Totally Laparoscopic Right Hepatectomy for Living Donor Liver Transplantation: Analysis of a Preliminary Experience on 5 Consecutive Cases

New insights into the regulation of bile acids synthesis during the early stages of liver regeneration: A human and experimental study

BACKGROUND AND AIMS

Liver regeneration is essential for the preservation of homeostasis and survival. Bile acids (BAs)-mediated signaling is necessary for liver regeneration, but BAs levels need to be carefully controlled to avoid hepatotoxicity. We studied the early response of the BAs-fibroblast growth factor 19 (FGF19) axis in healthy individuals undergoing hepatectomy for living donor liver transplant. We also evaluated BAs synthesis in mice upon partial hepatectomy (PH) and acute inflammation, focusing on the regulation of cytochrome-7A1 (CYP7A1), a key enzyme in BAs synthesis from cholesterol.

METHODS

Serum was obtained from twelve human liver donors. Mice underwent 2/3-PH or sham-operation. Acute inflammation was induced with bacterial lipopolysaccharide (LPS) in mice fed control or antoxidant-supplemented diets. BAs and 7α-hydroxy-4-cholesten-3-one (C4) levels were measured by HPLC-MS/MS; serum FGF19 by ELISA. Gene expression and protein levels were analyzed by RT-qPCR and western-blot.

RESULTS

Serum BAs levels increased after PH. In patients with more pronounced hypercholanemia, FGF19 concentrations transiently rose, while C4 levels (a readout of CYP7A1 activity) dropped 2 h post-resection in all cases. Serum BAs and C4 followed the same pattern in mice 1 h after PH, but C4 levels also dropped in sham-operated and LPS-treated animals, without marked changes in CYP7A1 protein levels. LPS-induced serum C4 decline was attenuated in mice fed an antioxidant-supplemented diet.

CONCLUSIONS

In human liver regeneration FGF19 upregulation may constitute a protective response from BAs excess during liver regeneration. Our findings suggest the existence of post-translational mechanisms regulating CYP7A1 activity, and therefore BAs synthesis, independent from CYP7A1/Cyp7a1 gene transcription.

Robotic and laparoscopic right lobe living donation compared to the open approach: A multicenter study on 1194 donor hepatectomies

Due to the success of minimally invasive liver surgery, laparoscopic and robotic minimally invasive donor hepatectomies (MIDH) are increasingly performed worldwide. We conducted a retrospective, multicentre, propensity score-matched analysis on right lobe MIDH by comparing the robotic, laparoscopic, and open approaches to assess the feasibility, safety, and early outcomes of MIDHs. From January 2016 until December 2020, 1194 donors underwent a right donor hepatectomy performed with a robotic (n = 92), laparoscopic (n = 306), and open approach (n = 796) at 6 high-volume centers. Donor and recipients were matched for different variables using propensity score matching (1:1:2). Donor outcomes were recorded, and postoperative pain was measured through a visual analog scale. Recipients' outcomes were also analyzed. Ninety-two donors undergoing robotic surgery were matched and compared to 92 and 184 donors undergoing laparoscopic and open surgery, respectively. Conversions to open surgery occurred during 1 (1.1%) robotic and 2 (2.2%) laparoscopic procedures. Robotic procedures had a longer operative time (493 ± 96 min) compared to laparoscopic and open procedures (347 ± 120 and 358 ± 95 min; p < 0.001) but were associated with reduced donor blood losses ( p < 0.001). No differences were observed in overall and major complications (≥ IIIa). Robotic hepatectomy donors had significantly less pain compared to the 2 other groups ( p < 0.001). Fifty recipients of robotic-procured grafts were matched to 50 and 100 recipients of laparoscopic and open surgery procured grafts, respectively. No differences were observed in terms of postoperative complications, and recipients' survival was similar ( p =0.455). In very few high-volume centers, robotic right lobe procurement has shown to be a safe procedure. Despite an increased operative and the first warm ischemia times, this approach is associated with reduced intraoperative blood losses and pain compared to the laparoscopic and open approaches. Further data are needed to confirm it as a valuable option for the laparoscopic approach in MIDH.

Minimally Invasive Surgery in Liver Transplantation: From Living Liver Donation to Graft Implantation

Since the end of the 20th century and the establishment of minimally invasive techniques, they have become the preferred operative method by many surgeons. These techniques were applied to liver surgery for the first time in 1991, while as far as transplantation is concerned their application was limited to the living donor procedure. We performed a review of the literature by searching in Pubmed and Scopus using the following keywords: Liver transplantation, Minimally invasive surgery(MIS) living liver donor surgery. Applications of MIS are recorded in surgeries involving the donor and the recipient. Regarding the recipient surgeries, the reports are limited to 25 patients, including combinations of laparoscopic, robotic and open techniques, while in the living donor surgery, the reports are much more numerous and with larger series of patients. Shorter hospitalization times and less blood loss are recorded, especially in centers with experience in a large number of cases. Regarding the living donor surgery, MIS follows the same principles as a conventional hepatectomy and is already the method of choice in many specialized centers. Regarding the recipient surgery, significant questions arise mainly concerning the safe handling of the liver graft.

