Living donor liver transplantation
Background/purpose. 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 method. 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 to IV) and 24 were of the full-right lobe (FR, liver segments V-VIII). We divided the procedures into three periods: Period 1 comprised the years 1991 to 1995 (LL: n=49, L: n=2, FR: n=1), period 2 covers 1996-2000 (LL: n=47) and period 3 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 on ICU, postoperative hospital stay, laboratory results (bilirubin, INR and LFTs) and morbidity, as well as the different types of grafts in the three 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 one 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 to that of the left lateral lobe, resulted in a significantly diminished liver function (bilirubin and INR) during the first five days after donation but did not increase morbidity. One donor from period 1 experienced late death due to amyotrophic lateral sclerosis.
Conclusion. 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, in order to avoid the learning curve.