Living liver donor death related to complications of myeloma

Living donor liver transplantation in Europe

Living donor liver transplantation (LDLT) sparked significant interest in Europe when the first reports of its success from USA and Asia were made public. Many transplant programs initiated LDLT and some of them especially in Germany and Belgium became a point of reference for many patients and important contributors to the advancement of the field. After the initial enthusiasm, most of the European programs stopped performing LDLT and today the overall European activity is concentrated in a few centers and the number of living donor liver transplants is only a single digit fraction of the overall number of liver transplants performed. In this paper we analyse the present European activities and highlight the European contribution to the advancement of the field of LDLT.

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.

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.

Platelet count reduction and outcomes in living liver donors

BACKGROUND

Platelet count reduction in living donors after graft harvesting is very common. The mechanisms and the subsequent adverse consequences are not clear. The present study was to explore the mechanisms and the consequences of platelet count reduction in living donors.

METHODS

We collected data from 231 living liver donor patients who donated at our transplant center between July 2002 and August 2009. Baseline and post-operative platelet counts were collected and analyzed. Multivariate logistic regression analysis was used to compare the risk factors for the persistent decrease in platelet counts. Complications and other post-operative recovery were compared between the donors.

RESULTS

Platelet count decreased differently at each of the follow-up intervals, and the average reduction from baseline evaluation to year 3 was 18.2%. A concomitant decrease in white blood cells was observed with platelet count reduction. All of the splenic volumes at the post-operative follow-up time points were significantly higher than those at baseline (P<0.01). Multivariate logistic regression analysis indicated that the graft-to-donor weight ratio was a risk factor for low post-operative platelet counts in living donors at the three follow-up time points: one week (P=0.047), one month (P=0.034), and three months (P=0.047). At the one week follow-up time, 77 donor platelet counts were higher (group 1) and 151 donor platelet counts were lower (group 2) than baseline levels. Two hemorrhage events (1.3%) were observed in group 2, while three hemorrhage events (3.9%) were observed in group 1 (P=0.211). The overall complication rate was comparable between the two groups (P=0.972).

CONCLUSION

An increase in harvesting graft may decrease platelet counts, but this reduction does not produce short- or long-term damage in living liver donors.

2012 Liver resections in the 21st century: we are far from zero mortality

OBJECTIVES

Recent improvements in surgical technique have extended the indications for liver resection. The aims of this study were to assess whether this extension is associated with a changing patient profile and to evaluate how this potential shift has influenced mortality after liver resection in order to define standard expectations for hepatectomy.

METHODS

The characteristics and postoperative outcomes of all patients undergoing elective hepatectomy from 2000 to 2009 were reviewed retrospectively. Multivariate analysis was conducted to determine the factors associated with mortality in the subgroup of patients with malignant disease.

RESULTS

Among the 2012 patients in whom hepatectomies were performed, the percentage of patients operated for malignancy increased from 66.4% in 2000 to 82.3% in 2009 (P < 0.001). These patients experienced higher mortality (4.5% versus 0.7%; P < 0.001), were significantly older, and displayed greater comorbidity and underlying parenchymal disease compared with those with benign lesions. Mortality over the entire study period was 3.5% and was fairly stable, dropping from 3.8% in 2000 to 3.1% in 2009 (P = 0.686). On multivariate analysis, age of >60 years, an American Society of Anesthesiologists score of ≥3, major resection, vascular procedure, severe fibrosis (F3-F4) and steatosis of >30% were associated with increased mortality in patients with malignant disease.

CONCLUSIONS

The profile of patients undergoing liver resection has changed and now includes more high-risk patients with diseased parenchyma undergoing major hepatectomy for malignancy. This change in patient profile is responsible for the stability in mortality rates over the years.

Up-to-seven criteria for hepatocellular carcinoma liver transplantation: A single center analysis

AIM: To detect whether the up-to-seven should be used as inclusion criteria for liver transplantation for hepatocellular carcinoma.