Pure laparoscopic donor hepatectomy: Experience of 556 cases at Seoul National University Hospital

Pure laparoscopic donor hepatectomy (PLDH) has become a routine procedure at Seoul National University Hospital, and the pure laparoscopic method is now being applied to liver recipients as well. This study aimed to review the procedure and outcomes of PLDH to identify any areas that required improvement. Data from 556 donors who underwent PLDH between November 2015 and December 2021 and their recipients were retrospectively reviewed. Among these, 541 patients underwent pure laparoscopic donor right hepatectomy (PLDRH). The mean hospital stay of the donor was 7.2 days, and the rate of grade I, II, IIIa, and IIIb complications was 2.2%, 2.7%, 1.3%, and 0.9%, respectively, without any irreversible disabilities or mortalities. The most common early and late major complications in the recipient were intraabdominal bleeding (n = 47, 8.5%) and biliary problems (n = 198, 35.6%), respectively. Analysis of the PLDRH procedure showed that operative time, liver removal time, warm ischemic time, Δhemoglobin%, Δtotal bilirubin%, and postoperative hospital stay decreased significantly as the number of cases accumulated. In conclusion, the operative outcomes of PLDRH improved as the number of cases increased. However, continuous caution is needed because major complications still occur in donors and recipients even after hundreds of cases.

Systematic review and meta-analysis of open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy

The value of minimally invasive approaches for living donor hepatectomy remains unclear. Our aim was to compare the donor outcomes after open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy (OLDH vs. LALDH vs. PLLDH vs. RLDH). A systematic literature review of the MEDLINE, Cochrane Library, Embase, and Scopus databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (up to December 8, 2021). Random-effects meta-analyses were performed separately for minor and major living donor hepatectomy. The risk of bias in nonrandomized studies was assessed using the Newcastle-Ottawa Scale. A total of 31 studies were included. There was no difference in donor outcomes after OLDH versus LALDH for major hepatectomy. However, PLLDH was associated with decreased estimated blood loss, length of stay (LOS), and overall complications versus OLDH for minor and major hepatectomy, but also with increased operative time for major hepatectomy. PLLDH was associated with decreased LOS versus LALDH for major hepatectomy. RLDH was associated with decreased LOS but with increased operative time versus OLDH for major hepatectomy. The scarcity of studies comparing RLDH versus LALDH/PLLDH did not allow us to meta-analyze donor outcomes for that comparison. There seems to be a marginal benefit in estimated blood loss and/or LOS in favor of PLLDH and RLDH. The complexity of these procedures limits them to transplant centers with high volume and experience. Future studies should investigate self-reported donor experience and the associated economic costs of these approaches.

Risk-Adjusted Assessment of the Learning Curve for Pure Laparoscopic Donor Hepatectomy for Adult Recipients

BACKGROUND

Studies on pure laparoscopic donor hepatectomy (PLDH) have been reported. However, only few studies have reported on the learning curve of PLDH. In this report, we aimed to determine the learning curve of PLDH in adult patients using cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) analyses.

METHODS

The data of donors who underwent PLDH at a single center between December 2012 and May 2022 were retrospectively reviewed. The learning curve was evaluated using the CUSUM and RA-CUSUM methods based on surgery duration.

RESULTS

Forty-eight patients were finally included in the present study. The mean operation time was 393.6 ± 80.3 min. PLDH was converted to laparotomy in three cases (6.3%). According to the Clavien-Dindo classification, nine cases (18.8%) had higher-than-grade III postoperative complications and the most frequent complications were biliary complications. The CUSUM graph shows two peaks, at the 13th and 27th case. The multivariate analysis revealed that a body mass index ≥ 23 kg/m2 and intraoperative cholangiography were the only factors that were independently associated with longer operation time. Based on these results, an RA-CUSUM analysis was performed to assess the learning curve, which showed a decrease in the learning curve after 33 to 34 PLDH procedures.

CONCLUSIONS

A learning curve effect was demonstrated in this study after 33 to 34 PLDH procedures. There are relatively many biliary complications, and it is necessary to further examine the method of bile duct transection.

Mapping early serum proteome signatures of liver regeneration in living donor liver transplant cases

The liver is the only solid organ capable of regenerating itself to regain 100% of its mass and function after liver injury and/or partial hepatectomy (PH). This exceptional property represents a therapeutic opportunity for severe liver disease patients. However, liver regeneration (LR) might fail due to poorly understood causes. Here, we have investigated the regulation of liver proteome and phosphoproteome at a short time after PH (9 h), to depict a detailed mechanistic background of the early LR phase. Furthermore, we analyzed the dynamic changes of the serum proteome and metabolome of healthy living donor liver transplant (LDLT) donors at different time points after surgery. The molecular profiles from both analyses were then correlated. Insulin and FXR-FGF15/19 signaling were stimulated in mouse liver after PH, leading to the activation of the main intermediary kinases (AKT and ERK). Besides, inhibition of the hippo pathway led to an increased expression of its target genes and of one of its intermediary proteins (14-3-3 protein), contributing to cell proliferation. In association with these processes, metabolic reprogramming coupled to enhanced mitochondrial activity cope for the energy and biosynthetic requirements of LR. In human serum of LDLT donors, we identified 56 proteins and 13 metabolites statistically differential which recapitulate some of the main cellular processes orchestrating LR in its early phase. These results provide mechanisms and protein mediators of LR that might prove useful for the follow-up of the regenerative process in the liver after PH as well as preventing the occurrence of complications associated with liver resection.

Global dissemination of minimally invasive living donor hepatectomy: What are the barriers?

