Lobe Donation Research Articles

Role of mentorship in the learning curve of robotic right lobe donor hepatectomy.

Role of mentorship in the learning curve of robotic right lobe donor hepatectomy.

Indications and results of right-lobe living donor liver transplantation.

The shortage of deceased liver donor organs over the years has always posed the need to expand the donor pool. A viable alternative to deceased donors is that of the living donor. Indeed, the living donor in liver transplantation, initially in pediatric transplantation, but for several years now also in adult transplantation, is a more than viable alternative to deceased liver donation. In fact, right liver lobe donation has proven to be a surgical procedure with low impact on the donor's life in terms of morbidity and mortality, with excellent results in recipients of such organs. In recent years, an increasing number of studies have been published that show excellent results in right-lobe living donor liver transplantation, encouraging this practice not only in countries that have historically had a shortage of deceased donor organs, such as Asian countries, but making it a practice of increasing use in Western countries as well. In addition, thanks to improvements in surgical technique and the experience of high-volume centers, this surgery has also begun to be performed using minimally invasive surgical techniques, allowing us to envision ever better outcomes for both donor and recipient in the coming years.

Defining Surgical Difficulty During Open Right Lobe Donor Hepatectomy and its Prediction Using Preoperative Donor Computed Tomography Morphometry

BackgroundThere is no accepted way to define difficult donor hepatectomy (DiffDH) during open right living donor hepatectomy (ORLDH). There are also no studies exploring association between DiffDH and early donor outcomes or reliable pre-operative predictors of DiffDH. MethodsConsecutive ORLDH performed over 18 months at a single center were included. Intra-operative parameters were used to develop an objective definition of DiffDH. The impact of DiffDH on early postoperative outcomes and achievement of textbook outcome (TO) was evaluated. Donor morphometry data on axial and coronal sections of donor CT at the level of portal bifurcation were collected. Donor and graft factors predictive of DiffDH were evaluated using univariate and multivariate logistic regression. ResultsOne hundred and eleven donors (Male-40.5%, Age-34± 9.5 years) underwent ORLDH during the study period. Difficulty score was constructed using five intra-operative parameters i.e. operating time, transection time, estimated blood loss, need for intra-operative vasopressors and need for Pringle maneuver. Donors were classified as DiffDH (score ≥ 2) or Standard DH (score<2). Twenty nine donors (26%) were classified as DiffDH. DiffDH donors suffered greater all cause morbidity (p=0.004) but not major morbidity (Clavien-Dindo score>2; p=0.651), more peri-operative transfusion (p=0.013), increased post-operative SIRS (p=0.034), delay in achieving full oral diet (p=0.047) and a 70% reduced chance of achieving TO as compared to StDH (p=0.007). On logistic regression analysis, increasing right lobe antero-posterior depth (RLdepth) was identified as an independent predictor of DiffDH (Odds ratio- 2.0(95% ci =1.2,3.3), p<0.006). ROC curve analysis identified RLdepth>14 cms as the best predictor of DiffDH (Sensitivity-79%, specificity-66%, Area under curve=0.803, p<0.001). ConclusionWe report a novel definition of DiffDH and show that it is associated with worse post-operative outcomes, including a lesser chance of achieving TO. We also report that DiffDH can be predicted from readily available donor CT parameters.

Safety of right liver donation after improving steatosis through weight loss in living donors: a retrospective study.

Living donor liver transplantation using hepatic steatosis-improved grafts mitigates donor shortage. Herein, we aimed to evaluate the safety and feasibility of right-lobe adult-to-adult living donor liver transplantation using grafts improved through donor weight loss. In this retrospective study conducted in a single institution in the Republic of Korea, we reviewed the medical records of living liver donors who lost ≥ 10% of their body weight to improve steatosis before right lobe donation between January 2015 and December 2020. Overall, 1040 right-lobe donors were included, with 150 and 890 donors in the weight loss and control (non-steatosis) groups, respectively. We performed 1:1 individual matching using the greedy matching method, by which 124 patients were included in each group. The median period from the date of the first visit to donation was 113 (interquartile range: 78-184) days in the weight loss group. As body weight changed from 82.8 ± 13.7kg to 70.8 ± 11.8kg (p < 0.0001), body mass index also improved from 27.8 ± 3.9kg/m2 to 23.8 ± 3.1kg/m2 (p < 0.0001). No significant between-group differences existed in the postoperative laboratory data for living donors and recipients. The incidence of postoperative complications in donors was comparable between the groups (control group, 9.7%; weight loss group, 13.7%; p = 0.3185). The graft and recipient survival rates were comparable between the groups (p = 1.000). Weight loss through diet and exercise significantly could improve hepatic steatosis in living donor candidates for liver transplantation, with the surgical outcomes in recipients and donors being equivalent to those in recipients and non-steatotic donors.

