Improving outcomes of living-donor right hepatectomy

Indications and results of right-lobe living donor liver transplantation

The shortage of deceased liver donor organs over the years has always posed the need to expand the donor pool. A viable alternative to deceased donors is that of the living donor. Indeed, the living donor in liver transplantation, initially in pediatric transplantation, but for several years now also in adult transplantation, is a more than viable alternative to deceased liver donation. In fact, right liver lobe donation has proven to be a surgical procedure with low impact on the donor's life in terms of morbidity and mortality, with excellent results in recipients of such organs. In recent years, an increasing number of studies have been published that show excellent results in right-lobe living donor liver transplantation, encouraging this practice not only in countries that have historically had a shortage of deceased donor organs, such as Asian countries, but making it a practice of increasing use in Western countries as well. In addition, thanks to improvements in surgical technique and the experience of high-volume centers, this surgery has also begun to be performed using minimally invasive surgical techniques, allowing us to envision ever better outcomes for both donor and recipient in the coming years.

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.

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

BACKGROUND

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

OBJECTIVES

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

DATA SOURCES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dualistic role of platelets in living donor liver transplantation: Are they harmful?

Platelets are anucleate fragments mainly involved in hemostasis and thrombosis, and there is emerging evidence that platelets have other nonhemostatic potentials in inflammation, angiogenesis, regeneration and ischemia/reperfusion injury (I/R injury), which are involved in the physiological and pathological processes during living donor liver transplantation (LDLT). LDLT is sometimes associated with impaired regeneration and severe I/R injury, leading to postoperative complications and decreased patient survival. Recent studies have suggested that perioperative thrombocytopenia is associated with poor graft regeneration and postoperative morbidity in the short and long term after LDLT. Although it is not fully understood whether thrombocytopenia is the cause or result, increasing platelet counts are frequently suggested to improve posttransplant outcomes in clinical studies. Based on rodent experiments, previous studies have identified that platelets stimulate liver regeneration after partial hepatectomy. However, the role of platelets in LDLT is controversial, as platelets are supposed to aggravate I/R injury in the liver. Recently, a rat model of partial liver transplantation (LT) was used to demonstrate that thrombopoietin-induced thrombocytosis prior to surgery accelerated graft regeneration and improved the survival rate after transplantation. It was clarified that platelet-derived liver regeneration outweighed the associated risk of I/R injury after partial LT. Clinical strategies to increase perioperative platelet counts, such as thrombopoietin, thrombopoietin receptor agonist and platelet transfusion, may improve graft regeneration and survival after LDLT.

Robotic donor hepatectomy: A major breakthrough in living donor liver transplantation

Living donation in many countries is the main resource of organs. Healthy, volunteering individuals deserve the highest safety standards possible in addition to the least invasive technique to procure the organs. Since the introduction of living donor liver transplantation, many efforts have been made to minimize the surgical trauma inherent to living donor surgery. The journey started with a large Mercedes incision and evolved to reverse L-shaped and small upper midline incisions before the introduction of minimally invasive laparoscopic techniques originated. The technical difficulties of the laparoscopic approach due to suboptimal instrumentation, challenging ergonomics, and the long learning curve limited the application of the fully laparoscopic approach to a few centers. The recent introduction of the robotic platform with its superb optical system and advanced instruments allows for the first time, a genuine emulation of open donor surgery in a closed abdomen, thus allowing all liver donors to benefit from minimally invasive surgery (better cosmesis, less pain and morbidity, and better quality of life) without compromising donor safety. This attribute in combination with the ubiquitous presence of the robot in major transplant centers may well lead to the desired endpoint of this technology, namely, the widespread dissemination of minimally invasive donor surgery.

Handling of Hilar Vasculature in Living Donor Right Hepatectomy Using Extrahepatic Glissonean Approach

Donor hepatectomy is one of the most important procedures in LDLT because it affects the safety of donors and the outcome of the recipients. We standardized a method of securing the important vessels at the hepatic hilum while advancing the dissection toward the central direction. This research introduces our technique of handling hilar vasculature in living donor hepatectomy, using the extrahepatic Glissonean approach, and discusses its efficacy. At first, after the extrahepatic right Glissonean approach, the resected hepatic artery and portal vein are secured on the same line as with the secured Glisson. The resected hepatic artery and portal vein are followed in the central direction, and the surrounding area is dissected. The dissection is continued up to the main brunch of the hepatic artery and portal vein. The bile duct can be secured by subtracting the hepatic artery and portal vein from the tape that secured the Glissonean pedicle. The bile duct, hepatic artery, and the portal vein are dissected in this order, before dissecting the right hepatic vein, completing the surgery. This method of dissection approaching the extrahepatic Glisson carried out toward the central direction suggests to acquire minimal tissue removal and to shorten operative time. This could result in adequate perfusion to the remaining liver and donor safety, taken together effective results on the recipient.

Survival Analysis after Living Donor Liver Transplantation for Hepatocellular Carcinoma: A Single Center Cohort Study

Background: Living-donor liver transplantation (LDLT) for hepatocellular carcinoma (HCC) has been used as a curative treatment option for hepatocellular carcinoma (HCC) because of a shortage of deceased donors. This study aimed to investigate survival outcomes after LDLT for HCC. Method: This study included 359 patients undergoing LDLT for HCC. We analyzed overall survival (OS) and recurrence-free survival (RFS) and the prognostic factors related to them. Results: The 5-year OS and RFS rates of patients within the Milan criteria (WM) were better than those of patients beyond the Milan criteria (BM) (87.3% vs. 64.1% and 87.6% vs. 57.8%, respectively, both p < 0.05). Alpha-fetoprotein level (AFP) > 400 ng/mL (hazard ratio (HR), 2.07; 95% CI, 1.28–3.36; p < 0.05) and HCC of BM (HR, 2.61; 95% CI, 1.60–4.26; p < 0.05) at immediate pretransplant were independent risk factors of OS. AFP > 400 ng/mL (HR, 2.16; 95% CI, 1.34–3.49; p < 0.05) and HCC of BM (HR, 3.01; 95% CI, 1.81–5.01; p < 0.05) were also independent risk factors of RFS. In pathologic findings of explanted liver, tumor size, Edmondson–Steiner grade III–IV, and microvascular invasion were independent risk factors of both OS and RFS (p < 0.05). Conclusions: BM and AFP > 400 ng/mL at immediate pretransplant are unfavorable predictors of survival outcomes after LDLT for HCC.