Minimally invasive donor hepatectomy (MIDH) is a relatively novel procedure that can potentially increase donor safety and contribute to faster rehabilitation of donors. After an initial period in which donor safety was not effectively validated, MIDH currently seems to provide improved results, provided that it is conducted by experienced surgeons. Appropriate selection criteria are crucial to achieve better outcomes in terms of complications, blood loss, operative time, and hospital stay. Beyond a pure laparoscopic technique, various approaches have been recommended such as hand-assisted, laparoscopic-assisted, and robotic donation. The latter has shown equal outcomes compared to open and laparoscopic approaches. A steep learning curve seems to exist in MIDH, mainly due to the fragility of the liver parenchyma and the experience needed for adequate control of bleeding. This review investigated the challenges and the opportunities of MIDH and the barriers to its global dissemination. Surgeons need expertise in liver transplantation, hepatobiliary surgery, and minimally invasive techniques to perform MIDH. Barriers can be categorized into surgeon-related, institutional-related, and accessibility. More robust data and the creation of international registries are needed for further evaluation of the technique and the acceptance from more centers worldwide.

A systematic review and network meta-analysis of outcomes after open, mini-laparotomy, hybrid, totally laparoscopic, and robotic living donor right hepatectomy

BACKGROUND

A systematic review and network meta-analysis was performed to compare outcomes after living donor right hepatectomy via the following techniques: conventional open (Open), mini-laparotomy (Minilap), hybrid (Hybrid), totally laparoscopic (Lap), and robotic living donor right hepatectomy (Robotic).

METHODS

PubMed, EMBASE, Cochrane, and Scopus were searched from inception to August 2021 for comparative studies of patients who underwent living donor right hepatectomy.

RESULTS

Nineteen studies comprising 2,261 patients were included. Operation time was longer in Lap versus Minilap and Open (mean difference 65.09 min, 95% confidence interval 3.40-126.78 and mean difference 34.81 minutes, 95% confidence interval 1.84-67.78), and in Robotic versus Hybrid, Lap, Minilap, and Open (mean difference 144.72 minutes, 95% confidence interval 89.84-199.59, mean difference 113.24 minutes, 95% confidence interval 53.28-173.20, mean difference 178.33 minutes, 95% confidence interval 105.58-251.08 and mean difference 148.05 minutes, 95% confidence interval 97.35-198.74, respectively). Minilap and Open were associated with higher blood loss compared to Lap (mean difference 258.67 mL, 95% confidence interval 107.00-410.33 and mean difference 314.11 mL, 95% confidence interval 143.84-484.37) and Robotic (mean difference 205.60 mL, 95% confidence interval 45.92-365.28 and mean difference 261.04 mL, 95% confidence interval 84.26-437.82). Open was associated with more overall complications compared to Minilap (odds ratio 2.60, 95% confidence interval 1.11-6.08). Recipient biliary complication rate was higher in Minilap and Open versus Hybrid (odds ratio 3.91, 95% confidence interval 1.13-13.55 and odds ratio 11.42, 95% confidence interval 2.27-57.49), and lower in Open versus Minilap (OR 0.07, 95% confidence interval 0.01-0.34).

CONCLUSION

Minimally invasive donor right hepatectomy via the various techniques is safe and feasible when performed in high-volume centers, with no major differences in donor complication rates and comparable recipient outcomes once surgeons have mounted the learning curve.

Perioperative management of living donor liver transplantation: Part 2 - Donors

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.

Extended criteria donors for Robotic Right Hepatectomy- A Propensity Score matched Analysis

BACKGROUND

Robotic right donor hepatectomy (RDH) has been reported from experienced centers with reduced morbidity when compared to open RDH. However, outcomes in donors with large grafts/ complex biliovascular anatomy are unknown.

METHODS

Out of 170 robotic RDH, 100 had one or more of the following: graft weight ≥ 800gms, type 2/3 portal vein, >1 bile duct or hepatic artery and inferior hepatic veins >5mm requiring reconstruction (extended criteria donors- ExRDH), while the remaining 70 had standard anatomy (SRDH). After propensity score matching, 66 ExRDH were compared with 66 SRDH. Additionally, all robotic RDH performed were analysed in 3 temporal phases (60, 60 and 50).

RESULTS

Peak AST and ALT were higher among donors and recipients in the ExRDH arm compared to SRDH. Other intraoperative parameters and post-operative complications were similar between the two groups. During the last phase, donors demonstrated reduction in duration of surgery, postoperative complications and hospital stay while recipients showed decreased blood loss and hospital stay.

CONCLUSION

Robotic right hepatectomy performed in donors with extended criteria have similar perioperative outcomes as standard donors. However, a significant learning curve needs to be traversed. Further studies are required before safely recommending robotic RDH for all donors.

Comparative outcomes of pure laparoscopic and open donor right hepatectomy: the first report from a Southeast Asian transplant center

Background

Pure laparoscopic donor right hepatectomy (PLDRH) can provide better operative outcomes for the donor than conventional open donor right hepatectomy (CODRH). However, the complexity of the procedure typically makes transplant teams reluctant to perform it, especially in low-volume transplant centers. We compared the outcomes of PLDRH and CODRH to demonstrate the feasibility of PLDRH in a low-volume transplant program.

Methods

We carried out a retrospective study of adult living donor liver transplantation in Chiang Mai University Hospital from January 2015 to March 2021. The patients were divided into a PLDRH group and a CODRH group. Baseline characteristics, operative parameters, and postoperative complications of donors and recipients were compared between the two groups.

Results

Thirty patients underwent donor hepatectomy between the dates selected (9 PLDRH patients and 21 CODRH patients). The baseline characteristics of the 2 groups were not significantly different. The median graft volume of the PLDRH group was 693.8 mL, which was not significantly different from that of the CODRH group (726.5 mL) The PLDRH group had a longer operative time than the CODRH group, but the difference was not statistically significant (487.5 min vs 425.0 min, p = 0.197). The overall complication rate was not significantly different between the two groups (33.3% vs 22.2%, p = 0.555). Additionally, for the recipients, the incidence of major complications was not significantly different between the groups (71.3 vs 55.6%, p = 0.792).

