Right Hepatic Lobe Donation: Impact on Donor Quality of Life

Anxiety, pain intensity, and decision regret of living liver donors during postoperative period

AIM

The aim of this study was to explore and examine the relationship between anxiety, acute pain intensity, and decision regret of living liver donors in the postoperative stage.

METHODS

This is a prospective correlational study. Data were collected consecutively for one year (from September 2017 to September 2018) at a medical center in northern Taiwan. Information about anxiety and acute pain intensity was collected preoperatively and on postoperative day (POD) 3 and POD 7. Satisfaction with pain management and decision regret was inquired about on POD 7.

RESULTS

Data of 57 consecutive living liver donors (56.1 % male, mean age 34.12 ± 9.92 years) were analyzed. Living liver donors experienced moderate anxiety and acute pain levels in the postoperative period. The mean score of decision regret was 12.63 (range 0-60), indicating a low level of regret. The acute pain intensity decreased significantly between POD 3 and POD 7 (p < .001); however, the anxiety level slightly increased (p = .031). Older and married living liver donors had higher anxiety levels. The satisfaction level of pain management was negatively correlated with the POD 7 acute pain intensity (r = -0.26, p = .049) and decision regret (r = -0.37, p = .005), but it was positively correlated with POD 7 anxiety (r = 0.38, p = .004).

CONCLUSIONS

The postoperative period was hard for living liver donors as they would experience moderate acute pain and anxiety. Although the decision regret was low, the satisfaction level of pain management would negatively affect it. Therefore, the effectiveness of pain management and anxiety management should be continually ensured in the postoperative period.

When is it safe for the liver donor to be discharged home and prevent unnecessary re-hospitalizations? - A systematic review of the literature and expert panel recommendations

BACKGROUND

Few data are available on discharge criteria after living liver donation (LLD).

OBJECTIVES

To identify the features for fit for discharge checklist after LLD to prevent unnecessary re-hospitalizations and to provide international expert recommendations.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The critical outcomes included were complications rates and liver function (defined by elevated bilirubin and INR) (CRD42021260725).

RESULTS

Total 57/1710 studies were included in qualitative analysis and 28/57 on the final analysis. No randomized controlled trials were identified. The complications rate was reported in 20/28 studies and ranged from 7.8% to 71.2%. Post hepatectomy liver function was reported in 13 studies. The Quality of Evidence (QoE) was Low and Very-Low for complications rate and liver function test, respectively.

CONCLUSIONS

Monitoring and prevention of donor complications should be crucial in decision making of discharge. Pain and diet control, removal of all drains and catheters, deep venous thrombosis prophylaxis, and use routine imaging (CT scan or liver ultrasound) before discharge should be included as fit for discharge checklist (QoE; Low | GRADE of recommendation; Strong). Transient Impaired liver function (defined by elevated bilirubin and INR), a prognostic marker of outcome after liver resection, usually occurs after donor right hepatectomy and should be monitored. Improving trends for bilirubin and INR value should be observed by day 5 post hepatectomy and be included in the fit for discharge checklist. (QoE; Very-Low | GRADE; Strong).

Complications and outcomes of 890 living liver donor hepatectomies at a single center: risks of saving loved one's life

OBJECTIVES

Living liver donor surgery is a major surgical procedure applied to healthy people with mortality and morbidity risks and does not provide any direct therapeutic advantage to the donor. We retrospectively analyzed the postoperative complication of our living liver donors to figure out the risks of donation.

MATERIAL AND METHODS

Between November, 2006 and December, 2018, a total of 939 living liver donor hepatectomies were performed with no mortality to the living-related donors. Eight hundred and ninety donors with a minimum 1-year follow-up were analyzed retrospectively.