Advances in the surgical outcomes of 300 cases of pure laparoscopic living donor right hemihepatectomy divided into three periods of 100 cases: a single-centre case series

Background

Minimally invasive surgery has been widely used for hepatobiliary operations. This study aimed to determine the safety and feasibility of pure laparoscopic living donor right hepatectomy.

Methods

From November 2015 to April 2019, 300 cases of adult pure laparoscopic living donor right hepatectomy performed at Seoul National University Hospital were divided into three subgroups of periods 1-3 of 100 cases each: 1-100, 101-200, and 201-300, respectively. We retrospectively reviewed and analysed the safety and feasibility outcomes.

Results

The operative time (period 1: 318.9±62.2 min, period 2: 256.7±71.4 min, period 3: 227.7±57.4 min) and blood loss (period 1: 419.7±196.5 mL, period 2: 198.9±197.2 mL, period 3: 166.0±130.0 mL) gradually decreased (P<0.01). Similarly, the length of hospital stay decreased (period 1: 8.1±2.0 days, period 2: 7.3±3.1 days, period 3: 6.9±2.4 days, P<0.01). There was no requirement for intraoperative transfusions or care in the intensive care unit. The overall complication rate was 20/300 (6.7%), of which 8/300 (2.7%) were Clavien-Dindo grade III and above. Complications were not different among the three periods. In terms of anatomical variations, the incidences of multiple portal veins, multiple hepatic arteries, and multiple bile ducts were 32/300 (10.7%), 11/300 (3.7%), and 161/300 (53.7%), respectively. No differences were found among the three periods.

Conclusions

Owing to the technical improvements over time, pure laparoscopic living donor hepatectomy is currently feasible and safe even for donors with anatomical variations.

Safety and Efficacy of Living Donor Hepatectomy Without Systemic Heparinization: Short- and Long-Term Outcomes

There is no consensus regarding the use of systemic heparin, and long-term outcomes of living donor hepatectomy (LDH) without systemic heparinization have not yet been determined. This study was performed to determine whether systemic heparinization can be omitted during LDH, with a focus on donor safety and long-term outcomes. We retrospectively analyzed the outcomes of 175 cases of LDH performed in our institution between January 2011 and December 2014: group I (n = 79) received systemic heparinization, whereas group II (n = 96) did not, but liver graft was flushed with a heparinized perfusate. Postoperative bleeding requiring blood transfusion or intervention was more frequent in group I than in group II (P = .028). The decreases in donor hemoglobin and hematocrit levels, and platelet count during the early postoperative period, were greater in group I than in group II. In multivariate analysis, systemic heparin was the only independent risk factor for blood transfusion (odds ratio [OR] = 5.114; 95% confidence interval [CI]: 1.201-21.775; P = .027) and significant postoperative bleeding (OR = 7.731; 95% CI: 1.345-44.429; P = .022) after LDH. Most postoperative complications including graft vascular thrombosis were similar between the 2 groups, as was the survival rate, and neither graft loss due to vascular thrombosis nor non-anastomotic biliary stricture was evident. In conclusion, omission of systemic heparinization during LDH is a feasible and safe option without adverse effects.

Impact of ABO-incompatibility on hepatic artery thrombosis in living donor liver transplantation

Background

The current era of rituximab-based regimens brought improved survival in ABO-incompatible (ABO-I) living donor liver transplantation (LDLT). Nevertheless, the actual risk for hepatic artery thrombosis (HAT) still remains to be investigated. The aim of this study was to evaluate the impact of ABO-incompatibility on HAT in adult LDLT patients.

Methods

Patients who received ABO-I LDLT were compared to those who received ABO-compatible (ABO-C) LDLT with a special focus on HAT.

Results

A total of 378 patients underwent LDLT from January 2012 to February 2018. Of those, ABO-I LDLT was performed in 78 consecutive patients. The other 300 patients with ABO-C LDLT constituted the comparator group. No significant differences were observed between the two groups in baseline and perioperative characteristics. HAT occurred in 11 (2.9%) patients, 2 and 9 patients in ABO-I and ABO-C LDLT groups, respectively, which didn't show any significant difference between the two groups (P=0.84). All were categorized into early HAT. Immediate revascularization by intraarterial thrombolysis was successfully employed in 8 patients. Surgical revision of anastomosis and retransplantation were performed in 1 and 2 patients, respectively. No one-year mortality was related to HAT in the two groups. The overall outcomes including biliary complications made no significant difference between the two groups.

Conclusions

ABO-incompatibility has no adverse impact on the incidence and treatment outcome of HAT in the current rituximab-based desensitization.

Improved hemostasis with major hepatic resection in the current surgical era

BACKGROUND

Major hepatic resection, predominantly performed for oncologic intent, is a complex procedure with the potential for severe intraoperative hemorrhage. The current surgical era has the ability to improve hemostasis throughout the performance of major hepatic resections which decreases blood transfusions and the detrimental effects associated with transfusion. We evaluated hemostasis and outcomes in the current surgical era of performing hepatic resections.

METHODS

Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database all major hepatic resections performed between 2012 and 2016 were analyzed in regards to hemostasis. Hemostasis was evaluated by the need for and magnitude of blood transfusions. Additional perioperative variables (including operative time, length of hospital stay, and mortality rates) were analyzed to assess for outcomes with hemostasis. The NSQIP results were compared to previous publications involving major hepatic resections to detect improvement in hemostasis and outcomes in the current surgical era.

