Journal of Hepatology 34 (2001) 613±624
www.elsevier.com/locate/jhep
Review
Live donor liver transplantation
Elizabeth A. Pomfret*, James J. Pomposelli, Roger L. Jenkins
Department of Liver Transplantation and Hepatobiliary Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805, USA
1. Historical perspectives
Live donor liver transplantation (LDLT) is an outgrowth
of a series of surgical innovations in segmental liver trans-
plantation driven initially by the need for pediatric cadave-
ric livers. The unique segmental anatomy of the liver allows
it to be separated into independent anatomic units able to
retain normal function. Reduced-sized liver transplantation
(RLT) was ®rst reported in 1984 by Bismuth, and involves
ex vivo resection of an adult cadaveric liver in order to
create an appropriate sized liver graft for an infant or
small child [1]. Introduced as a surgical solution for decreas-
ing the pediatric liver transplant waiting list mortality, RLT
uses organs from donors much larger than the recipient, but
does not increase the total number of livers available for
transplantation. This is because the reduced-sized portion
is not used and discarded.
Initially, RLT was criticized because it disadvantaged
adult patients awaiting liver transplantation and was thought
to be associated with inferior results. The allegations regard-
ing inferior graft and patient survival were proven wrong
[2±4], and several proponents of this technique actually
reported a lower incidence of vascular complications since
the caliber of the hepatic artery was larger than that seen in a
pediatric donor [5]. Since this technique resulted in discard-
ing the remaining portion of liver, it clearly had a negative
impact on the adult population awaiting liver transplanta-
tion, and for that reason, is rarely used today.
In 1988, Pichlmayr in Germany and Bismuth in France
simultaneously performed split liver transplantation (SLT),
an ex vivo splitting of a cadaveric liver allowing transplan-
tation to a pediatric recipient and one adult [6,7]. Unlike
RLT, SLT resulted in an increased number of organs in the
donor pool with each cadaveric liver giving rise to two
functioning allografts. The initial results of SLT reported
by Broelsch et al. [8] had a high rate of graft failure with
a survival rate of only 67% in children and 20% in adults
receiving a split liver transplants. In addition, 35% of
* Corresponding author. Tel.: 11-781-744-2500; fax: 11-781-744-5743.
E-mail address: elizabeth.a.pomfret@lahey.org (E.A. Pomfret).
0168-8278/01/$20.00 q 2001 European Association for the Study of the Liver. Published by Elsevier Science B.V. All rights reserved.
PII: S 0168-827 8(01)00031-9
patients required retransplantation and more than a quarter
had biliary complications [8]. More recently, in situ SLT has
provided patient and graft survival similar to that seen in
whole liver cadaveric transplantation [9±11].
2. LDLT: pediatric experience
The introduction of LDLT was a natural extension of
RLT and SLT, however, it provoked serious ethical debate.
In 1988, Raia in Brazil reported the ®rst LDLT, establishing
the technical feasibility of this procedure, yet both pediatric
recipients died of complications [12]. Strong and colleagues
subsequently reported the ®rst successful pediatric LDLT
using a left lobe graft from the child's mother [13]. Broelsch
et al. reported the ®rst successful series of LDLT with an
overall graft survival of 75% and patient survival of 85%
[14]. Furthermore, this group was the ®rst to report a
prospective ethical analysis of this radical surgical innova-
tion prior to performing their ®rst LDLT [15]. Since then, it
is estimated that nearly 1500 LDLT have been performed in
children worldwide with results equivalent, and in some
cases, superior, to those reported with conventional pedia-
tric cadaveric liver transplantation [16,17]. The combina-
tion of SLT and LDLT has signi®cantly reduced the
pediatric waiting list mortality [16,17].
Some centers have proposed the implementation of
routine in situ or ex situ splitting of all suitable cadaveric
livers as a means to eliminate the need for living donation in
the pediatric population [10]. Recently a modi®cation of the
in situ split liver technique has resulted in the successful
transplantation of two adults [18]. Both adult recipients
were operated on simultaneously while the donor procure-
ment was underway in an adjacent operating room, resulting
in cold ischemic times of less than 2 h for both recipients.
The requirement for three experienced teams of anesthesiol-
ogists and surgeons, increased duration of donor procure-
ment and appropriate sized recipients limits the widespread
application of this technique; however, it does offer an alter-
native to live donation and expansion of the adult donor
pool.
