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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2019  |  Volume : 30  |  Issue : 2  |  Page : 359-364
Postoperative complications in living liver donors: A retrospective study, single-center experience in Saudi Arabia


1 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Department of Hepatobiliary Surgery and Liver Transplantation, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia

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Date of Submission06-Feb-2018
Date of Acceptance12-Mar-2018
Date of Web Publication23-Apr-2019
 

   Abstract 


Living donor liver transplantation (LDLT) offers life to patients with end-stage liver disease. The balance between the benefit to the recipient and the risk to the donor plays a central role in justifying LDLT. However, the incidence rates of complications posttransplant differ widely. This study is designed to identify postoperative complications in LDLT in a tertiary care center King Abdulaziz Medical City (KAMC). This was a retrospective cohort study. All donors at KAMC between January 2003 and December 2015 were reviewed through a hospital database and patient charts to determine the postoperative complications based on the modified Clavien classification system. All donors were relatives of the recipients and assessed before the surgery. A total of 101 donors underwent LDLT: 75 were male and 26 were female, with a mean age of 27.7 ± 6.6. The breakdown of specific surgical procedures was as follows: 65 (64.3%) donors underwent right hepatic lobectomy, 31 (30.6%) underwent left lateral hepatectomy, three (2.97%) underwent extended right hepatectomy with the inclusion of the middle hepatic vein, and two (1.98%) underwent left hepatectomy. Postoperative complications were determined in 20 patients (19.8%), but no mortality was observed. Complications were reported in 14 (21.5%) right and six (19.4%) left lateral hepatectomy donors. A total of 12 patients had Grade I complications, six patients had Grade II complications, and Grade III complications were reported in two cases. The most frequent complications were upper limb weakness to brachial plexus neuropathy and mild bile leak. Life-threatening complications in our center have not been reported in LDLT; however, some donors may experience postoperative morbidity, which usually were mild and had a good prognosis.

How to cite this article:
Althonaian NA, Alsaiari AS, Almanea WA, Alsubaie NJ, Almuharimi AA, Althubaiti A, Altamimi AR, Abdullah KO, Ohali WA. Postoperative complications in living liver donors: A retrospective study, single-center experience in Saudi Arabia. Saudi J Kidney Dis Transpl 2019;30:359-64

How to cite this URL:
Althonaian NA, Alsaiari AS, Almanea WA, Alsubaie NJ, Almuharimi AA, Althubaiti A, Altamimi AR, Abdullah KO, Ohali WA. Postoperative complications in living liver donors: A retrospective study, single-center experience in Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Jul 21];30:359-64. Available from: http://www.sjkdt.org/text.asp?2019/30/2/359/256843



   Introduction Top


Liver transplantation is the treatment of choice for patients with end-stage liver disease. Living donor liver transplantation (LDLT) is one of the options in the absence of cadaveric liver.[1] Since the first LDLT was performed,[2] there has been a steady growth in the number of these procedures performed worldwide.[3],[4] The inception of LDLT was followed by an extensive ethical discussion. The balance between the benefit to the recipient and the risk to the donor plays a central role in justifying LDLT.[5],[6] In worldwide reports of LDLTs, donor morbidity ranges between 0% and 67%.[7],[8]

Since LDLT has been globally recognized, donor safety should be a top priority. Potential donors undergo a comprehensive multistep evaluation protocol to avoid any conditions that may lead to increased operative risks.[9] Each donation has to be approved by the local living donation commission. Given the technically complicated hepatectomy procedure and the considerable resection of the donor’s liver, a preoperative evaluation involving invasive tests for the donor is mandatory to exclude any biliary anomalies, focal hepatic masses, and fatty infiltration of the liver.[10],[11] During donors’ evaluation, the willingness of the donor candidate, is repeatedly confirmed.[12] Prior to the surgery, a consent form must be filled and signed by the donor candidate and his/her relative.[13] These donor procedures are also crucial for assurance of donor safety. During intraoperative procedures, anatomic variation of the hepatic vasculature and biliary system should be considered. This anatomic variation represents the major intraoperative risk faced by donors.[11]

Postoperative complications in LDLT are evaluated with the modified Clavien classification system. Clavien and Dindo introduced a classification system of surgical complications in 1992, which was modified to assess living donor scenarios by Broering in 2004.[14] In light of the apparent risks to the donors, several large centers have documented LDLT outcomes. However, the incidence rates of complications differ widely.[15] In this study, we aim to evaluate donor outcomes and morbidity in LDLT at a single center in Saudi Arabia.


