Donor quality of life after living donor liver transplantation

Living donor liver transplantation (LDLT) for children and adults has gained widespread acceptance due to the severe organ shortage. LDLT provides potential recipients with timely transplantation, but this procedure engenders a potentially significant risk to the donor. This study analyzed medical, functional, and psychological donor outcomes after LDLT. Nineteen donors (mean age 33.9 +/- 12 years), who underwent hepatectomy for LDLT (13 right lobectomy for adult LDLT) from March 1998 to November 2002, were interviewed at a median of 13 months after donation (range, 2 to 58 months). According to the Clavien System classification, major complications occurred in three donors (16%), and minor in four (21%). The mean length of hospital stay was 5.7 +/- 1.6 days. Five patients (27%) needed rehospitalization. Complete recovery was achieved at a mean time of 8.5 +/- 3.5 weeks. All 19 donors were able to return to predonation activities. The donor's relationship to the recipient and to their families was improved after donation in all cases; 12 (63%) cited a positive psychological impact on their lives. About 90% would donate again and 84% would recommend donation to someone contemplating it. In conclusion, all donors are alive and well after donation and were able to return to their predonation occupation. Most of them felt that this experience changed their lives for the better and would donate again. Donor safety and quality of life should remain the priority in all donation processes.     

Applicability of histidine-tryptophan-ketoglutarate solution in right lobe adult-to-adult live donor liver transplantation.

In a consecutive series of 60 right lobe adult-to-adult live donor liver transplantations (ALDLTs), safety and efficacy of the University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solution were evaluated. The first 30 liver grafts were perfused with UW solution and the subsequent 30 by HTK solution. Donor and recipient characteristics of both groups were comparable. All liver graft implantations were performed with cross-clamping of the inferior vena cava (IVC) and without veno-venous bypass. Main outcome measures were posttransplantation liver biochemistry, prothrombin time, and recipient morbidity, as well as graft and recipient survival. There were no significant differences of the outcome measures between the 2 groups. The low potassium content of the HTK solution nonetheless offered logistic advantages. In 25 of the 30 recipients of the HTK group, portal vein anastomosis was performed with a clamp on the donor portal vein while the clamps on the IVC were already released. This shortened the period during which the IVC was being cross-clamped. HTK solution was as safe and effective as a cold storage solution as UW solution in ALDLT. Its low potassium content has advantage of earlier restoration of patency of the IVC and thus hemodynamic stability. The cost of using HTK solution was also lower.     

Donor evaluation,donor risks,donor outcome,and donor quality of life in adult-to-adult living donor liver transplantation

Right lobe living donor liver transplantation (LD-LTx) is currently performed at an increasing number of transplant centers. Donor selection, donor safety, donor recovery, and postdonation psychological impairment are essential criteria to determine whether and under which conditions LD-LTx is justifiable. Before commencing the LD-LTx program, approval was obtained from the local ethics committee. Potential donors underwent a comprehensive multistep evaluation protocol to exclude any conditions that could lead to an increased operative risk. Each donation was approved by the local Living Donation Commission. Follow-up investigations were performed after 6 and 12 months. Liver regeneration was assessed by computed tomography scan and magnetic resonance imaging scan derived volumetries. Quality of life (QOL) was investigated according to the Anamnestic Comparative Self-Assessment Scale (ACSA) before donation, and 6 and 12 months after donation. As of December 2001, 43 right lobe living donations have been performed at the Charité, Campus Virchow, Berlin. None of the donors died or has suffered life-threatening or persisting complications. All patients recovered completely. Complications occured in 8 donors (18%). The incidence of perioperative surgical complications was 9%, comprising temporary biliary leakages (n = 3; 6.8%) as well as postoperative bleeding (n = 1). Liver volume regeneration approximated 72% ± 15% of predonation volume by 6 months and 85% ± 18% (mean ± SD) by 12 months. There was no evidence of significant psychological impairment after donation. QOL increased after donation compared with the preoperative state (P < .05). In our experience, LD-LTx has proven to be a practicable and safe procedure. However, there is a considerable risk of postoperative complications. The donor selection process plays a pivotal role in preventing complications. The discussion of potential risks, especially potential life-threatening risks, must be an integral part of informed consent. (Liver Transpl 2002;8:829-837.)     

