Donor complications associated with living donor liver transplantation in Japan

Analysis of donor morbidity in 177 donor hepatectomies for living donor liver transplant: Experience from a high-volume centre in western India

BACKGROUND

Living donor liver transplant (LDLT) is based on the principle of double equipoise. Organ shortage in Asian countries has led to development of high-volume LDLT programs with good outcomes. Safety of live liver donor is the Achilles heel of LDLT program and every effort should be made to achieve low morbidity and near zero mortality rates.

METHODS

We retrospectively analyzed our prospectively maintained donor morbidity data (outcomes) of 177 donors in a new transplant program setup in western India by an experienced surgeon. The primary end point was to analyze the morbidity rates and the factors associated with it.

RESULTS

None of the donors in our cohort of 177 donors developed grade IV or V complication (Clavien-Dindo classification). One-fourth (1/4th) of the donors developed complications ranging from grade I to grade III(b). The rate of complications according to modified Clavien-Dindo classification is as follows: (1) grade I in 5.6% (n = 10), (2) grade II in 14.6% (n = 26), (3) grade III(a) in 3.9% (n = 7), (4) grade III(b) in 2.2% (n = 4). Three donors (1.6%) developed post-hepatectomy intra-abdominal bleeding and required re-exploration (grade IIIb). All of them recovered well post-surgery and are doing well in follow-up. The mean follow-up of the entire cohort was 2871 ± 521 days (range 1926-3736 days).

CONCLUSION

Donor safety (outcome) is determined by meticulous donor surgery and good-quality remnant.

Current Status and Outcomes of Living Donor Liver Transplantation for Pediatric Acute Liver Failure: Results From a Multicenter Retrospective Study Over Two Decades

BACKGROUND

Although the outcomes of living donor liver transplantation (LDLT) for pediatric acute liver failure (PALF) have improved, patient survival remains lower than in patients with chronic liver disease. We investigated whether the poor outcomes of LDLT for PALF persisted in the contemporary transplant era.

METHODS

We analyzed 193 patients who underwent LDLT between December 2000 and December 2020. The outcomes of patients managed in 2000-2010 (era 1) and 2011-2020 (era 2) were compared.

RESULTS

The median age at the time of LDLT was 1.2 years both eras. An unknown etiology was the major cause in both groups. Patients in era 1 were more likely to have surgical complications, including hepatic artery and biliary complications (p = 0.001 and p = 0.013, respectively). The era had no impact on the infection rate after LDLT (cytomegalovirus, Epstein-Barr virus, and sepsis). The mortality rates of patients and grafts in era one were significantly higher (p = 0.03 and p = 0.047, respectively). The 1- and 5-year survival rates were 76.4% and 70.9%, respectively, in era 1, while they were 88.3% and 81.9% in era 2 (p = 0.042). Rejection was the most common cause of graft loss in both groups. In the multivariate analysis, sepsis during the 30 days after LDLT was independently associated with graft loss (p = 0.002).

CONCLUSIONS

The survival of patients with PALF has improved in the contemporary transplant era. The early detection and proper management of rejection in patients, while being cautious of sepsis, should be recommended to improve outcomes further.

The incidence of adverse outcome in donors after living donor liver transplantation: A meta-analysis of 60,829 donors

The scarcity of liver grafts has prompted developments in living donor liver transplantations (LDLT), with previous literature illustrating similar outcomes in recipients compared to deceased donor transplants. However, significant concerns regarding living donor morbidity and mortality have yet to be examined comprehensively. This study aims to provide estimates of the incidence of various outcomes in living liver donors. In this meta-analysis, Medline and Embase were searched from inception to July 2022 for articles assessing the incidence of outcomes in LDLT donors. Complications in the included studies were classified into respective organ systems. Analysis of incidence was conducted using a generalized linear mixed model with Clopper-Pearson intervals. Eighty-seven articles involving 60,829 living liver donors were included. The overall pooled incidence of complications in LDLT donors was 24.7% (CI: 21.6%-28.1%). The incidence of minor complications was 17.3% (CI: 14.7%-20.3%), while the incidence of major complications was lower at 5.5% (CI: 4.5%-6.7%). The overall incidence of donor mortality was 0.06% (CI: 0.0%-0.1%) in 49,027 individuals. Psychological complications (7.6%, CI: 4.9%-11.5%) were the most common among LDLT donors, followed by wound-related (5.2%, CI: 4.4%-6.2%) and respiratory complications (4.9%, CI: 3.8%-6.3%). Conversely, cardiovascular complications had the lowest incidence among the subgroups at 0.8% (CI: 0.4%-1.3%). This study presents the incidence of post-LDLT outcomes in living liver donors, illustrating significant psychological, wound-related, and respiratory complications. While significant advancements in recent decades have contributed towards decreased morbidity in living donors, our findings call for targeted measures and continued efforts to ensure the safety and quality of life of liver donors post-LDLT.

Cost-effectiveness analysis of adult living-donor liver transplantation in Japan

AIM

Living-donor liver transplantation (LDLT) is a highly effective life-saving procedure; however, it requires substantial medical resources, and the cost-effectiveness of LDLT versus conservative management (CM) for adult patients with end-stage liver disease (ESLD) remains unclear in Japan.

METHODS

We performed a cost-effectiveness analysis using the Diagnostic Procedure Combination (DPC) data from the nationwide database of the DPC research group. We selected adult patients (18 years or older) who were admitted or discharged between 2010 and 2021 with a diagnosis of ESLD with Child-Pugh class C or B. A decision tree and Markov model were constructed, and all event probabilities were computed in 3-month cycles over a 10-year period. The willingness-to-pay per quality-adjusted life-year (QALY) was set at 5 million Japanese yen (JPY) (49,801 US dollars [USD]) from the perspective of the public health-care payer.

RESULTS

After propensity score matching, we identified 1297 and 111,849 patients in the LDLT and CM groups, respectively. The incremental cost-effectiveness ratio for LDLT versus CM for Child-Pugh classes C and B was 2.08 million JPY/QALY (20,708 USD/QALY) and 5.24 million JPY/QALY (52,153 USD/QALY), respectively. The cost-effectiveness acceptability curves showed the probabilities of being below the willingness-to-pay of 49,801 USD/QALY as 95.4% in class C and 48.5% in class B. Tornado diagrams revealed all variables in class C were below 49,801 USD/QALY while their ranges included or exceeded 49,801 USD/QALY in class B.

CONCLUSIONS

Living-donor liver transplantation for adult patients with Child-Pugh class C was cost-effective compared with CM, whereas LDLT versus CM for class B patients was not cost-effective in Japan.

An international survey of venous thromboembolic events and current practices of peri-operative VTE prophylaxis after living donor hepatectomy

BACKGROUND

Venous thromboembolic complications are an uncommon but significant cause of morbidity & mortality after live donor hepatectomy . The precise incidence of these events and the current practices of centers performing living donor liver transplantation worldwide are unknown.

METHODS

An online survey was shared amongst living donor liver transplantation centers containing questions regarding center activity, center protocols for donor screening, peri-operative thromboembolic prophylaxis and an audit of -perioperative venous thromboembolic events after live donor hepatectomy in the previous five years (2016-2020).

