LIVER TRANSPLANTATION 21:72–78, 2015

ORIGINAL ARTICLE

Clinical Outcomes of and Patient Satisfaction With Different Incision Methods for Donor Hepatectomy in Living Donor Liver Transplantation Suk-Won Suh, Kwang-Woong Lee, Jeong-Moo Lee, YoungRok Choi, Nam-Joon Yi, and Kyung-Suk Suh Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

With the decrease in the average donor age and the increase in the proportion of female donors, both donor safety and cosmetic appearance are major concerns for some living donors in living donor liver transplantation (LDLT) because a large abdominal incision is needed that may influence the donor’s quality of life. In all, 429 donors who underwent donor hepatectomy for LDLT from April 2010 to February 2013 were included in the study. Donors were divided into 3 groups based on the type of incision: conventional inverted L incision (n 5 268; the C group), upper midline incision (n 5 147; the M group), and transverse incision with laparoscopy (n 5 14; the T group). Demographics, perioperative outcomes, postoperative complications for donors and recipients, and questionnaire-derived donor satisfaction with cosmetic appearance were compared. The mean age was lower (P < 0.001), the female ratio was higher (P < 0.001), and the body mass index (BMI) was lower (P 5 0.017) in the M and T groups versus the C group. The operation time (P < 0.001) and the hospital stay duration (P 5 0.010) were lowest in the M group. The postoperative complications did not differ by the type of incision and also did not show any significant effect in a multivariate analysis (P 5 0.867). In the assessment of questionnaire-derived donor satisfaction matched by age (65 years), sex, graft, height, weight, and BMI, a more satisfactory cosmetic result and more selfconfidence were noted in the M and T groups versus the C group. In conclusion, the use of a minimal incision is technically feasible for some donor hepatectomy cases with a favorable safety profile. The patient satisfaction levels were greater with improved cosmetic outcomes in cases of minimal incision versus cases of conventional incision. Liver Transpl 21:72-78, C 2014 AASLD. 2015. V Received April 11, 2014; accepted September 29, 2014. Living donor liver transplantation (LDLT) is a valuable alternative for the treatment of end-stage liver disease because of the limited availability of deceased donor organs in some countries.1 Living donors are typically healthy adults who do not derive any medical benefit from the procedure. However, the quality of life (QOL) of donors as well as donor safety should be considered. The cosmetic appearance of a large abdominal incision is a major concern for some living donors, especially young, unmarried female donors.2 There have been several attempts to use minimally invasive approaches to reduce the incision scar

size.3,4 The conventional incision is an inverted L incision similar to that used in the majority of liver resections for tumors.5 Laparoscopy-assisted living donor hepatectomy was first performed in children in 2002 as a left lateral sectionectomy for LDLT.6 Several centers subsequently reported successful outcomes with hybrid techniques for right hepatectomy with handassisted laparoscopic surgery.2,7,8 We introduced the laparoscopy-assisted donor hepatectomy method2 and recently began using an upper midline incision without any laparoscopic assistance for living donor right hepatectomy.9

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; CA, celiac axis; LDLT, living donor liver transplantation; LT, liver transplantation; QOL, quality of life. Potential conflict of interest: Nothing to report. Address reprint requests to Kwang-Woong Lee, M.D., Department of Surgery, Seoul National University College of Medicine, 101 Daehak-No, Jongno-Gu, Seoul 110-744, Republic of Korea. Telephone: 82-2-2072-2511; FAX: 82-2-766-3975; E-mail: [email protected]. DOI 10.1002/lt.24033 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases

C 2014 American Association for the Study of Liver Diseases. V

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Several reports have focused on the clinical outcomes of donors,10-12 but few have assessed the effects on QOL. QOL after surgery for donors is an important aspect of donor outcomes and should be considered. Using a questionnaire designed to evaluate body image, cosmetic results, and self-confidence after surgery, we evaluated the cosmetic aspects of QOL for donors according to the type of incision.