RESULTS

A total of 22777 major hepatic resections met the inclusion criteria for analysis in the NSQIP database. An additional 21198 cases were compiled within the selected publications for comparative analysis. The transfusion rate in the current surgical era was 13.3% versus 38.7% in the previous era (P = 0.0001). When a transfusion was required in the current surgical era there was a two-fold reduction in the number of units transfused (1.5 U vs. 3.8 U, P = 0.0001). Statistically significant improvements in operative time and length of hospital stay were presented within the current surgical era (P = 0.0001). When a transfusion was required there was an increased relative risk score of 7 for mortality (4.9% vs. 0.7%, P = 0.0001), however, improvement in mortality rates did not reach statistical significance across surgical eras (1.3% vs. 4.0%, P = 0.0001).

CONCLUSIONS

The conduction of major hepatic resection in the current surgical era is more hemostatic. Correlated with improved hemostasis are better outcomes for both clinical and financial endpoints. These findings should encourage continued and increased performance of major hepatic resections.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

[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.

Living-donor Liver Retransplantation Using the Vessels of the Previous Allograft by Means of Intragraft Dissection

Retransplantation with the use of a living-donor graft can be the only therapeutic option for patients with irreversible graft failure, especially in regions with limited access to deceased donors, but it can be technically demanding because of severe adhesion around the hepatic hilum and inferior vena cava. We introduce an effective and safe technique to overcome this challenge for right-lobe living-donor liver retransplantation by using the vessels of the previous right liver allograft with the use of intragraft dissection. The technique was used in 2 critically ill patients undergoing the graft failure. The operative times were 360 and 410 minutes. The recipients were discharged on days 18 and 25 with normal liver function. One postoperative complication occurred 3 months after retransplantation: biliary leakage, corrected with the use of percutaneous transhepatic biliary drainage. Both patients were alive with a functioning allograft at last follow-up of >3 years. Intragraft dissection to use the vessels of the previous right-liver allograft can be a useful technique and should be considered for right-lobe living-donor liver retransplantation.

Safety and Efficacy of Once-Daily Prolonged-Release Tacrolimus in Living Donor Liver Transplantation: An Open-Label, Prospective, Single-Arm, Phase 4 Study

BACKGROUND After liver transplantation (LT), nonadherence to immunosuppressants due to the complex regimen can lead to graft rejection and loss. This study assessed the efficacy and safety of conversion from twice-daily tacrolimus (Bid-Tac) to once-daily prolonged-release tacrolimus (OD-Tac) in living donor LT (LDLT) recipients. MATERIAL AND METHODS Among patients who underwent LDLT between November 2015 and October 2016, those who agreed to participate in this study were screened, and those with good general condition and stable liver functions were enrolled. Participants underwent a conversion from Bid-Tac to OD-Tac with a dose ratio of 1: 1 at about 10-14 weeks after LDLT and were followed-up for 24 weeks. RESULTS Thirty-one patients were enrolled. The median number of conversion days after LDLT was 12.3 weeks (range, 10.3-13.8). Adherence was evaluated during the outpatient visits at weeks 2, 4, 8, 16, and 24 after Tac conversion, and 100% adherence was observed at all time points. There were no cases of acute rejection, graft loss, or patient death after Tac conversion. Nineteen cases of adverse events occurred in 11 patients (35.5%), none of which were severe. Alopecia was the most common, affecting 3 (9.7%) patients, followed by pruritus (n=2, 6.45%). There were no changes in renal function or in liver function test, serum glucose level, and lipid profile. CONCLUSIONS Early Tac conversion from Bid-Tac to OD-Tac is safe and feasible. However, further studies are needed to elucidate its long-term effects.

Impact of ABO-incompatibility on hepatocellular carcinoma recurrence after living donor liver transplantation

BACKGROUND

ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) has been reported to have acceptable outcomes in the era of rituximab-based prophylaxis. However, the outcomes of ABO-I LDLT for hepatocellular carcinoma (HCC) remain to be elucidated. This study aimed to clarify the impact of ABO-Incompatibility on oncologic outcomes of LDLT for HCC.

METHODS

Patients with HCC who underwent ABO-I LDLT were randomly matched by 1:2 ratio to those who underwent ABO-compatible (ABO-C) LDLT according to propensity score. HCC recurrence and patient survival were analyzed using the Kaplan-Meier method and log-rank test.

RESULTS

Between January 2012 and December 2015, a total of 160 patients underwent LDLT for HCC confirmed by pathology analysis of liver explants. Thirty-nine consecutive patients underwent ABO-I LDLT for HCC, and 78 ABO-C LDLT patients were selected by propensity score matching, which made no significant difference between the two groups in baseline, perioperative, and tumor characteristics. The 1-, 3-, and 5-year recurrence-free survival rates in the ABO-I and ABO-C LDLT groups were 76.9%, 68.5%, 63.6% and 74.4%, 70.5%, 70.5%, respectively (p = 0.77). The site distribution of initial recurrence showed no significant difference between the two groups. The overall survival rates over the same period in the ABO-I and ABO-C LDLT groups were 82.1%, 73.5%, 73.5% and 92.2%, 80.3%, 80.3%, respectively (p = 0.34).

CONCLUSIONS

ABO-I LDLT, having no adverse impact on oncological outcomes, can be a feasible transplant option for HCC.

