World J Surg (2014) 38:1560–1561 DOI 10.1007/s00268-013-2297-x
Laparoscopy-Assisted Hybrid Left-side Donor Hepatectomy: Is it Truly Less Invasive for Living Donors? Takeaki Ishizawa • Kiyoshi Hasegawa Norihiro Kokudo
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Published online: 19 October 2013 Ó Socie´te´ Internationale de Chirurgie 2013
To the Editor, We read with great interest the article by Marubashi et al. [1] evaluating the efficacy of laparoscopy-assisted hybrid donor hepatectomy (LADH) in procuring left-side liver grafts. We agree that the hybrid technique can improve postoperative quality of life (QOL) in patients with hepatobiliary diseases. In donor hepatectomy, however, the efficacy of the laparoscopic approach should prioritize the safety of living donors. Marubashi et al. [1] compared the short-term outcomes of LADH from 31 donors of left-side liver grafts with the outcomes of a historical control group of 79 individuals who underwent open donor hepatectomy (ODH). Statistical analyses revealed that the length of the midline incision was significantly shorter and the operative time significantly longer in the LADH group. Although postoperative hospital stay was also significantly shorter in the LADH group, this may have largely been affected by the periodical difference in postoperative management strategies in the LADH group (2009–2012) and in the ODH group (before 2009).The authors stated that LADH enabled faster physical recovery; however, this was based on healthrelated QOL questionnaires administered to the LADH group alone. Postoperative requirements for pain medication did not differ in the two groups. Thus, careful interpretation of the operative outcomes would lead to the conclusion that LADH effectively shortened the incision but extended operative time for procurement of left-side liver grafts.
T. Ishizawa K. Hasegawa N. Kokudo (&) Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan e-mail: [email protected]
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More important, two donors suffered incidental injuries to the diaphragm or the right hepatic vein during laparoscopic mobilization of the right liver. As mentioned by the authors, the most important issue in living donor liver transplantation is donor safety. A recent worldwide survey [2] revealed that the donor mortality rate was 0.20 % (23/ 11,553), with 19 of these 23 deaths related to the donation surgery. In addition, potentially life-threatening near-miss events have been reported, with an incidence not less than 1.1 %, even in ODH. Considering that living donor hepatectomy is peculiar in that healthy humans are exposed to the risk of death, surgeons should not underestimate nearmiss events during laparoscopic procedures that never occur during open hepatectomy. The Louisville statement (2008) acknowledged that donor hepatectomy is the most controversial application of laparoscopic surgery [3]. More recently, Lin et al. [4] reviewed surgical outcomes of laparoscopic living donor hepatectomy and concluded that ‘‘the laparoscopy-assisted method is a safe, minimally invasive procedure for a living-donor right hepatectomy,’’ but this was based on only five case series involving a total of 87 donors. In contrast, one of the authors of this letter (N. K.) has performed more than 380 open donor hepatectomies since 2001, and still regards this procedure as neither easy nor perfectly safe. Again, we believe that laparoscopic surgery will improve the postoperative QOL of living donors [5] in the future. However, surgeons should not use a laparoscopic approach for donor hepatectomy if it may increase the risk of operative mortality even minimally, say from 0.20 to 0.21 %, because it has a deleterious impact on ‘‘the healthy living donor’’! We are deeply concerned that laparoscopic surgery has been too rapidly extended to living liver donor candidates without sufficient concerns for donor safety or proper informed consent.
World J Surg (2014) 38:1560–1561 Acknowledgments This work was supported by grants from the Takeda Science Foundation and the Ministry of Education, Culture, Sports, Science and Technology of Japan.
