Editorial

Left Versus Right Lobe Liver Donation

G. R. Roll and J. P. Roberts*
Division of Transplant, Department of Surgery,
University of California, San Francisco, CA

Corresponding author: John Paul Roberts,

john.roberts@ucsfmedctr.org
Received and revised 04 October 2013, accepted for
publication 22 October 2013
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) complica-
tion rates decreased from 15%in Era I to 5% in Era III. This
rate of complications for RHin Era III was not different from
the rates for LH, and this was the major nding 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 RHin adults (LHmade up only 2.2%of donors in
the rst (2) and 2.8%in the second (4)). Surgeon preference
for RHmakes these data difcult 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). Complica-
tion rates were 8.7%for 1088 LL versus 9.7%for 1378 RL.
This study is difcult 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 eld is that
LH is safer than RH.
We would like to offer some insight about why the ndings
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 nding is difcult to
reconcile with other large-scale reports from authors
describing donor complications where gastric outlet
obstruction makes up 00.7% of complications (68).
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
signicant 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 LHcompared 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).
American Journal of Transplantation 2014; 14: 251252
Wiley Periodicals Inc.
C
Copyright 2013 The American Society of Transplantation
and the American Society of Transplant Surgeons
doi: 10.1111/ajt.12556
251
The authors conclude by stating, Although the safety of
RHwas conrmed by the current study, we will continue to
advocate the use of LH grafts whenever possible for the
sake of donor safety. We agree.
Disclosure
The authors of this manuscript have no conicts of interest
to disclose as described by the American Journal of
Transplantation.
References
1. Uchiyama H, Shirabe K, Nakagawara H, et al. Revisiting the safety of
living liver donors by reassessing 441 donor hepatectomies: Is a
larger hepatectomy complication-prone? Am J Transplant 2014; 14:
367374.
2. Roll GR, Parekh JR, Parker WF, et al. Left hepatectomy versus
right hepatectomy for living donor liver transplantation: Shifting
the risk from the donor to the recipient. Liver Transpl 2013; 19:
472481.
3. Shin M, Song S, Kim JM, et al. Donor morbidity including biliary
complications in living-donor liver transplantation: Single-center
analysis of 827 cases. Transplantation 2012; 93: 942948.
4. Ozgor D, Dirican A, Ates M, Go nu ltas F, Ara C, Yilmaz S. Donor
complications among 500 living donor liver transplantations at a
single center. Transplant Proc 2012; 44: 16041607.
5. Hashikura Y, Ichida T, Umeshita K, et al for Japanese Liver
Transplantation Society. Donor complications associated with
living donor liver transplantation in Japan. Transplantation 2009;
88: 110114.
6. Lo C. Complications and long-term outcome of living liver donors:
A survey of 1,508 cases in ve Asian centers. Transplantation 2003;
75 (3 Suppl): S12S15.
7. Usta S, Ates M, Dirican A, Isik B, Yilmaz S. Outcomes of left-lobe
donor hepatectomy for living-donor liver transplantation: A single-
center experience. Transplant Proc 2013; 45: 961965.
8. Abecassis MM, Fisher RA, Olthoff KM, et al. Complications of
living donor hepatic lobectomyA comprehensive report. Am J
Transplant 2012; 12: 12081217.
Roll and Roberts
252 American Journal of Transplantation 2014; 14: 251252