Low Preoperative Platelet Count Predicts Risk of Subclinical Posthepatectomy Liver Failure in Right Lobe Donors for Liver Transplantation

Living donor right hepatectomy (LDRH) is a common procedure in adult-to-adult living donor liver transplantation, but it is associated with a higher risk of posthepatectomy liver failure (PHLF) compared with left hepatectomy because of a smaller remnant. We identified risk factors for PHLF and other complications in LDRH, verified the appropriateness of the criteria, and explored the possibility of adjusting the minimum remnant liver volume (RLV) based on individual risk. Between October 2005 and November 2017, 254 donors undergoing LDRH at Kyoto University Hospital were enrolled. Clinical data were collected retrospectively. All complications were graded according to the Clavien-Dindo classification. No donors had grade 4 or 5 complications or clinically significant grade B or C PHLF. Grade A PHLF occurred in 30 donors (11.8%). Male sex (P = 0.01), lower preoperative platelet count (PLT; P = 0.01), higher prothrombin time-international normalized ratio (P = 0.03), higher total bilirubin (P = 0.01), smaller RLV (P = 0.03), and greater blood loss (P = 0.04) were associated with increased risk of PHLF in the univariate analysis, whereas PLT, RLV, and blood loss remained significant in the multivariate analysis. Grade 2 or 3 complications were observed in 32 (12.6%) donors. Higher body mass index (BMI; P = 0.002) and larger blood loss (P = 0.02) were identified as risk factors for complications (Clavien-Dindo grade ≥ 2) in univariate analysis. Only BMI remained significant in the multivariate analysis. In conclusion, LDRH is performed safely with acceptable morbidity under the current criteria. Minimum RLV may be marginally adjusted by PLT and reducing intraoperative blood loss minimizes PHLF risk. Liver Transplantation 00 000-000 2018 AASLD.

A simplified protocol using rituximab and immunoglobulin for ABO-incompatible low-titre living donor liver transplantation

BACKGROUND & AIMS

No consensus has been reached regarding optimal treatment strategies for ABO-incompatible (ABO-I) living donor liver transplantation (LDLT). We introduce a simplified protocol using rituximab and intravenous immunoglobulin (IVIG).

METHODS

Data were analysed on adult patients who underwent ABO-I LDLT of which protocol added rituximab (300 mg/m² ) before surgery and IVIG (0.8 g/kg) on post-operative days 1 and 4 to the conventional immunosuppressive regimen used in ABO-compatible (ABO-C) LDLT, without plasmapheresis, splenectomy or graft local infusion. The outcomes were compared with those of ABO-C LDLT by 1:2 propensity score-matched analysis.

RESULTS

Consecutive 43 ABO-I LDLT patients were identified between 2014 and 2016. Before desensitization, the median isoagglutinin titre was 1:8 (range, 1:2-1:64). The titre was reduced to 4 (range, 0-16) at the time of LDLT. None showed a rebound rise of isoagglutinin titres. No antibody-mediated rejection occurred. Biliary stricture was the most common complication with an incidence of 30.2%. A comparator group of 86 ABO-C LDLT patients were selected. There was no statistical difference in the overall complication rate including acute cellular rejection, biliary complications and infection between ABO-I and ABO-C groups. The 3-year cumulative patient survival rates in the ABO-I and ABO-C groups were 82.4% and 85.9% respectively (P = .115).

CONCLUSIONS

A simplified protocol using rituximab and IVIG for ABO-I LDLT was safe and effective in achieving sufficient desensitization and comparable outcomes in patients with the titre no higher than 1:64.

A comparison of desensitization methods: Rituximab with/without plasmapheresis in ABO-incompatible living donor liver transplantation

BACKGROUND

Plasmapheresis is a desensitization method used prior to ABO-incompatible (ABO-I) living donor liver transplantation. However, studies on its usefulness in the rituximab era are lacking.

METHODS

Fifty-six adult patients underwent ABO-I living donor liver transplantation between January 2012 and October 2015. A single dose of rituximab (300 mg/m²) was administered 2 weeks before surgery with plasmapheresis in all patients until February 2014 (RP group, n = 26). Patients were administered rituximab only, without plasmapheresis between March 2014 and October 2015 (RO group, n = 30).

RESULTS

The 6-, 12- and 18-month overall survival rates were 92.3%, 80.8% and 76.9% in the RP group and 96.6%, 85.4% and 85.4% in the RO group, respectively (P = 0.574). When the initial isoagglutinin titers < 16, neither group showed a rebound rise of isoagglutinin titers. For patients with initial isoagglutinin titers ≥ 16, the rebound rise of isoagglutinin titers was more prominent in the RP group. There was no difference in time-dependent changes in B cell subpopulations and ABO-I-related complications.

CONCLUSIONS

Sufficient desensitization for ABO-I living donor liver transplantation can be achieved using rituximab alone. This desensitization strategy does not affect the isoagglutinin titers, ABO-I-related complications and patient survival.

Impact of preserved collateral veins on small-for-size grafts in living donor liver transplantation

AIM

Graft size is a critical issue in living donor liver transplantation (LDLT). We hypothesized that too much portal flow could possibly be diverted into pre-existing collateral veins, alleviating small-for-size syndrome (SFSS) in LDLT. This study evaluated the impact of the preserved collateral veins in the outcomes of LDLT using a small-for-size graft.

METHODS

For patient safety, a graft-to-recipient weight ratio (GRWR) <0.8% was strictly confined to patients with collateral veins (group A), and the patient group was compared in a 1:3 ratio to a matched group of patients with GRWR ≥0.8% (group B) using propensity score analysis.

RESULTS

Forty and 120 patients were included in group A and B, respectively. No significant differences in baseline patient characteristics were observed between the two groups except for graft weight and GRWR. The lowest GRWR was 0.4%. The graft portal inflow showed no significant differences for 7 days after graft implantation, ranging from 1668 to 5100 mL/min. Small-for-size syndrome occurred in no patients (0.0%) in group A and in 10 (8.3%) in group B (P = 0.067). Overall survival rates at 1, 3, and 5 years were not different between the two groups (85.0%, 82.5%, and 82.5% vs. 92.5%, 86.7%, and 85.0%, respectively; P = 0.670).

CONCLUSION

Pre-existing collateral veins saved during surgery may have a reserve buffer for excessive portal flow to obviate SFSS in LDLT.

Robot-Assisted Transplant Surgery - Vision or Reality? A Comprehensive Review

Minimally invasive surgery is standard procedure for many operations. Further refinements include the introduction of robotic surgery which is still an emerging field especially in laparoscopic surgery. Since the successful introduction of the da Vinci Robotic Surgical System, the robotic approach in organ transplantation has become of great interest in both the live donor organ retrieval and the recipient operation. Robotic surgery for kidney, liver, and pancreas transplantation is feasible. Over 700 donor nephrectomies and 100 kidney transplantations have been performed already, and robotic surgery is standard in a small number of pioneer centers; however, larger series and most importantly randomized controlled trials for the highest evidence are needed. Longer warm ischemia time and higher costs limit these procedures at the moment.

