Living Donor Liver Transplantation Program Research Articles

Donor Safety First: Postoperative Hepatectomy Outcomes in Living Liver Donors

Living donor liver transplantation (LDLT) has become a popular treatment option because some countries lack a deceased organ program and the growing demand for liver transplants. Although postoperative outcomes are similar to deceased donor liver transplants, there is still an element of risk to the donor. The Clavien-Dindo classification system has been used to standardize reporting across different institutions and surgeons to categorize surgical outcomes. Between January 1, 2022, and December 31, 2022, 207 living donors underwent hepatectomies at our center. All donors underwent a 3-step process of mandatory screening. Postsurgical complications were classified using the Clavien-Dindo classification. A total of 207 donor hepatectomies for LDLT were performed during our study period. Most donors (92.8%) were aged between 18 and 39 years. The most common type of graft used was a right lobe without the middle hepatic vein (82.6%). Most donors (91.7%) experienced an intraoperative blood loss of ≤500 mL. A total of 140 patients had an ordinary postoperative course. Grade 1 complications were observed in 16.9%, grade 2 in 12.1%, and grade 3 in 3.4% of the remaining patients. No grade 4 or grade 5 (patient death) complications were observed in this cohort. Living donor liver transplantation remains the most practiced liver transplant surgery in Pakistan. Our findings highlight the safety of the LDLT program with minimal risk of significant complications. The study also underscores the importance of careful screening and monitoring of living donors and the need for standardized reporting of surgical outcomes using the Clavien-Dindo classification system.

Safely Implementing a Program of Pure Laparoscopic Donor Right Hepatectomy: The Experience From a Southeast Asian Center.

Our center systematically introduced a laparoscopic hepatectomy program in 2006. We started with minor wedge resections followed by major hepatectomies with increasing complexities. In 2017, we performed our first laparoscopic living donor left lateral sectionectomy. Since 2018, we have performed 8 cases of right lobe living donor hepatectomy (laparoscopy-assisted: 4 and pure laparoscopic: 4). The median operative time was 418 (298-540) min, whereas the median blood loss was 300 (150-900) mL. Two patients (25%) had surgical drain placed intraoperatively. The median length of stay was 5 (3-8) d, and the median time to return to work was 55 (24-90) d. None of the donors sustained any long-term morbidity or mortality. Small- to medium-sized transplant programs face unique challenges in adopting LDRH. Progressive introduction of complex laparoscopic surgery, a mature living donor liver transplantation program, appropriate patient selection, and the invitation of an expert to proctor the LDRH are necessary to ensure success.

Toronto Management of Initially Unresectable Liver Metastases from Colorectal Cancer in a Living Donor Liver Transplant Program.

Living donor liver transplantation (LDLT) is an attractive option for patients with unresectable, bilobar colorectal liver metastases (CRLM). However, it is not available in most centres beyond study protocols. This study describes the interim experience with LDLT for CRLM at a large North American transplant and hepatobiliary centre. Adults with unresectable CRLM, receiving systemic chemotherapy were recruited into a prospective clinical trial. Data on demographics, referral patterns, and clinical characteristics were extracted from October 2016 to February 2023. Patients were divided into three groups: transplanted, resected, and control (excluded, with continuation of systemic chemotherapy). Overall survival (OS) and recurrence-free survival (RFS) were compared. 81 referred patients were assessed for LDLT. 7 received transplants, 22 underwent resection, and 48 control. All had similar pre-assessment baseline characteristics. Median time from initial assessment to transplantation was 15.4 months. The control population had significantly worse post-assessment OS than the transplanted population (p=0.002) and resected population (p<0.001). The median post-operative follow-up duration was 21.4 months (resection) and 14.8 months (LDLT). There was no difference in OS between the transplanted and resected populations (1-year 100% vs. 93.8%; 3-year 100% vs. 43.3%, p=0.17). However, RFS was superior in the LDLT group (1-year 85.7% vs. 11.4%; 3-year 68.6% vs. 11.4%, p=0.012). Most patients with unresectable CRLM referred for LDLT are deemed ineligible for trial inclusion. However, the excellent oncologic outcomes in patients who meet criteria for LDLT supports its role in highly selected populations. Future results after the trial's completion will inform long-term outcomes.

