Intraoperative 'no go' donor hepatectomies in living donor liver transplantation

Hilar Anatomy in 3035 Living Liver Donors: A Novel Classification for Donor Surgery and Suitability, Hepatic Surgeries, and Hepatobiliary Interventions

BACKGROUND

This study examines the vascular and biliary variations in 3035 liver donors. We propose a novel classification of hepatic arteries, portal veins, and bile ducts and clinically relevant donor classification.

METHODS

Preoperative imaging and operative details of 3035 donors from 2005 to 2020 were reviewed. Hilar anatomical variations were identified and grouped on the basis of incidence and clinical relevance.

RESULTS

Hilar structures are classified according to the numbers supplying or draining the graft: for the hepatic artery, right (R) and left (L), RA1/LA1 (1 artery), RA2/LA2 (2 arteries), and RA3/LA3 (3 arteries), respectively, further defined on the basis of the inflow trunk into C (for common hepatic artery), S (for superior mesenteric artery), and L (for left gastric artery); for the portal vein, RP1 (1 vein) and RP2 (2 veins) for the right lobe; and for the hepatic duct, RB1/LB1 (1 duct), RB2/LB2 (2 ducts), RB3 (3 right ducts), and RB4 (4 right ducts). Donors were classified on the basis of anatomical variations into 3 groups: class 1 and class 2 donors, who can donate liver with acceptable risks, and class 3 donors, who are high-risk donors because they are anatomically unacceptable ( Figures S1 to S4, SDC , http://links.lww.com/TP/C918 ).

CONCLUSIONS

Defining hilar anatomical variations and donor grouping into anatomy-based clinical classes helps in operative planning of donors, hepatobiliary surgeries, and interventional procedures.

Aborted living-donor liver transplantation in the real-world setting, lessons from 13 937 cases of Vanguard Multi-center Study of International Living Donor Liver Transplantation Group

There are exceedingly uncommon but clearly defined situations where intraoperative abortions are inevitable in living-donor liver transplantation (LDLT). This study aimed to summarize the cases of aborted LDLT and propose a strategy to prevent abortion or minimize donor damage from both recipient and donor sides. We collected data from a total of 43 cases of aborted LDLT out of 13 937 cases from 7 high-volume hospitals in the Vanguard Multi-center Study of the International Living Donor Liver Transplantation Group and reviewed it retrospectively. Of the 43 cases, there were 24 recipient-related abortion cases and 19 donor-related cases. Recipient-related abortions included pulmonary hypertension (n = 8), hemodynamic instability (n = 6), advanced hepatocellular carcinoma (n = 5), bowel necrosis (n = 4), and severe adhesion (n = 1). Donor-related abortions included graft steatosis (n = 7), graft fibrosis (n = 5), primary biliary cholangitis (n = 3), anaphylactic shock (n = 2), and hemodynamic instability (n = 2). Total incidence of aborted LDLT was 0.31%, and there was no remarkable difference between the centers. A strategy to minimize additional donor damage by delaying the donor's laparotomy or trying to open the recipient's abdomen with a small incision should be effective in preventing some causes of aborted LDLT, such as pulmonary hypertension, advanced cancer, and severe adhesions.

Uses of a dedicated 3D reconstruction software with augmented and mixed reality in planning and performing advanced liver surgery and living donor liver transplantation (with videos)

The development of digital intelligent diagnostic and treatment technology has opened countless new opportunities for liver surgery from the era of digital anatomy to a new era of digital diagnostics, virtual surgery simulation and using the created scenarios in real-time surgery using mixed reality. In this article, we described our experience on developing a dedicated 3 dimensional visualization and reconstruction software for surgeons to be used in advanced liver surgery and living donor liver transplantation. Furthermore, we shared the recent developments in the field by explaining the outreach of the software from virtual reality to augmented reality and mixed reality.

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.

