Correspondence
Transplantation of the Right Hepatic Lobe
N Engl J Med 2002; 347:615-618August 22, 2002
- Article
To the Editor:
We appreciate the valuable article by Trotter et al. (April 4 issue)1 on living-donor liver transplantation, but we believe that it underestimates the psychosocial evaluation of donors and conveys an unduly narrow understanding of altruism. The decision to donate emerges from an interplay of developmental and sociocultural factors. Potential donors contemplate an act that is entirely altruistic in terms of their own physiologic health. They are supported or buffeted by diverse interpersonal dynamics; they have unique psychological strengths and burdens, unique personality styles, and unique understandings of their roles vis-à-vis their fellow human beings.2 We are skeptical that this profound and intricate psychosocial complex can be evaluated through a telephone conversation.
At our center, outcomes in donors indicate clearly that serious complications can result from inadequate psychosocial assessment. We therefore require that a psychiatrist and a social worker see each prospective donor independently; their respective assessments sometimes extend over several appointments. We feel strongly that a nuanced understanding of a donor's motivations and risks can be attained only through such intensive evaluation.
Furthermore, we disagree that donor acceptability must be predicated on a “long-term, significant relationship with the recipient.” Altruistic motivations do transcend — however rarely — the limits of personal relationships. As we discuss elsewhere,3 privileging an altruism that is based on genetic or emotional proximity risks devaluing one that is based on broader, humanitarian foundations. It is not self-evident that an inclusive, universal altruism is psychologically pathologic, simply because it is unusual. Many religions, for example, extol such altruism as the very ideal of generosity. Again, the issue is complicated and demands thorough, individualized assessment.
3 ReferencesDavid J. Dixon, M.D.
Susan E. Abbey, M.D.
University Health Network, Toronto, ON M5G 2C4, Canada1
Trotter JF ,Wachs M ,Everson GT ,Kam I . Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 2002;346:1074-1082
Full Text | Web of Science | Medline2
Olbrisch ME ,Benedict SM ,Haller DL ,Levenson JL . Psychosocial assessment of living organ donors: clinical and ethical considerations. Prog Transplant 2001;11:40-49
Medline3
Dixon DJ ,Abbey SE . Religious altruism and organ donation. Psychosomatics 2000;41:407-411
CrossRef | Web of Science | Medline
To the Editor:
The review article by Trotter et al. is timely and thorough. However, there is one factual error. The first successful adult-to-adult transplantation of a right hepatic lobe from a living donor was reported by us,1 not by Yamaoka et al.2 The patient treated by Yamaoka et al. was a nine-year-old child. Contrary to the view of Trotter et al. that living-donor liver transplantation has a limited role in the treatment of patients with acute liver failure, we found that this procedure is most valuable in patients who have acute liver failure or cirrhosis with acute deterioration.3
Some centers have reported that the results of living-donor liver transplantation in patients whose United Network for Organ Sharing (UNOS) status is 1 or 2A have not been satisfactory. We believe the reason is that the surgeons chose to use right-lobe grafts without the middle hepatic vein — a type of graft that is suboptimal in function and that cannot meet the metabolic demands of critically ill patients. To improve the results, more attention should be paid to improving the venous drainage of the right-lobe graft rather than to increasing the graft volume.
3 ReferencesSheung-Tat Fan, M.D.
Chung-Mau Lo, M.S.
Chi-Leung Liu, M.S.
