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Bonaccorsi-Riani E, Daudré-Vignier V, Ciccarelli O, Coubeau L, Iesari S, Castanares-Zapatero D, Collienne C, Annet L, Danse E, Balligand JL, Lefebvre C, Dieu A, Benoit L, Reding R. Improving Safety in Living Liver Donation: Lessons From Intraoperative Adverse Events in 438 Donors Undergoing a Left Liver Resection. Transplant Direct 2023; 9:e1531. [PMID: 37636484 PMCID: PMC10455133 DOI: 10.1097/txd.0000000000001531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 08/29/2023] Open
Abstract
Background Donor safety is paramount in living organ donation. Left liver resections are considered safer than right lobe hepatectomies. However, unexpected intraoperative adverse events (iAEs), defined as any deviation from the ideal intraoperative course, can also occur during left liver resections and may be life threatening or lead to postoperative complication or permanent harm to the donor and recipient. Methods Records of 438 liver living donors (LDs) who underwent 393 left lateral sectionectomies (LLSs) and 45 left hepatectomies (LHs) between July 1993 and December 2018 in a pediatric living-donor liver transplantation center were reviewed for the appearance of iAEs that could have influenced the donor morbidity and mortality and that could have contributed to the improvement of the LD surgical protocol. Results Clinical characteristics of LLS and LH groups were comparable. Nine iAEs were identified, an incidence of 2%, all of them occurring in the LLS group. Seven of them were related to a surgical maneuver (5 associated with vascular management and 2 with the biliary tree approach). One iAE was associated with an incomplete donor workup and the last with drug administration. Each iAE resulted in subsequent changes in the surgical protocol. Donor outcome was at risk by 5 iAEs classed as type a, recipient outcome by 2 iAEs (type b) and both by 2 iAEs (type c). Postoperative complications occurred in 87 LDs (19.9%), with no differences between the LLS and LH groups (P = 0.227). No Clavien-Dindo class IVa or b complications or donor mortality (Clavien-Dindo class V) were observed. Conclusions iAEs debriefings induced changes in our LD protocol and may have contributed to reduced morbidity and zero mortality. iAEs analysis can be used as a quality and safety improvement tool in the context of LD procedures, which may include right liver donation, laparoscopic, and robotic living liver graft procurement.
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Affiliation(s)
- Eliano Bonaccorsi-Riani
- Transplantation and Abdominal Surgery Section, Department of Surgery, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
- Institute de Recherche Expérimentale et Clinique – IREC, UCLouvain, Brussels, Belgium
| | - Victoria Daudré-Vignier
- Transplantation and Abdominal Surgery Section, Department of Surgery, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Olga Ciccarelli
- Transplantation and Abdominal Surgery Section, Department of Surgery, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
- Institute de Recherche Expérimentale et Clinique – IREC, UCLouvain, Brussels, Belgium
| | - Laurent Coubeau
- Transplantation and Abdominal Surgery Section, Department of Surgery, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Samuele Iesari
- Kidney Transplantation, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Christine Collienne
- Adult Intensive Care Unit, Cliniques universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Laurence Annet
- Department of Radiology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Etienne Danse
- Department of Radiology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Jean-Luc Balligand
- Institute de Recherche Expérimentale et Clinique – IREC, UCLouvain, Brussels, Belgium
- Department of Internal Medicine, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Chantal Lefebvre
- Institute de Recherche Expérimentale et Clinique – IREC, UCLouvain, Brussels, Belgium
- Department of Internal Medicine, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Audrey Dieu
- Department of Anesthesia, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Loïc Benoit
- Department of Anesthesia, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Raymond Reding
- Transplantation and Abdominal Surgery Section, Department of Surgery, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
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Vargas PA, Khanmammadova N, Balci D, Goldaracena N. Technical challenges in LDLT - Overcoming small for size syndrome and venous outflow reconstruction. Transplant Rev (Orlando) 2023; 37:100750. [PMID: 36878038 DOI: 10.1016/j.trre.2023.100750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/22/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023]
Abstract
Living Donor Liver Transplantation (LDLT) emerged as an alternative treatment option for patients with end-stage liver disease waiting for an organ from a deceased donor. In addition to allowing for a faster access to transplantation, LDLT provides improved recipient outcomes when compared to deceased donor LT. However, it represents a more complex and demanding procedure for the transplant surgeon. In addition to a comprehensive preoperative donor assessment and stringent technical considerations during the donor hepatectomy to ensure upmost donor safety, the recipient procedure also comes with intrinsic challenges during LDLT. A proper approach during both procedures will result in favorable donor and recipient's outcomes. Hence, it is critical for the transplant surgeon to know how to overcome such technical challenges and avoid deleterious complications. One of the most feared complications following LDLT is small-for-size syndrome (SFSS). Although, surgical advances and deeper understanding of the pathophysiology behind SFSS has allowed for a safer implementation of LDLT, there is currently no consensus on the best strategy to prevent or manage this complication. Therefore, we aim to review current practices in technically challenging situations during LDLT, with a particular focus on management of small grafts and venous outflow reconstructions, as they possess one of the biggest technical challenges faced during LDLT.
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Affiliation(s)
- Paola A Vargas
- Department of Surgery, Division of Transplantation, University of Virginia Health System, Charlottesville, VA, USA
| | | | - Deniz Balci
- Bahçeşehir University School of Medicine Medical Park Göztepe Hospital, Liv Ulus Hospital, Istanbul, Turkey
| | - Nicolas Goldaracena
- Department of Surgery, Division of Transplantation, University of Virginia Health System, Charlottesville, VA, USA.
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Lai Q, Lerut J. A Western World Perspective of Survival Benefit of Living Donor Liver Transplantation: A Commentary to the Article by Jackson et al. Published in JAMA Surgery. Transpl Int 2022; 35:10931. [PMID: 36388426 PMCID: PMC9640363 DOI: 10.3389/ti.2022.10931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/13/2022] [Indexed: 08/29/2023]
Affiliation(s)
- Quirino Lai
- General Surgery and Organ Transplantation Unit, Department of General and Specialty Surgery, AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Jan Lerut
- Institut de Recherche Clinique et Expérimentale (IREC), Université Catholique de Louvain (UCL), Brussels, Belgium
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Vargas PA, McCracken EKE, Mallawaarachchi I, Ratcliffe SJ, Argo C, Pelletier S, Zaydfudim VM, Oberholzer J, Goldaracena N. Donor Morbidity Is Equivalent Between Right and Left Hepatectomy for Living Liver Donation: A Meta-Analysis. Liver Transpl 2021; 27:1412-1423. [PMID: 34053171 DOI: 10.1002/lt.26183] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/15/2021] [Accepted: 05/14/2021] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Emily K E McCracken
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Indika Mallawaarachchi
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, School of Medicine, Charlottesville, VA
| | - Sarah J Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, School of Medicine, Charlottesville, VA
| | - Curtis Argo
- Division of Gastroenterology, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Shawn Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Victor M Zaydfudim
- Division of Surgical Oncology, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Jose Oberholzer
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
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Lerut JP. Bilateral proficiency over time leads to reduced donor morbidity in living donor hepatectomy. Hepatobiliary Surg Nutr 2020; 9:339-341. [PMID: 32509823 PMCID: PMC7262619 DOI: 10.21037/hbsn.2019.10.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/24/2019] [Indexed: 08/29/2023]
Affiliation(s)
- Jan P Lerut
- Institut de Recherche Expérimentale et Clinique (IREC), Université catholique Louvain (UCL), Brussels, Belgium
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