- Email: [email protected]
Using the Clavien Grading System to Classify the Complications of Right Hepatectomy in Living Donors
Using the Clavien Grading System to Classify the Complications of Right Hepatectomy in Living Donors B. Liu, L.-N. Yan, J. Li, B. Li, Y. Zeng, W.-T. Wang, M.-Q. Xu, J.-Y. Yang, and J. Zhao
ABSTRACT Introduction. The ratios of complications for living related liver donors after right hepatectomy differ widely among numerous single institutions. This study sought to use the Clavien classification system to define and graded the severity of these complications. Materials and methods. This study retrospectively analyzed the outcomes of 160 consecutive living donor right hepatectomies performed between July 2002 and February 2008. Complications among living donors for liver transplantation after right hepatectomy were stratified according to the Clavien classification of postoperative surgical complications. Results. Fifty-two living donors displayed one or more perioperative complications Grade 1 complications were recorded in 18.1%; grade 2 in 6.3%; grade 3a in 5%; and grade 3b in 3.1%. Biliary complications were the most frequent. No donor mortality was present in this series. Conclusions. The Clavien grading system is useful to comparise surgical outcomes. This study demonstrated that donor right hepatectomy was a relatively safe procedure, but reducing donor complications after right hepatectomy has to be the first priority during the entire process of living related transplantation. HE NUMBER OF PATIENTS waiting liver transplantation still outnumbers the limited supply of deceased donor organs. With the development of hepatic surgery, living donor liver transplantation (LDLT) has become an acceptable modality to cope with the increasing waiting list mortality. Several large centers have reported outstanding outcomes of LDLT to decrease waiting list mortality. Although the ratio of complications differ widely.1– 4 Moreover, there is still no consensus on how to define and stratify complications by severity.5 The Clavien classification system has been proposed to grade perioperative complications in general surgery.6 Recently, this classification system has also been used to grade postoperative complications following live donor right hepatectomy.7 The aim of this study was to review our donor hepatectomy experience.
T
PATIENTS AND METHODS Between July 2002 and February 2008, 160 LDLT procedures were performed at our institution. All donor and recipient data were maintained in http://www.cltr.org. All potential donors
underwent full examinations, including blood group verification; virological assays for hepatotropic viruses; serological screening for human immunodeficiency virus, cytomegalovirus, and Epstein-Barr virus; calculations of body mass index and standard liver volume; liver and renal biochemistry; complete blood count; and coagulation profile. Computed tomography with volumetry was routinely performed before and at 3 months postoperation. All donated livers were right lobe grafts without the middle hepatic vein (MHV) seeking to avoid outflow obstruction to the remaining donor segment 4. The donor procedures began with a cholecystectomy with intraoperative cholangiography to delineate the biliary anatomy. We dissected the right hepatic artery and right portal vein, using intraoperative ultrasound to define the hepatic venous drainage of the right liver lobe, then isolating From the Division of Liver Transplantation (B.L., L.-N.Y., B.L., Y.Z., W.-T.W., M.-Q.X., J.-Y.Y., J.Z.) Department of Anesthesiology and Critical Care Medicine (J.L.), West-China Hospital, Sichuan University, Chengdu, China. Address reprint requests to Lu-Nan Yan, Division of Liver Transplantation, West-China Hospital, Sichuan University, Chengdu 610041, China. E-mail: [email protected]
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2008.11.014
Transplantation Proceedings, 41, 1703–1706 (2009)
1703
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the right hepatic vein. Next, we divided the attachments between the right lobe and the diaphragm to expose the inferior right hepatic veins (IRHVs). All IRHVs of ⬎5-mm diameter were preserved for subsequent anastomoses to the recipient inferior vena cava. The right bile duct was then cut sharply. Without hepatic vascular exclusion, the hepatic parenchyma was divided along Cantline’s line 1 cm to the right of the main stem of the MHV using a Cavitron Ultra-Sonic Aspirator (CUSA EXcel, Valleylab, Boulder, Col, USA) and an argon knife. When the right lobe was completely separated, we quickly removed the right lobe graft to the back table and perfused with University of Wisconsin solution at 4°C. Our follow-up protocols included weekly visits over the first month, biweekly visits for the second month, monthly visits for the subsequent 4 months, and then yearly rechecks. Additional visits outside the routine follow-up were arranged with the surgeon, internist, or psychiatrist according to clinical circumstances. Sonography was performed on all donors at 6 weeks postoperatively. Data on physical examinations, laboratory results, and radiological examinations were collected by one person in our center. The status of the donor was investigated by phone. Additionally, when the donor could not be reached by phone, we investigated through speaking with the recipient during follow-up visits. We classified postoperative complications among liver donors according to the Clavien system (Table 1). Data were expressed as mean values ⫾ standard deviations [SDs] or medians (range). Statistical analysis was performed using SPSS 13.0 for Windows computer software (SPSS Inc, Chicago, Ill, USA). P values less than .05 indicated significance.
