LIVING DONOR LIVER TRANSPLANTATION, 2 ED - 2nd
Edition
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vi Contents
12 Biliary Complications of Right Liver LDLT 249
Sheung Tat FAN
13 Small-for-Size Graft and Injury 281
Sheung Tat FAN
14 Donor Results 293
Sheung Tat FAN
15 Recipient Results 311
Sheung Tat FAN
Index 329
Authors
Sheung Tat FAN, SBS
MBBS, MS, MD, PhD, DSc, FRCS (Glasg), FRCS ad hominem (Edin), FACS, FCSHK, FHKAM (Surg); Doctor
of Humane Letters (honoris causa); Academician, Chinese Academy of Engineering (Medicine and Health)
Sun C.Y. Chair Professor of Hepatobiliary and Pancreatic Surgery and Head, Department of Surgery, The
University of Hong Kong, Queen Mary Hospital, Hong Kong
William Ignace WEI
MBBS, MS, DLO (Lond), FRACS (Hon), FACS (Hon), FRCS (Eng & Edin), FRACS (Hon), FCSHK, FHKCORL
(Hon), FHKAM (Surg), FHKAM (ORL)
Head, Department of Surgery and Director, Li Shu Pui ENT Head & Neck Surgery Centre, Hong Kong
Sanatorium & Hospital, Hong Kong; Li Shu Pui Professor of Surgery, Chair in Otorhinolaryngology,
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
Boon Hun YONG
MBBS, FRCP (Edin), FANZCA, FHKCA, FHKCA (Intensive Care), FHKAM
Consultant Anesthetist and Team Head, Liver Transplantation Anesthesia, Department of Anesthesiology,
Queen Mary Hospital, Hong Kong; Honorary Clinical Associate Professor, Department of Anesthesiology,
The University of Hong Kong, Hong Kong
Theresa Wan-Chun HUI
MBBS, FANZCA, FHKCA, FHKAM (Anesthesiol)
Consultant, Department of Anesthesiology, Queen Mary Hospital, Hong Kong; Honorary Clinical Associate
Professor, Department of Anesthesiology, The University of Hong Kong, Hong Kong
Alex CHIU
MBChB, MRCP (UK), FHKCP, FHKAM (Med), FRCP (Edin)
Specialist in Critical Care Medicine and Cluster Director (Quality and Safety), Hong Kong West Cluster,
Hospital Authority, Hong Kong
Peter Wing-Ho LEE
BSocSc, MSocSc (Clin Psychol), PhD, C Psychologist (BPS, HPC, UK), JP
Honorary Consultant, Clinical & Health Psychology Centre, Hong Kong Sanatorium & Hospital, Hong Kong;
Honorary Professor, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong
vii
Contributors
John CHAN
MBBS, DMRD (UK), FRCR (UK), FHKCR, FHKAM (Radiol)
Honorary Consultant Radiologist, Hong Kong Sanatorium & Hospital, Hong Kong; Honorary Clinical Assistant
Professor, Department of Diagnostic Radiology, The University of Hong Kong, Queen Mary Hospital,
Hong Kong
Kwong Leung CHAN
MBBS, MS, FRCS (Glasg), FACS, FHKAM, FCSHK
Senior Medical Officer, Department of Surgery, Queen Mary Hospital, Hong Kong; Honorary Clinical Associate
Professor, Department of Surgery, The University of Hong Kong, Hong Kong
See Ching CHAN
MS, PhD, FRACDS, FRCSEd, FHKAM
Consultant, Department of Surgery, Queen Mary Hospital, Hong Kong; Honorary Clinical Associate Professor,
Department of Surgery, The University of Hong Kong, Hong Kong
Siu Tim CHEUNG
BSc (Hon), PhD
Assistant Professor, Department of Surgery, The University of Hong Kong, Hong Kong
Tan To CHEUNG
MBBS, FRCS (Edin), FCSHK, FHKAM
Associate Consultant, Department of Surgery, Queen Mary Hospital, Hong Kong; Honorary Clinical Assistant
Professor, Department of Surgery, The University of Hong Kong, Hong Kong
Barbara CHIK
MBBS, FRCS (Edin), FCSHK, FHKAM (Gen Surg)
Senior Transplant Surgical Fellow, Transplantation Services, Royal Prince Alfred Hospital, New South Wales,
Camperdown, Australia
ix
x Contributors
Kenneth Shiu-Ho CHOK
MBBS, FRCS, FHKAM
Associate Consultant, Department of Surgery, Queen Mary Hospital, Hong Kong; Honorary Clinical Assistant
Professor, Department of Surgery, The University of Hong Kong, Hong Kong
