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Volume: 11 Issue: 6 December 2013 - Supplement - 2

FULL TEXT

LECTURE
High Volume of Living Donor Liver Transplant Without Deceased Donor Backup: Outcomes, Insight and Lessons To Be Learned

Introduction: Living donor liver transplantation (LDLT) is a well established and acceptable therapeutic modality for end stage liver diseases especially in countries like Egypt where transplantation from a deceased donor is not a viable alternative. We present the outcomes of 1905 LDLT cases from the Egyptian registry performed in eleven years and discuss the lessons learned from our collectible experience.

Methods: Between August 2001 to December 2012, 1905 LDLT cases were performed in ten centers, adults represented 93.5% (1781 patients, mean age 53.65 years) while 124 (6.5%) were pediatrics cases (mean age 7.7 years). The main indication for LDLT in adults was HCV cirrhosis (92%, with or without hepatocellular carcinoma [HCC]) with a mean MELD score of 18. HCC cases were 450 (27%) and 86% of them were within Milan criteria. Down staging was performed in 42 cases (12%) either by liver resection, radiofrequency ablation and/or trans-arterial chemo-embolization (TACE). The main indication in the pediatric was biliary atresia (52%). A single pediatric case with central hepatoblastoma received LDLT and chemotherapy.

Results: Operative mortality occurred in 22 recipients (1%). Donor mortality occurred in four donors (0.21%); the first died3 months post donation due to biliary leak followed by severe infection, septicemia and multi organ failure, the 2nd died 12 days after donation due to portal vein thrombosis, in the3rd donor mortality occurred due to right sub-clavian artery injury during central line insertion with massive hemo-thorax and the 4th died one month after donation due to hepatic insufficiency and hepatic failure. Major morbidity: Hepatic insufficiency and LDLT was done after 4 weeks post donation. In the adult recipients mortality was 31.4% versus 22.7% for the pediatrics. Biliary complications occurred in 24.7% and clinical HCV recurrence was 11% requiring anti-viral treatment. In adult recipients with HCC, first year recurrence was 10%, 3 years recurrence was 15%. Five year survival was 58% and the mortality rate due to tumor recurrence was 13.6%. The hepatoblastoma case has been doing well for the last 8 years with no recurrence.

Lessons learned from our collectible experience.

  1. Assessment of CT arteriography, portography and MRCP for all donors for anatomical variations. Exclusion of donors if the graft includes more than 3 ducts. This because of the problems of high incidence of biliary complications and its impact on the results. Increased incidence graft congestion and failure due to increase number of hepatic veins (V5and V8).
  2. Liver biopsy for all donors, and the remaining liver volume not less than 35% because, abundance of donor operation (12cases) due to liver quality. Also because of the prevalence of liver diseases, donor mortality and major morbidity that leads to Hepatic insufficiency and LDLT for a donor 4 weeks post donation.
  3. Age limit of the recipients Males 65years females 60 years.
  4. Recipients having HCC must be within Milan criteria.

Conclusion: LDLT is a potentially safe procedure especially when cadaveric liver transplantation is unavailable in countries like Egypt. The long term survival and disease free survival rate in patients with HCC transplanted by LDLT is comparable to those using diseased donors. Although LDLT had reasonable outcomes; yet, it carries considerable risks to healthy donors, lacks cadaveric back up and is not feasible for all patients.



Volume : 11
Issue : 6
Pages : 6


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Past President, PALTS
Professor of Hepatobiliary and Liver Transplant Surgery
National Liver Institute, Menoufyia Universiy
Menoufiya, Egypt