Donor complications among 500 living donor liver transplantations at a single center

Introduction

Living donor liver transplantation (LDLT) has become necessary because of the shortage of cadaveric organs. We retrospectively analyzed 500 living donor hepatectomies using the Clavien classification system for complications to grade their severity.

Materials and methods

We retrospectively identified and applied the Clavien clasification to 500 consecutive donors who underwent right for LDLT left hepatectomy between January 2007 and August 2011.

Results

The 149 complications were observed in 93 of 500 (18.6%) donors who were followed for a mean 30 months. There wan no donor mortality. Complications developed in 85 (18.6%) right 5 (35.7%) left, and 3 (10%) left lateral segment hepatectomy donors. The overall incidence of reoperations was 7.2%. Seventy-seven of 149 complications were grade I (51.6%) or 9 grade II (6%). The major complications consisted of 27 (18.1%) grade IIIa, 35 (23.4%) grade IIIb, and 1 (0.6%) grade IVa. Grade IVb and grade V complications did not occur. The most common problems were biliary complications in 14 of 181 donors (7.7%).

Conclusion

Donors for LDLT experienced a range of complications.     

Results of Surgery-Related Complications in Donors of Right Lobe Liver Graft: Analysis of 272 Cases

Background

Living donor liver transplantation has been a new light of hope for patients with end-stage liver failure on the cadaveric waiting list. However, living donor liver transplantation still has ethical problems which cannot be overcome. Exposure of healthy donor candidates to major surgery which can be fatal is the largest of these ethical problems. In this study, we aimed to determine our rate of complications associated with surgery in donors who underwent right lobe donor hepatectomy.

Materials and Methods

Between September 2004 and December 2009, 548 liver donor candidates were examined. The right liver lobe donor hepatectomy was performed on 272 donor candidates who passed the elimination system. Demographic data as well as intraoperative findings, complication rates, and numbers were collected retrospectively. Donor complications were categorized according to the Clavien classification.

Results

Two hundred seventy-two donors who underwent right lobe donor hepatectomy were included in this study. One hundred sixteen (42.6%) of 272 donors were female, whereas 156 (57.4%) were male. There was no donor mortality. Grade 1 and grade 2 complications were observed in 105 (38%) of 272 donors. The most common complications were fever of unknown origin (20.9%) and prolonged hyperbilirubinemia (3.6%). Grade 3 complications and grade 4 complications were observed in 6 donors (2%) and 3 donors (1%), respectively. Three donors were underwent re-operation due to bleeding. The re-laparatomy rate in our series was detected as 1.10%. One donor, categorized as grade 4B according to the Clavien classification, had small bowel perforation and intra-abdominal sepsis secondary to mechanical bowel obstruction.

Conclusions

Donor mortality is a fact of living donor liver transplantation that cannot be ignored like donor morbidity. However, right liver lobe donor hepatectomy can be performed successfully with minimal complication rates with multidisciplinary and rigorous donor care in the preoperative and postoperative period.     

A New Systematic Classification of Peripheral Anatomy of the Right Hepatic Duct: Experience From Adult Live Liver Donor Transplantation

Objective

The peripheral intrahepatic biliary anatomy, especially at the sectorial level on the right side, has not been adequately described. The purpose of our study was to systematically describe this complex anatomy in clinically applicable fashion.

Patients and Methods

We analyzed three-dimensional computed tomography (CT) imaging reconstructions of 139 potential living liver donors evaluated at our institution between January 2003 and June 2007.

Results

Eighty-nine (64%) donors had a normal right bile duct sectorial anatomy. In the other 50/139 (36%) cases, we observed abnormal sectorial branching patterns, with 45/50 abnormalities as trifurcations, whereas the remaining ones were quadrifurcations. In 22/50 (44%) abnormalities, a linear branching pattern (types B1/C1) and an early segmental origin off the right hepatic duct (types B3/C3) were present, a finding of particular danger when performing a right graft hepatectomy. In 2 cases, we noted a mixed type (B6/C6) of a rare complex anatomy.

Conclusions

Our proposed classification of the right sectorial bile duct system clearly displays the “area at risk” encountered when performing right graft adult live donor liver transplantation and tumor resections involving the right lobe of the liver.     