614 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624
3. Rationale for live donor adult liver transplantation
(LDALT)
Currently, there are more than 17 000 patients awaiting
liver transplantation in the United States. It is argued that
this number is arti®cially low since all patients who might
bene®t from a liver transplant, if organ availability were
unlimited, are not necessarily listed for transplantation.
The reasons for not being listed include other comorbidities,
belief by the medical team that the patient would not survive
the transplant, persistent alcohol use, social and psycholo-
gical circumstances negatively impacting the patient's
candidacy as a potential liver transplant recipient.
In 1998, 4540 liver transplants were performed in the
United States, with 72 of these being live donor liver trans-
plants (51 pediatric LDLT and 21 adult LDLT) [19]. Over the
past decade, the number of people awaiting liver transplant
has increased more than 15-fold, while the number of cada-
veric donors has increased only three-fold [19]. Conse-
quently, the waiting list mortality has increased by 628%
during this time period [19]. Since many patients are removed
from the waiting list prior to the patient's imminent death, this
number is also an underestimate of the true number of patients
who die while waiting for a suitable organ.
The organ shortage problem is further exacerbated by the
reality that over four million people are currently infected
with hepatitis C in the United States alone. It is estimated
that 20% of these people will progress to cirrhosis and 15%
(n ˆ 600 000) will require liver transplantation [20]. Even if
only half of these people were acceptable candidates for
liver transplantation, it would take more than 67 years to
transplant this group of patients alone, with the current
number of available cadaveric donors.
The expansion of LDLT to the adult population began in
countries where the availability of cadaveric donors was
scarce, and in some cases, totally unavailable [21±23].
The law for cadaveric organ retrieval was instituted in
1998 in Japan, however, the lack of societal acceptance of
organ retrieval from brain dead donors results in live dona-
tion being the main source of grafts for patients awaiting
transplantation in Japan and much of Asia [24].
The obvious advantage of LDALT is the ability to elec-
tively transplant patients when medically indicated and
avoid the serious decompensation or death that occurs
while patients are waiting for cadaveric transplantation. In
addition, the occurrence of primary graft non-function is
rare since donor quality and cold ischemic times are more
favorable with LDLT [8,23,25±27]. The undisputed disad-
vantage is the risk of serious complications or death in the
otherwise healthy donor undergoing a partial liver resection
and general anesthesia [28±33].
4. Live donor adult liver transplantation: graft size
The application of LDLT to the adult population has been
limited by the inability to accurately determine the minimal
amount of liver tissue that can safely be removed from a
healthy donor, while providing an adequate amount of liver
for the recipient. Multiple calculations have been derived in
an attempt to estimate adequate graft size, yet an exact
formulation resulting in minimal donor morbidity and
excellent recipient survival has not been elucidated [34].
Although successful hepatic resection in excess of 70% of
the total liver volume is well described in non-cirrhotic
patients, a partial liver allograft may not provide suf®cient
volume [35]. Warm ischemia, preservation and reperfusion
injury, and the possibility of acute cellular rejection can all
signi®cantly reduce the viability of a partial liver graft.
Several liver transplant centers have examined the impact
of graft size on overall graft and patient survival [36±38].
Graft size is generally reported as either graft to recipient
body weight ratio (GRWR) [36], or as a percentage of the
calculated standard liver volume (SLV) [39,40]. A linear
correlation exists between the two, and both are considered
an acceptable means of expressing the estimated graft
volume [36]. Kyoto reported the largest single series of
276 patients undergoing elective LDLT and demonstrated
that small-for-size grafts (de®ned as either ,1% GRWR or
,40% of recipient SLV) have signi®cantly lower graft
survival than those grafts .1%. Furthermore, early
synthetic and metabolic graft dysfunction and prolonged
cholestasis commonly seen in small-for-size grafts make
these patients prone to complications, such as sepsis and
hemorrhage [36,37].
Recent reports suggest that graft function is in¯uenced
not only by graft size, but also by recipient pretransplant
disease severity. Recipients with normal liver function and a
hepatocellular carcinoma as the indication for liver trans-
plantation tolerated GRWR as low as 0.6%, while recipients
with end stage cirrhosis and portal hypertension required a
minimum GRWR of 0.80% to ensure 70% graft survival.