The current landscape of pediatric living donor liver transplantation in the United States: Benefits, challenges, and future directions.

The current landscape of pediatric living donor liver transplantation in the United States: Benefits, challenges, and future directions.

Living donor liver transplant: A strategy to increase transplant access

Living donor liver transplant: A strategy to increase transplant access

The toronto management of initially unresectable liver metastases from colorectal cancer in a living donor liver transplant program

Background: Living donor liver transplantation (LDLT) is an attractive option for patients with unresectable, bilobar, liver-only colorectal liver metastases (CRLM). However, it is not available in most centres beyond study protocols. This study describes the interim experience with LDLT for CRLM at a large transplant and hepatobiliary centre in North America.

Experience from Vietnam and lessons learned in setting up a living donor liver transplant program

Experience from Vietnam and lessons learned in setting up a living donor liver transplant program

Right Lobe Liver Donation After Bariatric Surgery. A Case Series of 4 Living Donors

The increasing prevalence of obesity and need for bariatric surgery as well as the expanding use of living donors for liver transplantation means that potential donors could present with this surgical history. We present 4 cases of liver donors with previous bariatric surgery in our living donor liver transplant program. A retrospective descriptive analysis of patients with a bariatric surgery history who underwent right hepatectomy in our living donor liver transplant program is presented. Case 1: A 53-year-old man with body mass index (BMI) of 33 who underwent laparoscopic sleeve gastrectomy (LSG). Pretransplant BMI was 21.5. Case 2: A 46-year-old woman with a BMI maximum of 40.8 who underwent LSG and required conversion to Roux-en-Y gastric bypass. Pretransplant BMI was 35.1. Case 3: A 53-year-old woman with a BMI maximum of 31.6 who underwent LSG. Pretransplant BMI was 24.2. Case 4: A 38-year-old man with a BMI maximum of 41.5 who underwent Roux-en-Y gastric bypass 6 years before the hepatectomy. Pretransplant BMI was 29.4. No complications were observed. Average operative time was 367.5 minutes, with a hospital stay of 5.8 days and 100% graft survival to date. Utilization of selected donors with previous bariatric surgery appears to be a safe option and increases the donor pool.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Anatomical characterization of potential liver donor in a living donor liver transplantation program in Latin America

Anatomical characterization of potential liver donor in a living donor liver transplantation program in Latin America

Preoperative Evaluation of Potential Liver Donor in a Living Donor Liver Transplantation Program in Latin America

Introduction: The living donor liver transplantation (LDLT) technique was developed to face the problem of low-rate donation. Living donor selection is crucial to minimize postoperative donor complications and to improve recipient outcomes This study evaluates the reasons for discarding potential donors in our LDLT program. Methods: Retrospective descriptive analysis from all potential donors evaluated in our LDLT program between April 2018 and July 2021. Selection criteria included age 18-60 years old, no significant medical or mental comorbidities, ABO and anatomical suitability. Results: A total of 231 patients were evaluated. Mean age was 37+11 years and male gender in 52%. 101 potential donors (43.7%) did not complete the evaluation because of the availability of a deceased donor (n=26; 11.3%), ABO incompatibility (n=13; 5.6%), progression or death of the recipient (n=14; 6.1%). Of the 130 who completed their radiological evaluation, the main causes of inadequate candidacy were small liver remnant size (SLRS) (n=17/130; 13.1%) and steatosis (n=15/130; 11.5%). Out of the 231 potential donors, 75 were accepted as adequate donors (32.4%) and 32 candidates underwent liver donation (13.8%). Conclusions: 43.7% of the potential donors didn’t complete the evaluation because of progression, death or deceased donor transplantation of the recipient. Steatosis, SRLS and anatomical variation are the main causes for dropout. Only 1/3 of potential donors are suitable for donation and half of them will undergo surgery. It is important to know main exclusion criteria met by potential donors, in order to make a more efficient use of time and financial resources.