Laparoscopic Hepatectomy for a Modified Right Graft in Adult-to-Adult Living Donor Liver Transplantation

Background

We performed a modified right hepatectomy completely by laparoscopic techniques preserving the middle hepatic vein (MHV) branches in adult-to-adult living donor liver transplantation (LDLT).

Patients and Methods

Two young women (24 and 25 years old) volunteered to be live donors for their parents who had hepatocellular carcinomas. As the donors expressed concerns about scarring, we performed a laparoscopic procedure using a hand port device. Mobilization of the right liver and the hepatic parenchymal transection were performed under pneumoperitoneum. Parenchymal transection was performed using a laparoscopic ultrasonic aspirator without the Pringle maneuver. During parenchymal transection, major MHV branches >5 mm were preserved using Hem-o-lock clips. The graft was extracted through the hand port site. On the back table, the 3 MHV branches were reconstructed using an artificial vascular graft. The livers were transplanted without complications.

Results

The operative times for the donors were 765 and 898 minutes. The donors did not require transfusions or reoperation; they were discharged on postoperative days 10 and 14 with normal liver functions.

Conclusion

A hepatectomy performed completely by laparoscopic techniques for a right graft with preservation of the MHV branches was technically feasible.     

Living-Donor Liver Transplantation: Donor Selection Criteria and Postoperative Outcomes. A Single-Center Experience With a 10-Year Follow-up

Background

Donor safety must be considered to be a priority in live-donor liver transplantation (LDLT). The aim of this study was to evaluate these outcomes with special attention to surgical complications and their treatment.

Methods

From March 2001 to March 2012, 80 live donors underwent right hepatectomy (5-8 segments). The middle hepatic vein was always left in the donor. Our retrospective study analyzed surgical outcomes and complications according to the Clavien classification modified for live donors.

Results

With a median follow up of 63.2 ± 12.6 months, the mortality was 0%. Two donors experienced intraoperative complications, but all of them had complete recovery there after. Among the 22 complications in 17 donors (21.2%), 7 (8.7%) were major complications (Clavien grade 2b) but only 2 donors required surgical treatment.

Conclusions

LDLT is a safe and feasible modality to alleviate the cadaveric donor shortage. The efficacy of this procedure is similar to that with deceased donors.     

Complications in Donors Using Right Liver Graft: Analysis of 280 Consecutive Cases

Introduction

Living donor liver transplantation (LDLT) is performed with increasing frequency worldwide due to the shortage of donated organs. It is a life-saving procedure for the recipient, but, on the other hand, a major surgical procedure for healthy donors and it may cause morbidity and even mortality.

Donor quality of life after living donor liver transplantation: single-institute experience

Aim

Living donor liver transplantation (LDLT) has been widely accepted because of the severe shortage of hepatic grafts. However, the healthy donor is exposed to risks of morbidity and mortality. In this study, we analyzed medical, functional, and psychological outcomes of donors after hepatectomy for liver donation.

Patients and methods

Among 41 donor hepatectomy cases for LDLT performed in our institute from January 1994 to May 2011, we reviewed the medical records (liver function tests, complications, etc) of 27 subjects who donated to recipients older than 12 years. We also performed a questionnaire survey based on the Japanese Short Form-36 version 2 Health Survey scales as a measure of physical and mental health, to which 31 subjects responded.

Results

Six of the 27 donors experienced prolonged jaundice. Their ratios of graft volume/standard donor liver volume (GV/SDLV) were higher than those of the 21 donors without prolonged jaundice (60.0% vs 41.5%). According to the questionnaires, social functioning among those having undergone emergency hepatectomy as well as general health perceptions declined in those with postoperative complications. Physical component summary declined among those having undergone emergency hepatectomy and with postoperative complications.

Conclusion

In liver donation from a living donor, massive hepatectomy should be avoided. A ratio of GV/SDLV around 50% seems reasonable. Donors with emergency transplantations or postoperative complications must be more carefully followed after donor hepatectomy.     

Renal Vein Extension Using Gonadal Vein: A Useful Strategy for Right Kidney Living Donor Harvested Using Laparoscopy

Introduction

Vascular management of the right renal vein during laparoscopic living donor nephrectomy is still an unsolved problem. This short vessel has limited the use of right kidneys. However, the right kidney should be harvested in some instances. Based on experience in open donor nephrectomy, our unit has used the donor gonadal vein to obtain a longer renal vein in this setting.