Ma. Vanessa H. DE VILLA
BS, MD (Philippines), PhD (Navarre), FPCS, FPSTS
Director, Center for Liver Disease Management and Transplantation and Consultant, Department of Surgery,
The Medical City, The Philippines
Wendy FONG
BNurs
Advanced Practice Nurse, Operating Theatre, Hong Kong Baptist Hospital, Hong Kong
Amy Shuk-Man FUNG
BSocSc (First Class Hons), PGCert (Psychol), MSocSc (Clin Psychol), PhD
Head of Hong Kong West Cluster (Clinical Psychology) of Hospital Authority, Hong Kong; Head and Senior
Clinical Psychologist, Department of Clinical Psychology, Queen Mary Hospital, Hong Kong
Ching Lung LAI
MBBS (Hons), MD, FRCP (Lond, Edin & Glasg), FRACP, FHKAM (Med), FHKCP
Professor of Medicine and Hepatology, Department of Medicine, The University of Hong Kong,
Queen Mary Hospital, Hong Kong
Banny LAM
BSc (Kinesiol)
Liver Transplant Coordinator, Department of Surgery, The University of Hong Kong,
Queen Mary Hospital, Hong Kong
Brenda LAM
MSocSc (Clin Psychol)
Clinical Psychologist, Department of Clinical Psychology, Queen Mary Hospital, Hong Kong
Lai Kun LAM
MBBS, FRCSEd, FRACS, FCSHK, FHKAM (Surg)
Honorary Clinical Associate Professor, Department of Surgery, The University of Hong Kong,
Queen Mary Hospital, Hong Kong
George Ka-Kit LAU
MBBS, MD, MRCP (UK), FHKCP, FHKAM (Med), FRCP (Lond & Edin)
Gastroenterology and Hepatology Specialist, Humanity and Health Liver Clinic, Hong Kong;
Honorary Clinical Professor, Department of Medicine, The University of Hong Kong, Queen Mary Hospital,
Hong Kong; Honorary Clinical Professor, Beijing 302 Military Hospital, Beijing, China;
Honorary Clinical Professor, Institute of Hepatology, University College London, London, UK
Contributors xi
Evelyn LEE
RN, MSN
Nurse Instructor, School of Nursing, Union Hospital, Hong Kong
Libby LEE
MBBS, FHKCA, FHKAM, FANZCA, Dip Pain Mgt
Chief Manager, Patient Safety and Risk Management Department, Quality and Safety Division,
The Hospital Authority Head Office, Hong Kong
Chi Leung LIU
MBBS, MS, MD, FRCS (Edin), FACS, FCSHK, FHKAM (Surg)
Honorary Professor, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
Chung Mau LO
MBBS, MS, FRCS (Edin), FRACS, FHKAM (Surg), FCSHK
Chin Lan Hong Professor in Hepatobiliary and Pancreatic Surgery and Chief of Division of Hepatobiliary and
Pancreatic Surgery/Liver Transplantation, Department of Surgery, The University of Hong Kong,
Queen Mary Hospital, Hong Kong
Ying LUO
MS, PhD
Associate Professor, Division of Hepatobiliary Surgery, Department of Surgery,
General Hospital of P.L.A, Beijing, China
Kwan MAN
MBBS, MS, PhD
Associate Professor, Department of Surgery, The University of Hong Kong, Hong Kong
Irene Oi-Lin NG
MBBS, MD, PhD, FRCPath (UK), FHKAM (Pathol), FHKCPath
Chair Professor and Loke Yew Professor in Pathology, Department of Pathology, The University of Hong Kong,
Queen Mary Hospital, Hong Kong; Director of State Key Laboratory for Liver Research,
The University of Hong Kong, Hong Kong
Kelvin Kwok-Chai NG
MBBS, MS, PhD, FRCSEd (Gen), FHKAM (Surg)
Honorary Clinical Associate Professor, Department of Surgery, The University of Hong Kong,
Queen Mary Hospital, Hong Kong
Wai Man NG
MBBS, MMedSc, MS, FRCSEd, FACS, FCSHK, FHKAM (Surg)
Honorary Clinical Associate Professor, Department of Surgery, The University of Hong Kong,
Queen Mary Hospital, Hong Kong
xii Contributors
William Wei SHARR
MBBS, FRCSEd (Gen), FCSHK, FHKAM (Surg)
Associate Consultant, Department of Surgery, Queen Mary Hospital, Hong Kong; Honorary Clinical Assistant
Professor, Department of Surgery, The University of Hong Kong, Hong Kong
Tony Wai-Hung SHEK
