title: Day-of-surgery rejection of donors in living donor liver transplantation.
abstract: OBJECTIVE
  To study diagnostic laparoscopy as a tool for excluding donors on the day of surgery in living donor liver transplantation (LDLT).
  
  
  METHODS
  This study analyzed prospectively collected data from all potential donors for LDLT. All of the donors were subjected to a three-step donor evaluation protocol at our institution. Step one consisted of a clinical and social evaluation, including a liver profile, hepatitis markers, a renal profile, a complete blood count, and an abdominal ultrasound with Doppler. Step two involved tests to exclude liver diseases and to evaluate the donor's serological status. This step also included a radiological evaluation of the biliary anatomy and liver vascular anatomy using magnetic resonance cholangiopancreatography and a computed tomography (CT) angiogram, respectively. A CT volumetric study was used to calculate the volume of the liver parenchyma. Step three included an ultrasound-guided liver biopsy. Between November 2002 and May 2009, sixty-nine potential living donors were assessed by open exploration prior to harvesting the planned part of the liver. Between the end of May 2009 and October 2010, 30 potential living donors were assessed laparoscopically to determine whether to proceed with the abdominal incision to harvest part of the liver for donation.
  
  
  RESULTS
  Ninety-nine living donor liver transplants were attempted at our center between November 2002 and October 2010. Twelve of these procedures were aborted on the day of surgery (12.1%) due to donor findings, and eighty-seven were completed (87.9%). These 87 liver transplants were divided into the following groups: Group A, which included 65 transplants that were performed between November 2002 and May 2009, and Group B, which included 22 transplants that were performed between the end of May 2009 and October 2010. The demographic data for the two groups of donors were found to match; moreover, no significant difference was observed between the two groups of donors with respect to hospital stay, narcotic and non-narcotic analgesia requirements or the incidence of complications. Regarding the recipients, our study clearly revealed that there was no significant difference in either the incidence of different complications or the incidence of retransplantation between the two groups. Day-of-surgery donor assessment for LDLT procedures at our center has passed through two eras, open and laparoscopic. In the first era, sixty-nine LDLT procedures were attempted between November 2002 and May 2009. Upon open exploration of the donors on the day of surgery, sixty-five donors were found to have livers with a grossly normal appearance. Four donors out of 69 (5.7%) were rejected on the day of surgery because their livers were grossly fatty and pale. In the laparoscopic era, thirty LDLT procedures were attempted between the end of May 2009 and October 2010. After the laparoscopic assessment on the day of surgery, twenty-two transplantation procedures were completed (73.4%), and eight were aborted (26.6%). Our data showed that the levels of steatosis in the rejected donors were in the acceptable range. Moreover, the results of the liver biopsies of rejected donors were comparable between the group A and group B donors. The laparoscopic assessment of donors presents many advantages relative to the assessment of donors through open exploration; in particular, the laparoscopic assessment causes less pain, requires a shorter hospital stay and leads to far superior cosmetic results.
  
  
  CONCLUSIONS
  The laparoscopic assessment of donors in LDLT is a safe and acceptable procedure that avoids unnecessary large abdominal incisions and increases the chance of achieving donor safety.
authors.affiliation: Bassem Hegab, Mohamed Rabei Abdelfattah, Ayman Azzam, Hazem Mohamed, Waleed Al Hamoudi, Faisal Aba Alkhail, Hamad Al Bahili, Hatem Khalaf, Mohammed Al Sofayan, Mohammed Al Sebayel, Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia.
authors.forename: Bassem
authors.initials: B
authors.lastname: Hegab
authors.forename: Mohamed Rabei
authors.initials: MR
authors.lastname: Abdelfattah
authors.forename: Ayman
authors.initials: A
authors.lastname: Azzam
authors.forename: Hazem
authors.initials: H
authors.lastname: Mohamed
authors.forename: Waleed
authors.initials: W
authors.lastname: Al Hamoudi
authors.forename: Faisal Aba
authors.initials: FA
authors.lastname: Alkhail
authors.forename: Hamad Al
authors.initials: HA
authors.lastname: Bahili
authors.forename: Hatem
authors.initials: H
authors.lastname: Khalaf
authors.forename: Mohammed Al
authors.initials: MA
authors.lastname: Sofayan
authors.forename: Mohammed Al
authors.initials: MA
authors.lastname: Sebayel
keywords: Day of surgery; Fatty liver; Laparoscopic assessment; Live donor; Rejected donors