One-Year Recipient Morbidity of Liver Transplantation Using Pure Laparoscopic Versus Open Living Donor Right Hepatectomy: Propensity Score Analysis

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.

Dimethyloxalylglycine pretreatment of living donor alleviates both donor and graft liver ischemia-reperfusion injury in rats

Background: Under the circumstance of the increasing waiting list for liver transplantation, living donor liver transplantation (LDLT) can alleviate the shortage of liver donors to some extent. However, how to reduce both donor and graft ischemia-reperfusion injury (IRI) is still an unsolved problem in LDLT. Hypoxia-induced transcription factor 1 (HIF1) activation is considered an important mechanism of cellular adaptation to hypoxia, and early activation of HIF1 may be a new way to alleviate liver IRI. Therefore, we aimed to investigate the impact of the HIF1 stabilizer dimethyloxalylglycine (DMOG) on IRI and the survival rate of donors and recipients of rat LDLT. Methods: Seventy percent partial liver resection and 30% partial liver transplantation were used to simulate donor and recipient of clinical LDLT. Rats were treated with DMOG (40 mg/kg) or with an equivalent amount of saline. The expression of HIF1 and downstream targets was analyzed after 2 h of reperfusion. Liver function and histopathology, apoptosis and oxidative stress levels were detected 6 h after reperfusion. At the same time, the 7-day survival rate of rats was calculated. Results: DMOG pretreatment significantly reduced IR-induced injury in the donor and recipient, which was manifested by reducing liver function damage and promoting tissue recovery. Meanwhile, compared with the untreated group, the oxidative stress level and the cell apoptosis rate were decreased in the group pretreated with DMOG. In addition, the transcription and expression of HIF1 target genes in the DMOG group were significantly enhanced. Remarkably, DMOG also increased the survival rate of the recipient. Conclusion: This study provides the first evidence that DMOG pretreatment of donors significantly alleviates liver IRI in both donors and recipients and increases the survival rate of recipients in LDLT. Therefore, DMOG may be a promising strategy for improving LDLT in the future.

Safely Implementing a Program of Pure Laparoscopic Donor Right Hepatectomy: The Experience From a Southeast Asian Center

Laparoscopic donor right hepatectomy (LDRH) is a technically challenging procedure. There is increasing evidence demonstrating the safety of LDRH in high-volume expert centers. We report our center's experience in implementing an LDRH program in a small- to medium-sized transplantation program.

Methods

Our center systematically introduced a laparoscopic hepatectomy program in 2006. We started with minor wedge resections followed by major hepatectomies with increasing complexities. In 2017, we performed our first laparoscopic living donor left lateral sectionectomy. Since 2018, we have performed 8 cases of right lobe living donor hepatectomy (laparoscopy-assisted: 4 and pure laparoscopic: 4).

Results

The median operative time was 418 (298-540) min, whereas the median blood loss was 300 (150-900) mL. Two patients (25%) had surgical drain placed intraoperatively. The median length of stay was 5 (3-8) d, and the median time to return to work was 55 (24-90) d. None of the donors sustained any long-term morbidity or mortality.

Conclusions

Small- to medium-sized transplant programs face unique challenges in adopting LDRH. Progressive introduction of complex laparoscopic surgery, a mature living donor liver transplantation program, appropriate patient selection, and the invitation of an expert to proctor the LDRH are necessary to ensure success.

Pure Laparoscopic Donor Left Hepatectomy Reduces Postoperative Analgesic Use and Pain Scale

BACKGROUND

Many recent reports have described the efficacy and safety of pure laparoscopic donor hepatectomy (PLDH). Here we investigated the extent to which this technique could reduce patients' experienced pain.

METHODS

Among donor left hepatectomy procedures performed between July 2011 and November 2022, we retrospectively analyzed 20 open donor hepatectomy (ODH), 20 laparoscopy-assisted donor hepatectomy (LADH), and 5 PLDH cases. We compared these 3 procedures regarding the total amount of postoperative analgesic use (narcotics and non-narcotics) and the first date when the donor was completely pain-free, as evaluated by the patients using a pain scale.

