The Unreachable Goal in Living-Donor Hepatectomy (2012)

Thank you for your interest in our article titled “Donor Morbidity including Biliary Complications in Living-Donor Liver Transplantation: A Single-Center Analysis of 827 Cases” in the latest issue of Transplantation. We would like to first congratulate you on the improvements your team has achieved on live liver donor morbidity during the past 4½ years. Nevertheless, we would like to address some points concerning your data and express our thoughts about it. Your report revealed that the number of complications was reduced over time, from 31.8% in the first stage to 18.8% in the second stage, which is an enormous improvement. The Adult-to-Adult Living Donor Liver Transplant (A2ALL) consortium suggested that the learning curve for living-donor liver transplantation is 20 procedures (1), and accordingly, we estimate that you have already achieved the learning curve in the first stage, and the result of the latter stage are the results after reaching it. The complication rate which you have described to be “better” (18.8%) was still higher than the period with the highest complication rate (13%) from our series, and as reported in our article, we estimate that the overall donor morbidity is unlikely to reduce below our series’ data, emphasizing the importance of sharing these results with the donor before they undertake the operation. We totally agree to your conclusion that improvement in surgical techniques will definitely reduce the morbidity of the donor, but we would like to cautiously say that, “no matter what we do,” there will be a minimal complication rate that will not be possible to ameliorate. Your potential explanation was that decreased donor morbidity was strongly correlated with the center’s improving experience and the advent of new techniques such as laparoscopic-assisted donor hepatectomy and upper midline incision. We often exploit various commercial equipments for hemostasis, preventing bile leakage, and relieving pain and we have been using the mini-incision method including an upper midline incision since March 2009. We have found that the donors complain of less pain and express a higher level of satisfaction with these techniques. However, there are limitations to using the upper midline incision in all cases. Our preference is to use an upper midline incision extending to a point approximately 5 cm above the umbilicus, and if a mini-incision does not provide adequate operative exposure to assure the lowest morbidity, then a rightward horizontal extension to the midclavicle line is added without hesitation. In a recent series of nearly 150 graft resections performed at our center, however, this extended incision proved necessary in only 7% of donors. The guiding principle of all living-donor transplantations should be the minimization of morbidity to the donor. What procedures to apply and what method of resection to use lie on the decision of the surgical team, and it is their responsibility to offer the donor the best result from what resources they have available within their team. New techniques and ideas may reduce donor complications and improve patient satisfaction, but even with the implementation of these state-of-the-art techniques, the donor complications of a certain degree will still exist, and the number of complications cannot be zero. The main issue is not whether one is good at donor hepatectomy or not. No inexperienced surgeon should undertake donor hepatectomy, and all surgeons in charge should be experienced and be good at it. The main issue lies in whether these “unpreventable risks” have been thoroughly explained to the donors, and written informed consent should be obtained before undergoing surgery even in experienced hands. Milljae Shin Choon Hyuck David Kwon Sung-Joo Kim Suk-Koo Lee Jae-Won Joh Department of Surgery Samsung Medical Center Sungkyunkwan University School of Medicine Seoul, Korea