

Textbook outcome among voluntary donors undergoing major living donor hepatectomy

“…This technique has been proposed to reduce postoperative infections and damage to portal pedicles, preserve venous drainage and functional liver tissue [ 28 ]. In addition, modified right lobe grafts were preferred over extended grafts due to recent evidence indicating improved FLR regeneration with modified grafts [ 24 ]. We assume all these factors led to improvement in TO in the later period.…”

Technique of robotic right donor hepatectomy

“…Our evaluation process for LDRH has been described before. [ 3 ] In addition, prospective donors underwent magnetic resonance cholangiopancreatogram (MRCP) for delineation of bile duct anatomy.…”

Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in Living Donor Liver Transplantation: A Randomized Trial

“…A routine intraoperative cholangiogram was done to assess the donor biliary anatomy and to define the line of transection of the bile duct. As a unit protocol for all our patients, we choose the graft for implantation based on the future liver remnant in the recipient, graft‐to‐recipient weight ratio (GRWR), and the segment IV venous drainage . Among the study cohort in whom a right lobe was used, we used a modified right lobe graft (right lobe with reconstructed middle hepatic vein).…”

“…As a unit protocol for all our patients, we choose the graft for implantation based on the future liver remnant in the recipient, graft-to-recipient weight ratio (GRWR), and the segment IV venous drainage. (8) Among the study cohort in whom a right lobe was used, we used a modified right lobe graft (right lobe with reconstructed middle hepatic vein). The middle hepatic vein was reconstructed using the recipient portal vein except in patients with hepatocellular carcinoma (HCC) or when the native portal vein was deemed unusable wherein a polytetrafluoroethylene (GORE-TEX, Newark, DE) graft was used.…”