PATIENTS AND METHODS The study population consisted of 429 consecutive living donors who underwent donor hepatectomy for LDLT between April 2010 and February 2013 according to a prospective database. This cohort study using a questionnaire was approved by the institutional review board of Seoul National University Hospital (Seoul, Korea) and was exempted from the requirement to obtain informed consent. Donors were selected according to a standardized protocol described elsewhere.13 The patients were divided into 3 groups depending on the type of incision: conventional inverted L incision (C group; n 5 268), upper midline incision (M group; n 5 147), and transverse incision with laparoscopy (T group; n 5 14). The type of incision was based on surgeon preference regardless of the graft type, body mass index (BMI), or body shape; however, a minimal incision was used more frequently for young and/or female donors. The demographics, operation-related variables, and clinical outcomes of the donors and recipients were compared for the 3 groups. The following data were collected: age, sex, type of graft, height, weight, BMI, and celiac axis (CA) depth ratio for donors and age, sex, Model for End-Stage Liver Disease score, and indication for liver transplantation (LT) for recipients. The CA depth ratio is the ratio of the distance between the skin of the anterior abdominal wall and the root of the celiac artery to the length of the horizontal plane at a right angle to this distance, and it was calculated with preoperative computed tomography images. Operationrelated variables such as the operation time and estimated blood loss were compared. In addition, we compared the clinical outcomes, including the length of the hospital stay, the peak levels of total bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT), and postoperative complications according to a modified version of the original Clavien system for LT recipients. A multivariate analysis was also performed to evaluate the influence of the type of incision on postoperative complications. During the postoperative follow-up, the patients were invited to complete a questionnaire that was designed to evaluate their body image, cosmetic results, and self-confidence. Roughly half of the questionnaires (52.9%) were administered within 3 to 12 months after the operation, and the others were administered 2 or 3 years after the operation. Although a patient’s opinion about the scar and numbness may change with time, there was no significant difference in questionnaire results (including

SUH ET AL. 73

results for the sense of dullness or itching) during the survey time of this study. To our knowledge, no study in the literature has evaluated cosmesis in such cases with objective criteria. Dunker et al.14 developed a body image questionnaire consisting of a body image scale and a cosmetic scale to compare laparoscopically assisted and open ileocolic resection and restorative proctocolectomy. This questionnaire was also used and tested in several studies involving cesarean section, appendectomy, and donor nephrectomy15,16; particularly with respect to the study on donor nephrectomy, the elective laparoscopically assisted procedure was very similar to that used in the present study, so we used this questionnaire for our study. The original English questionnaire was translated into Korean and retranslated into English to confirm that the translation was appropriate. The questionnaire included questions about a patient’s attitude toward his or her body image (items 1-5) and about his or her degree of satisfaction with the appearance of the scar (items 6 and 7). Items 8 and 9 of the questionnaire asked about a patient’s self-confidence before and after surgery. A high score indicated an appreciable degree of patient satisfaction. To overcome the differences in demographics among the 3 groups, they were matched by age (65 years), sex, graft, height, weight, and BMI before the analysis.

Surgical Techniques All donors were administered endotracheal anesthesia in the supine position. No central catheterization was performed. A nasogastric tube and a Foley catheter were inserted before the incision was made for all patients. An inverted L incision was made from the xiphoid process to the umbilicus on the sagittal plane and was extended to the right rectus abdominis muscle on the transverse plane (Fig. 1A). The upper midline incision ranged from 12 to 18 cm in length; this depended on the shape of the abdominal cavity (Fig. 1B). A transverse incision by laparoscopy was made under the pneumoperitoneum (CO2 at 12 mm Hg) with a 30 laparoscope (Olympus, Hamburg, Germany) through the umbilical port. A 9-cm transverse incision was made for a hand port device (Applied GelPort; Applied Medical, Rancho Santa Margarita, CA) in the right upper quadrant area for the left hand of the operator (Fig. 1C). Surgical techniques for mobilization of the liver, dissection of the hilum and parenchyma, and graft retrieval have been described in detail elsewhere.2,9 After the completion of hemostasis, a closed suction drain was inserted into the right subphrenic space. The abdominal wall was closed layer by layer. After subepidermal suturing, a sterile strip was applied to the skin incision.