MBBS, FRCPA, FHKCPath, FHKAM (Pathol)
Consultant Pathologist, Department of Pathology, Queen Mary Hospital, Hong Kong; Honorary Clinical
Associate Professor, Department of Pathology, The University of Hong Kong, Hong Kong
Paul Kwong-Hang TAM
MBBS, ChM (Liverpool), FRCS ad eundem (Eng), FRCS (Edin, Glasg & Ire), FHKAM (Surg),
FCSHK, FRCPCH
Pro-Vice-Chancellor and Vice-President (Research), The University of Hong Kong, Hong Kong;
Chair Professor of Pediatric Surgery and Chief of Division of Pediatric Surgery, Department of Surgery,
The University of Hong Kong, Queen Mary Hospital, Hong Kong
Wai Kuen TSO
MBBS, DMRD (Lond), FRCR (UK), FHKCR, FHKAM (Radiol)
Consultant Radiologist, Department of Radiology, Queen Mary Hospital, Hong Kong; Honorary Clinical
Associate Professor, Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong
Nai Shun TSOI
MBBS, MRCP (UK), DCH (Lond), FRCP (Edin & Glasg), FRCPCH (UK), FHKAM (Ped), FHKCPed
Consultant Pediatrician and Director of Pediatric and Neonatal Intensive Care Unit,
Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong
Yik WONG
MBChB, FRCR (UK), FHKAM (Radiol)
Consultant Radiologist, Department of Radiology, Baptist Hospital, Hong Kong; Honorary Assistant Professor,
Department of Diagnostic Radiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
Zhen Fan YANG
MBBS, MS, PhD
Principle Scientist I, Innovation Center China, AstraZeneca Global R&D, Shanghai, China;
Honorary Associate Professor, Department of Surgery, The University of Hong Kong, Hong Kong
Karl YOUNG
MBBS, FKHCA (Intensive Care), FHKCA (Anesthesia), FJFICM
Consultant, Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
Kwok Yung YUEN
MBBS, FRCS (Glasg), FRCP (Lond, Edin & Irel), FRCPath, MD
Henry Fok Professor of Infectious Disease, Head and Chair of Microbiology, Department of Microbiology,
The University of Hong Kong, Queen Mary Hospital, Hong Kong
Contributors xiii
Man Fung YUEN
MBBS, MD, PhD, FRCP (Lond, Edin & Glasg), FHKCP, FHKAM
Professor, Chief of Division of Gastroenterology and Hepatology, Department of Medicine,
The University of Hong Kong, Queen Mary Hospital, Hong Kong
Preface
This year marks the 15th anniversary of the world’s first successful adult-to-adult right liver living donor liver
transplantation (LDLT) at Queen Mary Hospital, The University of Hong Kong. Since 1996, over 400 patients with
end-stage liver disease have undergone right liver LDLT at our center and begun a new life. In regions where
deceased organs are scarce, such as Hong Kong, LDLT has given hope to patients who are desperately waiting for
liver transplantation. There has been a significant progress in LDLT over the past few years owing to the wide adop-
tion and modifications from leading liver transplant centers around the world. We, in Hong Kong, as the pioneer
of the technique, have been making untiring efforts in refining the operation design, improving the recipient results
and lowering donor morbidity.
Since the first edition of Living Donor Liver Transplantation was published in 2007, the Liver Transplant Team
at Queen Mary Hospital has made impressive strides in various aspects of the operation. Publication of a second
edition is warranted to allow us to make a more comprehensive account of the technique basing on the 15 years of
Asian experience. In this edition, the co-authors Professor William I. Wei, Dr. Boon Hun Yong, Dr. Theresa W.C.
Hui, Dr. Alexander Chiu and Professor Peter W.H. Lee have contributed their expertise in microvascular surgery,
anesthesiology, critical care medicine and psychiatry and made this edition an even more valuable reference.
