Living Donor Surgery Research Articles

Resource Utilization of Living Donor Versus Deceased Donor Liver Transplantation Is Similar at an Experienced Transplant Center

Although living donor liver transplantation (LDLT) has been shown to decrease waiting-list mortality, little is known of its financial impact relative to deceased donor liver transplantation (DDLT). We performed a retrospective cohort study of the comprehensive resource utilization, using financial charges as a surrogate measure-from the pretransplant through the posttransplant periods-of 489 adult liver transplants (LDLT n = 86; DDLT n = 403) between January 1, 2000, through December 31, 2006, at a single center with substantial experience in LDLT. Baseline characteristics differed between LDLT versus DDLT with regards to age at transplantation (p = 0.02), male gender (p < 0.01), percentage Caucasians (p < 0.01) and transplant model for end-stage liver disease (MELD) score (p < 0.01). In univariate analysis, there was a trend toward decreased total transplant charges with LDLT (p = 0.06), despite increased surgical charges associated with LDLT (p < 0.01). After adjustment for the covariates that were associated with financial charges, there was no significant difference in total transplant charges (p = 0.82). MELD score at transplant was the strongest driver of resource utilization. We conclude that at an experienced transplant center, LDLT imposes a similar overall financial burden than DDLT, despite the increased complexity of living donor surgery and the addition of the costs of the living donor. We speculate that LDLT optimizes transplantation by transplanting healthier and younger recipients.

Psychosocial factors in living organ donation: clinical and ethical challenges

Living donor surgery has come to the forefront of public attention because increasing numbers of potential donors respond to the organ shortage. Because of several factors including decreased morbidity from donor surgery, online resources appealing for organs, and increased publicity about donation, new populations of unrelated donors are seeking evaluation for donor surgery. However, concern about potential coercion of vulnerable individuals, the potential for adverse psychosocial outcomes, and recent reports of donor deaths have reinvigorated discussion within the medical community about how best to assess donors. Research on the long-term quality of life outcomes for donors suggests that most donors are satisfied with their decision to donate. Small single-center studies on psychosocial outcomes have reported psychiatric sequelae after donor surgery. Little is known about the psychosocial outcomes for donors who are psychosocially excluded from donating. A multidisciplinary team approach, including social work and psychiatry evaluations, allows for the comprehensive assessment of important areas including motivation and expectations about surgery, current and past psychiatric conditions, history of substance or alcohol abuse, family support, understanding of the risks and alternatives of donor surgery for the donor and recipient, and motivation for donation including any evidence of coercion.

Biliary strictures following liver transplantation: Past, present and preventive strategies

Biliary complications are still the major source of morbidity for liver transplant recipients. The reported incidence of biliary strictures is 5%-15% after deceased donor liver transplantation and 28%-32% after right-lobe live donor surgery. Presentation is usually within the first year, but the incidence is known to increase with longer follow-up. The anastomotic variant is due to technical factors, whereas the nonanastomotic form is due to immunological and ischemic events, which later may lead to graft loss. Endoscopic management of anastomotic strictures achieves a success rate of 70%-100%; it drops to 50%-75% for nonanastomotic strictures with a higher recurrence rate. Results of endoscopic maneuvers are disappointing for biliary strictures after live donor liver transplantation, and the success rate is 60%-75% for anastomotic strictures and 25%-33% for the nonanastomotic variant. Preventive strategies in the cadaveric donor include the standardization of the type of anastomosis and maintenance of a vascularized ductal stump. In right-lobe live donor livers, donor liver duct harvesting also involves a major risk. The concept of high hilar intrahepatic Glissonian dissection, dissecting the artery and the duct as one unit, use of microsurgical techniques for smaller ducts, use of ductoplasty, and flexibility in the performance of double ductal anastomosis are the critical components of the preventive strategies in the recipient. In the case of live donors, judicious use of intraoperative cholangiograms, minimal dissection of the hilar plate, and perpendicular transection of the duct constitute the underlying principals for obtaining a vascularized duct.

