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Safety of donor right hepatectomy without abdominal drainage: A prospective evaluation in 100 consecutive liver donors†
Article first published online: 17 FEB 2005
Copyright © 2005 American Association for the Study of Liver Diseases
Volume 11, Issue 3, pages 314–319, March 2005
How to Cite
Liu, C. L., Fan, S. T., Lo, C. M., Chan, S. C., Yong, B. H. and Wong, J. (2005), Safety of donor right hepatectomy without abdominal drainage: A prospective evaluation in 100 consecutive liver donors. Liver Transpl, 11: 314–319. doi: 10.1002/lt.20359
Presented in the plenary session of the 10th Meeting of the International Liver Transplantation Society, June 9–12, 2004, Kyoto, Japan.
- Issue published online: 17 FEB 2005
- Article first published online: 17 FEB 2005
- Committee on Research and Conferences Grant
- Sun C.Y. Research Foundation for Hepatobiliary and Pancreatic Surgery
- Distinguished Research Achievement Award of the University of Hong Kong
Although the role of routine abdominal drainage after liver resection for tumors has been questioned, abdominal drainage after donor right hepatectomy for live donor liver transplantation (LDLT) has been a routine practice in most transplant centers. The present study aimed to evaluate the safety of the procedure without abdominal drainage. A prospective study was performed on 100 consecutive liver donors who underwent right hepatectomy for LDLT from July 2000 to September 2003. Biliary anatomy was carefully studied with intraoperative cholangiography using fluoroscopy. The middle hepatic vein was included in the graft in all except 1 patient. Parenchymal transection was performed using an ultrasonic dissector. The right hepatic duct was transected at the hilum and the stump was closed with 6-O polydioxanone continuous suture. Absence of bile leakage was confirmed with methylene blue solution instilled through the cystic duct stump. The abdomen was closed after careful hemostasis without drainage in all donors. The median age of the donors was 36 years (range 18–56 years). Median operative blood loss and operating time were 350 mL (range 42–1,400 mL) and 7.5 hours (range 5.2–10.7 hours), respectively. None of the donors required any blood or blood product transfusion. There was no operative mortality. The median postoperative hospital stay was 8 days (range 5–30 days). Postoperative morbidity occurred in 19 patients (19%), most of which were minor complications. No donor experienced bile leakage, intraabdominal bleeding, or collection. None required surgical, radiologic, or endoscopic intervention for postoperative complications, except for 1 donor who developed late biliary stricture that required endoscopic dilatation. All donors were well with a median follow-up of 32 months (range 11–50 months). In conclusion, with detailed study of the biliary anatomy and meticulous surgical technique, donor right hepatectomy can be safely performed without abdominal drainage. Abdominal drainage is not a mandatory procedure after donor hepatectomy in LDLT. (Liver Transpl 2005;11:314–319.)
Adult-to-adult live donor liver transplantation (LDLT) using right lobe grafts has emerged successfully to partially relieve the refractory shortage of deceased donor grafts because of the increasing demands of patients with end-stage liver diseases.1–4 The safety of the healthy donors, among all the concerns in LDLT, is considered of prime importance, and every attempt has been made to minimize the operative morbidity and mortality of the donor operation. Traditionally, in patients who undergo hepatic resection for various conditions including tumors, an abdominal drain is routinely inserted into the subphrenic or subhepatic space close to the resection surface. Abdominal drainage after donor right hepatectomy for LDLT has also been a common or even mandatory practice in most transplant centers. This serves to monitor the occurrence of postoperative intraabdominal bleeding, and is used for the detection and drainage of any bile leakage. Postoperative bile leakage has been reported to occur in 10 to 20% of donors after donor hepatic resection, and abdominal drainage is therefore considered mandatory.5, 6 Nevertheless, abdominal drains are not without risk: they have been reported to result in bowel injury, increased rates of intraabdominal and wound infection, increased abdominal pain, decreased pulmonary function, and prolonged hospital stay.7–11 In addition, the role of routine abdominal drainage after liver resection for tumors has recently been questioned. Studies have suggested that hepatic resection can be performed safely without drainage, especially in patients with normal livers.12, 13 One recent prospective randomized study also pointed out that patients with abdominal drainage after hepatic resection had inferior operative outcomes, including a higher postoperative morbidity rate and longer hospital stay, compared with those without abdominal drainage.14 We therefore performed a prospective study to evaluate the safety of donor right hepatectomy for LDLT without abdominal drainage, paying particular attention to the operative morbidities. We also evaluated whether abdominal drainage could have avoided some of the complications after the procedure.
