Donor safety in adult-to-adult living donor liver transplantation

Results of 1001 liver transplantations in 23 years: Ege University experience

BACKGROUND/AIMS

Liver transplantation (LT) is now the standard of care for most end-stage liver diseases. Over the next 30 years, advances in medicine and technology will greatly improve the survival rates of patients after this procedure. The aim of the present study was to analyze retrospectively the results of 1001 patients withLT.

MATERIALS AND METHODS

Medical reports of 989 patients were analyzed retrospectively. Data were obtained from the patient's data chart. Descriptive statistics were used to describe continuous variables (mean, median, and standard deviation).

RESULTS

A total of 1001 LTs for 989 recipients were performed at Ege University Organ Transplantation and Research Center between 1994 and 2017. Therewere 639 male and 350 female recipients. Among 1001 LTs, there were 438 deceased donors and 563 living donors. The age interval of the patients was 4 months to 71 years old. The median Model for End-Stage Liver Disease score was 20. There were 12 deceased liver donors using the split method. There were 12 cases subject to retransplantation. In living donor LT grafts, 423 right lobes, 46 left lobes, and 94 left lateral sectors were used. In the first monitoring,the total annual mortality rate was 130 cases (13%). The mortality rate in retransplantation was found to be 66%. A 1-year survival rate of 87% was generally stablished.

CONCLUSION

LThas been improving consistently over the last two decades. Ege University is one of the biggest liver transplant centers in Turkey for both technical and educational perspective.

Three-dimensional computed tomography for planning donor hepatectomy

BACKGROUND

An accurate estimation of preoperative volumetric measurements of the donor liver is essential in living donor liver transplantation.

METHODS

Three-dimensional (3-D) computed tomography (CT) was applied to 56 living donors. 3-D images of the liver were constructed using the region-growing method and the volume of each sector was measured.

RESULTS

The median volume ratios of the left liver, caudate lobe, right paramedian, and lateral sectors were 34%, 4%, 38%, and 25% of the total liver volume, respectively. The shape of the congestive area in the right paramedian sector was properly demonstrated by 3-D CT. The volume of the region corresponded to 32% of the right liver. The actual volume of the graft correlated well with the estimated graft volume (n = .86).

CONCLUSIONS

The region-growing method was useful for graft selection and for determining the indication of middle hepatic vein reconstruction in right liver grafts.

Living-related liver transplantation: implication for the anaesthetist

PURPOSE OF REVIEW

Living donor liver transplantation, originally introduced about a decade ago to overcome paediatric cadaveric organ shortage, has rapidly gained acceptance within the transplant community and is nowadays almost routinely applied to the growing number of adult and paediatric patients awaiting a live-saving liver transplantation. In fact its introduction has contributed to a continuing decrease of waiting list deaths.

RECENT FINDINGS

The risk of potential complications and even death for the donor increases with the extent of liver tissue resected. Better preoperative evaluation of suitability, refinement of surgical technique and smarter anaesthetic management, based on extended knowledge of underlying pathophysiology, have made the procedure safer for donors, with low morbidity and even lower mortality rates, tending towards zero in experienced centres. Despite these improvements, a certain risk is inherent. Yet from an ethical point of view it has to remain unacceptable especially because donors are otherwise healthy people and their only motives are altruistic. The procedure of living donor liver transplantation like conventional liver transplantation involves various disciplines, each of which contributes in a specific manner. There is a broad scope of issues that anaesthetists are responsible for and these largely depend on the department and hospital requirements. These issues may range from perioperative anaesthetic management and pain relief, to--and there are definite continental differences--the coordination of donor evaluation, intensive care management, postoperative complication management, as well as psychological support for donors, recipients and their relatives.

SUMMARY

In this paper we review and summarize the potential impact of findings and advances made in this particular field as described by the most important articles published during the past year.

Anesthetic management and complications in living donor hepatectomy

A total of 112 living donor hepatectomies (LDHs) performed from October 1999 to April 2003 at Ege University Hospital Organ Transplantation Center were reviewed and perioperative anesthetic courses and complications were determined. There was no perioperative mortality. Mean duration of operations was 333 +/- 77 minutes (range, 160 to 540 minutes) for right lobectomies and 277 +/- 88 minutes (range, 150 to 500 minutes) for left lateral segment plus left lobe operations. The remnant liver volume ratios of the patients was 0.58 +/- 0.16 (range, 0.30 to 0.91) after harvesting. Crystalloids, colloid infusions, and transfusions aimed to keep hematocrit >25%, central venous pressure (CVP) <5 mm Hg and to maintain a urine output >1 mL/kg(-1) while nitroglycerin was infused (0.5 to 2.0 microg/kg(-1)h(-1)) when needed to allow fluid infusions freely without increasing the CVP values. No transfusion was needed for 91 patients (81%) and 21 right lobectomy patients needed transfusion of blood products. Initial mean hematocrit of 38.9 +/- 4.9% (range, 27% to 50%) for all patients was found 31.5% +/- 5% (21% to 44%) at the end of the operation. Albumin blood levels averaged 4.27 +/- 0.49 g/dL(-1) at the beginning and 3.28 +/- 0.45 g/dL(-1) after hepatic resection. Perioperative complications were one air embolism, postoperative systemic inflammatory response syndrome in one patient, transient but severe hemoglobinuria due to a predonated autologous blood transfusion in another, prolonged recovery for neuromuscular blocker overdose in one patient, and postoperative atelectasis in three patients, two of whom had pneumonia later while two other patients had pleural effusions. One required a drainage. Living donor hepatectomies were performed with acceptable complications in anesthetic management during this study. The operation provides us with an optimal liver segment without resulting in mortality.