Living Donor Right Hepatectomy Research Articles

P9.21: Future Liver Remnant Volume Ratio Less Than 30% Is Not A Contraindication to Living Donor Right Hepatectomy

Background: The evidence for defining a safe remnant/total volume ratio(RTVR) for in living donors undergoing right hepatectomy for living donor liver transplantation (LDLT) is still not clear yet. The current practice of arbitrarily requiring an RTVR of at least 30% is based on the experience of early studies to keep donor safety. Recently, some centers reported that extended resection with RTVR less than 30% for living donor right hepatectomy but there is no consensus has been established for future remnant liver volume (FRLV) ratio limit. Herein, we describe out center’s experience for living donor right hepatectomy with RTVR < 30% and evaluate the outcomes of living donors with RTVR < 30%. Methods: We retrospectively reviewed the outcomes of 473 living donor right hepatectomy (LDRH) which performed at our institution from January 2010 to December 2020. We performed right hepatectomy for living donors with RTVR <30% under the following criteria; 1) Age ≤40 2) Preservation of MHV 3) No or Minimal fatty changes (<15%) 4) Flat fish shaped left hemiliver 5) RTVR > 25% and FRLV/ BW ≥ 0.45. The outcomes in these extended living donors were compared with those in living donors under conventional criteria. Results: The mean RTVR in extended group was 27.1 ± 1.2 % (range, 25.1-28.9). Posthepatectomy liver failure (PHLF) occurred in 50 donors (10.6%) and most cases were grade A except one case in conventional group and no clinically significant PHLF was not evident for these extended donor group. PHLF and major complications were not more frequent in living donor group with RTVR <30%. In multivariate only the event for major complications was associated with PHLF but RTVR less than 30% was related to PHLF. To adjust for between-group differences, donors with FLR ≤30% and >30% were matched based on baseline characteristics and overall complication rates and the incidence of PHLF were not different between the two groups. Conclusion: DRH under our extended criteria could be performed safely in donors with RTVR ratio <30% under our strict criteria when no other donors are available and our extended criteria might be helpful to expand donor pools without adverse effects on donor safety.

Use of a Mini-subcostal Incision for Living Donor Right Hepatectomy: A Series of 189 Consecutive Cases

Introduction: Living donor hepatectomy is now a well-established surgical procedure. However, a large abdominal incision is still required, which results in a large permanent scar, especially for a right liver graft. Minimally invasive surgery has been widely used for donor operations. This study aimed to determine the safety and feasibility of mini- subcostal incision for living donor right hepatectomy. Methods: We reviewed 1456 patients who underwent living donor right hepatectomy (LDRH) between January 2015 and December 2019 at Asan Medical Center. We performed 1:1 propensity score matching of the LDRH with mini- subcostal incision and the LDRH with conventional incision (J-shape), with 144 patients subsequently included in each group. Results: The total operation time (P =0.018) were longer in the mini- subcostal incision group. None of the donors required intraoperative transfusion or experienced any irreversible disabilities or mortalities. The length of postoperative hospital stay was significantly shorter in the mini- subcostal incision group (P =0.043). The rate of complications in donors was similar between the 2 groups. Graft steatosis were independent predictors of postoperative morbidity after LDRH with mini- subcostal incision on multivariable analysis. Vascular and biliary complication rates in recipients were similar between the 2 groups. Conclusions: LDRH with mini- subcostal incision is feasible when performed at an experienced living donor liver transplantation center. Donor safety is paramount in living donor liver transplantation. In centers with difficulties in performing pure laparoscopic donor right hepatectomy, LDRH with mini-subcostal incision can be an alternative to pure laparoscopic donor right hepatectomy.

