Surgical technique for right lobe adult living donor liver transplantationwithout venovenous bypass or portocaval shunting and with duct-to-duct biliary reconstruction

Objective To report the authors' experience with adult living donor liver t ransplantation (ALDLT) without venovenous bypass and to describe modificati ons that will allow for a direct duct-to-duct biliary reconstruction. Summary Background Data Adult living donor liver transplantation is being e valuated as a method to alleviate the organ shortage. Descriptions of the p rocedure have emphasized the use of venovenous bypass, portocaval decompres sion, and the mandatory use of a Roux-en-Y biliary enteric anastomosis. The authors describe a technique for ALDLT without venovenous bypass, portocav al decompression, or caval clamping in 11 recipients and describe the modif ications to the procedure that may allow a duct-to-duct biliary reconstruct ion in certain cases. Methods Between March 1999 and March 2000, 11 ALDLTs were performed at the authors' institution. All procedures were performed without venovenous bypa ss, portocaval decompression, or caval clamping. After a modification to th e procedure, five of the last six recipients underwent biliary reconstructi on with a direct duct-to-duct anastomosis. Data regarding donor, recipient, and graft survival, complications, and graft function were collected. Results Recipients comprised five women and six men, mean age 48 years. Don ors comprised five women and six men, mean age 36.5 years. Donor to recipie nt relationships included sibling, spouse, son, and daughter. Indications f or transplantation were hepatitis C, hepatitis C with hepatocellular carcin oma, primary biliary cirrhosis, primary sclerosing cholangitis, ethanol, an d cryptogenic. No case required venovenous bypass or portocaval shunting. T he right hepatic vein of the donor graft was anastomosed to the confluence of the left and middle hepatic veins in all cases, All donors are alive and well, with no adverse complications reported. Recipient and graft survival rates were 91% and 82%, respectively, for ALDLT versus 92% and 92% for rec ipients of cadaveric organs during the same time period. One recipient died of multiple organ failure and sepsis. Biliary reconstruction was performed by Roux-en-Y hepaticojejunostomy in the six cases. In five of the last six recipients, direct duct-to-duct biliary reconstruction with a T tube was u sed. No anastomotic leaks or strictures occurred in the patients undergoing duct-to-duct reconstruction. Conclusions Adult living donor liver transplantation can be performed safel y and may help alleviate the organ shortage. Neither venovenous bypass nor portocaval shunting is necessary to perform the procedure, and modification s to both the donor and recipient hepatectomy procedures may allow biliary reconstruction to be performed by a direct duct-to-duct anastomosis in sele cted cases.