American Journal of Transplantation 2014; 14: 735 Wiley Periodicals Inc.
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Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12612
Letter to the Editor
Laparoscopic Living Donor Left Hepatectomy: Donor Safety Remains the Overriding Concern 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, [email protected]
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References 1. Troisi RI, Wojcicki M, Tomassini F, et al. Pure laparoscopic full-left living donor hepatectomy for calculated small-for-size LDLT in adults: Proof of concept. Am J Transplant 2013; 13: 2472–2478. 2. Pomfret EA, Lodge JPA, Villamil FG, Siegler M. Should we use living donor grafts for patients with hepatocellular carcinoma? Ethical considerations. Liver Transpl 2011; 17: S128–S132. 3. Ishizaki Y, Kawasaki S, Sugo H, Yoshimoto J, Fujiwara N, Imamura H. Left lobe adult-to-adult living donor liver transplantation: Should portal inflow modulation be added? Liver Transpl 2012; 18: 305– 314. 4. Kaido T, Mori A, Ogura Y, et al. Lower limit of the graft-to-recipient weight ratio can be safely reduced to 0.6% in adult-to-adult living donor liver transplantation in combination with portal pressure control. Transplant Proc 2011; 43: 2391–2393. 5. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205– 213.
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Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12612
Letter to the Editor
Laparoscopic Living Donor Left Hepatectomy: Donor Safety Remains the Overriding Concern 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, [email protected]
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References 1. Troisi RI, Wojcicki M, Tomassini F, et al. Pure laparoscopic full-left living donor hepatectomy for calculated small-for-size LDLT in adults: Proof of concept. Am J Transplant 2013; 13: 2472–2478. 2. Pomfret EA, Lodge JPA, Villamil FG, Siegler M. Should we use living donor grafts for patients with hepatocellular carcinoma? Ethical considerations. Liver Transpl 2011; 17: S128–S132. 3. Ishizaki Y, Kawasaki S, Sugo H, Yoshimoto J, Fujiwara N, Imamura H. Left lobe adult-to-adult living donor liver transplantation: Should portal inflow modulation be added? Liver Transpl 2012; 18: 305– 314. 4. Kaido T, Mori A, Ogura Y, et al. Lower limit of the graft-to-recipient weight ratio can be safely reduced to 0.6% in adult-to-adult living donor liver transplantation in combination with portal pressure control. Transplant Proc 2011; 43: 2391–2393. 5. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205– 213.
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