Biliary complications in living liver donors

Textbook outcome among voluntary donors undergoing major living donor hepatectomy

Purpose

Textbook outcome (TO) is a composite measure of outcome and provides superior assessment of quality of care after surgery. TO after major living donor hepatectomy (MLDH) has not been assessed. The objective of this study was to determine the rate of TO and its associated factors, after MLDH.

Methods

This was a single center retrospective review of living liver donors who underwent MLDH between 2012 and 2021 (n = 1022). The rate of TO and its associated factors was determined.

Results

Among 1022 living donors (of whom 693 [67.8%] were males, median age 26 [range, 18–54] years), TO was achieved in 714 (69.9%) with no donor mortality. Majority of donors met the cutoffs for individual outcome measures: 908 (88.8%) for no major complications, 904 (88.5%) for ICU stay ≤ 2 days, 900 (88.1%) for hospital stay ≤ 10 days, 990 (96.9%) for no perioperative blood transfusion, 1004 (98.2%) for no 30-day re-admission, and 1014 (99.2%) for no post-hepatectomy liver failure. Early donation era (before streamlining of donor operative pathways) was associated with failure to achieve TO [OR 1.4, CI 1.1–1.9, P = 0.006]. TO was achieved in 506/755 (67%) donors in the early donation era versus 208/267 (77.9%) in the later period (P = 0.001).

Conclusion

Despite zero mortality and low complication rate, TO was achieved in approximately 70% donors. TO was modifiable and improved with changes in donor operative pathway.

Diagnostic and therapeutic management algorithm for biliary complications in living liver donors

This study aimed to demonstrate the efficacy of our diagnostic and therapeutic management algorithm and catheter-assisted (percutaneous transhepatic biliary tract drainage [PTBD] or transanastomotic feeding tube) hepaticojejunostomy (HJ) procedures in living liver donors (LLDs) with biliary complications. Living donor hepatectomy (LDH) was performed between September 2005 and April 2021 in 2 489 LLDs. Biliary complications developed in 220 LLDs (8.8%), 136 of which were male, and the median age was 29 (interquartile range [IQR]: 12) years. Endoscopic sphincterotomy ± stenting was performed in 132 LLDs, which was unsuccessful in 9 LLDs and required HJ. Overall, 142 LLDs underwent interventional radiologic procedures. Fifteen LLDs with biliary complications underwent HJ (PTBD catheter = 6 and transanastomotic feeding tube = 9) at a median of 44 days (IQR: 82). Following HJ, 14 LLDs did not have any complications throughout the median follow-up period of 1619 days (IQR: 1454). However, percutaneous dilation for HJ anastomotic stricture was performed in one patient. Biliary complications are very common following LDH; therefore, surgeons in the field should have a low threshold to perform HJ for biliary complications that persist after other treatments. Our catheter-assisted HJ techniques demonstrated a high success rate and aided HJ in a hostile abdomen during revisional surgery.

Long-term morbidity and mortality in 2-year hepatoblastoma survivors treated with SIOPEL risk-adapted strategies

BACKGROUND AND AIMS

Prognosis of hepatoblastoma patients has increased with cisplatin-based chemotherapy and high-quality resection including liver transplant. Consequently current risk-adapted therapeutic strategy aims to reduce long-term side effects in patients with standard risk disease.

METHODS

We report long-term mortality and morbidity data concerning 151 2-year hepatoblastoma survivors treated with SIOPEL risk-adapted strategies (sex-ratio M/F = 1.6, median age at diagnosis = 2.6 years [range 0-17.7], median year at diagnosis = 2008 [1994-2017]). Fifty-three patients had loco-regional risk factors VPEFR, 12 were PRETEXT-IV and 30 were metastatic. All received cisplatin and 84 anthracyclines. Twelve had liver transplant. To assess hearing, renal and cardiac functions, audiograms were performed in 116/151 patients (76.8%), glomerular filtration rate in 113/151 (74.8%) and cardiac ultrasound in 65/84 (77.4%) anthracycline-exposed patients.

RESULTS

With a median follow-up of 9.4 years (range 2.1-25.8), four late relapses, one second malignancy (Acute Myeloid Leukemia AML-M5) and two deaths (one from hepatoblastoma, one from AML) occurred. The 10-years event free survival and overall survival probabilities were 95.5% (95% CI 91.9-99.1) and 98.7% (95% CI 96.8-100), respectively. Sixty-eight non-oncologic health-events included 57 cases of hearing loss (including 25 Brock 3-4), three liver cirrhosis, three pre-operative portal cavernoma, two focal nodular hyperplasia, two grade-1 chronic kidney diseases and one asymptomatic cardiac dysfunction were reported. Ototoxicity was significantly associated with cisplatin cumulative dose (OR = 2.07, 95% CI 1.32-3.24, p = 0.001) and carboplatin exposure (OR = 3.14, 95% CI 1.30-7.58, p = 0.01) in multivariable analysis adjusted for sex and age at diagnosis.