Right liver adult-to-adult live donor liver transplantation in Hong Kong

The extension of live donor liver transplantation (LDLT) from children to adults went in parallel with the shift from using the left-liver graft to the right. Donor right hepatectomy, being a more major procedure, only intensifies the ethical controversy, which is central to LDLT. Since its debut in 1996, right-liver adult-to-adult LDLT has gone through a number of technical innovations and refinements based on constant review of outcomes and study of the relevant pathophysiology. To achieve unimpeded graft venous outflow, the middle hepatic vein was universally included and underwent venoplasty with the right hepatic vein before anastomosis with the recipient inferior vena cava. Donor safety was never compromised and was acquired by preservation of segment 4b hepatic vein in the remnant left lobe. Venovenous bypass, which was associated with adverse outcomes, is no longer used. Early restoration of the circulation through the inferior vena cava was made possible by release of the clamps to the latter before portal vein anastomosis. Through judicious use of the procedure, which was executed with a high degree of precision, using right-liver grafts more than 35% of the estimated liver mass, a 1-year recipient survival of more than 90% is achievable in our series.     

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.     

Long-term biological consequences of donor right hepatectomy including the middle hepatic vein in adult-to-adult live donor liver transplantation.

The right lobe liver graft has become the workhorse of adult-to-adult live donor liver transplantation. Donor right hepatectomy is feasible only because of the immense regenerative ability of the liver. The long-term biological consequences of this very major donor procedure on the donor however are unknown. Twenty-nine donors of this procedure in our centre, all of whom included the middle hepatic vein, were studied. On long-term follow-up at a median of 47.4 months, there was a discernible but statistically insignificant decrease in size of the regenerated left lobe compared to the original whole liver volume. There was paradoxically a trend of incompleteness of regeneration in relation to the original liver volume for those with a larger remnant left lobe. The volume ratio of the regenerated left lobe to the original left lobe before hepatectomy was inversely proportional to the left lobe proportion preoperatively. This strong but inverse linear correlation reflected the good regenerative ability of the remnant left lobe. None of the donors developed thrombocytopenia. Although demonstrable decrease in white cell count, increase in serum alanine aminotransferase, aspartate aminotransferase, and creatinine did occur, the changes remained within normal limits and were of yet uncertain clinical significance. In conclusion, donor right hepatectomy including the middle hepatic vein is biologically acceptable to the live donor.     

Safety of donor right hepatectomy for adult-to-adult living donor liver transplantation

The purpose of this study was to ascertain the usefulness of preoperative evaluations of donors by computed tomography (CT) volumetry and CT cholangiography for prevention of unexpected liver failure and biliary complications after donor right hepatectomy for adult-to-adult living donor liver transplantation. Fifty-two donors who underwent right hepatectomy without the middle hepatic vein were enrolled in this study. The values of graft weight (GW) were significantly correlated with those of estimated graft volume (GV; P < 0.0001). GW was predicted by the following formula: GW = 155.25 + 0.658 x GV; r(2) = 0.489. CT cholangiography revealed anatomical variants of biliary structure in one-third of the donors and also clearly showed one or two small biliary branches from the caudate lobe to the right hepatic ducts or the confluence in 58% of the donors. Biliary leakage, which was treated by conservative therapy, occurred in only one donor (1.9%). No donors received homologous blood transfusion. Hyperbilirubinemia (serum total bilirubin >5 mg/dl) occurred in 5.8% of the donors during their early postoperative periods. Precise evaluations of liver remnant volume by CT volumetry and biliary variation by CT cholangiography are essential for performing safe donor hepatectomy, preventing hepatic insufficiency and minimizing the risk of biliary tract complications.     