RESULTS
All donors were alive and well at the endpoint of follow-up. The mean follow-up time for the 160 cases was 24 months (range ⫽ 3–56). The characteristics of the patients in the Table 1. Classification of Complications According to the Clavien System Grade 1
Grade 2
Grade 3 Grade 3a Grade 3b Grade 4
Grade 4a Grade 4b Grade 5
Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions. Allowed therapeutic regimens are drugs as antiemetics, antipyretics, analgesics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside. Complications requiring pharmacological treatment with drugs other than such allowed for grade 1 complications. Blood transfusions and total parenteral nutrition are also included. Complications requiring surgical, endoscopic, or radiological intervention. Intervention not under general anesthesia. Intervention under general anesthesia. Life-threatening complications (including central nervous system complications) requiring intensive care unit stay. Single organ dysfunction (including dialysis). Multiorgan dysfunction. Death of the patient.
Table 2. Donors LDLT Information (160 cases) Age (y) Gender (female/male) Follow-up time (mo), mean (range) Volume of total donor liver (mL), mean (range) Volume of remnant liver (mL), mean (range) Mean operation time (mins), mean (range) Hospital stay (d), mean (range) Body mass index (kg/m2), mean Relationship to recipient Wife Husband Mother Father Son Daughter Sister Brother Nephew Uncle Friend
23–52 82/78 24 (3–56) 1158 ⫾ 275 (974–1823) 547 ⫾ 203 (382–966) 369 ⫾ 87.2 (309–592) 11 (5–44) 22.9 ⫾ 4.8 36 19 26 14 10 9 15 11 5 1 14
LDLT, living donor liver transplantation.
study group are summarized in Table 2. The total volume of the donor liver ranged from 974 to 1823 mL (mean ⫾ SD ⫽ 1158 ⫾ 275 mL). The volume of remnant liver after right hemihepatectomy ranged from 382 to 966 mL (mean ⫽ 547 ⫾ 203 mL). The ratio of the remnant to the whole liver ranged from 32.3% to 46.5% (mean ⫽ 39.1% ⫾ 5.4%). Operative time ranged from 309 to 592 minutes (mean ⫽ 369 ⫾ 87.2 minutes). Red blood cell concentrate transfusions during the operation ranged from 0 to 600 mL (mean ⫽ 248 ⫾ 241 mL). The volume of salvaged autotransfusion ranged from 250 to 735 mL (mean ⫽ 345 ⫾ 107 mL). The mean intensive care unit stay was less than 48 hours, and the mean hospital stay, 11 days (range ⫽ 5– 44 days). All donors exhibited transient liver enzyme elevations, hyperbilirubinemia, and hypoalbuminemia. Similar abnormalities were shown in prothrombin time, but the biochemical profiles in most cases normalized within 7 days postoperative. The complications in 52 (32.9%) of donors were evaluated by the Clavien grading system.6 The occurrence of complications is detailed in Table 3. Grade 1 complications were recorded in 18.1%; grade 2 in 6.3%; grade 3a in 5%; and grade 3b in 3.1%. No grade 4 or grade 5 complications were encountered in this series. The more common complications in the grade 1 group were prolonged hyperbilirubinemia and transient bile leaks. As grade 2 complications, four donors developed bile leaks, which required abdominal cavity drainage. Wound infections or pneumonia necessitating additional antibiotics other than prophylactics were also classified as grade 2 complications. Biliary complications were more common in the grade 3 group. Two bile leakages needing endoscopic retrograde cholangiopancre-
