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Living Donor Hepatectomy

Background

The history of liver surgery stretches back to ancient times, when battle surgeons introduced debridement of damaged liver segments from open wounds. However, formal entry into the abdominal cavity to treat a liver tumor or to drain an abscess began with the advent of general anesthesia and antisepsis in the late 1800s.

With a better understanding of hepatic anatomy and the segmental structure of the liver, surgeons started performing partial liver resections. The first successful resection of a liver tumor was performed in 1887 in Germany by Langenbuch, the same surgeon who performed the first successful cholecystectomy 5 years earlier.

The lessons learned during World War II concerning liver trauma, blood supply to the liver, and bleeding control spurred the confidence of liver surgeons and marked the beginning of the modern era of liver operations.
Two landmarks of paramount importance have marked this period. The first was Cuinaud’s detailed description of the segmental anatomy of the liver based on blood supply (see image below).
The second, and probably brightest landmark of this period, was the first whole-liver transplantation by Thomas Starzl in 1963.

Couinaud's segmental liver anatomy.

Couinaud’s segmental liver anatomy.

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As experience with liver resections increased dramatically while the supply of cadaveric liver grafts became increasingly inadequate to meet the needs for liver transplants, the concept of resecting a healthy person’s liver to use for support of another person’s life was raised.

The concept of living donor liver transplantation (LDLT) emerged originally for pediatric patients because of the high mortality rate among children awaiting a cadaveric graft
and the fact that a child needs only a small allograft, so an adult donor would not need to undergo major hepatectomy.

Raia et al
from Brazil described the first attempt of LDLT in children in 1989. Although the recipient did not survive, other centers followed, and the first successful pediatric LDLT, from a mother to her son, was performed by Strong in Australia that same year.

In the United States, the first successful LDLT from a parent to a child was performed the same year at the University of Chicago.
Before this first procedure, the physicians involved published a manuscript describing the protocol for donor and recipient selection, risks and benefits, and the use of the donor advocacy panel.
A few years later, reports first showed that the introduction of LDLT dramatically decreased the mortality of children on the waiting list.

With the success of the LDLT in the pediatric population, transplant centers started to embrace the idea of using LDLT in adult recipients. The first successful cases were reported in Japan, where cadaveric grafts are extremely scarce owing to cultural constrains to organ donation.
 Japanese transplant teams reported excellent results with the use of left- and right-lobe grafts.

The initial results from the LDLT experience in the United States were not as encouraging,
so the first decade of adult-to-adult LDLT developed very slowly, with only 34 such procedures performed between 1991 and 1998.
Many of the failures resulted from the underappreciated importance of donor graft size to recipient size. In the pediatric population, this issue was absent, since the size of the recipient was always much smaller than that of the donor. In adult patients, the graft was often too small, the posttransplant function was poor, and, in some cases, there was primary nonfunction.

After surgeons realized this concept and avoided smaller grafts for larger recipients, the success of adult-to-adult LDLT increased, along with the number of such transplantations performed. Thus, from 1998-2003, 1374 adult recipients underwent LDLT in the United States.
Enthusiasm for adult-to-adult LDLT in the United States peaked in 2000, with 49 centers performing this operation. However, the enthusiasm fell sharply after a donor death in 2001, which changed the climate for living donation.

From 2001-2006, the number of centers performing adult LDLT and the number of operations performed declined and then stabilized at around 250 cases per year, or 5% of the total number of liver transplantations in adults, approximately half of the peak in 2001.
After the donor death, numerous position papers, conferences, and review boards took place.
New York State created a review committee and document that mandated guidelines for transplant centers and physicians who perform LDLT.
Additionally, the National Institute of Health (NIH) sponsored a multicenter prospective study of adult-to-adult LDLT, which includes 9 centers in the United States. The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) has published outcomes and suggestions concerning LDLT in adult patients.

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