Living Liver Donor With Fasciola Hepatica: First Case Report in the Literature

The major advantage of preoperative magnetic resonance cholangiopancreatography is that living liver donor candidates with complicated biliary tracts may not be exposed to unnecessary laparotomy. To the best of our knowledge, the case presented here features a condition so far not seen by the Liver Transplantation Society. A 27-year-old woman who presented to our clinic as a living liver donor candidate was evaluated but did not have a preoperative magnetic resonance cholangiopancreatography due to technical factors. After parenchymal transection, the right hepatic duct was incised just distal to the bifurcation when 8 fasciola hepatica parasites left the orifice of the remnant bile duct. The common bile duct was then irrigated, and the remnant bile duct orifice was closed, followed by a cholangiography, which showed no suspicious lesions in the biliary tracts. In addition, no suspicious lesions were identified during the postoperative cholangiography of the graft implanted in the recipient. The donor and recipient had postoperative enzyme-linked immunosorbent assay immunoglobulin G antibody titers of 12 and 4 U/mL (cutoff value = 10) for fasciola hepatica, respectively. Both the recipient and the donor received 2 doses of triclabendazole (10 mg/kg) during the postoperative period.

Increased Surgical Complications but Improved Overall Survival with Adult Living Donor Compared to Deceased Donor Liver Transplantation: A Systematic Review and Meta-Analysis

BACKGROUND

Living donor liver transplantation (LDLT) provides an alternative to deceased donor liver transplantation (DDLT) for patients with end-stage liver disease in the circumstance of scarcity of deceased grafts. However, the outcomes of LDLT remain controversial.

METHOD

A systematic review and meta-analysis were performed to compare the outcomes of LDLT with DDLT. Twelve outcomes were assessed.

RESULTS

Thirty-nine studies involving 38563 patients were included. LDLT was comparable in red blood cell transfusion, perioperative mortality, length of hospital stay, retransplantation rate, hepatitis C virus recurrence rate, and hepatocellular carcinoma recurrence rate with DDLT. Cold ischemia time was shorter and duration of recipient operation was longer in LDLT. Postoperative intra-abdominal bleeding rate occurred less frequently in LDLT recipients (odds ratio (OR) = 0.64, 95%confidence interval (CI) = 0.46 - 0.88, P = 0.006), but this did not decrease the perioperative mortality. LDLT was associated with significantly higher biliary (OR = 2.23, 95%CI = 1.59 - 3.13, P < 0.00001) and vascular (OR = 2.00, 95%CI = 1.31 - 3.07, P = 0.001) complication rates and better overall survival (OS) (1 year: OR = 1.32, 95%CI = 1.01 - 1.72, P = 0.04; 3 years: OR = 1.39, 95%CI = 1.14 - 1.69, P = 0.0010; and 5 years: OR = 1.33, 95%CI = 1.04 - 1.70, P = 0.02). According to subgroup analysis, biliary complication rate and OS improved dramatically as experience increased, while vascular complication rate could not be improved because it was mainly caused by the difference of the donor type itself.

CONCLUSIONS

LDLT remains a valuable option for patients in need of liver transplantation for it provides an excellent alternative to DDLT without compromising recipient outcomes. Further refinement in biliary and vascular reconstruction techniques and the accumulation of liver transplantation centers' experience are the key factors in expanding the application of LDLT.

Aborting a neurosurgical procedure: analyzing the decision factors, with endoscopic third ventriculostomy as a model

Aborting a neurosurgical procedure is a situation in which the surgeon modifies the original surgical plan and decides to stop a procedure without achieving the pre-operative goal. While adhering to predefined goals is important, intra-operative judgment, especially in terms of adjusting the risk/benefit ratio in response to real-time data, may change the balance and lead, in selective scenarios, to aborting of a procedure. The literature regarding aborting a surgical procedure is sparse, with no objective guidelines on when, and how, to make such a decision. Defining "when to abort" is difficult and is influenced by many factors, including unexpected intraoperative findings, the surgeon's surgical experience and perspective, and the patient and family perspective. Aborting a procedure is a decision that must be ultimately determined by the surgical findings and the individual treatment alternatives. The aim of this paper is to discuss the condition of aborting a neurosurgical procedure, using the relatively common endoscopic third ventriculostomy (ETV) as a model procedure prototype.