Methods

Four consecutive living related donors with the indication for laparoscopic right nephrectomy underwent this procedure. Three donors were females and the overall average age was 48.5 years. The renal vein was controlled with a 30-mm stapler and we included 5-6 cm of the ipsilateral gonadal vein during the harvest. The donor kidney was perfused and renal vessels prepared under cold conditions. The gonadal vein was opened longitudinally and sutured to the donor right renal vein as a wide tube in 3 cases and as a spiral tube in 1 case with 6-0 monofilament suture.

Results

This procedure extended the bench work between 25 to 40 minutes permitting an 2.5- to 3.5-cm extension of the donor vein. The transplantations were performed in the usual mode and the vein enlargement enormously facilitated the implantation surgery. All recipients displayed immediate graft function; no complications were observed with this strategy.

Conclusions

Vein extension with the gonadal vein was a simple, safe method to enlarge the renal vein among right living donor kidneys procured using laparoscopy.     

Living-donor hepatectomy

Background

Organ transplantation from deceased donors is still far below the need. Because of this deficiency, liver transplantations are performed mostly from live donors in many transplant centers in our country. Living-donor liver transplantation (LDLT) has evolved dramatically over the past decade. The aim of this study was to present our clinical experience with living-donor hepatectomy.

Methods

We retrospectively analyzed all patients who underwent donor hepatectomy between March 2000 and September 2010. We reviewed demographic data, operation type, operation and cold ischemia times, duration of hospital stay, and postoperative complications.

Results

During the study period, 140 living donors underwent operations for liver transplantation. We performed 108 right hepatectomies, 17 left hepatectomies, and 15 left lateral hepatectomies. The mean age of the donors was 30.8 years. There was no operative or postoperative mortality. Overall morbidity rate was 13.57% (n = 19). Nine patients had biliary leakages, 4 biliomas; 2 urinary tract infections, and 1 each inferior vena caval injury, pneumonia, portal vein thrombosis, and acute tubular necrosis. Reoperation was not required in any of these patients.

Conclusions

Living-donor liver transplantation is a valuable alternative for patients awaiting a cadaver organ. Live-donor hepatectomy can be performed with low morbidity. The greatest disadvantage of this procedure is the risk of the surgical operation for the individual who will experience no medical benefit from this procedure.     

Risk Factors for Delayed Graft Function After Hand-Assisted Laparoscopic Donor Nephrectomy

Background

Delayed graft function (DGF) has a negative effect on the results of living-donor kidney transplantation.

Objective

To investigate potential risk factors for DGF.

Methods

This prospective study included 200 consecutive living donors and their recipients between January 2002 and July 2007. Delayed graft function was defined as need for dialysis within the first postoperative week.

Results

Delayed graft function was diagnosed in 12 patients (6%). Intraoperative complications occurred in 10 donors (5%), and postoperative complications in 24 donors (13.5%). One-year kidney graft survival with vs without DGF was 52% and 98%, respectively (P < .002). In donors, 2 univariate risk factors for DGF identified were lower counts per second at peak activity during scintigraphy, and multiple renal veins. In recipients, only 2 or more kidney transplantations and occurrence of an acute rejection episode were important factors. At multivariate analysis, increased risk of DGF was associated with the presence of multiple renal veins (odds ratio, 151.57; 95% confidence interval, 2.53-9093.86) and an acute rejection episode (odds ratio, 78.87; 95% confidence interval, 3.17-1959.62).

Conclusion

Hand-assisted laparoscopic donor nephrectomy is a safe procedure. The presence of multiple renal veins and occurrence of an acute rejection episode are independent risk factors for DGF.     

Impact of hepatic macrovesicular and microvesicular steatosis on the postoperative liver functions after right hepatectomy in living donors

Purpose

The aim of this study was to evaluate the impact of macrovesicular (MaS) and microvesicular steatosis (MiS) on postoperative liver function in living donors undergoing right hepatectomy.