Donor Complications Following Living Donor Hepatectomy: 17-Year Experience of a Single Team in One Institution of Japan.

Donor safety is paramount in living donor liver transplantation. However, there remains a risk of postoperative complications for some donors. Here, we provide a comprehensive assessment of donor morbidity by a single team with 17 years of experience at a single center. We retrospectively reviewed 453 donor hepatectomies of living donor liver transplants at Kumamoto University from August 2000 to March 2017. Posterior segment graft cases were excluded in this study. The donors were classified by graft type as follows: right lobe (n = 173), left lobe (n = 149), and left lateral segment (n = 131). The overall complication rate was 29.8%, and the severe complication (Clavien-Dindo grade IIIa or higher) rate was 9.1%. The most frequent complication was bile leakage, with an overall incidence of 13.9% and severe incidence of 4.6%. Among the 3 types of graft, there were no significant differences in bile leakage with any Clavien-Dindo grade. However, upper gastrointestinal complications, such as a duodenal ulcer and gastric stasis, were related to left lobe donation. There were no significant differences in the incidence of postoperative donor complications, except upper gastrointestinal complications, among the 3 types of graft.

Early Graft Failure After Living-Donor Liver Transplant.

Living-donor liver transplantation (LDLT) has been increasing in the USA. While data exist on longer-term patient and graft outcomes, a contemporary analysis of short-term outcomes is needed. Evaluate short-term (30-day) graft failure rates and identify predictors associated with these outcomes. Adult (≥ 18) LDLT recipients from 01/2004 to 12/2021 were analyzed from the United States Scientific Registry of Transplant Recipients. Graft status at 30 days was assessed with graft failure defined as retransplantation or death. Comparison of continuous and categorical variables was performed and a multivariable logistic regression was used to identify risk factors of early graft failure. During the study period, 4544 LDLTs were performed with a graft failure rate of 3.4% (155) at 30 days. Grafts from male donors (aOR: 0.63, CI 0.44-0.89), right lobe grafts (aOR: 0.40, CI 0.27-0.61), recipients aged > 60years (aOR: 0.52, CI 0.32-0.86), and higher recipient albumin (aOR: 0.73, CI 0.57-0.93) were associated with superior early graft outcomes, whereas Asian recipient race (vs. White; aOR: 3.75, CI 1.98-7.10) and a history of recipient PVT (aOR: 2.7, CI 1.52-4.78) were associated with inferior outcomes. LDLTs performed during the most recent 2016-2021 period (compared to 2004-2009 and 2010-2015) resulted in significantly superior outcomes (aOR: 0.45, p < 0.001). Our study demonstrates that while short-term adult LDLT graft failure is uncommon, there are opportunities for optimizing outcomes by prioritizing right lobe donation, improving candidate nutritional status, and careful pre-transplant risk assessment of candidates with known PVT. Notably, a period effect exists whereby increased LDLT experience in the most recent era correlated with improved outcomes.

Intermittent Inflow Occlusion [IIO] in robotic right lobe donor hepatectomy – Early results of an ongoing RCT

Intermittent Inflow Occlusion [IIO] in robotic right lobe donor hepatectomy – Early results of an ongoing RCT

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

Glucose 6 phosphate dehydrogenase (G6PD) deficiency (G6PDd) can trigger hemolysis following surgical stress. Differentiating G6PDd-related post-operative hemolytic episodes (PHE) and post-hepatectomy liver failure may be challenging especially in living donors where donor safety is paramount. We analysed outcomes of our cohort of G6PDd liver donors. G6PDd individuals with no evidence of hemolysis were considered as living donors if there was no alternative family donor. Outcomes of G6PDd donors undergoing left lateral/left lobe donation (Group LL) and right lobe donation (Group RL) were compared with non-G6PDd donors matched in a 1:3 ratio using propensity score matching. 59 G6PDd donors (5.8% of 1011) underwent living donor hepatectomy (LiDH) during the study period. LL-G6PDd donors (22.37%) had higher post-operative peak bilirubin level compared to matched controls, but no difference in morbidity or need for post-operative blood transfusion.RL-G6PDd donors (37.63%) had higher peak bilirubin level, morbidity (16.2% vs. 3.6%, p = 0.017) and more post-operative blood transfusion (21.6% vs. 6.4%, p = 0.023) as compared to matched non-G6PDd cohort. Four RL-G6PDd donors (10.8%) developed PHE. Low G6PD activity (15% vs. 40%, p = 0.034) and lower future liver remnant (FLR) (34.3% vs. 37.8%, p = 0.05) were identified as risk factors for PHE. We report the largest to-date series of G6PDd individuals undergoing LiDH and confirm the safety of LL donation in G6PDd. Our analysis identifies specific risk factors for PHE and suggests that right lobe LiDH be avoided in individuals with less than 25% G6PD activity when the FLR is less than 36%.

