Biliary complications following living donor hepatectomy

The long-term follow-up of the living liver donors

Living donor liver transplantation (LDLT) has been proposed in many countries to reduce organ shortage. While the early postoperative outcomes have been well investigated, little is known about the long-term follow-up of the living donors. We, therefore, designed a systematic review of the literature to explore long-term complications and quality of life among living donors. We searched MEDLINE and EMBASE registries for studies published since 2013 that specifically addressed long-term follow-up following living-donor liver donation, concerning both physical and psychological aspects. Publications with a follow-up shorter than 1 year or that did not clearly state the timing of outcomes were excluded. A total of 2505 papers were initially identified. After a thorough selection, 17 articles were identified as meeting the eligibility criteria. The selected articles were mostly from North America and Eastern countries. Follow-up periods ranged from 1 to 11.5 years. The most common complications were incision site discomfort (13.2-38.8%) and psychiatric disorders (1-22%). Biliary strictures occurred in 1-14% of cases. Minimally invasive donor hepatectomy could improve quality of life, but long-term data are limited. About 30 years after the first reported LDLT, little has been published about the long-term follow-up of the living donors. Different factors may contribute to this gap, including the fact that, as healthy individuals, living donors are frequently lost during mid-term follow-up. Although the reported studies seem to confirm long-term donor safety, further research is needed to address the real-life long-term impact of this procedure.

Effect of Donors' Biliary Variation on Postoperative Biliary Complications in Living Donor Liver Transplantation: A Single-Center Observational Study in Vietnam

BACKGROUND

Our study aims to evaluate the biliary anatomy variation according to the Varotti classification and its correlation with surgical outcomes for both donors and recipients undergoing living donor liver transplants (LDLTs).

METHODS

A retrospective analysis of 150 LDLT cases performed at a single center in Vietnam with preoperative radiologic evaluations and intraoperative surgical assessments to identify biliary variant anatomy. Postoperative biliary complications were documented and analyzed. Statistical analysis was performed to determine any significant associations between biliary variations and post-transplant outcomes.

RESULTS

One hundred fifty cases of LDLT at 108 Military Central Hospital from October 2017 to December 2022 were included in our study. Among the donors, the mean age was 30.89 ± 7.23, with male predominance (77.3%). The prevalence of type 1 biliary anatomy was 84.67%. Type 2, 3a, 3b, 4a, and 4b accounted for 5.33%, 2.67%, 5.33%, 0.67%, and 1.33% of cases, respectively. Donors' complications were witnessed in 7 cases (4.67%), and all needed intervention (Clavien-Dindo grade 3). Biliary complications were found in 36 (24.0%) recipients, with 22 (14.67%) cases of biliary stenosis and 16 (10.67%) cases of biliary leak, including 2 cases encountering both complications. Age, gender, graft type, preoperative liver function, biliary variant anatomy, number of graft orifices, Model for End-Stage Liver Disease score, and blood loss were not significant risk factors for recipients' biliary complications. Cold ischemia time significantly increased the biliary complication rate.

CONCLUSIONS

This study shows that biliary variant anatomy is common in living liver donors. Such variations should not be a contraindication to liver donation. However, accurate pre- and intraoperative radiologic and surgical evaluations are fundamental for a careful reconstruction plan.

Living Donor Liver Transplantation: Left Lobe or Right Lobe

Living Donor Liver Transplantation (LDLT) has seen great advancements since its inception in 1988. Herein, the nuances of LDLT are discussed spanning from donor evaluation to the recipient operation. Special attention is given to donor anatomy and graft optimization techniques in the recipient.

Donor Safety and Risk Factors of Pure Laparoscopic Living Donor Right Hepatectomy: A Korean Multicenter Study

OBJECTIVE

The aim of this study was to identify safety and risk factors of living donor after pure laparoscopic donor right hepatectomy in a Korean multicenter cohort study.

BACKGROUND

Pure laparoscopic donor right hepatectomy is not yet a standardized surgical procedure due to lack of data.

METHODS

This retrospective study included 543 patients undergoing PLRDH between 2010 and 2018 in 5 Korean transplantation centers. Complication rates were assessed and multivariate logistic regression analyses were performed to identify risk factors of open conversion, overall complications, major complications, and biliary complications.