RESULTS

Of the 890 donors, 519 (58.3%) were males and 371 (41.7%) were females. Mean age was 35 years (18-64) and mean body mass index was 25.7 kg/m2 (17.7-40). Right donor hepatectomy was performed to 601 (67.5%), left donor hepatectomy to 28 (3.2%) and left lateral sector hepatectomy to 261 (29.3%) of the donors. Of the 890 donors, 174 (19.5%) donors experienced a total of 204 early and late complications including life- threatening and nearly life- threatening complications in 26 (2.9%) of them. Intraoperative complication occurred in 4 (0.5%) donors. Right donors hepatectomy complication rate (23.3%) was higher than left donor (14.3%) and left lateral sector donor hepatectomy (11.5%).

CONCLUSION

All donor candidates should be well-informed not only on the details of early and late complications of living liver donation, also possible outcomes of the recipient. In addition to detailed physical evaluation, preoperative psychosocial evaluation is also mandatory. Comprehensive donor evaluation, surgical experience, surgical technique, close postoperative follow-up and establishing a good dialog with the donor allows better outcomes.

Challenges and future developments in liver transplantation

Liver transplantation (LT) has become the treatment of choice for a wide range of liver diseases in both adult and pediatric patients. Until recently, the largest proportion of LT in adults, were performed in patients with hepatitis C (HCV) related cirrhosis. The recent availability of safe and effective direct antiviral agents to cure HCV infection in almost all patients whatever the HCV genotype and severity of liver disease, will reduce the need for LT in this category of recipients. Thus, it is presumed that in the next 1 to 2 decades HCV related liver disease will diminish substantially, whereas non-alcoholic steato-hepatitis (NASH) will correspondingly escalate as an indication for LT. The greatest challenges facing LT remain the limited supply of donor organs, and the need for chronic immunosuppression, which represent the true obstacles to the greater application and durable success of the LT procedure. This review aimed to highlight, in different sections, the main open issues and future developments in LT. These will be focused to explore current and future strategies to maximize the use of limited organs, to offer an update on potential new approaches to immunosuppression and to imagine new indications for LT when the number of patients awaiting transplants for HCV related liver disease is reduced.

Analysis of risk factors affecting coagulopathy after donor hepatectomy in a newly established liver transplant center

OBJECTIVE

As might be expected, living donor liver surgery is associated with serious morbidity and mortality risks. Coagulopathy after donor hepatectomy is an important risk factor affecting morbidity. In this study, risk factors affecting the development of coagulopathy after donor hepatectomy was evaluated in a newly-established liver transplant center.

MATERIAL AND METHODS

A retrospective evaluation of 46 liver donors to whom hepatectomy was applied in Medipol Universty of School of Medicine Department of Organ Transplantation between April 2014 and July 2015 was made. Coagulopathy was defined as prothrombin time ≥15 sec. or platelet count <80000/mm³ on postoperative day 3. Donors were separated into 2 groups as those with (n=24) and without (n=22) coagulopathy. Preoperative, intraoperative and postoperative factors acting on coagulopathy were analyzed.

RESULTS

In the intergroup analysis, it was seen that remnant liver volume, remnant liver volume % and remnant liver volume to body weight ratio were factors associated with coagulopathy. The cut-off values for these 3 parameters were calculated as 773.5 cm³, 40.5% and 0.915 cm³/kg, respectively. Only remnant liver volume % was determined as a risk factor for coagulopathy after donor hepatectomy on multiple logistic regression analysis.

CONCLUSION

The results of this study showed that the most important risk factors affecting coagulopathy after donor hepatectomy were the parameters associated with remnant liver volume.

