A Comparison of Right and Left Lobectomies for Living Donor Liver Transplantation: An Anesthesiologist's Point of View

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doi:10.1016/j.transproceed.2007.11.057 Copyright © 2008 Elsevier Inc. All rights reserved.

Organ donation

A Comparison of Right and Left Lobectomies for Living Donor Liver Transplantation: An Anesthesiologist’s Point of View

P. Zeyneloglu, a, , A. Pirata, S.T. Balcia, A. Torgaya, O. Cinara, S. Sevmisa and G. Arslana aDepartments of Anesthesiology, and General Surgery, Baskent University Faculty of Medicine, Ankara, Turkey. Available online 6 February 2008.

Abstract

Because of the shortage of cadaveric donor organs, living donor liver transplantation (LDLT) has become an established therapy modality for end-stage liver disease. Based on recipient size, both right and left liver lobe grafts have been used successfully in LDLT. The aim of this study was to compare the risk of intraoperative complications and transfusion requirements between right and left lobe donors. We reviewed the charts of 54 right lobe (Group RL), 29 left lobe (Group LL), and 31 left lateral segment (Group LLS) donors who underwent lobectomy from January 2003 through January 2007. We recorded patient demographics, perioperative laboratory values, intraoperative fluid and transfusion requirements, intraoperative hemodynamic parameters, and complications. Demographic features and preoperative laboratory values were similar for the 3 groups, except for age (Group RL, 37.3 ± 8.7; Group LL, 36.0 ± 9.3; Group LLS, 31.7 ± 9.4; P = .02). There were no significant differences in mean liver volumes among the groups (P > .05). Respective graft volumes were 803.1 ± 139.2 mL, 438.0 ± 122.7 mL, and 308.2 ± 76.6 mL for Groups RL, LL, and LLS, respectively (P < .001). More patients in Group LLS required heterologous blood transfusion than did those in the other groups (P = .01). The incidence of intraoperative hypotension was similar for all groups (P > .05). Group RL had a significantly higher rate of intraoperative hypothermia than the other groups (P = .01). There were no intraoperative respiratory complications or cardiac events. These results indicated that both right and left donor lobectomies for LDLT were safe procedures with acceptable rates of minor intraoperative complications.

Article Outline

Patients and Methods Results Discussion References

The number of living-donor liver transplantations (LDLT) has increased progressively because of the chronic shortage of cadaveric livers. Based on recipient size both right and left liver lobe grafts have been used successfully in LDLT. Compared with a cadaveric liver graft, the quality of a transplant from a living donor is better, owing to the shorter preservation time and better maintenance of systemic hemodynamics. The graft volume for a successful transplant is ideally more than 40% of the standard liver volume.1 In the early stages of LDLT, left lobectomy was performed predominantly with regard to donor safety. However, in many cases, the left lobe was insufficient for the recipient. Right lobe grafts have now become popular for LDLT to ensure adequate graft volume for adult recipients.2 Although the benefits of transplanting a larger graft are obvious for the recipient, the potential risks to the donor need to be better defined. There are several reports that morbidity is greater among right than left lobe donors.[3] and [4] At present, donor safety after right lobe liver donation has been assessed by many studies. LDLT with a right lobe liver graft has become a feasible option for adult patients with end-stage liver disease.[5] and [6] The aim of this study was to compare the risk of intraoperative complications and transfusion requirements between right and left lobe donors. Patients and Methods