A Worldwide Survey of Live Liver Donor Selection Policies at 24 Centers With a Combined Experience of 19 009 Adult Living Donor Liver Transplants

BACKGROUND

Although surgical technique in living donor liver transplantation (LDLT) has evolved with a focus on donor safety and recipient challenges, the donor selection criteria remain considerably disparate.

METHODS

A questionnaire on donor selection was sent to 41 centers worldwide. 24 centers with a combined experience of 19 009 LDLTs responded.

RESULTS

Centers were categorized into predominantly LDLT (18) or deceased donor liver transplantation (6), and high- (10) or low-volume (14) centers. At most centers, the minimum acceptable graft-to-recipient weight ratio was 0.7 or less (67%), and remnant was 30% (75%). The median upper limit of donor age was 60 years and body mass index of 33 kg/m. At 63% centers, age influenced the upper limit of body mass index inversely. Majority preferred aspartate transaminase and alanine transaminase less than 50 IU/mL. Most accepted donors with nondebilitating mild mental or physical disability and rejected donors with treated coronary artery disease, cerebrovascular accident and nonbrain, nonskin primary malignancies. Opinions were divided about previous psychiatric illness, substance abuse and abdominal surgery. Most performed selective liver biopsy, commonly for steatosis, raised transaminases and 1 or more features of metabolic syndrome. On biopsy, all considered macrovesicular and 50% considered microvesicular steatosis important. Nearly all (92%) rejected donors for early fibrosis, and minority for nonspecific granuloma or mild inflammation. Most anatomical anomalies except portal vein type D/E were acceptable at high-volume centers. There was no standard policy for preoperative or peroperative cholangiogram.

CONCLUSIONS

This first large live liver donor survey provides insight into donor selection practices that may aid standardization between centers, with potential expansion of the donor pool without compromising safety.

Intraoperative abortion of adult living donor liver transplantation: 15 cases from 1,179 cases in 20 years of experience in a single center

Purpose

This study aimed to report intraoperative abortion of adult living donor liver transplantation (LDLT).

Methods

From June 1997 to December 2016, 1,179 adult LDLT cases were performed. 15 cases (1.3%) of intraoperative abortions in LDLT were described.

Results

Among 15 cases, 5 intraoperative abortions were donor-related, and remaining 10 cases were recipient-related. All donor-related abortions were due to unexpected steatohepatitis. Among remaining 10 recipient-related intraoperative abortions, unexpected extension of hepatocellular carcinoma was related in 5 cases. Two cases of intraoperative abortions were related to bowel inflammation, and 2 cases were associated with severe adhesion related to previous treatment. One recipient with severe pulmonary hypertension was also aborted.

Conclusion

Complete prevention of aborted LDLT is still not feasible. In this regard, further efforts to minimize intraoperative abortion are required.

Right lobe living-donor hepatectomy-the Toronto approach, tips and tricks

Living-donor liver transplantation (LDLT) is a well-established treatment for end-stage liver disease. Nevertheless, it has not been extensively accepted in North America or Europe as it has been in Asia. At the University of Toronto we initiated our LDLT program in 2000 and since then our program has grown each year, representing today the largest LDLT program in North America. Our right-lobe LDLT experience from 2000-2014 includes 474 right lobes. Only 30% of our grafts have included the middle hepatic vein. We present excellent outcomes in terms of graft and patient survival which is not different to that achieved with deceased donor liver transplantation. In the present study we will discuss the evolution, challenges and current practices of our LDLT program. We will discuss what is and has been the program philosophy. We will also discuss how we evaluate our donors and the extensive workup we do before a donor is accepted for live donation. Furthermore we will discuss some tips and tricks of how we perform the right hepatectomy for live donation.

