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Increased risk for living liver donors after extended right lobectomy
Increased Risk for Living Liver Donors After Extended Right Lobectomy C.M. Lo, S.T. Fan, C.L. Liu, B.H. Yong, J.K. Chan, and J. Wong
T
HE SAFETY of the donor in living-donor transplantation (LDLT) using a left lateral segment or left lobe graft has been documented.1 Although the use of an extended right lobe graft2 extends the limit on the size of the adult recipient and overcomes the restriction imposed by the donor-to-recipient size match, the extra risk for the donor is the issue of major concern. The aim of the present study is to compare the risk of an extended right lobectomy to that of left lateral segmentectomy or left lobectomy for a living donor. PATIENTS AND METHODS The records of donors in 30 LDLTs using 11 left lateral segments, 6 full left lobes, and 13 extended right lobe grafts were retrospectively reviewed. The donors included 8 spouses, 7 fathers, 7 mothers, 3 brothers, 2 sisters, 1 daughter, 1 uncle, and 1 nephew, with a mean age of 36 years (range, 18 to 51 years). A cell saver, intraoperative ultrasonography, and cholangiography were used during the donor operation, and hepatic transection was performed with an ultrasonic dissector without vascular inflow or outflow occlusion. The operative data and outcome of donors of extended right lobe grafts (group R) were compared to those of left lateral segment or left lobe grafts (group L). The donor’s standard liver weight (SLW) was calculated according to the Urata’s formula,3 and the graft fraction was defined as the actual graft weight divided by the donor’s SLW. Continuous variables were expressed as median (range) and compared using the Mann-Whitney U test. Categoric variables were compared using Fisher exact test, and a P , .05 was considered significant.
RESULTS
The median graft weight was 710 g (490 to 1140 g) for group R and 343 g (185 to 623 g) for group L (P , .001). Although the graft fraction was much larger in group R (65%) than in group L (27%, P , .001), there was no significant difference in the operative blood loss (900 mL vs 750 mL; P 5 NS). Only one donor of group R with preoperative anemia required one unit of homologous blood transfusion. The operative time, however, was significantly longer in group R (780 minutes vs 633 minutes; P , .01). In the postoperative period, the lowest hemoglobin level and the peak serum aspartate aminotransferase levels were similar (Table 1). Patients of group R, however, had more significant transient liver dysfunction as reflected by a higher peak serum © 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Table 1. Comparison of the Outcome of 30 Living Donors Group L (n 5 17)
Group R (n 5 13)
Resume normal diet (day) 3 (2– 6) 3 (2– 6) Lowest hemoglobin (g/dL) 10.5 (7.8 –13.5) 9.7 (7.1–12.9) Peak AST (IU/L) 252 (82–967) 188 (91– 459) Peak prothrombin time (sec) 14.5 (11.7–17.3) 18.7 (16.5–23.2)* Peak serum total bilirubin (mmol/L) 31 (12–50) 45 (27–203)* Postoperative complications 1 (6%) 3 (23%) Hospital stay (day) 8 (5–23) 16 (6 –38)# Values are expressed as median (range). AST, aspartate aminotransferase. *P , .001. # P , .05.
total bilirubin level and prothrombin time. Postoperative complications developed in three (23%) donors of group R (cholestasis, two; bile duct stricture, one; incisional hernia, one) and one (6%) of group L (pulmonary collapse). The median hospital stay was 16 days for group R and 8 days for group L (P , .05). All donors were alive with normal liver function at a median follow up of 25 months (2 to 59 months), and all had returned to their previous level of activities. DISCUSSION
Harvesting an extended right lobe graft involves a more extensive resection of nearly two thirds of the liver, as compared with a quarter to one-third for a left lateral segment or left lobe graft. Despite successful measures to minimize blood loss and transfusion requirement for the donor, an extended right lobectomy is associated with an increased risk of transient postoperative liver dysfunction, a prolonged hospital stay, and possibly increased morbidity. While technical refinement may prevent the development of surgical complications, removal of two thirds of the liver From the Departments of Surgery (C.M.L., S.T.F., C.L.L., J.W.), Anesthesiology (B.H.Y.), and Diagnostic Radiology (J.K.C.), The University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, China. Address reprint requests to Dr C.M. Lo, Department of Surgery, the University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, China. 0041-1345/99/$–see front matter PII S0041-1345(98)01541-3 533
Transplantation Proceedings, 31, 533–534 (1999)
534
puts the donor at a higher risk inherent with a small liver remnant. At least one donor mortality has been reported in left lobe LDLT,4 and the risk of mortality in an extended right lobectomy is estimated at 1% to 2%.2 The risk of the donor operation can only be justified in countries where cadaveric grafts are not readily available, and the procedure should only be attempted in transplant centers with extensive experience in hepatic resection.