From January 2003 to January 2007, 114 patients underwent donor hepatectomy for LDLT by a single team. Following approval from our institutional review board, we reviewed the charts of 54 right lobe (Group RL), 29 left lobe (Group LL), and 31 left lateral segment (Group LLS) donors. Data were abstracted from anesthesia records, operative records, and computerized hospital database. Preoperatively all donors underwent various medical and psychological assessments, including laboratory tests and hepatobiliary imaging studies. Resection borders were determined preoperatively with the aid of computed tomography (CT) by manual delineation; the hepatic vessels were used as guides. We calculated the volumes of total liver parenchyma, right and left hepatic lobes, and left lateral segments. To identify the resection line of the left or right hepatic lobes, the related portal vein and hepatic artery were transiently occluded intraoperatively. We resected the left lateral segment from 1 cm lateral and parallel to the falciform ligament. Following midazolam premedication, anesthesia monitoring included ECG, intraarterial (via radial artery catheter) and central venous pressure (CVP) via a peripherally inserted catheter, pulse oxymetry, capnography, urine output, and nasopharyngeal temperature. Anesthesia induced with thiopental (5 mg/kg), vecuronium (0.1 mg/kg), and fentanyl (2 μg/kg) was maintained with isoflurane (end tidal concentration, 1%–2%) in 50% oxygen- air and an infusion of remifentanil (0.1–0.2 μg/kg/min). Additional vecuronium and fentanyl were administered as appropriate. Pressure points were padded, compression stockings were applied to lower extremities, and donors were kept warm with a convective heating blanket, warm intravenous fluids, and warm humidified gases. Intravenous fluid therapy was initiated with routine infusion of 500 mL colloid solution (hydroxyethyl starch or gelatine) followed by a crystalloid solution. Mean arterial pressure (MAP) was maintained at ≥60 mm Hg, and urine output was maintained at >0.5 mL/kg/h by administering fluid boluses when needed. Acute isovolemic hemodilution was performed and autologous blood was used in all patients. Transfusion threshold was a hematocrit value <25% for all patients. At the end of the surgical procedure, donors were extubated in the operating room and transferred to the surgical ward. Postoperative analgesia was provided by intravenous morphine by patient- controlled analgesia. Patient demographics, intraoperative fluid and transfusion requirements, urine output, intraoperative hemodynamic parameters, and complications such as hypotension, hypothermia, hypoxemia, and cardiac events were recorded. Preoperative and peak postoperative serum hemoglobin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, international normalized ratio (INR), and total bilirubin levels were analyzed. Liver and graft volumes, duration of anesthesia, and length of hospital stay were also investigated. The statistical program was SPSS 11.0 for Windows (SPSS Inc., Chicago, Ill, United States). Data are presented as mean values ± standard derivations (mean ± SD) or fractions (%). For continous data, overall differences were tested using one-way analysis of variance (ANOVA) followed by Bonferroni tests for post-hoc analysis. For categorical data, the significance of differences was determined using chi-square or Fisher exact test. P < .05 was considered significant. Results

Donor demographics are summarized in Table 1. Patients in Group LLS were significantly younger than those in Group RL (P = .026). Other demographic and preoperative laboratory values were similar for the 3 groups (Table 1 and Table 2). Patients in Group RL had significantly higher peak postoperative serum levels of AST and total bilirubin than those in Group LLS (Table 2; P = .035 and P = .006, respectively). Postoperative INR was also longer in Group RL when compared with the other groups (P = .001). There were no significant differences in the mean liver volumes among the groups (Table 2). The graft volume was significantly greater in Group RL than that in the other 2 groups (Table 2; P < .001). Duration of anesthesia and length of hospital stay were similar between the groups (Table 2; P > .05).

Table 1. Demographic Data

Group RL (n = 54)

Group LL (n = 29)

Group LLS (n = 31)

P

Age (y)

37.3 ± 8.7

36.0 ± 9.3

31.7 ± 9.4

..026

Gender (M/F)

30/24

17/12

18/13

NS

Weight (kg)

70.1 ± 11.4

69.4 ± 10.9

71.5 ± 8.4

NS

Height (cm)

168.8 ± 8.8

167.8 ± 6.4

170.5 ± 9.0

NS

ASA status (I/II)

53/1

25/4

28/3

NS

Blood type (A/B/AB/O)

22/6/4/22

7/6/2/14

8/4/1/18

NS

Abbreviation: NS, not significant; ASA, American Society of Anesthesiology. Note: Values are expressed as mean ± SD or number of donors.