CLAVIEN GRADING SYSTEM
1705
Table 3. Complications of 160 Donors Classified According the Clavien System Grades
Complications
Grade 1 (n ⫽ 29; 18.1%)
Transient bile leak treated conservatively Superficial wound infection treated without antibiotics Postoperative voice change Mild pleural effusion treated conservatively Mild subphrenic effusion treated conservatively Hyperbilirubinemia ⬎ 1.3 mg/dL 7 days after operation Intra-abdominal bleeding requiring blood transfusion Bile leak not requiring ERCP or surgical intervention Dyspepsia Chyle leak Wound infection requiring antibiotics Pneumonia requiring antibiotics Bile leakage needing ERCP Pleural effusion requiring thoracic cavity puncture Pleural effusion requiring thoracic drainage Subphrenic infection requiring abdominal cavity puncture Chylothorax requiring thoracic cavity puncture Portal vein thrombosis requiring relaparotomy Biliary stricture requiring ERCP with stent placement Abdominal hematoma requiring intervention Intra-abdominal bleeding requiring relaparotomy
Grade 2 (n ⫽ 10; 6.3%)
Grade 3a (n ⫽ 8; 5%)
Grade 3b (n ⫽ 5; 3.1%)
Grade 4a Grade 4b Grade 5
n
8 2 3 2 5 10 1 4 1 1 1 2 3 2 1 1 1 1 2 1 1 0 0 0
centers on how to define and stratify complications by severity.5 It is necessary to establish reliable accurate assessment criteria for postoperative morbidity in donors. The modified Clavien grading system has been proposed to evaluate perioperative complications in general surgery. It has been validated in a cohort of 6336 patients.6 We adapted this classification for liver donor morbidity in this study. Grade 1 complications were recorded in 18.1%; grade 2 in 6.3%; grade 3a in 5%; and grade 3b in 3.1%. There was no donor postoperative mortality in this series. Our results were similar to an other report,9 showing that most complications after liver donation were minor and self-limited, but several patients experienced grade 3b complications, which were potentially threatening to the donors’ life. This study also showed that the incidence of biliary complications was more frequent among right liver donors, including eight grade 1; four grade 2; three grade 3a; and two grade 3b. These complications were related to the donor evaluation protocol,10 types of donor hepatectomy,11 and each center’s experience. Mild complications in grade 1 and grade 2 were often selflimited, not requiring additional treatment. However, major grade 3 or grade 4 complications were often life-threatening, requiring surgical or endoscopic intervention. So we must perform a complete preoperative medical and anatomic evaluation of the potential donors as well as improve surgical technique and postoperative care to decrease donors complications after right hemiliver donation. In conclusion, the Clavien grading system is useful to evaluate and compare surgical outcomes among various surgeons and centers. Although this graded classification scheme demonstrated that donor right hepatectomy is a relatively safe procedure, reducing donor complications after right hepatectomy has to be our first priority.
ERCP, endoscopic retrograde cholangiopancreatography.