LO, FAN, LIU ET AL
REFERENCES 1. Yamaoka Y, Morimoto T, Inamoto T, et al: Transplantation 59:224, 1995 2. Lo CM, Fan ST, Liu CL, et al: Ann Surg 226:261, 1997 3. Urata K, Kawasaki S, Matsunami H, et al: Hepatology 21:1317, 1995 4. Malago M, Rogiers X, Burdelski M, et al: Transplant Proc 26:3620, 1994
T
HE SAFETY of the donor in living-donor transplantation (LDLT) using a left lateral segment or left lobe graft has been documented.1 Although the use of an extended right lobe graft2 extends the limit on the size of the adult recipient and overcomes the restriction imposed by the donor-to-recipient size match, the extra risk for the donor is the issue of major concern. The aim of the present study is to compare the risk of an extended right lobectomy to that of left lateral segmentectomy or left lobectomy for a living donor. PATIENTS AND METHODS The records of donors in 30 LDLTs using 11 left lateral segments, 6 full left lobes, and 13 extended right lobe grafts were retrospectively reviewed. The donors included 8 spouses, 7 fathers, 7 mothers, 3 brothers, 2 sisters, 1 daughter, 1 uncle, and 1 nephew, with a mean age of 36 years (range, 18 to 51 years). A cell saver, intraoperative ultrasonography, and cholangiography were used during the donor operation, and hepatic transection was performed with an ultrasonic dissector without vascular inflow or outflow occlusion. The operative data and outcome of donors of extended right lobe grafts (group R) were compared to those of left lateral segment or left lobe grafts (group L). The donor’s standard liver weight (SLW) was calculated according to the Urata’s formula,3 and the graft fraction was defined as the actual graft weight divided by the donor’s SLW. Continuous variables were expressed as median (range) and compared using the Mann-Whitney U test. Categoric variables were compared using Fisher exact test, and a P , .05 was considered significant.
RESULTS
The median graft weight was 710 g (490 to 1140 g) for group R and 343 g (185 to 623 g) for group L (P , .001). Although the graft fraction was much larger in group R (65%) than in group L (27%, P , .001), there was no significant difference in the operative blood loss (900 mL vs 750 mL; P 5 NS). Only one donor of group R with preoperative anemia required one unit of homologous blood transfusion. The operative time, however, was significantly longer in group R (780 minutes vs 633 minutes; P , .01). In the postoperative period, the lowest hemoglobin level and the peak serum aspartate aminotransferase levels were similar (Table 1). Patients of group R, however, had more significant transient liver dysfunction as reflected by a higher peak serum © 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Table 1. Comparison of the Outcome of 30 Living Donors Group L (n 5 17)
Group R (n 5 13)
Resume normal diet (day) 3 (2– 6) 3 (2– 6) Lowest hemoglobin (g/dL) 10.5 (7.8 –13.5) 9.7 (7.1–12.9) Peak AST (IU/L) 252 (82–967) 188 (91– 459) Peak prothrombin time (sec) 14.5 (11.7–17.3) 18.7 (16.5–23.2)* Peak serum total bilirubin (mmol/L) 31 (12–50) 45 (27–203)* Postoperative complications 1 (6%) 3 (23%) Hospital stay (day) 8 (5–23) 16 (6 –38)# Values are expressed as median (range). AST, aspartate aminotransferase. *P , .001. # P , .05.
total bilirubin level and prothrombin time. Postoperative complications developed in three (23%) donors of group R (cholestasis, two; bile duct stricture, one; incisional hernia, one) and one (6%) of group L (pulmonary collapse). The median hospital stay was 16 days for group R and 8 days for group L (P , .05). All donors were alive with normal liver function at a median follow up of 25 months (2 to 59 months), and all had returned to their previous level of activities. DISCUSSION
Harvesting an extended right lobe graft involves a more extensive resection of nearly two thirds of the liver, as compared with a quarter to one-third for a left lateral segment or left lobe graft. Despite successful measures to minimize blood loss and transfusion requirement for the donor, an extended right lobectomy is associated with an increased risk of transient postoperative liver dysfunction, a prolonged hospital stay, and possibly increased morbidity. While technical refinement may prevent the development of surgical complications, removal of two thirds of the liver From the Departments of Surgery (C.M.L., S.T.F., C.L.L., J.W.), Anesthesiology (B.H.Y.), and Diagnostic Radiology (J.K.C.), The University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, China. Address reprint requests to Dr C.M. Lo, Department of Surgery, the University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, China. 0041-1345/99/$–see front matter PII S0041-1345(98)01541-3 533
Transplantation Proceedings, 31, 533–534 (1999)
534
puts the donor at a higher risk inherent with a small liver remnant. At least one donor mortality has been reported in left lobe LDLT,4 and the risk of mortality in an extended right lobectomy is estimated at 1% to 2%.2 The risk of the donor operation can only be justified in countries where cadaveric grafts are not readily available, and the procedure should only be attempted in transplant centers with extensive experience in hepatic resection.
LO, FAN, LIU ET AL
REFERENCES 1. Yamaoka Y, Morimoto T, Inamoto T, et al: Transplantation 59:224, 1995 2. Lo CM, Fan ST, Liu CL, et al: Ann Surg 226:261, 1997 3. Urata K, Kawasaki S, Matsunami H, et al: Hepatology 21:1317, 1995 4. Malago M, Rogiers X, Burdelski M, et al: Transplant Proc 26:3620, 1994