Working up donors for high-urgency and elective adult-to-adult live donor liver transplantation.

Donor workup for adult-to-adult live donor liver transplantation is done to ensure that the donor remains physically and psychologically healthy after saving or improving the life of the recipient. Even though two-thirds of the liver transplants in our center were from live donors, this life-saving procedure remains a mere treatment option, given the magnitude of the donor operation with the associated donor risks. Live donor liver transplantation was also adopted for high-urgency situations provided that the donor was suitable and the recipient considered salvageable. Donor workup in this setting had not been reported in the literature. In this cohort of 399 potential donors, 128 (32.1%) ultimately underwent donor surgery. Donors in the high-urgency situation had a lower operation rate of 28.4% (64/225) compared with that of 36.8% (64/174) of donors in the elective situation (P = 0.049). Dropouts from step 1 mainly because of ABO incompatibility, positive hepatitis serology, comorbidities, and voluntary donor withdrawal were 52.6% (210/399). Only 11.6% (22/189) of the potential donors who proceeded to subsequent steps of the workup dropped out (2 were psychologically unsuitable, 10 were anatomically prohibitive). The transplantation rate of potential recipients with 1 or more potential donors was also high. The rates were similar for the high-urgency (55%, 64/116) and the elective (51%, 64/125) situations. In a region with scarcity of deceased donor liver grafts, careful and expeditious initial donor workup minimizes dropouts from subsequent steps and allows timely transplantation in high-urgency situations.     

Hemophagocytic syndrome after adult-to-adult living donor liver transplantation

Hemophagocytic syndrome is a fatal complication after liver transplantation that is rarely reported. Among 260 adult patients who underwent living donor liver transplantation at our hospital, three cases (1%) were complicated with hemophagocytic syndrome. Intensive investigation revealed Aspergillus, cytomegalovirus, and hepatitis C virus as the most likely causative organisms in each patient. Despite the immediate initiation of anti-infectious treatment and supportive care, all patients died. When pancytopenia with possible underlying infectious disease is observed in liver transplant recipients, hemophagocytic syndrome should be suspected and bone marrow biopsy considered. The prognosis of hemophagocytic syndrome remains poor and further investigations are required to establish effective therapeutic options.     

Toward current standards of donor right hepatectomy for adult-to-adult live donor liver transplantation through the experience of 200 cases

OBJECTIVE: To define the current standards of donor right hepatectomy, including the middle hepatic vein for adult-to-adult live donor liver transplantation. SUMMARY BACKGROUND DATA: Donor morbidity and mortality are inevitable given the ultra-major nature of the donor operation. Results from a matured center could define the true impact of this donor procedure most accurately. PATIENTS AND METHODS: From May 9, 1996 to April 13, 2005, 200 consecutive donors underwent donor right hepatectomy at the University of Hong Kong Medical Center. All right liver grafts except one included the middle hepatic vein. Donor characteristics, operation time, blood loss, hospital stay, laboratory results, and complications graded by Clavien's classification divided into four eras (each consecutive 50 cases) were compared. RESULTS: Donor characteristics of the four eras were generally comparable. Operative outcomes improved progressively through the four eras. From era 1 to era 4, operation time decreased from 598 minutes (range, 378-932 minutes) to 391 minutes (range, 304-635 minutes). Blood loss also decreased from 500 mL (200-1600 mL) of era 1 to 251 mL (range, 95-595 mL) of era 4. Overall complication rate was 20.5% (41 of 200). Complications rates from eras 1 to 4 were 34%, 16%, 16%, and 16%, respectively. The most common complications were of grade I (24 of 41, 58.5%). A late donor death occurred in era 4 from the development of a duodenocaval fistula 10 weeks postoperation, giving a donor mortality of 0.5% (1 of 200). CONCLUSIONS: This study validated the estimated morbidity and mortality of donor right hepatectomy of 20% and 0.5%, respectively. The data provide reference for counseling potential donors and setting the standards of donor right hepatectomy in the current era.     