In Light of a New Transplant Allocation Policy, Is a LDLT Program Still Justified in a High MELD Region?

Introduction: Living donor liver transplant (LDLT) has a unique role in providing life-saving organs for patients who do not have access to the deceased donor pool. The new liver allocation system expands availability of the national resource of donated organs to reduce waitlist mortality. Aim: To evaluate our LDLT program under the new allocation system and its justification in a high MELD region. Methods: We retrospectively reviewed outcomes of deceased donor LT (DDLT) and LDLT at our institution before (01/2018-01/2020) and after (02/2020-07/2021) allocation change. Results. A total of 247 transplants were included. The median OLTX MELD pre-allocation was 34 and 33 post-allocation. LDLT recipients had a non-significant decrease in MELD from 17 to 14. Only 4% of DDLT recipients were transplanted at a MELD within the LDLT IQR of 9-18 over both periods. The waiting time (WT) for DDLT pre-allocation was a median of 66 days (IQR 253) vs. 11 (213) (p=0.012) post. The WT for hepatocellular carcinoma (HCC) patients increased from 310 to 344 days after allocation change and the proportion of HCC transplants decreased from 28% to 13% (p=0.008) Discussion: Despite the positive impact of the allocation system on high MELD patients, lower MELD and HCC candidates seem to have less access to DDLT. In our institution, where a high MELD score at transplant is common, LDLT is an important option for these patients due to organ shortages.

Paired exchange Living Donor Liver Transplantation: A Nine-Year Experience from North India

Introduction: Liver paired exchange donation (LPD) or swap transplantation is an evolving strategy to overcome ABO incompatibility and other barriers like small for size syndrome that confront patients with end-stage Liver disease undergoing Living donor liver transplantation (LDLT). At the same time, for the transplant team to carry out 4 major operations simultaneously is a Herculean effort. Herein, we analyze our experience with LPD program over the past 9 years. Methods: This prospective study includes a total of 2340 LDLTs performed from May 2012 to April 2021. We started the Paired exchange LDLT program in May 2012. LPDs constituted approximately 1.45% (34 of 2340) of the total LDLT procedures. The reasons for LPD were ABO incompatibility in all (n=34) patients. The first and second recipient of each swap pair were divided into R1 and R2 groups for comparative analysis. Results: All patients included in paired exchange LDLT program were Indian citizens and donors were “near” relatives. After donor reassignment through 2-by-2 paired exchange with directed donors, the ABO matching status changed to A to A (n=17) and B to B (n=17) and this made all matches ABO-identical. Donor survival was 100%. The recipient’s (n=34, age 45.5 [11 -59] years; 31 men), UNOS status were 2b (n=5) and C (n=29) and they all underwent elective LDLT surgery with 4 OTs running simultaneously on the same day. The baseline clinical, peri-operative parameters, post-operative complications, median ICU/hospital stay, early deaths were comparable (P>0.1) between the R1 and R2 groups (Table 1). The overall recipient survival was 85.3 % (n=29) over the median follow up period of 20 (0-108) months. Conclusion: Our experience suggests that with careful attention to ethical and logistical issues, LPD program can expand the living donor liver pool and can facilitate a greater number of LDLTs. Keywords: Donor Exchange, Swap Liver Transplantation, Living Donor Liver Transplantation; ABO incompatibilityTable 1Comparative data between R1 and R2 groups of swap liver transplant recipients (n = 34).Parameters (Mean±SD)R1 (n=17)R2 (n=17)P valueAge (years)44.0 (±10.1)47.0 (±5.3)0.296MELD score21.8 (±11.1)19.4 (±6.3)0.445CTP score9.5 (±2.3)10.3 (±2.1)0.294Graft weight (grams)711 (±141.2)796 (±119.8)0.067GRWR1.01 (±0.34)1.18 (±0.26)0.136Warm ischemia time (minutes)32.7 (±7.8)36.1 (±7.1)0.257Cold ischemia time (minutes)109.7 (±61.2)112.6 (±40.9)0.870ICU stay (days)12.4 (±4.6)14.4 (±10.5)0.654Hospital stays (days)16.7 (±4.6)21.6 (±4.7)0.197Complications n (%)Bleeding01 (5.9%)1.00Bile leak02 (11.8%)0.485Acute rejection1 (5.9 %)1 (5.9 %)1.00Hepatic artery thrombosis01(5.9%)1.00Hepatic vein thrombosis2 (11.8%)1(5.9%)0.542Sepsis2 (11.8%)5 (29.4%)0.398Early mortality (Within 1 month)1 (5.8%)3(17.6%)0.6011 year survival16 (100 %)13 (92.8%)0.335Median follow up in months (IQR)27 (8-39)27 (8-43)1.00CTP, Child-Turcot-Pugh; GRWR, graft to recipient weight ratio; ICU, intensive care unit; IQR, inter quartile range; MELD, model for end stage liver disease. Open table in a new tab CTP, Child-Turcot-Pugh; GRWR, graft to recipient weight ratio; ICU, intensive care unit; IQR, inter quartile range; MELD, model for end stage liver disease.

