Post–living Liver Donation Diaphragmatic Hernia: A Life-threatening Complication Emphasizing the Need for Long-term Postdonation Care

The singularly paramount demerit of living donor liver transplantation (LDLT) is the risk of serious complications or death in the otherwise healthy living donor (LD). Despite all safeguards, LD complications and mortality occur even in the most experienced of hands.1,2 Nonetheless, with accumulating experience, the incidence of short- and long-term morbidity in LDs has reduced.3 Moreover, evolving knowledge based on these increasing numbers helps provide a better understanding of the likely complications and issues that may afflict an LD. In this regard, an underreported yet significant and potentially grievous post-LD complication is that of a diaphragmatic hernia (DiH). Reported incidences of DiH after LD donation range from 0.6% to 2.3%, of which the majority present in a delayed (≥12 mo) manner, and up to 45% present acutely with obstruction and strangulation.4 Kim et al5 have presented the largest experience of post-LD-DiH based on their cohort of 4014 LDLTs. They analyzed the risk factors for post-LD-DiH and have highlighted the dangers of this easily overlooked complication on follow-up. DiH occurred in 18 (0.4%) of their LDs, of whom 17 had undergone right lobe (RL) donation. Remarkably, 8 of these patients (44.4%) required emergency surgery at a median time period of 11 mo from the donation, further underlining the disquieting nature of this post-LD complication. This concurs with our own experience of 8 (0.33%) post-LD-DiH among a cohort of 2408 LDLTs. All of them occurred after RL donations. Their presentation was at a median time period of 16 (interquartile range, 7.5–46) mo from LD, and 37.5% of them presented acutely. There was 1 mortality in a donor who was being followed up elsewhere 18 mo after her donation. This patient had presented to the local clinic with upper abdominal pain; a chest and abdominal radiograph was performed and was discharged home with antacids and analgesics. This patient presented a week later with a strangulated DiH, in frank sepsis, and developed acute respiratory distress syndrome after the DiH operation, resulting in mortality. The pathophysiology of post-LD-DiH remains unclear, and several risk factors extrapolated from its occurrences after major liver resections for tumors have been postulated.6 These include direct or inadvertent thermal diaphragmatic injury (especially to the fragile diaphragmatic tissue on its posterior aspect) due to the application of hemostatic modalities such as argon beam coagulation. Other factors such as phrenic nerve injury, poor nutrition, impaired wound healing, and factors that increase the pressure difference between the abdominal and thoracic cavities, such as postoperative ileus, ascites, pregnancy, obesity, and chronic cough, have all been proposed to predispose to DiH. Nonetheless, several of these factors may not be applicable in the LD setting and need to be looked at closely. Kim et al mirrored the thoughts of another series on DiH, wherein the use of a particular bipolar hemostatic device was noted to be a reason for the sudden rise in the incidence of DiH in their units.5,7 Other reasons included increased operative time – which could reflect the difficulty and/or size of the RL being retrieved. Moreover, post-RL donation, there is a loss of the barrier effect, and this subdiaphragmatic space gets occupied by the bowel, which may be subject to ileus and abdominal increased pressures, placing them at risk of herniation. The incidence of DiH after minimally invasive donor hepatectomy (MIDH) appears to be lower than what has been observed after conventional open donor hepatectomy. Kim et al5 noted that none of the 351 patients who underwent MIDH developed DiH. This concurs with our series of 344 MIDH, wherein none of our patients developed this complication. The reason could be the difference in the manner in which the RL is mobilized from its attachments in MIDH. In MIDH, the enhanced visibility of the diaphragmatic fibers may help avoid thermal damage. However, these are hypotheses based on early experience and will need to be substantiated with increasing numbers of MIDH. Another crucial aspect of LD highlighted by Kim et al5 was the imperative need for long-term follow-up of LD. Most LT programs across the world have excellent short-term follow-up protocols to assess recovery of liver function and volume. However, there is an increasing awareness that LDs need follow-up over a longer period of time. Although there have been several formal discussions on following up LDs in the long term (including the formation of an international LDLT registry), the minimum duration and protocol of this post-LD surveillance remain variable.8 The Vancouver forum proposed a minimum follow-up of 1 y after LDLT.9 Most LDLT units rely on liberal use of ultrasound and chest radiography, especially beyond the first 6 mo. This bears significance as evidence suggests that the most common time of presentation of DiH is at a median time of 11–18 mo. Moreover, these modalities are limited in their accuracy and DiHs are often missed. As shown within the article and from our own experience, DiHs most often present with a sentinel episode of seemingly innocuous upper abdominal pain, and dependence on chest radiographs results in a delay in diagnosis, turning an elective issue into a potentially life-threatening one. Computed tomography is the superior modality but it comes with its own caveats, including financial considerations, compliance, and radiation exposure. Also, with increasing numbers of LDLTs being performed each year, the number of LD who will be on long-term follow-up will correspondingly increase. Thus, a blanket protocol for life-long LD follow-up may be prohibitive and impractical to sustain, and an equipoise needs to be achieved by recognizing those LDs who are likely to be “at risk” (large RL, longer operative times, difficult operations, etc) and will benefit from closer surveillance. Nonetheless, based on the above-mentioned evidence, following up LDs for a period of at least 3 y with an annual computed tomography scan appears to be a pragmatic approach to this conundrum. Importantly, an increased awareness and a high index of suspicion are required for the early detection and treatment of this potentially lethal complication of LD.

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