Liver grafts as small as 0.47% GRWR have been used
successfully in the setting of inborn errors of metabolism
not associated with cirrhosis; however, these anecdotal
cases should not be used as the safety standard for adequate
liver graft volume [24].
Surgeons at the Shinshu University in Japan initiated the
®rst successful LDALT procedure in 1993, using a left lobe
graft for a patient suffering from primary biliary cirrhosis
[41,42]. In a subsequent report of 13 adults receiving left
lobe grafts, including ®ve patients with a graft weight of
,40% SLV, the same investigators demonstrated an overall
85% graft survival rate [23]. It is important to note that the
majority of the patients included in this study suffered from
familial amyloid polyneuropathy or other metabolic liver
disease where the recipient had normal liver function.
Excessive portal ¯ow secondary to portal hypertension is
thought to result in a signi®cant degree of diffuse sinusoidal
injury responsible for the primary graft dysfunction seen in
small-for-size liver grafts [22,43]. In addition, small-for-
size grafts have been associated with signi®cantly more
 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624
early graft dysfunction, characterized by prolonged choles-
tasis, signi®cant ascites and histological features of ische-
mia. Disappointing results uniformly experienced with
LDALT using left lobe liver grafts for adult recipients
with portal hypertension, coagulopathy, hyperbilirubinemia
and other organ dysfunction prompted the expansion of
using extended left lobe grafts that include the caudate
lobe, right lobe grafts, and even, extended right lobe grafts
[22,27,37,38,44±48].
The University of Hong Kong Medical Center introduced
the utilization of extended right lobe liver grafts in LDALT
in 1996 in an attempt to overcome inadequate graft volume
and positional problems encountered with the smaller left
lobe grafts [22]. Although graft and recipient outcomes of
86% were signi®cantly better than those seen with left lobe
grafts, the number of complications reported in the donors,
including infection, prolonged cholestasis, bile leak and late
biliary stricture was considered unacceptable. After making
several technical modi®cations, they have recently
published a series of 22 patients undergoing LDALT
using an extended right hepatic graft with excellent results
and low donor morbidity [49]. The authors advise leaving
the donor with a residual liver volume of at least 30% of the
total liver volume and using grafts that contain minimal
fatty change (,15% fat).
Fig. 1. Schematic representation of donor right hepatectomy and graft
implantation. Simultaneous procedures utilizing two operative teams
minimizes graft ischemic time and improves outcome.
615
Concerns related to donor safety have limited the use of
extended right lobe liver grafts; however, many centers have
now demonstrated excellent results using right lobe grafts
for LDALT [44,48,50]. Until recently, LDALT has been
con®ned to countries in which cadaveric donation is either
limited or prohibited [25,38,51,52]. As the donor organ
shortage has become increasingly more severe throughout
Europe and the United States, more centers have embarked
on LDALT using right lobes (Fig. 1). At the May 2000
meeting of the American Society of Transplantation, it
was reported that more than 30 centers in the United States
have performed 275 LDALT procedures and 15 centers in
Europe have performed nearly 100 LDALT (Dr Christoph
Broelsch, Essen, Germany, personal communication).
5. Donor and recipient selection
Donor safety must be the primary focus of all discussions
concerning LDLT and primum non nocere (`®rst do no
harm') must be the dictum followed by the donor selection
committee at all times. Although donor safety does not
appear to be directly related to the extent of the liver resec-
tion performed, most transplant physicians would agree that
the selection criteria for right lobe donors should be more
stringent with respect to donor age, liver function and stea-
tosis [24]. There are selection criteria that apply to both the
donor and recipient that should be addressed separately
[53]. It is the combination of the favorable and unfavorable
characteristics of both that determines whether or not the
`pair' is suitable for consideration for LDALT.
Prior to a donor beginning evaluation as a live liver
donor, the transplant team must decide whether the recipient
is a candidate to undergo this procedure. All recipients being
considered for LDALT should meet the minimal listing
criteria for cadaveric liver transplantation. LDALT has
been successfully performed in both elective and urgent
cases, however, the disappointing results observed in
those patients with chronic cirrhotic liver disease and
acute decompensation (UNOS Status 2A) has prompted
debate as to whether LDALT should be offered to this subset
of patients [54±56]. In addition, those potential recipients
with multiple comorbid medical conditions or extensive
previous upper abdominal surgery may not be suitable
candidates.
