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

Uchiyama, Hideaki; Shirabe, Ken; Nakagawara, Hidekazu; Ikegami, Toru; Toshima, Takeo; Soejima, Yuji; Yoshizumi, Tomoharu; Yamashita, Yo Ichi; Harimoto, Norifumi; Ikeda, Tetsuo; Maehara, Yoshihiko

doi:10.1111/ajt.12559

Cited by 40 publications

(50 citation statements)

References 36 publications

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“…There were no biliary or major complications in the LG, and the biliary and major complication rates in the RG were 1.8% and 2.1%, respectively. A right lobe graft was previously suggested as a risk factor for donor complications, but a recent large‐scale study reported comparable outcomes for right lobe and left lobe donations . The volume of the liver graft should be determined to ensure the absolute safety of the donor but also to meet the need of the recipient.…”

Section: Discussionmentioning

confidence: 99%

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study

Lee

Kwon

et al. 2017

Liver Transpl

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Major concerns about donor safety cause controversy and limit the use of living donor liver transplantation to overcome organ shortages. The Korean Organ Transplantation Registry established a nationwide organ transplantation registration system in 2014. We reviewed the prospectively collected data of all 832 living liver donors who underwent procedures between April 2014 and December 2015. We allocated the donors to a left lobe group (n = 59) and a right lobe group (n = 773) and analyzed the relations between graft types and remaining liver volumes and complications (graded using the Clavien 5-tier grading system). The median follow-up was 19 months (range, 10-31 months). During the study period, 553 men and 279 women donated livers, and there were no deaths after living liver donation. The overall, biliary, and major complication (grade ≥ III) rates were 9.3%, 1.7%, and 1.9%, respectively. The graft types and remaining liver volume were associated with significantly different overall, biliary, and major complication rates. Of the 16 patients with major complications, 9 (56.3%) involved biliary complications (2 biliary strictures [12.5%] and 7 bile leakages [43.8%]). Among the 832 donors, the mean aspartate transaminase, alanine aminotransferase, and total bilirubin levels were 23.9 ± 8.1 IU/L, 20.9 ± 11.3 IU/L, and 0.8 ± 0.4 mg/dL, respectively, 6 months after liver donation. In conclusion, biliary complications were the most common types of major morbidity in living liver donors. Donor hepatectomy can be performed successfully with minimal and easily controlled complications. Our study shows that prospective, nationwide cohort data provide an important means of investigating the safety in living liver donation. Liver Transplantation 23 999-1006 2017 AASLD.

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Section: Discussionmentioning

confidence: 99%

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study

Lee

Kwon

et al. 2017

Liver Transpl

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“…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.…”

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confidence: 99%

Left Versus Right Lobe Liver Donation

Roll

Roberts

2014

American Journal of Transplantation

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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...

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“…Since the implementation of our LDLT program in 1996, our strict criteria for a RH graft donor have been as follows: the estimated remnant liver volume is no less than 35% of the total liver volume of the donor, and the MHV trunk is not included in the RH graft except for donors who have an extremely large left hepatic lobe. (5) In the period of the current study, only 4 RH grafts had the MHV trunk. Consequently, most RH grafts in our institute did not have the MHV trunk, instead they did have multiple venous orifices that had to be rigorously reconstructed.…”

Section: Discussionmentioning

confidence: 84%

Use of internal jugular vein grafts in reconstructing multiple venous orifices of right hepatic grafts without the middle hepatic vein trunk

et al. 2016

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

Cited by 40 publications

References 36 publications

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study

Left Versus Right Lobe Liver Donation

Use of internal jugular vein grafts in reconstructing multiple venous orifices of right hepatic grafts without the middle hepatic vein trunk

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