Propensity score matched analysis and risk stratification of donors with G6PD deficiency in living donor liver transplantation

INTRODUCTION

Glucose 6 phosphate dehydrogenase (G6PD) deficiency (G6PDd) can trigger hemolysis following surgical stress. Differentiating G6PDd-related post-operative hemolytic episodes (PHE) and post-hepatectomy liver failure may be challenging especially in living donors where donor safety is paramount. We analysed outcomes of our cohort of G6PDd liver donors.

METHODS

G6PDd individuals with no evidence of hemolysis were considered as living donors if there was no alternative family donor. Outcomes of G6PDd donors undergoing left lateral/left lobe donation (Group LL) and right lobe donation (Group RL) were compared with non-G6PDd donors matched in a 1:3 ratio using propensity score matching.

RESULTS

59 G6PDd donors (5.8% of 1011) underwent living donor hepatectomy (LiDH) during the study period. LL-G6PDd donors (22.37%) had higher post-operative peak bilirubin level compared to matched controls, but no difference in morbidity or need for post-operative blood transfusion.RL-G6PDd donors (37.63%) had higher peak bilirubin level, morbidity (16.2% vs. 3.6%, p = 0.017) and more post-operative blood transfusion (21.6% vs. 6.4%, p = 0.023) as compared to matched non-G6PDd cohort. Four RL-G6PDd donors (10.8%) developed PHE. Low G6PD activity (15% vs. 40%, p = 0.034) and lower future liver remnant (FLR) (34.3% vs. 37.8%, p = 0.05) were identified as risk factors for PHE.

CONCLUSION

We report the largest to-date series of G6PDd individuals undergoing LiDH and confirm the safety of LL donation in G6PDd. Our analysis identifies specific risk factors for PHE and suggests that right lobe LiDH be avoided in individuals with less than 25% G6PD activity when the FLR is less than 36%.

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.

Handling of Hilar Vasculature in Living Donor Right Hepatectomy Using Extrahepatic Glissonean Approach

Donor hepatectomy is one of the most important procedures in LDLT because it affects the safety of donors and the outcome of the recipients. We standardized a method of securing the important vessels at the hepatic hilum while advancing the dissection toward the central direction. This research introduces our technique of handling hilar vasculature in living donor hepatectomy, using the extrahepatic Glissonean approach, and discusses its efficacy. At first, after the extrahepatic right Glissonean approach, the resected hepatic artery and portal vein are secured on the same line as with the secured Glisson. The resected hepatic artery and portal vein are followed in the central direction, and the surrounding area is dissected. The dissection is continued up to the main brunch of the hepatic artery and portal vein. The bile duct can be secured by subtracting the hepatic artery and portal vein from the tape that secured the Glissonean pedicle. The bile duct, hepatic artery, and the portal vein are dissected in this order, before dissecting the right hepatic vein, completing the surgery. This method of dissection approaching the extrahepatic Glisson carried out toward the central direction suggests to acquire minimal tissue removal and to shorten operative time. This could result in adequate perfusion to the remaining liver and donor safety, taken together effective results on the recipient.

Narrowing of the Inferior Vena Cava following Closure of the Right Hepatic Vein Stump in a Patient undergoing Living Donor Hepatectomy

Living donor hepatectomy is not without risks, and some complications can end up with serious morbidities if not timely diagnosed and appropriately managed. In this report, we described a very unusual but significant surgical problem in living liver donor surgery in which a significant narrowing occurred in the inferior vena cava after the closure of the stump of the right hepatic vein and inferior right hepatic vein close to the right hepatic vein together, and describe the cavoplasty technique used to repair this narrowing. To the best of our knowledge, the technique of solving this problem in living liver donors was described only once in literature, which was previously published by our team.

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.

Simulation and navigation of living donor hepatectomy using a unique three-dimensional printed liver model with soft and transparent parenchyma

Three-dimensional printed liver models have been used for preoperative simulation. Unlike the standard three-dimensional system on a monitor, the three-dimensional printed model can be observed from any angle manually; therefore, surgeons can obtain a clear image directly from the model. We herein report the use of a unique three-dimensional liver model with a soft and transparent liver parenchyma. Through the parenchyma, the surgeons can observe the intrahepatic vessels and perform incisions in the model as a preoperative simulation. In this study, we applied this model to donor hepatectomy, which under most circumstances requires meticulous attention to detail. The actual processes and uses of a three-dimensional liver model in clinical surgery for liver transplantation are presented.

Comparison of clinical and histopathological features of patients who underwent incidental or emergency appendectomy

BACKGROUND

Incidental appendectomy can be defined as the removal of a clinically normal appendix during another surgical procedure unrelated to appendicitis or other appendicular diseases.

AIM

To compare the demographic, biochemical, and histopathological features of the patients who underwent incidental and standard appendectomy.

METHODS

The demographic, biochemical, and histopathological data of 72 patients (Incidental App group) who underwent incidental appendectomy during living donor hepatectomy at our Liver Transplant Center between June 2009 and December 2016 were compared with data of 288 patients (Acute App group) who underwent appendectomy for presumed acute appendicitis. The Incidental App group was matched at random in a 1:4 ratio with the Acute App group in the same time frame. Appendectomy specimens of both groups were re-evaluated by two experienced pathologists.