Safety of donor in adult-to-adult living donor liver transplantation using right lobe graft

BACKGROUND: The growing gap between the number of patients awaiting liver transplantation and available organs has continued to be the primary issue facing the transplant community. To overcome the waiting list mortality, living donor liver transplantation has become an option, in which the greatest concern is the safety of the donor, especially in adult-to-adult living donor liver transplantation (A-A LDLT) using a right lobe liver graft. OBJECTIVE: We evaluated the safety of donors after right lobe liver donation for A-A LDLT performed in our center. METHODS: From January 2002 to March 2006, 26 patients underwent A-A LDLT using right lobe liver grafts in our center. Seven donors were men and 19 were women (range, 19-65 years; median age, 38 years). The right lobe liver grafts were obtained by transecting the liver on the right side of the middle hepatic vein without interrupting the vascular blood flow. The mean follow-up time for these donors was 9 months. RESULTS: These donor residual liver volumes ranged from 30.5% to 60.3%. We did not experience any donor mortality. Two cases (7.69%) experienced major complications: intra-abdominal bleeding and portal vein thrombosis in one each and three (11.54%), minor ones: wound steatosis in two, and transient chyle leak in one. All donors were fully recovered and returned to their previous occupations. CONCLUSIONS: A-A LDLT using a right lobe liver graft has become a standard option. The donation of right lobe liver for A-A LDLT was a relatively safe procedure in our center.     

成人间右半肝活体肝移植的肝动脉重建

Objective To summarize our experience in hepatic artery reconstruction in adult-to-adult right lobe living donor liver transplantation(LDLT).Methods A retrospective analysis was made for 17 cases undergoing LDLT in our center from May 2007 to Oct 2008.Results All the 17 right lobe graft of the liver was supplied by single right hepatic artery and the mean diameter of right hepatic artery was 3.1 mm.The hepatic artery for segment 4 was mainly originated from left hepatic artery(12/17,70.1%).The recipient right or left hepatic artery was used in 14 cases of reconstruction,proper hepatic artery was used in 2 cases,and gastroduodenal artery was used in one case.Anastomosis was performed with interrupted 8-0 prolene and 12-16 stitches were made on the posterior wall first and then the anterior wall to avoid turning over the vessel.The mean anastomosis time was(51±26) minutes and all hepatic arteries were patent immediately after anastomosis.Hepatic arterial complications including hepatic artery thrombosis (HAT)did not occur after LDLT.Conclusions Detailed evaluation and careful protection of the hepatic artery of segment 4 are the key to successful reconstruction of hepatic artery in LDLT.Anastomosis was performed without flipping the artery wall helped to reduce the difficulty of operation remarkably and with a good result.     

成人间右半肝活体肝移植的肝动脉重建

目的 探讨成人间右半肝活体肝移植的肝动脉重建的相关问题.方法 我院移植中心2007年5月至2008年10月,共完成17例成人活体右半肝肝移植,结合此组病例的临床资料,就肝动脉重建的术前评估、手术技巧和并发症防治进行回顾性分析.结果 17例右半肝供体均为单一肝右动脉供血,动脉平均直径3.1 mm,S4段主要由左肝动脉供血有12例(12/17,70.1%),由肝右动脉供血4例(4/17,23.5%),肝右和肝左动脉均发出动脉分支供血的1例.利用胆囊动脉扩大供肝肝右动脉吻合口径2例.供肝肝右动脉与受体肝右动脉吻合10例(10/17,60%),与受体肝左动脉吻合4例,与受体肝固有动脉吻合2例.吻合方式均为间断吻合,先吻合动脉后壁再吻合前壁,缝合针数12～16针.均为一次吻合成功,平均吻合时间(51±26)min,术后未出现肝动脉相关并发症.结论 对供肝S4段肝动脉的详细评估和保护是活体肝移植肝动脉重建的重点,不翻转供受体动脉的吻合方法可以有效降低手术难度,减少动脉并发症的发生.     