CONCLUSIONS

With current risk-adapted strategies, hepatoblastoma is a highly curable disease, with very rare relapses, and few late effects except hearing loss which remains a serious condition in these very young patients.

Cystic duct patch closure of remnant bile duct in living donor hepatectomy when primary closure is difficult: An easy solution

Backgrounds/Aims

In living donor hepatectomy, hepatic duct division is a crucial step and often a technical challenge, with the aim of obtaining a good hepatic duct for anastomosis in the recipient and an adequate stump in the donor for closure. Very rarely, after duct division, the remaining stump may not be adequate for primary closure. In such a difficult situation, the options would be either to close stump transversely or a Roux-en-Y Hepaticojejunostomy.

Methods

We describe a novel surgical technique of “Cystic duct patch repair”, utilizing the available local tissues for closure of bile duct wall.

Results

Two year follow up of this technique showed satisfactory results with no evidence of stricture and normal liver functions.

Conclusions

In living donor hepatectomy, “Cystic duct patch closure” may be used if the post closure cholangiogram is not satisfactory. Although the best method is prevention by ensuring a stump for closure, very rarely this error can occur and can be sorted by cystic duct patch repair.

Endoscopic treatment of biliary complications in donors after living donor liver transplantation in a high volume transplant center

BACKGROUND/AIMS

Although living donor liver transplantation (LDLT) has been accepted as a primary treatment for adults with end-stage liver disease, concerns about donor health have been emerged. As LDLT is technically complex, it creates perioperative morbidity and mortality risk in donors. Biliary complications such as stricture and leakage are seen most frequently in donors after liver transplantation. While some of these complications get treated with conservative approach, endoscopic, surgical, and percutaneous interventions may be required in some others. We aimed to present endoscopic retrograde cholangiography (ERC) results in donors who developed biliary complications after LDLT.

MATERIALS AND METHODS

Between June 2010 and January 2018, a total of 1521 donors (1291 right lobe grafts, 230 left lobe grafts) of patients who underwent LDLT, were retrospectively reviewed. 63 donors who underwent ERC due to biliary complication, were included in the study.

RESULTS

Biliary stricture was found in 1.6% (25/1521), biliary leakage in 2.1% (33/1521), and stricture and leakage together in 0.3% (5/1521) donors. Our endoscopic success rates in patients with biliary leakage, biliary stricture, and stricture and leakage were 85% (28/33), 92% (23/25), and 80% (4/5), respectively. Surgical treatment was performed on 12.6% (8/63) donors who failed ERC.

CONCLUSION

We found that ERC is a successful treatment for post-LDLT donors who have biliary complications.

Changes in the quality of life of living liver donors: A meta-analysis

BACKGROUND

Comprehending the physical, psychological, social benefits, and harm associated with liver donation is critical in promoting practices to maintain donors' long-term health. However, changes in quality of life among living liver donors pre- and post-donation have not been established.

OBJECTIVE

This meta-analysis of prospective longitudinal studies examined the quality of life changes among living liver donors pre- and post-donation.

METHODS

PubMed, Embase, CINHAL with full text, and ProQuest Dissertations & Theses were mainly searched for full-text articles from inception till December 2018 to identify studies assessing the quality of life of living liver donors. The methodological quality of the included studies was examined. The quality of life post-donation at five assessment points, ≤1 month, 3 months, 6 months, 12 months, and ≥ 24 months were compared with the pre-donation, respectively.

RESULTS

The search yielded 2215 records, and a total of 15 articles (13 studies) with 715 donors were included in this meta-analysis. Physical functioning scores at ≤1 month, 3 months, 6 months, 12 months, and ≥24 months post-donation were significantly lower than pre-donation [overall standardized mean difference (SMD) = -0.67, 95% CI: -0.86, -0.49; p ≤]. Significantly higher level of pain was found at 3-month post-donation (SMD, -1.05; 95% CI: -1.26, -0.85; p < 0.00001). Also, a significantly higher level of anxiety was found at 3-month post-donation (SMD, -0.29; 95%CI: -0.51, -0.07; p = 0.01), but there were no significant changes in general psychological state and depression. A significant reduction in donors' social quality of life (SMD, -2.61; 95%CI: -4.75, 0.48; p = 0.02) was found at ≤1-month post-donation, and recovery to pre-donation levels occurred at 3 months post-donation.