University of Hong Kong Medical Centre, Hong Kong, China
hrmsfst@hkucc.hku. hk 1
Lo CM ,Fan ST ,Liu CL , et al. Adult-to-adult living donor liver transplantation using extended right lobe grafts. Ann Surg 1997;226:261-269
CrossRef | Web of Science | Medline2
Yamaoka Y ,Washida M ,Honda K , et al. Liver transplantation using a right lobe graft from a living related donor. Transplantation 1994;57:1127-1130
CrossRef | Web of Science | Medline3
Liu CL ,Fan ST ,Lo CM ,Yong BH ,Fung ASM ,Wong J . Right-lobe live donor liver transplantation improves survival of patients with acute liver failure. Br J Surg 2002;89:317-322
CrossRef | Web of Science | Medline
To the Editor:
Techniques for adult-to-adult living-donor liver transplantation have not been standardized, but we wish to point out our observations regarding the illustrations and the text concerning the operation in the article by Trotter et al. First, although the techniques used for all three of the major vascular reconstructions are critical, the establishment of unrestricted venous outflow is paramount. We perform right-hepatic-vein cavoplasty, anastomosis of all posterior hepatic veins larger than 5 mm, and reconstruction of the venous drainage of segment 8 if its major venous outflow crosses the plane of parenchymal transection into the middle hepatic vein, together with the extensive use of fine, interrupted sutures. Figure 5 in the article depicts a vessel identified as the middle hepatic vein. This vessel might more correctly be identified as a segmental tributary of the middle hepatic vein. In our program, the true middle hepatic vein, identified intraoperatively by ultrasonography, is never divided and always remains with the left lobe. Our plane of parenchymal transection is always to the right of it — which brings us to our second observation regarding Figure 5. The plane of parenchymal transection depicted in the illustration is midway between a true right lobectomy and a right trisegmentectomy and goes right through liver segment 4. Again, it is our practice to ensure that all of segment 4 remains with the donor. We suspect that the authors present these illustrations as general representations rather than exact depictions of operative details, and we hope that others interpret them as such.
Christopher R. Shackleton, M.D.
Steven D. Colquhoun, M.D.
John M. Vierling, M.D.
Cedars–Sinai Medical Center, Los Angeles, CA 90048
shackletonc@cshs.org To the Editor:
The article by Trotter et al. on living-donor liver transplantation and the Perspective by Surman on the ethics of this practice1 raise important issues concerning the complications donors have suffered, including death in two cases. Their discussion raises a fundamental question: Is it morally acceptable to remove organs from living donors?
The fundamental goal of medicine is to help a sick person in need, from which stems the principle of nonmaleficence: “First, do no harm.” Removing an organ or a portion of an organ from a healthy person harms that person by subjecting him or her to anesthetic, surgical, and postsurgical risks. The altruism of the donor does not change this. It is one thing for a soldier to jump on a grenade thrown by an enemy to save his or her fellow soldiers; it is quite another for a person to donate a healthy organ. In the former case, an enemy is harming the soldier; in the latter, a physician is harming the patient, even if the harm is at the patient's request, and even if the transplanted organ helps someone else. Public support for organ donation from living donors does not change this fact, nor does the popularity of a practice imply its moral rightness. Because the removal of organs from a living person does not benefit that person, but actually harms him or her, it violates the fundamental end of medicine to do no harm.
1 ReferencesMichael Potts, Ph.D.
Methodist College, Fayetteville, NC 28311-1420
mpotts20@hotmail.com 1
Surman OS . The ethics of partial-liver donation. N Engl J Med 2002;346:1038-1038
Full Text | Web of Science | Medline
To the Editor:
Surman suggests that the risks of donation of the right hepatic lobe are unknown. Although donor experience is limited, the risk of death and other complications in association with right lobectomy should be familiar to the experienced surgeon. Right lobectomy has been performed in many cases for years, and late complications are exceedingly rare.
Surman asserts that transplantation of the right lobe of the liver began without discussion in the medical community. As the surgeon who performed the first such transplantation in the United States, I recall the detailed discussion that occurred before the first procedure. The ethical issues involved in living-donor liver transplantation in children were laid out. Following the model of the University of Chicago, my colleagues and I developed a program of adult-to-adult liver transplantation. The principles followed included assignment of an independent physician who served as a donor advocate, a multistep informed-consent process, exclusion of emergency transplantations, and inclusion only of recipients who were qualified to receive a cadaveric transplant. Each donor was informed of the experiences of previous donors and recipients. The safety of the donor was the paramount concern.
Although right lobectomy for transplantation is risky, it is not qualitatively different from kidney donation or left-lobe liver donation. We are a society that highly values autonomy. How can we decide how much risk is acceptable to one who freely chooses risk in order to save another person? Our role in transplantation is to inform donors of the risks involved. We should not set an arbitrary standard of risk beyond which no one may be permitted to step.
Todd K. Howard, M.D.