Mental health status after living donor hepatectomy

Donor safety and preservation of donor health after living liver donation are of paramount importance. In addition, the preoperative mental state of a donor is an important factor in determining the psychological impact of donor hepatectomy. Thus, we aimed to explore the mental health status of living liver donors after hepatectomy. We enrolled 60 donors who were scheduled to undergo living donor hepatectomy during the period January 2014 to March 2015 at a single medical center. Mental health status was measured before and 3 months after surgery using 3 self-report questionnaires, namely the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depressive symptoms, the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire to measure quality of life, and the Chinese Health Questionnaire (CHQ) to screen for minor psychiatric disorders. A comparison of the pre- and postdonation CES-D scores revealed a significant reduction in depressive symptoms after surgery (P = .031). There were significant improvements in the physical health domain (P = .031), the psychological health domain (P = .005), the social relationships domain (P = .005), and the environmental health domain (P = .010) of the WHOQOL-BREF. There were no significant changes in CHQ scores after donor hepatectomy (P = .136). All donors reported that they would donate again if required. Approximately one-third (33.3%) of donors experienced more pain than they had anticipated in the immediate postoperative period, and 20.0% of donors had complications after donor hepatectomy. Donor mental health status tended to improve as donors regained physical function during the 1st 3 months of recovery. Long-term monitoring of living donors' mental health is needed to minimize the adverse psychological outcomes of living liver donation.

Current challenges and future directions for liver transplantation

Liver transplantation is an effective and widely used therapy for several patients with acute and chronic liver diseases. The discrepancy between the number of patients on the waiting list and available donors remains the key issue and is responsible for the high rate of waiting list mortality. The recent news is that the majority of patients with hepatitis C virus related liver disease will be cured by new antivirals therefore we should expect soon a reduction in the need of liver transplantation for these recipients. This review aims to highlight, in two different sections, the main open issues of liver transplantation concerning the current and future strategies to the best use of limited number of organs. The first section cover the strategies to increase the donor pool, discussing the use of older donors, split grafts, living donation and donation after cardiac death and mechanical perfusion systems to improve the preservation of organs before liver transplantation. Challenges in immunosuppressive therapy and operational tolerance induction will be evaluated as potential tools to increase the survival in liver transplant recipients and to reducing the need of re-transplantation. The second section is devoted to the evaluation of possible new indications to liver transplantation, where the availability of organs by implementing the strategies mentioned in the first section and the reduction in the number of waiting transplants for HCV disease is realized. Among these new potential indications for transplantation, the expansion of the Milan criteria for hepatocellular cancer is certainly the most open to question.

Predictors of Diarrhea after Hepatectomy and Its Impact on Gastrointestinal Quality of Life in Living Donors

Background

Donor safety and preservation of donor health after living liver donation are of paramount importance. Diarrhea has a significant influence on gastrointestinal quality of life among donors who have undergone living donor hepatectomy. Thus, we aimed to investigate predictors of diarrhea after hepatectomy and its impact on gastrointestinal quality of life in living donors.

Methods

We retrospectively examined the medical records of 204 living liver donors who underwent hepatectomy during the period January 2010 to June 2013 at a single medical center. Diarrhea was defined as the passing of three or more liquid stools per day. The Chinese version of the Gastrointestinal Quality of Life Index (GIQLI) was used to assess the influence of diarrhea on quality of life in donors.

Results

During the study period, diarrhea was diagnosed in 62 (30.3%) of the 204 donors and the duration of diarrhea in the majority of them (n = 46, 74%) was <12 months. Risk factors associated with diarrhea included age [risk ratio (RR) = 0.84, 95% confidence interval (CI): 0.79–0.89, risk difference = 16%], and chronic cholecystitis (RR = 0.48, 95% CI: 0.24–0.99, risk difference = 52%). Compared to donors without diarrhea, donors with diarrhea had lower GIQLI scores in the following GIQLI domains: GI symptoms (1.8 vs. 3.6), physical function (2.1 vs. 3.5), emotional function (3.0 vs. 3.6), social function (3.3 vs. 3.7), and treatment reaction (2.6 vs. 3.7).

Conclusions

Our findings show that younger donors and those without chronic cholecystitis are at increased risk for diarrhea after living donor hepatectomy and that diarrhea is associated with lower GIQLI scores after hepatectomy.

Long-Term Nononcologic Outcomes for Laparoscopic Liver Resection: Improvement over Open Hepatectomy?

