Outcomes of left-lobe donor hepatectomy for living-donor liver transplantation: a single-center experience

Measurement of oxidant and antioxidant levels in liver tissue obtained from patients with liver transplantation: A case-control study

OBJECTIVE

This study aimed to compare oxidant and antioxidant substance accumulation in the liver tissues of patients with chronic liver disease (recipients) who underwent liver transplantation (LT) with living liver donors (LLDs) who underwent living donor hepatectomy (LDH).

METHODS

This prospective study included 160 recipients (LT group) and 40 LLDs (LLD group). During surgery, a piece of liver tissue measuring a minimum of 10 × 10 mm was obtained from the edge of the right lobe of the liver of recipients and LLDs, incubated for 10 min in saline to remove blood, and stored at -70 °C until biochemical analysis was performed. Catalase (CAT), glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), myeloperoxidase (MPO), prolidase, reduced glutathione (GSH), malondialdehyde (MDA), total oxidant status (TOS), total antioxidant status (TAS), oxidative stress index (OSI), total thiol, native thiol, and disulfide levels were measured in stored liver tissues.

RESULTS

There was a statistically significant difference between LT and LLD groups in terms of age (p < 0.001), body mass index (p = 0.019), GSH-Px (p < 0.001), SOD (p = 0.001), MPO (p < 0.001), prolidase (p < 0.001), GSH (p < 0.001), and MDA (p = 0.003) values in favor of the LT group. Furthermore, there was a statistically significant difference between LT and LLD groups in terms of CAT (p < 0.001), TAS (p < 0.001), TOS (p < 0.001), OSI (p < 0.001), total thiol (p < 0.001), native thiol (p < 0.001), and disulfide (p < 0.001) values in favor of the LLD group. There were no differences between the groups in terms of sex.

CONCLUSION

This study demonstrated that it is possible to assess the extent of oxidative stress in liver tissues by measuring the levels of antioxidant enzymes, oxidants, or the end-products of oxidative stress. With the use of optimum and minimally invasive methods, quantifying these molecules will potentially help evaluate the extent of liver disease and prognostication of liver cirrhosis.

Diagnostic and therapeutic management algorithm for biliary complications in living liver donors

This study aimed to demonstrate the efficacy of our diagnostic and therapeutic management algorithm and catheter-assisted (percutaneous transhepatic biliary tract drainage [PTBD] or transanastomotic feeding tube) hepaticojejunostomy (HJ) procedures in living liver donors (LLDs) with biliary complications. Living donor hepatectomy (LDH) was performed between September 2005 and April 2021 in 2 489 LLDs. Biliary complications developed in 220 LLDs (8.8%), 136 of which were male, and the median age was 29 (interquartile range [IQR]: 12) years. Endoscopic sphincterotomy ± stenting was performed in 132 LLDs, which was unsuccessful in 9 LLDs and required HJ. Overall, 142 LLDs underwent interventional radiologic procedures. Fifteen LLDs with biliary complications underwent HJ (PTBD catheter = 6 and transanastomotic feeding tube = 9) at a median of 44 days (IQR: 82). Following HJ, 14 LLDs did not have any complications throughout the median follow-up period of 1619 days (IQR: 1454). However, percutaneous dilation for HJ anastomotic stricture was performed in one patient. Biliary complications are very common following LDH; therefore, surgeons in the field should have a low threshold to perform HJ for biliary complications that persist after other treatments. Our catheter-assisted HJ techniques demonstrated a high success rate and aided HJ in a hostile abdomen during revisional surgery.

Donor Morbidity Is Equivalent Between Right and Left Hepatectomy for Living Liver Donation: A Meta-Analysis

