The role of adult living donor liver transplantation and recent advances

Abstract

Twenty years since the first cases were described, adult living donor liver transplantation (ALDLT) is now considered a valid option to expand the donor pool in view of the ongoing shortage of organs and the high waiting list mortality rate. Despite the rapid evolution and acceptance of this complex process of donation and transplantation in clinical practice, the indications, outcome, ethical considerations and quality and safety aspects continue to evolve based on new data from large cohort studies. This article reviews the surgical and clinical advances in the field of liver transplantation, focusing on technical refinements and discussing the issues that may lead to a further expansion of this complex surgical procedure and the role of ALDLT.

Keywords:

• biliary complications
• donor mortality
• donor outcomes
• donor safety
• graft size
• HCC
• liver transplantation
• living donor
• recent advances
• robotic liver surgery

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• While left lobe (LL) living donor liver transplantation (LDLT) may represent the ideal option to markedly reduce the risk of liver failure or any other related donor complications, it is generally accepted that right lobe (RL) LDLT is a satisfactory option to overcome recipient size-related problems.

• The choice must balance the donor’s risk of morbidity and mortality related to the type of hepatectomy, with the recipient’s risk of liver dysfunction related to a small-for-size transplanted liver mass.

• Other than graft size, aspects related to portal inflow and venous outflow are determinants of successful recipient outcome in adult living donor liver transplantation (ALDLT).

• Regardless of the preferred biliary reconstruction technique, particular attention must be paid to avoid anastomotic tension and ischemic injury. The preservation of the anastomotic blood supply is of paramount importance and excessive manipulation and dissection of both donor and recipient bile ducts should be avoided.

• In ALDLT, HCC recipients should be carefully selected to avoid exposing the donor to an unacceptable risk if compared with a recipient poor outcome.

• The role of loco-regional treatments in patients awaiting ALDLT seems to be crucial in the selection process to control tumor progression and minimize the risk of recurrence.

• Several concerns related to donor safety still limit the wide-scale expansion and practicability of the minimally invasive approach in the field of living donor liver surgery. A careful donor selection and meticulous intra-operative technique are essential to the successful application of this approach.

• Transparency in reporting results after ALDLT is mandatory.