Live donor profile in paediatric liver transplantation: a three-year experience

Introduction: Liver transplantation for paediatric patients was started in Sri Lanka in 2020, focusing on living donors. This retrospective study examines the donors evaluated at the Colombo North Centre for Liver Disease for the first twelve paediatric liver transplants.Methods: Related donors and undirected donors were encouraged. Donor assessment was done in stages: initial screening, haematological investigations, imaging, and ethical approval. Twelve donors were selected for ethical approval and donor surgery.Results: A total of 36 donors underwent workup. 24 were rejected, and 12 were accepted. The reasons to reject were abnormal LFTs and fatty liver disease 16 (67%), the presence of comorbidities 5 (21%), and unfavourable anatomy 2 (8%). In one donor (4%), surgery was abandoned due to rising intraoperative lactate levels. Of the rejected group, 17 were males and 7 were females, and the median age was 33 (Range 43-20) years. 12 donors (7 related and 5 non-related) had a median age of 33 (range 25-41) and a median BMI of 19.25 (16.3-22.5) and a male-to-female ratio of 7:5. Left lateral sector donation was done in 6 while left lobe donation in 4 and right lobe donation in 2 were done respectively.Conclusion: Fatty liver disease was the predominant cause of donor disqualification. Living donor paediatric liver transplantation is feasible in the Sri Lankan setting. It would be a safer option due to the detailed donor workup given the high prevalence of fatty liver disease in the population.

Utilizing ultra-small volume graft in auxiliary liver transplantation for portal hypertension

Objective: To examine the clinical effect of auxiliary liver transplantation with ultra-small volume graft in the treatment of portal hypertension. Methods: Twelve cases of portal hypertension treated by auxiliary liver transplantation with small volume graft at Liver Transplantation Center,Beijing Friendship Hospital, Capital Medical University between December 2014 and March 2022 were studied retrospectively. There were 8 males and 4 females,aged 14 to 66 years. Model for end-stage liver disease scores were 1 to 15 points and Child scores were 6 to 11 points. The grafts was derived from living donors in 9 cases,from split cadaveric donors in 2 cases,from whole cadaveric liver of child in 1 case. The graft recipient body weight ratios of 3 cadaveric donor livers were 0.79% to 0.90%, and of 9 living donor livers were 0.31% to 0.55%.In these cases, ultra-small volume grafts were implanted. The survivals of patient and graft, complications, portal vein blood flow of residual liver and graft, abdominal drainage and biochemical indexes of liver function were observed. Results: All the grafts and patients survived. Complications included outflow tract torsion in 2 cases, acute rejection in 1 case, bile leakage in 1 case, and thyroid cancer at the later stage of follow-up in 1 case, all of which were cured. The torsion of outflow tract was attributed to the change of anastomotic angle after the growth of donor liver. After the improvement of anastomotic method, the complication did not recur in the later stage. There was no complication of portal hypertension. The measurement of ultrasonic portal vein blood flow velocity showed that the blood flow of residual liver decreased significantly in the early stage after operation, and maintained a very low blood flow velocity or occlusion in the long term after operation, and the blood flow of transplanted liver was stable. Conclusions: Auxiliary liver transplantation can implant ultra-small donor liver through compensation of residual liver. This method may promote the development of living donor left lobe donation and split liver transplantation. However, the auxiliary liver transplantation is complex, and it is difficult to control the complications. Therefore, this method is currently limited to centers that are skilled in living related liver transplantation and that have complete ability to monitor and deal with complications.

Does Radiological Assessment of Steatosis of the Liver Affect Postoperative Outcomes in Robotic Right Lobe Donor Hepatectomy?

Does Radiological Assessment of Steatosis of the Liver Affect Postoperative Outcomes in Robotic Right Lobe Donor Hepatectomy?