RESULTS

Regarding open conversion, the incidence was 1.7% and the risk factor was body mass index >30 kg/m 2 [ P =0.001, odds ratio (OR)=22.72, 95% CI=3.56-146.39]. Rates of overall, major (Clavien-Dindo classification III-IV), and biliary complications were 9.2%, 4.4%, and 3.5%, respectively. For overall complications, risk factors were graft weight >700 g ( P =0.007, OR=2.66, 95% CI=1.31-5.41), estimated blood loss ( P <0.001, OR=4.84, 95% CI=2.50-9.38), and operation time >400 minutes ( P =0.01, OR=2.46, 95% CI=1.25-4.88). For major complications, risk factors were graft weight >700 g ( P =0.002, OR=4.01, 95% CI=1.67-9.62) and operation time >400 minutes ( P =0.003, OR=3.84, 95% CI=1.60-9.21). For biliary complications, risk factors were graft weight >700 g ( P =0.01, OR=4.34, 95% CI=1.40-13.45) and operation time >400 minutes ( P =0.01, OR=4.16, 95% CI=1.34-12.88).

CONCLUSION

Careful donor selection for PLRDH considering body mass index, graft weight, estimated blood loss, and operation time combined with skilled procedure can improve donor safety.

Biliary Complications in Living Liver Donors After Donor Hepatectomy: A Single-Center Experience

OBJECTIVES

The most frequent postoperative morbidity following living donor liver transplant is biliary complications, which can happen for both anatomical and procedural reasons.

MATERIALS AND METHODS

We conducted a retrospective analysis of 104 patients who were living liver donors undergoing hepatectomy from January 2011 to April 2022. We evaluated all perioperative finding such as age, sex, remnant liver volume, biliary anatomy, theduration of operation time and hospitalization, and blood loss.

RESULTS

Clavien-Dindo classification grade III complications were observed in 24% of all donors, with rate of biliary complications of 7.6% (n = 8). All biliary complications were typified as biliary leakage, and an endoscopic retrograde cholangiopancreatography procedure was performed for 5 patients. We analyzed the clinical and surgical features and discovered that the duration of hospitalization was longer in the biliary leakage group than the group without leakage (15.7 ± 5.8 days vs. 30.8 ± 9.3 days, respectively; P < .08). There was no significant statistical relationship between age, the duration of operation time, intraoperative blood loss, and remnant liver volume versus biliary leakage (P = .074, P = .217, P = .219, and P = .363, respectively).

CONCLUSIONS

Early detection and treatment of complications are ensured during the perioperative process by carefuldonor selection andaccurate identification of the patient atrisk for biliary complications.

Comparison of Biliary Complications Rates After Brain Death, Donation After Circulatory Death, and Living-Donor Liver Transplantation: A Single-Center Cohort Study

Donation-after-circulatory-death (DCD), donation-after-brain-death (DBD), and living-donation (LD) are the three possible options for liver transplantation (LT), each with unique benefits and complication rates. We aimed to compare DCD-, DBD-, and LD-LT-specific graft survival and biliary complications (BC). We collected data on 138 DCD-, 3,027 DBD- and 318 LD-LTs adult recipients from a single center and analyzed patient/graft survival. BC (leak and anastomotic/non-anastomotic stricture (AS/NAS)) were analyzed in a subset of 414 patients. One-/five-year graft survival were 88.6%/70.0% for DCD-LT, 92.6%/79.9% for DBD-LT, and, 91.7%/82.9% for LD-LT. DCD-LTs had a 1.7-/1.3-fold adjusted risk of losing their graft compared to DBD-LT and LD-LT, respectively (p < 0.010/0.403). Bile leaks were present in 10.1% (DCD-LTs), 7.2% (DBD-LTs), and 36.2% (LD-LTs) (ORs, DBD/LD vs. DCD: 0.7/4.2, p = 0.402/<0.001). AS developed in 28.3% DCD-LTs, 18.1% DBD-LTs, and 43.5% LD-LTs (ORs, DBD/LD vs. DCD: 0.5/1.8, p = 0.018/0.006). NAS was present in 15.2% DCD-LTs, 1.4% DBDs-LT, and 4.3% LD-LTs (ORs, DBD/LD vs. DCD: 0.1/0.3, p = 0.001/0.005). LTs w/o BC had better liver graft survival compared to any other groups with BC. DCD-LT and LD-LT had excellent graft survival despite significantly higher BC rates compared to DBD-LT. DCD-LT represents a valid alternative whose importance should increase further with machine/perfusion systems.

Outcomes of right lobe donors with BMI≥30 for living donor liver transplantation

BACKGROUND

Donor BMI above 30 is generally considered contraindication for donor hepatectomy. We compared the donor outcomes based on BMI threshold and weight loss.