The donor evaluation team should be a completely sepa-
rate entity from the physicians involved in the care of the
recipient. The donor team acts as an independent advocate
for the potential donor in order to ensure that his or her best
interests are served in the process of determining donor
suitability from a medical, surgical and psychological stand-
point. The donor evaluation protocol utilized by our group is
outlined in Fig. 2A±C.
5.1. Phase I (Fig. 2A)
Voluntary, unsolicited contact by the donor to the trans-
616 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624

Fig. 2. (A±C) Donor evaluation occurs in three phases. (A) Phase I: donors undergo preliminary screening with blood typing and liver function tests.
(B) Phase II: includes volumetric CT scan and complete medical and psychosocial evaluation. (C) Phase III: acceptable donors undergo celiac
arteriogram and the recipient is reassessed to ensure that they are medically suitable for transplant.
 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624 617

Fig. 3. (A±D) Volumetric CT scan with three-dimensional renderings provides excellent preoperative images to plan resection planes and to anticipate
vascular anomalies. (A) Shows right lobe liver volume calculated after virtual resection plane. Right and inferior right hepatic veins in orange and
middle and left hepatic veins in pink. Some variations in donor hepatic vein (B) and portal vein (C) anatomy are shown. (D) Arterial anatomy is
con®rmed with celiac angiography.

plant team initiates the evaluation process. A brief telephone
interview conducted by a transplant coordinator obtains
donor demographic data and documents the relationship of
the donor and recipient. The potential donor is then sent a
packet of information including a description of the evalua-
tion process, surgical procedure, and a letter to present to
their primary care physician requesting screening liver func-
tion tests and blood type veri®cation. All potential donors
with compatible blood type and normal screening liver func-
tion test results meet with a transplant surgeon to discuss the
details of the surgery, postoperative care, complications and
reported outcomes associated with the LDALT.
5.2. Phase II (Fig. 2B)
Since anatomic considerations are often the most
common reason for donor rejection, our policy has been to
perform a helical abdominal CT scan with three-dimen-
sional renderings for morphology, liver volume and vascu-
lar anatomy prior to the medical evaluation of the donor
(Fig. 3A±D). The potential recipient also undergoes CT
imaging to evaluate the liver for the presence of tumor
and portal vein patency. Donors with an estimated right
lobe liver volume to recipient body weight ratio
(GWBWR) of .0.8% are referred for complete medical
and psychosocial evaluation.
In circumstances where the initial patient interview
reveals signi®cant risk factors for human immunode®ciency
virus (HIV) or viral hepatitis (i.e. history of drug depen-
dency, signi®cant body piercing or tattoos), then the CT
scan is postponed until the serological testing has taken
place.
The internal medicine physician and psychiatrist evaluat-
ing potential donors are completely independent of the
transplant team and have no prior knowledge of the reci-
pient's condition or interests. Laboratory tests including
complete blood count, liver and renal biochemistry values,
thyroid function tests, coagulation pro®le, alpha fetoprotein
618 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624
and serological studies for hepatitis A, B, C and cytomega-
lovirus (CMV), Epstein-Barr virus (EBV), and HIV are
performed as part of the medical evaluation. Chest X-ray,
EKG and Doppler ultrasound of the liver are also obtained.
Additional studies deemed necessary by the examining
physician are obtained on a selective basis (i.e. pulmonary
function studies, cardiac stress test, colonoscopy, mammo-
graphy, etc.) depending upon the individual donor.
A multidisciplinary screening committee composed of
representatives from internal medicine, transplant surgery,
anesthesia, blood bank, nursing, social work, psychiatry and
ethics meet weekly to review each potential donor's candi-
dacy. No exception is made in the donor selection protocol
to accommodate the needs or interests of the recipient.
Facilitated work-up can be accomplished in a few days in
urgent situations. The screening committee reviews all data
to determine the suitability of the `donor/recipient pair' as
candidates for LDALT. The decision of the committee is
discussed with the donor ®rst, so that those potential donors
who may have changed their minds during the evaluation
period have the opportunity to abort the donation process.