Small-for-size grafts increase recurrence of hepatocellular carcinoma in liver transplantation beyond milan criteria

Living donor liver transplantation (LDLT) has been reported to have high rates of hepatocellular carcinoma (HCC) recurrence compared with deceased donor liver transplantation (DDLT). This has been assumed to be due to the frequent use of small-for-size grafts (SFSGs) in LDLT rather than DDLT, but the relationship between graft size and prognosis remains controversial. This study aimed to clarify the effect of SFSGs on the oncologic outcomes of patients with HCC who underwent LDLT. Between January 2005 and December 2015, 597 consecutive patients underwent LDLT. Among these patients, those with HCC who underwent LDLT were randomly matched at a 1:3 ratio (graft-to-recipient body weight ratio [GRWR] < 0.8%:GRWR > 0.8%) according to propensity score. HCC recurrence and patient survival were analyzed using the Kaplan-Meier method and log-rank test. In addition, stratified subgroup analysis based on the Milan criteria was performed. SFSG was defined as a GRWR < 0.8%. Using propensity score matching, 82 patients with GRWR < 0.8% and 246 patients with GRWR ≥ 0.8% were selected. For patients with HCC within the Milan criteria, no significant difference of HCC recurrence (P = 0.82) and patient survival (P = 0.95) was found based on GRWR. However, for patients with HCC beyond the Milan criteria, 1-, 3-, and 5-year recurrence-free survival rates were 52.4%, 49.3%, and 49.3%, respectively, for patients with GRWR < 0.8%, and 76.5%, 68.3%, and 64.3%, respectively, for patients with GRWR ≥ 0.8% (P = 0.049). The former group exhibited poor patient survival rates (P = 0.047). In conclusion, for patients with HCC within the Milan criteria, no significant difference in oncologic outcomes was found based on liver graft size. However, among the patients with HCC beyond the Milan criteria, SFSG recipients showed poor oncologic outcomes. Because extended criteria are frequently used in LDLT for HCC, a recipient's prognosis can be improved if a liver graft of appropriate size is carefully selected during donor selection. Liver Transplantation 24 35-43 2018 AASLD.

Right lobe living donors ages 55 years old and older in liver transplantation

The evidence is insufficient for safe use of elderly donors in adult-to-adult living donor liver transplantation (LDLT). The aim of this study was to evaluate the outcomes of right lobe LDLT by donor age (≥55 versus < 55 years). All living donors who underwent right hepatectomy at the authors' institution between March 2008 and December 2015 were divided into 2 groups: group A with an age ≥ 55 years and group B with an age of <55 years. The selection criteria for elderly donor were preservation of middle hepatic vein, remnant liver volume ≥30%, and no or mild fatty liver. The matching criteria of recipients for the elderly donor grafts were Model for End-Stage Liver Disease score of <25, graft-to-recipient weight ratio of >0.8%, and body mass index of <25 kg/m² . Perioperative data, complications by the Clavien classification, and the outcomes with at least 12 months follow-up were compared. A total of 42 donors were enrolled in group A and 498 in group B. No significant differences in operative parameters were observed between the 2 groups. The peak postoperative aspartate aminotransferase, alanine aminotransferase, and total bilirubin levels made no difference between the 2 groups. The peak international normalized ratio level was significantly lower in group A than in group B (P = 0.001). All donors recovered completely with no significant differences in overall complications between the 2 groups. All recipients of grafts from donors in group A showed good initial function with no significant differences in 1-year graft and patient survival or biliary complications between 2 groups. These results provide clinical evidence for feasibility of right hepatectomy in living donors aged ≥ 55 years without compromising donor safety or recipient outcomes. Liver Transplantation 23 1305-1311 2017 AASLD.

Use of robotics in liver donor right hepatectomy

Liver transplantation is the best solution for end stage liver disease, and has been widely accepted and rapidly developed in the past decades. Along with the improved outcomes of liver transplantation, living-related donor transplantation has been conducted to overcome the shortage of the deceased donor. The most important aspects of the living-related liver transplantation are donor safety and fast recovery after graft procurement. Meanwhile, the rapid progress of minimally invasive surgery (MIS) in general surgery has generated heated debate regarding the appropriateness of MIS in living-related donor graft hepatectomy. Technical innovations and instrument enhancements have been allowing recruitment of more potential candidates through smaller wounds and better surgical experience. Although MIS has been documented with safety and feasibility in complex liver surgery, the progress is slow in regard to the application of MIS in donor graft hepatectomy. Pioneer surgeons have devoted themselves to develop the pure MIS approach for the liver donor surgery, but the steep learning curve for pure MIS major hepatectomy remains a major barrier for wide adoption. The introduction of robotic system may lower the barrier for entry for practice into MIS donor hepatectomy.

Summary of the British Transplantation Society UK Guidelines for Living Donor Liver Transplantation

The British Transplantation Society Guidelines for Living Donor Liver Transplantation was published in July 2015 and is the first national guideline in the field of living donor liver transplantation. The guideline aims to review the evidence relating to the evaluation process of both recipient and donor candidates; address the moral and ethical issues surrounding the procedure; outline the technical aspects of the procedure, including the middle hepatic vein controversy and the "small for size syndrome"; review donor and recipient outcomes and complications including donor mortality; and examine evidence relating to the advantages and disadvantages of living donor liver transplantation. In line with previous guidelines published by the BTS, the guideline has used the Grading of Recommendations Assessment, Development and Evaluation system to rate the strength of evidence and recommendations. This article summarizes the Statements of Recommendation contained in the guideline, which provide a framework for the delivery of living liver donation in the United Kingdom and may be of wide international interest. It is recommended that the full guideline document is consulted for details of the relevant references and evidence base. This may be accessed at http://www.bts.org.uk/BTS/Guidelines_Standards/Current/BTS/Guidelines_Standards/Current_Guidelines.aspx?hkey=e285ca32-5920-4613-ac08-fa9fd90915b5.