Suburban Surgical Associates, St. Louis, MO 63131
tkh@ssainc.net To the Editor:
Although the medical and psychiatric well-being of the donor is of paramount importance in the ethics of living-donor liver transplantation, so is an accurate portrayal of the medical risk, which we believe is overestimated by Surman. He reports seven deaths among all partial-liver donors in the United States and concludes that the incidence of death among right-lobe donors is “1 percent or more.” To date, three donors have died during the course of approximately 1000 living-donor liver transplantations performed in the United States and recorded by UNOS. One donor died after providing a left lateral segment to a child, and two donors died after right-lobe donation to adults. Thus, the mortality rate among all partial-liver donors in the United States is approximately 0.3 percent, a rate similar to that reported worldwide and noted by Trotter et al. Unfortunately, the erroneous data presented by Surman are now being widely quoted as fact both in print and by the broadcast media and may have a deleterious effect on organ donation in general.
Many centers are considering initiating programs of living-donor adult-to-adult liver transplantation because of the apparently high success rates and the low morbidity rates in donors. However, enthusiasm must be tempered. Proper education and informed consent are mandatory, given the reality that transplantation involving living donors is associated with a small but real possibility of death for the healthy donor.1
1 ReferencesAndrea L. Seek, M.D.
Mary Anna Sullivan, M.D.
Elizabeth A. Pomfret, M.D., Ph.D.
Lahey Clinic Medical Center, Burlington, MA 01805
andrea.l. seek@lahey. org 1
Pomfret EA ,Pomposelli JJ ,Lewis WD , et al. Live donor adult liver transplantation using right lobe grafts: donor evaluation and surgical outcome. Arch Surg 2001;136:425-433
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Trotter replies:
To the Editor: My colleagues and I appreciate the comments of Drs. Dixon and Abbey. We agree that the psychosocial evaluation of donors cannot adequately be performed through a telephone conversation. In fact, all potential donors evaluated at our center are seen in person by a social worker affiliated with our transplantation team. These assessments frequently require several appointments with the potential donor or his or her family or friends. Currently, our program evaluates only potential donors who have a long-term relationship with the recipient. The evaluation of the good Samaritan donor — that is, a donor with no emotional relationship to the recipient — is extremely complex. As a result, it seems to us that good Samaritan donors will not substantially increase the number of donors available for living-donor liver transplantation.
Dr. Fan and colleagues are correct in stating that the first right-hepatic-lobe recipient was only nine years of age. However, the report of that transplantation, by Yamaoka et al.,1 was published three years before the report by Lo et al.2 and therefore is the first description of transplantation of the right hepatic lobe. Therefore, we should clarify our statement that the “first adult-to-adult transplantation of a right hepatic lobe was reported in 1994” by stating that the “first transplantation of a right hepatic lobe was reported in 1994.” We agree that some patients with acute liver failure benefit from living-donor liver transplantation. However, the rapid nature of acute liver failure frequently precludes the evaluation of donors. In addition, the number of patients with acute liver failure is small relative to the number with chronic liver disease. As a result, acute liver failure will probably remain an uncommon indication for living-donor liver transplantation.
The comments by Dr. Shackleton and colleagues are important. The illustrations in our article are accurate, but they are general representations and therefore do not depict the critical details of the operative procedure. The review was intended for a general medical audience, and for this reason and reasons of space limitations the details of the operative procedure could not be included. My colleagues and I have previously published a full description of the operative technique used at our center.3
The comments by Dr. Potts are very interesting, especially because he speaks as a nonclinician. We obviously disagree with his opinion that living-donor liver transplantation lacks “moral rightness.” Having observed the remarkable long-term clinical improvement in our recipients and the apparent absence of major injury to donors, we believe that this procedure is ethical. However, the events surrounding a recent death of a donor in New York have forced liver-transplantation physicians to reexamine their own personal views on living-donor liver transplantation. Shaw has written a very thoughtful and cautionary editorial about living-donor liver transplantation, one that outlines critical ethical issues from the standpoint of a transplantation doctor.4
