Key words : Biliary leakage, Clavien-Dindo classification, Living donor liver transplant, Remnant liver volume

Introduction

To increase the organ pool, a procedure called living donor liver transplant (LDLT) has been developed as an alternative to deceased donor liver transplant. The LDLT procedure is used to treat end-stage liver disease in both adults and children in nations like Turkey where there is a shortage of deceased donor grafts. Experiences with donor hepatectomy are rising along with an increase in LTDT procedures. Donor safety should be the top priority for all centers with high patient volume and success.

The mortality rate for donors is less than 1%, while the morbidity rate is approximately 40%.¹ The most frequent and feared complications in living donors are biliary issues. Cases of right lobe donation and extended right lobe donation have shown more frequent and severe complications than non-right lobe donation.²

However, in recent years, the majority of nonsur-gical interventions have replaced relaparotomies as the primary method for treatment of this comp-lication, potentially resulting in a decline in procedure-related complications and an increase in improved outcomes. There are a number of management techniques available, including percutaneous and endoscopic drainage of biliary leakage, in addition to conservative treatment options like drainage and antibiotics.³

The objectives of this study were to assess the effectiveness of bile injury management after liver resection and to look at the prevalence and conse-quences of biliary leakage in donors.

Materials and Methods

A retrospective analysis was performed on data from 104 patients who were living liver donors under-going hepatectomy between January 2011 and April 2022 at the Department of Liver Transplant Surgery and Hepatology, Yuksek Ihtisas Training and Research Hospital, and Ankara Bilkent City Hospital. All donors were followed up for at least 180 days to check for biliary leakage-associated events. All donors were older than 18 years of age. Living donor LT procedures were with first-degree and second-degree relatives of the respective recipients. Our study was approved by Ankara Bilkent City Hospital Scientific Research Evaluation and Ethics Committee (decision No. E2-22-2386). The study was conducted in accordance with accepted clinical practice principles and the Declaration of Helsinki. We evaluated preoperative demographic data including donor age, sex, body mass index, graft type, and remnant liver volume (RLV), as well as surgical outcomes (operation time, blood loss) and postoperative complications.

To evaluate the biliary and vascular anatomy, the donors underwent a number of preoperative imaging tests, including triphasic liver computed tomography (measurement of volume and hepatic attenuation index) and magnetic resonance cholangiopan-creatography (Huang classification of the biliary tract anatomy). In the process of preoperative examination, all donors are evaluated for hepatosteatosis by abdominal ultrasonography and hepatic attenuation index. In case of doubt about steatosis, a liver biopsy was performed; furthermore, if the donor had macrovesicular steatosis that was higher than 10%, then the donor was excluded.

In intraoperative procedures, the initial step included a typical cholecystectomy and a typical intraoperative cholangiography. The demarcation line was noted by temporally clamping the graft’s side vessels after the separation of the right or left portal vein and hepatic artery. The anterior surface of the hilar plate was exposed after the hepatic parenchymal resection was performed along the transaction plane without inflow occlusion. Fluorescent imaging enabled the clear visualization of the hepatic duct. With the aid of this imaging, we were able to choose the bile duct cutting line that was suitable for both donor and recipient. After classic intraoperative cholangiography, at the end of the hepatic resection, a sterile fat emulsion was injected via an olive-tip cannula through the cystic duct for detection of biliary leakage (the White test).

All donors were in intensive care for the first 3 days after transplant and were closely monitored for bilioma and additional vascular complications with daily abdominal ultrasonography and doppler. The abdominal drains of donors were removed after the bilirubin level was checked 7 to 10 days later.

The statistical analyses were performed with SPSS software (version 26.0 for Windows; IBM). Continuous variables are expressed as median and range. Categorical variables are summarized as count and percentage. Between-group comparisons were performed with the Mann-Whitney U test for continuous variables and a chi-square test (or Fisher exact test where appropriate) for categorical variables. P values are given as indicated using the chi-square test or a nonparametric t test. P < .05 was considered statistically significant.

Results

Right hepatectomy was performed on 103 donors (97%) and left hepatectomy on 1 donor (3%). The average length of the operation was 468 minutes. Seventy-four patients (71%) were men. Clavien-Dindo grade III complications were shown in 16 donors (24%); these included 6 cases of biliary leakage, 1 case of pleural effusion, 5 cases of wound site infection, 3 cases of organized liquid collection, and 1 case of ileus (Table 1).

Biliary leakage of patients was examined on postoperative days 6 to 9. One patient needed pleural drainage, 1 patient needed percutaneous drainage, and only 1 of the patients with biliary leakage could be treated conservatively. The other 5 needed additional endoscopic retrograde cholangiopancreatography (ERCP). Biliary stents were placed in all patients during the ERCP procedure, and 2 patients also had nasobiliary drainage. All patients with biliary leakage were successfully treated without postoperative biliary stricture. Long-term complications did not arise in the patients.

