Systematic Grading of Surgical Complications in Live Liver Donors†

Live donor liver transplantation (LDLT) offers a solution to the most serious problem currently facing the field of liver transplantation, which is the shortage of deceased donors. The demand for liver transplantation continues to increase and has far outpaced the supply of organs from deceased donors throughout the world. Pioneering efforts for LDLT have led to a safer procedure with excellent outcome, comparable to that in deceased donor liver transplantation.1 The procedure, however, comes at the price of hepatectomy in an otherwise healthy individual.2 To date, the deaths of 13 live liver donors have been definitively linked to the procedure.3 LDLT, living donor liver transplantation. In 2002, Beavers et al.4 conducted an extensive review of the literature and identified 12 reports covering more than 400 right-lobe donors. Morbidity rates in these reports ranged from 0% to 67%. The variation among different centers highlighted the need for a large registry to collect accurate and consistent data so that potential donors can base their decision on accurate information. It was soon recognized, however, that although the definition of surgical mortality is straightforward, the definition of morbidity is not. How morbidity is defined influences how centers report their complications and calculate the incidence of morbidities. In this issue of the journal, Yi et al.5 address this important issue and present the outcome of live liver donors from their LDLT series and classified the surgical morbidity. They report that 65 (78%) of 83 donors experienced postoperative complications. Of these 65, 64 experienced grade I, 11 experienced grade II, and 1 experienced grade III complications. None had grade IV or V complications. Grades I through V were defined as follows: I, minor complications; II, potentially life-threatening complications requiring pharmacologic treatment; III, complications requiring invasive intervention; IV, complications causing organ dysfunction requiring management in the intensive care unit; and V, complications resulting in the death of the patient. Unfortunately, they originally devised this system with reference to the classification system of Broering et al.6 Recently, Ibrahim et al.7 reported that among the 204 live donors, 10 (5%) experienced complications that ranged from grade I to III. It must be pointed out, however, that the classification system was also based on the severity of the complications and lacked validation in a large cohort of patients for its application in different countries. The classification system of surgical complications introduced by Clavien et al.8 in 1992 was originally intended for procedures with relatively low morbidity. Since then, the classification system has undergone modifications to better address complications specific to organ transplant recipients.9 Ghobrial et al.10 applied a classification system to describe morbidity in a small number of LDLT cases, both recipient and donor, and suggested that it might serve as the basis to assess outcome in the field. In 2003, Broelsch et al.11 suggested a uniform definition of complications as introduced by Clavien et al.9 in 1994 to enable the transplant community to critically discuss donor outcome. Following these suggestions, Broering et al.6 modified the morbidity classification of Clavien et al. for liver transplantation recipients, to adapt it to the living donor situation. The classification system failed to gain popularity, however, most likely because of the lack of validation in a large cohort of patients for its application in different countries, where definitions of negative outcome vary greatly depending on cultural and social factors, such as differences in medical insurance policies. LDLT is performed worldwide in different countries with varying medical systems supporting the procedure. Application of an internationally unvalidated classification system of surgical complications will result in incoherence of both the act of reporting and the cumulative data reported, preventing a simple comparison of outcomes among different transplant centers worldwide. For a uniform understanding of donor morbidity, this must be avoided. The modified version of the “Clavien classification” presented in 200412 overcomes this shortcoming. The modified system is based on the use of therapeutic consequences, with a major emphasis on the risk and invasiveness of the therapy used to correct a complication, which is the most readily available and objective information regarding the postoperative course. Most importantly, its simplicity and objectivity were evaluated with a cohort of over 6,000 patients, and its acceptability and reproducibility were validated by an international survey conducted in centers from each continent, with different cultural backgrounds, including surgeons with different levels of training. Applying such an objectively validated system to describe the outcome of live liver donor surgery will facilitate international comparisons, which will be beneficial for further improvement in donor care. Recently, we analyzed the morbidity among our 243 consecutive adult-to-adult LDLT donors on the basis of this internationally validated system.13 In brief, the definitions for grades I through V in the system are: I, deviation from the normal postoperative course, but without the need for therapy; II, complication requiring pharmacologic treatment; III, complication with the need for surgical, endoscopic, or radiologic intervention (IIIa/b: without/with the need for general anesthesia); IV, life-threatening complication requiring intensive care; and V, death. In our series, surgical morbidity was recognized in 67 donors (28%). No deaths occurred. The numbers of patients with complications were: grade I, 36 (15%); II, 10 (4%); IIIa, 12 (5%); IIIb, 9 (4%); IV, 0; V, 0. Six patients with grade IIIb complications underwent surgical repair for bile leakage. Mulligan14 wrote in 2006 that “A worldwide database for living donor liver transplantation is long overdue.” The modified Clavien classification system introduced in 200412 is simple and informative. We believe its use will greatly enhance the comparison of LDLT outcome. Any deviation from the cumulative data according to the system might lead to questions about why and how such a deviation occurred, thus providing useful information to improve surgical care of live liver donors, regardless of the region. From now on, this modified Clavien classification system should be used whenever surgical complications of live liver donors are discussed.