Statistical Analysis For intergroup comparisons, the distribution of the data was first evaluated for normality with the Shapiro-Wilk test. Normally distributed data are

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Figure 1.

LIVER TRANSPLANTATION, January 2015

Shapes of the incisions: (A) inverted L incision, (B) upper midline incision, and (C) transverse incision with laparoscopy.

TABLE 1. Demographics of Living Donors Demographic Age (years)* Sex: male/female (%) Graft: right liver [n (%)] Height (cm)* Weight (kg)* BMI (kg/m2)* CA depth ratio

C Group (n 5 268)

M Group (n 5 147)

T Group (n 5 14)

P Value

34.0 6 9.7 76.9/23.1 247 (92.2) 168.9 6 9.3 66.5 6 11.6 23.2 6 3.0 0.35 (0.23-0.50)

29.4 6 8.5 66.7/33.3 137 (93.2) 169.9 6 7.7 65.7 6 11.7 22.7 6 3.3 0.34 (0.24-0.43)

24.9 6 8.7 7.7/92.3 14 (100.0) 163.3 6 4.7 55.8 6 8.2 20.9 6 2.9 0.32 (0.27-0.38)

0.000 0.000 0.611 0.032 0.005 0.017 0.019

*The data are presented as means and standard deviations.

presented here as means and standard deviations, and groups were compared with the Student t test or Kruskal-Wallis test. Descriptive variables were subjected to v2 analysis, Fisher’s exact test, or the general model analysis of variance as appropriate. Multivariate analysis with an ordinary logistic regression model was performed to investigate the influence of the type of incision on postoperative complications. P < 0.05 was regarded as statistically significant. Statistical analysis was conducted with SPSS 19.0 (SPSS, Inc., Chicago, IL).

RESULTS The mean ages of the patients in the M and T groups (29.4 6 8.5 and 24.9 6 8.7 years, respectively) were lower than the mean age of the patients in the C group (34.0 6 9.7 years, P < 0.001). The proportion of female donors was higher in the M and T groups (33.3% and 92.3%, respectively) versus the C group (23.1%, P < 0.001). The most common graft type among the donors was a right hemiliver graft (93.2%). The height, weight, BMI, and CA depth ratio were significantly lower in the T group versus the C and M groups (Table 1). Among the perioperative characteristics of the donors, the operation time was shorter in the M group (258.3 6 43.3 minutes) and longer in the T group (338.8 6 61.7 minutes) versus the C group (275.9 6 45.7

minutes, P < 0.001). The length of the hospital stay was shorter in the M group (8.4 6 1.6 days) and longer in the T group (10.2 6 4.4 days) versus the C group (9.2 6 3.3 days, P 5 0.010). There were no significant differences in the peak levels of total bilirubin (P 5 0.164), AST (P 5 0.057), or ALT (P 5 0.063) among the groups (Table 2). The mean period of follow-up after the operation was 32.6 months (range 5 6.4-55.4 months). The rate of overall postoperative complications did not significantly differ between the C group (16.8%), the M group (16.4%), and the T group (0%, P 5 0.576). The postoperative complications in the liver donors and recipients, according to the classification system proposed by Clavien are presented in detail in Table 3. Five patients in the C group had wound-related complications, and they included 3 patients with wound seroma that was treated conservatively without any intervention and 2 patients with wound infections that required antibiotic treatment. Most of the complications were minor (grade I, 81.8%), and they were treated conservatively without any specific intervention. Progression to death did not occur in any of the cases, and there were no cases of life-threatening organ dysfunction or irreversible disability. Moreover, no significant difference in the postoperative complications or mortality was noted among the 3 groups during the follow-up of recipients. In the multivariate analysis, we did not observe any influence of the type