Maximizing liver graft volume benefits the living donor liver recipient. Whether maximizing graft volume negatively impacts living donor recovery and outcomes remains controversial. Patient randomization between right and left hepatectomy has not been possible due to anatomic constraints; however, a number of published, nonrandomized observational studies summarize donor outcomes between 2 anatomic living donor hepatectomies. This meta-analysis compares donor-specific outcomes after right versus left living donor hepatectomy. Systematic searches were performed via PubMed, Cochrane, ResearchGate, and Google Scholar databases to identify relevant studies between January 2005 and November 2019. The primary outcomes compared overall morbidity and incidence of severe complications (Clavien-Dindo >III) between right and left hepatectomy in donors after liver donation. Random effects meta-analysis was performed to derive summary risk estimates of outcomes. A total of 33 studies (3 prospective and 30 retrospective cohort) were used to identify 7649 pooled patients (5993 right hepatectomy and 1027 left hepatectomy). Proportion of donors who developed postoperative complications did not significantly differ after right hepatectomy (0.33; 95% confidence interval [CI], 0.27-0.40) and left hepatectomy (0.23; 95% CI, 0.17-0.29; P = 0.19). The overall risk ratio (RR) did not differ between right and left hepatectomy (RR, 1.16; 95% CI, 0.83-1.63; P = 0.36). The relative risk for a donor to develop severe complications showed no differences by hepatectomy side (Incidence rate ratio, 0.97; 95% CI, 0.67-1.40; P = 0.86). There is no evidence that the overall morbidity differs between right and left lobe donors. Publication bias reflects institutional and surgeon variation. A prospective, standardized, multi-institutional study would help quantify the burden of donor complications after liver donation.

Liver transplantation in acute liver failure: Dilemmas and challenges

Acute liver failure (ALF) refers to a state of severe hepatic injury that leads to altered coagulation and sensorium in the absence of pre-existing liver disease. ALF has different causes, but the clinical characteristics are strikingly similar. In clinical practice, however, inconsistency in the definition of ALF worldwide and confusion regarding the existence of pre-existing liver disease raise diagnostic dilemmas. ALF mortality rates used to be over 80% in the past; however, survival rates on medical treatment have significantly improved in recent years due to a greater understanding of pathophysiology and advances in critical care management. The survival rates in acetaminophen-associated ALF have become close to the post-transplant survival rates. Given that liver transplantation (LT) is an expensive treatment that involves a major surgical operation in critically ill patients and lifelong immunosuppression, it is very important to select accurate patients who may benefit from it. Still, emergency LT remains a lifesaving procedure for many ALF patients. However, there is a lack of consistency in current prognostic models that hampers the selection of transplant candidates in a timely and precise manner. The other problems associated with LT in ALF are the shortage of graft, development of contraindications on the waiting list, vaguely defined delisting criteria, time constraints for pre-transplant evaluation, ethical concerns, and comparatively poor post-transplant outcomes in ALF. Therefore, there is a desperate need to establish accurate prognostic models and explore the roles of evolving adjunctive and alternative therapies, such as liver support systems, plasma exchange, stem cells, auxiliary LT, and so on, to enhance transplant-free survival and to fill the void created by the graft shortage

Thoracic epidural analgesia in donor hepatectomy: An analysis

The purpose of this study is to analyze whether supplementation of general anesthesia (GA) with thoracic epidural analgesia (TEA) for right lobe donor hepatectomy is a safe modality of pain relief in terms of changes in postoperative coagulation profile, incidence of epidural catheter-related complications, and timing of removal of epidural catheter. Retrospective analysis of the record of 104 patients who received TEA for right lobe donor hepatectomy was done. Platelet count, international normalized ratio, alanine aminotransferase, and aspartate aminotransferase were recorded postoperatively until the removal of the epidural catheter. The day of removal of the epidural catheter and visual analogue scale (VAS) scores were also recorded. Any complication encountered was documented. Intraoperatively, central venous pressure (CVP), hemodynamic variables, and volume of intravenous fluids infused were also noted. Statistical analysis was performed by using SPSS statistical package, version 17.0 (SPSS Inc. Chicago, IL). Continuous variables were presented as mean ± standard deviation. A total of 90% of patients had mean VAS scores between 1 and 4 in the postoperative period between days 1 and 5. None of the patients had a VAS score above 5. Although changes in coagulation status were encountered in all patients in the postoperative period, these changes were transient and did not persist beyond postoperative day (POD) 5. There was no delay in removal of the epidural catheter, and the majority of patients had the catheter removed by POD 4. There was no incidence of epidural hematoma. Aside from good intraoperative and postoperative analgesia, TEA in combination with balanced GA and fluid restriction enabled maintenance of low CVP and prevention of hepatic congestion. In conclusion, vigilant use of TEA appears to be safe during donor hepatectomy. Living liver donors should not be denied efficient analgesia for the fear of complications. Liver Transplantation 24 214-221 2018 AASLD.