METHODS: Between April 2002 and July 2008, 220 hepatocellular carcinoma (HCC) patients who were diagnosed with HCC and underwent liver transplantation (LT) at our liver transplantation center were included. These patients were divided into three groups according to the characteristics of their tumors (tumor diameter, tumor number): the Milan criteria group (Group 1), the in up-to-seven group (Group 2) and the out up-to-seven group (Group 3). Then, we compared long-term survival and tumor recurrence of these three groups.

RESULTS: The baseline characteristics of transplant recipients were comparable among these three groups, except for the type of liver graft (deceased donor liver transplant or live donor liver transplantation). There were also no significant differences in the pre-operative α-fetoprotein level. The 1-, 3-, and 5-year overall survival and tumor-free survival rate for the Milan criteria group were 94.8%, 91.4%, 89.7% and 91.4%, 86.2%, and 86.2% respectively; in the up-to-seven criteria group, these rates were 87.8%, 77.8%, and 76.6% and 85.6%, 75.6%, and 75.6% respectively (P < 0.05). However, the advanced HCC patients’ (in the group out of up-to-seven criteria) overall and tumor-free survival rates were much lower, at 75%, 53.3%, and 50% and 65.8%, 42.5%, and 41.7%, respectively (P < 0.01).

CONCLUSION: Considering that patients in the up-to-seven criteria group exhibited a considerable but lower survival rate compared with the Milan criteria group, the up-to-seven criteria should be used carefully and selectively.

Incidence of death and potentially life-threatening near-miss events in living donor hepatic lobectomy: a world-wide survey

The incidence of morbidity and mortality after living donor liver transplantation (LDLT) is not well understood because reporting is not standardized and relies on single-center reports. Aborted hepatectomies (AHs) and potentially life-threatening near-miss events (during which a donor's life may be in danger but after which there are no long-term sequelae) are rarely reported. We conducted a worldwide survey of programs performing LDLT to determine the incidence of these events. A survey instrument was sent to 148 programs performing LDLT. The programs were asked to provide donor demographics, case volumes, and information about graft types, operative morbidity and mortality, near-miss events, and AHs. Seventy-one programs (48%), which performed donor hepatectomy 11,553 times and represented 21 countries, completed the survey. The average donor morbidity rate was 24%, with 5 donors (0.04%) requiring transplantation. The donor mortality rate was 0.2% (23/11,553), with the majority of deaths occurring within 60 days, and all but 4 deaths were related to the donation surgery. The incidences of near-miss events and AH were 1.1% and 1.2%, respectively. Program experience did not affect the incidence of donor morbidity or mortality, but near-miss events and AH were more likely in low-volume programs (≤50 LDLT procedures). In conclusion, it appears that independently of program experience, there is a consistent donor mortality rate of 0.2% associated with LDLT donor procedures, yet increased experience is associated with lower rates of AH and near-miss events. Potentially life-threatening near-miss events and AH are underappreciated complications that must be discussed as part of the informed consent process with any potential living liver donor.

Donor safety in living donor liver transplantation: a single-center analysis of 300 cases

Aim

To evaluate the safety to donors of living-donor liver transplantation.

Methods

This study included 300 consecutive living liver tissue donors who underwent operations at our center from July 2002 to December 2012. We evaluated the safety of donors with regard to three aspects complications were recorded prospectively and stratified by grade according to Clavien’s classification, and the data were compared in two stages (the first 5 years’ experience (pre-January 2008) and the latter 5 years’ experience (post-January 2008); laboratory tests such as liver function and blood biochemistry were performed; and the health-related quality of life was evaluated.

