Objectives: While LDLT represents the dominant method of LTx in the East, it remains an underutilized procedure in the US, accounting for <5% of all transplants despite a high waitlist mortality. We present the largest single center series of LDLT in the US, describe technical modifications that have improved results, and argue towards a change in the paradigm for LDLT utilization in this country.

Methods: A retrospective single center review of 500 LDLTs (357 adult, 143 pediatric) performed from 1999 to present was conducted. This analysis concentrated on the 357 adult LDLTs, including the impact of more recent technical modifications on outcomes.

Results: In the 357 adult LDLTs, mean donor age was 37 years and 58.5% were female; 37% of the donors were biologically unrelated to the recipients. Right hepatectomy was performed in 92%, left in the remainder. There have been no early or late donor deaths. The incidence of early (<3 months) reoperation in donors was 2.0%. Mean calculated MELD score in the recipients was 15 at transplant, with 14% having a diagnosis of HCC. Early reoperation rate in recipients was 41%. Patient and graft survival at 3 month were 94% and 90%, respectively; 1 year were 89% and 84% respectively. These results were statistically superior to outcomes with deceased donor transplants performed in the same time period (p<0.05), albeit in patients with lower MELD scores. Since 2009, technical modifications included optimization of outflow using hepatic vein patch venoplasty and reconstruction of significant MHV tributaries. Intraoperative targets of hepatic arterial flow (>50mls/min), portal flow (100-250 mls/min/100gm) and portal pressure (<18) were obtained with flow modulation that included splenic or GDA ligation, creation of mesorenal or portacaval shunt, or renal vein ligation. This has resulted in improved results in the >2009 cohort with superior early (3 months) graft survival (92.5% vs 88%, p<0.01), decreased reoperation rate (30.5% vs 52%, p<0.01), and lower incidence of complications such as small for size. Improved results were seen despite a higher MELD score (17 vs 12.6, p<0.01).

Conclusion: LDLT represents a viable option for patients needing LTX. With meticulous attention to technical details in the OR and objective measurements to optimize flow to the graft, excellent results can be obtained. It is time to change the paradigm of how we think about LDLT in this country.

CITATION INFORMATION: Humar A., Ganesh S., Tevar A., Molinari M., Hughes C. Living Donor Liver Transplant (LDLT) at a Single Center- Intraoperative Technical Modifications and Optimization of Flow Dynamics to Improve Outcomes Am J Transplant. 2017;17 (suppl 3).

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