Prior studies of laparoscopic liver resection (LLR) have evaluated long-term outcomes in terms of cancer survival, but few have evaluated nononcologic outcomes. This study analyzes long-term nondisease-specific complications associated with LLR and open liver resection (OLR). We performed a retrospective single-institution review of patients undergoing liver resection for any reason from January 2005 to December 2014. Long-term complication was defined as any complication not related to the primary disease process, and occurring more than 90 days after surgery, emphasizing incisional hernia (IH) and small bowel obstruction (SBO). A total of 208 patients were included in the OLR group and 79 patients in the LLR group. Forty-one patients (19.6%) developed IH after OLR, whereas only six patients (7.5%) developed IH after LLR ( P = 0.01). About 3.8 per cent of patients developed IH requiring surgical repair in both groups. Seven patients developed SBO (3.4%) after OLR; no patient developed SBO after LLR. Median time to development of complications was 13.8 months (range 3–54 months) after OLR compared with 8.5 months after LLR (range 6–36 months). Male gender, body mass index, prior abdominal surgery, and OLR were independent risk factors for development of long-term complications. There is a higher incidence of nondisease-specific complications after OLR than LLR.

Long-term quality of life after liver donation in the adult to adult living donor liver transplantation cohort study (A2ALL)

BACKGROUND & AIMS

There are few long-term studies of the health-related quality of life (HRQOL) in living liver donors. This study aimed to characterize donor HRQOL in the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) up to 11 years post-donation.

METHODS

Between 2004 and 2013, HRQOL was assessed at evaluation, at 3 months, and yearly post-donation in prevalent liver donors using the short-form survey (SF-36), which provides a physical (PCS) and a mental component summary (MCS).

RESULTS

Of the 458 donors enrolled in A2ALL, 374 (82%) had SF-36 data. Mean age at evaluation was 38 (range 18-63), 47% were male, 93% white, and 43% had a bachelor's degree or higher. MCS and PCS means were above the US population at all time points. However, at every time point there were some donors who reported poor scores (>1/2 standard deviation below the age and sex adjusted mean) (PCS: 5.3-26.8%,

MCS

10.0-25.0%). Predictors of poor PCS and MCS scores included recipient's death within the two years prior to the survey and education less than a bachelor's degree; poor PCS scores were also predicted by time since donation, Hispanic ethnicity, and at the 3-month post-donation time point.

CONCLUSIONS

In summary, most living donors maintain above average HRQOL up to 11 years prospectively, supporting the notion that living donation does not negatively affect HRQOL. However, targeted support for donors at risk for poor HRQOL may improve overall HRQOL outcomes for living liver donors.

Clinical outcomes of and patient satisfaction with different incision methods for donor hepatectomy in living donor liver transplantation

With the decrease in the average donor age and the increase in the proportion of female donors, both donor safety and cosmetic appearance are major concerns for some living donors in living donor liver transplantation (LDLT) because a large abdominal incision is needed that may influence the donor's quality of life. In all, 429 donors who underwent donor hepatectomy for LDLT from April 2010 to February 2013 were included in the study. Donors were divided into 3 groups based on the type of incision: conventional inverted L incision (n = 268; the C group), upper midline incision (n = 147; the M group), and transverse incision with laparoscopy (n = 14; the T group). Demographics, perioperative outcomes, postoperative complications for donors and recipients, and questionnaire-derived donor satisfaction with cosmetic appearance were compared. The mean age was lower (P < 0.001), the female ratio was higher (P < 0.001), and the body mass index (BMI) was lower (P = 0.017) in the M and T groups versus the C group. The operation time (P < 0.001) and the hospital stay duration (P = 0.010) were lowest in the M group. The postoperative complications did not differ by the type of incision and also did not show any significant effect in a multivariate analysis (P = 0.867). In the assessment of questionnaire-derived donor satisfaction matched by age (±5 years), sex, graft, height, weight, and BMI, a more satisfactory cosmetic result and more self-confidence were noted in the M and T groups versus the C group. In conclusion, the use of a minimal incision is technically feasible for some donor hepatectomy cases with a favorable safety profile. The patient satisfaction levels were greater with improved cosmetic outcomes in cases of minimal incision versus cases of conventional incision.