Decisions of donors to abort the donation process are kept
con®dential and are ascribed to medical or anatomic
constraints to preserve the relationship between the donor
and recipient. This type of excuse allows the donor to be
`rejected' without being ostracized by the recipient's family
and friends, and avoids creating potential problems for the
donor in terms of future health or life insurance bene®ts.
5.3. Phase III (Fig. 2C)
The recipient is re-evaluated by the transplant hepatolo-
gist to insure that the patient has not become `too sick' for
LDALT while the donor evaluation has progressed. Doppler
ultrasound is performed to insure recipient portal vein
patency. The ®nal test performed is donor splanchnic arter-
iography to con®rm anatomy and to clearly identify the
origin of the vessel supplying segment IV. Branches derived
from the right hepatic artery, which cross Cantle's line to
supply the left lobe of the liver, are identi®ed 15±30% of the
time [57,58]. Segment IV receives the principal supply of
these branches and aggressive surgical dissection with
disruption of these vessels is thought to contribute to the
5% incidence of donor bile leaks that has been observed in
LDALT [57]. Hepatic and portal vein anatomy is carefully
evaluated using three-dimensional CT imaging. With re®ne-
ment of the images obtained with CT angiography, it is
likely that celiac arteriography will be unnecessary in
most potential donors. Several groups routinely use vascular
MRI to assess the hepatic arterial anatomy. Preoperative
liver biopsy is performed in donors exhibiting mildly
elevated liver enzyme levels, evidence of fatty liver by heli-
cal CT and those persons with positive hepatitis B serolo-
gical studies (surface and/or core hepatitis B antibody
positive and surface antigen negative). People with positive
hepatitis C serological results are not considered for donor
evaluation. Prior to surgery, 1±2 units of autologous blood is
collected from each donor. Informed consent is obtained for
both donor and recipient operations approximately 1 week
prior to surgery. The entire evaluation process usually takes
a month to complete; however, the process can be signi®-
cantly accelerated depending on the needs of the donor/
recipient pair.
6. Intraoperative donor evaluation
Despite the extensive preoperative donor evaluation,
further evaluation at the time of living liver donation has
been associated with termination of the donor hepatectomy.
Aborted donor hepatectomy occurred approximately 3% of
the time as reported at the May 2000 meeting of the Amer-
ican Society of Transplantation. Reasons of steatosis, aber-
rent vascular anatomy and the presence of unexpected
conditions that preclude donation resulted in the donor
operation being terminated.
Anatomic variations in the biliary tree are seen in up to
40% of all liver donors [59]. Intraoperative cholangiogra-
phy, preoperative magnetic resonance cholangiography
(MRC), CT and endoscopic retrograde cholangiopancrea-
tography (ERCP) have all been used to assess the anatomy
of the biliary tract in an attempt to prevent inadvertent
ligation of signi®cant branches draining the donor remnant
liver or the graft. Operative cholangiography via cystic
duct cannulation is often performed to evaluate the bile
duct anatomy. Division of the right hepatic duct can be
performed safely in the donor without intraoperative
cholangiography at the level of the hilar plate; however,
the cholangiogram may guide the location of transection to
optimize the chance of having a single bile duct for anasto-
mosis in the recipient.
Intraoperative ultrasound in conjunction with preopera-
tive imaging is essential for identifying the course of the
middle hepatic vein so that it can be preserved with the
donor liver remnant. In the case of extended right donor
hepatectomy, identi®cation of the course of the middle
hepatic vein is critical to guide the extent of resection, as
the middle hepatic vein will be included with the livergraft.
Temporary in¯ow occlusion allows the surgeon to deter-
mine the line of demarcation for a right lobe resection, but
is unable to map the direction of the middle hepatic vein or
the large crossing branches draining the anterior segments
of the right lobe. Intraoperative ultrasound allows identi®-
cation of these structures so that the course of the parench-
ymal transection might be altered to preserve important
vascular landmarks and minimize blood loss. The identi®-
cation of signi®cant (.0.5 cm) accessory inferior hepatic
veins identi®ed by CT scan is con®rmed with intraopera-
tive ultrasound. Accessory right inferior hepatic veins
measuring .5 mm in diameter should be preserved during
the right lobe procurement for later anastomosis to the
recipient inferior vena cava (Fig. 4A,B).
