Author Affiliations: Center for Liver Cancer, National Cancer Center, 111 Jungbalsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 410-769, Korea (Kim SH, Lee SD, Kim YK and Park SJ)

Corresponding Author: Seong Hoon Kim, MD, PhD, Center for Liver Cancer, National Cancer Center, 111 Jungbalsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 410-769, Korea (Tel: +82-31-920-1647; Fax: +82-31-920- 2798; Email: kshlj@hanmail.net)

 

© 2017, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(16)60146-7

Published online October 17, 2016.

 

 

Contributors: KSH proposed the study and wrote the first draft. KSH, LSD, KYK and PSJ performed research, and collected and analyzed the data. All authors contributed to the design and interpretation of the study and to further drafts. KSH is the guarantor.

Funding: None.

Ethical approval: This study was approved by the institutional review board of National Cancer Center, Korea.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 

 

BACKGROUND: 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.

 

METHODS: 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.

 

RESULTS: 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%.

 

CONCLUSION: A history of PAS is not a contraindication to LDRH in the current era of advanced surgical techniques.

 

(Hepatobiliary Pancreat Dis Int 2017;16:33-38)

 

KEY WORDS: living donor; liver transplantation; liver surgery; liver function

Living donor liver transplantation (LDLT) is being performed worldwide to solve the problem of a great and ongoing shortage of organ donors, which ends up with increased waitlist mortality for patients who require liver transplants. Living donor right hepatectomy (LDRH) is currently the most common form of living donor surgery in adult-to-adult LDLT despite concerns about donor safety, an issue with no room for compromise. But, as surgical technique and management for living donor surgery get improved with time and experience, several steps to get closer to the cliff edge have been taken as the means to expand the living donor pools for LDLT in patients who have no other alternatives, which include the use of ABO incompatible grafts,^[1] selection of living donors with liver remnants <30%,^[2] obese donors,^[3] elderly donors,^[4] and donors with intra-abdominal adhesion.^[5]

 

One of surgically unfavorable factors in selecting living donor candidates is previous abdominal surgery (PAS), which can develop postoperative adhesion intraperitoneally so that LDRH as repeat abdominal surgery is expected to be more technically demanding with a higher risk of complication. So PAS were regarded as a relative contraindication to donation.^[6] With the focus on the intraoperative findings, the specific impact of intra-abdominal adhesion on the technical aspects and postoperative outcomes of LDRH was reported in a recent study.^[5] But it is difficult to accurately predict intra-abdominal adhesion before surgery, even if the patient has a history of PAS. Furthermore, the correlation between PAS and intra-abdominal adhesion in LDRH has never been studied fully.

 

Therefore, this study aimed to assess the outcomes of right lobe LDLT in both the donor and recipient by limiting the investigation only to living donors with a history of PAS, a preoperatively recognizable factor.

 

 

This retrospective study considered all living donors who underwent right hepatectomy at National Cancer Center, Korea between March 2008 and November 2014, and was approved by the institutional review board of National Cancer Center, Korea. A prospectively maintained database was used for reviewing donor characteristics, operative outcomes, and postoperative complications. To evaluate the effect of PAS on the outcomes of LDRH, the donors were divided into the following three groups: group 1, donors with upper PAS; group 2, donors with lower PAS; group 3, donors without PAS. The donors in group 3 were selected to match 1:1 on the basis of age, gender, and body mass index to donors in group 1 and group 2 in the same time period.

 

According to Beck et al,^[7] the severity of adhesion was assessed as mild (grade 1: thin, filmy, and divided by blunt dissection; grade 2: thin, vascular, and easily divided by sharp dissection) or severe (grade 3: extensive, thick, and vascular, requiring division by sharp dissection; grade 4: dense, putting the bowel at risk of injury with division). Only adhesions that needed to be divided to complete the LDRH or to place the abdominal retractor were considered relevant. The primary outcome measure was postoperative complications graded according to the Clavien classification.^[8] The secondary outcome measures included operative outcomes and postoperative peak serum levels of total bilirubin (TB), international normalized ratio (INR), alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Postoperative liver failure was defined as prothrombin time <50% and TB >50 µmol/L on postoperative day 5 (the 50-50 criteria) on postoperative day 5.^[9]

 

In recipients, early graft function was evaluated by the INR and TB levels checked on postoperative day 7. The recipient 30-day mortality rate and 1-year survival rate were compared between the three groups.

 

The selection criteria and evaluation for living donors have been specified previously.^[10-12] Briefly, the informed consent was obtained from all voluntary living donors about the items deliberated by the Ethics Group of the Vancouver Forum,^[13] and all LDLTs were approved by Korean Network for Organ Sharing. Donor candidates with PAS were not allowed to donate a part of their liver if they had any adhesion-related abdominal symptom within 6 months prior to LDRH. Potential donors with a malignancy history were denied from donation.