CONCLUSIONS

Living liver donation was associated with a decline in physical functioning, which was sustained for longer than 2 years post-donation. Impaired social and psychological quality of life affected donors for 1-3 months after their donation. The quality of life of living liver donors has become a pressing issue requiring more attention from doctors and nurses within the transplant team. However, multicenter, prospective, and longitudinal studies are needed to confirm the long-term safety of living liver donors.

Clamp-Crush Technique Versus Harmonic Scalpel for Hepatic Parenchymal Transection in Living Donor Hepatectomy: a Randomized Controlled Trial

BACKGROUND

Hepatic parenchymal transection is the most invasive step in donor operation. During this step, blood loss and unintended injuries to the intrahepatic structures and hepatic remnant may occur. There is no evidence to prove the ideal techniques for hepatic parenchymal transection. The aim of this study is to compare the safety, efficacy, and outcome of clamp-crush technique versus harmonic scalpel as a method of parenchymal transection in living-donor hepatectomy.

METHODS

Consecutive living liver donors, undergoing right hemi-hepatectomy, during the period between May 2015 and April 2016, were included in this prospective randomized study. Cases were randomized into two groups; group (A) harmonic scalpel group and group (B) Clamp-crush group.

RESULTS

During the study period, 72 cases underwent right hemi-hepatectomy for adult living donor liver transplantation and were randomized into two groups. There were no statistically significant differences between the two groups regarding preoperative demographic and radiological data. Longer operation time and hepatectomy duration were found in group B. There were no significant differences between the two groups regarding blood loss, blood loss during hepatectomy, and blood transfusion. More unexpected bleeding events occurred in group A. Higher necrosis at the cut margin of the liver parenchyma was noted in group A. There were no statistically significant differences between the two groups regarding postoperative ICU stay, hospital stay, postoperative morbidities, and readmission rates.

CONCLUSION

Clamp-crush technique is advocated as a simple, easy, safe, and cheaper method for hepatic parenchymal transection in living donors.

Donor ductal anomaly is not a contraindication to right liver lobe donation

BACKGROUND

Data of living-donor liver transplantation (LDLT) suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors. This retrospective study aimed to determine if the occurrence of postoperative biliary stricture in donors or recipients in right-lobe LDLT (RLDLT) is related to donor biliary anatomy type.

METHODS

We analyzed our RLDLT recipients' clinical data and those of their graft donors. The recipients were divided into 2 groups: with and without postoperative biliary stricture. The 2 groups were compared. The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence; the secondary endpoints were 1-, 3- and 5-year graft and patient survival rates.

RESULTS

Totally 127 patients were included in the study; 25 (19.7%) of them developed biliary anastomotic stricture. In these 25 patients, 16 had type A biliary anatomy, 3 had type B, 2 had type C, 3 had type D, and 1 had type E. In the 127 donors, 96 (75.6%) had type A biliary anatomy, 13 (10.2%) had type B, 6 (4.7%) had type C, 10 (7.9%) had type D, and 2 (1.6%) had type E. Biliary stricture was seen in 2 donors, who had type A biliary anatomy. None of the recipients or donors developed bile leakage. No association between the occurrence of postoperative biliary stricture and donor biliary anatomy type was found (P = 0.527).

CONCLUSIONS

The incidence of biliary stricture in donors or recipients after RLDLT was not related to donor biliary anatomy type. As postoperative complications were similar in whatever type of donor bile duct anatomy, donor ductal anomaly should not be considered a contraindication to donation of right liver lobe.

[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.

Outcome of donor biliary complications following living donor liver transplantation

BACKGROUND/AIMS

Biliary complications are the most common donor complication following living donor liver transplantation (LDLT). The aim of this study is to investigate the long-term outcomes of biliary complications in right lobe adult-to-adult LDLT donors, and to evaluate the efficacy of endoscopic treatment of these donors.

METHODS

The medical charts of right lobe donors who developed biliary complications between June 2000 and January 2008 were retrospectively reviewed.

RESULTS

Of 337 right lobe donors, 49 developed biliary complications, including 36 diagnosed with biliary leakage and 13 with biliary stricture. Multivariate analysis showed that biliary leakage was associated with the number of right lobe bile duct orifices. Sixteen donors, five with leakage and 11 with strictures, underwent endoscopic retrograde cholangiography (ERC). ERC was clinically successful in treating eight of the 11 strictures, one by balloon dilatation and seven by endobiliary stenting. Of the remained three, two were treated by rescue percutaneous biliary drainage and one by conservative care. Of the five patients with leakage, four were successfully treated using endobiliary stents and one with conservative care. In overall, total 35 improved with conservative treatment. All inserted stents were successfully retrieved after a median 264 days (range, 142 to 502) and there were no recurrences of stricture or leakages during a median follow-up of 10.6 years (range, 8 to 15.2).

