World J Surg DOI 10.1007/s00268-014-2479-1
Is It Worth Discussing the Feasibility of Deceased Donor Liver Transplantation in Centers with a Strong Experience in Living Donor Liver Transplantation? Franc¸ois Durand
Ó Socie´te´ Internationale de Chirurgie 2014
Deceased donors are by far the main source of organs for liver transplantation in Western countries where living donor liver transplantation (LDLT) remains marginal. In contrast, living donors remain by far the main source of organs for transplantation in Asian countries, where deceased donor liver transplantation (DDLT) remains marginal. In this issue of World Journal of Surgery, Chu and colleagues from Honk Kong report on the results of low-volume DDLT in a center alongside a strong LDLT service [1]. Based on their series, they show that even if the experience of DDLT is relatively limited in Hong Kong (242 transplantations over an 18-year period), excellent results could be achieved, with 5-year survival rates exceeding 85 %. The results of DDLT in Hong Kong compare favourably with the results reported in North America and Europe. The results of this study are not surprising for transplant surgeons and physicians from Western countries. Indeed, beyond the fact that donor hepatectomy requires particular caution in order to limit morbidity as much as possible [2], transplanting a partial graft procured from a living donor remains technically much more complex than transplanting a whole graft procured from a deceased donor. In the setting of LDLT, anastomoses have to be performed with very small-sized branches of the hepatic artery and portal vein, as well as small-sized bile ducts. The outflow needs to be optimized to guarantee early graft recovery, especially in
F. Durand (&) Service d’He´patologie, Hepatology & Liver Intensive Care, Hospital Beaujon, University Paris VII, 100 Boulevard du General Leclerc, 92110 Clichy, France e-mail: [email protected]
cases of low graft-to-body weight ratio [3]. No such highly complex techniques are needed in most DDLT procedures. Postoperative technical complications of LDLT (especially biliary complications) are more frequent, and their management is generally more complex. Overall, as LDLT is a complex procedure, surgeons with skills in living donation may not be faced with difficulties when performing DDLT, even if they perform the procedure only occasionally. Experience and expertise in LDLT is markedly superior in high-volume Asian centers to that in most Western centers. The study by Chu and colleagues [1] is thus an incentive for Asian centers with a strong experience in LDLT not to abandon DDLT when they are offered this opportunity. Even though excellent results can be achieved with LDLT in Asian countries, this complex option has inherent and unavoidable limitations, including significant donor morbidity [2], a higher rate of difficult-to-treat biliary and vascular complications in the recipient, psychological concerns in donors and recipients, and limited access to re-transplantation if needed. Because of these limitations, the future of liver transplantation in Asian countries could come from DDLT. Again, technical issues may not be a limitation for surgeons experienced at performing LDLT. From a technical viewpoint, no learning curve effect might be expected if Asian centers develop DDLT programs. However, management and selection of deceased donors are complex issues. Indeed, in a context of organ shortage, optimizing the selection of expanded criteria donors, matching donors and recipients, and improving organ preservation and reducing cold ischemia time as much as possible are central issues in DDLT [4]. Overall, centers without any experience in LDLT or with a low-volume LDLT program should not be encouraged to continue with living donation. However, if a DDLT program has to be expanded in a large-volume LDLT center,
123
World J Surg
attention should refocus on the selection and management of donors.