RESULTS

Fifty-one centers from twenty countries completed the survey. These centers had cumulatively performed 11500 living donor liver transplants between 2016-2020. All centers included pre-operative l assessment for thromboembolic risk amongst potential liver donors in their protocols. Testing for inherited prothrombotic conditions was performed by 58% of centers. Dual-mode prophylaxis was the most common practice (65%), while eight and four centers used single mode or no routine prophylaxis respectively. Twenty (39%) and 15 (29%) centers reported atleast one perioperative deep venous thrmobosis or pulmonary embolism event respectively. There was one donor mortality directly related to post-operative pulmonary embolism. Overall incidence of deep venous thrombosis and pulmonary embolism events was 3.65 and 1.74 per 1000 live donor hepatectomies respectively. Significant variations in center practices and incidence of thromboembolic events was identified in the survey primarily divided along world regions. 75% of participating centers agreed on the need for clear international guidelines.

CONCLUSION

Venous thromboembolic events after live donor hepatectomy are an uncommon but important cause of donor morbidity. There is significant variation in practice among centers. Evidence-based guidelines regarding risk assessment, and peri-operative prophylaxis are needed.

Liver transplantation in ornithine transcarbamylase deficiency: A retrospective multicentre cohort study

Ornithine transcarbamylase deficiency (OTCD) is an X-linked defect of ureagenesis and the most common urea cycle disorder. Patients present with hyperammonemia causing neurological symptoms, which can lead to coma and death. Liver transplantation (LT) is the only curative therapy, but has several limitations including organ shortage, significant morbidity and requirement of lifelong immunosuppression. This study aims to identify the characteristics and outcomes of patients who underwent LT for OTCD. We conducted a retrospective study for OTCD patients from 5 UK centres receiving LT in 3 transplantation centres between 2010 and 2022. Patients' demographics, family history, initial presentation, age at LT, graft type and pre- and post-LT clinical, metabolic, and neurocognitive profile were collected from medical records. A total of 20 OTCD patients (11 males, 9 females) were enrolled in this study. 6/20 had neonatal and 14/20 late-onset presentation. 2/20 patients had positive family history for OTCD and one of them was diagnosed antenatally and received prospective treatment. All patients were managed with standard of care based on protein-restricted diet, ammonia scavengers and supplementation with arginine and/or citrulline before LT. 15/20 patients had neurodevelopmental problems before LT. The indication for LT was presence (or family history) of recurrent metabolic decompensations occurring despite standard medical therapy leading to neurodisability and quality of life impairment. Median age at LT was 10.5 months (6-24) and 66 months (35-156) in neonatal and late onset patients, respectively. 15/20 patients had deceased donor LT (DDLT) and 5/20 had living related donor LT (LDLT). Overall survival was 95% with one patient dying 6 h after LT. 13/20 had complications after LT and 2/20 patients required re-transplantation. All patients discontinued dietary restriction and ammonia scavengers after LT and remained metabolically stable. Patients who had neurodevelopmental problems before LT persisted to have difficulties after LT. 1/5 patients who was reported to have normal neurodevelopment before LT developed behavioural problems after LT, while the remaining 4 maintained their abilities without any reported issues. LT was found to be effective in correcting the metabolic defect, eliminates the risk of hyperammonemia and prolongs patients' survival.

Early drain removal after live liver donor hepatectomy is safe - a randomized controlled pilot study

INTRODUCTION

The current study aimed to assess the safety of early drain removal after live donor hepatectomy (LDH).

METHODS

One hundred eight consecutive donors who met the inclusion criteria were randomized to early drain removal (EDR - postoperative day (POD) 3 - if serous and the drain bilirubin level was less than 3 mg/dl - "3 × 3" rule) and routine drain removal (RDR - drain output serous and less than 100 ml). The primary outcome was to compare the safety. The secondary outcome was to compare the postoperative morbidity.

RESULTS

Preoperative, intraoperative, and postoperative parameters except for the timing of drain removal were comparable. EDR was feasible in 46 out of 54 donors (85.14%) and none required re-intervention after EDR. There was significantly better pain relief with EDR (p = 0.00). Overall complications, pulmonary complications, and hospital stay were comparable on intention-to-treat analysis. However, pulmonary complications (EDR - 1.9% vs RDR - 16.3% P = 0.030), overall complications (18.8% vs 36.3%, P = 0.043), and hospital stay (8 vs 9, P = 0.014) were more in the RDR group on per treatment analysis. Bile leaks were seen in three donors (3.7% in the EDR group vs 1.9% in RDR, P = 0.558), and none of them required endo-biliary interventions. Re-exploration for intestinal obstruction was required for 3 donors in RDR (0% vs 5.7%; p = 0.079).

CONCLUSION

EDR by the "3 × 3" rule after LDH is safe and associated with better pain relief. On per treatment analysis, EDR was associated with significantly less hospital stay and lower pulmonary and overall complications.

CLINICAL TRIAL REGISTRY

Clinical Trials.gov - NCT04504487.

Right Lobe Versus Left Lobe Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Donor and Recipient Outcomes

BACKGROUND

Living donor liver transplantation (LDLT) is an established treatment for advanced liver disease. Whether right lobe (RL) or left lobe (LL) LDLT provides the best outcomes for donors and recipients remains contentious.

METHODS

MedLine, Embase, PubMed, and Cochrane Central were searched to identify studies comparing RL- and LL-LDLT and reporting donor and/or recipient outcomes. Effect sizes were pooled using random-effect meta-analysis. Meta-regressions were used to explore heterogeneity.

RESULTS

Sixty-seven studies were included. RL donors were more likely to experience major complications (relative risk [RR] = 1.63; 95% confidence interval [CI] = 1.30-2.05; I2 = 19%) than LL donors; however, no difference was observed in the risk of any biliary complication (RR = 1.41; 95% CI = 0.91-2.20; I2 = 59%), bile leaks (RR = 1.56; 95% CI = 0.97-2.51; I2 = 52%), biliary strictures (RR = 0.99; 95% CI = 0.43-1.88; I2 = 27%), or postoperative death (RR = 0.51; 95% CI = 0.25-1.05; I2 = 0%). Among recipients, the incidence of major complications (RR = 0.85; 95% CI = 0.68-1.06; I2 = 21%), biliary complications (RR = 1.10; 95% CI = 0.91-1.33; I2 = 8%), and vascular complications (RR = 0.79; 95% CI = 0.44-1.43; I2 = 0%) was similar. Although the rate of small for size syndrome (RR = 0.47; 95% CI = 0.30-0.74; I2 = 0%) and postoperative deaths (RR = 0.62; 95% CI = 0.44-0.87; I2 = 0%) was lower among RL-LDLT recipients, no differences were observed in long-term graft (hazard ratio = 0.87; 95% CI = 0.55-1.38; I2 = 74%) and overall survival (hazard ratio = 0.86; 95% CI = 0.60-1.22; I2 = 44%).

CONCLUSIONS

LL donors experience fewer complications than RL donors, and LL-LDLT recipients had similar outcomes to RL-LDLT recipients. These findings suggest that LL-LDLT offers the best outcomes for living donors and similar outcomes for recipients when measures are taken to prevent small for size syndrome.

