Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver ...transplantation(LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.
Background
This study analyzed the feasibility of laparoscopic living donor hepatectomy compared to open surgery.
Methods
Donors who underwent living donor right from May 2013 to October 2017 were ...included. Comparisons between laparoscopy and open surgery were performed using Student's t‐test, Mann–Whitney test, χ2 test, Fisher's exact test, and linear‐by‐linear association.
Results
Among 305 donors, 100 and 205 underwent laparoscopy and open surgery, respectively. The laparoscopy group had more type I (95.0%) bile ducts than the open group (59.5%, P < 0.001) and had longer operation time (378.2 ± 93.5 min vs. 329.1 ± 68.0 min, P < 0.001), while estimated blood loss was smaller (298.3 ± 162.9 ml vs. 344.3 ± 149.9 ml, P = 0.015). Although Clavien‐Dindo grade IIIb complication was higher in the laparoscopy (n = 4, 4.0%) compared to the open group (0.0%, P = 0.011), it was only significant in the initial 25 cases (8.0%, P = 0.011), and became comparable afterwards. Furthermore, grade IIIb complication was comparable when type I bile duct donors were selected (P = 0.072).
Conclusions
Laparoscopic living donor hepatectomy can cause significant complication in the initial stage. Therefore, careful donor selection and well‐established training program are required for introducing the laparoscopic donor program.
Although laparoscopic living donor hepatectomy can be beneficial in terms of donor recovery, it is prone to significant complications in the initial stage. Rhu and colleagues suggested careful donor selection and a well‐established training course for introducing a laparoscopic donor program based on their data of 100 laparoscopic donor cases.
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.
This study was designed to review laparoscopic living donor liver transplantations (LDLTs) at a single center that achieved complete transition from open surgery to laparoscopy. LDLTs performed from ...January 2013 to July 2021 were reviewed. Comparisons between open and laparoscopic surgeries were performed according to periods divided into initial, transition, and complete transition periods. A total of 775 LDLTs, 506 laparoscopic and 269 open cases, were performed. Complete transition was achieved in 2020. Bile duct variations were significantly abundant in the open group both in the initial period (30.2% vs. 8.1%; p < 0.001) and transition period (48.1% vs. 24.3%; p < 0.001). Portal vein variation was more abundant in the open group only in the initial period (13.0% vs. 4.1%; p = 0.03). Although the donor reoperation rate (0.0% vs. 4.1%; p = 0.02) and Grade III or higher complication rate (5.6% vs. 13.5%; p = 0.03) were significantly higher in the laparoscopy group in the initial period, there were no differences during the transition period as well as in overall cases. Median number of opioids required by the donor (three times interquartile range, IQR, 1–6 vs. 1 time IQR, 0–3; p < 0.001) was lower, and the median hospital stay (10 days IQR, 8–12 vs. 8 days IQR, 7–9; p < 0.001) was shorter in the laparoscopy group. Overall recipient bile leakage rate (23.8% vs. 12.8%; p < 0.001) and overall Grade III or higher complication rate (44.6% vs. 37.2%; p = 0.009) were significantly lower in the laparoscopy group. Complete transition to laparoscopic living donor hepatectomy was possible after accumulating a significant amount of experience. Because donor morbidity can be higher in the initial period, donor selection for favorable anatomy is required for both the donor and recipient.
This study is designed to analyze the feasibility of laparoscopic living donor right hemihepatectomy in living donors with portal vein variation. Living donor liver transplantation cases using a ...right liver graft during the period of January 2014 to September 2019 were included. Computed tomographic angiographies of the donor were 3‐dimensionally reconstructed, and the anatomical variation of the portal vein was classified. To reduce selection bias, a 1:1 ratio propensity score–matched analysis between the laparoscopy group and the open group was performed. Surgical and recovery‐related outcomes as well as portal vein complication‐free survival, graft survival, and overall survival rates were analyzed. After matching, 171 cases in each group from 444 original cases were compared. The laparoscopy group had a shorter operation time (P < 0.001), a smaller number of additional opioids required by the donor (P < 0.001), and a shorter hospital stay (P < 0.001). There were no differences in the portal vein complication‐free survival (P = 0.16), graft survival (P = 0.26), or overall survival rates (P = 0.53). Although portal vein complication‐free survival was inferior in portal veins other than type I (P = 0.01), the laparoscopy group showed similar portal vein complication‐free survival regardless of the anatomical variation of portal vein (P = 0.35 in type I and P = 0.30 in other types). Laparoscopic living donor right hemihepatectomy can be performed as safely as open surgery regardless of the anatomical variation of the portal vein.