4 ReferencesJames F. Trotter, M.D.
University of Colorado Health Sciences Center, Denver, CO 80262
james.trotter@uchsc. edu 1
Yamaoka Y ,Washida M ,Honda K , et al. Liver transplantation using a right lobe graft from a living related donor. Transplantation 1994;57:1127-1130
CrossRef | Web of Science | Medline2
Lo CM ,Fan ST ,Liu CL , et al. Adult-to-adult living donor liver transplantation using extended right lobe grafts. Ann Surg 1997;226:261-269
CrossRef | Web of Science | Medline3
Bak T ,Wachs M ,Trotter J , et al. Adult-to-adult living donor transplant using right-lobe grafts: results and lessons learned from a single-center experience. Liver Transpl 2001;7:680-686
CrossRef | Web of Science | Medline4
Shaw BW Jr . Where monsters hide. Liver Transpl 2001;7:928-932
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Surman replies:
To the Editor: Dr. Seek and colleagues are right in noting that the number of deaths I described in my Perspective is incorrect. Eight deaths are now known to have occurred in worldwide experience with partial-liver donation (the seven mentioned by Dr. Seek and colleagues as well as an additional, recent death).1 Three of these deaths occurred in the United States, two of them in right-lobe donors. Compare this with the results of a survey of member centers of the Organ Procurement Transplant Network between January 1, 1999, and June 30, 2001. In the course of 10,000 living-donor kidney transplantations, at least two donors died from perioperative complications, and another donor entered a persistent vegetative state. These 3 donors were among the 5000 who underwent laparoscopic nephrectomy.2
Mortality is greater among right-hepatic-lobe donors than among kidney donors or those undergoing left-hepatic-lobe resection. A high relative rate of complications after right-lobe donation has also been well documented, and the effect on quality of life is still being defined.3 Busuttil recommends a reimbursement-linked certification process for centers performing living-donor liver transplantation.4 He suggests that requirements include demonstration of the need to perform this type of transplantation as well as extensive experience with hepatobiliary surgery and liver resection and expert capacity and resources for surgery in the donor. There should also be an established means of recording outcomes and a comprehensive process of informed consent that ensures autonomy.4
Dr. Howard's contribution is important. Stringent criteria for right-hepatic-lobe donation are needed until other means of treatment, such as tissue engineering, are available. Unlike kidney or left-lobe donation, right-lobe donation depends on subsequent hepatic regeneration. Its use creates an ethical slippery slope. In 1989, the University of Chicago group made public their intent to perform parent-to-child liver transplantation after a six-month period for national discussion.5 I am unaware of any such moratorium before right-lobe transplantation, which entails higher risk. Dr. Howard states that our society values autonomy, but this ethical principle is in ultimate conflict with a utilitarian focus on the greatest good for society.6
Dr. Potts's concern about harm to living donors was a source of controversy in the 1960s but yielded to an appreciation of substantial psychological benefits, both personal and altruistic. Organ donors typically find great meaning in this life-sustaining experience. Emotionally related donors may also benefit personally when the recipient becomes socially productive and is relieved of suffering. There is an ethical conundrum, however, when the risks are high and when the surgeon's acceptance of those risks causes potential donors to feel obligated.
6 ReferencesOwen S. Surman, M.D.
Massachusetts General Hospital, Boston, MA 02114
osurman@partners.org 1
Boillot O ,Dawahra M ,Mechet I , et al. Liver transplantation using a right liver lobe from a living donor. Transplant Proc 2002;34:773-776
CrossRef | Web of Science | Medline2
Matas A ,Leichtman A ,Bartlett S ,Delmonico F . A survey of kidney donor morbidity and mortality. Am J Transplant 2002;2:Suppl 3:138-138 abstract.
Medline3
Beavers KL ,Sandler RS ,Fair JH ,Johnson MW ,Shrestha R . The living donor experience: donor health assessment and outcomes after living donor liver transplantation. Liver Transpl 2001;7:943-947
CrossRef | Web of Science | Medline4
Busuttil RW . How safe are donors in adult-to-adult living related liver transplantation? Liver Transpl 2002;8:121-122
CrossRef | Web of Science | Medline5
Singer PA ,Siegler M ,Whitington PF , et al. Ethics of liver transplantation with living donors. N Engl J Med 1989;321:620-622
Full Text | Web of Science | Medline6
Surman OS ,Purtilo R . Reevaluation of organ transplantation criteria: allocation of scarce resources to borderline candidates. Psychosomatics 1992;33:202-212
Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
David C. Cronin, Mark Siegler. 2005. Ethics of Living Donor Liver Transplantation. , 725-740.
CrossRef