Is left lateral sectionectomy of the liver without operative site drainage safe and effective?

Backgrounds/Aims

Despite its limited benefits, operative site drainage after elective hepatectomy is routinely used. This study aimed to investigate the safety and effectiveness of left lateral sectionectomy without operative site drainage.

Methods

This study retrospectively collected data from 31 patients who underwent elective left lateral sectionectomy between January 2017 and June 2020. Based on whether operative site drainage was used, the patients were divided into two groups: drainage and non-drainage of the operative site and a comparative analysis was conducted.

Results

A total of 31 patients underwent left lateral sectionectomy during the study period. Of these, 22 patients were diagnosed with hepatocellular carcinoma; three, with intrahepatic cholangiocarcinoma; three, with liver metastasis; and three, with benign liver disease. Ten patients underwent laparoscopy. No significant differences were observed between the open and laparoscopic surgery groups. In the univariate analysis, there were no significant differences in the pre-, intra-, and postoperative clinicopathological factors between the non-drainage and drainage groups. The hospitalization period in the non-drainage group was significantly shorter than in the drainage group (8.44 days vs. 5.87 days, p < 0.05). In the operative site drainage non-use group, there were no cases of intraperitoneal fluid collection requiring additional procedures.

Conclusions

Routine use of surgical drainage for left lateral sectionectomy of the liver to prevent intraperitoneal fluid collection is unnecessary.

Living donor hepatectomy in medium volume liver transplant centre has comparable outcomes to high volume centres: validation of donabedian quality assurance framework

BACKGROUND

Given the complexity of living donor hepatectomy, it is expected that high hospital volume will better outcomes. This study aims to evaluate post-operative outcomes for living donor hepatectomy in a medium volume liver transplant centre and compare to outcomes in high volume centres. Also, it serves as a validation tool for framework of structure-process-outcome model for safe living donor hepatectomy program.

METHODS

204 donors who underwent donor hepatectomy between June 1996 to September 2019 were reviewed retrospectively and compared to outcomes in high volume centres.

RESULTS

At 6 months, overall donor morbidity rate was 20/204 (9.8%). Wound complications were most common at 5/204 (2.5%). Majority of complications were either Clavien grade 1 or 2 and only 3 donors had Clavien grade 3 complications. There was zero donor mortality.

DISCUSSION

Our centre's donor morbidity rate of 9.8% is the one of the lowest reported in the published literature. With increased experience, stringent donor selection and enhanced perioperative care by a multi-disciplinary team, outcomes in a medium volume centre can match the outcomes reported in high volume centres. The framework for quality in terms of structure, process and outcomes is presented which can be adopted for developing programs.

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.

Randomized control trial on perioperative antibiotic prophylaxis in live liver donors: Are three doses enough?

INTRODUCTION

The duration of perioperative antibiotic prophylaxis following live liver donor hepatectomy (LDH) is not known.

METHODS

This is a double-blind equivalence trial. All consecutive LDH were randomized into: group A (three doses) and group B (nine doses) of perioperative antibiotics (piperacillin + tazobactam - 4.5 g intravenous) at fixed 8 hourly intervals. Primary end point was incidence of infective complications as per CDC (Centers for Disease Control and Prevention) criteria. Secondary end points were liver function tests, total leukocyte count, international normalized ratio, hospital stay, morbidity, and cost analysis.

RESULTS

One hundred and twenty-six LDHs were enrolled. A total of 19.8% (n = 25) experienced postoperative complications, 11 (17.7%) in group A and 14 (21.9%) in group B (P = .561). Infective complications were seen in 11 donors (8.1%), five in group A and six in group B (P = .79). A total of 8.1% of donors required continuation/up-gradation of antibiotics in group A and 9.4% in group B. Return to soft diet was delayed in group B (P = .039). Median hospital stay and cost were similar.

CONCLUSION

Three doses of perioperative antibiotic are equally effective in preventing infective complications.

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.

Healthcare Resource Utilization After Living Liver Donation: A Retrospective Case-control Study

BACKGROUND

Living liver donation is generally considered safe, but donors may experience short or long-term complications. The purpose of this study was to assess healthcare resource utilization after liver donation in living liver donors in comparison to the general population.

METHODS

Outpatient or emergency department visits and hospital admissions were compared between living liver donors who underwent hepatic resection for living liver donation between 2004 and 2018 and the matched general population. Healthcare resource utilization data for 5 years after liver donation were collected from the National Health Insurance Service (NHIS) database. For every living liver donor, 4 individually matched nondonors were selected from the NHIS database using age, sex, preexisting comorbidities, and previous healthcare utilization history.

RESULTS

A total of 1886 living liver donors and 7309 nondonors were included. In the first year after donation, living liver donors required more outpatient department visits (7 [4-13] vs. 3 [1-7], P < 0.001) and more emergency department visits (13.33% vs. 0.15%, P < 0.001) compared to matched nondonors. A similar trend persisted for 5 years after donation. The number of hospital admissions of living liver donors was higher for up to 2 years after donation with longer hospital length of stay (13.0 [10.5-16.0] vs. 5.0 [3.0-9.0] days, P < 0.0001).

CONCLUSIONS

Healthcare resource utilization in living liver donors for 5 years after donation were higher compared to matched nondonors. The higher healthcare resource demand may be related to postoperative complications or lowered threshold for healthcare resource utilization after donation.Supplemental Visual Abstract; http://links.lww.com/TP/C291.

Fatty liver disease in Living Liver Donors: A Single-Institute Experience of 220 Donors

We retrospectively reviewed 220 living liver donors, with a focus on the development of postoperative fatty liver. Data regarding demographics, comorbidities, imaging tests, operations, and biopsies were obtained from medical records. We used unenhanced CT and USG to diagnose fatty liver. Donor candidates with fatty liver underwent weight loss intervention until imaging tests no longer demonstrated any features of fatty liver. Among 220 donors, 61 were diagnosed with preoperative fatty liver. The mean BMI of these 61 donors significantly decreased from 24.9 at the first visit to 23.6 kg/m² immediately before surgery (p=0.0386). A multivariate analysis revealed the following significant risk factors for postoperative fatty liver: male sex (p=0.0033), BMI immediately before surgery (p=0.0028), and a history of treatment for preoperative fatty liver (p=0.0231). Postoperative fatty liver was often refractory to weight loss intervention. No improvement was observed in 14 of the 32 donors who had been diagnosed with fatty liver postoperatively, and 1 of the 14 donors even developed NASH. In conclusion, special attention should be paid to prevent fatty liver after surgery in male donors who show a high BMI immediately before surgery and with a history of treatment for preoperative fatty liver, and lifelong follow-up is recommended.

Prevention of delayed gastric emptying after living donor left hepatectomy

BACKGROUND

Delayed gastric emptying (DGE) is uncomfortable complication after left hepatectomy. The aim of this study is to show our strategy to prevent DGE after living donor left hepatectomy.

METHODS

The cases were divided into 3 groups as without any prevention (control group), prevented DGE with putting omentum between the liver and pylorus (O group), and with putting a Seprafilm (S group). The incidence of DGE and the CT finding 1 month after surgery were retrospectively compared between the groups.