Impact of extended living donor criteria focusing on donor safety in living donor liver transplantation

Donor safety has been the primary concern during living donor liver transplantation (LDLT) and therefore most centers keep the strict selection criteria for donor safety. Recently, conventional donor selection criteria have been modified to expand the donor pool in LDLT. Herein, we describe out center's experience for extended living donor criteria focusing on remnant liver volume (RLV) and graft steatosis. We retrospectively reviewed the outcomes of 452 living donor right hepatectomy (LDRH) including 115 extended criteria donors who performed at our institution from January 2010 to June 2020. Extended donor was defined with criteria as follows: 1) old donor (age > 40 years) with RLV of < 35%; 2) young donor (age ≤ 40 years) with RLV < 29% and minimal fatty change (< 15%); 3) young donor with mild hepatosteatosis (15%-30%) and RLV of < 35%. The outcomes in extended living donors were compared with those in living donors under conventional criteria. Posthepatectomy liver failure (PHLF) occurred in 48 donors (10.6%) and most cases were grade A except one case with conventional criteria. PHLF and major complications were not more frequent in extended donor group . In multivariate analysis, the only the event for major complications was associated with PHLF but neither extended criteria nor RLV ratio was related to PHLF. LDRH under our extended criteria could be performed to expand donor pools without adverse effects on donor safety and could be performed safely in donors with RLV ratio < 30% under our strict criteria when no other donors are available.

IMPACT OF EXTENDED LIVING DONOR CRITERIA ON DONOR SAFETY IN LIVING DONOR LIVER TRANSPLANTATION

Introduction: Donor safety has been the primary focus of transplant programs that perform living donor liver transplantation (LDLT) and major living donor complications could be avoidable under the strict selection criteria of living donors. Recently, strict donor selection criteria has been modified to expand the donor pool in LDLT but the concept for extended donor is not clearly defined yet. Herein, we describe out center’s experience for extended criteria donors in LDLT focusing on donor safety. Materials and Methods: We retrospectively reviewed the outcomes of 424 living donor right hepatectomy (LDRH) including 105 extended criteria donors who performed at our institution from January 2010 to June 2019. Extended Donor criteria was defined as follows; 1) old donor (age >40 years) with remnant liver volume of <35%, 2) young donor (age ≤40 years) with remnant liver volume <29% and minimal fatty change (<15%), 3) young donor with mild hepatosteatosis (15%-30%) and remnant liver volume of < 35%. The outcomes in extended living donors were compared with those in living donors using conventional criteria focusing on donor safety. Posthepatectomy liver failure (PHLF) was defined according to the International Study Group of Liver Surgery (ISGLS) criteria. We also included statistical analysis of risk factors that are related to PHLF. Results: PHLF occurred in 43 donors (10.1%) and most cases were grade A except one case in conventional donor group (grade B) and PHLF did not occur more frequently in extended donor group. (7.6% vs. 11.0% % P = 0.32) and the incidence of major complications requiring radiological or surgical interventions did not differ between the 2 groups. Moreover, no difference in either posttransplant graft function or survival was apparent between the 2 groups. In multivariate logistic regression analyses, only major complication (OR, 3.002; 95% CI, 1.042-8,649; P = 0.04) was associated with PHLF but not related to our extended donor criteria. Conclusion: LDRH under our extended criteria could be performed to expand donor pools without adverse effects on donor safety.

Low Preoperative Platelet Count Predicts Risk of Subclinical Posthepatectomy Liver Failure in Right Lobe Donors for Liver Transplantation.

Living donor right hepatectomy (LDRH) is a common procedure in adult-to-adult living donor liver transplantation, but it is associated with a higher risk of posthepatectomy liver failure (PHLF) compared with left hepatectomy because of a smaller remnant. We identified risk factors for PHLF and other complications in LDRH, verified the appropriateness of the criteria, and explored the possibility of adjusting the minimum remnant liver volume (RLV) based on individual risk. Between October 2005 and November 2017, 254 donors undergoing LDRH at Kyoto University Hospital were enrolled. Clinical data were collected retrospectively. All complications were graded according to the Clavien-Dindo classification. No donors had grade 4 or 5 complications or clinically significant grade B or C PHLF. Grade A PHLF occurred in 30 donors (11.8%). Male sex (P = 0.01), lower preoperative platelet count (PLT; P = 0.01), higher prothrombin time-international normalized ratio (P = 0.03), higher total bilirubin (P = 0.01), smaller RLV (P = 0.03), and greater blood loss (P = 0.04) were associated with increased risk of PHLF in the univariate analysis, whereas PLT, RLV, and blood loss remained significant in the multivariate analysis. Grade 2 or 3 complications were observed in 32 (12.6%) donors. Higher body mass index (BMI; P = 0.002) and larger blood loss (P = 0.02) were identified as risk factors for complications (Clavien-Dindo grade ≥ 2) in univariate analysis. Only BMI remained significant in the multivariate analysis. In conclusion, LDRH is performed safely with acceptable morbidity under the current criteria. Minimum RLV may be marginally adjusted by PLT and reducing intraoperative blood loss minimizes PHLF risk. Liver Transplantation 00 000-000 2018 AASLD.