RESULTS

Total postoperative fentanyl use did not significantly differ among the 3 procedures: median (range), ODH, 0.5 mg (0-2 mg); LADH 1.2 mg (0-7 mg); PLDH, 0.5 mg (0-3.5; P = .172). The percentage of patients who completely discontinued analgesics on postoperative day (POD) 5 was significantly higher for PLDH (80%) than for ODH (35%) or LADH (20%) (P = .041). The day when 50% of donors were completely pain-free on a pain scale was POD9 for ODH, POD11 for LADH, and POD5 for PLDH, significantly shorter in the PLDH group (P = .004).

CONCLUSION

At our institution, we found that PLDH was a useful technique for postoperative pain management compared with PDH and LADH. Our results suggest that PLDH effectively reduces the duration of postoperative analgesia use. Further studies are warranted as the number of PLDH cases gradually increases.

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.

Pure Laparoscopic Versus Open Approach for Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis

Background: Pure laparoscopic liver donor right hepatectomy (LLDRH) remains challenging, and its value is still unclear compared with open liver donor right hepatectomy (OLDRH). Objective: To provide comprehensive evidence about the safety and efficacy of LLDRH. Methods: The MEDLINE, Embase, Web of Science, and Cochrane Library electronic databases were searched from the date of inception to July 2021. A fixed-effects or random-effects model was used to analyze the pooled data by using Review Manager Version 5.3. Results: A total of 1940 patients from 6 studies were enrolled in this meta-analysis. For perioperative outcomes of donors, LLDRH had a longer operative time than OLDRH (weighted mean difference [WMD] = 29.75 [4.23-55.26] minutes, P = .02), but it had lower overall morbidity (odds ratio [OR] = 0.67 [0.45-0.99], P = .04), fewer pulmonary complications (OR = 0.47 [0.29-0.76], P = .002), and shorter hospital stays (WMD = -1, P < .001) than OLDRH. However, major complications, biliary complications, portal vein problems, and intra-abdominal bleeding were comparable between the 2 groups. With regard to the postoperative data of recipients, the risks of biliary problems, hepatic artery problems, portal vein problems, hepatic vein problems, and postoperative liver failure were similar between the 2 groups. Conclusions: LLDRH for living donors is safe and effective, and it offers superior perioperative outcomes to OLDRH.

Influence of Large Grafts Weighing ≥ 1000 g on Outcome of Pure Laparoscopic Donor Right Hepatectomy

BACKGROUND

Depending on a transplant center's level of experience, utilization of pure laparoscopic donor right hepatectomy (PLDRH) may be limited due to graft size or anatomical variations. Here, we aimed to evaluate the influence of large hepatic grafts (≥ 1000 g) when performing PLDRH in both donors and recipients of such grafts.

METHODS

Medical records of living donors who underwent either PLDRH from November 2015 to August 2019 or open conventional donor right hepatectomy (CDRH) from January 2010 to August 2019 and those of the graft recipients were retrospectively reviewed. Donors were separated into three groups: PLDRH graft ≥ 1000 g (n = 10; study group), PLDRH graft < 1000 g (n = 280; control-I group), and CDRH graft ≥ 1000 g (n = 24; control-II group).

RESULTS

Total operative duration (P = 0.017) and warm ischemia time (P < 0.001) were significantly longer in the study than in the control-I and control-II groups, respectively. ΔAlanine aminotransferase% was significantly lower in the study than in the control-I group (P = 0.001). There was no significant difference in minor complication incidence between the study and control-I (P = 0.068) and control-II (P = 0.618) donors. There were no major complications in the study and control-II donors, whereas six control-I donors (2.1%) experienced a major complication (P = 1.000). Length of hospitalization was significantly shorter in the study than in the control-II group (P < 0.001). There was no significant difference in early and late major complication incidence for recipients between the study and control-I and control-II groups.

CONCLUSIONS

PLDRH for grafts weighing ≥ 1000 g appears to be safe and feasible when performed by experienced surgeons in a well-equipped center.