Table 2. Perioperative Laboratory Values and Recorded Data for All Group

Group RL (n = 54)

Group LL (n = 29)

Group LLS (n = 31)

P

Hemoglobin (g/dL)

Preoperative

13.9 ± 1.5

13.9 ± 1.7

13.8 ± 1.7

NS

Postoperative (min)

10.6 ± 1.8

10.3 ± 2.1

10.9 ± 1.9

NS

AST (U/L)

Preoperative

19.8 ± 6.4

19.3 ± 4.9

20.0 ± 6.3

NS

Postoperative (max)

370.9 ± 141.8

326.8 ± 171.4

284.8 ± 131.4

..035

ALT (U/L)

Preoperative

20.5 ± 12.6

18.8 ± 10.2

18.7 ± 10.0

NS

Postoperative (max)

380.4 ± 153.6

385.9 ± 193.4

375.7 ± 218.2

NS

Albumin (g/dL)

Preoperative

4.4 ± 0.3

4.4 ± 0.4

4.5 ± 0.4

NS

Postoperative (min)

3.1 ± 0.5

2.9 ± 0.5

3.2 ± 0.4

NS

INR

Preoperative

1.0 ± 0.1

1.0 ± 0.1

1.1 ± 0.1

NS

Postoperative (max)

1.8 ± 0.4

1.5 ± 0.2

1.5 ± 0.4

..001

Total bilirubin

Preoperative

0.6 ± 0.3

0.6 ± 0.4

0.6 ± 0.8

NS

Postoperative (max)

3.5 ± 2.2

2.5 ± 1.4

2.2 ± 1.6

..006

Liver volume (mL)

1511.0 ± 214.0

1522.3 ± 257.8

1445.0 ± 216.4

NS

Graft volume (mL)

803.1 ± 139.2

438.0 ± 122.7

308.2 ± 76.6

<.001

Duration of anesthesia (h)

7.4 ± 1.5

7.5 ± 1.5

6.7 ± 0.9

..047

Length of hospital stay (d)

8.8 ± 4.8

9.4 ± 4.9

8.4 ± 4.7

NS

Abbreviations: min, minimum; max, maximum. Data are presented as mean ± SD.

Intraoperative MAP, CVP, and heart rate measurements are shown in Fig 1, Fig 2 and Fig 3. Compared with the other groups, significantly less crystalloid and colloid were administered during anesthesia in Group LLS (Table 3; P = .015 and P = .002, respectively). Intraoperative urine outputs were similar for the 3 groups (Table 3). More patients in Group LLS required heterologous blood transfusions than did those in the other groups (Table 3; P = .01). The incidence of intraoperative hypotension was similar for all groups (P > .05). However, Group RL displayed a significantly higher rate of intraoperative hypothermia than the other groups (Table 3; P = .01). There were no intraoperative respiratory complications or cardiac events.

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Fig 1. Intraoperative MAP values of the groups.

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Fig 2. Intraoperative CUP values of the groups.

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Fig 3. Intraoperative heart rates of the groups.

Table 3. Intraoperative Data

Group RL (n = 54)

Group LL (n = 29)

Group LLS (n = 31)

P

Crystalloids (mL/kg)

83.1 ± 26.5

91.7 ± 30.2

71.5 ± 23.1

..015

Colloids (mL/kg)

8.9 ± 3.5

9.5 ± 3.5

6.6 ± 2.7

..002

Urine output (mL/kg/h)

2.5 ± 1.6

2.5 ± 1.3

1.8 ± 1.0

NS

Heterologous transfusion

Yes/no

5/49

9/20

2/29

..009

Amount (mL)

80.6 ± 301.0

341.4 ± 635.0

67.7 ± 265.1

..01

Complications (%)

Hypotension

14 (36.8)

14 (36.8)

10 (26.3)

NS

Hypothermia

42 (60.0)

12 (17.1)

16 (22.9)

..01

Note: Values are expressed as mean ± SD or number of donors.