PATIENTS AND METHODS

All potential donors were identified and data were collected retrospectively. Steatosis was assessed based on liver-spleen Hounsfield unit difference and absolute liver intensity values. We compared BMI≥30 (n = 53) and BMI<30 (n = 64) donor outcomes. Donors with weight loss (WL) prior to surgery were also analyzed separately. Complications were graded by Clavien-Dindo classification.

RESULTS

All donors underwent open right donor hepatectomy. There was no difference between BMI≥30 and <30 groups except female predominance in BMI≥30 group (p = 0.006). Both groups had similar rates of complication rates in all categories, similar remnant volume, operative time, length of stay and similar postoperative liver function recovery (all p>0.05). On the other hand, donors with WL were more commonly male, had smaller graft size, and higher biliary complications rates compared to no-WL donors (all p<0.05). Multivariate binary logistics regression analysis revealed no association between BMI or WL and outcomes.

CONCLUSION

We demonstrate that donors with BMI≥30 have similar outcomes compared to BMI<30 donors with our defined selection criterion, therefore BMI≥30 is not an absolute contraindication to donate right liver, provided that there is no significant steatosis and remnant liver is satisfactory. For potential overweight donors, WL down to BMI<30 is a reasonable target. Higher biliary complication rates after WL should be investigated further. This article is protected by copyright. All rights reserved.

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.

Donor Morbidity Is Equivalent Between Right and Left Hepatectomy for Living Liver Donation: A Meta-Analysis

Maximizing liver graft volume benefits the living donor liver recipient. Whether maximizing graft volume negatively impacts living donor recovery and outcomes remains controversial. Patient randomization between right and left hepatectomy has not been possible due to anatomic constraints; however, a number of published, nonrandomized observational studies summarize donor outcomes between 2 anatomic living donor hepatectomies. This meta-analysis compares donor-specific outcomes after right versus left living donor hepatectomy. Systematic searches were performed via PubMed, Cochrane, ResearchGate, and Google Scholar databases to identify relevant studies between January 2005 and November 2019. The primary outcomes compared overall morbidity and incidence of severe complications (Clavien-Dindo >III) between right and left hepatectomy in donors after liver donation. Random effects meta-analysis was performed to derive summary risk estimates of outcomes. A total of 33 studies (3 prospective and 30 retrospective cohort) were used to identify 7649 pooled patients (5993 right hepatectomy and 1027 left hepatectomy). Proportion of donors who developed postoperative complications did not significantly differ after right hepatectomy (0.33; 95% confidence interval [CI], 0.27-0.40) and left hepatectomy (0.23; 95% CI, 0.17-0.29; P = 0.19). The overall risk ratio (RR) did not differ between right and left hepatectomy (RR, 1.16; 95% CI, 0.83-1.63; P = 0.36). The relative risk for a donor to develop severe complications showed no differences by hepatectomy side (Incidence rate ratio, 0.97; 95% CI, 0.67-1.40; P = 0.86). There is no evidence that the overall morbidity differs between right and left lobe donors. Publication bias reflects institutional and surgeon variation. A prospective, standardized, multi-institutional study would help quantify the burden of donor complications after liver donation.

Evaluation of clinical characteristics and outcomes of postoperative ınfections in living liver donors

AIM

To analyze developing infections after living donor hepatectomy (LDH) in living liver donors (LLDs).

METHODS

Demographic and clinical characteristics of 1106 LLDs were retrospectively analyzed in terms of whether postoperative infection development. Therefore, LLDs were divided into two groups: with (n = 190) and without (n = 916) antimicrobial agent use.

RESULTS

The median age was 29.5 (min-max: 18-55). A total of 257 (23.2%) infection attacks (min-max: 1-8) was developed in 190 (17.2%) LLDs. The patients with the infection that were longer intensive care unit (ICU) and hospital stays, higher hospital admissions, emergency transplantation, invasive procedures for ERCP, PTC biloma, and abscess drainage, and the presence of relaparatomies and transcystic catheters. Infection attacks are derived from a 58.3% hepatobiliary system, 13.2% urinary system, 6.6% surgical site, and 5.8% respiratory system. The most common onset symptoms were fever, abdominal pain, nausea, and vomiting. A total of 125 positive results was detected from 77 patients with culture positivity. The most detected microorganisms from the cultures taken are Extended-Spectrum β-lactamases (ESBL) producing Klebsiella pneumonia (16.8%) and Escherichia coli (16%), Methicillin-Resistant Staphylococcus aureus [(MRSA) (9.6%)], Methicillin-susceptible S aureus [(MSSA) (9.6%)], and Pseudomonas aeruginosa (8.8%), respectively. The average number of ICU hospitalization days was 3 ± 2 (min 1-max 30, IQR:1) and hospitalization days was 14 ± 12 (min 3-max 138, IQR: 8). All infection attacks were successfully treated. No patients died because of infection or another surgical complication.