Patients and Methods
A prospective study was performed on 100 consecutive liver donors who underwent right hepatectomy for LDLT from July 2000 to September 2003. The current series represented donor number 39 to number 138 of the experience of adult-to-adult right lobe LDLT at our institution. There were 40 men and 60 women, with a median age of 36 years (range 18–56 years).
Once the indication for liver transplantation was established for the potential LDLT recipients, either in a high-urgency situation or an elective situation, detailed counseling was provided to the patients and their relatives. Information included the prognosis with and without a timely liver transplantation, the chance of obtaining a timely deceased donor liver graft being less than 10% in high-urgency situations,15 outcomes of deceased donor liver transplantation and LDLT, option of LDLT, and the risks involved in the donor operation. The potential donor was self-identified, not identified by the medical staff, to ensure true voluntarism. Complete psychological assessment was then performed by the clinical psychologist, and the voluntary intention of the potential donor for liver donation without coercion was confirmed.
The 2nd stage of the donor evaluation consisted of a medical assessment of the donor, including blood group, blood biochemistry, and hepatitis serology. Anatomic assessment of the potential liver graft was performed with computed tomography and hepatic angiography. The volumetric measurement of both the right and left lobes of the liver of the potential donor was performed. The estimated right lobe liver graft volume should be larger than 40% of the recipient standard liver volume.16 To ensure safety of the liver donor, the estimated donor liver remnant by computed tomography should be greater than 30% of the total liver volume with minimal fatty change.17
Surgical techniques for donor right hepatectomy have been previously described.18, 19 The middle hepatic vein was included in the right lobe liver graft in all except 1 donor (donor number 85 of the experience of adult-to-adult right lobe LDLT of the institution). Routine intraoperative cholangiography was performed with fluoroscopy before parenchymal transection to determine the anatomy of the bile ducts. The X-ray tube was positioned to obtain the right-anterior-oblique view of the biliary tree to allow the best view for studying the biliary anatomy, especially the caudate branches. The proposed location of right duct transection was marked with a large metal clip on the liver capsule about 2 mm to the right of the confluence of the hepatic duct, and was confirmed with fluoroscopic examination.20 Minimal dissection was performed at the hilar plate around the right hepatic duct. The liver was then transected with ultrasonic dissector without inflow occlusion. Parenchymal tissue was left covering the hepatic duct. During the process of parenchymal transection and on approaching the hilar plate, the right hepatic duct was transected with scissors about 2 mm from the confluence. The ductal opening on the patient's side was closed with 6-O polydioxanone monofilament suture (PDS; Ethicon, Edinburgh, UK). The hilar plate was also divided with sharp dissection and small bile duct openings of the caudate branches were plicated with 6-O polypropylene sutures (Prolene; Ethicon, Edinburgh, UK). After completion of parenchymal transection, a bile leakage test was performed with methylene blue solution injected via the cystic duct, and cholangiography was repeated to ensure there was no stricture. The falciform ligament of the liver remnant was reanchored to the anterior abdominal wall to prevent the risk of twisting of the inflow pedicle or the venous drainage. After careful and complete hemostasis, the abdomen was closed without any drainage.
Flushing of the right lobe liver graft was made on the back-table with either University of Wisconsin solution, or, after case number 110, histidine-tryptophan-ketoglutarate solution.21 Hepatic venoplasty joining the right and middle hepatic veins of the graft together to form a triangular cuff for a single anastomosis to the recipient's inferior vena cava has also been performed since case number 86 of the series.22 The recipient operations were performed as described previously.19 All intraoperative complications and postoperative morbidities were recorded prospectively by a single research assistant.
The demographics of the 100 consecutive liver donors who underwent donor right hepatectomy without abdominal drainage are listed in Table 1. The majority of the donors were direct relatives of the recipients (Table 2). The body weight of the donors was less than that of the corresponding recipients in 72 cases (72%). The median duration of the donor operation was 7.5 hours (range 5.2–10.7 hours), and the mean operative blood loss was 350 mL (range 42–1,400 mL; Table 3). None of the donors received any blood product transfusion. The calculated median liver remnant volume in the donors was 387 mL (range 220–708 mL), which represented 23.6 to 49.5% of the total liver volume estimated by preoperative computed tomography volumetry. The median peak postoperative serum total bilirubin level of the donors was 59 μmol/L (range 10–279 μmol/L), and the peak postoperative prothrombin time was 17.9 seconds (range 14.6–24.4 seconds). There was no donor mortality. The median postoperative intensive care unit stay and hospital stay were 1 day and 8 days, respectively.