 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624
Fig. 4. (A,B) CT rendering and intraoperative picture of right and
inferior right hepatic vein branches. Inferior right hepatic vein
branches requiring reimplantation ( . 5 mm) are observed in the
majority of donors.
7. Complications and technical considerations
7.1. Donor morbidity and mortality
Although the morbidity for right lobe liver donation is
generally considered to be low [48,60], many believe that
the `true' complication rate is underestimated [61]. A donor
right hepatic lobectomy induces transient, but signi®cant
hyperbilirubinemia, even when blood loss and the operative
time are kept to a minimum, and there is no vascular occlu-
sion employed during the parenchymal transection [62]. An
accurate estimate of preoperative right and left lobe liver
volume with correction for the degree of steatosis is critical
to the safety of the donor [49]. Prolonged cholestasis and
infection are more prevalent in donors left with less than
30% of their original liver volume, and those donors known
to have more than 15% fatty change in the liver [49,50].
Routine preoperative percutaneous liver biopsy to establish
microvesicular and macrovesicular fat content has been
suggested by some authors [63,80]. It has been the practice
619
of our program to perform selective liver biopsies in those
potential donors exhibiting mildly elevated liver enzyme
levels, evidence of fatty liver by helical CT and persons
with positive hepatitis B serological studies (surface and/
or core hepatitis B antibody positive and surface antigen
negative). We do not consider any potential donor with
positive hepatitis C serological results.
A recent review of the US experience with LDALT
presented at the May 2000 meeting of the American
Society of Transplant Surgeons reported a 4% biliary
complication rate in the donors requiring either surgical
intervention (2/12), ERCP (3/12) or percutaneous catheter
drainage of a postoperative biloma. Reexploration was
required in two additional patients for portal vein throm-
bosis and small bowel obstruction, respectively. Seven
donors (3%) had the donor hepatectomy aborted for unsus-
pected granulomatous disease (one), steatosis (two), prohi-
bitive anatomy (two), cardiac dysfunction (one) and
intraoperative hemorrhage (one). Additional complications
reported in the donor population include: neuropraxia,
phlebitis, pressure sores, pleural effusion, pneumonia,
pulmonary embolus, deep venous thrombosis, prolonged
ileus and incisional hernia.
A total of four deaths have been known to occur world-
wide in approximately 2000 live liver donors to date. The
®rst donor death, a fatal pulmonary embolus, occurred in an
adult-to-child LDLT and was reported in the literature in
detail [64]. The second death, anaphylaxis secondary to a
medication, was also in a left lateral segment donor. Two
deaths have occurred in right lobe donors to adult recipients.
These were discussed publicly by a member of each trans-
plant team and were reported to be multifactorial in nature
with sepsis playing a prominent role (`Controversies in
Transplantation' Conference: Breckenridge, Colorado;
March 2000 and the XVIII International Congress of the
Transplantation Society: Rome, Italy; August 2000).
Although these four deaths have been accidental or related
to technical failure, they underscore the reality that living
donation is associated with a small, but real possibility of
mortality in the healthy donor.
A recent review of 747 hepatectomies demonstrated a 1%
mortality rate associated with patients undergoing elective
major liver resection with normal livers (n ˆ 478) [65]. For
this reason, our program limits the range of donor selection
to those individuals who share either a genetic or `signi®-
cant emotional' relationship with the recipient. Other
programs have accepted `Good Samaritan' donors without
any untoward events in the donor, yet most centers agree
that the issue of the `Good Samaritan' liver donation should
be approached with caution and that the ethics of this type of
donation require further examination. Education of the
donor's family members regarding the potential risk of
living donation should occur early on in the donor evalua-
tion period. The donor should be encouraged to have family
members or signi®cant others involved in the evaluation and
consent process.
620 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624

8. Recipient complications and technical considerations inferior hepatic vein (present in 40±60% of livers) primarily
drain the right lobe of the liver (Fig. 4).