Conclusion

Even in the context of this low-volume transplant program, whose staff have a high level of experience in minimally invasive hepatobiliary surgery, PLDRH showed similar results to CODRH in terms of perioperative outcomes for donors and recipients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01507-0.

Pure laparoscopic versus open donor hepatectomy for adult living donor liver transplantation - A systematic review and meta-analysis

Background

Pure laparoscopic donor hepatectomy (PLDH) for adult living donor liver transplantation (LDLT) remains controversial. The aim of this study was to undertake a systematic review and meta-analysis of donor outcomes following PLDH for adult LDLT.

Materials and Methods

Systematic review in line with the meta-analysis of observational studies in epidemiology guidelines.

Results

Eight studies were included in the systematic review and six in the meta-analysis. A total of 575 donors underwent PLDH for adult LDLT. The mean donor age was 32.8 years with a BMI of 23.4 kg/m² and graft weight of 675 g. The mean operative time was 353 min and the conversion rate was 2.8% (n = 16). Overall morbidity was 10.8% with 1.6% major complications (Clavien-Dindo grade 3b), zero mortality and 9.0 days length of stay (LOS). The meta-analysis demonstrated that the operative time was significantly shorter for the open donor hepatectomy group (mean difference 29.15 min; P = 0.006) and the LOS was shorter for the PLDH group (mean difference -0.73 days; P = 0.02), with a trend towards lesser estimated blood loss in PLDH group. However, no difference between the two groups was noted in terms of overall morbidity or major complications.

Conclusions

Perioperative outcomes of PLDH are similar to the standard open approach in highly specialised centers with trend towards lesser blood loss and overall shorter hospital stay. Careful donor selection and standardisation of the technique are imperative for the successful implementation and adoption of the procedure worldwide.

World Survey on Minimally Invasive Donor Hepatectomy: A Global Snapshot of Current Practices in 2370 Cases

BACKGROUND

Having little evidence on the real extent of the minimally invasive donor hepatectomy (MIDH), a world survey was conducted aiming to picture the spread of MIDH and to identify geographical, institutional, and individual differences.

METHODS

A web-based survey was created with 5 sections (general, institutional, surgeon's experience, technical, and spread and dissemination), comprising up to a total of 47 questions. A thorough search was carried out to identify all possible centers and surgeons performing MIDH.

RESULTS

A global MIDH experience of 2370 cases was collected: 1587 right hepatectomies (RHs; 48.9% pure laparoscopic), 471 left lateral sectionectomies (LLS; 81.1% pure laparoscopic), and 366 left hepatectomies (LHs; 77.6% laparoscopic-assisted). LLS and adult MIDH conversion rates were 5.4% and 3.9%, respectively. Median blood loss was 250 mL (100-600), 100 mL (50-250), and 150 mL (50-500) for RH, LLS, and LH, respectively. Intra- and postoperative transfusion rates were 0.5%, 0%, and 0.3%; and 1.3%, 1.6%, and 0% for RH, LLS, and LH, respectively. Geographically, Asia accounts up to 1730 cases (73% of the global experience, 49.6% pure lap), of which 1374 cases are RH; Europe and Middle East-395 cases-stands out for its experience in left lateral sectionectomy: 289 cases (93% pure lap). Finally, America accounts for 245 cases, using a laparoscopic-assisted technique in 72.6% of the cases (178).

CONCLUSIONS

This world survey provides evidence and data on the global spread of MIDH and anticipates how in a near future a large-scale adoption of these techniques may be observed.

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.

Safety and feasibility of laparoscopic living donor right hepatectomy for adult liver transplantation: a meta-analysis

BACKGROUND

Laparoscopic living donor right hepatectomy (LDRH) was a controversial topic due to its unknown safety and feasibility.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched for studies comparing LDRH with open living donor right hepatectomy (ODRH), which were published between the date of database establishment and June 2020. Revman5.3 was used for statistical analysis.

RESULTS

Fourteen studies were included. For the donors, there was no significant difference in warm ischemic time, hospital stay, graft weight, hepatic arterial anomalies (HAA), hepatic vein anomalies (HVA), portal vein anomalies (PVA), biliary anomalies, bleeding, wound infection, severe complication rate and readmission rate. The estimated blood loss, incidence of complication, intra-abdominal fluid rate in the LDRH group were significantly lower than those in the ODRH group, while the operation time, time to remove liver in the LDRH group were significantly higher than those in the ODRH group. For the recipients, there was no significant difference in complication rate, bleeding, HAA, PVA, biliary anomalies, graft failure and mortality. The HVA rate in the LDRH group was significantly higher than that in the ODRH group.

CONCLUSION

LDRH is safe and feasible for adult living donor liver transplantation compared with ODRH and it can reduce intraoperative bleeding and postoperative complication in donors, which requires further verification by more multi-center comparative studies with large sample and high quality.

Expert Consensus Guidelines on Minimally Invasive Donor Hepatectomy for Living Donor Liver Transplantation From Innovation to Implementation: A Joint Initiative From the International Laparoscopic Liver Society (ILLS) and the Asian-Pacific Hepato-Pancreato-Biliary Association (A-PHPBA)

OBJECTIVE

The Expert Consensus Guidelines initiative on MIDH for LDLT was organized with the goal of safe implementation and development of these complex techniques with donor safety as the main priority.

BACKGROUND

Following the development of minimally invasive liver surgery, techniques of MIDH were developed with the aim of reducing the short- and long-term consequences of the procedure on liver donors. These techniques, although increasingly performed, lack clinical guidelines.