Biliary complications following living donor hepatectomy

BACKGROUND

Living donor liver transplantation (LDLT) has become increasingly common in an effort to increase organ availability for the treatment of end-stage liver disease. Donor safety is a primary concern in LDLT. The majority of complications experienced by living donors are infectious or biliary in nature. The purpose of this paper was to review the existing literature on biliary complications in living donors.

METHODS

Studies were eligible for inclusion if they were published in English between 2006-present, focused on adult-to-adult LDLT, and were available via PubMed/MEDLINE.

RESULTS

A total of 33 studies reporting outcomes from 12,653 donors (right lobe: 8231, left lobe: 4422) were included. Of 33 studies, 12 reported outcomes from right lobe donors, 1 from left lobe donors, 14 compared left and right, and 6 focused specifically on biliary complications. A total of 830 biliary complications (6.6%) were reported, with 75 donors requiring re-operation for biliary complications and 1 donor death attributed to biliary complications.

CONCLUSION

Although bile leaks and strictures are still relatively common following living donor hepatectomy, the majority of complications are minor and resolve with conservative measures. Approximately 6% of living donors will experience a biliary complication and, of these 6%, approximately 9% (total of 0.6% of donors) will require operative management of the biliary complication.

Postoperative pulmonary complications in living-liver donors: a retrospective analysis of 188 patients

OBJECTIVES

Living-donor liver transplant has become a viable option and an important source of hepatic grafts. The goal of this study is to establish postoperative pulmonary complications of liver donation surgery in our center.

MATERIALS AND METHODS

Data from 188 subjects (median age, 33.7 ± 8.4 y; male/female, 51.1%/48.9%) who had liver donation surgery from 1988 to 2013 were analyzed retrospectively. Patient demographic and clinical features were recorded. Postoperative complications and the correlation of risk factors for postoperative pulmonary complications were investigated.

RESULTS

The incidence of early postoperative complications was 17% (n = 32), and 16 of these patients had postoperative pulmonary complications (8.5%); 2 of the postoperative pulmonary complications were detected on the day of surgery and the other 14 complications were observed between the second and seventh day after surgery. Most postoperative pulmonary complications were minor complications including atelectasis, pleural effusion, and pneumonia. There was 1 major postoperative pulmonary complication: pulmonary embolism that occurred on the fourth day after surgery in 1 patient. Late pulmonary complications also were reviewed and no late postoperative pulmonary complications were observed. There was no significant difference in early and late postoperative pulmonary complications between ex-smokers and smokers. Postoperative atelectasis was significantly higher in patients with body mass index ≤ 20 kg/m ² than patients with body mass index > 21 kg/m ² (P = .027). In our study population, no postoperative mortality was recorded.

CONCLUSIONS

We believe that preoperative weight reduction strategies and early mobilization with postoperative respiratory physiotherapy could be important factors to reduce postoperative pulmonary complications in liver donors.

Pulmonary Complications After 1,150 Living Donor Hepatectomies

AIM

Donor safety is the major concern in living-donor liver transplantation. Studies in literature related to donor hepatectomy (DH) have generally considered intra-abdominal complications. The aim of this study is to specifically evaluate pulmonary complications (PCs) after DH.

MATERIALS AND METHODS

We evaluated retrospectively 1150 living donors who underwent to DH between January 2007 and July 2014. Patients with PCs, such as pneumonia, pleural effusion, pneumothorax, and respiratory insufficiency, were considered. A complication was considered only when it was clinically apparent and/or requiring interventions. Any special diagnostic tool was used to expose the clinically silent pathologies.

RESULTS

A total of 986 right hepatectomies (RH) and 164 left hepatectomies (LH) (left lobectomy or left lateral segmentectomy) were performed in the study interval. There were 18 (1.6%) donors with PCs (15 males and 3 females). Mean age was 33.8 ± 9.3 years (18-51). Mean hospital stay was 23.8 ± 13.5 days (5-62). Presented PCs were pleural effusion (n = 5, 0.4%), pneumonia (n = 4, 0.3%), combinations (n = 2, 0.2%), pneumothorax (n = 2, 0.2%), and acute respiratory insufficiency (n = 5, 0.4%). Sixteen cases (1.7%) were seen after RH, whereas 2 cases (1.2%) were seen after LH (P = 1.000).

CONCLUSION

The most common PCs after living donor hepatectomy were pleural effusion and acute respiratory insufficiency. There was no significant difference between RH and LH. It is possible to overcome those PCs with careful monitoring and timely and appropriate treatment.