CONCLUSIONS

All donors with biliary complications were successfully treated non-surgically, with most improving after endoscopic placement of endobiliary stents and none showing recurrence on long term follow-up.

Pure laparoscopic donor right hepatectomy in a living donor with type 3a biliary variation: A case report

RATIONALE

With refinements in the operative technique, laparoscopic surgery has become the standard practice for liver resection. In the field of living donor liver transplantation, a few centers adopted laparoscopic surgery as an alternative to conventional open donor hepatectomy, and the application of pure laparoscopic donor right hepatectomy has been limited to the donors with simple, favorable biliary anatomy.

PATIENT CONCERNS

The candidate donor was a 19-year-old woman with type 3a bile duct variation.

INTERVENTIONS

After confirming precise cutting points under the guidance of a radiopaque marker rubber band, the bile ducts were divided and the remnant stumps were closed with suture and clipping using Hem-o-lok, respectively.

OUTCOMES

The postoperative course was uneventful and she was satisfactory 6 months after surgery.

LESSONS

A laparoscopic donor hepatectomy for the living donor with biliary variation was feasible. Biliary variations are commonly encountered during living donor surgery, and we think that such variations in laparoscopic donor hepatectomy need to be overcome to expand the selection criteria.

Quality of life of liver donors following donor hepatectomy

BACKGROUND

Although morbidity following living liver donation is well characterized, there is sparse data regarding health-related quality of life (HRQOL) of donors.

METHODS

HRQOL of 200 consecutive live liver donors from 2011-2014 performed at an Indian center were prospectively collected using the SF-36 version 2, 1 year after surgery. The effect of donor demographics, operative details, post-operative complications (Clavien-Dindo and 50-50 criteria), and recipient mortality on the quality-of-life (QOL) scoring was analyzed.

RESULTS

Among 200 donors (female/male=141:59), 77 (38.5%) had complications (14.5%, 16.5%, 4.5%, and 3.5%, Clavien-Dindo grades I-IV, respectively). The physical composite score (PCS) of donors 1 year after surgery was less than ideal (48.75±9.5) while the mental composite score (MCS) was good (53.37±6.16). Recipient death was the only factor that showed a statistically significant correlation with both PCS (p<0.001) and MCS (p=0.05). Age above 50 years (p<0.001), increasing body mass index (BMI) (p=0.026), and hospital stay more than 14 days ( p= 0.042) negatively affected the physical scores while emergency surgery (p<0.001) resulted in lower mental scores. Gender, postoperative complications, type of graft, or fulfillment of 50-50 criteria did not influence HRQOL. On asking the hypothetical question whether the donors would be willing to donate again, 99% reiterated there will be no change in their decision.

CONCLUSION

Recipient death, donation in emergency setting, age above 50, higher BMI, and prolonged hospital stay are factors that lead to impaired HRQOL following live liver donation. Despite this, 99% donors did not repent the decision to donate.

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

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

Spray Diathermy Versus Harmonic Scalpel Technique for Hepatic Parenchymal Transection of Living Donor

BACKGROUND

Liver parenchymal transection is the most invasive and challenging part in the living donor operation. The study was planned to compare the safety, efficacy, and outcome of harmonic scalpel versus spray diathermy as a method of parenchymal liver transection in donor hepatectomy.

PATIENT AND METHOD

Eighty consecutive patients, who were treated by living donor liver transplantation (LDLT), were included in the study. The study population was divided into two groups according to the method of liver transection: group A by harmonic scalpel (HS) and group B by spray diathermy (SD). The primary outcome was the volume of blood loss during transection. Secondary outcomes were time of transection, number of ligatures needed during transection, pathological changes at cut surface, postoperative morbidities, cost, and hospital stay RESULTS: Blood loss during overall liver transection and in each zone was significantly less in the SD than in the HS group (P = 0.015). The number of ligatures was significantly less in the SD than in the HS group (P = 0.0001). The SD group had significantly higher level of serum bilirubin, serum glutamic pyruvic transaminase (SGPT), and international normalized ratio (INR) levels on postoperative day 3 than the HS group. Lateral tissue coagulation and hepatic necrosis are significantly less in HS group. The overall incidence of postoperative morbidities was the same in both groups. The cost was higher in HS group than SD group (US$760 vs. US$40 P = 0.0001).

CONCLUSION

Spray diathermy is an effective method of parenchymal transection with significantly lower blood loss and lower cost compared to HS with no increase in morbidity. HS is associated with earlier recovery of liver functions.