Ligation and cut as a method for bile duct division in living donor right hepatectomy

The importance of bile duct division cannot be overemphasized in living donor surgery. Ligation and cut (LC) as a method for bile duct division in living donor right hepatectomy (LDRH) has never been reported. The purpose of this study was to introduce the LC method of bile duct division in LDRH. All LDRH donors were identified through a prospectively maintained database at the authors' institution between September 2009 and March 2013, and the 2 methods, LC and cut and oversewing (CO), were compared both in terms of donor and recipient outcomes of right lobe living donor liver transplantation. In the LC method, after complete parenchymal transection, the right hepatic duct was dissected in the Glisson's sheath and ligated just at the right side of the confluence, and then the right side of the ligature was cut. The LC and CO methods were performed in 109 and 134 donors, respectively. Bile duct division time (P < 0.001) and operative time (P < 0.001) were significantly shorter in the LC group than in the CO group. With a median follow-up of 60.2 months, biliary complication rate was lower in the LC group than in the CO group (0% versus 5.2%; P = 0.01), but with no significant difference between the recipient groups. All donors made a complete recovery. In conclusion, the bile ducts of living donors can be dissected safely from the Glisson's sheath, and the LC method facilitates bile duct division and has a lower incidence of biliary complication in LDRH without compromising the recipient outcomes. Liver Transplantation 23 448-456 2017 AASLD.

Right hepatectomy in living donors with previous abdominal surgery

BACKGROUND

Few studies have evaluated the impact of previous abdominal surgery (PAS) on living donor right hepatectomy (LDRH). The aim of this study was to investigate the outcomes of liver transplantation using right lobe grafts of living donors with PAS.

METHODS

Data were reviewed from LDRH patients at the authors' institution between March 2008 and November 2014. LDRH patients with PAS were divided into two groups according to upper PAS (group 1) or lower PAS (group 2), and they were compared to those without PAS (group 3) who were matched 1:1 based on age, gender, and body mass index. Perioperative data, complications by the Clavien classification, and the outcomes with more than 14 months follow-up were compared.

RESULTS

Twenty-three (4.9%) of a total of 471 LDRH donors had PAS. Eleven donors were assigned to group 1, 12 to group 2, and 23 to group 3. Intraperitoneal adhesions were found in 20 (87.0%) of 23 donors with PAS, of whom 5 (21.7%) had adhesiolysis-related injuries that happened more commonly in group 1 than in group 2 (P=0.025). LDRH was successfully completed under upper midline laparotomy in all donors. No donors received perioperative blood transfusion. The peak postoperative AST, ALT, INR, and total bilirubin levels made no difference between the three groups. Compared with group 3, groups 1 and 2 had a longer operative time (P=0.012) and a higher grade I complication rate (P=0.047). All donors recovered fully to their routine activities. The 23 recipients of grafts from donors with PAS showed good liver function with 1-year graft and patient survivals of 100%.

CONCLUSION

A history of PAS is not a contraindication to LDRH in the current era of advanced surgical techniques.

Robotic liver donor right hepatectomy: A pure, minimally invasive approach

Right hepatectomy for a living liver donor via a pure minimally invasive approach is a challenging procedure and only a few cases have been reported. Between May 2013 and August 2015, 13 patients underwent robotic living donor right hepatectomy in our institute, and 54 patients received open surgery. In this series, no conversion was conducted for robotic donor right hepatectomy. The 2 groups shared similar blood loss (169 versus 146 mL), complication rates (7.7% versus 9.3%), and recovery of donor liver function (peak alanine aminotransferase, 269 versus 252 IU/mL). The robotic group needed longer operation time (596 versus 383 minutes) but less postoperative patient-controlled analgesia (0.58 versus 0.84 ng/kg) and a shorter period before returning to work/school (52.9 versus 100.0 days) and sex (100.0 versus 156.0 days). For recipient outcomes regarding the donor procedure, the robotic group shared similar experiences in early allograft dysfunction, complications, and 1-year recipient liver function with the open group. With respect to documented benefits of minimally invasive left-sided liver donor procedure, the development of right donor hepatectomy is slow. In conclusion, with substantial improvements in patient recovery after the minimally invasive approach, the robotic platform would be a big step toward completing pure minimally invasive liver donor surgery. Liver Transplantation 22 1509-1518 2016 AASLD.

Impact of Intra-Abdominal Adhesion on Living Donor Right Hepatectomy

The impact of intra-abdominal adhesion (IAA) on living donor right hepatectomy (LDRH) remains to be clarified. The purpose of this study was to compare both the donor and recipient outcomes of right lobe living donor liver transplantation according to IAA detected intraoperatively. LDRH donors were identified through a prospectively maintained database at the authors' institution between March 2008 and February 2014. IAA was graded according to Beck et al (Dis Colon Rectum 2000; 43: 1749-1753). LDRH donors with IAA (group A) were matched 1:3 to those without IAA (group B) based on age, gender, and BMI. Perioperative data, complications by the Clavien classification, and the outcomes with at least 12 months follow-up were compared. Thirty-two (7.6%) of a total of 420 LDRH donors had IAA around the liver. Nineteen donors had previous abdominal surgery. LDRH was successfully completed under upper midline laparotomy in all donors. Compared with group B, group A had a longer operative time (270 vs. 172 min; p < 0.001), a higher wound complication rate (28.1% vs. 4.2%; p = 0.009), and a longer postoperative stay (10 vs. 7 days; p = 0.009). All donors recovered completely to their previous activities. The 1-year graft and recipient survivals of recipients were comparable between two groups. These findings support the feasibility and safety of LDRH in patients with IAA.