 

A single primary surgeon (KSH) performed all LDRH procedures following a standardized operative protocol. The detailed surgical technique and procedural refinements on LDRH have been described elsewhere.^{[11, 14, 15]} In all donors even with a history of PAS, an upper midline incision above umbilicus was chosen (Fig.). Adhesions, if present under the incision, were carefully separated enough to make use of a self-retaining abdominal retractor. Adhesions were removed if they hindered surgical performance of LDRH or interfered with securing a surgical field. The right lobe of liver was completely mobilized and the sizable right inferior hepatic veins, if present, were saved for reconstruction. After cholecystectomy, careful dissection was made to encircle the right Glisson’s pedicle by a tape.^[15] By temporarily occluding the right Glisson’s pedicle, the transection line was marked by electrocautery on the liver surface, and the inferior part of caudate lobe was divided along the surface marking up to the hepatic hilum. A tape for hanging was positioned along the anteromedian surface of inferior vena cava with its upper end between right hepatic vein and middle hepatic vein (MHV) and with its lower end between the right and left Glisson’s pedicles. The liver parenchymal transection was done along the right side of the main trunk of MHV with hanging maneuver employed continuously until parenchymal transection was completed. Any MHV branch over 5 mm in diameter was preserved and reconstructed. After completion of parenchymal transection, the right hepatic artery, portal vein, and hepatic duct were dissected from the right Glisson’s pedicle. Ligation of right hepatic duct was done just at the right side of the confluence under a direct view and a cut was made at the left side of ligature. Heparin (5 IU/kg) was injected intravenously. The right hepatic artery, portal vein, and hepatic vein were clamped sequentially and cut at each bifurcation. The graft was delivered to an iced basin and perfused with histidine-tryptophan-ketoglutarate solution. Then, the falciform ligament was fixed in original anatomic position, and a drain was left adjacent to the cut liver surface.

 

Postoperative management and follow-up after LDRH was reported previously.^{[5, 11, 12, 16]} Donors left the operating room after extubation and were transferred to the recovery room. To prevent thromboembolism, graduated compressive stockings were worn on one day before operation and continued until discharge, and low-molecular-weight heparin was given to donors over age 60 for 1 week postoperatively. Early feeding and early ambulation were encouraged within two days after operation. Laboratory tests were done during hospital stay. Follow-up CT was routinely performed at 1 week, 1 month, and 1 year after LDRH. All donors were regularly followed up with routine laboratory tests after discharge.

 

Categorical variables presented as the numbers of cases and percentages were compared using the Chi-square test. Continuous variables expressed as medians and ranges were compared using the ANOVA. For analysis between the two groups out of three donor groups, Fisher’s exact test was used. The statistical significance was set at P value less than 0.05. All analyses were performed using SAS version 9.1.3 for Windows (SAS institute, Cary, NC, USA).

 

 

A total of 471 donors underwent right hepatectomy during over a 6-year study period. There were 23 (4.9%) donors who had a history of PAS, and they had altogether 24 PASs. All the donors underwent one PAS each except for one donor who had two PASs. The PAS comprised 10 cholecystectomies (6 laparoscopic, 4 open), 5 appendectomies, 2 small bowel resections, 4 Cesarean sections, 1 sigmoid colon resection, 1 adhesiolysis for postoperative ileus, and 1 operation for duodenal ulcer perforation. The PAS preceded LDRH by a median elapsed time of 10.5 years (range 3.1-15.8).

 

Eleven donors were assigned to group 1, 12 to group 2, and 23 to group 3. Demographic and preoperative characteristics for the three groups are listed in Table 1. No significant differences were found in age, gender, body mass index, remnant-to-total liver volume ratio, and fatty change on ultrasonography between the three groups.

 

Relevant intraperitoneal adhesions were found in 20 (87.0%) of 23 donors with PAS in groups 1 and 2, and one donor in group 3 with the incidence making a significant difference between the 3 groups (P<0.001). All of 10 cholecystectomized donors had severe hilar adhesion. Five (21.7%) of 23 donors with PAS had adhesiolysis-induced injuries that included 1 enterotomy of small intestine, 2 bile duct injuries, 1 portal vein injury, and 1 right hepatic artery injury. These 5 injuries were treated by suture repair, especially with microsurgical technique used in the vascular and bile duct injuries. The incidence of iatrogenic injuries due to adhesiolysis was significantly higher in group 1 than in group 2 (P=0.025). No blood products were used in any donor perioperatively. Operative time made a significant difference between the three groups (P=0.012). No significant differences were observed between the three groups in the other operative parameters (Table 2).

 

No significant differences were noted in the levels of postoperative peak serum AST, ALT, INR, and TB between three groups (Table 3). Postoperative liver failure did not occur in donors enrolled in this study.

 

In groups 1 and 2, a total of 7 (30.4%) complications, all grade I, occurred and resolved spontaneously within one month. Compared with control donors in group 3, the grade I complication rate was higher in donors with PAS in group 1 and group 2 (P=0.047), which could be due to a higher wound complication rate (Table 4). The median postoperative follow-up was 35.8 months (range 14.5-76.4) in groups 1 and 2, and 42.1 months (range 14.3-81.2) in group 3. All donors went back to their previous activities with full recovery.