The complication rate for the recipients of right lobe Reconstruction of segmental (segments I, V, and VIII)
grafts is higher than that for recipients of cadaveric whole and accessory hepatic veins in the recipient is an area of
livers, although the survival is comparable [22,66,67]. Bili- controversy [45,71]. Generally, those accessory right infer-
ary complications are more prevalent in LDALT, and range ior hepatic veins measuring .5 mm in diameter are
between 15 and 30% [50]. Multiple hepatic ducts and preserved untransected during the right lobe procurement
damage to the delicate peribiliary arterial supply is specu- and anastomosed to the side of the inferior vena cava of
lated to account for the increased incidence of biliary
complications reported in right lobe grafts. Division of the
right hepatic duct at the hilum can result in a right anterior
and right posterior duct, and occasionally, more than two
ducts requiring anastomosis [24,68]. The optimal surgical
management of multiple bile ducts in the adult recipient has
not been established. Enteric biliary drainage using a chole-
dochojejunostomy is universally employed in the pediatric
population and often the only means of managing multiple
small-caliber bile ducts encountered in LDALT. Several
centers have performed duct-to-duct anastomosis in the
adult recipients of right lobe liver grafts; however, the
outcome is limited [24,44].
Adequate graft venous out¯ow is an area of controversy
and debate. Inadequate venous out¯ow and congestion can
result in varying degrees of graft dysfunction, including
rapid progressive liver failure with graft loss [22,69,70].
Particular attention must be paid to the anatomy of the
middle hepatic vein since it typically drains both the medial
segment of the left lobe of the liver (segment IV) and the
anterior segments of the right lobe (segments V and VIII).
The right hepatic vein, and commonly, an accessory right

Fig. 5. An example of a donor rejected for unsafe anatomy. Lack of a

dominant hepatic vein draining the right lobe of the liver would neces-
sitate resecting the middle hepatic vein with the liver graft, leaving the
donor with a small residual volume (essentially the left lateral Fig. 6. CT image (A) and portal vein cast (B) of a donor exhibiting
segment). separate anterior and posterior branches of the right portal vein.
 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624
the recipient after completion of the right hepatic vein
anastomosis) [24].
Major venous obstruction resulting in a recipient death
was the rationale for the group in Hong Kong to endorse the
use of extended right hepatic grafts with reconstruction of
both the right and middle hepatic veins. Although some
advocate reconstruction of the draining segmental (V and
VIII) venous branches to prevent congestion of the anterior
segments of the right hepatic graft, we have routinely
ligated and transected these branches without consequence.
The absence of a dominant right hepatic vein is considered a
contraindication to right lobe donation (Fig. 5) [72].
Innovative techniques for portal vein reconstruction have
been successful in dealing with the size mismatch
commonly encountered between adult live donors to pedia-
tric recipients [25,73,74]. The presence of separate anterior
and posterior branches of the right portal vein in the donor
graft pose a challenging problem that is perhaps best
avoided if there is a possibility of another potential donor
(Fig. 6). Techniques of using interposition grafts for either
portal vein or hepatic artery reconstruction are associated
with a signi®cant increase in vascular complications. Micro-
vascular surgery for the reconstruction of the hepatic artery
has been credited with signi®cantly reducing the incidence
of hepatic artery thrombosis in living donor liver transplan-
tation [75,76].
9. Liver regeneration
Rapid liver regeneration begins immediately after living
liver donation and transplantation in both the donor and
recipient [77,78]. Three phases of liver regeneration after
massive hepatic resection describe an early phase of rapid
regeneration occurring in the ®rst 2 weeks postoperatively
which is associated with vascular engorgement. The second
phase takes place 1±2 months postoperatively, and is char-
acterized by a decrease in liver volume that is thought to be
associated with the normalization of the vascular engorge-
ment and resolution of tissue edema. In the ®nal phase, there
is a slow increase in volume until the liver volume reaches a
constant level. Liver regeneration has been reported to halt
after the liver achieves 75±95% of its original liver volume.
The liver regeneration observed in both our donors and
recipients is consistent with these ®ndings. A recent
prospective analysis of liver regeneration in donors and
recipients after right lobe LDALT reports a 100% increase
in volume within 7 days of surgery for both donor and
recipient [79]. Preservation of the artery and portal vein
branches supplying segment IV is thought to be the critical
factor responsible for the dramatic regeneration observed. In
addition, it has been the practice of our group and others to
begin total parenteral nutrition in the immediate postopera-
tive period for all of the donors in order to meet protein and
caloric requirements and to correct metabolic and acid±base
disturbances [49].