成人间右半肝活体肝移植的肝动脉重建

Objective To summarize our experience in hepatic artery reconstruction in adult-to-adult right lobe living donor liver transplantation(LDLT).Methods A retrospective analysis was made for 17 cases undergoing LDLT in our center from May 2007 to Oct 2008.Results All the 17 right lobe graft of the liver was supplied by single right hepatic artery and the mean diameter of right hepatic artery was 3.1 mm.The hepatic artery for segment 4 was mainly originated from left hepatic artery(12/17,70.1%).The recipient right or left hepatic artery was used in 14 cases of reconstruction,proper hepatic artery was used in 2 cases,and gastroduodenal artery was used in one case.Anastomosis was performed with interrupted 8-0 prolene and 12-16 stitches were made on the posterior wall first and then the anterior wall to avoid turning over the vessel.The mean anastomosis time was(51±26) minutes and all hepatic arteries were patent immediately after anastomosis.Hepatic arterial complications including hepatic artery thrombosis (HAT)did not occur after LDLT.Conclusions Detailed evaluation and careful protection of the hepatic artery of segment 4 are the key to successful reconstruction of hepatic artery in LDLT.Anastomosis was performed without flipping the artery wall helped to reduce the difficulty of operation remarkably and with a good result.     

Technical refinement in adult-to-adult living donor liver transplantation using right lobe graft

OBJECTIVE: To report the authors' experience with living donor liver transplantation in adults using right lobe liver grafts, performed by a modified technique. SUMMARY BACKGROUND DATA: The initial results of seven living donor liver transplants in adults using extended right lobe grafts were satisfactory, but serious complications occurred in two donors, and six recipients required repeat laparotomy. Another 11 similar operations were performed. Further evaluation was made with the aim of improving the postoperative outcome. METHODS: From December 1996 to August 1998, 11 patients underwent living donor liver transplantation using right lobe grafts. The first four patients underwent surgery using methods previously designed and the next seven underwent a modification designed to minimize devitalized tissues on the liver transection surface, improve hepatic venous drainage, and reduce the number of hepatic duct orifices. RESULTS: There were no donor deaths. Donor complications included cholestasis (n = 1) and minor wound infection (n = 1). All the first four recipients required a repeat laparotomy for infected necrotic liver transection surface (n = 1), acute pancreatitis (n = 1), hepatic vein thrombosis (n = 1), and leakage from one of the two bilioenteric anastomoses (n = 1). The patient with hepatic vein thrombosis died. In the last seven recipients, all of whom survived the operation, one required a repeat laparotomy with the discovery of a methicillin-resistant Staphylococcus aureus culture of fibrinous exudate at the left subphrenic peritoneum, and another had right hepatic duct stump necrosis. The latter was likely related to hypovolemic shock secondary to bleeding from the right saphenous vein on removal of a hemofiltration catheter. Comparison of the incidence of repeat laparotomy between the first four and the remaining seven recipients showed a significant trend of improvement. Combining the result of the seven patients reported previously, the improvement in terms of relaparotomy rate is significant. CONCLUSION: With modification of surgical technique, living donor liver transplantation in adults using right lobe liver grafts can become a relatively safe procedure.     

Operative outcomes of adult-to-adult right lobe live donor liver transplantation: a comparative study with cadaveric whole-graft liver transplantation in a single center