[Living liver donor: indications and technical aspects]

Living donor liver transplantation (LDLT) nowadays represents an important and safe alternative to conventional deceased donor liver transplantation (DDLT). A major concern related to the LDLT procedure is still represented by donor safety because a serious operation not without risks must be carried out on a healthy individual. In the present review of the indications for LDLT the technical concepts of donor surgery, criteria for donor selection and evaluation and morbidity and mortality results related to the procedure are presented. In general, the indications for LDLT are almost the same as for DDLT. The donor hepatectomy (right, left or left lateral) is presented in five main phases. The reported morbidity rates vary between 10 % and 60 % and are strongly related to the experience of the transplant center. The currently reported postoperative mortality rates for left and right hepatectomy are 0.1 % and 0.5 %, respectively. The results of LDLT are similar if not even better than those for DDLT depending on the specific indications.

Donor safety in live donor laparoscopic liver procurement: systematic review and meta-analysis

BACKGROUND

Donor safety is a major concern in live organ donation. Live donor laparoscopic liver procurement is an advanced surgical procedure that is performed in highly specialized centers. Since its first report, not much progress has been endeavored for that procedure.

METHODS

We planned to include all the randomized and comparative nonrandomized studies. Patients' population: live donors who are submitted to organ procurement via laparoscopy.

RESULTS

Out of 5,636 records retrieved from the literature, only seven nonrandomized studies were included in this review, which encompassed 418 patients, 151 patients of whom underwent laparoscopic procurement. The quality scores for the included studies ranged from 66 to 76 %. The operative time was significantly shorter in the conventional open group (SD = 0.863, 95 % CI 0.107-1.819). Blood loss in the laparoscopic group was comparable with the conventional open approach (SD = -0.307, 95 % CI -0.807 to 0.192). In subgroup analysis, laparoscopy was protective against blood loss in laparoscopic parenchymal dissection (SD = -1.168, 95 % CI -1.758 to -0.577). The hospital stay was equal in both groups. Patients in laparoscopic group consumed fewer analgesics compared with conventional open group (SD = -0.33, 95 % CI -0.63 to -0.03). Analgesics use was lower in the laparoscopic group compared with the conventional approach. The rate of Clavien complications was equal in both groups (OR 0.721, 95 % CI 0.303-1.716). No difference was found between subgroup analysis based on the harvested liver lobe. Funnel plot and statistical methods used revealed low probability of publication BIAS.

CONCLUSIONS

Live donor laparoscopic liver procurement could be as safe as the conventional open approach. Lower blood loss and lower consumtion of analgesics might be offered in the laparoscopic approach.

The role of adult living donor liver transplantation and recent advances

Twenty years since the first cases were described, adult living donor liver transplantation (ALDLT) is now considered a valid option to expand the donor pool in view of the ongoing shortage of organs and the high waiting list mortality rate. Despite the rapid evolution and acceptance of this complex process of donation and transplantation in clinical practice, the indications, outcome, ethical considerations and quality and safety aspects continue to evolve based on new data from large cohort studies. This article reviews the surgical and clinical advances in the field of liver transplantation, focusing on technical refinements and discussing the issues that may lead to a further expansion of this complex surgical procedure and the role of ALDLT.