atography (ERCP) in grade 3a, and two biliary strictures requiring ERCP with stent placement in grade 3b. In grade 3a group, two donors showed pleural effusions, which were cured by thoracic cavity puncture or drainage. This study also demonstrated that biliary complications were the most frequent ones among right liver donors, including eight grade 1; four grade 2; three grade 3a, and two grade 3b. Prolonged hyperbilirubinemia was definied as a bilirubin level ⬎ 1.3 mg/dL for 7 days after a right hepatectomy. There were 10 cases of grade 1 hyperbilirubinemia, which did not require additional treatment. DISCUSSION
Despite the high success rates of LDLT, the complication rates range from 0% to 67%, with an overall complication rate of 31%.8 There is no consensus among various
REFERENCES 1. Olthoff KM, Merion RM, Ghobrial RM, et al: Outcomes of 385 adult-to-adult living donor liver transplant recipients: a report from the A2ALL Consortium. Ann Surg 242:314, 2005 2. Broering DC, Wilms C, Bok P, et al: Evolution of donor morbidity in living related liver transplantation: a single-center analysis of 165 cases. Ann Surg 240:1013, 2004 3. Chan SC, Fan ST, Lo CM, et al: Toward current standards of donor right hepatectomy for adult-to-adult live donor liver transplantation through the experience of 200 cases. Ann Surg 245:110, 2007 4. Fujita S, Kim ID, Uryuhara K, et al: Hepatic grafts from live donors: donor morbidity for 470 cases of live donation. Transpl Int 13:333, 2000 5. Beavers KL, Sandler RS, Shrestha R: Donor morbidity associated with right lobectomy for living donor liver transplantation to adult recipients: a systematic review. Liver Transpl 8:110, 2002
1706 6. Dindo D, Demartines N, Clavien PA: Classification of surgical complications: a new proposal with evaluation in a cohort of a 6336 patients and results of a survey. Ann Surg 240:205, 2004 7. Patel S, Orloff M, Tsoulfas G, et al: Living-donor liver transplantation in the United States: identifying donors at risk for perioperative complications. Am J Transplant 7:2344, 2007 8. Surman OS: The ethics of partial-liver donation. N Engl J Med 346:1038, 2002
LIU, YAN, LI ET AL 9. Yi N-J, Suh K-S, Cho JY, et al: Three-quarters of right liver donors experienced postoperative complications. Liver Transpl 13:797, 2007 10. Schroeder RA, Marroquin CE, Bute BP, et al: Predictive indices of morbidity and mortality after liver resection. Ann Surg 243:373, 2006 11. Umeshita K, Fujiwara K, Kiyosawa K, et al: Operative morbidity of living liver donors in Japan. Lancet 362:687, 2003
ABSTRACT Introduction. The ratios of complications for living related liver donors after right hepatectomy differ widely among numerous single institutions. This study sought to use the Clavien classification system to define and graded the severity of these complications. Materials and methods. This study retrospectively analyzed the outcomes of 160 consecutive living donor right hepatectomies performed between July 2002 and February 2008. Complications among living donors for liver transplantation after right hepatectomy were stratified according to the Clavien classification of postoperative surgical complications. Results. Fifty-two living donors displayed one or more perioperative complications Grade 1 complications were recorded in 18.1%; grade 2 in 6.3%; grade 3a in 5%; and grade 3b in 3.1%. Biliary complications were the most frequent. No donor mortality was present in this series. Conclusions. The Clavien grading system is useful to comparise surgical outcomes. This study demonstrated that donor right hepatectomy was a relatively safe procedure, but reducing donor complications after right hepatectomy has to be the first priority during the entire process of living related transplantation. HE NUMBER OF PATIENTS waiting liver transplantation still outnumbers the limited supply of deceased donor organs. With the development of hepatic surgery, living donor liver transplantation (LDLT) has become an acceptable modality to cope with the increasing waiting list mortality. Several large centers have reported outstanding outcomes of LDLT to decrease waiting list mortality. Although the ratio of complications differ widely.1– 4 Moreover, there is still no consensus on how to define and stratify complications by severity.5 The Clavien classification system has been proposed to grade perioperative complications in general surgery.6 Recently, this classification system has also been used to grade postoperative complications following live donor right hepatectomy.7 The aim of this study was to review our donor hepatectomy experience.
