Living Donor and Split Liver Transplantation

Sat, Nov 01 - 2:00 PM

Liver Transplantation – Live Liver Donor

629. A high MELD score is not a contraindication for right lobe adult living donor liver transplantation.

M. Selzner; N. Selzner; P. D. Greig; G. Therapondos; M. S. Cattral; L. E. Adcock; L. Lilly; I. McGilvray; E. L. Renner; A. Kashfi; G. A. Levy; D. Grant.

Introduction:

The effect of MELD score on recipient outcomes in adult living donor liver transplantation (RLDLT) is unclear.

Aim:

To analyze the effect of MELD on recipient outcomes in RLDLT.

Methods:

Since 2000 we have performed 251 RLDLT. Thirty nine recipients had a medical MELD score (i.e. without extra points for HCC) >25, while 212 patients had a MELD score of <24. Outcome measures included biochemical markers of hepatocyte injury (AST, ALT) and graft function (INR, serum bilirubin); postoperative renal failure, incidence of infections, biliary complications, and acute cellular rejection, length of hospital stay (LOS), as well as patient and graft survival at 30 days, 1-, 3-, and 5-years.

Results:

Overall 30 day, 1-, 3-, and 5-year patient and graft survival was 98%, 91%, 86%, 82% and 95%, 89%, 85%, and 78% respectively. A MELD 25 was associated at day 7 with increased postoperative bilirubin (252 vs. 123 U/L, p< 0.001) and INR (3.4 vs. 2.5, p< 0.02), but did not significantly affect graft injury with similar maximum AST (541 vs 543 U/L, p= 0.9) and ALT (445 vs 427 U/L, p= 0.8) levels within 48hr post transplant. Postoperative complications within 90 days such as bleeding (1.9% vs 2.5%, p=0.8), pneumonia (2.4% vs 5%, p=0.35), rejection (22% vs 19%, p=0.57), biliary strictures (15% vs 17%, p= 0.9), and biliary leaks (13% vs 10% p=0.6), and renal failure (4.8% vs 8%, p=0.47) were similar in high and low MELD recipients. A MELD >25 carried a slightly - albeit not significantly - increased 30 day mortality (7 vs. 2%, p= 0.14) and graft loss rate (7 vs. 4%, p= 0.42), while 1-, 3-, and 5-year patient (91%, 86%, 81% vs 85%, 82%, 82%, p= 0.47) and graft survival (91%, 85%, 77% vs 83%, 79%, 79%, p= 0.51) were not affected. Two of the 12 recipients with a MELD score >35 died within 30 days, while 10 patients are alive with functioning grafts at a median follow-up of 26 months.

Conclusion:

While 30 day mortality increases slightly, long-term outcomes after RLDLT are excellent and not significantly affected by high recipient MELD scores. A high MELD score should therefore per se not be considered as a contraindication for RLDLT.

Liver Transplantation – Live Liver Donor

631. Minimally invasive donor hepatectomy in adult-to-adult living donor liver transplantation: Single center experience.

K. Suh; N. Yi; J. Kim; W. Shin; T. Kim ; H. Lee; J. Cho; K. Lee.

Background.

Live donor hepatectomy is well established and is performed safely in the vast majority of cases. However, a large abdominal incision is still required that results in a permanent Mercedes scar and make some live donors reluctant to undergo the procedure due to concerns about their self-image especially in adult-to-adult living donor liver transplantation (ALDLT). Herein, we report 11 donor hepatectomies (DHs) done by minimally invasive technique.

Methods.

Clinical information of donors and recipients were shown in Table 1. Totally laparoscopic right DHs under pneumoperitoneum using a hand-assisted device (L-RDHs) were performed in 2 cases, laparoscopy-assisted RDHs (LA-RDHs) in 7 cases, and DH using mini-laparotomy incision (M-DH) in 2 cases. Parenchymal transection was performed without the Pringle maneuver using a lap-CUSA under pneumoperitoneum and a CUSA under minilaparotomy status. In right DHs, major MHV branches were preserved to the graft using Hem-o-lock clips and reconstructed on the bench surgery.

Results.

The graft was transplanted without any problem. The donor operation time was ranged from 340 to 898 minutes. The donors did not require a transfusion or reoperation; they were discharged on postoperative day (POD) from 9 to 17 with normal liver function.

Conclusion.

Various DHs performed by minimally invasive techniques, including a totally L-RDH, were technically feasible in ALDLT and may be a new therapeutic option improving the quality of life of donors participating.

