Live donor liver transplantation: Staging hepatectomy in a Jehovah's Witness recipient

Orthotopic liver transplantation (OLT) is usually associated with significant blood loss and frequently requires the usage of blood products. OLT has been offered sparingly in Jehovah's Witness (JW) patients because of their refusal to accept blood products for religious reasons. Several innovations have made surgery safer in these patients. These include the preoperative use of erythropoietin to increase red cell mass, the use of intraoperative cell salvage and acute normovolemic hemodilution, and judicious postoperative blood testing. Thoughtful perioperative decision-making and careful surgical techniques remain the cornerstone to a successful outcome. We report our experience in a two-stage hepatectomy done for a JW patient who underwent live donor liver transplant from his mother, also a JW, without blood transfusion. The recipient had an unusually enlarged left lateral segment of the liver which was densely adherent to the spleen. Removing these adhesions in the presence of significant portal hypertension would have resulted in considerable blood loss. This was successfully avoided by leaving this portion of the liver attached to the spleen while proceeding with the hepatectomy. The right lobe of the liver from the donor was then implanted uneventfully. Two weeks later the remaining segment of the recipient liver was removed without incident. The two-stage procedure was life-saving in this JW patient.