Except for biliary complications, wound site infection was the most frequent complication. Five patients required debridement and large spectrum antibiotherapy. Pneumonia was diagnosed in 2 patients during short-term postoperative follow-up.

Among all donors, the biliary anatomy of 54 donors (51.9%) was compatible with Huang type 1, with 44 (42.3%) compatible with Huang type 2 and 6 (5.8%) compatible with Huang type 3. We observed no significant association between Huang type and biliary leakage (P = .672). The duration of hospitalization was longer in the biliary leakage group than the group without leakage (15.7 ± 5.8 days vs. 30.8 ± 9.3 days, respectively; P = .08). We observed no significant relationship between biliary leakage and age (P = .074), the duration of operation time (P = .219), and RLV (P = .363) (Table 2).

Discussion

In the present study, the rate of operation-related complications in living donors was shown to be 22%. Also, the adult-to-adult LDLT donors had a biliary complication rate of 9.5%. Only 1 of the 8 patients with biliary leakage recovered spontaneously without any interventional procedure. Five of these patients were treated with the ERCP procedure in a short time and effectively. Donors had no long-term complications.

In our study, there was no statistically significant relationship between age, the duration of operation time, and RLV versus biliary leakage. In another study involving 130 donors, shorter operating time (P = .02) and larger future RLV (P = .005) were found to be independent risk factors for biliary complications.4 In the study, both of the patients who had intraoperative bile duct injuries were treated with duct-to-duct biliary anastomosis and placement of a biliary stent or T-tube.⁴

In a previous study of 381 patients who had liver resection for any reason (nondonor hepatectomy), compared with patients without biliary leak, all patients with postoperative biliary leakage had significantly longer hospital stays, longer operation time, and more frequently underwent relaparotomies. There were no discernible differences in terms of age or sex.³ Although none of the donors underwent relaparotomy in our study, biliary leakage was found to be associated with long hospital stays and was unrelated to sex and age.

Another study has reported the results of graft type and donor-related demographic characteristics on the donor.⁵ The development of biliary com-plications in living donors was independently correlated with the right or extended right hepatectomy, donor age (>40 years), and lengthy operation time (>400 minutes).The same study group showed that older donors may experience posto-perative outcomes that are comparable to those of younger donors,6 and they suggested that donors 60 years of age or older may be suitable for LDLT. We do not accept individuals over the age of 50 years as living liver donors in our center. In our present study, no significant relationship was found between biliary complications and age in donors under 50 years of age, and we had just 21 liver donors over the age of 40 years.

In a study in which graft types of more than 1000 donors were examined, the risk of biliary com-plications was found to be significantly higher in a subgroup of patients with either extended right or right lobe grafts versus a subgroup of patients with non-right grafts.² The incidence of major com-plications was 17.0% (85 of 500) in the subgroup with either extended right or right lobe grafts, but only 2.6% (20 of 762) in the subgroup with non-right graft, and this difference was statistically significant. Despite biliary complications being the most frequent complication in both groups, there was a significant difference in frequency between the group with either extended right or right lob grafts (12.2%) versus the group with non-right grafts (4.9%; P < .05). In our donor population, there was just 1 donor who underwent left hepatectomy.

In our center, donors with a future RLV of 30% and above are accepted as living donors. In the subgroup analyses (RLV of 30%-35% and >35%), no relationship was found between biliary leakage and RLV (P = .174). Preoperative, intraoperative, and postoperative data from the 157 donors were divided into 3 groups: group 1 had RLV of 35%, group 2 had RLV of 36% to 40%, and group 3 had RLV of >40%.⁷ In that study, although the risk of perioperative complications was found to be less in the group with a RLV greater than 35%, no specific analysis for biliary complications was performed.

Although the number of patients is the main limitation of our study, this number of living liver donors is substantial compared with many centers due to the scarcity of deceased donors. The diversity of patient data for RLV, age, or graft type is limited. Although a limitation, our low complication rates are associated with well-chosen donors.

A decreasing trend has been observed in recent years in the incidence of biliary complications following orthotopic liver transplant, which ranges from 11% to 35%.^8,9 In our study, Clavien-Dindo grade III complications were observed in 24% of all donors, and the rate of biliary complications was 7.6% (n = 8). All biliary complications were typified as biliary leakage, and an ERCP procedure was performed for 5 patients. After the 2 or 3 ERCP procedures, all biliary leakage complications were resolved. Patient selection and perioperative close patient follow-up and early detection of leakage, which are detailed in the methods section, are thought to be effective for good clinical outcomes.

Conclusions

Careful donor selection and good identification of the patient at risk for complications in the perioperative process can facilitate early recognition and treatment of complications (especially biliary complications) and reduced morbidity. Studies with larger populations are needed to find independent risk factors for donor biliary complications.

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