Left Versus Right Lobe Liver Donation

Abstract

The authors historically have been proponents of left hepatectomy (LH) and left lateral segmentectomy (LLS) donation for living donor liver transplantation, and here they retrospectively review 441 liver donors, reporting complications over 15 years (1). Donor complication rates decreased overall during the study period, which they attributed to the cumulative experiences resulting in mastery of both surgical technique and postoperative management. In addition, they describe the introduction of real-time C-arm cholangiography in Era II, allowing them to divide the bile duct under direct vision. With these changes they report that right hepatectomy (RH) complication rates decreased from 15% in Era I to 5% in Era III. This rate of complications for RH in Era III was not different from the rates for LH, and this was the major finding of the paper.We recently reviewed complications between RH and LH donation in 10 large series (2). One additional series was published recently (3). Of these 11 reports, two found complications to be equal between RH and LH, and a third reported complications to be actually more frequent after LH. In two of these three studies, donors were almost exclusively RH in adults (LH made up only 2.2% of donors in the first (2) and 2.8% in the second (4)). Surgeon preference for RH makes these data difficult to interpret. Additionally, it is challenging to quantify differences in the occurrence of rare events in two groups of dramatically different sizes. The third report is a retrospective multicenter report from the Japanese Liver Transplantation Society (5). Complication rates were 8.7% for 1088 LL versus 9.7% for 1378 RL. This study is difficult to reconcile with previous reports from Japan, and it was also possibly subject to reporting bias as the data were obtained retrospectively through a voluntarily submitted questionnaire. The consensus in the field is that LH is safer than RH.We would like to offer some insight about why the findings from Uchiyama et al are at odds with much of the established literature. One clue is demonstrated in Figure 1 (1) where it can be seen that while the complication rates after RH fell dramatically, the rate of complications (Clavien ! 2) after LH increased from approximately 5% to approximately 20%. Why did the complication rate for LH not fall concomitantly with the improvements with RH, and more surprisingly, why did it actually rise? This is counterintuitive given the improvements in process the authors describe, and the advancements in critical care and liver anesthesia over the same time period. Of note, they describe surgeon replacement in Era II and then go on to discuss their strategy for training new surgeons with graded responsibility. One possible explanation for the rise in complications of LH donors is that junior surgeons in training perform LH and LLS, while the more experienced surgeons perform RH in their system. This would be consistent with the largest blood loss occurring with LH in the most recent ERA. Also puzzling were the 11 LH pat...

Live Liver Donors: Is Right Still Right?

“…Our data confirm previous reports that right lobe donation can be performed as safely as left lobe donation [7][8][9][10]. Despite minor biochemical differences, there appears to be no clinically significant difference in donor outcomes between both groups, especially when the middle hepatic vein is left with the donor.…”

“…Literature evidence suggests that a cumulative experience with living donors hepatectomies reduces the overall complication rate, particularly for RH. [4,7,[10][11][12][13]. Hwang et al reported that major complications were more in right lobe Fig.…”

“…In a review of 11 reports, two showed similar morbidity for RL and LL donor hepatectomies, while one series had more complications with left lobe donations. The authors concluded that since most surgeons preferred a right lobe graft, the data was difficult to interpret due to dramatically different sample sizes [10]. With increasing surgeon and centre experience, the risks of donor mortality and morbidity decrease significantly and so too the differences in outcomes between the two types of donor hepatectomy (RL vs. LL) [4,7,[10][11][12][13][14].…”

Pediatric Liver Transplantation

“…Also to considerer is the fact that LDLT is surgically more challenging than whole organ transplantation. Donor major complications, exceeding Clavien's classification grade II, were described in up to 44% after right-lobe LDLT with a mortality risk up to 0.8% [128][129][130]. Donors of right liver lobe experience operating procedures with longer duration, have significant longer hospital stay and require more blood transfusions [131,132].…”