Donor safety in living donor liver transplantation: a single-center analysis of 300 cases

Aim

To evaluate the safety to donors of living-donor liver transplantation.

Methods

This study included 300 consecutive living liver tissue donors who underwent operations at our center from July 2002 to December 2012. We evaluated the safety of donors with regard to three aspects complications were recorded prospectively and stratified by grade according to Clavien’s classification, and the data were compared in two stages (the first 5 years’ experience (pre-January 2008) and the latter 5 years’ experience (post-January 2008); laboratory tests such as liver function and blood biochemistry were performed; and the health-related quality of life was evaluated.

Results

There was no donor mortality at our center, and the overall morbidity rate was 25.3%. Most of the complications of living donors were either grade I or II. There were significantly fewer complications in the latter period of our study than in the initial period (19.9% vs 32.6%, P<0.001), and biliary complications were the most common complications, with an incidence of 9%. All of the liver dysfunction was temporary; however, the post-operative suppression of platelet count lasted for years. Although within the normal range, eight years after operation, 22 donors showed lower platelet levels (189×10⁹/L) compared with the pre-operative levels (267×10⁹/L) (P<0.05). A total of 98.4% of donors had returned to their previous levels of social activity and work, and 99.2% of donors would donate again if it was required and feasible. With the exception of two donors who experienced grade III complications (whose recipients died) and a few cases of abdominal discomfort, fatigue, chronic pain and scar itching, none of the living donors were affected by physical problems.

Conclusion

With careful donor selection and specialized patient care, low morbidity rates and satisfactory long-term recovery can be achieved after hepatectomy for living-donor liver transplantation.

Living-donor liver transplantation: impact on donor's health-related quality of life

OBJECTIVE

The aim of this study was to evaluate the health-related quality of life of living liver donors after living-donor liver transplantation (LDLT).

METHODS

Health-related quality of life (HRQOL) in 55 living liver donors operated on at our center between 2002 and 2009 was assessed using the German Version of the 36-Item Health Survey (SF-36).

RESULTS

Donors after full right-lobe hepatectomy (n=18) scored similarly to and without statistically significant difference from the German reference population, whereas donors after left lateral segmentectomy (n=37) revealed statistically significant higher average score values (P<.005) in the categories of physical functioning, bodily pain, and general health compared with the German reference population. In the analysis between donors after full right-lobe hepatectomy and donors after left lateral segmentectomy no statistically significant difference was observed in any of the SF-36 categories. Postoperative complications of the donors and postoperative recipient mortality were particularly revealing regarding HRQOL. Donors who developed postoperative complications presented a lower HRQOL, especially in the categories of role physical, bodily pain, and social functioning, where statistically significant differences (P<.005) were observed. Similarly, postoperative recipient mortality correlated with lower mean score values in all SF-36 categories, but a statistically significant difference (P<.005) was reached only in the categories of role emotional and mental health.

CONCLUSIONS

Donors did not regret their decision to donate, because HRQOL was not negatively affected by the donation procedure. Living liver donors scored as well as or even better than the German reference population, but it was clearly shown that the development of postoperative donor complications and the postoperative recipient mortality had a negative effect on the HRQOL of donors.

Living Donor Liver Transplantation

A perception that living donor liver transplantation can be accomplished with an acceptable donor complication rate and recipient survival rate has led to the acceptance of living donor liver transplantation as a viable alternative to decreased deceased donor transplantation. Careful candidate evaluation and selection has been crucial to the success of this procedure. Advancements in the understanding of the lobar nature of the liver and of liver regeneration have advanced the surgical technique. Initial attempts at adult-to-adult donation utilized the left hepatic lobe, but now have evolved into use of the right hepatic lobe. Size matching is very important to successful graft function in the recipient. There is great concern regarding morbidity and mortality in donors. Biliary complications and infections continue to be among the most highly reported complications, although rates vary among centers and countries. Reports of single center complications have ranged from 9% to 67%. A survey of centers in the United States in 2003 reported complications of 10%. A series from our institution reported complications arising in 13 (33%) of 39 patients. A review focused on documenting donor deaths found 33 living liver donor deaths worldwide. The much publicized immediate postoperative mishap of 2002 that resulted in a donor’s death resulted in a drop in the utilization of living donor liver transplantation in the United States, from which this procedure has never fully recovered. The future development and expansion of living donor liver transplantation depends on open communication regarding donor complications and deaths. Close immediate postoperative monitoring and meticulous management will remain an essential aspect in limiting donor complications and deaths.