T
PATIENTS AND METHODS Between July 2002 and February 2008, 160 LDLT procedures were performed at our institution. All donor and recipient data were maintained in http://www.cltr.org. All potential donors
underwent full examinations, including blood group verification; virological assays for hepatotropic viruses; serological screening for human immunodeficiency virus, cytomegalovirus, and Epstein-Barr virus; calculations of body mass index and standard liver volume; liver and renal biochemistry; complete blood count; and coagulation profile. Computed tomography with volumetry was routinely performed before and at 3 months postoperation. All donated livers were right lobe grafts without the middle hepatic vein (MHV) seeking to avoid outflow obstruction to the remaining donor segment 4. The donor procedures began with a cholecystectomy with intraoperative cholangiography to delineate the biliary anatomy. We dissected the right hepatic artery and right portal vein, using intraoperative ultrasound to define the hepatic venous drainage of the right liver lobe, then isolating From the Division of Liver Transplantation (B.L., L.-N.Y., B.L., Y.Z., W.-T.W., M.-Q.X., J.-Y.Y., J.Z.) Department of Anesthesiology and Critical Care Medicine (J.L.), West-China Hospital, Sichuan University, Chengdu, China. Address reprint requests to Lu-Nan Yan, Division of Liver Transplantation, West-China Hospital, Sichuan University, Chengdu 610041, China. E-mail: [email protected]
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2008.11.014
Transplantation Proceedings, 41, 1703–1706 (2009)
1703
1704
LIU, YAN, LI ET AL
the right hepatic vein. Next, we divided the attachments between the right lobe and the diaphragm to expose the inferior right hepatic veins (IRHVs). All IRHVs of ⬎5-mm diameter were preserved for subsequent anastomoses to the recipient inferior vena cava. The right bile duct was then cut sharply. Without hepatic vascular exclusion, the hepatic parenchyma was divided along Cantline’s line 1 cm to the right of the main stem of the MHV using a Cavitron Ultra-Sonic Aspirator (CUSA EXcel, Valleylab, Boulder, Col, USA) and an argon knife. When the right lobe was completely separated, we quickly removed the right lobe graft to the back table and perfused with University of Wisconsin solution at 4°C. Our follow-up protocols included weekly visits over the first month, biweekly visits for the second month, monthly visits for the subsequent 4 months, and then yearly rechecks. Additional visits outside the routine follow-up were arranged with the surgeon, internist, or psychiatrist according to clinical circumstances. Sonography was performed on all donors at 6 weeks postoperatively. Data on physical examinations, laboratory results, and radiological examinations were collected by one person in our center. The status of the donor was investigated by phone. Additionally, when the donor could not be reached by phone, we investigated through speaking with the recipient during follow-up visits. We classified postoperative complications among liver donors according to the Clavien system (Table 1). Data were expressed as mean values ⫾ standard deviations [SDs] or medians (range). Statistical analysis was performed using SPSS 13.0 for Windows computer software (SPSS Inc, Chicago, Ill, USA). P values less than .05 indicated significance.
RESULTS
All donors were alive and well at the endpoint of follow-up. The mean follow-up time for the 160 cases was 24 months (range ⫽ 3–56). The characteristics of the patients in the Table 1. Classification of Complications According to the Clavien System Grade 1
Grade 2
Grade 3 Grade 3a Grade 3b Grade 4
Grade 4a Grade 4b Grade 5
Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions. Allowed therapeutic regimens are drugs as antiemetics, antipyretics, analgesics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside. Complications requiring pharmacological treatment with drugs other than such allowed for grade 1 complications. Blood transfusions and total parenteral nutrition are also included. Complications requiring surgical, endoscopic, or radiological intervention. Intervention not under general anesthesia. Intervention under general anesthesia. Life-threatening complications (including central nervous system complications) requiring intensive care unit stay. Single organ dysfunction (including dialysis). Multiorgan dysfunction. Death of the patient.