Right hepatectomy in living donors with previous abdominal surgery

Few studies have evaluated the impact of previous abdominal surgery (PAS) on living donor right hepatectomy (LDRH). The aim of this study was to investigate the outcomes of liver transplantation using right lobe grafts of living donors with PAS. Data were reviewed from LDRH patients at the authors' institution between March 2008 and November 2014. LDRH patients with PAS were divided into two groups according to upper PAS (group 1) or lower PAS (group 2), and they were compared to those without PAS (group 3) who were matched 1:1 based on age, gender, and body mass index. Perioperative data, complications by the Clavien classification, and the outcomes with more than 14 months follow-up were compared. Twenty-three (4.9%) of a total of 471 LDRH donors had PAS. Eleven donors were assigned to group 1, 12 to group 2, and 23 to group 3. Intraperitoneal adhesions were found in 20 (87.0%) of 23 donors with PAS, of whom 5 (21.7%) had adhesiolysis-related injuries that happened more commonly in group 1 than in group 2 (P=0.025). LDRH was successfully completed under upper midline laparotomy in all donors. No donors received perioperative blood transfusion. The peak postoperative AST, ALT, INR, and total bilirubin levels made no difference between the three groups. Compared with group 3, groups 1 and 2 had a longer operative time (P=0.012) and a higher grade I complication rate (P=0.047). All donors recovered fully to their routine activities. The 23 recipients of grafts from donors with PAS showed good liver function with 1-year graft and patient survivals of 100%. A history of PAS is not a contraindication to LDRH in the current era of advanced surgical techniques.

Comparison of Upper Midline Incision With and Without Laparoscopic Assistance for Living-Donor Right Hepatectomy

Since minimally invasive procedures for living-donor right hepatectomy (LDRH) became popular in recent years, several studies comparing the outcomes of donors undergoing an upper midline incision (UMI) under laparoscopic assistance for LDRH with those undergoing the traditional open LDRH have been published. However, there are very few comparative studies of outcomes for a UMI for LDRH with and without laparoscopic-assistance. We designed the present study to compare the benefits and shortcomings of a UMI for LDRH with and without laparoscopic assistance. Forty-eight patients in our center were included in the study: group hybrid (n=28) versus group UMI (n= 20). Their surgical outcomes, postoperative course, and cosmetic outcomes were studied from medical records. No differences existed between the 2 groups regarding their baseline characteristics except that group Hybrid had more donors with positive hepatitis B core antibody. No difference was observed in operative time, graft weight, warm ischemia time, blood loss, incision length, liver and coagulation function test results, postoperative complications, or cosmetic parameters. No deaths occurred in both groups. The length of postoperative hospital stay was similar for both groups, but the hospital cost was significantly lower for group UMI than for group hybrid (6,906.7 ± 777.4 USD vs 7,643.3 ± 918.6 USD; P=.005). An UMI without laparoscopic assistance can be considered as the first-line incision of choice for LDRH.

The Impact of a Surgical Protocol for Enhanced Recovery on Living Donor Right Hepatectomy: A Single-Center Cohort Study.