RESULTS

The incidence of DGE was significantly decreased in O and S group than control group (P < 0.05, Fisher's test). In S group, fluid collection along the cutting surface of the liver was observed on CT significantly more than other groups, but the incidence of bile leakage was adversely less in S groups than other groups, meaning that collected fluid in S group were presumed as the ascites without bile.

CONCLUSION

Omentum patching and Seprafilm were equally effective to prevent DGE after living donor left hepatectomy, and Seprafilm might be better because it is more physiologic.

Live Liver Donors: Is Right Still Right?

BACKGROUND

Conventional wisdom dictates that a larger hepatectomy is more prone to complications. Consequently, with the donor safety as paramount, the transplant community has intuitively been proponents of left lobe donation in live donor liver transplantation (LDLT), thereby satisfying the tenet of double equipoise. More recently some data suggest that this may not always be the case, especially in established centres. Our aim was to compare right and left lobe donor outcomes in LDLT from a centre with cumulative experience.

METHODS

Review of a prospectively collected database of right and left lobe liver donors operated between August 2009 and July 2017 was performed. Their preoperative demographics, operative and post-operative outcomes were compared.

RESULTS

Of 904 liver transplantations, 458 were right lobe donors [379 without middle hepatic vein (MHV), 79 with MHV] and 58 left lobe donors. There was a significant difference in GRWR and functional liver remnant between the right and left lobe donors (1.27 ± 0.45 vs. 1.03 ± 0.28 p = 0.004, and 63.2 ± 7.9 vs. 37.7 ± 16.3, respectively, p value). The end portal pressure (7 vs. 8 mmHg p = <0.001), peak bilirubin (1.6 ± 0.8 vs. 2.9 ± 1.5 p = <0.001) and day 5 bilirubin (0.8 ± 0.3 vs. 1.4 ± 0.9 p = <0.001) were significantly higher in right lobe donors. There was no difference in blood loss, duration of surgery or peak lactate between the groups. Complications (20.7% vs. 25.9% p = 0.48), including serious complications (Clavien-Dindo > III) (6.9% vs. 8.1% p = 0.95), duration of ICU and hospital stay, were comparable between the groups. Subgroup analysis between left lobe and right lobe with and without MHV donor was also comparable.

CONCLUSION

Though biochemical differences exist between the groups, no difference in outcomes was noted. Despite larger liver mass loss in right lobe donors, a strict protocol-based approach to donor selection leads to comparable outcomes between left lobe and right lobe donations.

Long-Term Financial, Psychosocial, and Overall Health-Related Quality of Life After Living Liver Donation

BACKGROUND

To assess the impact of living liver donation (LD) in a diverse and aging population up to 20 y after donation, particularly with regard to medical, financial, psychosocial, and overall health-related quality of life (HRQOL).

METHODS

Patients undergoing LD between 1999 and 2009 were recruited to respond to the Short-Form 36 and a novel Donor Quality of Life Survey at two time points (2010 and 2018).

RESULTS

Sixty-eight living liver donors (LLDs) completed validated surveys, with a mean follow-up of 11.5 ± 5.1 y. Per Donor Quality of Life Survey data, physical activity or strength was not impacted by LD in most patients. All respondents returned to school or employment, and 82.4% reported that LD had no impact on school or work performance. LD did not impact health insurability in 95.6% of donors, and only one patient experienced difficulty obtaining life insurance. Overall, 97.1% of respondents did not regret LD. Short-Form 36 survey-measured outcomes were similar between LLDs and the general U.S.

POPULATION

LLDs who responded in both 2010 and 2018 were followed for an overall average of 15.4 ± 2.4 y and HRQOL outcomes in these donors also remained statistically equivalent to U.S. population norms.

CONCLUSIONS

This study represents the longest postdonation follow-up and offers unique insight related to HRQOL in a highly diverse patient population. Although LLDs continue to maintain excellent HRQOL outcomes up to 20 y after donation, continued lifetime follow-up is required to accurately provide young, healthy potential donors with an accurate description of the risks that they may incur on aging.

Respiratory Complications Among Living Liver Donors: A Single-Center Retrospective Observational Study

OBJECTIVES

The safety of living liver donors is considered a high priority. In this study, we aimed to highlight the incidence and risk factors of respiratory complications among living liver transplant donors at our institute.

MATERIALS AND METHODS

We evaluated data of 178 related living liver donors who were seen from January 2014 to December 2018. We recorded significant respiratory complications, such as pulmonary embolism, pleural effusion, pneumothorax, pneumonia, acute lung injury, acute respiratory distress syndrome, and transfusion-related acute lung injury. Complications were noted as clinically evident and/or needing intervention. We also recorded the frequency of nonrespiratory complications and duration of intensive care unit and hospital stays.

RESULTS

Ten donors (5.6%) developed significant respiratory complications: 2 (1.1%) had pulmonary embolisms, 3 (1.7%) developed symptomatic pleural effusion that required thoracentesis, and 4 (2.25%) had chest infections. The remaining donor (0.6%) had unexplained respiratory insufficiency. Logistic regression analyses identified age ≥ 35 years and previous surgery as the main risk factors of significant respiratory complications. There were no recorded cases of pneumothorax, acute lung injury, acute respiratory distress syndrome, and transfusion-related acute lung injury. Raw surface collection (14.6%) and biliary leakage (7.9%) were the most frequent nonrespiratory complications. There was no significant difference between patients with and without significant respiratory complications with regard to intensive care unit and hospital stays.

CONCLUSIONS

Despite the low incidence of significant respiratory complications among our living liver donor cohort, close monitoring and early management are essential to achieve better prognosis, especially in donors older than 35 years or those with previous surgery.

Risk of biliary tract disease in living liver donors: A population-based cohort study

BACKGROUND & AIMS

Whether living liver donors have a higher risk of biliary tract disease compared with non-donors remains unknown.

METHODS

Data were collected from the Taiwan Longitudinal Health Insurance Database for the 2003-2011 period. The study cohort comprised 1,446 patients aged ≥ 18 years who had served as living liver donors. The primary outcome was the incidence of biliary tract disease. Cox proportional hazards modeling was used to determine the hazard ratios.

RESULTS

The incidence density rate of biliary tract disease was 13.9-fold higher in the liver donor (LD) cohort than in the non-LD cohort (10.2 vs. 0.71 per 1,000 person-years), with an adjusted hazard ratio (HR) of 14.2 (95% confidence interval [CI] = 7.73-26.1). Stratified by comorbidity, the relative risk of biliary tract disease was higher in the LD cohort than in the non-LD cohort for both patients with or without comorbidity. The incidence density rate of biliary tract disease was significantly higher in the first 3 years (13.5 per 1,000 person-years in the LD cohort). The highest adjusted HR of biliary tract disease for LD patients compared with the non-LD cohort was 22.4 (95% CI = 10.8-46.1) in the follow-up ≤ 3 years.

CONCLUSION

Living liver donors had a higher risk of biliary tract disease compared with non-donors.

Liver Transplantation

The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.