Methods

We retrospectively reviewed the medical records of 450 living liver donors who underwent right hepatectomy between 2000 and 2009. First, we divided the donors into two groups according to the degree of MaS regardless of MiS: group MaS_5 (n = 250), donors with <5% MaS and group MaS_30 (n = 200), donors with 5% to 30% MaS. Second, we stratified donors according to the degree of MiS regardless of Mas: group MiS_5 (n = 163), donors with < 5% MiS, group MiS_30 (n = 287), and 5% - 30% MiS. We evaluated the peak values of total bilirubin (TB), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) until the thirtieth postoperative day (POD). Next, we assessed the relation between MaS or MiS and postoperative peak liver function tests using regression analysis.

Results

Peak values of postoperative AST (227 ± 77 vs 203 ± 67, respectively) and ALT (232 ± 85 vs. 198 ± 72, respectively) were significantly higher in the group MaS_30 than MaS_5. Similarly, the peak values of AST (225 ± 80 vs 194 ± 50, respectively) and ALT (228 ± 85 vs 186 ± 60, respectively) were significantly higher in the group MiS_30 than the group MiS_5. Regression models showed a significant modifying influence of MiS (P < 0.001) on postoperative peak ALT levels in addition to MaS (P < .036), suggesting have comparable influences of both MiS and MaS on hepatic injury.

Conclusion

Our results suggested that a mild degree of either MaS or MiS was associated with higher postoperative peak AST and ALT values. A regression analysis showed both MaS and MiS to display similar impacts on postoperative liver functions after living donor right hepatectomy.     

Single-port laparoscopy-assisted donor right hepatectomy in living donor liver transplantation: sensible approach or unnecessary hindrance?

Background

Single-port laparoscopic (SPL) surgery has rapidly gained attention worldwide. Since May 2008, we have propagated the use of SPL surgery, mainly for cholecystectomy and appendectomy. Recently, we have used this modality of minimally invasive surgery for various liver surgeries. We hereby discuss our outcomes of SPL-assisted donor right hepatectomies.

Methods

The preoperative workup is the same as for a standard donor hepatectomy. We retrospectively reviewed the data of 150 patients who underwent donor right hepatectomy from October 2008 to May 2011. We divided them into 3 groups depending on the type of surgical procedure.

Results

Among 150 patients, 20 underwent laparoscopy-assisted donor right hepatectomy (LADRH); 40 underwent single-port laparoscopy-assisted donor right hepatectomy (SPLADRH); and 90 underwent open donor right hepatectomy (ODRH). The donor demographics were comparable among the groups. Postoperative complication and reoperation rates revealed no significant differences. The SPLADRH group showed the lowest level of postoperative pain, thereby leading to a better quality of life postoperatively.

Conclusions

SPLADRH seems to be a simple, feasible approach.     

Does stroke volume variation predict intraoperative blood loss in living right donor hepatectomy?

Background

Although stroke volume variation (SVV) is a valuable index of preload responsiveness, there is limited information about the association between low SVV and increased hepatectomy-related bleeding. We therefore evaluated whether SVV predicts blood loss during living donor hepatectomy.

Methods

We evaluated 93 adult liver donors undergoing right hepatectomy for transplantation. Arterial blood pressure, heart rate, body temperature, central venous pressure, SVV, cardiac output, and systemic vascular resistance were measured. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to determine independent factors and optimal cutoff values of hemodynamic parameters for predicting intraoperative blood loss ≥ 700 mL.

Results

Of these 93 donors, 36 (38.7%) had blood loss ≥ 700 mL. Univariate logistic regression analysis showed that factors associated with blood loss ≥ 700 mL included heart rate, SVV, cardiac output, and systemic vascular resistance. Multivariate logistic regression analysis revealed that only SVV was an independent predictor of blood loss ≥ 700 mL. ROC curve analysis showed that the optimal cutoff value for SVV predicting blood loss ≥ 700 mL was 6% (area under the curve = 0.64).

Conclusions

SVV is a significant independent predictor of blood loss ≥ 700 mL during donor hepatectomy, suggesting that low SVV may provide useful information on intraoperative bleeding in donors undergoing right hepatectomy.     

Living Donor Renal Transplantation Using Grafts With Multiple Arteries Procured by Laparoscopic Nephrectomy

Objective

Kidney grafts with multiple renal arteries (MRAs) are not uncommon, but they do make transplantation more difficult. Laparoscopic graft nephrectomy has become the standard; however, the safety and reliability must be maintained for both a donor and a recipient even in case of MRAs. This study evaluated the short-term outcomes of living donor renal transplant using grafts with MRAs procured by laparoscopic nephrectomy.