   Materials and Methods Top


Between January 2003 and December 2015, a total of 101 LDLT operations were performed in King Abdulaziz Medical City (KAMC). In terms of demographics, 33 of the recipients were in the pediatric age group (aged <18 years), whereas the rest were in the adult age group (aged >18 years). The indication for the surgery was end-stage liver disease secondary to any of the following: liver cirrhosis, autoimmune disease, nonalcoholic steatohepatitis, and hepatobiliary cancer or cryptogenic causes.

All donors were blood relatives with the recipients, and their ages varied between 18 and 46 years. Each donor went through a preoperative assessment aiming to confirm that they were fit for the procedure clinically, with full awareness of the potential risks. The preoperative clinical assessment included the following: detailed history, complete physical examination, blood grouping, complete blood count, body mass index (BMI) calculation, biochemistry, liver function test, coagulation profile, renal function test, iron studies, viral serology screening, imaging studies [i.e., abdominal ultrasound, computed tomography (CT) scan, magnetic resonance cholangiopancreatography (MRCP) angiography with volumetry], and liver biopsy if needed.

The indications for determining if the liver biopsy was necessary was a CT finding of fatty liver, hepatitis B core antibody positive serology and BMI more than 28. After biopsy, the liver was considered to be suitable for donation if the steatosis was <15% (mild steatohepatitis). The other aspects of preoperative assessment included the following: surgeon consultation, psychiatric assessment and meeting with the anesthesia, and psychosocial team. After the procedure was performed, all donors were monitored in the postoperative care unit where analgesia had been given, and spirometry was encouraged for 24 h. The donors were followed according to the subsequent schedule: two weeks, one month, three months, and six months after the procedure and then annually for life. At each visit, the donors were assessed for normal liver and renal function. The donors were scanned through ultrasound in the first visit after surgery and imaging were conducted if indicated.

We retrospectively reviewed the course of admission after surgery for all donors. We used the Clavien system [Table 1] to classify any postoperative complications.
Table 1: Clavien-Dindo classification of surgical complications.[5]

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   Statistical Analysis Top


Data are presented as the mean ± standard deviation for continuous variables and percentages for categorical variables the continuous variables of many groups were compared with the ANOVA or Kruskal–Wallis tests. Categorical variables were compared using the Chi-square test. Multiple logistic regression was used to determine independent significant predictors of outcome. Incidence, relative risk with 95% confidence intervals was expressed relative to a reference baseline category. Values of P <0.05 were used to establish the significance level. Data were analyzed using the SPSS database (IBM SPSS Statistics, SPSS Inc., Chicago, Illinois, USA).


   Results Top


In this study, 101 donors underwent LDLT: 75 males and 26 females, with a mean age of 27.7 ± 6.6 years. The breakdown of specific surgical procedures was as follows: 65 (64.3%) donors underwent right hepatic lobectomy, 31 (30.6%) underwent left lateral hepatectomy, three (2.97%) underwent extended right hepatectomy with the inclusion of the middle hepatic vein, and two (1.98%) underwent left hepatectomy. All donors had normal biliary anatomy according to MRCP. Blood transfusion during operation was not needed and 14% of donors were managed in the liver transplantation intensive care unit (ICU) for monitoring and observation (24–48 h). Other variables are summarized in [Table 2].
Table 2: Donors characteristics.

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The postoperative complications of LDLT operations were graded according to the modified Clavien classification system [Table 3]. In this study, the postoperative complications were identified in 20 patients (19.8%); in these patients, no Grade IV complications or mortality were observed. Complications were reported in 14 (21.5%) right and six (19.4%) left hepatectomy donors. A total of 12 (11.8%) patients experienced Grade I complications, with the most frequent being upper limb weakness to brachial plexus neuropathy and mild bile leak. A total of six (5.9%) patients experienced Grade II complications, with the most frequently encountered being lung atelectasis and abdominal hematoma. Grade III complications were reported only in two (1.98%) cases. Patients with all grades of complications were successfully managed with an outcome of complete recovery. The donors’ characteristics and preoperative profiles showed no significant difference between the different grades of complications, except hospital length of hospital stay (LOS; [Table 4]). The LOS was significantly greater in patients with Grade II complications compared with donors without complications.
Table 3: Complications in liver donors according to the modified Clavien classification system.

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Table 4: Comparison of preoperative and operative variables between different grades of complications.