Computer Simulation of Hemodynamic Changes After Right Lobectomy in a Liver with Intrahepatic Portal Vein Aneurysm

Intrahepatic portal vein aneurysm is rare and its natural history is unknown. A 22-year-old healthy man, who wished to donate part of his liver to his diseased father, was incidentally diagnosed to have an intrahepatic portal vein aneurysm. The surgical decision of performing live donor hepatectomy for such a patient is normally difficult. We combined modern imaging reconstruction technologies with scientific computing as a new modality to foresee the risks of surgical complications. Cross-sectional computed tomography images were used to reconstruct the three-dimensional image of portal vein distribution using the 3D-Doctor v3.5 software. The reconstructed images were further employed to generate surface and interior meshes with CFX software. Simulated hemodynamic changes in velocity, pressure, and wall stress were determined for the right lobectomy case pre- and postoperatively. The simulation results indicated that aneurismal pressure would be elevated significantly to 12.03 mmHg after operation. The left segmental portal venous blood flow would increase from 2.95- to 4.25-fold. The area near the branch point of one left segmental portal vein, which supplies blood to liver segment 4, and the portal vein aneurysm would endure high shear stress gradient. The resulting elevated aneurismal pressure may cause the thin wall to enlarge and rupture, while the high shear stress gradient would lead to vascular endothelial cell injury. Living donor surgery was not recommended hemodynamically based on the simulated results. Scientific computing and modern imaging technologies can be applied together to aid surgeons to make the best decision in difficult clinical situations.

Reconstructing the drainage vein of the right paramedian sector in right liver grafts

The use ofvascular conduits to restore the outflow of segments 5and 8 in RL grafts without the MHV trunk, keeping theMHV with the donor, alleviates this concern and sub-stantially increases the safety margin in live donor sur-gery, and therefore might lead to further universal ap-proval of live donor liver transplantation.Various methods have been devised to establish per-fect graft outflow for RL grafts without the MHV, includ-ing the use of various types of autogenous or allogenicinterposition vascular grafts.

Which is the best timing of bile duct division in living liver donor surgery?

Which is the best timing of bile duct division in living liver donor surgery?

Reply to: Which is the best timing of bile duct division in living liver donor surgery?

We thank Dr. Takatsuki and colleagues for their comments on our article.1 In the cases described in our work, the recipient died when the operation in the donor had already progressed beyond the division of the hepatic duct. As a consequence of the resulting “hepar divisum” we found that biliary complications are almost the norm and main point of our article was to share our experience with the surgical management of the “hepar divisum” in the donor. The timing of the hepatic duct division is a totally separate but still much debated issue.2-4 Our center and others have adopted early hepatic division for the same reasons that made Dr. Takatsuki opt for division after parenchymal transection: it is easy, and it preserves hilar plate tissues and blood supply. Moreover, the claim of bile contamination is totally unfounded and certainly does not reflect our extensive experience with more than 200 cases.1, 4, 5 Also, in our center the donor and the recipient surgeries run parallel and constant communication between the two surgical teams is in place. Therefore, it remains our preference to divide the hepatic duct prior to the transection of the liver parenchyma and we do not think that hepatic duct division after parenchymal transection should be adopted as standard procedure for right living donor hepatectomy based only on the unfortunate events described in our article. Silvio Nadalin*, Giuliano Testa , * Department of General-, Visceral-, and Transplantation Surgery University Hospital Essen Essen, Germany, Division of Transplantation, University of Chicago, Chicago, IL.

Systematic grading of surgical complications in live liver donors according to Clavien's system