Biliary complications after living donor hepatectomy: A first report from India

Biliary complications after donor hepatectomy can result in significant morbidity. We herein present our experience of donor hepatectomy, highlighting surgical techniques that prevent complications. Data were reviewed from a prospectively maintained database of all donors who underwent hepatectomy from April 2011 to April 2015. Standard operative technique as described was followed in all patients. Biliary complications and morbidity were recorded and stratified as per Clavien-Dindo classification. Results were compared with published literature. During the study period, 160 donors underwent hepatectomy. The majority of the graft types were right hemiliver without the middle hepatic vein (71.9%). Major complications (grade III and above) occurred in 5.6% of the donors. There was no donor mortality. Only 1 out of the 160 donors (0.6%) has had a grade III biliary complication requiring endoscopic retrograde cholangiography and papillotomy. There were 3 grade II biliary complications, all occurring after left lateral sectionectomy, necessitating prolonged retention of the intra-abdominal drain. The median duration of hospital stay was 11 days (range, 5-67 days), and the duration of follow-up was 16 months (range, 3-52 months). There was no loss to follow-up, and no donor required readmission or outpatient procedures for any biliary complication. In conclusion, with careful donor selection and a standardized surgical technique, biliary complications can be minimized. Liver Transplantation 22 607-614 2016 AASLD.

The Impact of a Surgical Protocol for Enhanced Recovery on Living Donor Right Hepatectomy: A Single-Center Cohort Study

The concept of surgery for enhanced recovery (SFER) program has never been an issue in the context of living donor right hepatectomy (LDRH), much less its effects. The purpose of this study was to evaluate outcomes after the establishment of an SFER protocol for LDRH in a single center.A single-center cohort study was performed in 500 consecutive living donors who underwent right hepatectomy from January 2005 to June 2014 by analyzing the outcomes before and after an established SFER protocol that evolved with continuous refinements in surgical technique and management over 300 LDRHs, being in place on September 2011. Donor characteristics, operative outcomes, and postoperative complications divided into 2 groups (group 1, stepwise adjustment; group 2, complete adherence to the protocol) were compared.Donor characteristics were comparable in the 2 groups. Overall complication rate was 10.0% with no mortality. In group 2, operative time, hospital stay, and overall complication rate decreased significantly, and the morbidity was 1% and confined in grade I complication without reoperation, perioperative blood transfusion, or readmission. All donors in this series recovered fully and returned to the previous functional lifestyle.An SFER protocol on LDRH can be established by the gradual implementation of various refinements of surgical technique, and the recent outcomes achieved after the establishment of an SFER protocol could provide a current guidance on LDRH toward the ultimate goal of zero morbidity.

Clinical Impact of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Living Donor Liver Transplantation for Advanced Hepatocellular Carcinoma

BACKGROUND

The relevant number of patients with hepatocellular carcinoma (HCC) beyond the Milan criteria have undergone living donor liver transplantation (LDLT). However, the prognostic factors for these patients with advanced HCC remain unclear.

METHODS

From March 2005 to May 2013, 280 patients with HCC underwent LDLT at the National Cancer Center. Of these, patients with HCC beyond the Milan criteria were retrospectively enrolled. We analyzed the prognostic significance of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) for selecting appropriate candidates.

RESULTS

Of the total 280 patients, 147 (52.5%) were confirmed to have HCC beyond the Milan criteria on the basis of pathological reports. The patients who met and exceeded the Milan criteria had 5-year overall survival (OS) rates of 87.2% and 64.6%, respectively (P < 0.001). Multivariable analysis for OS and disease-free survival (DFS) in patients with HCC beyond the Milan criteria revealed PET/CT positivity (hazards ratio [HR], 2.714; P = 0.013 for OS; HR, 3.803; P < 0.001 for DFS), total tumor size over 10 cm (HR, 2.333; P = 0.035 for OS; HR, 3.334, P = 0.001 for DFS), and microvascular invasion (HR, 2.917; P = 0.025 for DFS) to be significant prognostic factors. In particular, patients with HCC beyond the Milan criteria with a PET/CT-negative status and total tumor size less than 10 cm showed similar OS and DFS in comparison with those with HCC within the Milan criteria.

CONCLUSIONS

A PET/CT status in LDLT is a useful marker for predicting survival of patients with advanced HCC.

2014 KLCSG-NCC Korea Practice Guideline for the Management of Hepatocellular Carcinoma

The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.

2014 Korean Liver Cancer Study Group-National Cancer Center Korea practice guideline for the management of hepatocellular carcinoma

The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.

Major complications of adult right lobe living liver donors

BACKGROUND

The right lobe of the liver is generally preferred for living donor liver transplantation in adult patients with end-stage liver disease. It is important to know the preoperative factors relating to the major postoperative complications. We therefore evaluated the possible risk factors for predicting postoperative complications in right lobe liver donors.

METHODS

Data from 378 donors who had undergone right lobe hepatectomy at our center were evaluated retrospectively. The factors we evaluated included donor age, gender, body mass index (BMI), remnant liver volume, operation time, history of previous abdominal surgery, inclusion of the middle hepatic vein and variations in the portal and bile systems.

RESULTS

Of the 378 donors, 219 were male and 159 female. None of the donors died, but 124 (32.8%) donors experienced complications including major complications (Clavien scores III and IV) in 27 (7.1%). Univariate analysis showed that complications were significantly associated with male gender and higher BMI (P<0.05), but not with donor age, remnant liver volume, operation time, graft with middle hepatic vein, variations in the portal and bile systems and previous abdominal surgery (P<0.05). Multivariate logistic regression analysis showed that major complications were significantly associated with male gender (P=0.005) and higher BMI (P=0.029). Moreover, the Chi-square test showed that there were significant relationships between major complications and male gender (P=0.010, X2=6.614, df=1) and BMI >25 kg/m2 (P=0.031, X2=8.562, df=1). Of the 96 male donors with BMI >25 kg/m2, 14 (14.6%) with major complications had significantly smaller mean remnant liver volume than those (82, 85.4%) without major complications (32.50%+/-4.45% vs 34.63%+/-3.11%, P=0.029).

CONCLUSION

Male donors with BMI >25 kg/m2 and a remnant liver volume ≤32.50% had a significantly increased risk for major complications.