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   Discussion Top


Liver transplantation is a treatment of choice and life-saving therapy for many patients with end-stage liver disease. Despite the high success rates of LDLT, the donor complication rate worldwide is estimated at 25%–40% with approximately 0.2% to 0.5% mortality.[16] Meticulous donor selection criteria and precise operative technique are crucial for improving donor outcomes in LDLT. The presence of >1 risk factor (e.g., age >55, BMI <30, ≤30% hepatosteatosis, future liver remnants <30%) in a potential donor may be considered as relative contraindication to liver donation.[17]

The Clavien-Dindo classification of postoperative complications was chosen for the assessment of study patients for reporting all liver transplantation complications. The incidence of postoperative complications in our center was 21.7%. In these patients, no Grade IV complications or deaths were observed. A total of 12 (11.8%) patients experienced Grade I complications and six (5.9%) experienced Grade II complications. Complications of Grade I and Grade II were often self-limited and did not require additional treatment.

Biliary tract complications occurred in 3%–8% of donors. Bile leaks and bilomas accounted for the majority of these complications, whereas stenosis resulting from injury to the bile duct occurred in 1% of donors.[18] In this study, Grade III complications were reported in two (1.9%) cases. Biloma and bile leak was in one patient and treated by endoscopic retrograde cholangiopancreatography and sphincterotomy. Another subject suffered from pneumothorax and was treated by chest tube insertion. Furthermore, no significant differences were observed in ICU and hospital stay among the different types of graft in donor hepatectomy.

One limitation of this study is the small sample of donors (n = 101). Thus, data from more donors with different types of grafts should be collected and analyzed to identify the correlation between graft type and donor morbidity. Another limitation is that the longterm complications after donation are difficult to capture because some donors might be lost to follow-up. In conclusion, our single-center experience showed that life-threatening complications have not been reported in LDLT at KAMC; however, some donors may experience postoperative morbidity, which emphasizes the need for donor safety through careful selection and precise operative technique.

Conflict of interest: None declared.



 
   References Top

1.
Chen CL, Fan ST, Lee SG, Makuuchi M, Tanaka K. Living donors liver transplantation: 12 years of experience in Asia. Transplantation 2003;75:6-11.  Back to cited text no. 1
    
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Lee SG, Park KM, Hwang S, et al. Adult-to-adult living donor liver transplantation at the Asian medical center, Korea. Asian J Surg 2002;25:277-84.  Back to cited text no. 4
    
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Singer PA, Lantos JD, Whitington PF, Broelsch CE, Siegler M. Equipoise and the ethics of segmental liver transplantation. Clin Res 1988; 36:539-45.  Back to cited text no. 5
    
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Singer PA, Siegler M, Lantos JD, et al. The ethical assessment of innovative therapies: Liver transplantation using living donors. Theor Med 1990;11:87-94.  Back to cited text no. 6
    
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Brown RS Jr., Russo MW, Lai M, et al. A survey of liver transplantation from living adult donors in the United States. N Engl J Med 2003;348:818-25.  Back to cited text no. 7
    
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Pascher A, Sauer IM, Walter M, et al. Donor evaluation, donor risks, donor outcome, and donor quality of life in adult-to-adult living donor liver transplantation. Liver Transpl 2002;8:829-37.  Back to cited text no. 9
    
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11.
Ran S, Wen TF, Yan LN, et al. Risks faced by donors of right lobe for living donor liver transplantation. Hepatobiliary Pancreat Dis Int 2009;8:581-5.  Back to cited text no. 11
    
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Hashikura Y, Kawasaki S, Miyagawa S, et al. Donor selection for living-related liver transplantation. Transplant Proc 1997;29:3410-1.  Back to cited text no. 12
    
13.
Sugawara Y, Makuuchi M, Takayama T, Imamura H, Kaneko J. Right lateral sector graft in adult living-related liver transplantation. Transplantation 2002;73:111-4.  Back to cited text no. 13
    
14.
Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992;111:518-26.  Back to cited text no. 14
    
15.
Broering DC, Wilms C, Bok P, et al. Evolution of donor morbidity in living related liver transplantation: A single-center analysis of 165 cases. Ann Surg 2004;240:1013-24.  Back to cited text no. 15
    
16.
Cheah YL, Simpson MA, Pomposelli JJ, Pomfret EA. Incidence of death and potentially life-threatening near-miss events in living donor hepatic lobectomy: A world-wide survey. Liver Transpl 2013;19:499-506.  Back to cited text no. 16
    
17.
Dirican A, Ozsoy M, Ates M, et al. Consequences of the use of extended criteria donors in living donor liver transplantation. Ann Transplant 2015;20:211-7.  Back to cited text no. 17
    
18.
Humar A. Donor and recipient outcomes after adult living donor liver transplantation. Liver Transpl 2003;9:S42-4.  Back to cited text no. 18
    

Top
Correspondence Address:
Nouf Abdulaziz Althonaian
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, P. O. Box: 22490, Riyadh 11426
Saudi Arabia
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DOI: 10.4103/1319-2442.256843

PMID: 31031372

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