Living donor hepatectomy: The importance of the residual liver volume

Abstract

Living liver donation is a successful treatment for patients with end-stage liver disease. Most adults are provided with a right lobe graft to ensure a generous recipient liver volume. Some centers are re-exploring the use of smaller left lobe grafts to potentially reduce the donor risk. However, the evidence showing that the donor risk is lower with left lobe donation is inconsistent, and most previous studies have been limited by potential learning curve effects, small sample sizes, or poorly matched comparison groups. To address these deficiencies, we conducted a case-control study. Forty-five consecutive patients who underwent left hepatectomy (LH; n ¼ 4) or left lateral segmentectomy (LLS; n ¼ 41) were compared with matched controls who underwent right hepatectomy (RH) or extended right hepatectomy (ERH). The overall complication rates of the 3 groups were similar (31%-37%). There were no grade 4 or 5 complications. There were more grade 3 complications for the RH patients (13.3%) and the ERH patients (15.6%) versus the LH/LLS patients (2.2%). The extent of the liver resection significantly correlated with the peak international normalized ratio (INR), the days to INR normalization, and the peak bilirubin level. A univariate analysis demonstrated that hepatectomy, the spared volume percentage, and the peak bilirubin level were strongly associated with grade 3 complications. A higher peak bilirubin level, which correlated with a lower residual liver volume, was associated with grade 3 complications in a multivariate analysis (P ¼ 0.005). RH and grade 3 complications were associated with an increased length of stay (>7 days) in a multivariate analysis. In conclusion, this analysis demonstrates a significant correlation between the residual liver volume and liver dysfunction, serious adverse postoperative events, and longer hospital stays. Donor safety should be the first priority of all living liver donor programs. We propose that the surgical procedure removing the smallest amount of the liver required to provide adequate recipient graft function should become the standard of care for living liver donation. Liver Transpl 17:1404-1411, 2011. V C 2011 AASLD.Received December 31, 2010; accepted August 1, 2011.Living donor liver transplantation (LDLT) is a successful procedure with patient survival rates that are equivalent to those with deceased donor liver transplantation. [1][2][3][4] In regions in which donor rates are low, LDLT reduces wait-list death rates and improves survival from the time of listing in comparison with deceased donor liver transplantation. 5 Currently, right lobe liver grafts are procured for most adult recipients of living donor organs in North America, whereas left lobe grafts or left lateral segment grafts, which typically provide less liver mass, are reserved for infants and children. Recipient outcomes are excellent with right lobe LDLT, but donor morbidity rates range from 20% to 40%. 6 The drive to identify safer alternatives has stimulated renewed interest in the use of left late...

Revisiting the Safety of Living Liver Donors by Reassessing 441 Donor Hepatectomies: Is a Larger Hepatectomy Complication-Prone?

“…The safety of living liver donors is of paramount importance and this issue has been aggressively discussed so far (10)(11)(12)(13)(14)(15)(16). Although the liver has a capacity to regenerate, it is generally believed that the larger the resected liver parenchyma is, the more frequently postoperative complications will occur (13,14,17,18). We implemented the LDLT program in 1996 and have performed more than 400 LDLTs so far.…”

Evaluation of reasons for rejecting candidates for living donor liver transplantation

“…Moreover, the ratio of the remnant liver volume to the total liver volume is an important predictive risk factor. Most transplant centers still consider >35% a safe percentage [6,7], but a great number of studies have presented >30% as an acceptable ratio [8,9]. Our current limit of GRBW is 0.8 like the literature, although some recent studies have recommended 0.6 [10].…”

Living Donor Liver Transplantation: Donor Selection and Living Donor Hepatectomy

“…Regeneration is brisk in donors and substantial but not complete by 3 months [32 • ]. [37,38]. It is this thinking that has pushed increased utilization of left lobe grafts.…”