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TABLE 2. Perioperative Characteristics of the Living Donors Perioperative Characteristic

C Group (n 5 268)

M Group (n 5 147)

T Group (n 5 14)

P Value

Operation time (minutes) Estimated blood loss (L) Hospital stay (days) Peak total bilirubin (mg/dL) Peak AST (IU/L) Peak ALT (IU/L)

275.9 6 45.7 333.0 6 215.2 9.2 6 3.3 3.1 6 1.8 145.9 6 63.8 142.6 6 83.6

258.3 6 43.3 319.9 6 200.4 8.4 6 1.6 3.1 6 1.9 158.4 6 56.3 163.0 6 75.2

333.8 6 61.7 298.3 6 118.8 10.2 6 4.4 2.1 6 1.0 176.7 6 56.7 160.2 6 64.1

0.000 0.760 0.010 0.164 0.057 0.063

NOTE: The data are presented as means and standard deviations.

TABLE 3. Classification of Postoperative Complications of Living Donors and Recipients Complication

C Group (n 5 268)

M group (n 5 147)

T group (n 5 14)

P Value

1 (0.4) 0 6 (2.2) 5 (1.9) 2 (0.7)

1 (0.7) 1 (0.7) 0 2 (1.4) 0

0 0 0 0 0

0.58 0.188 0.098 0.24 0.43

3 (1.1) 3 (1.1) 0

1 (0.7) 0 1 (0.7)

0 0 0

0.82 0.35 0.47

2 (0.7) 0 0 0 0

0 2 (1.4) 1 (0.6) 0 0

0 0 0 0 0

0.29 0.06 0.19 NS NS

45 (16.8) 17 (6.3) 19 (7.1) 8 (3.0)

31 (21.1) 8 (5.4) 9 (6.1) 2 (1.4)

2 (14.3) 2 (14.3) 1 (7.1) 0

0.47 0.24 0.78 0.47

Living donors Clavien I Hyperbilirubinemia Fluid collection Pleural effusion Ileus Wound seroma Clavien II Bleeding Wound infection Cholangitis Grade III Biliary stricture Intra-abdominal bleeding Dislocation of liver Grade IV Grade V Recipients Major postoperative complications (grade III) Biliary complications Vascular complications Intra-abdominal bleeding Death during follow-up NOTE: The data are presented as numbers and percentages.

of incision on the postoperative complications of the living donors (P 5 0.867; Table 4). The results of the questionnaires for donor satisfaction according to different incision methods are summarized in Table 5. The overall response rate was 58.5%. The results of the questionnaires before and after matching by demographics such as age (65 years), sex, graft, height, weight, and BMI showed similar patterns. Most of the scores on questionnaires were significantly higher in the M group and T group versus the C group. There were no significant differences in body image among the 3 groups, although the patients in the M group, in comparison with the patients in the C and T groups, stated that they were more satisfied in response to the following question: “Are you less satisfied with your body since the operation?” (P 5 0.036). However, significant differences in the cosmetic score and the self-confidence score were

noted between the M and T groups and the C group. A sense of dullness or numbness on the scar was observed significantly more often in the C and T groups versus the M group (P 5 0.010; Table 5).

DISCUSSION Donor safety is of paramount importance in LDLT. Previous reports have described the catastrophic complications that can occur after donor operations for LDLT.1,11 However, technical advancements and experience in donor surgery have led to a significant reduction in the incidence of donor morbidity and mortality.10,13,17 With this improvement in clinical outcomes, another important aspect of donor outcomes has emerged: the impact of donation on QOL.18-20 It is possible to perform a minimally invasive donor operation through a smaller incision without compromising

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TABLE 4. Risk Factor Analysis for Postoperative Complications in the Living Donors