The lack of consensus on how to evaluate surgical complications of donors in live donor liver transplantation (LDLT) and incoherence of cumulative data hampers efficient comparison of the outcome worldwide. We considered that the application of the internationally validated classification system introduced by Clavien in 2004 might be beneficial. Operative complications of 243 patients who underwent live donor hepatectomy for adult LDLT between January 1996 and October 2005 at the University of Tokyo were analyzed according to the system. Definitions for each grade in the system are: grade I, deviation from the normal postoperative course but without the need for therapy; grade II, complication requiring pharmacologic treatment; grade III, complication with the need for surgical, endoscopic or radiological intervention (IIIa/b: without/with the need for general anesthesia); grade IV, life-threatening complication requiring intensive care; grade V, death. Surgical morbidity was recognized in 67 donors (28%). No deaths occurred. The numbers of patients with complications were: grade I, 36 (15%); II, 10 (4%); IIIa, 12 (5%); IIIb, 9 (4%); IV, 0; V, 0. Six in IIIb underwent surgical repair for bile leakage. Clavien's system is simple and informative. It may serve as a common tool for the quality assessment in live liver donor surgery worldwide, and we propose its application whenever surgical complication of live donor is discussed.

Anesthetic Management and Analysis of Postoperative Morbidity of Donors in Living-Related Liver Transplantation

Background: Living liver donor surgery will become more common because of a shortage of donor organs. Howerver, donor hepatectomy has a potentially significant risk to the donor and raises important issues about the safety of the procedure. Our experience in the anesthetic management of donors is discussed and complications encountered are recorded. Methods: The charts, anesthetic records and computerized hospital data of 100 consecutive donors for living-related liver transplantations from June 1996 to March 2002 were retrospectively reviewed. Donor characteristics, blood loss, fluids and blood administered, surgical and anesthetic duration, hospital stay time, postoperative complications, and perioperative changes in hemoglobin (Hb), aspartate transferase (AST), alanine transferase (ALT), and prothrombin time (PT) were investigated. Results: A graft type consisted of 31 left lateral segments, 8 left lobes and 61 right lobes. The average operating time was 401.3 79.0 minutes and total duration of hospital stay was 14.1 2.6 days. The mean blood loss was 731.3 481.2 ml and 9 donors received a transfusion of heterologous packed red blood cells. Seven donors developed postoperative complications, all of which were managed conservatively. The average Hb decreased significantly from a preoperative value of 14.2 1.6 g/dl to the lowest postoperative value of 11.6 1.5 g/dl. AST, ALT and PT reached their highest level on the first postoperative day and decreased rapidly afterwards. All of these values were significantly different from the preoperative values for the postoperative 30 days. Conclusions: Serious complications did not occur after a living donor hepatectomy at our hospital, but the risk to the donor cannot be completely eliminated. Therefore the donor's safety and quality of life as well as graft function should be considered in living donor operation.

Anaesthetic management and outcome in right-lobe living liver-donor surgery.

