American Journal of Transplantation Editorial: Left vs Right Lobe Liver Donation

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http://onlinelibrary.wiley.com/doi/10.1111/ajt.12556/full

Editorial
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Left Versus Right Lobe Liver Donation
G. R. Roll, J. P. Roberts*
Article first published online: 4 DEC 2013
DOI: 10.1111/ajt.12556
American Journal of Transplantation
Early View (Online Version of Record published before inclusion in an issue)

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 patients in Era III that developed “gastric stasis.” This finding is difficult to reconcile with other large-scale reports from authors describing donor complications where gastric outlet obstruction makes up 0–0.7% of complications [6-8]. Uchiyama et al [1] report gastric stasis in 12.8% of donors in a single era. These 13 incidences of complications occurring only in the LH and LLS donors, and increasing dramatically over the study period, become the second most common complication after the 18 total biliary complications. They hypothesize that more upper abdominal scarring occurred in these donors compared to RH donors. This scarring, they speculate, leads to gastric stasis and peptic ulcer disease. The authors do not provide a reference for these statements, and experienced surgeons may not agree that LH produces significant anatomic changes in the foregut, nor more scar formation.

We understand the variability in small numbers that cannot be fully explained, but if LH and LLS donors are prone to foregut complications, why were there only three of these events in ERA I and Era II (212 LH and LLS) and 12 in Era III (105 LH and LLS donors)? If foregut complications are removed, there is a trend toward a lower complication rate after LH compared to RH, with three complications in 86 LH donors versus four complications in 56 RH donors (3.49% vs. 7.84%, p = ns). Additionally the complication rate after LH would essentially remain stable from Era I to Era III (2.9% vs. 3.5%, p = ns).

The authors conclude by stating, “Although the safety of RH was confirmed by the current study, we will continue to advocate the use of LH grafts whenever possible for the sake of donor safety.” We agree.