References 1. Chu KK, Chan CC, Sharr WW et al (2013) Low volume deceased donor liver transplantation alongside a strong living donor liver transplantation service. World J Surg 37(3):525–529. doi:10.1007/ s00268-012-1871-y
123
2. Belghiti J, Liddo G, Raut V et al (2012) ‘‘Inherent limitations’’ in donors: control matched study of consequences following a right hepatectomy for living donation and benign liver lesions. Ann Surg 255:528–533 3. Umeda Y, Yagi T, Sadamori H et al (2008) Effects of prophylactic splenic artery modulation on portal overperfusion and liver regeneration in small-for-size graft. Transplantation 86:673–680 4. Durand F, Renz JF, Alkofer B et al (2008) Report of the Paris consensus meeting on expanded criteria donors in liver transplantation. Liver Transpl 14:1694–1707
Is It Worth Discussing the Feasibility of Deceased Donor Liver Transplantation in Centers with a Strong Experience in Living Donor Liver Transplantation? Franc¸ois Durand
Ó Socie´te´ Internationale de Chirurgie 2014
Deceased donors are by far the main source of organs for liver transplantation in Western countries where living donor liver transplantation (LDLT) remains marginal. In contrast, living donors remain by far the main source of organs for transplantation in Asian countries, where deceased donor liver transplantation (DDLT) remains marginal. In this issue of World Journal of Surgery, Chu and colleagues from Honk Kong report on the results of low-volume DDLT in a center alongside a strong LDLT service [1]. Based on their series, they show that even if the experience of DDLT is relatively limited in Hong Kong (242 transplantations over an 18-year period), excellent results could be achieved, with 5-year survival rates exceeding 85 %. The results of DDLT in Hong Kong compare favourably with the results reported in North America and Europe. The results of this study are not surprising for transplant surgeons and physicians from Western countries. Indeed, beyond the fact that donor hepatectomy requires particular caution in order to limit morbidity as much as possible [2], transplanting a partial graft procured from a living donor remains technically much more complex than transplanting a whole graft procured from a deceased donor. In the setting of LDLT, anastomoses have to be performed with very small-sized branches of the hepatic artery and portal vein, as well as small-sized bile ducts. The outflow needs to be optimized to guarantee early graft recovery, especially in
F. Durand (&) Service d’He´patologie, Hepatology & Liver Intensive Care, Hospital Beaujon, University Paris VII, 100 Boulevard du General Leclerc, 92110 Clichy, France e-mail: [email protected]
cases of low graft-to-body weight ratio [3]. No such highly complex techniques are needed in most DDLT procedures. Postoperative technical complications of LDLT (especially biliary complications) are more frequent, and their management is generally more complex. Overall, as LDLT is a complex procedure, surgeons with skills in living donation may not be faced with difficulties when performing DDLT, even if they perform the procedure only occasionally. Experience and expertise in LDLT is markedly superior in high-volume Asian centers to that in most Western centers. The study by Chu and colleagues [1] is thus an incentive for Asian centers with a strong experience in LDLT not to abandon DDLT when they are offered this opportunity. Even though excellent results can be achieved with LDLT in Asian countries, this complex option has inherent and unavoidable limitations, including significant donor morbidity [2], a higher rate of difficult-to-treat biliary and vascular complications in the recipient, psychological concerns in donors and recipients, and limited access to re-transplantation if needed. Because of these limitations, the future of liver transplantation in Asian countries could come from DDLT. Again, technical issues may not be a limitation for surgeons experienced at performing LDLT. From a technical viewpoint, no learning curve effect might be expected if Asian centers develop DDLT programs. However, management and selection of deceased donors are complex issues. Indeed, in a context of organ shortage, optimizing the selection of expanded criteria donors, matching donors and recipients, and improving organ preservation and reducing cold ischemia time as much as possible are central issues in DDLT [4]. Overall, centers without any experience in LDLT or with a low-volume LDLT program should not be encouraged to continue with living donation. However, if a DDLT program has to be expanded in a large-volume LDLT center,
123
World J Surg
attention should refocus on the selection and management of donors.
References 1. Chu KK, Chan CC, Sharr WW et al (2013) Low volume deceased donor liver transplantation alongside a strong living donor liver transplantation service. World J Surg 37(3):525–529. doi:10.1007/ s00268-012-1871-y
123
2. Belghiti J, Liddo G, Raut V et al (2012) ‘‘Inherent limitations’’ in donors: control matched study of consequences following a right hepatectomy for living donation and benign liver lesions. Ann Surg 255:528–533 3. Umeda Y, Yagi T, Sadamori H et al (2008) Effects of prophylactic splenic artery modulation on portal overperfusion and liver regeneration in small-for-size graft. Transplantation 86:673–680 4. Durand F, Renz JF, Alkofer B et al (2008) Report of the Paris consensus meeting on expanded criteria donors in liver transplantation. Liver Transpl 14:1694–1707