Risk Factor Age (years)* Sex: male [n (%)] Graft: right liver [n (%)] Height (cm)* Weight (kg)* BMI (kg/m2)* Incision methods [n (%)] C group M group T group

Presence of

Absence of

Complications

Complications

(n 5 30)

(n 5 399)

Univariate P

Multivariate P

34.1 6 8.5 20 (66.7) 27 (0.90) 168.3 6 8.6 64.1 6 10.8 22.5 6 2.8

32.0 6 9.7 285 (71.4) 372 (93.2) 169.1 6 8.7 66.0 6 11.7 30.0 6 3.2

0.26 0.82 0.98 0.644 0.41 0.46

0.36 0.80 0.42 0.89 0.89 0.81

22 (8.2) 8 (5.4) 0

246 (91.8) 139 (94.6) 14 (100.0)

0.33

0.87

*The data are presented as means and standard deviations.

donor safety and with better cosmetic results and reduced requirements for analgesia.21 In the present study, we assessed 3 different incision methods for donor hepatectomy in LDLT. The inverted L incision, which has been used for many years, was the most common approach. This conventional incision facilitates adequate exposure of all segments of the liver and complete access for dissecting the short hepatic veins. However, it is associated with poorer cosmetic outcomes and a prolonged length of hospital stay, so surgeons have sought to develop less invasive incisions for this type of procedure.21 The upper midline incision without any laparoscopic assistance for donor hepatectomy can be used safely regardless of the graft type or donor characteristics, and improved cosmetic outcomes can be achieved.9 A transverse incision using laparoscopy-assisted techniques for modified right hepatectomy while preserving the middle hepatic vein branches in LDLT was first reported in 2007. It is technically feasible and has a favorable safety profile.2 The CA depth ratio is reportedly a good marker for defining the shape of the abdominal cavity.22 A markedly elevated CA depth ratio has been found to be a risk factor for a long operation time (up to graft retrieval in donor hepatectomy), so the parameter can be considered during the selection of the type of incision9. In the present study, the type of incision usually depended on the surgeon’s personal choice and experience, regardless of donor characteristics; however, the transverse incision with laparoscopy was selectively performed when donor preference was considered. The proportion of young female donors was significantly greater in the T group, and this reflected concerns about the donor’s body image and cosmetic appearance after the operation; this resulted in a significant difference in the CA depth ratio. The mean operation time was shorter in the M group. This might have been due to a shorter wound incision length; closure by absorbable subcuticular

sutures is time-consuming. In contrast to the M group, the mean operation time was significantly longer in the T group, whose surgery required frequent installation and removal of laparoscopic devices for mobilization of the liver, application of the hanging maneuver, and dissection of the deep parenchyma. The length of the hospital stay, but not the donor condition, significantly differed among the 3 groups, and this may indicate that the differences in the surgeons’ postoperative protocols are reflected in the outcomes. The postoperative complications did not significantly differ between the donors and the recipients, so the different methods of incision seem to have favorable safety profiles and can be performed satisfactorily without significant risk. The results of the questionnaire for patient satisfaction according to the incision method showed that the M group and the T group had better outcomes than the C group. In particular, the T group reported the greatest satisfaction among the 3 groups. The location of the incision in the T group was decided before the operation after consideration of the skin crease of the right upper abdomen. Although the operation time was long in some donors, no visible scar was noted because it was hidden by the previous skin crease. This incision had the greatest advantages in terms of cosmetic appearance. Liver donation is reported to have a negative impact on QOL, with throbbing, itching, or numbness around the wound being the most common physical symptoms.19 Changes in the QOL of donors after LDLT have also been reported: 24% of subjects had woundrelated physical symptoms, and 19% experienced anxiety concerning their future health.20 In the present study, dullness or itching of the wound was more common in the C and T groups versus the M group; these symptoms are caused by the division of abdominal rectus muscles and adjunct cutaneous nerves. These symptoms should be carefully considered because they can affect QOL after donor operation.