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Background
While minimal invasive surgery is becoming popular in liver resection, right posterior sectionectomy (RPS) is still considered as a difficult procedure. We summarize the clinical data and ...investigate the feasibility of laparoscopic right posterior sectionectomy (LRPS) in hepatocellular carcinoma (HCC) by comparing its outcomes with those of open right posterior sectionectomy (ORPS).
Methods
We retrospectively reviewed 191 patients who underwent RPS for HCC during January 2009 to August 2016 at Samsung Medical Center. After 1:2 propensity score matching, 53 patients in LRPS group were matched to 97 patients in ORPS group.
Results
There was no statistical difference in preoperative data. While operation time was significantly longer in LRPS group (381.1 ± 118.7 vs. 234.4 ± 63.7 min,
P
< 0.001), transfusion rate (13.2 vs. 2.1%,
P
= 0.061) and complication rate (9.4 vs. 8.3%,
P
= 0.709) were not statistically different between groups. Clustered Cox proportional hazards regression analysis for matched paired data showed no difference in both disease-free survival (
P
= 0.607) and overall survival (
P
= 0.858).
Conclusions
In HCC, LRPS can be performed safely compared to ORPS, regarding the operative outcome, patient recovery, and oncological outcomes.
Donor death is the most serious complication of living liver donation but is reported rarely. We investigated the actual mortality of living liver donors (LLDs) compared with matched control groups ...based on analysis of the Korean National Health Insurance Services (NHIS) database.
This cohort study included 12,372 LLDs who donated a liver graft between 2002 and 2018, and were registered in the Korean Network for Organ Sharing. They were compared to 3 matched control groups selected from the Korean NHIS and comprising a total of 123,710 individuals: healthy population (Group I); general population without comorbidities (Group II); and general population with comorbidities (Group III).
In this population, 78.5% of living liver donors were 20-39 years old, and 64.7% of all donors were male. Eighty-nine donors (0.7%) in the LLD group died (68 males and 21 females), a mortality rate (/1,000 person-years) of 0.91 (0.74-1.12). Mortality rate ratio and the adjusted hazard ratio of the LLD group was 2.03 (1.61-2.55) and 1.71 (1.31-2.25) compared to Control Group I, 0.75 (0.60-0.93) and 0.63 (0.49-0.82) compared to Control Group II, and 0.58 (0.46-0.71) and 0.49 (0.39-0.60) compared to Control Group III. LLD group, depression, and lower income were risk factors for adjusted mortality. The incidence of liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the LLD group was significantly higher than in Control Group I.
Outcomes of the LLD group were worse than those of the matched healthy control group despite the small number of deaths and medical morbidities in this group. LLDs should receive careful medical attention for an extended period after donation.
The incidence of mortality, liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the living liver donor group was significantly higher than in the matched healthy group. Careful donor evaluation and selection processes can improve donor safety and enable safe living donor liver transplantation.
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•The incidence of mortality and mortality rate (1,000 person/year) of the LLD group was 0.7% and 0.91.•LLDs had twice the all-cause mortality of matched healthy controls despite there being few deaths.•LLD group, depression, and lower income were risk factors for adjusted mortality.•Incidence of diseases affecting multiple organ systems was significantly higher in the LLD group compared to healthy controls.•LLDs should receive careful medical and psychiatric attention for an extended period after donation.
Background
Spousal donors have gradually been accepted as an alternative living liver donors to alleviate the organ shortage and prevent donations from children. No information is available regarding ...the effects of spousal donation on donor safety and recipient outcomes. Our purpose in this study was to determine how spousal liver grafts in living donor liver transplantation (LDLT) affect donor safety and recipient outcomes compared with those of LDLT from children.