Bilateral proficiency over time leads to reduced donor morbidity in living donor hepatectomy

Background

Although left-lobe donation is considered safer, right-sided donor hepatectomy predominates in adult living donor liver transplantation (LDLT). We hypothesized that bilateral proficiency with donor hepatectomy reduces overall donor complications.

Methods

A retrospective review of 834 adult LDLT donors (221 left lobes) from January 2004 to December 2014 was performed, dividing cases into two eras based on left-graft experience. Donor complications within 6 months were investigated, focusing on graft side and surgical era.

Results

The overall complication rate was 17.6%, and was higher in right-lobe donors. In Era 2, during which left-lobe donation rates were three times higher, total complications decreased (14.7% vs. 20.9%, P=0.02). A significant reduction in postoperative ascites accounted for the lower overall complication rate. The proportion of major biliary complications (BCs) was halved from 62.5% to 25.0%. Right-lobe donor complications also decreased significantly (15.8% vs. 22.9%, P=0.032), demonstrating that it was not only increased left-lobe donations leading to lowered complication rates, but also greater experience with donor hepatectomy in general.

Conclusions

Accumulating experience with bilateral donor hepatectomy leads to decreased donor morbidity and comparable outcomes for right and left lobes, further enhancing the goal of donor safety while balancing recipient needs.

Suggested guidelines for the diagnosis and management of urea cycle disorders: First revision

In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.

Atrophy of the Rectus Abdominis After Left-Side Donor Hepatectomy: Comparison of Upper Abdominal Midline vs Mercedes Incision

OBJECTIVE

This study of living liver transplant donors compared postoperative atrophy of the rectus abdominis after an upper abdominal midline incision vs a Mercedes incision.

METHODS

A total of 110 donors underwent left-side donor hepatectomy in our hospital from 2007 to 2016. We analyzed the postoperative computed tomography data of 102 cases 3, 6, and 12 months after surgery. Donors were categorized as having a midline incision (MID group, n = 39) or a Mercedes incision (MER group, n = 63). The rectus abdominis was assessed on computed tomography images, and the percentage of muscle thickness (PMT) was compared in the 2 groups.

RESULTS

Patient age, sex, and body mass index did not differ in the 2 groups. Laparoscope-assisted hepatectomy was only performed in the MID group, while open hepatectomy was performed mainly in the MER group. The mean PMT of the rectus abdominis did not change 3, 6, and 12 months after surgery in the MID group but decreased to 80%, 76%, and 72% of the baseline value in the MER group 3, 6, and 12 months after surgery, respectively. The PMT values were significantly lower in the MER group than in the MID group at all 3 time points (P < .001). In the MER group, rectus abdominis atrophy was significantly worse on the right side than on the left. There was no significant difference in morbidity between the 2 groups.

CONCLUSION

In living donor liver transplant, the Mercedes incision resulted in significantly greater atrophy of the rectus abdominis in donors compared with the midline incision.

[Influence of bile duct anatomy on biliary complications in hepatic right lobe living donors]

Perioperative morbidity in the living donation of partial livers is mainly due to infections and biliary complications. Bile duct anatomy variants, in particular of the right system, are suspected to be causative. We investigated the influence of bile duct variants on the incidence of biliary donor complications in donations of the right liver lobe. We analyzed 103 donors. Twelve patients had a bile leak that required treatment. All of these were treated endoscopically without any residual defect. We did not see a central extrahepatic bile duct lesion Nagano type C. The anatomic variant Huang A3 is a challenge with respect to the surgical technique. Three of 17 patients with biliary anatomy Huang A3 developed leaks. The bile duct anatomy can be carefully evaluated by magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography. The anatomic variant Huang A3 warrants particular attention for the closure of the bile duct orifice.

Prediction of liver remnant regeneration after living donor liver transplantation using preoperative CT texture analysis

PURPOSE

To predict the rate of liver regeneration after living donor liver transplantation (LDLT) using pre-operative computed tomography (CT) texture analysis.

MATERIALS AND METHODS

112 living donors who performed right hepatectomy for LDLT were included retrospectively. We measured the volume of future remnant liver (FLR) on pre-operative CT and the volume of remnant liver (LR) on follow-up CT, taken at a median of 123 days after transplantation. The regeneration index (RI) was calculated using the following equation: [Formula: see text]. Computerized texture analysis of the semi-automatically segmented FLR was performed. We used a stepwise, multivariable linear regression to assess associations of clinical features and texture parameters in relation to RI and to make the best-fit predictive model.

RESULTS

The mean RI was 110.7 ± 37.8%, highly variable ranging from 22.4% to 247.0%. Among texture parameters, volume of FLR, standard deviation, variance, and gray level co-occurrence matrices (GLCM) contrast were found to have significant correlations between RI. In multivariable analysis, smaller volume of FLR (ß - 0.17, 95% CI - 0.22 to - 0.13) and lower GLCM contrast (ß - 1.87, 95% CI - 3.64 to - 0.10) were associated with higher RI. The regression equation predicting RI was following: RI = 203.82 + 10.42 × pre-operative serum total bilirubin (mg/dL) - 0.17 × V_FLR (cm³) - 1.87 × GLCM contrast (× 100).

CONCLUSION

Volume of FLR and GLCM contrast were independent predictors of RI, showing significant negative correlations. Pre-operative CT with texture analysis can be useful for predicting the rate of liver regeneration in living donor of liver transplantation.

Long-Term Health-Related Quality of Life in Living Liver Donors

BACKGROUND In living donor liver transplantation (LDLT), 2 patients undergo surgery, and the advantages and disadvantages for both patients should be considered. This study evaluated the long-term quality of life in living liver donors, and its impact on their activities of daily living focusing on mood and mental health. MATERIAL AND METHODS In total, 101 living liver donors (69 female and 32 male patients, median age of 36.8 years) were surveyed at a median time of 61.8 months after liver donation (range 7-169 months). The generic Short Form Health Survey (SF-36), the Patient Health Questionnaire 9 (PHQ-9), and the Questionnaire of Physical Activity (IPAQ) were used. The results of SF-36 were compared to a matched control group (n=72) using the Wilcoxon test; the SF-36, the PHQ-9, and the IPAQ scores were analyzed using Spearman's rank correlation. Linear regression model was used to check for dependencies between variables of interest. The IPAQ results were compared between the study group and the general Polish population. RESULTS There were no significant differences in the SF-36 domains between the study group and control group except body pain, which was higher in the living liver donor group (P<0.05). In 30.6% of patients, the PHQ-9 survey revealed mood disturbances. The PHQ-9 scores were higher in female-donors (P<0.05). Both summary scores of the SF-36 correlated to the PHQ-9 (P<0.001). In 89.1% of patients, physical activity was below the population norm and was lower in female donors than in male donors (P<0.01). CONCLUSIONS LDLT had no impact on donors' physical and mental health. Physical activity of living liver donors was lower than that of the general population. The SF-36 and the IPAQ measures seem to be reliable in the care of living liver donors. The PHQ-9 survey results and the inclination to depression of female living liver donors requires further study.