METHODS

A group of 12 international MIDH experts, 1 research coordinator, and 8 junior faculty was assembled. Comprehensive literature search was made and studies classified using the SIGN method. Based on literature review and experts opinions, tentative recommendations were made by experts subgroups and submitted to the whole experts group using on-line Delphi Rounds with the goal of obtaining >90% Consensus. Pre-conference meeting formulated final recommendations that were presented during the plenary conference held in Seoul on September 7, 2019 in front of a Validation Committee composed of LDLT experts not practicing MIDH and an international audience.

RESULTS

Eighteen Clinical Questions were addressed resulting in 44 recommendations. All recommendations reached at least a 90% consensus among experts and were afterward endorsed by the validation committee.

CONCLUSIONS

The Expert Consensus on MIDH has produced a set of clinical guidelines based on available evidence and clinical expertise. These guidelines are presented for a safe implementation and development of MIDH in LDLT Centers with the goal of optimizing donor safety, donor care, and recipient outcomes.

Robotic Versus Open Right Lobe Donor Hepatectomy for Adult Living Donor Liver Transplantation: A Propensity Score-Matched Analysis

Robotic right lobe donor hepatectomy (RRLDH) is rarely performed, and data concerning its safety and efficacy are lacking. Here we compare our series of RRLDHs with a similar cohort undergoing open right lobe donor hepatectomy (ORLDH) with a propensity score-matched (PSM) analysis. Among 263 consecutive adult patients undergoing right lobe living donor hepatectomy from January 2015 until July 2019, 35 RRLDHs were matched to 70 ORLDHs. A 1:2 PSM analysis was performed to make the groups comparable for donor sex, age, and body mass index (BMI) and for recipient sex, age, BMI, Model for End-Stage Liver Disease score, and indication for transplant. Operative time was longer in RRLDHs compared with ORLDHs (504 ± 73.5 versus 331 ± 65.1 minutes; P < 0.001) but significantly decreased with the number of patients (P < 0.001). No conversions occurred. First warm ischemia time was longer and blood loss significantly less in RRLDHs (P = 0.001 and 0.003, respectively). Overall donor complications were similar: 2 (6%) in RRLDHs versus 12 (17%) in ORLDHs (P = 0.13). Biliary leak occurred in 1 (3%) patient receiving a robotic procedure and 2 (3%) patients receiving the conventional approach. Donors undergoing robotic surgery required less patient-controlled analgesia and had a shorter hospital stay compared with the open surgery group (P < 0.001 and P = 0.001, respectively). No significant differences in graft anatomical data and recipient outcomes were recorded. RRLDH is feasible, safe, and reproducible, with significantly decreased blood loss and a shorter hospital stay compared with the open procedure. The first 35 patients receiving the robotic procedure showed a substantial reduction in operative time, reflecting a rapid shortening of the learning curve.

Influence of Body Mass Index ≥30 on Pure Laparoscopic Donor Right Hepatectomy

Background

Pure laparoscopic donor right hepatectomy (PLDRH) for donors with obesity has not been previously investigated. This study aimed to investigate the influence of donor obesity (BMI ≥30 kg/m²) on and clinical outcomes after PLDRH.

Material/Methods

Records of all living donors who underwent PLDRH between November 2015 and May 2018 and open conventional donor right hepatectomy (CDRH) between January 2011 and October 2015 at Seoul National University Hospital were retrospectively reviewed. The donors were divided into 3 groups: PLDRH BMI ≥30, PLDRH BMI <30, and CDRH BMI ≥30.

Results

Donors in the PLDRH BMI ≥30 group (n=7) were compared with those in the PLDRH BMI <30 (n=65; control 1) and CDRH BMI ≥30 (n=8; control 2) groups. Graft weight was significantly heavier in PLDRH BMI ≥30 than in control 1 (P=0.012). The lowest hemoglobin (Hb) value was higher (P=0.014) and ΔHb% was lower (P=0.005) in PLDRH BMI ≥30 than in control 1. Similarly, the lowest Hb value was higher (P=0.021) and ΔHb% was lower (P<0.001) in PLDRH BMI ≥30 than in control 2. The peak alanine aminotransferase (ALT) (P=0.029) and ΔALT% were higher in PLDRH BMI ≥30 than in control 2. No significant differences in hospital stay and postoperative complications were found between PLDRH BMI ≥3 and control 1, as well as between PLDRH BMI ≥3 and control 2.

Conclusions

This study revealed that PLDRH is feasible in donors with obesity.

Minimally Invasive Donor Hepatectomy for Adult Living Donor Liver Transplantation: An International, Multi-Institutional Evaluation of Safety, Efficacy and Early Outcomes

OBJECTIVE

Evaluating the perioperative outcomes of minimally invasive (MIV) donor hepatectomy for adult live donor liver transplants in a large multi-institutional series from both Eastern and Western centers.

BACKGROUND

Laparoscopic liver resection has become standard practice for minor resections in selected patients in whom it provides reduced postoperative morbidity and faster rehabilitation. Laparoscopic approaches in living donor hepatectomy for transplantation, however, remain controversial because of safety concerns. Following the recommendation of the Jury of the Morioka consensus conference to address this, a retrospective study was designed to assess the early postoperative outcomes after laparoscopic donor hepatectomy. The collective experience of 10 mature transplant teams from Eastern and Western countries was reviewed.

METHODS

All centers provided data from prospectively maintained databases. Only left and right hepatectomies performed using a MIV technique were included in this study. Primary outcome was the occurrence of complications using the Clavien-Dindo graded classification and the Comprehensive Complication Index during the first 3 months. Logistic regression analysis was used to identify risk factors for complications.