Patients and Methods

This study reviewed all living donor kidney transplantations performed from January 2008 to June 2009, which were divided into 3 groups according to the number of renal graft arteries. The serum creatinine level, warm ischemic time (WIT), rewarming time, total ischemic time (TIT), operative time, acute rejection episodes, and complications in each group were evaluated.

Results

The serum creatinine level showed no difference among the groups. Longer TIT was observed in the MRAs group, but WIT and rewarming time did not differ. The acute rejection rate was not different. There were no vessel complications in any donors and recipients.

Conclusion

Harvesting kidney grafts with MRAs by laparoscopic nephrectomy requires a longer TIT; however, transplantation can be performed safely and reliably for both donors and recipients.     

Change in Renal Function After Laparoscopic Donor Nephrectomy for Kidney Transplantation

Background

Laparoscopic donor nephrectomy (LDN) has become the method of choice for living-donor kidney transplantation. However, LDN may result in decreased renal function in the donor, and risk of end-stage renal failure has been reported.

Objective

To evaluate changes in renal function after LDN.

Patients and Methods

The study included 51 living donors of renal transplants between March 2002 and December 2008. Before kidney donation, we computed the initial function of the kidney preserved in the donor using 24-hour creatinine clearance (Ccr) and functional ratio as revealed at technetium 99m dimercaptosuccinic acid renal scanning. After kidney donation, serum creatinine concentration (sCr) and Ccr were calculated on postoperative day 2 and every 3 months thereafter.

Results

After LDN, mean sCr increased immediately, from 0.90 to 1.31, as did Ccr of the kidney preserved in the donor, from 58.2 to 79.6, a 36.9% increase. A greater percent increase in function was observed in younger donors and those with lower initial Ccr of the preserved kidney. Although 9.8% of donors demonstrated slightly decreased renal function of the preserved kidney at last follow-up, renal function was adequately preserved in most donors.

Conclusion

Younger donors and those with lower initial function of the preserved kidney before nephrectomy demonstrate a greater increase in function after nephrectomy. Age might be a risk factor for decreased renal function after LDN. Older potential living donors may need more careful evaluation before kidney donation.     

Effectiveness of different kidney exchange mechanisms to improve living donor transplantation in Chile

Introduction

Chile has a low cadaveric organ donation rate; at the same time, living donor transplantation activity is also low. The purpose of this study was to analyze the impact on the number and quality of transplants using various mechanisms for kidney exchange from living donors to patients on Chile's waiting list.

Methods

A computerized model was developed to simulate five options for living kidney donation: (1) direct donation; (2) direct donation plus pairwise and three-way exchanges; (3) pairwise exchange; (4) three-way exchange; and (5) allocation of donors based on the top trading cycles (TTC) mechanism. We calculated the projected number of transplantations, adjusting for the risk of a positive crossmatch, as well as the average quality in terms of the human leukocyte antigen (HLA) match.

Results

If all patients on the waiting list have a willing direct donor, 47.7% of patients will receive a transplant. Allowing for incompatible pairs or pairs with a positive crossmatch an exchange of kidneys, can increase the number to 51.8%. This figure rises to 60% or 61% for pairwise or three-way exchanges, respectively. Although TTC ensures that 55% of the patients could be transplanted, the graft quality is better with an average HLA match of 3.5 versus 1.25.

Conclusions

These results showed that kidney exchange mechanisms can increase the number of living donor transplantations by 4% and 13%.     

The effects of desflurane and isoflurane on hepatic and renal functions after right hepatectomy in living donors

Purpose

Considering the severe nature of living donor right hepatectomy (removal of two thirds of the original liver), identification of an anesthetic agent having a minimal impact on postoperative organ function seems important. We compared postoperative hepatic and renal functions between 2 inhalational anesthetics, desflurane (Des) and isoflurane (Iso) among living donors undergoing right hepatectomy.