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TABLE 5. Questionnaire for Donor Satisfaction According to Different Incision Methods C Group

M Group

T Group

Scale

(n 5 70)

(n 5 56)

(n 5 14)

P Value

1. Yes, extremely 2. Quite a bit 3. A little bit 4. No, not at all 1. Yes, extremely 2. Quite a bit 3. A little bit 4. No, not at all 1. Yes, extremely 2. Quite a bit 3. A little bit 4. No, not at all 1. Yes, extremely 2. Quite a bit 3. A little bit 4. No, not at all 1. Yes, extremely 2. Quite a bit 3. A little bit 4. No, not at all

2.67 6 0.84

2.95 6 0.77

2.36 6 1.00

0.036

3.14 6 0.80

3.27 6 0.73

3.43 6 0.94

0.397

2.93 6 0.94

3.25 6 0.72*

2.93 6 0.92

0.097

3.27 6 0.80

3.39 6 0.70

3.00 6 1.04

0.232

3.29 6 0.80

3.48 6 0.76

3.29 6 0.73

0.346

17.43 6 3.19

17.13 6 2.56

18.43 6 3.48

0.345

4.63 6 1.68

5.50 6 1.19*

5.64 6 1.33†

0.002

4.34 6 1.65

4.71 6 1.36

4.71 6 2.05

0.385

6.06 6 2.54

7.23 6 2.07*

7.43 6 2.28

0.010

15.03 6 5.35

17.45 6 3.78*

17.78 6 5.42

0.010

5.79 6 2.64

6.71 6 2.10*

6.93 6 2.87

0.066

6.24 6 2.55

7.46 6 2.23*

8.21 6 2.29†

0.003

12.03 6 4.63

14.18 6 3.79*

15.14 6 4.67†

0.005

19/48 (39.6)

6/42 (14.3)*

7/8 (87.5)†

0.010

Question Body image (5) 1. Are you less satisfied with your body since the operation? 2. Do you think the operation has damaged your body? 3. Do you feel less attractive as a result of your operation? 4. Do you feel less feminine/ masculine as a result of your operation? 5. Is it difficult to look at yourself naked?

Total Cosmetic (3) 1. How satisfied are you with your scar? 2. Could you score your own scar on another person? 3. Could you score your own scar? Total Self-confidence (2) 1. How confident were you before your operation? 2. How confident were you after your operation? Total Sense (1) 1. Do you have dullness or numbness on the scar? [n/N (%)]

1. Very unsatisfied 7. Very satisfied 1. Very bad 10. Great 1. Very bad 10. Great

1. Not very 10. Very 1. Not very 10. Very

confident confident confident confident

Yes or no

NOTE: Data are presented as means and standard deviations unless otherwise indicated. *P < 0.05 for the M group versus the C group. † P < 0.05 for the T group versus the C group.

Our study has several limitations. Some amount of selection bias might be present as a result of the involvement of surgeon preference in the different incisions used as well as the body habitus and sex of the donors. Moreover, the sample size of this study was another limitation, particularly in the T group, and the sample size was not sufficient to enable adjustments for these variables. However, the advantage of this study is that it assesses the QOL of living donors in terms of cosmetic appearance, and further studies involving a larger number of patients are warranted to confirm these promising results. Cosmetic outcomes, which

were analyzed on the basis of responses to certain questions, may be subjective; hence, other objective indexes such as the size and location of the incision and the extent of the scar should also be considered. In conclusion, minimal incisions such as an upper midline incision and a transverse incision with laparoscopy are technically feasible and have a favorable safety profile for donor hepatectomy in comparison with the conventional inverted L incision. Moreover, patient satisfaction levels are higher with minimal incisions versus the conventional incision because of the improved cosmetic outcomes.

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Clinical outcomes of and patient satisfaction with different incision methods for donor hepatectomy in living donor liver transplantation.

With the decrease in the average donor age and the increase in the proportion of female donors, both donor safety and cosmetic appearance are major co...
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