Table 2. Donors LDLT Information (160 cases) Age (y) Gender (female/male) Follow-up time (mo), mean (range) Volume of total donor liver (mL), mean (range) Volume of remnant liver (mL), mean (range) Mean operation time (mins), mean (range) Hospital stay (d), mean (range) Body mass index (kg/m2), mean Relationship to recipient Wife Husband Mother Father Son Daughter Sister Brother Nephew Uncle Friend
23–52 82/78 24 (3–56) 1158 ⫾ 275 (974–1823) 547 ⫾ 203 (382–966) 369 ⫾ 87.2 (309–592) 11 (5–44) 22.9 ⫾ 4.8 36 19 26 14 10 9 15 11 5 1 14
LDLT, living donor liver transplantation.
study group are summarized in Table 2. The total volume of the donor liver ranged from 974 to 1823 mL (mean ⫾ SD ⫽ 1158 ⫾ 275 mL). The volume of remnant liver after right hemihepatectomy ranged from 382 to 966 mL (mean ⫽ 547 ⫾ 203 mL). The ratio of the remnant to the whole liver ranged from 32.3% to 46.5% (mean ⫽ 39.1% ⫾ 5.4%). Operative time ranged from 309 to 592 minutes (mean ⫽ 369 ⫾ 87.2 minutes). Red blood cell concentrate transfusions during the operation ranged from 0 to 600 mL (mean ⫽ 248 ⫾ 241 mL). The volume of salvaged autotransfusion ranged from 250 to 735 mL (mean ⫽ 345 ⫾ 107 mL). The mean intensive care unit stay was less than 48 hours, and the mean hospital stay, 11 days (range ⫽ 5– 44 days). All donors exhibited transient liver enzyme elevations, hyperbilirubinemia, and hypoalbuminemia. Similar abnormalities were shown in prothrombin time, but the biochemical profiles in most cases normalized within 7 days postoperative. The complications in 52 (32.9%) of donors were evaluated by the Clavien grading system.6 The occurrence of complications is detailed in Table 3. Grade 1 complications were recorded in 18.1%; grade 2 in 6.3%; grade 3a in 5%; and grade 3b in 3.1%. No grade 4 or grade 5 complications were encountered in this series. The more common complications in the grade 1 group were prolonged hyperbilirubinemia and transient bile leaks. As grade 2 complications, four donors developed bile leaks, which required abdominal cavity drainage. Wound infections or pneumonia necessitating additional antibiotics other than prophylactics were also classified as grade 2 complications. Biliary complications were more common in the grade 3 group. Two bile leakages needing endoscopic retrograde cholangiopancre-
CLAVIEN GRADING SYSTEM
1705
Table 3. Complications of 160 Donors Classified According the Clavien System Grades
Complications
Grade 1 (n ⫽ 29; 18.1%)
Transient bile leak treated conservatively Superficial wound infection treated without antibiotics Postoperative voice change Mild pleural effusion treated conservatively Mild subphrenic effusion treated conservatively Hyperbilirubinemia ⬎ 1.3 mg/dL 7 days after operation Intra-abdominal bleeding requiring blood transfusion Bile leak not requiring ERCP or surgical intervention Dyspepsia Chyle leak Wound infection requiring antibiotics Pneumonia requiring antibiotics Bile leakage needing ERCP Pleural effusion requiring thoracic cavity puncture Pleural effusion requiring thoracic drainage Subphrenic infection requiring abdominal cavity puncture Chylothorax requiring thoracic cavity puncture Portal vein thrombosis requiring relaparotomy Biliary stricture requiring ERCP with stent placement Abdominal hematoma requiring intervention Intra-abdominal bleeding requiring relaparotomy
Grade 2 (n ⫽ 10; 6.3%)
Grade 3a (n ⫽ 8; 5%)
Grade 3b (n ⫽ 5; 3.1%)
Grade 4a Grade 4b Grade 5
n
8 2 3 2 5 10 1 4 1 1 1 2 3 2 1 1 1 1 2 1 1 0 0 0