I hope that this book will continue to serve as a useful resource to experts in the field of liver transplantation.
Some of the topics have remained controversial in the transplant community. They await further discussions and
exploration.
S.T. Fan, MS, MD, PhD, DSc
Sun C.Y. Chair Professor of Hepatobiliary Surgery
Head, Department of Surgery
The University of Hong Kong
Queen Mary Hospital
Hong Kong
January 2011
xv
Acknowledgements
The establishment of liver transplantation in Hong Kong owes enormous support to Professor John Wong,
previously Head of Department of Surgery of The University of Hong Kong, and the Hospital Authority, Hong
Kong. We are also grateful for the world leaders of liver transplantation, who allowed us to observe and learn from
their experiences. They are Professor Russell Strong of the University of Queensland, Australia, Professor Nancy
Ascher and Professor John Roberts of the University of California, San Francisco, USA, Professor Ronald Busuttil
of the University of California, Los Angeles, USA, Professor Kazue Ozawa, Professor Yoshio Yamaoka and
Professor Koichi Tanaka of Kyoto University, Japan, and Professor Masatoshi Makuuchi and Professor Hideo
Kawarasaki of the University of Tokyo, Japan.
This book could not have been completed without the assistance of Ms. Maggie Ho, drawings of Mr. T. T. Ng
and, most importantly, our patients, from whom we have learned so much.
xvii
Abbreviations
ALT Alanine aminotransferase
AST Aspartate aminotransferase
BMI Body mass index
CT Computed tomography
ERCP Endoscopic retrograde cholangiopancreatography
ESLV Estimated standard liver volume
ESLW Estimated standard liver weight
HBcAb Hepatitis B core antibody
HBIG Hepatitis B immunoglobulin
HBsAb Hepatitis B surface antibody
HTK Histidine-tryptophan-ketoglutarate
INR International normalized ratio
IVC Inferior vena cava
LDLT Living donor liver transplantation
LHA Left hepatic artery
LHD Left hepatic duct
LHV Left hepatic vein
LPV Left portal vein
MRI Magnetic resonance imaging
MELD Model for End-stage Liver Disease
MHV Middle hepatic vein
MPV Main portal vein
PELD Pediatric End-stage Liver Disease
RHA Right hepatic artery
RHD Right hepatic duct
RHV Right hepatic vein
RPV Right portal vein
VEGF Vascular endothelial growth factor
xix
Nomenclature
The nomenclature of liver anatomy follows that of Couinaud C (Surgical Anatomy of the Liver Revisited, Couinaud C,
1989, ISBN 2-903672-01-6) and the Japanese Society of Biliary Surgery (Nimura Y. Surgical Anatomy of the
Biliary Ducts. In: Rossi P, ed. Biliary Tract Radiology, Berlin, New York: Springer Verlag, 1997: 21–30).
xxi
1
History
Sheung Tat FAN
The idea of using a living donor liver graft for orthotopic liver transplantation started in 19661 and 1969.2 But it
took more than 20 years before the idea was realized in clinical practice. The surge in living donor liver transplan-
tation (LDLT) in the late 1980s was a response to an increased demand for organs, at a time when liver
transplantation was increasingly successful. The demand for liver grafts has remained high, especially in countries
without deceased organ donation.
On 8 December 1988, Raia et al.3 made their first attempt on a 4½-year-old girl with biliary atresia. The donor
of liver segments II and III survived, but the recipient succumbed on postoperative day 6 during hemodialysis. They
made a second attempt on 21 July 1989. The recipient suffered from hepatic fibrosis and Caroli’s disease. The
donor recovered from the operation uneventfully, whereas the recipient had delayed graft function and remained
jaundiced on postoperative day 24. The outcome of this recipient was not reported subsequently. In the same
month, Strong et al.4 performed the first successful adult-to-child LDLT using a segment II and III graft. Both the
donor and recipient were Japanese and they had traveled to Brisbane to seek the possibility of deceased donor liver
transplantation. In the same year, Singer et al.5 at the University of Chicago, USA, conducted a research ethics con-
sultation to establish a consensus and guideline for informed consent. Thereafter, Broelsch et al.6 refined the
technique and rendered LDLT a valuable salvage procedure for pediatric patients.