CONCLUSION

Infections commonly observed infected biloma, cholangitis, and abscess arising from the biliary system and other nosocomial infections are the feared complications in LLDs. These infections should be managed multidisciplinary without delay and carefully.

Mental Health and Well-Being of Solid Organ Transplant Donors. The Forgotten Sacrifices

In light of a global organ shortage, living donor transplantation has become increasingly relevant as an alternative to deceased donor transplantation. While current research has revolved around the medical aspects of transplantation, there remains a paucity of literature regarding the quality of life (QOL) of living donors. Hence, this review aims to provide a comprehensive outline of the current landscape of living liver and kidney transplantation, with a focus on the mental health and wellbeing of donors. As highlighted in previous studies, organ donation has a significant impact on both physical and mental aspects of donor wellbeing, with marked deteriorations occurring in the short term. Furthermore, other qualitative aspects such as financial burden contribute greatly to donor distress, reflecting a need for improved donor care. To address these pertinent issues, recommendations for a successful transplant program are detailed in this review, which encompasses psychological and social aspects of donor care throughout the donation process. Further research can be done on the impact of recipient deaths on donor QOL and appropriate interventions. Overall, given the selfless sacrifices of living donors, the care of their mental wellbeing is essential. Therefore, greater emphasis should be placed on the provision of adequate psychosocial support for them.

CT and MR imaging evaluation of living liver donors

Preoperative cross-sectional imaging evaluation of potential living liver donors allows to exclude donors with an increased risk for morbidity and mortality, and to assure that a suitable graft for the recipient can be obtained, minimizing the risk of complications in both the donor and the recipient. CT is routinely performed to delineate the anatomy of the liver, relevant vasculature, and liver volumes in whole right or left lateral segment donation. MR imaging is the gold standard for the assessment of biliary anatomy and allows a better quantification of hepatic steatosis compared to CT. Knowledge of normal and variant vascular and biliary anatomy and their surgical relevance for liver transplantation is of paramount importance for the radiologist. The purpose of this review is to outline the current role of CT and MR imaging in the assessment of hepatic parenchyma, hepatic vascular anatomy, biliary anatomy, and hepatic volumetry in the potential living liver donor with short notes on acquisition protocols and the relevant reportable findings.

Complications and outcomes of 890 living liver donor hepatectomies at a single center: risks of saving loved one's life

Objectives

Living liver donor surgery is a major surgical procedure applied to healthy people with mortality and morbidity risks and does not provide any direct therapeutic advantage to the donor. We retrospectively analyzed the postoperative complication of our living liver donors to figure out the risks of donation.

Material and Methods

Between November, 2006 and December, 2018, a total of 939 living liver donor hepatectomies were performed with no mortality to the living-related donors. Eight hundred and ninety donors with a minimum 1-year follow-up were analyzed retrospectively.

Results

Of the 890 donors, 519 (58.3%) were males and 371 (41.7%) were females. Mean age was 35 years (18-64) and mean body mass index was 25.7 kg/m² (17.7-40). Right donor hepatectomy was performed to 601 (67.5%), left donor hepatectomy to 28 (3.2%) and left lateral sector hepatectomy to 261 (29.3%) of the donors. Of the 890 donors, 174 (19.5%) donors experienced a total of 204 early and late complications including life- threatening and nearly life- threatening complications in 26 (2.9%) of them. Intraoperative complication occurred in 4 (0.5%) donors. Right donors hepatectomy complication rate (23.3%) was higher than left donor (14.3%) and left lateral sector donor hepatectomy (11.5%).

Conclusion

All donor candidates should be well-informed not only on the details of early and late complications of living liver donation, also possible outcomes of the recipient. In addition to detailed physical evaluation, preoperative psychosocial evaluation is also mandatory. Comprehensive donor evaluation, surgical experience, surgical technique, close postoperative follow-up and establishing a good dialog with the donor allows better outcomes.