centers on how to define and stratify complications by severity.5 It is necessary to establish reliable accurate assessment criteria for postoperative morbidity in donors. The modified Clavien grading system has been proposed to evaluate perioperative complications in general surgery. It has been validated in a cohort of 6336 patients.6 We adapted this classification for liver donor morbidity in this study. Grade 1 complications were recorded in 18.1%; grade 2 in 6.3%; grade 3a in 5%; and grade 3b in 3.1%. There was no donor postoperative mortality in this series. Our results were similar to an other report,9 showing that most complications after liver donation were minor and self-limited, but several patients experienced grade 3b complications, which were potentially threatening to the donors’ life. This study also showed that the incidence of biliary complications was more frequent among right liver donors, including eight grade 1; four grade 2; three grade 3a; and two grade 3b. These complications were related to the donor evaluation protocol,10 types of donor hepatectomy,11 and each center’s experience. Mild complications in grade 1 and grade 2 were often selflimited, not requiring additional treatment. However, major grade 3 or grade 4 complications were often life-threatening, requiring surgical or endoscopic intervention. So we must perform a complete preoperative medical and anatomic evaluation of the potential donors as well as improve surgical technique and postoperative care to decrease donors complications after right hemiliver donation. In conclusion, the Clavien grading system is useful to evaluate and compare surgical outcomes among various surgeons and centers. Although this graded classification scheme demonstrated that donor right hepatectomy is a relatively safe procedure, reducing donor complications after right hepatectomy has to be our first priority.
ERCP, endoscopic retrograde cholangiopancreatography.
atography (ERCP) in grade 3a, and two biliary strictures requiring ERCP with stent placement in grade 3b. In grade 3a group, two donors showed pleural effusions, which were cured by thoracic cavity puncture or drainage. This study also demonstrated that biliary complications were the most frequent ones among right liver donors, including eight grade 1; four grade 2; three grade 3a, and two grade 3b. Prolonged hyperbilirubinemia was definied as a bilirubin level ⬎ 1.3 mg/dL for 7 days after a right hepatectomy. There were 10 cases of grade 1 hyperbilirubinemia, which did not require additional treatment. DISCUSSION
Despite the high success rates of LDLT, the complication rates range from 0% to 67%, with an overall complication rate of 31%.8 There is no consensus among various
REFERENCES 1. Olthoff KM, Merion RM, Ghobrial RM, et al: Outcomes of 385 adult-to-adult living donor liver transplant recipients: a report from the A2ALL Consortium. Ann Surg 242:314, 2005 2. Broering DC, Wilms C, Bok P, et al: Evolution of donor morbidity in living related liver transplantation: a single-center analysis of 165 cases. Ann Surg 240:1013, 2004 3. Chan SC, Fan ST, Lo CM, et al: Toward current standards of donor right hepatectomy for adult-to-adult live donor liver transplantation through the experience of 200 cases. Ann Surg 245:110, 2007 4. Fujita S, Kim ID, Uryuhara K, et al: Hepatic grafts from live donors: donor morbidity for 470 cases of live donation. Transpl Int 13:333, 2000 5. Beavers KL, Sandler RS, Shrestha R: Donor morbidity associated with right lobectomy for living donor liver transplantation to adult recipients: a systematic review. Liver Transpl 8:110, 2002
1706 6. Dindo D, Demartines N, Clavien PA: Classification of surgical complications: a new proposal with evaluation in a cohort of a 6336 patients and results of a survey. Ann Surg 240:205, 2004 7. Patel S, Orloff M, Tsoulfas G, et al: Living-donor liver transplantation in the United States: identifying donors at risk for perioperative complications. Am J Transplant 7:2344, 2007 8. Surman OS: The ethics of partial-liver donation. N Engl J Med 346:1038, 2002
LIU, YAN, LI ET AL 9. Yi N-J, Suh K-S, Cho JY, et al: Three-quarters of right liver donors experienced postoperative complications. Liver Transpl 13:797, 2007 10. Schroeder RA, Marroquin CE, Bute BP, et al: Predictive indices of morbidity and mortality after liver resection. Ann Surg 243:373, 2006 11. Umeshita K, Fujiwara K, Kiyosawa K, et al: Operative morbidity of living liver donors in Japan. Lancet 362:687, 2003