|Number of patients||100|
|Age (years)*||36 (18–56)|
|Preoperative serum total bilirubin (μmol/L)*||11 (3–40)|
|Preoperative aspartate aminotransferase (U/L)*||18 (10–37)|
|Estimated liver remnant weight (gm)*||387 (220–708)|
|Estimated liver remnant volume/total liver volume (%)*||35.2 (23.6–49.5)|
|Relationship||Number of donors|
|Graft weight (g)*||600 (400–1020)|
|Graft weight/recipient ESLW (%)*||49.8 (31–89)|
|Operating time (hours)*||7.5 (5.2–10.7)|
|Intraoperative blood loss (mL)*||350 (42–1400)|
|Intraoperative and postoperative blood product transfusion (units)|
|Fresh frozen plasma||0|
|Postoperative intensive care unit stay (days)*||1 (0–5)|
|Postoperative hospital stay (days)*||8 (5–30)|
|Postoperative morbidity||19 (19%)|
|Follow-up duration (months)*||32 (11–50)|
A total of 20 complications occurred in 19 donors after donor right hepatectomy, resulting in an overall operative morbidity rate of 19% (Table 4). Most of them were minor complications. However, major complications occurred in 4 donors. Two donors developed significant cholestasis with serum total bilirubin of higher than 100 μmol/L. Cholestasis gradually subsided on conservative treatment. One donor developed intraoperative portal vein thrombosis, which was recognized and rectified immediately. The donor had an uneventful postoperative recovery. Follow-up ultrasound Doppler study showed patent hepatic vessels with normal flow pattern. One donor developed late biliary stricture that required endoscopic dilatation for 2 sessions. Subsequently he was well, without any evidence of biliary stricture at a follow-up of 41 months. None of the donors developed postoperative bile leakage or intraabdominal hemorrhage, in which abdominal drainage could have been helpful. As a result, no donors required surgical reexploration, percutaneous radiological intervention, or early endoscopic intervention. With a median follow-up of 32 months (range 11–50 months), all donors had no residual morbidity and had returned to normal preoperative activities at the time of preparation of the manuscript.
|Complications||No. of patients|
|Occipital pressure sore||2|
|Urinary tract infection||1|
|Intraoperative portal vein thrombosis||1|
The indications for liver transplantation for the 100 corresponding recipients were end-stage liver disease with cirrhosis (n = 53), fulminant hepatic failure (n = 9), acute-on-chronic liver failure (n = 37), and retransplantation for recurrent hepatitis B (n = 1). Hospital mortality occurred in 2 recipients (2%) after LDLT from the 100 right lobe liver donors without abdominal drainage. One patient died of systemic fungal infection, and the other died of pneumonia from Legionella disease. With a median follow-up of 30 months (range .8–50 months), the graft survival rate was 88% and patient survival rate was 91%.
Prophylactic drainage of the peritoneal cavity after hepatic resection has been a very common practice for many years, although its benefits have recently been challenged. In a nonrandomized study reported by Franco et al.,23 the complication rate of 61 patients who underwent liver resection without abdominal drainage was 8%. The authors suggested that routine use of drains was unnecessary. Belghiti et al.12 conducted a prospective randomized study on 81 patients, who were randomized to have either closed suction drainage, or no drainage after hepatic resection. The overall complication rates appeared similar between the 2 groups. However, postoperative ultrasonography showed that there was a significantly higher rate of subphrenic collections in patients who had minor hepatic resection in the drainage group. These collections were also more frequently infected in the drainage group. The findings suggested that abdominal drainage might exert a negative effect on patients who underwent hepatic resection.
Similar results were also reported by Fong et al.,13 who prospectively randomized 120 patients either to have abdominal drainage or no drainage after hepatic resection. No significant difference between the 2 groups was observed with regard to the rates of mortality and morbidity, the length of hospital stay, or the need for subsequent percutaneous drainage. Three patients developed infected subhepatic collection in the drainage group, whereas there was none in the nondrainage group. Although the number of patients with the complication was not large enough to determine whether drainage was truly responsible, the observation was consistent with that reported by Belghiti et al.12 While these 2 prospective randomized studies suggested that there might be a negative effect of routine abdominal drainage on the operative outcomes of patients undergoing liver resection, they were statistically underpowered to show any significant differences between the 2 groups, because of the low morbidity rates of hepatic resection for normal livers.
A more recent study reported from our institution has clearly demonstrated that routine abdominal drainage was associated with unfavorable outcomes in patients undergoing hepatic resection.14 In that study, 104 patients who had underlying chronic liver diseases were prospectively randomized to have either closed suction abdominal drainage or no drainage after elective hepatic resection. It was observed that the drainage group had a significantly higher operative morbidity and longer postoperative hospital stay when compared with the nondrainage group.