Is Systemic heparinization necessary during living donor hepatectomy?

Systemic heparinization has traditionally been performed during living donor hepatectomy (LDH) at most transplant centers because of the possibility of graft vascular thrombosis. However, no consensus on the use of systemic heparinization during LDH has yet emerged. The aims of the present study were to compare donor and recipient outcomes with reference to systemic heparinization and to determine whether or not systemic heparin needs to be administered to living donors. Via a retrospective review, we analyzed the outcomes of 137 LDHs performed at our institution from January 2011 to October 2013; 79 donors received systemic heparinization (group I), whereas 58 did not, but the liver graft was flushed with a heparinized perfusate (group II). Patient demographics, intraoperative parameters, laboratory data, postoperative complications, and survival rates were compared between the 2 groups. The overall complication rates did not differ significantly between the 2 groups, but postoperative bleeding requiring red blood cell transfusions occurred more frequently in group I versus group II (7.6% versus 0.0%, P = 0.03). The incidences of graft vascular thrombosis were similar in the 2 groups, and no graft loss caused by vascular thrombosis was evident during the early postoperative period. Moreover, no difference in either posttransplant graft function or survival was apparent between the 2 groups. The rates of decreases in donor hemoglobin, hematocrit, and platelet count levels during the early postoperative period were significantly higher in group I versus group II. In conclusion, the omission of systemic heparinization during LDH is both feasible and safe, with no adverse effects on donor or recipient outcomes.

Successful living donor liver transplantation between septuagenarians

We report a case of a 76-year-old female who underwent living donor right hepatectomy for her 75-year-old husband with recurrent hepatocellular carcinoma. With her voluntary decision, full medical and psychiatric assessment was performed. The operative time was 130 min in the donor and 399 min in the recipient. Both the donor and recipient had an uneventful recovery and were discharged on days 7 and 10, respectively with normal liver function. The couple has had no complication so far and is currently doing well in good health 26 months after living donor liver transplantation.

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.

Laparoscopic liver resection for living donation: Where do we stand?

In Western countries, living donor liver transplantation (LDLT) may represent a valuable alternative to deceased donor liver transplantation. Yet, after an initial peak of enthusiasm, reports of high rates of complications and of fatalities have led to a certain degree of reluctance towards this procedure especially in Western countries. As for living donor kidney transplantation, the laparoscopic approach could improve patient’s tolerance in order to rehabilitate this strategy and reverse the current trend. In this setting however, initial concerns regarding patient’s safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation and lack of evidence supporting the benefits of laparoscopy have delayed the development of this approach. Similarly to what is performed in classical resectional liver surgery, initial experiences of laparoscopy have therefore begun with left lateral sectionectomy, which is performed for adult to child living donation. In this setting, the laparoscopic technique is now well standardized, is associated with decreased donor blood loss and hospital stays and provides graft of similar quality compared to the open approach. On the other hand laparoscopic major right or left hepatectomies for adult-adult LDLT currently lack standardization and various techniques such as the full laparoscopic approach, the hand assisted approach and the hybrid approach have been reported. Hence, even-though several reports highlight the feasibility of these procedures, the true benefits of laparoscopy over laparotomy remain to be fully assessed. This could be achieved through standardization of the procedures and creation of international registries especially in Eastern countries where LDLT keeps on flourishing.

Controlled low central venous pressure reduces blood loss and transfusion requirements in hepatectomy

AIM: To evaluate the effect of low central venous pressure (LCVP) on blood loss and blood transfusion in patients undergoing hepatectomy.

METHODS: Electronic databases and bibliography lists were searched for potential articles. A meta-analysis of all randomized controlled trials (RCTs) investigating LCVP in hepatectomy was performed. The following three outcomes were analyzed: blood loss, blood transfusion and duration of operation.

RESULTS: Five RCTs including 283 patients were assessed. Meta-analysis showed that blood loss in the LCVP group was significantly less than that in the control group (MD = -391.95, 95%CI: -559.35--224.56, P < 0.00001). In addition, blood transfusion in the LCVP group was also significantly less than that in the control group (MD = -246.87, 95%CI: -427.06--66.69, P = 0.007). The duration of operation in the LCVP group was significantly shorter than that in the control group (MD = -18.89, 95%CI: -35.18--2.59, P = 0.02). Most studies found no significant difference in renal and liver function between the two groups.

CONCLUSION: Controlled LCVP is a simple and effective technique to reduce blood loss and blood transfusion during liver resection, and appears to have no detrimental effects on liver and renal function.

Selection and outcomes of living donors with a remnant volume less than 30% after right hepatectomy

The evidence for defining a safe minimal remnant volume after living donor hepatectomy is insufficient. The aim of this study was to evaluate the outcomes of living donors with a remnant/total volume ratio (RTVR) < 30% after right hepatectomy according to the following selection criteria: the preservation of the middle hepatic vein (MHV), an age < 50 years, and no or mild fatty changes in healthy adults. All living donors who underwent right hepatectomy preserving the MHV at our institution between January 2005 and September 2011 were divided into 2 groups: group A with an RTVR < 30% and group B with an RTVR ≥ 30%. Perioperative data, complications by the Clavien classification, and outcomes with at least 15.1 months' follow-up were compared. Twenty-eight donors were enrolled in group A, and 260 were enrolled in group B. The estimated liver volume was strongly correlated with the actual graft weight (R(2)  = 0.608, P < 0.001). The calculated donation liver volume and the RTVR were significantly different between the 2 groups (P = 0.03 and P < 0.001, respectively). The peak postoperative aspartate aminotransferase levels, alanine aminotransferase levels, and international normalized ratios did not differ between the 2 groups. The peak total bilirubin level was higher for group A versus group B (P = 0.04). The hospital stay was longer for group A versus group B (P < 0.001). All donors recovered completely, and there were no significant differences in overall complications between the 2 groups. In conclusion, right hepatectomy preserving the MHV with an RTVR < 30% can be safely indicated for carefully selected living donors less than 50 years old with no or mild fatty changes.