Total intravenous versus volatile anesthesia in living donor hepatectomy: A global prospective cohort study from the international LDLT registry

The choice between total intravenous anesthesia (TIVA) and volatile anesthesia for living donor hepatectomy remains controversial, with limited evidence comparing their impact on donor and recipient outcomes. This study evaluates the association between anesthetic technique and early postoperative outcomes using global prospective data. 1,466 donor-recipient pairs (September 2023-February 2025) from the International LDLT Registry (LDLTregistry.org) were analyzed. Donors were stratified by anesthetic technique (TIVA vs. volatile). Primary outcome was donor morbidity assessed by the Comprehensive Complication Index® (CCI®). Secondary outcomes included complication incidence (grouped by Clavien-Dindo grade), intraoperative blood loss, transfusion requirements, and biochemical markers. Multivariable regression analysis was adjusted for Human Development Index, surgical approach, and graft type. A linear mixed-effects model with a random intercept for transplant center, to account for outcome differences related to individual transplant center practices, was used to evaluate the association between anesthetic technique and donor CCI. TIVA was used for most donor hepatectomies (82.8%) but there was significant regional variation in its use (p<0.001). All seven centers contributing more than 50 cases (50.3% of the total cohort) used TIVA exclusively or predominantly. Use of volatile anesthesia was independently associated with higher donor CCI® scores (regression coefficient 1.69, 95% CI 0.29-3.09, p=0.018), more major complications (6.3% vs. 1.2%, p<0.001), and greater median blood loss (250 mL vs. 100 mL, p<0.001). TIVA was associated with lower transfusion rates (6.0% vs. 11.6%, p=0.002) and fewer biliary complications (2.5% vs. 8.3%, p<0.001). Recipient outcomes, including graft function and biochemical recovery, were comparable between groups. Our findings suggest an association between TIVA use and improved outcomes in living liver donors, with reduced morbidity in multivariable analysis accounting for transplant center and socioeconomic status of the countries where data originated. Further evaluation of this association with large scale international multicenter randomized trials is warranted.