Assessment of biliary anatomy in potential living liver donors: Added value of gadoxetic acid-enhanced T1 MR Cholangiography (MRC) including utilization of controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA) technique in comparison to T2W-MRC

OBJECTIVES

To assess the added value of gadoxetic-acid-enhanced T1-weighted magnetic resonance Cholangiography (T1W-MRC) including controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA)-Volumetric Interpolated Breathhold (VIBE) technique compared to T2-weighted MR Cholangiography (T2W-MRC) in depicting biliary anatomy in potential living liver donors.

METHODS

Eighty-five potential donors including 34 men with a mean age of 35.6 years (range, 18-55 years) and 51 women with a mean age of 36.7 years (range, 23-57 years), were enrolled in this ethics-approved retrospective study. Image quality for depiction of bile ducts was evaluated by two readers in consensus in 3 separate reading sessions: 1) T2W-MRC alone, 2) T1W-MRC alone (including CAIPI-VIBE and generalized autocalibrating partially parallel acquisitions (GRAPPA)-VIBE techniques, and 3) combined T1W/T2W-MRC. Accuracy of T2W-MRC, T1W-MRC, and combined T1W/T2W-MRC for the identification/classification of the biliary variants was calculated using intraoperative cholangiogram (IOC) as the reference standard. Image quality and reader diagnostic confidence provided by CAIPI-VIBE technique was compared with GRAPPA-VIBE technique. Datasets were compared using the Wilcoxon signed-rank test.

RESULTS

Image quality for depiction of the bile ducts was significantly superior in the combined T1W/T2W-MRC group, when compared to each of T2W-MRC and T1W-MRC groups independently (P value = 0.001-0.034). The combination of CAIPI-VIBE and GRAPPA-VIBE was superior compared to each of the sequences individually. The accuracy of T2W-MRC and T1W-MRC was 93% and 91%, respectively. T1W-MRC depicted four biliary variants better than T2W-MRC. Two variants not well seen in T2W-MRC were clearly shown on T1W-MRC.

CONCLUSION

Gadoxetic-acid-enhanced T1W-MRC and conventional T2W-MRC techniques are complementary for depiction of biliary variants in potential liver donors and the combination of the two improves the results. The combination of CAIPI-VIBE and GRAPPA-VIBE techniques appear to be complementary for optimal diagnostic yield of T1W-MRC.

The high-end range of biliary reconstruction in living donor liver transplant

PURPOSE OF REVIEW

To summarize recent evidence in literature regarding incidence and risk factors for biliary complications in living donor liver transplantation (LDLT), and current concepts in evaluation of donor biliary anatomy and surgical techniques of biliary reconstruction, to reduce the incidence of biliary complications.

RECENT FINDINGS

Advances in biliary imaging in the donor, both before surgery, and during donor hepatectomy, as well as safe hepatic duct isolation in the donor, have played a significant role in reducing biliary complications in both the donor and recipient. Duct-to-duct biliary anastomoses (DDA) is the preferred mode of biliary reconstruction currently, especially when there is a single bile duct orifice in the donor. The debate on stenting the anastomoses, especially a DDA, continues. Stenting a Roux en Y hepaticojejunostomy in children with small ductal orifices in the donor is preferred. With growing experience, and use of meticulous surgical technique and necessary modifications, the incidence of biliary complications in multiple donor bile ducts, and more than one biliary anastomoses can be reduced.

SUMMARY

Biliary anastomosis continues to be the Achilles heel of LDLT. Apart from surgical technique, which includes correct choice of type of reconstruction technique and appropriate use of stents across ductal anastomoses, better imaging of the biliary tree, and safe isolation of the graft hepatic duct, could help reduce biliary complications in the recipient, and make donor hepatectomy safe .

Bilateral proficiency over time leads to reduced donor morbidity in living donor hepatectomy

Background

Although left-lobe donation is considered safer, right-sided donor hepatectomy predominates in adult living donor liver transplantation (LDLT). We hypothesized that bilateral proficiency with donor hepatectomy reduces overall donor complications.

Methods

A retrospective review of 834 adult LDLT donors (221 left lobes) from January 2004 to December 2014 was performed, dividing cases into two eras based on left-graft experience. Donor complications within 6 months were investigated, focusing on graft side and surgical era.

Results

The overall complication rate was 17.6%, and was higher in right-lobe donors. In Era 2, during which left-lobe donation rates were three times higher, total complications decreased (14.7% vs. 20.9%, P=0.02). A significant reduction in postoperative ascites accounted for the lower overall complication rate. The proportion of major biliary complications (BCs) was halved from 62.5% to 25.0%. Right-lobe donor complications also decreased significantly (15.8% vs. 22.9%, P=0.032), demonstrating that it was not only increased left-lobe donations leading to lowered complication rates, but also greater experience with donor hepatectomy in general.