Healthy liver donors are a special group of patients who sacrifice themselves for the benefits of their beloved ones. It is well accepted that special care with a rational approach to minimize donor operative morbidity and postoperative hospital stay should be provided to the donors.24, 25 Detailed evaluations of the surgical procedure are therefore essential for the best surgical outcomes of this group of patients. In addition, right hepatectomy of healthy liver donors for LDLT represents an ideal model for the evaluation of the role of abdominal drainage. Having undergone thorough investigations to demonstrate normal livers with favorable vascular and biliary anatomy, the donors undergo a standardized operation (right hepatic resection with inclusion of the middle hepatic vein in the present study) without much variation. On the other hand, there appear to be good reasons for routine abdominal drainage, in view of a large parenchymal transection surface that is prone to result in postoperative bleeding and biliary leakage. The risk of biliary leakage is also considered to be higher in donor right hepatectomy compared with resection for hepatic tumors, as the right hepatic duct is transected very close to the confluence.
Abdominal drainage after donor right hepatectomy for LDLT has been a common or even mandatory practice in most transplant centers. Postoperative bile leakage has been reported to occur in 10 to 20% of the donors.5 In a retrospective analysis of 1,056 hepatic resections for 915 patients, including 174 healthy liver donors, the Tokyo group suggest that “a small and persistent amount of bile leakage from the cut surface is a unique but common phenomenon in liver surgery,” and that drain placement is a mandatory procedure in liver resection.6
In the present study, we have shown that donor right hepatectomy with the inclusion of the middle hepatic vein can be safely performed with satisfactory operative outcomes without abdominal drainage. The median postoperative hospital stay was 8 days, and none of the donors required any surgical, radiologic, or endoscopic intervention, except for 1 patient who required late endoscopic dilatation of biliary stricture. In fact, we have not encountered any postoperative bile leakage, hemorrhage, or intraabdominal collection in which abdominal drainage could have been helpful in all of the 180 right lobe liver donors since the beginning of the entire series in 1996.
In addition to careful hemostasis, prevention of postoperative biliary leakage is considered of paramount importance in the successful management of the donors with satisfactory outcomes after donor right hepatectomy without abdominal drainage. Postoperative bile leakage can occur in the parenchymal transection surface of the liver, the repair site of the right hepatic duct, and the caudate branches in the hilar plate. During donor right hepatectomy, the biliary anatomy was carefully evaluated with a real-time fluoroscopy instead of static cholangiograms. Images were carefully studied during a gradual rotation of the X-ray tube from the anteroposterior direction to the right anterior oblique direction. Special attention was also paid to the origins of the caudate branches at the liver hilum, which were frequently considered the culprits of postoperative biliary leakage. During donor hepatic resection, the hilar plate was cut with scissors and openings of the caudate branches were carefully sutured. Accurate division of the right hepatic duct at the liver hilum was also vital for the prevention of biliary complications in both the donor and recipient operations. To minimize biliary leakage in the parenchymal transection surface, we also stress the importance of accurate and careful transection at the midplane of the liver onto the middle hepatic vein with an ultrasonic dissector, keeping the middle hepatic vein with the right lobe liver graft. No large bile duct with a large caliber will be cut if the parenchymal transection is kept at the midplane. Small vessels or bile ducts should be carefully clipped, ligated or sutured without any excessive use of cautery. After parenchymal transection, no leakage of bile from the right hepatic duct suture site, caudate branches at the hilar plate, and the parenchymal transection surface should be ascertained with gentle instillation of methylene blue solution through the cystic duct. We consider all these steps crucial to minimize biliary leakage after donor hepatic resection.
While it is apparently clear that routine abdominal drainage after hepatic resection may not be necessary, abdominal drains are not without risk. They have been reported to result in bowel injury, increased rates of intraabdominal and wound infection, increased abdominal pain, decreased pulmonary function, and prolonged hospital stay.7–11 There is also a worry that placement of abdominal drains may provide a false sense of security to the surgeons. The effluent of the drain is often deceptive. It can be blocked by blood clot in the presence of postoperative intraabdominal bleeding and it may not be in the correct position to detect any biliary leakage. The deceptive information from the effluent of the drain may even lead to delay in appropriate patient intervention.
In conclusion, with detailed study of the biliary anatomy and meticulous surgical technique, donor right hepatectomy can be safely performed without abdominal drainage with a satisfactory operative outcome. Abdominal drainage is not mandatory after donor hepatectomy in LDLT.