Pushing the frontiers of living donor right hepatectomy

Living donor right hepatectomy (LDRH) is currently the most common donor surgery in adult-to-adult living donor liver transplantation although the morbidity and mortality reported in living donors still contradicts the Hippocratic tenet of “do no harm”. Achieving low complication rates in LDRH remains a matter of major concern. Living donor surgery is performed worldwide as an established solution to the donor shortage. The aim of this study was to assess the current status of LDRH and comment on the future of the procedure; assessment was made from the standpoint of optimizing the donor selection criteria and reducing morbidity based on both the authors’ 8-year institutional experience and a literature review. New possibilities have been explored regarding selection criteria. The safety of living donors with unfavorable conditions, such as low remnant liver volume, fatty change, or old age, should also be considered. Abdominal incisions have become shorter, even without laparoscopic assistance; upper midline laparotomy is the primary incision used in more than 400 consecutive LDRHs in the authors’ institution. Various surgical techniques based on preoperative imaging technology of vascular and biliary anomalies have decreased the anatomical barriers in LDRH. Operative time has been reduced, with low blood loss. Laparoscopic or robotic LDRH has been tried in only a few selected donors. The LDRH-specific, long-term outcomes remain to be addressed. The follow-up duration of these studies should be long enough to address possible late complications. Donor safety, which is the highest priority, is ensured by three factors: preoperative selection, intraoperative surgical technique, and postoperative management. These three focus areas should be continuously refined, with the ultimate goal of zero morbidity.

Live liver donors' risk thresholds: risking a life to save a life

BACKGROUND

There is still some controversy regarding the ethical issues involved in live donor liver transplantation (LDLT) and there is uncertainty on the range of perioperative morbidity and mortality risks that donors will consider acceptable.

METHODS

This study analysed donors' inclinations towards LDLT using decision analysis techniques based on the probability trade-off (PTO) method. Adult individuals with an emotional or biological relationship with a patient affected by end-stage liver disease were enrolled. Of 122 potential candidates, 100 were included in this study.

RESULTS

The vast majority of participants (93%) supported LDLT. The most important factor influencing participants' decisions was their wish to improve the recipient's chance of living a longer life. Participants chose to become donors if the recipient was required to wait longer than a mean ± standard deviation (SD) of 6 ± 5 months for a cadaveric graft, if the mean ± SD probability of survival was at least 46 ± 30% at 1 month and at least 36 ± 29% at 1 year, and if the recipient's life could be prolonged for a mean ± SD of at least 11 ± 22 months.

CONCLUSIONS

Potential donors were risk takers and were willing to donate when given the opportunity. They accepted significant risks, especially if they had a close emotional relationship with the recipient.

Intraoperative "no go" donor hepatectomy in living donor liver transplantation

BACKGROUND AND OBJECTIVE

Although there are many reports on donor safety, there are few concerning aborted donations. We sought to analyze the "no go" donor hepatectomies in our liver transplantation center over 10 years' experience.

METHODS

Among 290 living donors brought to the operating room for liver graft harvest from March 2002 to April 2012, we examined the reasons to abandon the procedure, comparing their data with those of successful donors.

RESULTS

The donor operation was aborted in 5 cases various for reasons. The main reason for the abandonment of the operation process was poor liver quality: in single cases there was: poor liver quality due to a massive cirrhotic nodule observed by laparoscopy; serious steatosis of the liver, indicated by an intraoperative biopsy; and an unsuitable biliary anatomy, including 4 branches with 2 small ones. In another case, a biliary duct variation in the intraoperative cholangiogram showed a narrow crotch of the left and right ducts. In the 5th case, the donor would have been left with only a small remaining left lobe (<30%) if the right lobe had been harvested. All 5 donors proceeded to accept a right lobe hepatectomy. Comparison with the 285 successful donors showed no significant differences in preoperative demographic data. All 5 donors recovered without complication and were in good condition over long-term follow-up.

CONCLUSIONS

A low rate of "no go" donor hepatectomy can be achieved. There was no short- or long-term harm to the living donor owing to abandonment of the procedure.