Safety of glucose-6 phosphate dehydrogenase deficient donors in living right lobe liver donation.

The literature lacks data on World Health Organization (WHO) class II and III deficient liver donors who underwent right hepatectomy during living donor liver transplantation (LDLT). In this prospective cohort study, we compared the perioperative outcomes of 15 glucose-6 phosphate dehydrogenase (G6PD) deficient living liver donors with a matched cohort of 39 nondeficient living liver donors undergoing right lobe donation. Out of 15 G6PD deficient donors, four (26.67%) donors had class II, and 11 (73.34%) had class III G6PD deficiency. The mean postoperative trough hemoglobin level was significantly lower in the deficient group than the nondeficient group (9.38±1.59g/dL vs. 10.27 ± .91g/dL, p=.046). The mean peak indirect bilirubin level was significantly higher in the deficient group than the nondeficient group (2.22± 1.38mg/dL vs. 1.40 ± .89mg/dL, p=.047), and a similar trend was observed in total serum bilirubin (3.99± 2.57mg/dL vs. 2.99± 1.46mg/dL, p=.038). Biochemical evidence of hemolysis was found only in three (20%) deficient donors, but none of them needed a blood transfusion. No mortality was observed in either group. All other parameters, including demographics, operative parameters, graft characteristics, and hospital stay were comparable between both groups (p>.05). G6PD deficiency with WHO class II and above should not be considered a contraindication for right lobe donation.

Expanding donor pool for live donor liver transplantation: utilization of donors with non-alcoholic steatohepatitis after optimization.

Potential live liver donors with non-alcoholic steatohepatitis (NASH) are rejected upfront for donation in live donor liver transplantation (LDLT). Herein, we share our experience of the feasibility of live liver donation in donors with NASH after successful donor optimization. Prospectively collected data of 410 consecutive donor hepatectomies from June 2011 to January 2018 were analyzed. During the study period, NASH was diagnosed histopathologically in 17 donors. Four donors were rejected in view of grade 2 fibrosis on histology. Out of remaining 13 donors, six became eligible for donation following lifestyle changes, dietary modifications, and target weight reduction of ≥5%. Reversal of NASH was confirmed on repeat liver biopsy in all the 6 donors. Five out of 6 underwent right lobe (without MHV) donor hepatectomies, while one had left lobe donation. These donors had significantly higher peak bilirubin levels in the immediate post-operative period as compared to other non-NASH donors (4.00 ± 0.32 vs. 2.57 ± 1.77mg/dL, p = 0.043). In addition, post-hepatectomy normalization of hyperbilirubinemia, if any, was slower in donors with NASH (7 ± 1.3 vs. 5 ± 1.7days, p = 0.016). However, none of these donors had post-hepatectomy liver failure. All these donors were discharged after an average hospital stay of 8 ± 1.7days. Their respective recipients had uneventful post-operative courses without complications. Both the recipients and donors are having satisfactory liver functions after 46.7 ± 10.2months of follow-up. Scrupulous selection of live liver donors with NASH can open a door for expanding the organ pool in LDLT after a successful donor optimization program.

Robotic Donor Hepatectomy in a Donor with Type III Portal Vein Configuration

Introduction: Donors with type III portal vein are often accepted for right lobe donations. Recently right donor hepatectomy by a minimally invasive technique using laparoscopy or Da Vinci robot has been described. However, donors with type III portal veins are usually avoided for minimally invasive techniques.

Is Remnant Donor Volume Less Than 35 % Safe to the Donor in Living Donor Liver Transplantation

Background: In adult (Living donor liver transplantation) LDLT, donor safety is of paramount importance, and ideally, there should not be any donor deaths. Objectives: To assess the prognosis of donor laboratory and clinical data according to the remnant liver volume. Patients and methods: The present study conducted on 200 consecutive cases of living donor liver transplantation over a period of 7 years (2012 and 2018). Patients were divided to two groups according to remnant liver volume (RLV): group (A) 60 patients with 30% to less than 35% RLV, while group (B) 140 patients with RLV more than or equal 35%. Results There were statistically significant difference between both studied group among ALT, total bilirubin and serum albumin. Conclusion: Right lobe donor hepatectomy can be performed with remnant liver volume of less than 35% with low risk on donor.