Laparoscopic living-donor hepatectomy: Review of its current status

The laparoscopic living-donor hepatectomy procedure has been developing rapidly. Although its use has increased worldwide, it is still only performed by experienced surgeons at a limited number of institutions. However, technical innovations have improved the feasibility of more widespread use of laparoscopic living-donor hepatectomy. The advantages of laparoscopic living-donor hepatectomy should not be overemphasized, and the fundamental principle of "living-donor safety first" cannot be neglected. This review aims to summarize the current status of laparoscopic living-donor hepatectomy and to emphasize that, while this procedure may soon be used as a reliable, donor-friendly substitute for traditional open donor hepatectomy, its safety and efficacy require further substantiation first.

Postoperative outcomes of purely laparoscopic donor hepatectomy compared to open living donor hepatectomy: a preliminary observational study

Purpose

To lessen the physical, cosmetic, and psychological burden of donors, purely laparoscopic donor hepatectomy (PLDH) has been proposed as an ideal method for living donors. Our study aimed to prospectively compare the effect of PLDH and 2 other types of open living donor hepatectomy (OLDH) on postoperative pain and recovery.

Methods

Sixty donors scheduled to undergo donor hepatectomy between March 2015 and November 2017 were included. Donors were divided into 3 groups by surgical technique: OLDH with a subcostal incision (n = 20), group S; OLDH with an upper midline incision (n = 20), group M; and PLDH (n = 20), group L. The primary outcomes were postoperative pain and analgesic requirement during postoperative day (POD) 3. Other variables regarding postoperative recovery were also analyzed.

Results

Although pain relief during POD 3, assessed by visual analog scale (VAS) score and analgesic requirement, was similar among the 3 groups, group L showed lower VAS scores and opioid requirements than group M. Moreover, group L was associated with a rapid postoperative recovery evidenced by the shorter hospital length of stay and more frequent return to normal activity on POD 30.

Conclusion

This pilot study failed to verify the hypothesis that PLDH reduces postoperative pain. PLDH did not reduce postoperative pain but showed faster recovery than OLDH.

Pure Laparoscopic Donor Hepatectomy: A Multicenter Experience

According to recent international consensus conferences, pure laparoscopic donor hepatectomy (PLDH), particularly right and left hepatectomies, is not yet considered a standard practice because studies remain limited. Thus, we present the outcomes of more than 500 PLDH patients, mostly receiving a right hepatectomy. To our knowledge, this is the largest study to date on PLDH. Data from all living liver donors who underwent PLDH at 5 centers in Korea until June 2018 were retrospectively analyzed. The outcomes of both donors and recipients were included. Pearson correlation analysis was used to explore the relationship between the duration of surgery and cumulative experience at each center, which reflects the learning curve. Overall, 545 PLDH cases were analyzed, including 481 right hepatectomies, 25 left hepatectomies, and 39 left lateral sectionectomies (LLS). The open conversion was necessary for 10 (1.8%) donors, and none of the donors died or experienced irreversible disability. Notably, there were 25 (4.6%) patients with major complications (higher than Clavien-Dindo grade 3). All centers except one showed a significant decrease in surgery duration as the number of cases accumulated. Regarding recipient outcomes, there were 110 cases (20.2%) of early major complications and 177 cases (32.5%) of late major complications. This study shows the early and late postoperative outcomes of 545 donors and corresponding recipients, including 481 right hepatectomies and 25 left hepatectomies, from 5 experienced centers. Although the results are comparable to those of previously reported open donor hepatectomy series, further studies are needed to consider PLDH a new standard practice.

[Living related liver transplantation]

Liver transplantation has become established as a standard procedure in the treatment of end-stage liver diseases. Despite intense efforts by all parties involved up to the amendment of the German Transplantation Act, the lack of suitable donor organs was still one of the limiting factors of this therapeutic procedure. One way out of this problem is to make so-called marginal organs usable, e.g. with the help of machine perfusion or by utilizing living liver donation, which are used in some countries for more than 90% of organ donations. In general, there is no difference in the indications for liver transplantation between a (partial) organ obtained by post-mortem or living donation. Before any living donation, a thorough evaluation of the donor is carried out in order to minimize postoperative morbidity as far as possible. Technically the partial liver donation is based on the oncological liver resection, while the partial liver transplantation is a further development of split liver transplantation after post-mortem liver donation. In specialized centers comparable or even better results can nowadays be achieved using living liver donation instead of post-mortem donation.