RESULTS

Statistically significant differences were found between groups in terms of age (P = 0.044), white blood cell count (P < 0.001), neutrophil (P < 0.001), lymphocyte (P < 0.001), red cell distribution width (P = 0.036), mean corpuscular hemoglobin (P = 0.001), bilirubin (P = 0.002), appendix width (P < 0.001), and presence of acute appendicitis histopathologically (P < 0.001). However, no statistically significant differences were found between groups in terms of gender, platelet, mean platelet volume, mean corpuscular volume, platelet distribution width, appendix length. While the most common histopathological findings in the Incidental App group were normal appendix vermiformis (72.2%), fibrous obliteration (9.7%) and acute appendicitis (6.9%), the most common histopathological findings in the Acute App group were non-perforated acute appendicitis (62.8%), perforated appendicitis (16.7%), lymphoid hyperplasia (8.3%), and appendix vermiformis (6.3%).

CONCLUSION

Careful inspection of the entire abdominal cavity is useful for patients undergoing major abdominal surgery such as donor hepatectomy. We think that experience is parallel to the surgeon’s foresight, and we should not hesitate to perform incidental appendectomy when necessary

Clinical utility of postoperative phosphate recovery profiles to predict liver insufficiency after living donor hepatectomy

BACKGROUND

Living donor hepatectomy (LDH) is associated with significant postoperative hypophosphatemia.

METHODS

From January 1997 through July 2017, we performed 176 LDH and compared donors who developed liver insufficiency (LI) to those that did not within 30 days of LDH. Using smoothing splines, we constructed a mixed-effects model and assessed receiver operating characteristic curves.

RESULTS

Of the 176 donors, 161 were included in our study and 10 (6.2%) developed LI. The cohorts differed in minimum observed phosphate levels (1.77 mg/dL, LI cohort; 2.01 mg/dL No LI cohort) at a median nadir of 1.6 days (38 h) postoperatively (p = 0.003). In the ROC analysis, intraoperative time and postoperative phosphate levels best predicted LI (sensitivity, 90%; specificity, 55.6%).

CONCLUSION

Mean postoperative phosphate profiles differ significantly between those patients who develop LI and those who do not in the first 38 h after LDH.

Neuroendocrine tumor incidentally detected during living donor hepatectomy: A case report and review of literature

To our best knowledge, no case of a tumor that was incidentally detected during living donor hepatectomy (LDH) has been reported in the English language medical literature. We present two cases in which grade I neuroendocrine tumors (NET) were incidentally detected during our twelve-year LDH experience. First Case: A 26-year-old male underwent LDH for his brother suffering from HBV-related chronic liver disease (CLD). After right lobe LDH, intestinal length was measured as part of a study concerning the relationship between small intestinal lengths and surgical procedure. At this stage, a mass lesion with a size of 10 mm × 10 mm was detected on the antimesenteric surface, approximately 90 cm proximal to the ileocecal valve. A wedge resection with primary intestinal anastomosis was performed. Second Case: A 29-year-old male underwent right lobe LDH for his father with hepatitis B virus (HBV)-related CLD. An abdominal exploration immediately prior to the closure of the incision revealed that the appendix vermiformis was edematous and had firmness with a size of 8-10 mm at its tip. An appendectomy was performed. The pathological examinations of the specimens of both patients revealed grade 1 NET. In conclusion, even if patients undergoing LDH are healthy individuals, whole abdominal cavity should be gently palpated and all findings recorded after completing laparotomy. Suspected masses or lesions should be confirmed by frozen section examination. Such an approach would avert potential medicolegal issues.

Massive Subcutaneous Emphysema, Pneumoperitoneum, Pneumoretroperitoneum, and Pneumoscrotum following Endoscopic Retrograde Cholangiopancreatography in a Living Liver Donor

Despite having many advantages, living donor liver transplantation has not been adopted by western countries due to risk of nearly life-threatening complications after living donor hepatectomy (LDH). Herein, we aimed at presenting the management of a 19-year-old patient who suffered life-threatening complications after right lobe LDH. A multiple detector computed tomography (MDCT) revealed a bilioma at the cut surface of the remnant liver, for which a transhepatic drainage catheter was placed. Endoscopic retrograde cholangiopancreatography (ERCP) performed to decompress biliary tract, but the biliary tract could not be cannulized due to post-precut bleeding. On the next day, extensive crepitation was detected and MDCT showed subcutaneous emphysema, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum (ERCP-related duodenal perforation?). However, the patient showed significant deterioration of physical examination findings, fever, and infectious parameters, and therefore was taken to the operating room. Kocher maneuver revealed no apparent duodenal perforation. Then, a 2-mm bile duct was found open at the caudate lobe, through which bile leaked. Then, common bile duct exploration and T-tube placement were performed, followed by suture closure of the bile orifice at the caudate lobe. Massive air previously identified completely disappeared one week after the operation.

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.