Living Liver Donors: Donor Safety Remains the Overriding Concern

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http://onlinelibrary.wiley.com/doi/10.1111/ajt.12612/full

Letter to the Editor
Laparoscopic Living Donor Left Hepatectomy: Donor Safety Remains the Overriding Concern
D. P. Borle, K. G. S. Bharathy, S. Kumar, V. Pamecha*
Article first published online: 7 JAN 2014
DOI: 10.1111/ajt.12612

American Journal of Transplantation
Early View (Online Version of Record published before inclusion in an issue)

To the Editor:

We read with great interest the article by Troisi et al [1] entitled “Pure laparoscopic full-left living donor hepatectomy for calculated small-for-size LDLT in adults: Proof of concept” and wish to commend the authors for sharing their experience. Living donor liver transplantation (LDLT) is based on the principle of double equipoise where donor risk is justified by recipient benefit [2]. Donor safety is considered paramount in all LDLT programs. Left hemihepatectomy undoubtedly reduces donor morbidity and there are reports attesting its feasibility without significant small-for-size syndrome in recipients[3, 4].

However, adding a completely laparoscopic approach may increase donor risk. The authors have had a Grade III biliary complication (Clavien Dindo) [5] in one of the four donors in this series, which is directly attributable to the laparoscopic approach.

In addition, there are some technical issues, inherent in the laparoscopic technique described, which may compromise the graft, when compared to a standard open technique. The warm ischemia time (up to 6.5 min in the series) is higher than in open procurement. The stapled transection of the outflow of the graft may prolong the venting of the graft and may lead to loss of length of the outflow. There may be shortening of portal vein as well due to stapling during laparoscopy. Did the authors need any specific reconstructive strategies on the bench prior to implantation?

It would also be interesting to know the authors' opinion on the use of radio-opaque markers instead of clips in cholangiograms performed just prior to bile duct division. It has been our experience that thin markers placed on either end of the proposed line of transection serve as a fairly accurate visual guide.

In conclusion though laparoscopic donor left hepatectomy is an attractive option, enthusiasm should be tempered by donor safety concerns. Any increase in donor morbidity would be a big price to pay for the sake of a potential for reduced postoperative pain and hospital stay. We are in agreement with the authors that it should be performed only with sufficient laparoscopy, hepatobiliary and transplant experience.

D. P. Borle, K. G. S. Bharathy, S. Kumar and V. Pamecha*
Department of Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
*Corresponding author: Viniyendra Pamecha, viniyendra@yahoo.co.uk

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http://onlinelibrary.wiley.com/doi/10.1111/ajt.12362/abstract

Pure Laparoscopic Full-Left Living Donor Hepatectomy for Calculated Small-for-Size LDLT in Adults: Proof of Concept
R. I. Troisi1,*, M. Wojcicki2, F. Tomassini1, P. Houtmeyers2, A. Vanlander1, F. Berrevoet1, P. Smeets3, H. Van Vlierberghe4, X. Rogiers1
DOI: 10.1111/ajt.12362
American Journal of Transplantation
Volume 13, Issue 9, pages 2472–2478, September 2013

Abstract
Adult-to-adult living donor liver transplantation (A2ALDLT) is an accepted mode of treatment for end-stage liver disease. Right-lobe grafts have usually been preferred in view of the higher graft volume, which lowers the risk of a small-for-size syndrome. However, donor left hepatectomy is associated with less morbidity than when it is compared to right hepatectomy. Laparoscopic donor hepatectomy (LDH) has been considered almost exclusively in pediatric transplantation. The results of laparoscopic left-liver graft procurement for calculated small-for-size A2ALDLT in four donors are presented. The graft-to-recipient body weight ratio was <0.8 in all recipients. The mean portal vein flow and the pressure and hepatic artery flows were measured at 190 ± 56 mL/min/100 g, 13 ± 1.4 mm/Hg and 109 ± 19 mL/min, respectively. No early postoperative donor complications were recorded. One graft was lost due to intrahepatic abscesses. Asymptomatic stenosis of a right posterior duct was treated with a Roux-en-Y loop 4 months later in one donor. We show that LDH of the full-left lobe is feasible. LDH is a very demanding operation, potentially decreasing donor morbidity. Standardization of this procedure, making it accessible to the growing number of experienced laparoscopic liver surgeons, could help renewing the interest for A2ALDLT in the Western world.