Practices and Perceptions of Living Donor Liver Transplantation, Nondirected Donation, and Liver Paired Exchange: A National Survey.

Living donor liver transplantation (LDLT) remains underutilized in the United States. Barriers to LDLT and acceptance of nondirected living liver donation (ND-LLD) and liver paired exchange (LPE) are unclear. The medical and surgical directors of 99 unique transplantation programs (56 LDLT programs and 43 non-LDLT programs) were surveyed to gain insight into perceptions and practices of LDLT and types of donors utilized. The response rate was 84%. Most LDLT programs (65%) reported performing ND-LLD, though opinions regarding allocation and the need for additional evaluation of these donors were mixed. Only a minority of LDLT programs reported performing LPE (12%), but most programs (78%) would be open to cross-institutional LPE barring logistical barriers. There were significant differences between LDLT and non-LDLT programs with regard to perceived barriers to LDLT, with LDLT programs reporting mainly donor and recipient factors and non-LDLT programs reporting institutional factors (P<0.001). Understanding perceptions and practices of LDLT, ND-LLD, and LPE is important to aid in the growth of LDLT.

Evaluation of Adult Living Donor Liver Transplantation in Largest Southeast Asian Transplantation Center: Benchmarking With Adult-to-Adult Living Donor Liver Transplantation (A2ALL) Experience

The volume-outcome relation for complex surgical procedures such as living donor liver transplantation (LDLT) generally favors high volume (HV) centers. It is important for low to medium volume (MV) centers to evaluate their centers' performance against HV centers to allow early detection and correction of potential systemic issues. There is a dearth of national and international comprehensive registries for LDLT that may allow reasonable risk-adjusted comparisons for benchmarking. This study aims to evaluate the LDLT program by comparing our center's performance against HV centers of the Adult-to-Adult Living Donor Liver Transplantation cohort. Patient outcomes from a MV transplant center were compared with 11 HV transplant centers from the Adult-to-Adult Living Donor Liver Transplantation cohort. Outcomes evaluated included length of hospital stay, same admission mortality, 90-day mortality, and overall survival. A total of 1381 patients were analzyed. HV 1 to 4, 6, 8, 9, and 11 centers had a shorter median length of hospital stay compared with the MV center (All Dunnett corrected P values all less than .05). HV 9 and 11 centers had lower same admission mortality compared with the MV center (Dunnett corrected P=.023 and .015). After adjusting for other significant predictors, the MV center had comparable 90-day mortality rates and overall survival rates to all HV centers. This benchmarking exercise has demonstrated that the limitation of low institutional case volume can be overcome with a protocol-based framework to implement a safe LDLT program. This framework presented can be adopted for developing programs.