Xenogeneic Heterotopic Auxiliary Liver transplantation (XHALT) promotes native liver regeneration in a Post-Hepatectomy Liver failure model

The liver's regenerative capacity is unique, but too small a segment can overwhelm its ability to simultaneously regenerate and support the host, resulting in liver dysfunction and death. Here we tested a temporary Xenogeneic Heterotopic Auxiliary Liver Transplant (XHALT) from Gal-KO miniature swine in a baboon model of Post-Hepatectomy Liver Failure (PHLF) by 90%- hepatectomy. Immunosuppression consisted of CVF, ATG, FK 506 and steroids. 90%-hepatectomized animals died within 4-5 days with the clinical picture of PHLF, (high LFTs and bilirubin, ascites, encephalopathy and coagulopathy). The 10% remnants had macroscopic and histological evidence of severe steatosis and absence of hepatocyte replication. In contrast, the addition of XHALT prolonged survival up to 11 days, with the cause of death being sepsis, rather than liver failure. The remnant liver appeared grossly normal, and on histology, there was no evidence of fatty infiltration, but there was pronounced Ki-67 staining. In conclusion, temporary auxiliary xenografts have the potential to support a small for size liver graft while it grows to adequate size or provide an opportunity for organ recovery in acute liver failure.

Portal vein stenosis preconditioning of living donor liver in swine: early mechanisms of liver regeneration and gain of hepatic functional mass

To reduce the morbidity and mortality risk for the donor in living donor liver transplantation (LDLT), we previously identified 20% left portal vein (LPV) stenosis as an effective preconditioning method to induce cell proliferation in the contralateral lobe without downstream ipsilateral atrophy. In this study, we report the pathways involved in the first hours after preconditioning and investigate the changes in liver volume and function. Fourteen pigs were used this study. Five pigs were used to study the genetic, cellular and molecular mechanisms set up in the early hours following the establishment of our preconditioning. The remaining nine pigs were equally divided into three groups: sham-operated animals, 20% LPV stenosis, and 100% LPV stenosis. Volumetric scanning and 99 mTc-Mebrofenin hepatobiliary scintigraphy were performed before preconditioning and 14 days after to study morphological and functional changes in the liver. We demonstrated that liver regeneration triggered by 20% LPV stenosis in the contralateral lobe involves TNF-α, IL-6, and inducible nitric oxide synthase 2 by means of STAT3 and hepatocyte growth factor. We confirmed that our preconditioning was responsible for an increase in the total liver volume. Finally, we demonstrated that this volumetric gain was associated with an increase in hepatic functional capacity. NEW & NOTEWORTHY We describe a new preconditioning method for major hepatectomy that is applicable to hepatectomy for donation. We identified 20% left portal vein stenosis as effective preconditioning that is capable of inducing cell proliferation in the contralateral lobe without the downstream ipsilateral atrophy. In this study, we report the pathways involved in the first hours following preconditioning, and we confirm that 20% left portal vein stenosis is responsible for an increase in the functional capacity and total liver volume in a porcine model.

Should living donor liver transplantation be an option when deceased donation is not?

When a liver transplantation candidate is declined for listing to receive a deceased organ, sometimes a loved one comes forward and offers to be a living donor. This raises the ethical question of whether a patient who is not eligible for deceased donor liver transplantation should be eligible for living donor liver transplantation. We compare living organ donation in kidney and liver transplantation and explore key ethical concepts of justice, fairness, and societal trust. Ultimately, because there is no alternative life-preserving therapy in end-stage liver disease, and because transplantation with a living donor organ does not involve removing a resource from the common pool of transplant organs, we argue that a standard of "slightly less benefit" than that required for deceased transplantation should be used to determine the acceptability of living donor liver transplantation.

Significance and indications for reoperative portoenterostomy in biliary atresia in light of long-term outcome

BACKGROUND

Among biliary atresia (BA) patients undergoing revision following failed portoenterostomy, long-term native liver survival (NLS), physical condition, and indications for revision were explored.

METHODS

From 1977-2015, 33 of 95 BA patients (35%) at our institution underwent revision. Ten- and 20-year NLS rates (NLSRs) and biochemical statuses of 20-year-old native liver survivors were compared between post-portoenterostomy BA patients with and without history of revision. Factors associated with 10-year NLS following revision and optimal cut-offs for potential predictors were analyzed.

RESULTS

Overall 10- and 20-year NLSRs were 57% and 54%, respectively. Ten- and 20-year NLSRs were 49% and 45% in the revision group and 63% and 61% in the non-revision group, respectively. Among 20-year-old native liver survivors, differences in admission rates between ages 10-20 years were not significant for cholangitis (revision, 46%; non-revision, 40%; P = 0.30) or portal hypertension (revision, 38%; non-revision, 15%; P = 0.21). Differences in hepatobiliary function-associated blood tests between these groups at 20 years old were only significant for aspartate aminotransferase (P = 0.02) and gamma-glutamyl transpeptidase (P = 0.047). Among potential predictors of 10-year NLS that we investigated, rate of change in total bilirubin (TB) over the first month post-portoenterostomy was best (P = 0.0019), and the receiver operating characteristic curve revealed an optimal cut-off for this first-month change in TB of -3.7 mg/dl (area under the curve, 0.85; sensitivity, 0.79; specificity, 0.83).

CONCLUSIONS

In approximately half of the patients, revision provided 10- and 20-year NLS, and biochemical status at 20 years old was comparable across revision and non-revision patients. Rate of change in TB during the first month post-portoenterostomy offers a sensitive predictor of revision.

Living donor liver transplantation for biliary atresia: An analysis of 2085 cases in the registry of the Japanese Liver Transplantation Society

Biliary atresia (BA) is the most common indication for liver transplantation (LT) in pediatric population. This study analyzed the comprehensive factors that might influence the outcomes of patients with BA who undergo living donor LT by evaluating the largest cohort with the longest follow-up in the world. Between November 1989 and December 2015, 2,085 BA patients underwent LDLT in Japan. There were 763 male and 1,322 female recipients with a mean age of 5.9 years and body weight of 18.6 kg. The 1-, 5-, 10-, 15-, and 20-year graft survival rates for the BA patients undergoing LDLT were 90.5%, 90.4%, 84.6%, 82.0%, and 79.9%, respectively. The donor body mass index, ABO incompatibility, graft type, recipient age, center experience, and transplant era were found to be significant predictors of the overall graft survival. Adolescent age (12 to <18 years) was associated with a significantly worse long-term graft survival rate than younger or older ages. We conclude that LDLT for BA is a safe and effective treatment modality that does not compromise living donors. The optimum timing for LT is crucial for a successful outcome, and early referral to transplantation center can improve the short-term outcomes of LT for BA. Further investigation of the major cause of death in liver transplanted recipients with BA in the long-term is essential, especially among adolescents.