Results

There was no donor mortality at our center, and the overall morbidity rate was 25.3%. Most of the complications of living donors were either grade I or II. There were significantly fewer complications in the latter period of our study than in the initial period (19.9% vs 32.6%, P<0.001), and biliary complications were the most common complications, with an incidence of 9%. All of the liver dysfunction was temporary; however, the post-operative suppression of platelet count lasted for years. Although within the normal range, eight years after operation, 22 donors showed lower platelet levels (189×10⁹/L) compared with the pre-operative levels (267×10⁹/L) (P<0.05). A total of 98.4% of donors had returned to their previous levels of social activity and work, and 99.2% of donors would donate again if it was required and feasible. With the exception of two donors who experienced grade III complications (whose recipients died) and a few cases of abdominal discomfort, fatigue, chronic pain and scar itching, none of the living donors were affected by physical problems.

Conclusion

With careful donor selection and specialized patient care, low morbidity rates and satisfactory long-term recovery can be achieved after hepatectomy for living-donor liver transplantation.

"Inherent limitations" in donors: control matched study of consequences following a right hepatectomy for living donation and benign liver lesions

OBJECTIVE

The aim of this study was to identify "inherent limitations" in healthy donors who are responsible for donor morbidity after right hepatectomy (RH) for adult-to-adult living donor liver transplantation (ALDLT).

BACKGROUND

Right hepatectomy for ALDLT remains a challenging procedure without significant improvement in morbidity over time. This suggests some "inherent limitations" in healthy individuals, which are beyond the recent improvements in the donor evaluation and selection process and refinements in surgical technique during the learning curve.

METHODS

To identify response of RH in ALDLT, we prospectively studied 32 patients requiring an RH for benign liver lesions (BL), matched with 32 living donors (LD) operated by same team. All patients underwent liver volume evaluation by computed tomographic (CT) volumetry preoperatively and 1 week after RH, postoperative complications graded with Clavien's system.

RESULTS

The comparison (LD vs BL) showed that remnant liver volume (RLV) on preoperative CT volumetry was higher in the BL group (450 ± 150 vs 646 ± 200 mL, P < 0.001) representing 31% ± 7% in LD group versus 36% ± 7% of the total liver volume in BL group (P = 0.03). On postoperative day 7, the RLV was similar in the 2 groups (866 ± 162 vs 941 ± 153 mL) resulting from a significantly higher regeneration rate in the LD group (89% vs 55%, P = 0.009). Overall complications rate was lower in the BL group (46% vs 21%, P = 0.035).

CONCLUSIONS

Right hepatectomy in LDLT induces a more severe deprivation of liver volume than in BL, which induce an accelerated regeneration. Accelerated regeneration could represent "inherent limitation" in healthy donors that makes them more vulnerable for postoperative complications.

[Practice guidelines for management of hepatocellular carcinoma 2009]

Hepatocellular carcinoma (HCC) is a major cancer in Korea, typically has a poor prognosis, and constitutes the majority of primary hepatic malignancies. It is the number one cause of death among people in their 50s in Korea. The five-year survival rate of liver cancer is poor; at 18.9%. Efforts to increase the survival rate through early diagnosis of HCC and optimal treatments are keenly needed. Western guideline for the management of HCC were developed, but these guidelines are somewhat unsuitable for Korean patients. Thus, the Korean Liver Cancer Study Group (KLCSG) and the National Cancer Center (NCC), Korea jointly produced the Clinical Practice Guidelines for HCC for the first time in Korea in 2003. Owing to medical advances over the following six years, diagnosis and treatment of HCC has changed considerably. As more national and foreign data are accumulated, KLCSG and NCC, Korea recently revised the Clinical Practice Guidelines for HCC. Forty or more specialists in the field of hepatology, general surgery, radiology and radiation oncology participated, and meticulously reviewed national and foreign papers, and collected opinions through advisory committee conferences. These multidisciplinary, evidence-based guidelines summarized diagnosis, surgical resection, liver transplantation, local treatments, transarterial chemoembolization, radiation therapy, chemotherapy, preemptive antiviral treatments, and response evaluation of HCC. These Korean guidelines are expected to be useful for clinical management of and research on HCC.