Nonalcoholic Fatty Liver Disease: Indian Perspective.

Nonalcoholic Fatty Liver Disease: Indian Perspective.

Robotic donor hepatectomy: Are we there yet?

In living donor liver transplantation (LDLT) the safety of the live donor (LD) is of paramount importance. Despite all efforts, the morbidity rates approach 25%-40% with conventional open donor hepatectomy (DH) operations. However, most of these complications are related to the operative wound and despite increased self- esteem and satisfaction in various quality of life analyses on LD, the most common grievance is that of the scar. Performing safe and precise DH through a conventional laparoscopic approach is a formidable task with a precipitous learning curve for the whole team. Due to the ramifications the donor operation carries for the donor, the recipient, the transplant team and for the LDLT program in general, the development and acceptance of minimally invasive DH (MIDH) has been slow. The robotic surgical system overcomes the reduced visualization, restricted range of motion and physiological tremor associated with laparoscopic surgery and allows for a comparatively easier transition from technical feasibility to reproducibility. However, many questions especially with regards to standardization of surgical technique, comparison of outcomes, understanding of the learning curve, etc. remain unanswered. The aim of this review is to provide insights into the evolution of MIDH and highlight the current status of robotic DH, appreciating the existing challenges and its future role.

Stepwise development of robotic donor right hepatectomy according to the anatomical variations in the hilum and the graft volume

Initial strict selections of donor without anatomical variations are recommended for minimally invasive living donor liver transplantation (LDLT) program because the donor safety is the most paramount. In this study, we introduced our stepwise development of robotic donor LDLT from donors with from favorable to unfavorable anatomies. From Apr. 2016 to Oct. 2020, 80 donors received robotic donor right hepatectomy. All donors were divided according to the variations of the portal vein and bile duct and the graft volume (> 800 cc). Donors who had at least one variable that satisfy beyond the three extended criteria were defined as 'unfavorable group'. The proportion of variations was analyzed according to the four periods and perioperative outcomes were compared between favorable and unfavorable group. Among 80 cases, portal vein variation and bile duct variation were observed 10 cases and 22 cases, respectively. Donors who had graft weight more than 800 g were 22 cases. Unfavorable group donors were 8 cases in 1st and 2nd period, respectively. In 3rd period, 9 donors were unfavorable group. In recent 20 cases, 14 donors were unfavorable group. Comparing the perioperative outcomes between favorable and unfavorable group, there were no significant differences regarding total operative time, warm ischemic time, estimated blood loss and postoperative complication. Stepwise development of robotic donor right hepatectomy showed comparable perioperative outcomes in donor with the anatomical variations in the hilum and larger graft volume and seems to a reasonable way for a safe and successful minimally invasive LDLT program.

Management of biliary complications after adult-to-adult living donor liver transplantation. Initial experience in a latin american center