References 1. Marubashi S, Wada H, Kawamoto K et al (2013) Laparoscopyassisted hybrid left-side donor hepatectomy. World J Surg 37:2202–2210. doi:10.1007/s00268-013-2117-3 2. Cheah YL, Simpson MA, Pomposelli JJ et al (2013) Incidence of death and potentially life-threatening near-miss events in living
1561 donor hepatic lobectomy: a world-wide survey. Liver Transpl 19:499–506. doi:10.1002/lt.23575 3. Buell JF, Cherqui D, Geller DA, World Consensus Conference on Laparoscopic Surgery et al (2009) The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 250:825–830 4. Lin NC, Nitta H, Wakabayashi G (2013) Laparoscopic major hepatectomy: a systematic literature review and comparison of 3 techniques. Ann Surg 257:205–213 5. Togashi J, Sugawara Y, Tamura S et al (2011) Donor quality of life after living donor liver transplantation: a prospective study. J Hepatobiliary Pancreat Sci 18:263–267. doi:10.1007/s00534010-0340-y
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Laparoscopy-Assisted Hybrid Left-side Donor Hepatectomy: Is it Truly Less Invasive for Living Donors? Takeaki Ishizawa • Kiyoshi Hasegawa Norihiro Kokudo
•
Published online: 19 October 2013 Ó Socie´te´ Internationale de Chirurgie 2013
To the Editor, We read with great interest the article by Marubashi et al. [1] evaluating the efficacy of laparoscopy-assisted hybrid donor hepatectomy (LADH) in procuring left-side liver grafts. We agree that the hybrid technique can improve postoperative quality of life (QOL) in patients with hepatobiliary diseases. In donor hepatectomy, however, the efficacy of the laparoscopic approach should prioritize the safety of living donors. Marubashi et al. [1] compared the short-term outcomes of LADH from 31 donors of left-side liver grafts with the outcomes of a historical control group of 79 individuals who underwent open donor hepatectomy (ODH). Statistical analyses revealed that the length of the midline incision was significantly shorter and the operative time significantly longer in the LADH group. Although postoperative hospital stay was also significantly shorter in the LADH group, this may have largely been affected by the periodical difference in postoperative management strategies in the LADH group (2009–2012) and in the ODH group (before 2009).The authors stated that LADH enabled faster physical recovery; however, this was based on healthrelated QOL questionnaires administered to the LADH group alone. Postoperative requirements for pain medication did not differ in the two groups. Thus, careful interpretation of the operative outcomes would lead to the conclusion that LADH effectively shortened the incision but extended operative time for procurement of left-side liver grafts.
T. Ishizawa K. Hasegawa N. Kokudo (&) Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan e-mail: [email protected]
123
More important, two donors suffered incidental injuries to the diaphragm or the right hepatic vein during laparoscopic mobilization of the right liver. As mentioned by the authors, the most important issue in living donor liver transplantation is donor safety. A recent worldwide survey [2] revealed that the donor mortality rate was 0.20 % (23/ 11,553), with 19 of these 23 deaths related to the donation surgery. In addition, potentially life-threatening near-miss events have been reported, with an incidence not less than 1.1 %, even in ODH. Considering that living donor hepatectomy is peculiar in that healthy humans are exposed to the risk of death, surgeons should not underestimate nearmiss events during laparoscopic procedures that never occur during open hepatectomy. The Louisville statement (2008) acknowledged that donor hepatectomy is the most controversial application of laparoscopic surgery [3]. More recently, Lin et al. [4] reviewed surgical outcomes of laparoscopic living donor hepatectomy and concluded that ‘‘the laparoscopy-assisted method is a safe, minimally invasive procedure for a living-donor right hepatectomy,’’ but this was based on only five case series involving a total of 87 donors. In contrast, one of the authors of this letter (N. K.) has performed more than 380 open donor hepatectomies since 2001, and still regards this procedure as neither easy nor perfectly safe. Again, we believe that laparoscopic surgery will improve the postoperative QOL of living donors [5] in the future. However, surgeons should not use a laparoscopic approach for donor hepatectomy if it may increase the risk of operative mortality even minimally, say from 0.20 to 0.21 %, because it has a deleterious impact on ‘‘the healthy living donor’’! We are deeply concerned that laparoscopic surgery has been too rapidly extended to living liver donor candidates without sufficient concerns for donor safety or proper informed consent.
World J Surg (2014) 38:1560–1561 Acknowledgments This work was supported by grants from the Takeda Science Foundation and the Ministry of Education, Culture, Sports, Science and Technology of Japan.
References 1. Marubashi S, Wada H, Kawamoto K et al (2013) Laparoscopyassisted hybrid left-side donor hepatectomy. World J Surg 37:2202–2210. doi:10.1007/s00268-013-2117-3 2. Cheah YL, Simpson MA, Pomposelli JJ et al (2013) Incidence of death and potentially life-threatening near-miss events in living
1561 donor hepatic lobectomy: a world-wide survey. Liver Transpl 19:499–506. doi:10.1002/lt.23575 3. Buell JF, Cherqui D, Geller DA, World Consensus Conference on Laparoscopic Surgery et al (2009) The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 250:825–830 4. Lin NC, Nitta H, Wakabayashi G (2013) Laparoscopic major hepatectomy: a systematic literature review and comparison of 3 techniques. Ann Surg 257:205–213 5. Togashi J, Sugawara Y, Tamura S et al (2011) Donor quality of life after living donor liver transplantation: a prospective study. J Hepatobiliary Pancreat Sci 18:263–267. doi:10.1007/s00534010-0340-y
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