Recipient severity, not the donor operative approach, is associated with bleeding and transfusion after adult living donor liver transplantation: A fixed final-hemostasis-surgeon cohort.

BACKGROUNDS/AIMS: The determinants of bleeding after living donor liver transplantation (LDLT) are difficult to isolate, because the surgeon who achieves final hemostasis varies. We characterized postoperative bleeding and intraoperative transfusion in a cohort with a single final-hemostasis surgeon.

METHODS

We reviewed 156 consecutive adult LDLTs (2016-2019) in which one surgeon performed biliary reconstruction, final hemostasis, and closure. The primary outcome was postoperative bleeding of Clavien-Dindo grade ≥ IIIa; intraoperative red blood cell transfusion was secondary. The source and the operative field of every event were determined from the operative records.

RESULTS

Bleeding occurred in 16 recipients (10.3%; median postoperative day 1.5). An identifiable source was found in all 16, and none was coagulopathic. Sources were in the recipient hepatectomy field (9), on the graft from vessels divided during donor hepatectomy (2), the closure field (2), a vascular anastomosis (1), and remote (2). No patient who bled died or lost the graft. On Firth penalized logistic regression, the estimates were largest for Model for End-stage Liver Disease (MELD) score (odds ratio 1.072, p = 0.062) and previous hilar surgery (odds ratio 3.133, p = 0.057). Transfusion was associated with MELD score (p < 0.001) and platelet count (p = 0.012), but not with laparoscopic donor hepatectomy (p = 0.954).

CONCLUSIONS

With the final-hemostasis surgeon held constant, bleeding arose from discrete anatomical sources rather than coagulopathy, whereas transfusion reflected recipient severity and thrombocytopenia. Neither was associated with the donor approach, although two events arose from graft-side vessels, and equivalence cannot be established.