RESULTS

In all, 412 MIV donor hepatectomies were recorded including 164 left and 248 right hepatectomies. Surgical technique was either pure laparoscopy in 175 cases or hybrid approach in 237. Conversion into standard laparotomy was necessary in 17 donors (4.1%). None of the donors died. Also, 108 experienced 121 complications including 9.4% of severe (Clavien-Dindo 3-4) complications. Median Comprehensive Complication Index was 5.2.

CONCLUSIONS

This study shows favorable early postoperative outcomes in more than 400 MIV donor hepatectomy from 10 experienced centers. These results are comparable to those of benchmarking series of open standard donor hepatectomy.

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

Donor safety and graft results of pure laparoscopic living donor right hepatectomy (LLDRH) have previously been compared with those of open living donor right hepatectomy (OLDRH). However, the clinical outcomes of recipients at 1-year follow-up have never been accurately compared. We aimed to compare 1-year outcomes of recipients of living donor right liver transplantation (LRLT) using pure LLDRH and OLDRH. From May 2013 to May 2017, 197 consecutive recipients underwent LRLT. Donor hepatectomies were performed either by OLDRH (n = 127) or pure LLDRH (n = 70). After propensity score matching, 53 recipients were included in each group for analysis. The clinical outcomes at 1-year follow-up were compared between the 2 groups. The primary outcome was recipient death or graft failure during the 1-year follow-up period. In the propensity-matched analysis, the incidence of death or graft failure during the 1-year follow-up period was not different between the 2 groups (3.8% versus 5.7%; odds ratio [OR], 1.45; 95% confidence interval [CI], 0.24-8.95; P = 0.69). However, the composite of Clavien-Dindo 3b-5 complications was more frequent in the pure LLDRH group (OR, 2.62; 95% CI, 1.15-5.96; P = 0.02). In conclusion, although pure LLDRH affords a comparable incidence of fatal complications in recipients, operative complications may increase at the beginning of the program. The safety of the recipients should be confirmed to accept pure LLDRH as a feasible option.

Laparoscopic donor right hepatectomy in a donor with type III portal vein anomaly: A case report

RATIONALE

Laparoscopic right donor hepatectomy has been reported sporadically in several experienced centers for selected donors. This report introduced a case of a donor with an independent right posterior segmental portal branching from the main portal vein.

PATIENT CONCERNS

A 47-year-old woman volunteered to donate her right liver to her 48-year-old husband.

DIAGNOSES

The recipient has been diagnosed as hepatocellular carcinoma meeting the Milan criteria and hepatitis B virus related cirrhosis.

INTERVENTIONS

The parenchymal transection was performed by ultrasonic aspirator and Hem-o-Lok clips. The right hepatic artery, right hepatic duct, and the anterior and posterior branches of right portal vein were meticulously dissected, clamped, and transected. The right hepatic vein was transected by vascular stapler. A Y-graft of the recipient's own portal confluence was reconstructed with the donor's separate right anterior and posterior portal veins.

OUTCOMES

The donor's operation time was 420 minutes and the warm ischemia time was about 9 minutes. Blood loss was less than 600 ml without transfusion. The donor was discharged at the 10th postoperative day without any complications.

LESSONS

Laparoscopic right hepatectomy for donors with anomalous portal vein branching and subsequent inflow reconstruction for adult living donor liver transplantation is safe and feasible in highly experienced center.

Pure laparoscopic donor right hepatectomy: perspectives in manipulating a flexible scope

BACKGROUND

Interest in pure laparoscopic donor hepatectomy (PLDH) is increasing worldwide with the donor's cosmetic demands and improvements in surgical techniques. Efficient manipulation of flexible scope is mandatory for successful PLDH, especially in right hepatectomy which requires more mobilization. This study provides guidelines on how to manipulate optimally a flexible scope.

METHODS

Data from 158 donors who underwent pure laparoscopic donor right hepatectomy (PLDRH) between November 2015 and December 2017 were retrospectively reviewed.

RESULTS

None of the donors required transfusion, conversion to open hepatectomy, or experienced any irreversible disabilities or mortalities. Three types of laparoscopic view provided by the flexible scope, which are bird's eye view, low angle view, and lateral view, were applied to each step of the procedure.

CONCLUSIONS

PLDRH can be successfully performed with maximizing visibility given by the tips and pitfalls in manipulating the flexible scope.

Laparoscopic Donor Hepatectomy for Adult Living Donor Liver Transplantation Recipients

Even after 2 decades of experience in laparoscopic hepatectomy, data on purely laparoscopic approach for donor hepatectomy in adult living donor liver transplantation (LDLT) are limited. We report our initial experience of a purely laparoscopic approach for donor hepatectomy for adult recipients to explore its potential application in the management of donors. We did a retrospective data analysis of 54 consecutive patients operated on between May 2013 and February 2015. There were 41 right, 10 extended right, and 3 left hepatectomies. The median operative time was 436 minutes (range 294-684 minutes), and warm ischemia time was 6 minutes (2-12 minutes). Estimated blood loss was 300 mL (10-850 mL), and none of the patients required intraoperative transfusion. Four cases were converted to open laparotomy. The major complication rate was 16.7%, and biliary complication was the most frequent cause. Patients with normal anatomy had a major complication rate of 9.3% as compared with 45.5% in patients with anatomic variations. All patients recovered, and there was no mortality. In conclusion, a purely laparoscopic donor hepatectomy for adult LDLT recipients seems to be a feasible option; with careful patient selection and when performed by experienced surgeons, it may afford results comparable to the open method.