We reviewed retrospectively the anaesthetic management and perioperative course of eight right hepatectomies for living liver donation. After preoperative psychiatric evaluation, eight ASA I-II individuals donated the right lobe of their liver to a family member. A graft-recipient body weight ratio of 0.8-1.0% was required for patient selection. Indications for liver transplantation were: hepatitis C viral-related cirrhosis in six patients; combined hepatitis C and B viral cirrhosis in one patient; multifocal hepatocellular carcinoma--four lesions, involving both liver lobes--of hepatitis C viral-related cirrhosis in another patient. Indication for adult-to-adult living-donor liver transplantation was retained in the latter because of rapid deterioration of liver disease, rare recipient's blood group and extended, unresectable hepatocellular carcinoma. Hepatitis C viral-related cirrhosis was casually the primary indication for adult-to-adult living-donor liver transplantation in this group. The condition of the donated hepatic lobe was optimized by appropriate drug and perfusion management. Preoperative investigations included: blood tests (full cell count and film, thyroid function tests, pregnancy tests, full virological tests and bacteriological cultures, and immunological typing), chest radiograph, electrocardiogram plus Doppler cardiac ultrasound, spirometry, aminopyrine breath test, liver Doppler examination, magnetic resonance imaging, angiography and cholangiography and a volumetric study of the whole liver and the right lobe. Haemoglobin and lactate concentrations, liver function tests and international normalized ratio were measured before and after operation. The volume and weight of the resected right lobe was calculated. Anaesthesia was induced with propofol 300 mL h(-1) and sufentanil 0.3 microg kg(-1) intravenously; cisatracurium, 0.15 mg kg(-1), was given to facilitate tracheal intubation. Anaesthesia was maintained during normocapnic ventilation of the lungs with oxygen 40% in air, isoflurane 1-1.5 MAC and sufentanil. Routine anaesthetic monitoring included electrocardiography, pulse oximetry, invasive blood pressure, central venous pressure, urine output, state of neuromuscular blockade and core temperature. Periods of hypotension (<80% of the preoperative blood pressure) or haemodynamic instability (requiring inotropic or vasoactive support) were registered. Total blood loss and transfusion (homologous, autologous or cell-saver blood) requirements were measured; volume replacements were derived. Data are presented as mean (range). There was no morbidity or mortality and no periods of intraoperative hypotension or haemodynamic instability. The operation time averaged 619 (525-780)min. Four donors were extubated in the operating room immediately after surgery; the others were extubated in the intensive care unit, where the mean extubation time was 16.3 (5-25)h after arrival. The estimated blood loss was 967 (550-1,600)mL. No homologous blood was administered; five donors received autologous blood, intraoperatively; three donors received a cell-saver blood transfusion. Intraoperative fluid replacement was with crystalloids, colloids and 4% albumin. Total urine output was 1,472 (700-3100)mL. Although intraoperative hypothermia occurred all subjects were normothermic at the end of operation. The pre- and immediately postoperative haemoglobin concentration averaged 13.6 (9.8-15.6) and 10.5 (6.9-13.0)gdL(-1), respectively. On the first postoperative day, the haemoglobin was 11.7 (8.4-15.1)gdL(-1). The donors' liver function tests were transiently elevated in the initial postoperative period. The intensive care unit discharge time was 2 (1-3) days. The hospital stay was 13 (7-17) days. There was no morbidity or mortality. The study demonstrates that right-lobe living-donor surgery was well tolerated, without intraoperative hypotension or haemodynamic instability, without perioperative anaesthetic or surgical complications, and with an excellent general outcome.

Anaesthetic management and outcome in right-lobe living liver-donor surgery

Background and objective: We reviewed retrospectively the anaesthetic management and perioperative course of eight right hepatectomies for living liver donation. Methods: After preoperative psychiatric evaluation, eight ASA I-II individuals donated the right lobe of their liver to a family member. A graft-recipient body weight ratio of 0.8-1.0% was required for patient selection. Indications for liver transplantation were: hepatitis C viral-related cirrhosis in six patients; combined hepatitis C and B viral cirrhosis in one patient; multifocal hepatocellular carcinoma - four lesions, involving both liver lobes - of hepatitis C viral-related cirrhosis in another patient. Indication for adult-to-adult living-donor liver transplantation was retained in the latter because of rapid deterioration of liver disease, rare recipient's blood group and extended, unresectable hepatocellular carcinoma. Hepatitis C viral-related cirrhosis was casually the primary indication for adult-to-adult living-donor liver transplantation in this group. The condition of the donated hepatic lobe was optimized by appropriate drug and perfusion management. Preoperative investigations included: blood tests (full cell count and film, thyroid function tests, pregnancy tests, full virological tests and bacteriological cultures, and immunological typing), chest radiograph, electrocardiogram plus Doppler cardiac ultrasound, spirometry, aminopyrine breath test, liver Doppler examination, magnetic resonance imaging, angiography and cholangiography and a volumetric study of the whole liver and the right lobe. Haemoglobin and lactate concentrations, liver function tests and international normalized ratio were measured before and after operation. The volume and weight of the resected right lobe was calculated. Anaesthesia was induced with propofol 300 mL h−1 and sufentanil 0.3 μg kg−1 intravenously; cisatracurium, 0.15 mg kg−1, was given to facilitate tracheal intubation. Anaesthesia was maintained during normocapnic ventilation of the lungs with oxygen 40% in air, isoflurane 1-1.5 MAC and sufentanil. Routine anaesthetic monitoring included electrocardiography, pulse oximetry, invasive blood pressure, central venous pressure, urine output, state of neuromuscular blockade and core temperature. Periods of hypotension (<80% of the preoperative blood pressure) or haemodynamic instability (requiring inotropic or vasoactive support) were registered. Total blood loss and transfusion (homologous, autologous or cell-saver blood) requirements were measured; volume replacements were derived. Results: Data are presented as mean (range). There was no morbidity or mortality and no periods of intraoperative hypotension or haemodynamic instability. The operation time averaged 619 (525-780) min. Four donors were extubated in the operating room immediately after surgery; the others were extubated in the intensive care unit, where the mean extubation time was 16.3 (5-25) h after arrival. The estimated blood loss was 967 (550-1600) mL. No homologous blood was administered; five donors received autologous blood, intraoperatively; three donors received a cell-saver blood transfusion. Intraoperative fluid replacement was with crystalloids, colloids and 4% albumin. Total urine output was 1472 (700-3100) mL. Although intraoperative hypothermia occurred all subjects were normothermic at the end of operation. The pre- and immediately post-operative haemoglobin concentration averaged 13.6 (9.8-15.6) and 10.5 (6.9-13.0) g dL−1, respectively. On the first postoperative day, the haemoglobin was 11.7 (8.4-15.1) g dL−1. The donors' liver function tests were transiently elevated in the initial postoperative period. The intensive care unit discharge time was 2 (1-3) days. The hospital stay was 13 (7-17) days. There was no morbidity or mortality. Conclusions: The study demonstrates that right-lobe living-donor surgery was well tolerated, without intraoperative hypotension or haemodynamic instability, without perioperative anaesthetic or surgical complications, and with an excellent general outcome.