Hepatectomy for hepatocellular carcinoma with portal vein tumor thrombus

Despite surgical removal of tumors with portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) patients, early recurrence tends to occur, and overall survival (OS) periods remain extremely short. The role that hepatectomy may play in long-term survival for HCC with PVTT has not been established. The operative mortality of hepatectomy for HCC with PVTT has also not been reviewed. Hence, we reviewed recent literature to assess these parameters. The OS of patients who received hepatectomy in conjunction with multidisciplinary treatment tended to be superior to that of patients who did not. Multidisciplinary treatments included the following: preoperative radiotherapy on PVTT; preoperative transarterial chemoembolization (TACE); subcutaneous administration of interferon-alpha (IFN-α) and intra-arterial infusion of 5-fluorouracil (5-FU) with infusion chemotherapy in the affected hepatic artery; cisplatin, doxorubicin and 5-FU locally administered in the portal vein; and subcutaneous injection of IFN-α, adjuvant chemotherapy (5-FU + Adriamycin) administration via the portal vein with postoperative TACE, percutaneous isolated hepatic perfusion and hepatic artery infusion and/or portal vein chemotherapy. The highest reported rate of operative mortality was 9.3%. In conclusion, hepatectomy for patients affected by HCC with PVTT is safe, has low mortality and might prolong survival in conjunction with multidisciplinary treatment.

Influence of outflow-obstructed liver volume and venous communication development: A three-dimensional volume study in living donors

Living donor liver transplantation using the left liver graft with the middle hepatic vein (MHV) is a well-established procedure. Following such procedures, outflow obstruction occurs in remnant livers. However, the effects of the outflow-obstructed liver volume (LVOut-Ob ), with or without venous communication development, remain unclear. The aim of the study is to investigate effects of outflow-obstructed regions by focusing on short-term outcomes and remnant liver hypertrophy in left liver procurement donors. Of 532 donors, we collected data from 119 undergoing left liver procurement with the MHV. Postoperative hepatic parameters, venous communication development, and liver hypertrophy were evaluated in 2 donor groups based on LVOut-Ob . The left liver was procured with the MHV in 119 donors, who formed 2 more groups based on the median LVOut-Ob : large-outflow-obstruction group (n = 60; LVOut-Ob  ≥ 263 mL) and small-outflow-obstruction (n = 59; LVOut-Ob  < 263 mL) group. Postoperative liver function parameters were significantly impaired in the large-outflow-obstruction group compared with the small-outflow-obstruction group. Postoperative venous communication developed in 52 (66.7%) of 78 donors analyzed. Hypertrophy ratios in remnant right livers and right paramedian sectors were significantly higher in the small-outflow-obstruction group than in the large-outflow-obstruction group (P = 0.01 and P = 0.02, respectively). The liver hypertrophy ratio of outflow-obstructed regions was better, especially in small regions developing venous communication (P =  0.001). The postoperative morbidity rate did not differ significantly (P = 0.66). In conclusion, the procurement of the left liver graft with the MHV was safely performed with minimal morbidity by assessing the donor remnant right liver volume with and without outflow obstruction. Attention should be paid that postoperative hepatic parameters and remnant liver hypertrophy were impaired in the remnant livers with large outflow-obstructed regions compared with those with small outflow-obstructed regions. Liver Transplantation 23 1531-1540 2017 AASLD.

Survival outcomes of hepatectomy for stage B Hepatocellular carcinoma in the BCLC classification

BACKGROUND

Because hepatectomy is not recommended in patients with stage B hepatocellular carcinoma (HCC) of the Barcelona Clinic Liver Cancer (BCLC) staging, we evaluated the survival outcomes of hepatectomy for stage B in the BCLC system.

METHODS

Data were collected from 297 consecutive adult stage B patients who underwent curative hepatectomy for HCC between 1996 and 2014 in Hokkaido University Hospital. Overall survival (OS), disease-free survival (DFS), and risk factors were analyzed using the Kaplan-Meier method. Independent prognostic factors were evaluated using a Cox proportional hazards regression model. AP-factor (alpha-fetoprotein [AFP] × protein induced by vitamin K absence or antagonism factor II [PIVKA-II]) was categorized according to the serum concentrations of AFP and PIVKA-II: AP1 (AFP < 200 ng/ml and PIVKA-II < 100 mAU/ml), AP2 (AFP × PIVKA-II < 105), and AP3 (AFP × PIVKA-II ≥ 105).

RESULTS

There were 130 deaths among our 297 stage B patients (43.8%). The causes of death in these cases were HCC recurrence (n = 106; 81.5%), liver failure (n = 7; 5.4%), and other causes (n = 17; 16.1%). The operative mortality rate was 0.34% (1/297). The 5-year OS and DFS rates for the stage B cases were 54.3 and 21.9%, respectively. By multivariate analysis, tumor number and AP-factor were risk factors for both survival and recurrence that were tumor related and could be evaluated preoperatively. The study patients with stage B HCC were classified into three groups by tumor number (B1, 1; B23, 2 or 3; B4over: ≥4) and into three groups stratified by AP-factor (AP1, AP2, and AP3). The 5-year OS rates of B1, B23, and B4over were 63.6, 52.3, and 29.0%. The 5-year OS rates of AP1, AP2, and AP3 were 67.6, 65.2, and 39.1%. Stratified by the 5-year OS rate, stage B HCC patients were classified into three subgroups (A-C).The 5-year OS rates of groups A (B1 or B23 and AP-1 or AP-2), B (B1 or B23 and AP-3, or B4over and AP-1 or AP-2), and C (B4over and AP-3) were 69.5, 43.7, and 21.3%.

CONCLUSION

Stage B HCC patients with a tumor number ≤ 3 and/or AP-factor < 1 × 105 show acceptable 5-year OS rates and could be treated by hepatectomy.

Current status of pediatric transplantation in Japan

Brain-dead donor organ transplantation has been available to children in Japan since the 2010 revision of the Organ Transplant Law. Of the 50–60 brain-dead donor organ transplants performed annually in Japan, however, very few (0–4 per year) are performed in children. Again, while those receiving liver, heart, and kidney transplants are reported to fare better than their counterparts in the rest of the world, organ shortage is becoming a matter of great concern. Very few organs become available from brain-dead donors or are transplanted to adults if made available at all, with some children dying while on the brain-dead organ waiting list. Against this background, living-donor transplants, split-liver transplants, domino transplants, and hepatocyte transplants represent alternative modalities, each of which is shown to be associated with favorable outcomes. Challenges exist, include streamlining the existing framework for promoting organ donation for children and between children.

Defining Benchmarks for Major Liver Surgery: A multicenter Analysis of 5202 Living Liver Donors

OBJECTIVE

To measure and define the best achievable outcome after major hepatectomy.

BACKGROUND

No reference values are available on outcomes after major hepatectomies. Analysis in living liver donors, with safety as the highest priority, offers the opportunity to define outcome benchmarks as the best possible results.

METHODS

Outcome analyses of 5202 hemi-hepatectomies from living donors (LDs) from 12 high-volume centers worldwide were performed for a 10-year period. Endpoints, calculated at discharge, 3 and 6 months postoperatively, included postoperative morbidity measured by the Clavien-Dindo classification, the Comprehensive Complication Index (CCI), and liver failure according to different definitions. Benchmark values were defined as the 75th percentile of median morbidity values to represent the best achievable results at 3 month postoperatively.