Pure laparoscopic right hepatectomy of living donor is feasible and safe: a preliminary comparative study in China

BACKGROUND

The adoption of laparoscopic techniques for living donor major hepatectomy has been controversial issue. The aim of this study is to present the preliminary experience of laparoscopic right hepatectomy in China.

METHODS

All the donors receiving right hepatectomy for adult-to-adult living donor liver transplantation (LDLT) were divided into three groups: pure laparoscopic right hepatectomy (PLRH) group, hand-assisted right hepatectomy (HARH) group and open right hepatectomy (ORH) group. We compared the perioperative data and surgical outcomes of donors and recipients among three groups.

RESULTS

From November 2001 to May 2017, 295 donors have received right hepatectomy for LDLT in our center. Among them, 7 donors received PLRH, 26 donors received HARH and 262 donors received ORH. The operation time of PLRH group (509.3 ± 98.9 min) was longer than that of the HARH group (451.6 ± 89.7 min) and the ORH group (418.4 ± 81.1 min, p = 0.003). The blood loss was the least in the PLRH group (378.6 ± 177.1 mL), compared with that in the HARH group (617.3 ± 240.4 mL) and that in the ORH group (798.6 ± 483.7 mL, p = 0.0013). The postoperative hospital stay was shorter in the PLRH group (7, 7-10 days) than that in the HATH group (8.5, 7.5-12 days) and ORH group (11, 9-14 days; p = 0.001). Only one donor had pleural effusion (Grade I) and another one experienced pulmonary infection (Grade II). One recipient (14.3%) in the PLRH group occurred hepatic venous stenosis.

CONCLUSIONS

Laparoscopic approaches for right hepatectomy contribute to less blood loss, better cosmetic satisfaction, less severe complications, and faster rehabilitation. PLRH is a safe and feasible procedure, which must be performed in highly specialized centers with expertise of both LDLT and laparoscopic hepatectomy, and requires a hybrid-to-pure stepwise development.

Pure Laparoscopic Living Donor Left Lateral Sectionectomy in Pediatric Transplantation: A Propensity Score Analysis on 220 Consecutive Patients

Left lateral sectionectomy for donor hepatectomy is a well-established alternative to deceased donor pediatric liver transplantation. However, very little is available on the laparoscopic approach (laparoscopic left lateral sectionectomy [L-LLS]). With the aim to assess safety, reproducibility under proctorship, and outcomes following living donor liver transplantation in children, a comparative single-center series using propensity score matching (PSM) to evaluate open left lateral sectionectomy (O-LLS) versus L-LLS was carried out in a relatively short time period in a high-volume pediatric transplant center. A retrospective, observational, single-center, PSM study was conducted on 220 consecutive living donor hepatectomies from January 2011 to April 2017. The variables considered for PSM were as follows: year of operation, recipient age, indication for transplant, recipient weight, donor sex, donor age, and donor body mass index. After matching, 72 O-LLSs were fit to be compared with 72 L-LLSs. Operative time and warm ischemia time were significantly longer in L-LLSs, whereas blood loss and overall donor complication rates were significantly lower. Postoperative day 1 and 4 pain scores were significantly less in the L-LLS group (P = 0.015 and 0.003, respectively). The length of hospital stay was significantly shorter in L-LLS (4.6 versus 4.1 days; P = 0.014). Overall donor biliary complications were 9 (12.5%) and 1 (1.4%) for O-LLS and L-LLS (P = 0.022), respectively. Vascular complications occurred in 3 (4.2%) children without graft loss in the laparoscopic group. The 1-, 3-, and 5-year overall patient survival rates were 98.5%, 90.9%, and 90.9% in the O-LLS group and in the L-LLS group 94.3%, 92.7%, and 86.8% (P = 0.28). In conclusion, L-LLS for donor hepatectomy is a safe and reproducible technique yielding better donor perioperative outcomes with respect to the conventional approach with similar recipient outcomes.

Laparoscopic donor hepatectomy

Laparoscopic liver resection has been applied to treat most indications for liver resection during the past two decades. According to the literature, patient numbers have increased exponentially as a result, and surgical difficulty has increased as well. In expert centers, laparoscopic anatomical hemihepatectomy and major liver resection more than 3 segments have become the acceptable treatment. Moreover, with surgical innovations and accumulated experience, living donor liver transplantation has become an established treatment choice for patients on the transplant waiting list. It is even considered an inevitable choice in regions with limited access to organs from deceased donors. However, significant morbidity and rare but catastrophic mortality are associated with donor hepatectomy and remain major concerns. Therefore, to decrease the incidence of complications, a minimally invasive approach in donor hepatectomy was adopted in the early 2000s. Initially, a minimally invasive approach was used for left lateral sectionectomy for pediatric liver transplant, then for laparoscopy-assisted hemihepatectomy and pure laparoscopic/robotic right donor hepatectomy, and more recently, for adult living donor liver transplantation. The extent of procedure complexity and potential complications depends on the approach and the size of the graft to be harvested. Early results from expert teams have seemed promising in terms of shortened donor recovery and improved perioperative outcomes. However, the combination of these two highly sophisticated surgical procedures raise more concerns about donor safety, especially with regard to unexpected events during the operation. A high level of evidence is very difficult to achieve in this highly specialized surgical practice with limited penetration. Therefore, an international registry has been suggested to determine the risks and benefits before the use of laparoscopic right donor hepatectomy spreads.