Short- and long-term donor morbidity in right lobe living donor liver transplantation: 91 consecutive cases in a European Center

The lack of use of a common grading system in reporting morbidity impedes estimation of the true risk to a right lobe living donor (RLLD). We report outcomes in 91 consecutive RLLD's using the validated 5-tier Clavien grading and a quality of life (QOL) questionnaire. The median follow-up was 79 months. The donors were predominantly female (66%), 22 (24%) received autologous blood transfusions. Fifty-three complications occurred in 43 donors (47% morbidity), 19 (37%) were ≥ Grade III, biliary fistula (14%) was the most common. There was no donor mortality. Two intraoperative complications could not be graded and two disfiguring complications in female donors were graded as minor. Two subgroups (first 46 vs. later 45 donors) were compared to study the presence if any, of a learning curve. The later 45 donors had lesser autologous transfusions, lesser rehospitalization and no reoperation and a reduction in the proportion of ≥ Grade III (major) complications (24% vs. 50%; p = 0.06). In the long term, donors expressed an overall sense of well being, but some sequelae of surgery do restrain their current lifestyle. Our results warn against lackadaisical vigilance once RLLD hepatectomy becomes routine.

Quality of life for donors after living donor liver transplantation: a review of the literature

Living donor liver transplantation (LDLT) decreases the shortage of liver grafts for patients in need of a liver transplant, but it involves 2 patients: a recipient and a living donor. Despite the magnitude of the procedure for LDLT donors, only a few studies have investigated the effect of LDLT on the quality of life (QOL) of donors. We performed a systematic search of the MEDLINE database to identify peer-reviewed articles assessing QOL in adults after LDLT donation. Nineteen studies describing 768 unique donors met our inclusion criteria for this review. The median number of donors enrolled in each study was 30 (range = 10-143), and the median follow-up period was 10.4 months (range = 3-51.3 months). Before donation, donor QOL was significantly better than that in control adult populations across all measured QOL domains. Within the first 3 months after donation, the physical domains of QOL were significantly worse than the predonation levels, but they returned to baseline levels within 6 months for the majority of patients (80%-93%). Mental domains of QOL remained unchanged throughout the donation process. Common donor concerns after LDLT included bloating, loss of muscle tone, poor body image, and fatigue. In conclusion, according to our review of the existing literature, most LDLT donors return to their baseline QOL within 6 months. However, there is a lack of long-term data on donor QOL after LDLT, and few standardized assessments include measures of common patient concerns. Additional studies are necessary to develop a comprehensive risk profile for LDLT that includes a rigorous assessment of donor QOL.

Gender-specific differences associated with living donor liver transplantation: a review study

Living donor liver transplantation (LDLT) has developed into an important therapeutic option for liver diseases. For living donor kidney transplantation (LDKT), gender-specific differences have been observed among both donors (two-thirds being women and one-third being men) and recipients (two-thirds being men and one-third being women). The aim of this study was to determine whether there is a gender disparity for LDLT. We contacted 89 national and international transplantation registries, single transplant centers, and coordinators. In addition, a sample of 274 articles dealing with LDLT and its outcomes was reviewed and compared with the registry data. The data included the gender of the donors and recipients, the country of transplantation, and the donor-recipient relationship. The investigation showed that overall there were slightly more men among the donors (53% male and 47% female). As for the recipients, 59% of the organs were distributed to males, and 41% were distributed to females. Differences in the gender distribution were observed with respect to individual countries. Worldwide, 80% of the donors were blood-related, 11% were not blood-related, and 9% were spouses. The data acquired from the publications were similar to the registry data. Our research has shown that there are hardly any registry data published, a lot of countries do not have national registries, or the access to these data is difficult. Even widely ranging published studies often do not give information on the gender distribution or the donor-recipient relationship. Further investigations are needed to understand the possible medical, psychosocial, or cultural reasons for gender distribution in LDLT and the differences in comparison with LDKT.