Presenter: Sergio Riveros MD | Pontificia Universidad Católica de Chile Background: Living donor liver transplantation (LDLT) is a complex therapeutic alternative that requires a specialized multidisciplinary team with the capacity to resolve complications. The number of anastomosed ducts has an impact on the rate of postoperative biliary complications, but the literature is still scarce. The objective of this study was to describe early and late postoperative biliary complications with a focus on therapeutic management in the initial experience of a LDLT program. Methods: Non-concurrent cohort study at a Pontificia Universidad Católica de Chile. All patients who underwent adult-to-adult LDLT were included from 2016 to 2020. Patients were divided into two groups according to the number of bile duct anastomoses (single duct, group A; and two or three ducts, group B). Demographic, perioperative, postoperative outcomes regarding early and late biliary complications (>2 months), treatment, major complications (Clavien-Dindo III-IV), mortality, and survival were evaluated and compared between groups. Results: single bile duct was anastomosed in 63.3% (n = 19), two bile ducts in 33.3% (n = 10) and three bile ducts in 3.3% (n = 1). Duct-to-duct (DD) anastomosis was performed in 56.7% (n = 17), hepaticojejunostomy (HJ) in 33.3% (n = 10) and combined in 10% (n = 3). Major complications were reported in 46.7% (n = 14), median length of postoperative stay was 15.5 days (7-46) and median follow-up 17 months (0.4-53.5). Overall graft and patient survival was 87% at 24 months. Group A (n = 19) had major complications in 21% (n = 4), early biliary complications in 15.8% (n = 3) and late biliary strictures in 26.7% (n = 4). None required percutaneous drainage, 5.3% surgical drainage (n = 1) and 10.5% re-anastomosis to a Roux-en-Y HJ (n = 2). They underwent ERCP in 26.7% (n = 4) and percutaneous transhepatic internal-external drainage in 6.7% (n = 1). Four patients (21.1%) had early mortality and one patient (6.7%) late mortality, all unrelated to biliary complications. Group B (n = 11) had major complications in 90.9% (n = 10), early biliary complications in 81.8% (n = 9) and late biliary strictures in 54.5% (n = 6). They required percutaneous drainage in 27.3% (n = 3), surgical drainage in 9.1% (n = 1), endoscopic transgastric drainage in 9.1% (n = 1), duct-to-duct reinforcement (n = 1) and re-anastomosis to Roux-en-Y HJ (n = 4). They underwent ERCP in 27.3% (n = 3) and percutaneous transhepatic internal-external drainage in 18.2% (n = 2). All patients are alive with 100% graft and patient survival. Conclusion: Living donor liver transplantation is a challenging treatment that requires a specialized high-volume center with the ability to rescue postoperative complications. The number of reconstructed ducts affects the rate of early biliary complications, without an impact on graft and patient survival. In our experience, patients with 2-3 graft bile ducts had a high rate of biliary complications, but with adequate management, all patients are alive with functioning grafts. Expertise in advanced endoscopy, interventional radiology, and complex reoperations are crucial to achieve excellent outcomes.

Outcomes of living versus deceased donor liver transplantation: initial single center experience from Thailand

Background: The availability of deceased donor in the northern region of Thailand is limited. In 2015, we initiated the adult to adult living donor liver transplantation program. To date, we are the only active adult to adult living donor liver transplantation pro gram in Thailand. We evaluated the short-term outcomes after liver transplantation compare between living and deceased donor liver transplantation. Methods: Retrospective study of adult liver transplantation in our center since 2014. The patients were divided in to a living do nor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT). Baseline characteristic, perioperative data and 1-year survival were compared between two groups. Results: There were 37 cases underwent LT in our hospital since October 2014 (20 DDLT cases and 17 LDLT cases). Baseline characteristics between two groups were not significantly difference. The operative time was longer in LDLT group (P<0.001). However, cold and warm ischemic time were shorter in LDLT group (P<0.001 and P=0.026, respectively). The median ventilator, intensive care unit and hospital stay were similar. The incidence of biliary complication was higher in LDLT group (47% vs 10%, P<0.001). The vascular related complications were not significant difference. Nighty-day and 1-year survival were not significant difference between LDLT and DDLT group (84.6% vs. 84.2% and 76.9% vs. 84.2% respectively, P=0.706). Conclusions: In the region where deceased donor shortage, LDLT showed similar results compare to DDLT in terms of peri-oper ative outcomes and patient survival even done by the beginner LDLT program. However, the incidence of biliary related complica tion was significant higher in LDLT group.