EFFECT OF PREOPERATIVE ASSESSMENT ON MINIMIZING LIVING DONOR LIVER TRANSPLANTATION DONOR COMPLICATIONS

Background: In adult Living donor liver transplantation (LDLT), donor safety is of paramount importance, and ideally, there should not be any donor deaths. Objective: To evaluate the potential donor for Living Donor Liver Transplantation as regard general condition, fitness, liver function and segmental anatomy; and assessment of intra- and postoperative complications up to 6 months post-operatively. Patients and methods: The present study conducted on 200 consecutive cases of living donor liver transplantation over a period of 7 years (2012 to 2018). All patients were admitted at the Department of Transplantation, International Medical Center, Armed Forces Egypt. The study was prospective and designed to evaluate the donors preoperatively, criteria of selection, possible intra-operative and postoperative complications. Results: One hundred and thirty two donors (66%) had grade I complications, 60 donors (30%) had grade II complications, 4 (2%) donors had grade IIIa complication, and 123 (6%) donors had grade IIIb complications. Biliary complications were 12% (24 donors) in the form of biliary leak. Conclusion: Right lobe donor hepatectomy can be performed with an acceptably low incidence of complications. LDLT using the right lobe provides adequate hepatic mass for most adult transplant recipients and gives recipient results similar to conventional cadaveric transplantation.

Initial experience of 40 cases pure-laparoscopic full lobe donor hepatectomy in Cleveland Clinic

Initial experience of 40 cases pure-laparoscopic full lobe donor hepatectomy in Cleveland Clinic

EFFECT OF PREOPERATIVE ASSESSMENT ON MINIMIZING LIVING DONOR LIVER TRANSPLANTATION DONOR COMPLICATIONS

Background: In adult Living donor liver transplantation (LDLT), donor safety is of paramount importance, and ideally, there should not be any donor deaths. Objective: To evaluate the potential donor for Living Donor Liver Transplantation as regard general condition, fitness, liver function and segmental anatomy; and assessment of intra- and postoperative complications up to 6 months post-operatively. Patients and methods: The present study conducted on 200 consecutive cases of living donor liver transplantation over a period of 7 years (2012 to 2018). All patients were admitted at the Department of Transplantation, International Medical Center, Armed Forces Egypt. The study was prospective and designed to evaluate the donors preoperatively, criteria of selection, possible intra-operative and postoperative complications. Results: One hundred and thirty two donors (66%) had grade I complications, 60 donors (30%) had grade II complications, 4 (2%) donors had grade IIIa complication, and 123 (6%) donors had grade IIIb complications. Biliary complications were 12% (24 donors) in the form of biliary leak. Conclusion: Right lobe donor hepatectomy can be performed with an acceptably low incidence of complications. LDLT using the right lobe provides adequate hepatic mass for most adult transplant recipients and gives recipient results similar to conventional cadaveric transplantation.

Middle-retroauricular Island Flap: A New Axial Flap for Reconstruction of Non-helical Ear Defects.

Background:Surgical treatment of ear carcinomas needs the selection of the appropriate reconstructive techniques, which depends on the location and the dimensions of the defect after excision of the cancer and the quality of blood supply to the peri-lesional skin.The aim of this study was to evaluate the efficacy and reliability of a new axial island retroauricular flap (middle-retroauricular island flap M-RIF) for coverage of non-helical ear defects with direct donor site closure.Methods:All patients, from January 2013 to January 2020, with skin tumors of the non-helix region and undergoing a combined skin-cartilage excision with M-RIF local flap reconstruction under local anesthesia, were enrolled in the study.Results:18 patients (14 men and 4 women) underwent auricle skin-cartilage excision and M-RIF flap reconstruction. The mean age was 65 years (range, 60–85); the type of primary lesions were 12 BCC and 6 SCC. One flap wound dehiscence and one donor site infection and partial necrosis of the posterior auricular skin occurred; no other complications were recorded.Conclusions:The M-RIF flap is a valid surgical option when dealing with non-helical defects of the anterior pinna. It allows the reconstruction of the defect of the entire anterior surface of the auricle apart from the helix and the lobe and primary donor site closure.

Small-for-size graft, small-for-size syndrome and inflow modulation in living donor liver transplantation.

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size syndrome (SFSS)." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extending to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume (GV) such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by a small-for-size graft (SFSG), such as a porto-systemic shunt or splenectomy and optimal outflow reconstruction, have been trialed with some positive results. To establish an effective strategy for transplanting SFSG and preventing SFSS, it is essential to have precise knowledge and tactics to evaluate graft quality and GV, when performing these LDLTs with portal pressure control and good venous outflow. Thus, we reviewed the updated literature on the pathogenesis of and strategies for using SFSG.