621
10. Impact of LDALT on existing technologies
Living donor liver transplantation is a life saving surgical
innovation that has been shown to be relatively safe and
ef®cacious. Until recently, LDALT has been con®ned to
countries in which cadaveric donation is either limited or
prohibited. As the organ shortage has become increasingly
more severe throughout Europe and the United States, more
centers have embarked on LDALT using right lobe grafts.
While it is too soon to predict the ultimate impact of
LDALT, proponents suggest that up to 40% of all liver
recipients (adults and children) may eventually be served
by this procedure [80]. This is a ®gure comparable with that
seen with living donor kidney transplantation [81].
Although LDALT is not expected to supplant any of the
other liver transplant modalities, it has helped to essentially
eliminate the pediatric liver transplant waiting list.
All of the advantages of living donor liver transplantation
have to be tempered by the risk of injury or death to a
healthy donor. The only bene®t to the donor is the psycho-
logical bene®t of helping to save a loved one. Living donors
have expressed extreme satisfaction when allowed to parti-
cipate in saving a life and take comfort in knowing that they
have done everything to help a friend or family member.
This has been true, even when the outcome of the transplant
has been unsuccessful [82].
Given the potential risk of harm to the donor, such proce-
dures should be limited to centers with demonstrated excel-
lence in complicated hepatobiliary surgery and established
liver transplant programs [83]. Our team had performed over
1000 liver resection procedures and over 600 cadaveric trans-
plants prior to initiating an LDALT program. Critical analy-
sis of the surgical outcome would suggest that the reported
morbidity rates are characteristically underestimated [84]. A
stepwise protocol for assessing donor candidacy, along with
appropriate institutional support, including ethical review
boards, dedicated anesthesiology, radiology, internal medi-
cine, psychiatry, nursing and social work departments all aid
in minimizing donor risk and maximizing safety.
Tempered enthusiasm must be maintained in the setting
where many centers are considering initiating LDALT
programs due to the apparent high success and low donor
morbidity rates suggested by others. Since the process of
LDALT is still in evolution, it is prudent to establish standard
guidelines for donor±recipient pairing, donor evaluation and
surgical technique before applying this technology widely.
Three ethical principals of therapeutic innovation were
eloquently outlined by Dr Francis D. Moore in 1988 when
the initial debates regarding LDLT were ®rst being
addressed [85]. The ®rst principle establishes the scienti®c
background on which the procedure is based. Secondly, the
skill, experience or `®eld-strength` of the team doing the
procedure should be evident. Finally, the ethical climate
of the institution must adequately support the endeavor.
The scienti®c background and ethical case for LDALT
have been established [15,49]. Results rivaling or exceeding
622 E.A. Pomfret et al. / Journal of Hepatology 34 (2001) 613±624
cadaveric transplantation have been observed by a number
of centers and only serve to encourage the more widespread
application of LDALT. Irrespective of the exact number of
potential patients who might derive bene®t from LDALT,
there is little debate that the need for more livers is acute.
Presumably, this need will become even more evident as
this new surgical innovation becomes a more widely
accepted treatment option. There has been little growth in
the supply of transplantable organs over the decade, yet the
number of people awaiting liver transplantation continues to
increase exponentially. To the degree that pretransplanta-
tion mortality results from a shortage of livers, LDALT can
be justi®ed as a needed procedure.
An equally compelling argument is that as the transplant
waiting list grows longer, the overall health of the potential
recipients declines. Transplanting sicker patients may
simultaneously reduce the chances of a successful transplant
and increase the likelihood of postoperative complications
and expense. Finally, LDALT frees up an entire cadaveric
graft that can be used for a split liver procedure or a whole
organ transplant, thus potentially allowing two other
patients to bene®t from transplantation.
What is less clear, is that in the current era of dwindling
healthcare dollars and competitive market forces that chal-
lenge the existence of many hospitals, some groups may
initiate LDALT programs to maintain `market share` without
appropriate `®eld-strength`. As pointed out by Dr Moore, this
is something that that the lay public cannot see or feel, legis-
lative bodies poorly understand, but is quite clear to physi-
cians and surgeons. The establishment of a national data base
for all LDALT procedures recorded on an `intent to treat`
basis will provide physicians and patients with the best
understanding of the true outcome of LDALT.
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