Intra-operative near-miss events during left liver lobe donation surgery: The hidden face of paediatric living-donor liver transplantation

Reding, Raymond;Daudré-Vignier, Victoria;Ciccarelli, Olga;Coubeau, Laurent;Bonaccorsi Riani, Eliano;et.al.
(2019) 10th Congress of the International Pediatric Transplant Association — Location: Vancouver, BC, Canada (4.May.2019)

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Introduction: Living donor liver transplantation (LDLT) was developed to alleviate post-mortem organ shortage in pediatric liver transplantation. Such program, however, should be performed under strict ethical guidelines, and optimal living donor (LD) safety. We hypothesized that serious unexpected peri-operative medical and/or surgical events during LD procedure indeed occur in a high volume LDLT center, being a major threat to donor safety. Methods: Between July 1993 and October 2018, a total of 433 paediatric LDLT were performed at Cliniques universitaires Saint-Luc, Brussels Belgium. Each LD was carefully selected through medical history, pre-operative work-up, medical advocate and psychologist consultations, and liver US and MRI imaging. Left liver lobectomy was performed through a midline laparotomy as previous detailed (1). All LD medical records were retrospectively reviewed searching for the occurrence of near-miss events (NME). NME was defined as any potentially harmful event during peri-operative period that was identified and controlled before definitive patient harm has happened. No recognition/no control of such events constitute a potential risk for subsequent donor and recipient morbi-mortality. Results: Paediatric recipients results were described elsewhere (1). Neither mortality nor persisting disability was encountered in our series. Morbidity consisted mainly in cut-surface bile collections, transient pleural effusions, and incisional hernias, in less than 3% each. The following 8 (1.85%) intra-operative NME were identified in LD (one case each): 1) tension pneumothorax secondary to right subclavian vein function, 2) accidental ligature-section of donor common hepatic duct, 3) unintended ligature-section of donor right hepatic artery (RHA),4) accidental vena cava clamp release resulting in a massive bleeding, 5) slipping of the left hepatic artery (LHA) Hemolock® clip, 6) full IV LD heparinization, 7) lateral injury of seg. II bile duct evidenced at intra-operatory cholangiography, 8) accidental section of LHA at liver graft hilum. NMEs management consisted in: chest drain insertion, Roux-en- Y biliary drainage, RHA microsurgical re-anastomosis, temporary Pringle maneuver and total vena cava clamping followed by left hepatic vein stump suture, temporary clamping of common hepatic artery and LHA stump clipping, immediate protamine infusion, repair of bile duct injury and microsurgical reconstruction of LHA both at back-table. None of these NME resulted in peri-operative morbidity. Conclusions: Despite our minimal morbidity and no mortality rates, unexpected potentially life-threatening intra-operative events were identified in this series. All NME were timely recognised and controlled with no donor or recipient definitive harm. Systematic debriefing of each NME conducted to safety refinements in our LD protocol. We suggest that LD/NME systematic record could be use as quality control tool to assess donor safety in LDLT programs. References: 1. Gurevich M et al. Annals of Surgery 2015; 262: 1141-1149.
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Reding, R., Daudré-Vignier, V., Ciccarelli, O., Coubeau, L., Iesari, S., De Magnée, C., Tambucci, R., Pire, A., & Bonaccorsi Riani, E. (2019). Intra-operative near-miss events during left liver lobe donation surgery: The hidden face of paediatric living-donor liver transplantation. Pediatric Transplantation, 23(Supplement 1), 52-53. https://doi.org/10.1111/petr.13480 (Original work published 2019)