RESULTS

Patients were young (34 ± [9] years), predominantly male (65%) and healthy. Surgery lasted 7 ± [2] hours; 2% needed blood transfusions. Mean hospital stay was 11.7± [5] days. 12% of patients developed at least 1 complication, of which 3.8% were major events (≥grade III, including 1 death), mostly related to biliary/bleeding events, and were twice higher after right hepatectomy. The incidence of postoperative liver failure was low. Within 3-month follow-up, benchmark values for overall complication were ≤31 %, for minor/major complications ≤23% and ≤9%, respectively, and a CCI ≤33 in LDs with complications. Centers having performed ≥100 hepatectomies had significantly lower rates for overall (10.2% vs 35.9%, P < 0.001) and major (3% vs 12.1%, P < 0.001) complications and overall CCI (2.1 vs 8.5, P < 0.001).

CONCLUSIONS

The thorough outcome analysis of healthy LDs may serve as a reference for evaluating surgical performance in patients undergoing major liver resection across centers and different patient populations. Further benchmark studies are needed to develop risk-adjusted comparisons of surgical outcomes.

Donor safety in living donor liver donation: An Italian multicenter survey

Major concerns about donor morbidity and mortality still limit the use of living donor liver transplantation (LDLT) to overcome the organ shortage. The present study assessed donor safety in LDLT in Italy reporting donor postoperative outcomes in 246 living donation procedures performed by 7 transplant centers. Outcomes were evaluated over 2 time periods using the validated Clavien 5-tier grading system, and several clinical variables were analyzed to determine the risk factors for donor morbidity. Different grafts were obtained from the 246 donor procedures (220 right lobe, 10 left lobe, and 16 left lateral segments). The median follow-up after donation was 112 months. There was no donor mortality. One or more complications occurred in 82 (33.3%) donors, and 3 of them had intraoperative complications (1.2%). Regardless of graft type, the rate of major complications (grade ≥ 3) was 12.6% (31/246). The overall donor morbidity and the rate of major complications did not differ significantly over time: 26 (10.6%) donors required hospital readmission throughout the follow-up period, whereas 5 (2.0%) donors required reoperation. Prolonged operative time (>400 minutes), intraoperative hypotension (systolic < 100 mm Hg), vascular abnormalities, and intraoperative blood loss (>300 mL) were multivariate risk factors for postoperative donor complications. In conclusion, from the standpoint of living donor surgery, a meticulous and well-standardized technique that reduces operative time and prevents blood loss and intraoperative hypotension may reduce the incidence of donor complications. Transparency in reporting results after LDLT is mandatory, and we should continue to strive for zero donor mortality. Liver Transplantation 23 184-193 2017 AASLD.

Live donor liver transplantation for alcoholic hepatitis

Liver transplantation is a definitive therapy for patients with end-stage liver disease and cirrhosis, with improvement in survival and quality of life. Patients are carefully screened and selected for this modality of treatment to achieve maximum survival benefit. For example, a patient with hepatocellular carcinoma is a candidate if he or she is within Milan criteria and has no significant comorbidity. Similarly, patients with alcoholic cirrhosis are transplant candidates if they are deemed to have been rehabilitated from abusive alcohol consumption and are at low risk for recidivism. More recently, carefully selected patients with alcoholic hepatitis have been successfully transplanted. The preferred transplantation modality is cadaveric liver transplantation. However, living donor liver transplantation is carried out if there is no cadaveric liver organ allocation system, or if the patient is deemed to be at low priority for cadaveric organ transplantation based on the allocation system. Living donor liver transplantation for alcoholic hepatitis needs to be addressed with this background in mind.

Liver transplantation in Japan

As of December 31, 2014, 7937 liver transplants (7673 living donor transplants and 264 deceased donor liver transplantations [DDLTs; 261 from heart-beating donors and 3 from non-heart-beating donors]) have been performed in 67 institutions in Japan. The revised Organ Transplant Law in Japan came into effect in July 2010, which allows organ procurement from brain-dead individuals, including children, with family consent if the patient had not previously refused organ donation. However, the number of deceased donor organ donations has not increased as anticipated. The rate of deceased organ donations per million population (pmp) has remained at less than 1. To maximize the viability of the limited numbers of donated organs, a system has been adopted that includes the partnership of well-trained transplant consultant doctors and local doctors. For compensating for the decreased opportunity of on-site training, an educational system regarding quality organ procurement for transplant surgeons has also been established. Furthermore, experts in the field of liver transplantation are currently discussing adoption of the Model for End-Stage Liver Disease score for allocation, promoting split-liver transplantation, arranging in-house coordinators, and improving the frequency of proposing the option to donate organs to the families. To overcome the shortage of donors during efforts to promote organ donation, living donor liver transplantation (LDLT) has been developed in Japan. Continuous efforts to increase DDLT in addition to the successful experience of LDLT will increase the benefits of liver transplantation for more patients. Liver Transplantation 22 1401-1407 2016 AASLD.

Peptic Ulcer Disease in Living Liver Donors: A Longitudinal Population-Based Study

The objective of this nationwide cohort study was to investigate the risk of peptic ulcer disease (PUD) in living liver donors (LDs). A total of 1333 LDs and 5332 matched nondonors were identified during 2003-2011. Hospitalized patients identified as LDs were assigned to the LD cohort, and the non-LD comparison cohort comprised age- and sex-matched nondonors. Cumulative incidences and hazard ratios (HRs) were calculated. The overall incidence of PUD was 1.74-fold higher in the LD cohort than in the non-LD cohort (2.14 vs. 1.48 per 1000 person-years). After adjustment for age, sex, monthly income and comorbidities, we determined that the LD cohort exhibited a higher risk of PUD than did the non-LD cohort (adjusted HR 1.74, 95% confidence interval [CI] 1.45-2.09). The incidence of PUD increased with age; the risk of PUD was 2.53-fold higher in patients aged ≥35 years (95% CI 2.14-2.99) than in those aged ≤34 years. LDs with comorbidities of osteopathies, chondropathies and acquired musculoskeletal deformities exhibited a higher risk of PUD (adjusted HR 3.93, 95% CI 2.64-5.86) compared with those without these comorbidities. LDs are associated with an increased risk of PUD after hepatectomy.

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.

Living-Donor Liver Transplantation for Hepatic Metastasis From Meningeal Hemangiopericytoma: A Case Report

We report the case of a 58-year-old man referred to our hospital for liver tumor treatment. The patient had a history of neurosurgery for a meningeal hemangiopericytoma 16 years previously. Pre-operative imaging revealed a hypervascular tumor extending from Couinaud segment 4 to segment 8 of the liver, measuring 95 mm in diameter, indicating an atypical hepatocellular carcinoma. Because right trisectionectomy of the liver was considered to be high risk, living-donor liver transplantation (LDLT) was indicated. After transcatheter arterial embolization, LDLT was performed with the use of a left-lobe liver graft from the patient's son. Post-operative histological findings of the liver tumor were identical to those for meningeal hemangiopericytoma, therefore the patient was diagnosed with meningeal hemangiopericytoma that had metastasized to the liver. After LDLT, the patient had a healthy, active life for 2 years; then, a subcutaneous relapse was discovered in the left chest. The patient did not undergo any systemic chemotherapy in response to the relapse. After thoracic and orthopedic surgeries and radiotherapy for multiple metastases, the patient died 5 years and 5 months after LDLT. LDLT could be an effective treatment for localized metastatic hemangiopericytoma in the liver, but it should be indicated only for carefully selected patients.