Liver transplantation: an update 2009

PURPOSE OF REVIEW

In this review we focus on three challenging aspects of liver transplantation: living donor liver transplant, transplantation in HIV-positive recipients and down-staging of hepatocellular carcinoma for liver transplantation.

RECENT FINDINGS

The adult-to-adult living donor liver transplantation cohort study is providing valuable information on recipient and donor outcomes associated with living donor liver transplantation. The recipient outcomes with living donor liver transplantation are comparable to those with deceased donor liver transplantation for most diseases, but increased hepatocellular carcinoma recurrence has been reported with living donor liver transplantation. Donor morbidity is not infrequent and donor mortality remains a concern. Liver transplantation for HIV-positive recipients is associated with equivalent outcomes as HIV-negative recipients for selected recipients. Transplantation in coinfected recipients (HIV and HCV+) is associated with less favorable outcomes. Drug interaction between immunosuppression and highly active antiretroviral therapy is increasingly recognized and requires major modifications in dosing. Down-staging hepatocellular carcinoma to within transplant criteria is being used in some centers using loco-regional therapy. Waiting time after loco-regional therapy is currently the best predictor of recurrence. The role of newer chemotherapeutics is being tested as part of neoadjuvant therapy after resection or loco-regional therapy.

SUMMARY

Living donor liver transplantation is a viable strategy to increase transplantation and reduce death on the waiting list. Donor morbidity should be the subject of further efforts to minimize these risks. The increased recurrence risk with living donor liver transplantation for hepatocellular carcinoma warrants further study. Careful coordination between transplant professionals and HIV experts is necessary to monitor issues of posttransplant care of the HIV-infected recipient. The role of loco-regional therapies in down-staging patients with hepatocellular carcinoma is expanding.

A comparison of right and left lobectomies for living donor liver transplantation: an anesthesiologist's point of view

Because of the shortage of cadaveric donor organs, living donor liver transplantation (LDLT) has become an established therapy modality for end-stage liver disease. Based on recipient size, both right and left liver lobe grafts have been used successfully in LDLT. The aim of this study was to compare the risk of intraoperative complications and transfusion requirements between right and left lobe donors. We reviewed the charts of 54 right lobe (Group RL), 29 left lobe (Group LL), and 31 left lateral segment (Group LLS) donors who underwent lobectomy from January 2003 through January 2007. We recorded patient demographics, perioperative laboratory values, intraoperative fluid and transfusion requirements, intraoperative hemodynamic parameters, and complications. Demographic features and preoperative laboratory values were similar for the 3 groups, except for age (Group RL, 37.3 +/- 8.7; Group LL, 36.0 +/- 9.3; Group LLS, 31.7 +/- 9.4; P = .02). There were no significant differences in mean liver volumes among the groups (P > .05). Respective graft volumes were 803.1 +/- 139.2 mL, 438.0 +/- 122.7 mL, and 308.2 +/- 76.6 mL for Groups RL, LL, and LLS, respectively (P < .001). More patients in Group LLS required heterologous blood transfusion than did those in the other groups (P = .01). The incidence of intraoperative hypotension was similar for all groups (P > .05). Group RL had a significantly higher rate of intraoperative hypothermia than the other groups (P = .01). There were no intraoperative respiratory complications or cardiac events. These results indicated that both right and left donor lobectomies for LDLT were safe procedures with acceptable rates of minor intraoperative complications.