 

All recipients of groups 1 and 2 had no other donor candidates but the ones with PAS. The perioperative characteristics of recipients were not significantly different between the recipients of the three donor groups. Both 30-day mortality rate and 1-year survival rate made no significant differences between the three recipient groups (Table 5).

 

 

Despite “First, do no harm”, one of the most widely accepted principles of medical ethics, the scarcity of donor organs have rendered LDRH the treatment of choice for adult patients who have no choice but to resort to living donors for liver transplantation. The potential surgery-related morbidity of living donors reportedly ranged from 16% to 78.3%.^[16] PAS is highly likely to add to this morbidity by peritoneal adhesions, which could possibly result in serious complications because the adhesion bring about more than 60% of all small bowel obstructions.^[17] Therefore, the use of living donors with PAS may be a surgical issue challenging the safety of these altruistic donors.

 

Considering the premier issue of donor safety, it was very tough decision to accept the donor candidates with a history of PAS. And very few reports in the literature have dealt with living donor liver surgery as repeat abdominal surgery. However, hepatectomy resection has been frequently performed in patients with a history of abdominal surgery.^{[18, 19]} In addition, even under the upper midline incision above umbilicus, partial hepatectomies resections as repeat abdominal surgery can be performed safely in patients even with previous larger incisions in the abdomen.^[20] The surgical technique and management has recently improved with time and experience. Therefore, the expected high risk of donors with PAS was judged to be reduced in the authors’ institution. Actually adhesiolysis-related iatrogenic injury that happened in 5 donors with PAS was managed successfully with advanced surgical management including microsurgical techniques.

 

This study showed a higher incidence of adhesion with the resultant adhesiolyis-related iatrogenic injury, a longer operative time, and a higher wound complication rate in living donors with PAS, when compared with donors without PAS. In view of adhesion, relevant adhesion and its related iatrogenic injury were more common in group 1 than in group 2, and all the donors in group 1 had adhesion, mostly of higher grade, highlighting that upper PAS can pose a higher risk than lower PAS in performing LDRH in donors with a history of PAS. These findings were linked to a longer operative time in group 1 than in group 2, and in group 2 than in group 3. This observation is consistent with the previous report that postoperative adhesions can add significantly to the operative time of subsequent surgeries due to the need for adhesiolysis.^[7] However, complete recovery was attained in all 23 donors with PAS without any serious complication or apparent sequelae, and the overall donor complication rate was not significantly different between the three groups with regard to PAS. These results demonstrate that LDRH can be performed safely in donors who have a history of PAS with morbidity rates comparable to donors who have not.

 

Notably, in this study, the relevant adhesion was found in 9 of 12 donors who had undergone lower PAS such as appendectomy or Cesarean section, and one of the 23 donors without PAS had mild adhesion. These findings remind that adhesions can also occur as the results of traumatic injury and inflammatory response besides surgery.^[21] Therefore, donor surgeons should get prepared for encountering unexpected adhesions.

 

Lysis of adhesions is one of the most sophisticated tasks performed by surgeon. Extensive adhesions demand abundant perseverance and meticulous dissection to minimize the risk of other organ or vascular injury. In addition to adhesiolysis, two distinctive techniques were employed for LDRH in this study. One is the upper midline incision above umbilicus. This was consecutively used in all living donors even with previous larger incisions in the abdomen, which was reported in patients who underwent partial hepatectomy as repeat surgery or repeat hepatectomy.^[20] The other is a unique procedure for hilar dissection of the author’s institution. Unlike the conventional method, the right hepatic artery, portal vein, and hepatic duct were dissected individually after complete parenchymal transection, following extrahepatic dissection of the right Glisson’s pedicle.^[15] Because complete parenchymal transection makes both lobes of liver separated away from each other and maintains the wide operative field, accidental vascular injuries during dissection of scarred hilum can be repaired easily.

 

Another important consideration for living donor with PAS is the possibility that the donor operation can be aborted due to severe adhesion for the sake of donor safety. So, the recipient was called to the operating room only after the donor operation was judged to be feasible. No donor operation was aborted in this study. However, the unpredictable can happen so that severe adhesion may lead to intraoperative ‘no go’ donor hepatectomy. Currently, even with rigorous preoperative evaluation, there is no specific factor to predict adhesion due to PAS that may preclude a donor candidate otherwise being deemed acceptable.

 

The limitation of this study was the small number of donors with PAS enrolled. Recruiting donors in sufficient numbers ultimately proved to be impossible because selecting donor candidates with PAS is uncommon with few data available. Although there is much remains to be done, this study generates important findings in the field of living donor liver surgery. To date, this study is the first to investigate the feasibility and safety of LDRH in donors with PAS in terms of the donor and recipient outcomes.

 

In conclusion, PAS cannot be an absolute contraindication for LDRH in the hands of expert surgeons armed with advanced surgical techniques and maximal care. Further studies are needed on specific predictive factors for PAS-related adhesion and long-term outcomes of LDRH in donors with PAS.

 

 

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