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The Evolving Role of Microsurgery in Living-Donor Liver Transplantation
Cassandra A. Ligh, MD, Ari M. Wes, BA, Kim M. Olthoff, MD, Abraham Shaked, MD, PhD, Peter L. Abt, MD, L Scott Levin, MD, FACS, Stephen J. Kovach, MD.
University of Pennsylvania, Philadelphia, PA, USA.

Purpose:Hepatic arterial (HA) reconstruction is challenging in living-donor-liver-transplantation (LDLT) as the artery diameter is small and has limited length at its origin. Hepatic artery thrombosis is a significant cause of graft loss and historically the most cited complication of LDLT (incidence 1-26%). The introduction of microsurgical techniques in HA reconstruction has improved graft survival and outcomes. The purpose was to analyze our experience transitioning to microsurgical techniques over the last 6-years.
Methods:A retrospective review was conducted for patients who underwent a LDLT either at CHOP or University of Pennsylvania, from 3/2010 through 6/2016. The primary outcome was HA thrombosis diagnosed by ultrasound, CT angiogram, or direct visualization. Other outcomes were collected in combination and analyzed using STATA.
Results:Seventy-one LDLT were performed 3/2010 to 6/2016, 23 (32%) were completed with microsurgical techniques and 48 (68%) without. The microsurgical cohort was significantly younger (average 28.2 years vs. 47.0 years; p=0.0199) with shorter follow-up time (average 456 days vs. 1100 days; p<0.001). The non-microsurgical cohort had 3 (6.25%) complete graft failures, 3 (6.25%) HA thrombosis, 2 (4.2%) HA pseudoaneurysms, 4 (8.3%) requiring non-operative procedures, and 3 (6.25%) mortalities, compared to zero in the microsurgical cohort. There were statistically significant differences between groups in biliary complications (21/43.8% vs. 1/4.3%; p=0.001), endoscopic retrograde cholangiopancreatography with stent (15/31.25% vs. 0/0%; p=0.002), and complications/return to the OR (10/20.8% vs. 3/13%; p=0.025).
Conclusion:Based on our institution’s short and long-term outcomes, microsurgical techniques have significantly improved post-surgical outcomes and reduced the morbidity and mortality in our LDLT population.


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