Adult-to-child LDLT was adopted rapidly in Asia where deceased liver donation was virtually absent. In Japan,
Nagasue et al.7 performed the first of its kind in 1989. The recipient survived for 285 days before he succumbed to
graft rejection and multi-organ failure. Subsequently, in June 1990, Ozawa et al.8 performed the first successful
operation in Japan. After experiencing four cases of hepatic artery thrombosis, they advocated a routine micro-
vascular surgery technique for hepatic artery reconstruction, which revolutionized the practice of LDLT and led to
remarkable results.9 In Hong Kong, Yeung et al.10 performed the first of such operations in their region in 1993. Later
that year, we performed similar, successful operations at Queen Mary Hospital, Hong Kong (Fig. 1.1). In 1994, Lee
et al.11 performed the first of such operations in Korea. In the same year, Chen et al.12 performed the first operation
in Taiwan. Dou et al.13 performed the first successful operation in China in 1997. By 2002, 509 adult-to-child LDLTs
had been performed in five major liver transplant centers in Asia, with Kyoto University, Japan, having the most
experience.14 In all of these operations, segment II and III grafts, sometimes extending to segment IV and left liver
grafts, were used except in one operation. In that operation, Yamaoka et al.15 performed an unplanned adult-to-child
LDLT using the right liver graft [without the middle hepatic vein (MHV)]. The donor operation was changed from
left hepatectomy to right hepatectomy because the anatomy of the left hepatic artery was found to be unfavorable.
In the subsequent years, LDLT was extended to infants using monosegment grafts16 and to neonates using reduced
monosegment grafts.17
1
2 Sheung Tat FAN
Figure 1.1. The first series of living donor liver transplantation for pediatric patients performed in 1993 at Queen Mary Hospital, Hong
Kong. Steroids and cyclosporine were responsible for the hairy moon-shaped face of the children at that time.
Pediatric LDLT was quickly adopted in Europe. The first operation was performed by Broelsch et al. in October
1991. Then Boillot et al.18 from Lyon and Otte et al. from Belgium performed the second and third operations in
July 1992 and July 1993, respectively.
Since there were many more adult than pediatric patients with terminal liver disease, LDLT was extended to
adults soon after the initial success in pediatric patients. In 1991, Haberal et al.19 made the first attempt in adult
recipients using left liver grafts, but the result was unsatisfactory. In 1993, Makuuchi20 and his team at Shinshu
University, Japan, performed the first successful adult-to-adult LDLT using a left liver graft. The recipient was
a 53-year-old woman suffering from primary biliary cirrhosis and the donor was her son. The left liver graft
(containing the MHV) was 45% of the ideal liver volume of the recipient. On 12 July 1994, we performed a similar
operation for a married couple in Hong Kong.21,22 The recipient had suffered from fulminant hepatic failure during
pregnancy. The husband, weighing 82 kg, was the donor to his wife, who weighed 57 kg (Fig. 1.2). The graft was
42% of the recipient’s estimated standard liver volume (ESLV). In both cases, the operations were possible because
the donors were heavier than the recipients.
However, despite the initial success of using left liver grafts, the number of adult-to-adult LDLTs had not
increased, primarily because of the graft size limitation. In Asia, the majority of chronic hepatitis B patients are
male. Their wives who are willing to donate are usually smaller in body size and so cannot be the donors.
To provide a larger graft for an adult recipient, we designed the right liver LDLT in Hong Kong in 1996.23,24 The
first operation was performed on 9 May 1996. The patient suffered from fulminant Wilson disease. He weighed
90 kg, whereas the donor (his elder brother) weighed 74 kg. The right liver graft including the MHV weighed
910 g and was about 39% of the patient’s ESLV. Both the donor and recipient had uneventful recoveries and are
currently alive and well. Including the MHV in the graft allows donation from a person of similar size as, or even
smaller than, the recipient (Figs. 1.3 and 1.4). Since then, the applicability of LDLT, especially for high-urgency
cases, has widened.25–28 Right liver LDLT has been adopted by many other liver transplant centers. Research interest
in LDLT has also been much enhanced (Fig. 1.5). LDLT has now been extended to Jehovah’s Witness patients
successfully.29
The first right liver LDLT in Europe was performed in Essen by Broelsch’s team in 1998.30 The first right liver
LDLT in the USA was reported by Wachs et al.31 in 1998. Subsequently, Marcos et al.32 and others in the world