Discussion

LDLT is rapidly emerging as an effective treatment for selected patients with end-stage liver disease. Concerns about increasing risks to the donor are evident, thus vigilance and optimal perioperative care are essential to minimize associated morbidity or mortality. The mortality rate among living liver donors has been reported to be ≤1% by the European Liver Transplant Registry.7 With respect to morbidity, the frequency of complications differed significantly by graft type. More right lobe donors had complications than those who had procedures involving the lateral segment or left lobe.3 The impact on clinical outcome of resection type among living-donor hepatectomies has been investigated by Salame et al; they distinguished risks to right lobe donors of liver failure, whereas the left lateral donor faces risks of major surgery and general anesthesia in undergoing donation.6 Besides, live donation of a right lobe graft for adult to adult liver transplantation has been evaluated to be a safe procedure provided that the residual liver volume of the donor exceeds 30% of the total liver volume.[8], [9] and [10] The present study focused on issues of concern to anesthesiologists during LDLT. We compared perioperative complications among the 3 donor hepatectomy resection types. Analysis of our data showed that intraoperative hemodynamic variables, including MAP, heart rate, CVP, urine output, duration of anesthesia, and frequency of intraoperative hypotension, were similar between right and left lobe donors. This observation indicated that right lobe donors tolerated surgery without hemodynamic instability or perioperative complications. More frequent heterologous blood transfusion was carried out in left lobe donors. Other studies have reported no difference in the frequency of blood transfusions according to graft type.[2] and [3] Early after donation, changes in perioperative AST, total bilirubin, and INR levels were greatest among right lobe donors. In addition, a higher rate of hypothermia was noted among right lobe donors. Similarly, Shimada et al stated that the postoperative AST and total bilirubin values for the right lobe donors were higher and postoperative hospital stay was longer than for the left-lobe graft donors.1 Choi et al has reported that the potential risk in the immediate postoperative period was highest among right lobe donors because perioperative prothrombin time and total bilirubin levels were higher and minor complications most frequent in these patients.2 Despite these findings, our results showed that the consequent impact on clinical outcomes, such as length of hospital stay and occurrence of major complications, was no different between right and left lobe donors. In conclusion, both right and left donor lobectomies for LDLT may be considered to be safe procedures with acceptable rates of minor intraoperative complications.

References

1 M. Shimada, S. Shiotani and M. Ninomiya et al., Characteristics of liver grafts in living-donor adult liver transplantation: comparison between right- and left-lobe grafts, Arch Surg 137 (2002), p. 1174. View Record in Scopus | Cited By in Scopus (27) 2 S.J. Choi, M.S. Gwak and M.H. Kim et al., Differences of perioperative liver function, transfusion, and complications according to the type of hepatectomy in living donors, Transpl Int 18 (2005), p. 548. View Record in Scopus | Cited By in Scopus (7) 3 K. Umeshita, K. Fujiwara and K. Kiyosawa et al., Operative morbidity of living liver donors in Japan, Lancet 362 (2003), p. 687. Abstract | Full Text + Links | PDF (73 K) | View Record in Scopus | Cited By in Scopus (73) 4 S. Fujita, I.D. Kim and K. Uryuhara et al., Hepatic grafts from live donors: donor morbidity for 470 cases of live donation, Transpl Int 13 (2000), p. 333. View Record in Scopus | Cited By in Scopus (65) 5 X.Z. Jiang, L.N. Yan and B. Li et al., Safety of donor in adult-to-adult living donor liver transplantation using right lobe graft, Transplant Proc 39 (2007), p. 150. Abstract | Full Text + Links | PDF (58 K) | View Record in Scopus | Cited By in Scopus (0) 6 E. Salame, M.J. Goldstein and M. Kinkhabwala et al., Analysis of donor risk in living-donor hepatectomy: the impact of resection type on clinical outcome, Am J Transplant 2 (2002), p. 780. View Record in Scopus | Cited By in Scopus (12) 7 C.E. Broelsch, M. Malago and G. Testa et al., Living donor liver transplantation in adults: outcome in Europe, Liver Transpl 6 (2000), p. S64. View Record in Scopus | Cited By in Scopus (114) 8 S.T. Fan, C.M. Lo and C.L. Liu et al., Safety of donors in live donor liver transplantation using right lobe grafts, Arch Surg 135 (2000), p. 336. View Record in Scopus | Cited By in Scopus (0) 9 S.J. Kim, D.G. Kim and E.S. Chung et al., Adult living donor liver transplantation using the right lobe, Transplant Proc 38 (2006), p. 2117. Abstract | Full Text + Links | PDF (169 K) | View Record in Scopus | Cited By in Scopus (1) 10 S. Sevmis, T. Diken and F. Boyvat et al., Right hepatic lobe donation: impact on donor quality of life, Transplant Proc 39 (2007), p. 826. Abstract | Full Text + Links | PDF (56 K) | View Record in Scopus | Cited By in Scopus (0)

Address reprint requests to Pinar Zeyneloglu, MD, Department of Anesthesiology, Baskent University Faculty of Medicine, 10. Sok. No: 45 Bahcelievler, 06490 Ankara, Turkey.

Transplantation Proceedings Volume 40, Issue 1, January-February 2008, Pages 53-56