[Liver transplantation with living donor : current aspects, perspectives and significance in Germany]

More than 20 years ago living donor liver transplantation was introduced into clinical practice. Specifics of this method were developed initially for children and later on for adults particularly in regions where a liver transplantation program using deceased donors was not readily available. The most sensitive aspect of living donation, namely the danger to a healthy relative in order to perform the transplantation is immanent in the system and, thus, it is definitively a secondary option as compared to deceased organ donation. Following worldwide initial euphoria the numbers have markedly decreased in the western world since the start of the new millennium. In Asian countries in particular, much work has been done to optimize the procedure so that the donor safety and the outcome quality for the recipient have been impressively demonstrated in large patient populations. There is still a severe donor organ shortage and the option to allocate an optimal (partial) organ on an individual basis by living donation has given new impact to the discussion about a further rise in the profile of living donations here as well. The new version of the German transplantation legislation implemented in summer 2012 requires a number of conditions with respect to insurance for living donors. The current state and perspectives are presented here.

Complications of living donor hepatic lobectomy--a comprehensive report

A wider application of living donor liver transplantation is limited by donor morbidity concerns. An observational cohort of 760 living donors accepted for surgery and enrolled in the Adult-to-Adult Living Donor Liver Transplantation cohort study provides a comprehensive assessment of incidence, severity and natural history of living liver donation (LLD) complications. Donor morbidity (assessed by 29 specific complications), predictors, time from donation to complications and time from complication onset to resolution were measured outcomes over a 12-year period. Out of the 760 donor procedures, 20 were aborted and 740 were completed. Forty percent of donors had complications (557 complications among 296 donors), mostly Clavien grades 1 and 2. Most severe counted by complication category; grade 1 (minor, n = 232); grade 2 (possibly life-threatening, n = 269); grade 3 (residual disability, n = 5) and grade 4 (leading to death, n = 3). Hernias (7%) and psychological complications (3%) occurred >1 year postdonation. Complications risk increased with transfusion requirement, intraoperative hypotension and predonation serum bilirubin, but did not decline with the increased center experience with LLD. The probability of complication resolution within 1 year was overall 95%, but only 75% for hernias and 42% for psychological complications. This report comprehensively quantifies LLD complication risk and should inform decision making by potential donors and their caregivers.

Outcomes of patients with benign liver diseases undergoing living donor versus deceased donor liver transplantation

BACKGROUND/AIMS

The number of people undergoing living donor liver transplantation (LDLT) has increased rapidly in many transplant centres. Patients considering LDLT need to know whether LDLT is riskier than deceased donor liver transplantation (DDLT). The aim of this study was to compare the outcomes of patients undergoing LDLT versus DDLT.

METHODS

A total of 349 patients with benign liver diseases were recruited from 2005 to 2011 for this study. LDLT was performed in 128 patients, and DDLT was performed in 221 patients. Pre- and intra-operative variables for the two groups were compared. Statistically analysed post-operative outcomes include the postoperative incidence of complication, biliary and vascular complication, hepatitis B virus (HBV) recurrence, long-term survival rate and outcomes of emergency transplantation.

RESULTS

The waiting times were 22.10±15.31 days for the patients undergoing LDLT versus 35.81±29.18 days for the patients undergoing DDLT. The cold ischemia time (CIT) was 119.34±19.75 minutes for the LDLT group and 346±154.18 for DDLT group. LDLT group had higher intraoperative blood loss, but red blood cell (RBC) transfusion was not different. Similar ≥ Clavien III complications, vascular complications, hepatitis B virus (HBV) recurrence and long-term survival rates were noted. LDLT patients suffered a higher incidence of biliary complications in the early postoperative days. However, during the long-term follow-up period, biliary complication rates were similar between the two groups. The long-term survival rate of patients undergoing emergency transplantation was lower than of patients undergoing elective transplantation. However, no significant difference was observed between emergency LDLT and emergency DDLT.

CONCLUSIONS

Patients undergoing LDLT achieved similar outcomes to patients undergoing DDLT. Although LDLT patients may suffer a higher incidence of early biliary complications, the total biliary complication rate was similar during the long-term follow-up period.

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

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