The concept of surgery for enhanced recovery (SFER) program has never been an issue in the context of living donor right hepatectomy (LDRH), much less its effects. The purpose of this study was to evaluate outcomes after the establishment of an SFER protocol for LDRH in a single center.A single-center cohort study was performed in 500 consecutive living donors who underwent right hepatectomy from January 2005 to June 2014 by analyzing the outcomes before and after an established SFER protocol that evolved with continuous refinements in surgical technique and management over 300 LDRHs, being in place on September 2011. Donor characteristics, operative outcomes, and postoperative complications divided into 2 groups (group 1, stepwise adjustment; group 2, complete adherence to the protocol) were compared.Donor characteristics were comparable in the 2 groups. Overall complication rate was 10.0% with no mortality. In group 2, operative time, hospital stay, and overall complication rate decreased significantly, and the morbidity was 1% and confined in grade I complication without reoperation, perioperative blood transfusion, or readmission. All donors in this series recovered fully and returned to the previous functional lifestyle.An SFER protocol on LDRH can be established by the gradual implementation of various refinements of surgical technique, and the recent outcomes achieved after the establishment of an SFER protocol could provide a current guidance on LDRH toward the ultimate goal of zero morbidity.

Impact of Intra-Abdominal Adhesion on Living Donor Right Hepatectomy.

The impact of intra-abdominal adhesion (IAA) on living donor right hepatectomy (LDRH) remains to be clarified. The purpose of this study was to compare both the donor and recipient outcomes of right lobe living donor liver transplantation according to IAA detected intraoperatively. LDRH donors were identified through a prospectively maintained database at the authors' institution between March 2008 and February 2014. IAA was graded according to Beck et al (Dis Colon Rectum 2000; 43: 1749-1753). LDRH donors with IAA (group A) were matched 1:3 to those without IAA (group B) based on age, gender, and BMI. Perioperative data, complications by the Clavien classification, and the outcomes with at least 12 months follow-up were compared. Thirty-two (7.6%) of a total of 420 LDRH donors had IAA around the liver. Nineteen donors had previous abdominal surgery. LDRH was successfully completed under upper midline laparotomy in all donors. Compared with group B, group A had a longer operative time (270 vs. 172 min; p < 0.001), a higher wound complication rate (28.1% vs. 4.2%; p = 0.009), and a longer postoperative stay (10 vs. 7 days; p = 0.009). All donors recovered completely to their previous activities. The 1-year graft and recipient survivals of recipients were comparable between two groups. These findings support the feasibility and safety of LDRH in patients with IAA.

Volumetry Guided Right Hepatectomy in The Presence of Hypolastic Left Lateral Segment in the LivingDonor.

Background: Variant anatomy often leads to exclusion of potential living donors. However, in Asia and India, there is near total reliance on living donation. We report the case of a successful living donor righthepatectomy in the presence of hypoplastic segments 2 &3. Method:A 42 year old male suffering fromcirrhosis, MELD 16, hepato-hydrothorax & ascites with SBP. was evaluated for Liver transplant. His brother,aged 32 years, volunteered to donate. On evaluation, his LAI(liver attenuation index) was +1 and Liver biopsyhad 15% macro-vesicular steatosis. After psychological, cardiac and pulmonology evaluation he was acceptedfor donation. His triphasic C T scan of liver & volumetry showed a congenitally small left lateral segment (Wholeliver 1107 ml; Segment 2&3 81 ml). Routine transection plane through the Middle Hepatic Vein (MHV) yielded aright graft of 840 ml {GRWR(Graft to Recipient Weight Ratio) =1.1} and RLV(Remnant Liver Volume) 267ml(24%)precluding safe donor hepatectomy. Since the left liver was mainly constituted by Segment 4, thehepatectomy plane was modified according to portal vein supply and leaving MHV in the donor to prevent anycongestion in Segment 4. The new plane yielded right graft volume of 750 ml and RLV 357 ml (32.2%). After extensive counseling and authorization committee approval, transplant was done. The recipient operation wasdelayed till the donor hilar dissection ensured that the transection plane matched the preoperative plan.Results:The donor hepatectomy was uneventful (blood loss 500 ml; no transfusion). The donor made anuneventful recovery and was discharged on POD 7. The retrieved graft was 720 grams (GRWR= 0.940).Therecipient had a smooth post -operative course. Follow up donor C T at 3 months showed increase in Left livervolume to 902 ml (RLV 357); segment 4 from 276 to 633 ml and seg 2&3 from 81 to 269 ml.C onclusion: In theabsence of a viable deceased donor program, predominantly living donor centers will be forced to acceptdonors with variant anatomy. Preoperative planning and use of imaging and volumetry to guide hepatectomy can allow retrieval of grafts from these donors without increasing the risk.

