Live donor hepatectomy for liver transplantation in Egypt: Lessons learned

Abstract

Purpose:To retrospectively review anesthesia and intensive care management of 145 consented volunteers subjected to right lobe or left hepatectomy between 2003 and 2011.Methods:After local ethics committee approval, anesthetic and intensive care charts, blood transfusion requirements, laboratory data, complications and outcome of donors were analyzed.Results:One hundred and forty-three volunteers successfully tolerated the surgery with no blood transfusion requirements, but with a morbidity rate of (50.1%). The most frequent complication was infection (21.1%) (intraabdominal collections), followed by biliary leak (18.2%). Two donors had major complications: one had portal vein thrombosis (PVT) treated with vascular stent. This patient recovered fully. The other donor had serious intraoperative bleeding and developed postoperative PVT and liver and renal failure. He died after 12 days despite intensive treatment. He was later reported among a series of fatalities from other centers worldwide. Epidural analgesia was delivered safely (n=90) with no epidural hematoma despite significantly elevated prothrombin time (PT) and international normalization ratio (INR) postoperatively, reaching the maximum on Day 1 (16.9±2.5 s and 1.4±0.2, P<0.05 when compared with baseline). Hypophosphatemia and hypomagnesemia were frequently encountered. Total Mg and phosphorus blood levels declined significantly to 1.05±0.18 mg/dL on Day 1 and 2.3±0.83 mg/dL on Day 3 postoperatively.Conclusions:Coagulation and electrolytes need to be monitored perioperatively and replaced adequately. PT and INR monitoring postoperatively is still necessary for best timing of epidural catheter removal. Live donor hepatectomy could be performed without blood transfusion. Bile leak and associated infection of abdominal collections requires further effort to better identify biliary leaks and modify the surgical closure of the bile ducts. Donor hepatectomy is definitely not a complication-free procedure; reported complication risks should be available to the volunteers during consenting.

An Elbow Patch Reconstruction Technique for Narrowed Remnant Portal Veins during Right Lobe Living Donor Hepatectomy: A Rescue Surgery

“…While biliary complications are considered the most common after living donor hepatectomy [15], portal vein complications are rare, occurring in 0.1-3.8% of patients [16][17][18]. Although portal vein complications after living donor hepatectomy are rare, it should be considered that these complications are associated with significant morbidity and even mortality in patients [19].…”

“…Especially in the presence of anomalous portal venous branching in the right lobe (Figure 1a), the donor surgeon's effort to remove the right portal vein as a single lumen is the most common cause of portal vein thrombosis after living donor hepatectomy [20][21][22]. In other words, at the immediate post-operative period, narrowing of the remnant portal vein may precipitate portal vein thrombosis, and this may become a life-threatening complication by causing portal hypertension, mesenteric congestion, and sepsis, which increase postoperative morbidity and mortality [17,21]. Long-term stenosis is associated with portal hypertension and its complications, which may be a significant source of morbidity for some donors after right lobe living donor hepatectomy [12,19,20,23,24].…”