Table 1. Clinical information of minimally invasive donor hepatectomy

Case no.	Age	Rec-age/ gender	Relationship	Original liver disease	Transplant date	Type of DH	Operative time (min.)	Hospital stay (POD)
1	22	62/F	daughter	HBV-LC, HCC	Jun, 2003	LA-RDH	405	11
2	28	65/M	daughter	HBV-LC, HCC	Jul, 2004	M-DH	340	10
3	23	54/M	daughter	HBV-LC, fulminant	Jan, 2005	M-DH	310	10
4	25	52/M	daughter	HBV-LC, HCC	Apr, 2007	L-RDH	765	10
5	24	62/F	daughter	HBV-LC, HCC	Aug, 2007	L-RDH	898	14
6	32	62/M	daughter	HBV-LC, HCC	Nov, 2007	LA-RDH	575	9
7	17	46/F	daughter	HBV-LC, HCC	Jan,2008	LA-RDH	505	12
8	28	58/M	daughter	HBV-LC, HCC	Feb,2008	LA-RDH	460	9
9	36	15/F	aunt	primary sclerosing cholangitis	Apr,2008	LA-RDH	310	9
10	29	59/M	daughter	HBV-LC	May, 2008	LA-RDH	545	8
11	24	54/F	daughter	HBV-LC, HCC	May, 2008	LA-RDH	495	17

Abbreviation. F, female; M, male; Rec, recipient; HBV-LC, hepatitis B related liver cirrhosis; HCC, hepatocellular carcinoma; PSC, primary sclerosing cholangitis

Liver Transplantation – General

633. Obesity, Diabetes, and Smoking are Important Determinants of Resource Utilization in Liver Resection: A Multicenter Analysis of 1029 Patients.

P. P. McHugh; D. L. Davenport; T. D. Johnston; H. Jeon; D. Ranjan; R. Gedaly.

Purpose:

Despite being highly resource-intensive, liver resections are now performed with increasing frequency. This study evaluates how potentially modifiable factors such as obesity, diabetes, and smoking, affect various measures of resource utilization after liver resection.

Methods:

The American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) public-use database was queried for patients undergoing trisegmentectomy or partial, left, or right lobectomy. Outcome variables were operative time, intraoperative blood transfusion, ventilator support at 48 hours, reoperation, and length of hospital stay. Bivariate and multivariable linear and logistic regressions were performed.

Results:

Between 7/05 and 6/06, 1029 patients underwent liver resection. Mean (±SD) age was 57.7 ±13.5 years (range 18 to 85); 49.8% were male. Most (852, 82.8%) underwent resection for malignancy. Mean BMI was 28.0 ±6.0; 39 patients (3.8%) were morbidly obese (BMI >40). There were 140 diabetics (13.6%), and the same number of smokers. Partial lobectomy was the most common procedure (599 patients, 58.2%). Mean operative time was 253 ±122 minutes (27 to 794 minutes) but varied greatly by procedure (p<0.001); trisegmentectomy was the lengthiest at 331 ±125 minutes. There were 297 patients (28.9%) who received blood transfusion (mean 4.2 ±4.6 units). Mean length of hospitalization was 8.7 ±10.8 days (0 to 202 days). Overall mortality was 3.1%, with no significant difference between resection types. Morbid obesity added 48 minutes (95% confidence interval (CI) 8−87, p=0.018), 1.11 units of blood transfused (CI 0.01−2.20, p=0.049), and a greater chance of prolonged ventilation (odds ratio (OR) 4.38, CI 1.23−15.58, p=0.023). Diabetics tended to require longer ventilation (OR 2.06, CI 0.98−4.31, p=0.055). Smokers stayed 1.9 days longer (CI 0.2−3.6, p=0.030), with increased risk of extended ventilator support (OR 3.25, CI 1.53−6.89, p=0.002) and reoperation (OR 2.27, CI 1.17−4.39, p=0.015). Resections for malignancy were 39 minutes longer than those for benign lesions (CI 18-61, p=0.001).

Conclusion:

Obesity, diabetes, and smoking are each associated with important components of healthcare expenditure after liver resection. These observations from a procedure-specific population support previous studies in general surgical patients. Given the prevalence of these factors, education and prevention programs will be needed to limit their impact on overall resource utilization.

Discussion:

There is growing interest in examining how obesity and related diseases impact resource utilization. Obesity has been shown to be associated with longer hospitalizations and operative times in general surgical procedures. In our study, multivariable analysis showed significant effects on operative time and PRBC transfusion as well as intubation beyond 48 weeks. Interestingly, underweight status resulted in the largest increase in hospital stay relative to normal weight patients, a pattern which has been described previously.

The net effect of obesity is not surprising in the context of an increased rate of medical comorbidities in obese patients, including diabetes, hypertension, cardiovascular disease, sleep apnea and respiratory compromise, and degenerative joint disease. Obesity and diabetes are also strongly linked to hepatic steatosis, a major risk factor for postoperative complications after liver resection; these conditions, along with dyslipidemia, comprise the major components of the metabolic syndrome.

Smoking has a negative impact on postoperative outcomes: longer hospitalizations, increased ICU admissions and in-hospital mortality. In our study, smokers had significantly longer hospital stays and were more likely to require extended ventilator support. Since ventilation necessitates a higher level care, these outcomes have an additive effect on resource utilization and implied cost. In addition, we found that smokers were more likely to return to the operating room after the initial procedure, independent of the type of resection performed. For most patients, the largest proportion of total cost is generated on the day of surgery, the impact of additional surgery on resource utilization should not be underestimated.

Our study shows that obesity, diabetes, and smoking are independently associated with healthcare expenditure. These observations from a procedure-specific population support previous analyses in other general surgical populations. Given the magnitude of the problem, a multi-level interventional will be needed to counteract these effects, including education and prevention programs for both obesity and smoking. Efforts in these areas could significantly impact the health care system by decreasing overall consumption of resources and subsequent cost.