Long-term outcome of ischemic type biliary stricture after interventional treatment in liver living donors: a report of two cases

The wall of normal proximal bile duct is occasionally thin with close approximation to the right hepatic artery. Thus, isolation of this hepatic artery can result in excessive weakening of the remnant proximal bile duct wall during hemiliver graft harvest. This type of injury can induce ischemic stricture of the donor common bile duct. This study aimed to review the clinical sequences of such ischemic type donor bile duct injuries primarily managed with endoscopic and radiological interventional treatments. A retrospective review of medical records was performed for two living donors who suffered from ischemic type donor bile duct injury. They were followed up for more than 10 years. The right and left liver grafts were harvested from these two donors. Bile duct anatomy was normal bifurcation in one and anomalous branching in the other. Bile duct stenosis was detected in them at 2 weeks and 1 week after liver donation. They underwent endoscopic balloon dilatation and temporary stent (endoscopic retrograde biliary drainage tube) insertion. After keeping the tube for 2 months, the tube was successfully removed in one donor. However, endoscopic treatment was not successful, thus additional radiological intervention was necessary in the other donor. On follow-up over 10 years, they are doing well so far with no recurrence of biliary stricture. Based on our limited experience, interventional treatment with subsequent long-term follow-up appears to be an essential and choice treatment for ischemic type biliary stricture occurring in liver living donors.

The role of adult living donor liver transplantation and recent advances

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

Comparison of different magnetic resonance cholangiography techniques in living liver donors including Gd-EOB-DTPA enhanced T1-weighted sequences

Objectives

Preoperative evaluation of potential living liver donors (PLLDs) includes the assessment of the biliary anatomy to avoid postoperative complications. Aim of this study was to compare T2-weighted (T2w) and Gd-EOB-DTPA enhanced T1-weighted (T1w) magnetic resonance cholangiography (MRC) techniques in the evaluation of PLLDs.

Materials and Methods

30 PLLDs underwent MRC on a 1.5 T Magnetom Avanto (Siemens, Erlangen, Germany) using (A) 2D T2w HASTE (Half Fourier Acquisition Single Shot Turbo Spin Echo) fat saturated (fs) in axial plane, (B) 2D T2w HASTE fs thick slices in coronal plane, (C) free breathing 3D T2w TSE (turbo spin echo) RESTORE (high-resolution navigator corrected) plus (D) maximum intensity projections (MIPs), (E) T2w SPACE (sampling perfection with application optimized contrasts using different flip angle evolutions) plus (F) MIPs and (G) T2w TSE BLADE as well as Gd-EOB-DTPA T1w images without (G) and with (H) inversion recovery. Contrast enhanced CT cholangiography served as reference imaging modality. Two independent reviewers evaluated the biliary tract anatomy on a 5-point scale subjectively and objectively. Data sets were compared using a Mann-Whitney-U-test. Kappa values were also calculated.

Results

Source images and maximum intensity projections of 3D T2w TSE sequences (RESTORE and SPACE) proved to be best for subjective and objective evaluation directly followed by 2D HASTE sequences. Interobserver variabilities were good to excellent (k = 0.622–0.804).

Conclusions

3D T2w sequences are essential for preoperative biliary tract evaluation in potential living liver donors. Furthermore, our results underline the value of different MRCP sequence types for the evaluation of the biliary anatomy in PLLDs including Gd-EOB-DTPA enhanced T1w MRC.

Biliary complications in living donor right hepatectomy are affected by the method of bile duct division

The bile duct division is a crucial step in the donor hepatectomy. Multiple small ducts will make the biliary reconstruction more difficult and may influence the outcome of the recipient. Biliary leakage, bilomas and biliary strictures are well recognized donor complications that may be directly linked to bile duct division. Biliary division still needs more standardization. This work aims to analyze our experience with two different methods of bile duct division in relation to the development of intraoperative and postoperative biliary complications. Between April 2004 and March 2013, 216 liver donors underwent right hepatectomy, in Gastro-Enterology Surgical Center, Mansoura University, Egypt. According to the method of bile duct division, the study population was divided into 2 groups; 1- extrahepatic dissection group (EDG) and 2- fluoroscopy guided transection group (FGG), each comprised 108 patients. Data were collected from a prospectively registered database, with special emphasis on the occurrence of biliary complications. Complications were classified according to the latest version of Clavien classification. Intraoperative biliary complications did not differ between both groups, p = 0.313. The commonest postoperative complication was biliary leak/biloma accounting for 32.5% of all donor complications, followed by non-biliary fluid collections. 24 (11.1%) donors developed 27 biliary complications. The FGG showed significantly less biliary complications (5.6%, 6 donors), when compared to EDG (15.7%, 18 donors), p = 0.015. Grade 3 complications were significantly higher in EDG, p = 0.024. On multivariate analysis, the only significant factor predicting the occurrence of biliary complications was the use of fluoroscopy guided bile duct division, p = 0.009. In conclusion, we believe that the proposed method of biliary division is safe, simple and reproducible.