Living liver donor surgery: report of initial anesthesia experience

The charts and anesthetic records of 12 patients who donated the left lateral segment of their liver to a related infant or child to treat liver failure were retrospectively reviewed. Blood loss, need for transfusion, fluids administered, surgical length, and perioperative complications were investigated. The records also were examined to determine the hemodynamic stability of patients undergoing donor hepatectomy to assess their need for invasive monitoring. There were no episodes of hypotension or hemodynamic instability. The average operating time was 9.6 ± 1.1 hours. The blood loss was 562 ± 244 mL (range 300 to 1100 mL). Four patients received their own cell saver blood (200 mL, 220 mL, 300 mL, 475 mL), and one patient received 1 U (350 mL) of predonated autologous blood. The average hemoglobin decreased significantly (p = 0.001) from a preoperative value of 14.1 ± 1.2 to 12.3 ± 1.8 g/dL in the recovery room. All patients were extubated in the operating room or recovery room. Patients were discharged home in 6.9 ± 1.3 days (range 5 to 9 days). Living-related liver resection can be performed with noninvasive monitoring and without the need for heterologous blood products.

Effects of different oestrous stages of ovaries and sizes of follicles on generation of bovine embryos in vitro

The aim of uterus transplantation is to treat uterine factor infertility, due to absence of a functional uterus. This review provides information on key research findings in the field of uterus transplantation. The animal-based preclinical uterus transplantation research started around 20 years back with systematic research in several animal species, including non-human primates. This research investigated important aspects such as surgery, immunosuppression, ischemia-reperfusion injury, rejection, and fertility. In 2013, the first clinical uterus transplantation trial started and this was a live donor trial including nine transplantations. The first live birth was reported in 2014 and this has been followed by several more births from the initial trial in Sweden but also from other trials. The published uterus transplantations procedures, both from live donors and deceased donors, will be reviewed in detail.The surgical procedures to harvest a uterus from a live or from a deceased donor have developed and minimal invasive techniques are being introduced in live donor surgery for uterus transplantation. Some modifications of anatomical sites of venous outflows have been introduced. The efficiency of the procedure, in terms of surgical success with viable grafts after one month, as well as the rate of successful transplantations, with live births as the primary endpoint, have proven to be high.Uterus transplantation is an experimental clinical procedure that is performed within clinical trials at many centers worldwide. The accumulated research data from these trials will pave the way for establishment of uterus transplantation as a safe and efficient procedure to treat uterine factor infertility.