OBJECTIVE: To evaluate and compare the operative and survival outcomes of patients who underwent right lobe live donor liver transplantation (RLDLT) and cadaveric whole-graft liver transplant (CWLT) recipients in a single institution. SUMMARY BACKGROUND DATA: Current data suggest that RLDLT has an inferior graft survival outcome when compared with CWLT. PATIENTS AND METHODS: A prospective study was performed on 180 consecutive adult patients who underwent primary liver transplantation from January 2000 to February 2004. The operative and survival outcomes of RLDLT (n = 124) were compared with those of CWLT (n = 56). RESULTS: Fifty-five (44%) and 16 (29%) patients were on high-urgency list in the RLDLT group and the CWLT group, respectively (P = 0.045). The preoperative Model for End-Stage Liver Disease scores were comparable in both groups. The waiting time for liver transplantation was significantly shorter in the RLDLT group. The graft weight to estimated standard liver weight ratio was significantly lower in the RLDLT group. The postoperative hospital stay and hospital mortality were comparable in the RLDLT group (1.6%) and the CWLT group (5.4%). Thirty-one (25%) patients in the RLDLT group and 3 (5%) patients in the CWLT group developed biliary stricture on follow-up (P = 0.002). At a median follow-up of 27 months, the actuarial graft and patient survival rates were 88% and 90%, respectively, in the RLDLT group, and both were 84% in the CWLT group. CONCLUSION: RLDLT results in favorable operative outcomes comparable with those of CWLT. However, there is a significantly higher incidence of biliary stricture associated with RLDLT.     

Safety and necessity of including the middle hepatic vein in the right lobe graft in adult-to-adult live donor liver transplantation

OBJECTIVE: To evaluate the safety of donors who have donated the middle hepatic vein in right lobe live donor liver transplantation (LDLT) and to determine whether such inclusion is necessary for optimum graft function. SUMMARY BACKGROUND DATA: The necessity to include the middle hepatic vein in a right lobe graft in adult-to-adult LDLT is controversial. Inclusion of the middle hepatic vein in the graft provides uniform hepatic venous drainage but may lead to congestion of segment IV in the donor. METHODS: From 1996 to 2002, 93 right-lobe LDLTs were performed. All right-lobe grafts except 1 contained the middle hepatic vein. In the donor operation, attention was paid to preserve the segment IV hepatic artery and to avoid prolonged rotation of the right lobe. The middle hepatic vein was transected proximal to a major segment IVb hepatic vein whereas possible to preserve the venous drainage in the liver remnant. RESULTS: There was no donor death. Two donors had intraoperative complications (accidental left hepatic vein occlusion and portal vein thrombosis) and were well after immediate rectification. Twenty-four donors (26%) had postoperative complications, mostly minor wound infection. The postoperative international normalized ratio on day 1 was better in the donors with preservation of segment IVb hepatic vein than those without the preservation, but, in all donors, the liver function was largely normal by postoperative day 7. The first recipient had severe graft congestion as the middle hepatic vein was not reconstructed before reperfusion. In 7 other recipients, the middle hepatic vein was found occluded intraoperatively owing to technical errors. The postoperative hepatic and renal function of the recipients with an occluded or absent middle hepatic vein was worse than those with a patent middle hepatic vein. The hospital mortality rate was also higher in those with an occluded middle hepatic vein (3/9 vs. 5/84, P = 0.028). CONCLUSIONS: Inclusion of the middle hepatic vein in right-lobe LDLT is safe and is essential for optimum graft function and patient survival.     

Hepatic venous outflow reconstruction in right live donor liver transplantation.

The increasing experience with live donor liver transplantation has allowed for the identification of potential morbidities associated with technical considerations. Technical graft failure can be associated with both inflow and outflow vascular compromise. Although the latter has not always been given the relevance of the former, evidence pointing to its pivotal role continues to mount. We believe that impaired venous outflow was a cause of previously unexplained graft failures during our initial experience. Based on this observation, we developed a technique to prevent the "choking" of the graft at the outflow anastomosis with the inferior vena cava (IVC). The enhanced outflow via a cloaca maximum is achieved by reconstructing the graft vessels with preserved veins or arteries (usually iliac vessels are used) from a blood-group-identical or blood-group-compatible deceased organ donor. Alternatively, hepatic vein or portal vein obtained from the resected native liver can be used. The reconstructed common outflow is anastomosed to a triangular opening of the IVC. Such enhanced outflow provides optimal venous drainage, especially during the early phase of growth of the graft.