Contrast-enhanced magnetic resonance angiography for the preoperative evaluation of hepatic vascular anatomy in living liver donors: a meta-analysis

RATIONALE AND OBJECTIVES

The objective of this study was to determine the diagnostic accuracy of contrast-enhanced magnetic resonance angiography (MRA) when used in the preoperative evaluation of hepatic vascular anatomy in living liver donors.

MATERIALS AND METHODS

A computer-assisted literature searching of EMBASE, PubMed (MEDLINE), and the Cochrane library databases was conducted to identify potentially relevant articles which primarily examined the utility of contrast-enhanced MRA in the preoperative evaluation of hepatic vascular anatomy in living liver donors. We used the Q statistic of chi-squared value test and inconsistency index (I-squared, I(2)) to estimate the heterogeneity of the data extracted from all selected studies. Meta-Disc software (version 1.4) (ftp://ftp.hrc.es/pub/programas/metadisc/Metadisc_update.htm) was used to perform our analysis.

RESULTS

Eight studies were included in the present meta-analysis. A total of 289 living liver donor candidates and 198 patients who underwent liver harvesting were included in the present study. The pooled sensitivities of hepatic artery (HA), portal vein (PV), and hepatic vein (HV) in this meta-analysis were 0.84, 0.97, and 0.94, respectively. The pooled specificities of HA, PV, and HV were 1.00, 1.00, and 1.00, respectively. The pooled diagnostic odds ratios of HA, PV, and HV were 127.28, 302.80, and 256.59, respectively. The area under the summary receiver-operating characteristic curves of HA, PV, and HV were 0.9917, 0.9960, and 0.9813, respectively.

CONCLUSIONS

The high sensitivity and specificity demonstrated in this meta-analysis suggest that contrast-enhanced MRA was a promising test for the preoperative evaluation of hepatic vascular anatomy in living liver donors.

Biliary and vascular anomalies in living liver donors: the role and accuracy of pre-operative radiological mapping

BACKGROUND

The aim of the present study was to determine the utility of computed tomography (CT) and magnetic resonance imaging (MRI) anatomic mapping in the detection of biliary and vascular anomalies prior to a living liver donor (LLD) operation.

METHODS

A retrospective study of all LLD patient charts, operative and radiology reports from 1 January 2002 to 1 January 2012 was conducted. Primary post-operative outcomes assessed included mortality, re-operation, readmission and need for endoscopic or percutaneous intervention. Sensitivity and specificity of MR and CT pre-operative screening was calculated against the gold standard of intra-operative findings.

RESULTS

A total of 34 donors had an average age of 38 years (range: 22-58) with a body mass index (BMI) of 25.6 kg/m(2) (range: 19.8-32.5) and a length of stay (LOS) of 10.1 days (range: 5-41). There were no donor mortalities. Sensitivity and specificity of CT was 70.0% and 91.3%, and of MRI screening 23.1% and 100.0%, respectively. Patients with inaccurate pre-operative CT or MRI did not have an increased risk of complications.

CONCLUSIONS

Even although it was specific, pre-operative MR screening missed up to 77.0% of biliary anomalies. An impeccable surgical technique remains the key in preventing biliary complications of a living donor hepatectomy where pre-operative MRI screening is false.

The right posterior bile duct anatomy of the donor is important in biliary complications of the recipients after living-donor liver transplantation

OBJECTIVE

To evaluate the influence of the anatomy of the right posterior bile duct (RPBD) of the donor on biliary complications in the recipients after living-donor liver transplantation (LDLT) using right hemi-liver grafts.

BACKGROUND DATA

During living-donor right hepatectomy, the RPBD was often exposed to the dissection plane. We hypothesized that biliary complications after anastomosis were increased in these cases because of potential injury to the RPBD.

METHODS

A total of 169 LDLTs using right hemi-liver grafts, with type I (typical) and type II (trifurcation) anatomy in conventional biliary classification, were retrospectively investigated. The patients were newly classified based on the confluence pattern of the RPBD. The patients were firstly divided into infraportal (IP, n = 12) and supraportal (SP, n = 157) types. SP type was subdivided into 3 groups: type A [ultrashort right bile duct (RBD), n = 20], type B (short RBD, n = 128), and type C (long RBD, n = 9). Type B was further subdivided into B-S (short caudal segment of the RPBD, n = 109) and B-L (long caudal segment of the RPBD, n = 19).

RESULTS

The biliary complication rate was 0% in type IP and type C, 40% in type A, 17.6% in type B-S, and 52.6% in type B-L (P < 0.01). In multivariate analysis, a new grouping of the RBD was a significant risk factor for biliary complications in LDLT.