Methods
We retrospectively analyzed 656 patients, including spouses and children, who underwent a right or extended right hepatectomy for living liver donation between January 2009 and December 2018.
Results
Spouses represented 18.8% (
n
= 123) of living liver donors. Female donors comprised 78.9% (
n
= 97) of spousal donors, and the proportion of male donors in the children group was 72.6% (
n
= 387). The mean donor operation time of the spousal group was shorter than that of the children group (330 min vs. 358 min;
P
= 0.011), and the complication rate in the spousal group was lower than that in the children group (12.2% vs. 22.9%;
P
= 0.006). However, there were no differences in severe complication rates, hospitalization, or liver function tests between the 2 groups at 3 months after donor surgery. The overall survival of recipients in the spousal group was not reduced compared to that of recipients in the children group.
Conclusion
The present study suggests that, with careful selection, spousal donation is feasible and safe in LDLT.
Background and Aims
Living liver donation with high model for end‐stage liver disease (MELD) score was discouraged despite organ shortage. This study aimed to compare graft survival between living ...donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) recipients with extremely high‐MELD (score of ≥35).
Methods
Between 2008 and 2018, 359 patients who underwent liver transplantation with a MELD score ≥35 were enrolled. We compared graft survival between LDLT and DDLT after propensity score matching (PSM) and performed subgroup analysis according to donor type.
Results
After PSM, there was no statistical difference in graft survival between the LDLT and DDLT groups (p = .466). Old age, acute on chronic liver failure, re‐transplantation, preoperative intensive care unit stay and red blood cell (RBC) transfusion during the operation were risk factors for graft failure (p = .046, .005, .032, .015 and .001, respectively). Biliary complications were more common in the LDLT group (p = .021), while viral infection, postoperative uncontrolled ascites, and postoperative hemodialysis were more common in the DDLT group (p = .002, .018, and .027, respectively). In the LDLT group, acute chronic liver failure, intraoperative RBC transfusion, and early postoperative complications were risk factors for graft failure (p = .007, <.001, and .001, respectively).
Conclusion
Our study showed that LDLT is not inferior to DDLT in graft survival if appropriate risk evaluation is performed in cases of extremely high‐MELD scores. This result will help overcome organ shortages in high‐MELD liver transplantation.
Yun and colleagues found that living donor liver transplantation is not inferior to deceased donor liver transplantation in terms of graft and overall survival in patients with a MELD score of 35 or higher. With appropriate risk evaluation, living donation for patients with high MELD scores can help alleviate organ shortages.
Abstract
This study was designed to build models predicting early graft failure after liver transplantation. Cox regression model for predicting early graft failure after liver transplantation using ...post-transplantation aspartate aminotransferase, total bilirubin, and international normalized ratio of prothrombin time was constructed based on data from both living donor (n = 1153) and deceased donor (n = 359) liver transplantation performed during 2004 to 2018. The model was compared with Model for Early Allograft Function Scoring (MEAF) and early allograft dysfunction (EAD) with their C-index and time-dependent area-under-curve (AUC). The C-index of the model for living donor (0.73, CI = 0.67–0.79) was significantly higher compared to those of both MEAF (0.69, P = 0.03) and EAD (0.66, P = 0.001) while C-index for deceased donor (0.74, CI = 0.65–0.83) was only significantly higher compared to C-index of EAD. (0.66, P = 0.002) Time-dependent AUC at 2 weeks of living donor (0.96, CI = 0.91–1.00) and deceased donor (0.98, CI = 0.96–1.00) were significantly higher compared to those of EAD. (both 0.83, P < 0.001 for living donor and deceased donor) Time-dependent AUC at 4 weeks of living donor (0.93, CI = 0.86–0.99) was significantly higher compared to those of both MEAF (0.87, P = 0.02) and EAD. (0.84, P = 0.02) Time-dependent AUC at 4 weeks of deceased donor (0.94, CI = 0.89–1.00) was significantly higher compared to both MEAF (0.82, P = 0.02) and EAD. (0.81, P < 0.001). The prediction model for early graft failure after liver transplantation showed high predictability and validity with higher predictability compared to traditional models for both living donor and deceased donor liver transplantation.
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