Impact of abdominal shape on living liver donor outcomes in mini-incision right hepatic lobectomy: Comparison among 3 techniques

Although minimally invasive techniques for living donor hepatectomy have been developed, the surgical feasibility and limitations remain to be elucidated. The risks and outcomes involved need to be better understood prior to their widespread application. The aim of this study was to assess feasibility of minimally invasive donor hepatectomy by reviewing our experience. A total of 99 living donor liver transplantations performed between 2000 and 2016 were retrospectively reviewed. All 99 living liver donors underwent right hepatectomy. The breakdown of the techniques is as follows: the standard technique in 33 patients; the laparoscopic-assisted minilaparotomy technique (hybrid technique group) in 19 patients; and the upper midline incision technique without laparoscopic assistance (minilaparotomy group) in 47 patients. An association between donor operative outcomes and body habitus, such as body mass index (BMI), abdominal truncal depth (approximated by celiac axis [CA] depth ratio), and umbilical circumference (UC) were assessed. Perioperative factors were compared between the standard technique and the minimally invasive technique. The minilaparotomy group had significantly shorter operative time (P = 0.046) and hospital stay (P = 0.005) than the standard technique group. Postoperative complication rates were similar between the 3 groups (P = 0.16). In the minilaparotomy group, greater BMI (P = 0.02), CA depth ratio (P = 0.04), and UC (P = 0.004) were found to be risk factors for postoperative complications. In the minilaparotomy group, CA depth ratio > 0.41, UC > 90 cm, and BMI > 30 kg/m² were significantly associated with longer operative time and hospital stay. In the standard technique group, none of the body size factors were associated with postoperative outcomes. In conclusion, the minilaparotomy technique is safe and feasible, though technical difficulties may be encountered when performed on donors with larger body habitus. Ongoing efforts are required to ensure living donor safety. Liver Transplantation 24 516-527 2018 AASLD.

Initial experience with purely laparoscopic living-donor right hepatectomy

BACKGROUND

There may be concerns about purely laparoscopic donor right hepatectomy (PLDRH) compared with open donor right hepatectomy, especially when performed by surgeons accustomed to open surgery. This study aimed to describe technical tips and pitfalls in PLDRH.

METHODS

Data from donors who underwent PLDRH at Seoul National University Hospital between December 2015 and July 2017 were analysed retrospectively. Endpoints analysed included intraoperative events and postoperative complications. All operations were performed by a single surgeon with considerable experience in open living donor hepatectomy.

RESULTS

A total of 26 donors underwent purely laparoscopic right hepatectomy in the study interval. No donor required transfusion during surgery, whereas two underwent reoperation. In two donors, the dissection plane at the right upper deep portion of the midplane was not correct. One donor experienced portal vein injury during caudate lobe transection, and one developed remnant left hepatic duct stenosis. One donor experienced remnant portal vein angulation owing to a different approach angle, and one experienced arterial damage associated with the use of a laparoscopic energy device. One donor had postoperative bleeding due to masking of potential bleeding foci owing to intra-abdominal pressure during laparoscopy. Two donors experienced right liver surface damage caused by a xiphoid trocar.

CONCLUSION

Purely laparoscopic donor hepatectomy differs from open donor hepatectomy in terms of angle and caudal view. Therefore, surgeons experienced in open donor hepatectomy must gain adequate experience in laparoscopic liver surgery and make adjustments when performing PLDRH.

Standardized hybrid living donor hemihepatectomy in adult-to-adult living donor liver transplantation

The aim of this study was to analyze the outcomes of the most updated version and largest group of our standardized hybrid (laparoscopic mobilization and hepatectomy through midline incision) living donor (LD) hemihepatectomy compared with those from a conventional laparotomy in adult-to-adult living donor liver transplantation (LDLT). Of 237 adult-to-adult LDLTs from August 1997 to March 2017, 110 LDs underwent the hybrid procedure. Preoperative and operative factors were analyzed and compared with conventional laparotomy (n = 126). The median duration of laparoscopic usage was 26 minutes in the hybrid group. Although there was improvement in applying this procedure over time from the beginning of the series of cases studied, blood loss and operative duration were still smaller and shorter in the hybrid group. There was no significant difference between the groups in the incidence of postoperative complications greater than or equal to Clavien-Dindo class III. There was no difference in recipient outcome between the groups. Our standardized procedure of hybrid LD hepatectomy is applicable and safe for all types of LD hepatectomies, and it enables the benefit of both the laparoscopic and the open approach in a transplant center without a laparoscopic expert. Liver Transplantation 24 363-368 2018 AASLD.

Pure laparoscopic living donor hepatectomy: Focus on 55 donors undergoing right hepatectomy

Although laparoscopic donor hepatectomy is increasingly common, few centers with substantial experience have reported the results of pure laparoscopic donor right hepatectomy (PLDRH). Here, we report the experiences of 60 consecutive liver donors undergoing pure laparoscopic donor hepatectomy (PLDH), with most undergoing right hepatectomy. None of the 60 donors who underwent PLDH had intraoperative complications and none required transfusions, reoperation, or conversion to open hepatectomy. Forty-five donors who underwent PLDRH between November 2015 and December 2016 were compared with 42 who underwent conventional donor right hepatectomy (CDRH) between May 2013 and February 2014. The total operation time was longer (330.7 vs 280.0 minutes; P < .001) and the percentage with multiple bile duct openings was higher (53.3% vs 26.2%; P = .010) in the PLDRH group. However, the length of postoperative hospital stay (8.4 vs 8.2 days; P = .495) and rate of complications (11.9% vs 8.9%; P = .733) and re-hospitalizations (4.8% vs 4.4%; P = 1.000) were similar in both groups. PLDH, including PLDRH, is feasible when performed by a highly experienced surgeon and transplant team. Further evaluation, including long-term results, may support these preliminary findings of comparative outcomes for donors undergoing PLDRH and CDRH.