CONCLUSIONS

The anatomy of the RPBD of the donor influenced the biliary outcome in the recipients. A short RBD and a long caudal segment of the RPBD of the donor were significant risk factors for biliary complications in LDLT.

Reliability and validity of a new living liver donor quality of life scale

PURPOSE

To develop a living liver donor (LLD) quality of life (QOL) scale and test its reliability and validity.

METHODS

We sent a draft questionnaire comprising 38 questions to 965 LLDs from five hospitals. To evaluate test-retest reliability, the questionnaire was re-sent 2 weeks later to some of the donors from one hospital.

RESULTS

Of the 447 (54.5 %) donors who responded, 15 were excluded. Factor analysis of 26 items extracted 7 subscales; namely, damage from the operation, scarring, satisfaction, burden, after-effects, digestive symptoms, and lack of understanding of donor health. We analyzed construct validity on the basis of factor analysis and observed significant correlations among the seven subscales. Criterion-related validity was confirmed by significant correlation with the 36-item Short-Form Health Survey scores. None of the subscales showed unreasonable values. We evaluated the subscale reliability for internal consistency (α = 0.670-0.868, except for "digestive symptoms", α = 0.431) and test-retest reliability (r = 0.749-0.918). The factor "digestive symptoms" needs careful consideration because of low internal consistency.

CONCLUSION

The findings of this study confirmed the reliability and validity of the LLD QOL scale, which can be used for quantitatively evaluating the QOL of LLDs.

Donor morbidity including biliary complications in living-donor liver transplantation: single-center analysis of 827 cases

BACKGROUND

Because of the shortage of deceased-donor livers for transplantation, living-donor liver transplantation (LDLT) has become an indispensible treatment strategy for end-stage liver disease. The critical prerequisite for LDLT is the maximal safety of healthy donors.

METHODS

From June 1996 to November 2010, a total of 827 completed donor hepatectomies were performed in our center. We analyzed donor morbidity associated with LDLT.

RESULTS

There was no donor mortality. No complications were observed in 744 (90.0%) donors, and 83 (10.0%) donors experienced complications. Wound complications were most common, occurring in 48 (5.8%) patients. According to a modified Clavien classification, grade I, grade II, grade IIIa, and grade IIIb complications were experienced in 56 (67.5%), 2 (2.4%), 15 (18.1%), and 10 (12.0%) donors, respectively. Surgical or interventional management was successful in all grade IIIa and grade IIIb donors. The incidence of biliary complications was significantly higher in younger donors. Donor morbidity did not decrease below the attained level even after time had passed.

CONCLUSIONS

This study demonstrates the safety of donor hepatectomy. Complications were relatively minor and easily controlled. The incidence of biliary complications and donor age was inversely correlated. The procedural experience of the surgeons was not associated with the donor complication rate.

Safety of living donor liver transplantation using older donors

BACKGROUND

There is limited information concerning older donors in living donor liver transplantation (LDLT). In the present study, we attempted to clarify whether it is safe to use older donors in LDLT.

METHODS

A total of 129 cases were reviewed in the present study. Donors and recipients were divided into group A (donors aged ≥ 50 y, n=21) and group B (donors aged <50 y, n=108). The pre-, intra-, and postoperative variables of the two groups were statistically compared.

RESULTS

Donors' complication rates were 38.10% and 28.70% for groups A and B, respectively (P=0.719). The overall 1-, 3-, and 5-y survival rates were 90%, 80%, and 66% for group A and 86%, 83%, and 75% for group B, respectively (P=0.573). Similar Clavien III or more complication rates for recipients were observed.

CONCLUSIONS

The present study suggested that LDLT using older donors had no negative influence on the outcomes of both donors and recipients.

A learning curve for living donor liver transplantation

BACKGROUND

The number of living donor liver transplantations performed has increased rapidly in many Eastern transplant centres. However, the impact of the transplant centres' experience and learning on the transplant outcomes are not well established. Aim of the study was to evaluate the learning curve for living donor liver transplantation in our centre.

METHODS

Data from 156 recipients and 156 donors who underwent surgery were reviewed. Intraoperative data and postoperative outcomes of both donors and recipients were retrospectively analysed. Recipients and donors were divided into three groups that consisted of 52 consecutive cases each.

RESULTS

Surgical duration and intraoperative blood loss during donor surgery were decreased significantly between the earlier and the more recent cases (423±39 vs. 400±44 min and 959±523 vs. 731±278 mL, respectively; P<0.01). Rates of postoperative complications and functional changes were not statistically different amongst the three donor groups. Immediate complication rate of the first 52 recipients was higher than those of the second and third cohorts. Long-term survival rates of the three recipient groups were similar.

