Third Forum on Liver Transplantation Living donor liver transplantation. Who needs it? How to do it? Who should do it?
Article Outline
Although living donor liver transplantation (LDLT) currently accounts for less than 6% of all types of liver transplantation in western countries, and considering that many of the expected hypes did not occur (1), the interest among the medical community, the public, and health care policy makers for this procedure has been surpassed only by a few other conditions over the past decade. This is well illustrated by the dramatic increase in publications (Fig. 1), which rose 7-fold between 1997 and 2003, while publications dealing with other topics of liver transplantation rose only by 17%. The explanation for this enthusiasm lies on the rising need to find alternative strategies to prevent death or dropout on the waiting list, the combined medical, psychological and ethical challenges to inflict major surgery upon a healthy patient, and the necessity to rationalize and concentrate high cost medicine in most health care systems. Two overviews of LDLT was also included in the first forum ‘liver transplantation: where do we stand?’ [1], [2] and discussed in the second forum as a treatment for hepatitis C cirrhosis [3].
Fig. 1.
Number of publications in MEDLINE referred to living related liver transplantation since the first reported case. Period 1989–2004.
In this third Forum on Liver Transplantation Drs HP Tan, K Patel-Tom and A Marcos define the ideal donor and recipient profiles, and propose guidelines to secure donor safety and optimize outcome of the recipient. As in other demanding procedures, development and results are strongly tied to institutional support as well as commitment and experience of the medical team. In this perspective, Drs CL Liu, CM Lo and ST Fan address critical technical issues, which are currently highly debated among transplant surgeons. Whether the mid hepatic vein should be included in the right hemiliver graft as they proposed or kept in the remnant left hemiliver in the donor as used by many others remains unresolved, but all surgeons would agree about the need to provide adequate venous drainage for the right anterior sector to ensure optimal early graft function. They also convincingly make the case that, when feasible, duct-to-duct biliary reconstruction should become the preferred technique for the biliary reconstruction. Biliary complications have remained the ‘Achilles heel’ of LDLT associated with significant early and late morbidity, mortality and cost. S Todo, H Furukawa and T Kamiyama look at how to prevent and manage biliary complications after living donation. They provide comprehensive information on risk factors and how to approach this often frustrating problem. Interestingly, they also present data about biliary complications in the donor. While these two latter papers may appear too technical, such information is paramount for all to understand and better treat these patients.
New ‘high tech’ procedures with associated complex ethical issues, as best illustrated by LDLT, unavoidably must go through the scrutinizing eye of the public and health policy makers. M Sagmeister and B Mullhaupt convincingly demonstrate that LDLT is not only life saving but indeed highly cost effective, if offered appropriately. This is particularly true for patients with hepatocellular carcinoma, if the waiting time for cadaveric organs is long leading to dropout from the waiting list. On the same token, considering the need to have LDLT available in most countries, the obvious question arises: where should LDLT be done? and who should do it? In the last paper, we would dare that only qualified centers and surgeons should be permitted to perform LDLT when mortality or drop out on the waiting lists exceed 10%, and that both institutional and peer reviewed oversights of all programs should be mandatory.
We began with forum # 2 to include letters from the previous forum. We hope the current forum on LDLT will trigger comments that may be published at the end of the next forum.
References
- . Living donor liver transplantation: is the hype over?. J Hepatol. 2005;42:20–25
- Tanaka K, Yamada T. Living donor liver transplantation in Japan and Kyoto University: what can we learn? J Hepatol 2005;42:25–28.
- . Should living donor liver transplantation be offered to patients with hepatitis C virus cirrhosis. J Hepatol. 2005;42:472–475
PII: S0168-8278(05)00289-8
doi:10.1016/j.jhep.2005.05.001
© 2005 Published by Elsevier Inc.