Pushing the frontiers of living donor right hepatectomy.

Living donor right hepatectomy (LDRH) is currently the most common donor surgery in adult-to-adult living donor liver transplantation although the morbidity and mortality reported in living donors still contradicts the Hippocratic tenet of "do no harm". Achieving low complication rates in LDRH remains a matter of major concern. Living donor surgery is performed worldwide as an established solution to the donor shortage. The aim of this study was to assess the current status of LDRH and comment on the future of the procedure; assessment was made from the standpoint of optimizing the donor selection criteria and reducing morbidity based on both the authors' 8-year institutional experience and a literature review. New possibilities have been explored regarding selection criteria. The safety of living donors with unfavorable conditions, such as low remnant liver volume, fatty change, or old age, should also be considered. Abdominal incisions have become shorter, even without laparoscopic assistance; upper midline laparotomy is the primary incision used in more than 400 consecutive LDRHs in the authors' institution. Various surgical techniques based on preoperative imaging technology of vascular and biliary anomalies have decreased the anatomical barriers in LDRH. Operative time has been reduced, with low blood loss. Laparoscopic or robotic LDRH has been tried in only a few selected donors. The LDRH-specific, long-term outcomes remain to be addressed. The follow-up duration of these studies should be long enough to address possible late complications. Donor safety, which is the highest priority, is ensured by three factors: preoperative selection, intraoperative surgical technique, and postoperative management. These three focus areas should be continuously refined, with the ultimate goal of zero morbidity.

Which Incision Is Better for Living-Donor Right Hepatectomy? Midline, J-Shaped, or Mercedes

Incision-related morbidity for donors is a major concern in living-donor right hepatectomy (LDRH). Open approaches use midline, J-shaped, and Mercedes incisions for LDRH. We retrospectively studied 95 consecutive donors who underwent LDRH between January 2009 and November 2010. They underwent midline (n = 32), J-shaped (n = 28), or Mercedes (n = 35) incisions. We studied resection times, perioperative bleeding, postoperative hospital stay, and postoperative pain assessed by the visual analog scale (VAS) and by analgesic requirements as well as laboratory data and complications. Postoperative analgesic requirements and postoperative VAS scores were significantly lower in the midline group (P < .05) upon univariate but not multivariate analyses. The postoperative complications as well as other parameters were similar between the groups. In conclusion, compared with a J-type shaped or not for Mercedes incision, a donor hepatectomy can be satisfactorily performed via a midline incision by experienced surgeons without increased risk.

Mini-incision right hepatic lobectomy with or without laparoscopic assistance for living donor hepatectomy

Minimally invasive procedures are considered to be safe and effective approaches to the management of surgical liver disease. However, this indication remains controversial for living donor hepatectomy. Between 2000 and 2011, living donor right hepatectomy (LDRH) was performed 58 times. Standard right hepatectomy was performed in 30 patients via a subcostal incision with a midline extension. Minimally invasive procedures began to be used for LDRH in 2008. A hybrid technique (hand-assisted laparoscopic liver mobilization and minilaparotomy for parenchymal dissection) was developed and used in 19 patients. In 2010, an upper midline incision (10 cm) without laparoscopic assistance for LDRH was innovated, and this technique was used in 9 patients. The perioperative factors were compared, and the indications for minimally invasive LDRH were investigated. The operative blood loss was significantly less for the patients undergoing a minimally invasive procedure versus the patients undergoing the standard procedure (212 versus 316 mL, P = 0.001), and the operative times were comparable. The length of the hospital stay was significantly shorter for the minimally invasive technique group (5.9 versus 7.8 days, P < 0.001). The complication rates were 23% and 25% for the standard technique and minimally invasive technique groups, respectively (P = 0.88). Patients undergoing minilaparotomy LDRH had a body mass index (24.0 kg/m(2)) similar to that of the hybrid technique patients (25.8 kg/m(2), P = 0.36), but the graft size was smaller (780 versus 948 mL, P = 0.22). In conclusion, minimally invasive LDRH can be performed without safety being impaired. LDRH with a 10-cm upper midline incision and without laparoscopic assistance may be appropriate for donors with a smaller body mass. Laparoscopic assistance can be added as needed for larger donors. This type of LDRH with a 10-cm incision is innovative and is recommended for experienced centers.