CONCLUSIONS

The learning curve greatly influenced immediate outcomes of recipients during the early transplant period. However, it had little influence on donor outcome; long-term outcome improvement of recipients did not depend on the accumulation of experience alone.

A Catheter-Based Suture-Free Approach to Bilioenteric Anastomosis

Bilioenteric anastomoses are commonly performed during liver transplantation, reconstruction following tumor resection, and repair of bile duct injury. Ischemia plays an important role in both short- and long-term complications related to biliary anastomoses. The authors describe a catheter-based, suture-free approach to bilioenteric anastomosis that aims to reduce or eliminate tissue trauma and foreign material that contribute to anastomotic ischemia. The device uses a novel “umbrella” anchoring mechanism to approximate bowel to the transected bile duct over a percutaneously placed transhepatic catheter. The authors performed an open choledochojejunostomy using the device in 7 pigs. The anastomosis was assessed with cholangiography, gross inspection, and histology at the time of necropsy. The procedure was well tolerated, with no evidence of anastomotic leak in any of the study animals. This alternative catheter-based approach to bilioenteric anastomoses is safe and effective, offers potential advantages over traditional approaches, and can be easily adapted to a minimal access surgery.

Surgical outcome of right liver donors in living donor liver transplantation: single-center experience with 500 cases

BACKGROUND

With the increasing number of living donor liver transplantation (LDLT), concerns regarding morbidity and mortality of donors have become inevitable. Thus, the aim of the present study was to find ways to reduce the rate of morbidity and mortality of donors by analyzing our experience.

METHODS

A retrospective clinicopathologic analysis was performed for 500 consecutive living donors who underwent donor right hepatectomy between May 1999 and February 2011. We chronologically divided those procedures into three periods: period A (n = 100), period B (n = 200), and period C (n = 200). Surgical outcomes according to each period were then compared.

RESULTS

Over time, the following factors have decreased: the operative time, the amount of transfusions during surgery, hospital stay, and the incidence of biliary complications. No mortality developed. Even though the total complication rate was high (21.6 %, n = 108) including 10.6 % (n = 53) of biliary complications, the grade 3 complication rate was only 9.4 % (n = 47). In most patients with grade 3 complication, interventional therapies via radiologic or endoscopic approaches corrected these complications, and reoperation was required for ten patients (2 %). Whereas biliary complications were related with operation period (period B or C compared to period A; relative risk [RR] 2.10, P = 0.049, 95 % CI 1.01-4.39) and operative time (RR 1.01, P = 0.027, 95 % CI 1.00-1.02), postoperative hyperbilirubinemia (serum total bilirubin ≥ 5 mg/dL) was related with male gender (RR 2.68, P = 0.039, 95 % CI 1.05-6.85) and ≥ 25 % liver steatosis (RR 3.35, P = 0.053, 95 % CI 0.99-11.38).

CONCLUSIONS

Optimization of donor selection as well as institutional experience is imperative to improve the surgical outcome. Even though donor hepatectomy was associated with relatively higher complication rate, most complications showed low-grade severity which could be corrected by interventional therapies.

Biliary complications after living donor liver transplantation

Biliary complications occur more frequently after living donor liver transplantation (LDLT) versus deceased donor liver transplantation, and they remain the most common and intractable problems after LDLT. The anatomical limitations of multiple tiny bile ducts and the differential blood supplies of the graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in patients undergoing LDLT. A clear understanding of the biliary blood supply, the Glissonian sheath, and the hilar plate has contributed to new techniques for preparing bile ducts for anastomosis, and these techniques have resulted in a dramatic drop in the incidence of biliary complications. Most biliary complications after LDLT can be successfully treated with nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge.

Biliary complications in recipients after living donor liver transplantation: influencing factors and imaging manifestations

AIM: To investigate the influencing factors for and imaging manifestations of biliary complications in patients after living donor liver transplantation (LDLT).

METHODS: The imaging data for 119 patients who underwent LDLT at West China Hospital from January 2007 to March 2011 were retrospectively analyzed. All biliary system images were read and analyzed independently by two radiologists.

RESULTS: A total of 119 patients were followed up for 1-18 mo. During the follow-up period, 22 patients developed biliary complications, including 9 cases of cholestasis, 5 cases of cholangitis, 4 cases of stenosis, and 4 cases of bile leakage. Different complications occurred at different time points. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can display cholestasis, cholangitis and biliary stenosis well, and MRI has greater diagnostic value than MDCT. Both methods had limited value in the diagnosis of bile leakage.

CONCLUSION: The influencing factors for biliary complications in recipients after LDLT are diverse. MDCT and MRI have great value in the detection of these complications.