Conclusions

Accumulating experience with bilateral donor hepatectomy leads to decreased donor morbidity and comparable outcomes for right and left lobes, further enhancing the goal of donor safety while balancing recipient needs.

Living Donor Liver Transplantation: Overview, Imaging Technique, and Diagnostic Considerations

OBJECTIVE. The purpose of this article is to discuss the process of becoming a liver donor, describe the surgical methods used for transplantation, and critically review preoperative and intraoperative imaging techniques. CONCLUSION. Radiologists play a vital role in ensuring the safety of living liver donors; however, consensus guidelines do not exist for imaging protocol or reporting. Standardization would provide more consistent image quality across centers, improve communication with the transplant team, and facilitate data mining for quality assurance and research.

Critical Care Management of Living Donor Liver Transplants

This article represents a review of the postoperative management of donors and recipients after living donor liver transplant, including monitoring, liberation from mechanical ventilation, nutritional support, and pain control. Vascular complications, such as biliary and sepsis, and bleeding are also discussed. Finally, commonly used immunosuppression and antimicrobial prophylaxes are reviewed.

Revisiting donor risk over two decades of single-center experience: More attention on the impact of overweight

OBJECTIVE

Morbidity rates after living donor hepatectomy vary greatly among centers. Donor morbidity in a tertiary center over the past two decades was revisited.

METHODS

Clinical data and grading of complications were reviewed by a nontransplant surgeon based on Clavien 5 tier grading. Risk factors were analyzed.

RESULTS

In total, 473 consecutive living liver donors from 1997 to 2016 were included for analysis; 305 were right liver donors and 168 left liver donors, and the corresponding morbidity rates were 27.2% and 9.5%. The majority (81/99, 81.2%) of complications were grade I and II. Donors with morbidity compared with those without were significantly younger, nonoverweight body figure (BMI < 25), more as the right liver donors, and longer length of hospital stay. Right liver donation had significantly higher morbidity rates than did left liver donation in earlier periods (before 2011), but not thereafter. Multivariate modeling revealed that right lobe donation and overweight (BMI ≥ 25 kg/m²) were significant factors associated with donor morbidity, with adjusted hazard ratios HR (95% confidence interval) of 3.401 (1.909-6.060) and 0.550 (0.304-0.996), respectively. Further, overweight was a paradoxical risk factor in right donor hepatectomy with HR 0.422 (0.209-0.851), but the effect was nonsignificant in left liver donors. Most complications in overweight donors were grade I and not specific to liver surgery.

CONCLUSIONS

The overall complication rate was 20.9%. Overweight might be protective against morbidity in right hepatectomy and warrants further deliberation.

Different techniques for harvesting grafts for living donor liver transplantation: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on minimally vs conventional invasive techniques for harvesting grafts for living donor liver transplantation.

METHODS

PubMed, Web of Science, EMBASE, and the Cochrane Library were searched comprehensively for studies comparing MILDH with conventional living donor hepatectomy (CLDH). Intraoperative and postoperative outcomes (operative time, estimated blood loss, postoperative liver function, length of hospital stay, analgesia use, complications, and survival rate) were analyzed in donors and recipients. Articles were included if they: (1) compared the outcomes of MILDH and CLDH; and (2) reported at least some of the above outcomes.

RESULTS

Of 937 articles identified, 13, containing 1592 patients, met our inclusion criteria and were included in the meta-analysis. For donors, operative time [weighted mean difference (WMD) = 20.68, 95%CI: -6.25-47.60, P = 0.13] and blood loss (WMD = -32.61, 95%CI: -80.44-5.21, P = 0.18) were comparable in the two groups. In contrast, analgesia use (WMD = -7.79, 95%CI: -14.06-1.87, P = 0.01), postoperative complications [odds ratio (OR) = 0.62, 95%CI: 0.44-0.89, P = 0.009], and length of hospital stay (WMD): -1.25, 95%CI: -2.35-0.14, P = 0.03) significantly favored MILDH. No differences were observed in recipient outcomes, including postoperative complications (OR = 0.93, 95%CI: 0.66-1.31, P = 0.68) and survival rate (HR = 0.96, 95%CI: 0.27-3.47, P = 0.95). Funnel plot and statistical methods showed a low probability of publication bias.

CONCLUSION

MILDH is safe, effective, and feasible for living donor liver resection with fewer donor postoperative complications, reduced length of hospital stay and analgesia requirement than CLDH.