Living Donor Right Hepatectomy Using the Hanging Maneuver by Glisson’s Approach Under the Upper Midline Incision

The purpose of this study was to introduce an advanced technique for the best living donor right hepatectomy (LDRH) using the hanging maneuver by Glisson's approach under an upper midline incision. From January 2005 to February 2010, a total of 196 consecutive LDRHs have been performed at the National Cancer Center, Korea. To assess the overall outcomes of LDRH done with two significant technical developments--the upper midline incision and the initial Glisson's approach--we performed a comparative analysis involving all consecutive living donors, who we divided into three groups based on the two technical modifications over 5 years. Compared with the previous two groups, the third group of 32 consecutive living donors, from September 2009 to February 2010, demonstrated shorter operative time, shorter duration of hospital stay, and lower complication rate with no operative mortality, major morbidity, blood transfusion, or reoperation. All donors were fully recovered and returned to their previous activities. This LDRH using the hanging maneuver by Glisson's approach can be completed safely and effectively with good outcomes through an upper midline incision above the umbilicus, which may be a new milestone toward the best LDRH that donor surgeons can pursue.

Upper midline incision for living donor right hepatectomy

Innovations and refinements in the techniques of living donor right hepatectomy (LDRH) have been made over the past decades, but the type and size of abdominal incision have been at a standstill since its inception. We introduce herein the upper midline incision for LDRH using the standard open technique. A prospective case-matched study was conducted on 23 consecutive donors who underwent LDRH under a supraumbilical upper midline incision (I group) from February to May 2008. These donors were matched 1:1 to 23 right liver donors with a conventional J-shaped incision (J group) according to age, gender, and body mass index. Under the mean incision length of 13.5 cm, LDRH was successfully completed in all 23 donors without extension of the incision, with a mean operative time of 232.3 +/- 29.2 minutes. No donors required blood transfusion during surgery. There were 2 cases of postoperative bleeding immediately controlled under the same incision and a case of pleural effusion. All donors fully recovered and returned to their previous activities. All grafts have been functioning well. Compared with the J group, the I group had a shorter operative time, a shorter period of analgesic use, and, after discharge, infrequent complaints of wound pain. This upper midline incision, even without laparoscopic assistance, can be used for LDRH with less pain and without impairing safety, reproducibility, or effectivity, allowing the seemingly insufficient incision to be recommended to the transplant centers that are practicing living donor liver transplantation.

Use of HTK solution for hypothermic machine perfusion: an alternative for the preservation of less than optimal donor livers?—An experimental study in rats

Since minimally invasive procedures for living-donor right hepatectomy (LDRH) became popular in recent years, several studies comparing the outcomes of donors undergoing an upper midline incision (UMI) under laparoscopic assistance for LDRH with those undergoing the traditional open LDRH have been published. However, there are very few comparative studies of outcomes for a UMI for LDRH with and without laparoscopic-assistance. We designed the present study to compare the benefits and shortcomings of a UMI for LDRH with and without laparoscopic assistance.Forty-eight patients in our center were included in the study: group hybrid (n = 28) versus group UMI (n = 20). Their surgical outcomes, postoperative course, and cosmetic outcomes were studied from medical records.No differences existed between the 2 groups regarding their baseline characteristics except that group Hybrid had more donors with positive hepatitis B core antibody. No difference was observed in operative time, graft weight, warm ischemia time, blood loss, incision length, liver and coagulation function test results, postoperative complications, or cosmetic parameters. No deaths occurred in both groups. The length of postoperative hospital stay was similar for both groups, but the hospital cost was significantly lower for group UMI than for group hybrid (6,906.7 ± 777.4 USD vs 7,643.3 ± 918.6 USD; P = .005).An UMI without laparoscopic assistance can be considered as the first-line incision of choice for LDRH.