Evolution of donor morbidity in living related liver transplantation: a single-center analysis of 165 cases

Abstract

Objective: During the last 14 years, living donor liver transplantation (LDLT) has evolved to an indispensable surgical strategy to minimize mortality of adult and pediatric patients awaiting transplantation. The crucial prerequisite to performing this procedure is a minimal morbidity and mortality risk to the healthy living donor. Little is known about the learning curve involved with this type of surgery.

Patients and methods: From January 1991 to August 2003, a total of 165 LDLTs were performed in our center. Of these, 135 were donations of the left-lateral lobe (LL, segments II and III), 3 were of the left lobe (L, segments II-IV), 3 were full-left lobes (FL, segments I-IV), and 24 were of the full-right lobe (FR, segments V-VIII). We divided the procedures into 3 periods: period 1 included the years 1991 to 1995 (LL, n = 49; L, n = 2; FR, n = 1), period 2 covered 1996 to 2000 (LL, n = 47), and period 3 covered 2001 to August 2003 (LL, n = 39; FR, n = 23; FL, n = 3; L, n = 1). Perioperative mortality and morbidity were assessed using a standardized classification. Length of stay in intensive care unit, postoperative hospital stay, laboratory results (bilirubin, INR, and LFTs), morbidity, and the different types of grafts in the 3 different periods were compared.

Results: One early donor death was observed in period 1 (03/07/93, case 30; total mortality, 0.61.%). Since 1991, the perioperative morbidity has continually declined (53.8% vs. 23.4% vs. 9.2%). In period 1, 28 patients had 40 complications. In period 2, 11 patients had 12 complications, and in period 3, 6 patients had 9 complications. Within the first period, 1 donor underwent relaparotomy because of bile leakage. Postoperative hospital stay was 10 days, 7 days, and 6 days, respectively. Donation of the full right lobe, in comparison with that of the left lateral lobe, resulted in a significantly diminished liver function (bilirubin and INR) during the first 5 days after donation but did not increase morbidity. One donor from period 1 experienced late death caused by amyotrophic lateral sclerosis.

Conclusions: In a single center, morbidity after living liver donation strongly correlates to center experience. Despite the additional risks associated with temporary reduction of liver function, this experience enabled the team to bypass part of the learning curve when starting right lobe donation. Specific training of the surgical team and coaching by an experienced center should be implemented for centers offering this procedure to avoid the learning curve.

FIGURE 1. Postoperative liver function score at p.o. days 1, 3, and 5 after harvesting of the left lateral lobe, comparing the 3 periods on the left side (period 1 [black column] versus period 2 [white column] versus period 3 [shaped column]) and between different grafts in the period 3 on the right side (LL grafts [shaped column] versus FR grafts [dot column]). *P < 0.05, ANOVA Bonferroni test.

FIGURE 2. AST level after LL donation in the 3 periods (period 1 [black square] versus period 2 [black triangle] versus period 3 [white circle]). On the right side, postoperative AST level in the LL group (white circle) compared with the FR group (black rhomb). *P < 0.05, ANOVA Bonferroni test.

FIGURE 3. Complications according to our standardized living donor classification of morbidity. Period 1 (black column), 1991 to 1995 (n = 52), versus period 2 (white column), 1996 to 2000 (n = 47), versus period 3 (gray column), 2001 to 2003 (n = 39). *P < 0.05, χ² test.

FIGURE 4. Morbidity after LL harvesting (black column) and hemiliver donor surgery (white column) between 1991 and 2003.