Method

Sixty-four adult donors included in this retrospective study were divided into a Des group (n = 32) and an Iso group (n = 32). Before the induction of anesthesia, morphine sulfate (400 μg) was injected intrathecally. Anesthesia was maintained with 1 minimum alveolar concentration (MAC) of Des or Iso plus intravenous remifentanil. Hepatic and renal function tests were analyzed preoperatively, immediately after operation, and on the first, second, third, fifth, seventh, and thirtieth postoperative days (POD).

Results

Total bilirubin showed significant elevations on POD 1, 5, 7, and 30 in the Des group. Estimated glomerular filtration rate was significantly lower immediately after operation and on POD 1 in the Des group. The postoperative complication rates were similar between the 2 groups, and no patient developed hepatic or renal failure.

Conclusion

The present study showed better postoperative hepatic and renal function tests with Iso than Des at an equivalent dose of 1 MAC among living donors undergoing right hepatectomy.     

Standardized less invasive living donor hemihepatectomy using the hybrid method through a short upper midline incision

Background

Recently, applications of less invasive liver surgery in living donor hepatectomy (LDH) have been reported. The objective of this study was to evaluate the safety and efficacy of a hybrid method with a midline incision for LDH.

Methods

Hemihepatectomy using the hybrid method was performed in the fifteen most recent among 150 living donors who underwent surgery between 1997 and August 2011. Six donors underwent right hemihepatectomy and 9 underwent left hemihepatectomy. An 8-cm subxiphoid midline incision was created for hand assistance during liver mobilization and graft extraction. After sufficient mobilization of the liver, the hand-assist/extraction incision was extended to 12 cm for the right hemihepatectomy and 10 cm for a left hemihepatectomy. Encircling the hepatic veins and hilar dissection were performed under direct vision. Parenchymal transection was performed with the liver hanging maneuver. Bile duct division was performed after visualizing the planned transection point by encircling the bile duct using a radiopaque marker filament under real-time C-arm cholangiography.

Results

All procedures were completed without any extra subcostal incision. All grafts were safely extracted through the 10-12-cm upper midline incision without mechanical injury. No donors required an allogeneic transfusion; all of them have returned to their preoperative activity levels.

Conclusion

LDH by the hybrid method with a short upper midline incision is a safe procedure.     

Two-surgeon technique using saline-linked electric cautery and ultrasonic surgical aspirator in living donor hepatectomy: its safety and efficacy

Background

Saline-linked electric cautery (SLC) is introduced as an effective device to reduce blood loss in liver surgery. The aim of the current study was to evaluate the safety and efficacy of a 2-surgeon technique using SLC and the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, CO) in living donor hepatectomy.

Methods

Forty-three living donor right hepatectomy cases were enrolled in this study. The first 28 cases underwent liver transection with CUSA alone (CUSA group), while additional SLC was applied in the current 15 cases (2-surgeon technique, TS group).

Results

Blood loss was significantly reduced by the 2-surgeon technique (1,115.2 ± 652.9 g in CUSA group vs 732.3 ± 363.6 g in TS group, P < .05). In the TS group, there was no bile leakage from the cut surface. The early graft function and postoperative recipient survival were not significantly different between the groups.

Conclusions

According to our single-center experience, blood loss and donor complications in living donor hepatectomies were significantly reduced using a 2-surgeon technique using CUSA and SLC, while maintaining the graft viability.     

Risk of late bleeding following hemorrhoidal banding in patients on antithrombotic prophylaxis

Background

The risk of bleeding following rubber band ligation of internal hemorrhoids is 1%-2%. This risk may be increased in patients taking antithrombotic therapy. The goal of the current study was to find a safer approach to banding without increasing the risk of bleeding.

Methods

This retrospective review identified patients undergoing banding while on antithrombotic therapy. These medications were held for 7-10 days following the procedure. The number of bands placed while on antithrombotic therapy and their post band complications were recorded.

Results

There were 605 bands placed on 364 patients taking antithrombotic medications. There were 23 complications involving bleeding, a value that was not statistically different from those not taking antithrombotic therapy. Patients on clopidogrel experienced 50% of the significant bleeding episodes and 18% of the insignificant bleeding episodes.

Conclusions

Holding antithrombotic medication following banding appears to equalize the risk of bleeding to that of patients not taking antithrombotic medications. Patients taking clopidogrel may be at higher risk for bleeding complications.