Liver Transplantation in Hong Kong
Liver transplantation (LT) is a life-saving operation for patients with acute liver failure (ALF) which is commonly caused by hepatitis B infection in Hong Kong. Without a timely LT, the prognosis of ALF is extremely poor. Unfortunately as a result of the very low organ donation rate in Hong Kong, 90% of patients with ALF die while waiting for a liver. In view of the unmet need for organ donation, the LT team at Queen Mary Hospital, The University of Hong Kong started the living donor liver transplant (LDLT) program in 1993. Since then, over 500 LDLT operations have been performed with an overall success rate greater than 90%.
Right lobe living donor liver transplantation
A major challenge for LDLT is the functional and volumetric adequacy a partial liver graft to meet the metabolic demand of the recipient. It has been shown that 40% of the recipient standard liver volume is the minimal graft size for recipient recovery. Any graft volume less than this size is regarded as small-for-size graft and would predispose the recipient to develop small-for-size syndrome, and subsequently graft failure especially in very sick patients with high urgency situations. To fulfill the graft size requirement of the recipient, we pioneered the use of a right liver graft which has now been adopted as the choice of graft in adult in most LDLT programs around the world. Despite a larger size, small-for-size phenomenon still occurs in half of the recipients with a right liver graft.
Dual graft liver transplantation
Mr Cheng is a 59-year-old Hong Kong citizen who worked in Macau as a security guard. He enjoyed good past health previously.
He was admitted to a hospital in Macau on 11/7/15 for yellowish discoloration of skin and fatigue. He was diagnosed to have hepatitis B infection and was in acute liver failure upon admission. He was transferred to Queen Mary Hospital on 15/7/15. His liver function continued to deteriorate after arrival and he soon went into grade 4 hepatic coma. Preparation for liver transplantation was started immediately after assessment. He was admitted to the adult intensive care unit and required mechanical ventilation.
Donor evaluation
Mr Cheng’s second daughter volunteered to be the living donor. Computed tomography of the liver estimated her right liver to be 507ml only, i.e. 33% of the standard liver volume of Mr Cheng. She was then declined for donation due to possible small-for-size liver graft problem. His third daughter who was studying at Portugal then returned to Hong Kong immediately for ldonor workup. However, both sisters had similar body size and her right liver was also regarded as too small for donation. In view of the insufficient liver volume for each donor, the idea of using a ‘dual’ liver graft was proposed.
On 20 July 2015, the LT team at Queen Mary Hospital performed the first dual right and left liver graft LDLT in Hong Kong and the world first simultaneous dual liver implantations. Two female donors, aged 22 and 23 donated each of their right and left livers to their father. Three simultaneous operations were undertaken in three operating theatres. The right and left lobe donor operations each lasted for about 6 hours and the recipient operation lasted for 12 hours. More than 40 medical personnels including 10 transplant surgeons, 6 anesthesiologists, 2 microvascular surgeons, 3 radiologists, 2 clinical psychologists and 22 nursing staffs in two shifts were involved. Both donors and the patient have smooth recovery and are now ready for discharge.
The world first simultaneous dual graft implantation
Dual graft LDLT is the most technically challenging operation. Each liver graft has three main vessels: portal vein, hepatic artery and hepatic vein that require reconstruction when implanted in the recipient. The usual approach for dual graft transplantation is to implant each graft in sequence that entails many separate vascular anastomoses. Such approach is cumbersome and inevitably prolongs the graft ischaemic time. In contrast, we developed a new unique approach that entailed joining up all the hepatic veins and portal veins of the two grafts into two common orifices in the backtable before implantation into the recipient’s body. Such operative strategy rendered the entire implantation process much simpler and more efficient, hence reducing the ischaemic time. To our knowledge, this was the first time in the world that a simultaneous dual liver graft implantation was conducted in this manner.
The love and courage of the two sisters has saved the life of their father, as their livers united in their father in Hong Kong’s first dual graft living donor liver transplant. The LT team at Queen Mary Hospital has discovered a new approach to transform a highly complex operation into a more simplified version.
Media Enquiry : 7306 9243 Media Relations Officer, QMH
2 August 2015
