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Suthantirakumar RL, Gupte GL. Timing and Indications for Liver Transplantation for Children with Chronic Liver Disease. CHILDREN (BASEL, SWITZERLAND) 2025; 12:449. [PMID: 40310116 PMCID: PMC12025402 DOI: 10.3390/children12040449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2025] [Revised: 03/17/2025] [Accepted: 03/28/2025] [Indexed: 05/02/2025]
Abstract
Chronic liver disease (CLD) in children poses significant challenges, necessitating timely management to mitigate morbidity and mortality. Liver transplantation (LT) has emerged as a transformative intervention, offering improved long-term survival for paediatric patients with CLD. This review explores the evolving landscape of liver transplantation, focusing on indications and timing considerations. The aetiology of CLD is diverse, encompassing intrahepatic, extrahepatic cholestatic conditions, metabolic diseases, malignancy, and drug-induced liver injury. LT is indicated when children exhibit signs of hepatic decompensation, necessitating a comprehensive evaluation to assess transplant suitability. Indications for LT include biliary atresia, inborn errors of metabolism, hepatocellular carcinoma, and emerging indications such as mitochondrial hepatopathies and acute on chronic liver failure. The timing of transplantation is critical, emphasizing the need for early recognition of decompensation signs to optimise outcomes. Advancements in LT techniques and immunosuppressive therapies have enhanced patient and graft survival rates. Various transplant modalities, including reduced-size LT and living-related LT, offer tailored solutions to address the unique needs of paediatric patients. While LT represents a cornerstone in the management of paediatric CLD, careful patient selection, multidisciplinary collaboration, and ongoing refinements in transplant protocols are imperative for optimizing outcomes and addressing the evolving landscape of paediatric liver disease management.
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Affiliation(s)
| | - Girish L. Gupte
- Liver Unit (Including Small Bowel Transplantation), Birmingham Children’s Hospital, Birmingham B4 6NH, UK;
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2
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Tchilikidi KY. Ex vivo liver resection and auto-transplantation and special systemic therapy in perihilar cholangiocarcinoma treatment. World J Gastrointest Surg 2024; 16:635-640. [PMID: 38577079 PMCID: PMC10989340 DOI: 10.4240/wjgs.v16.i3.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/26/2023] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
This editorial contains comments on the article "Systematic sequential therapy for ex vivo liver resection and autotransplantation: A case report and review of literature" in the recent issue of World Journal of Gastrointestinal Surgery. It points out the actuality and importance of the article and focuses primarily on the role and place of ex vivo liver resection and autotransplantation (ELRAT) and systemic therapy, underlying molecular mechanisms for targeted therapy in perihilar cholangiocarcinoma (pCCA) management. pCCA is a tough malignancy with a high proportion of advanced disease at the time of diagnosis. The only curative option is radical surgery. Surgical excision and reconstruction become extremely complicated and not always could be performed even in localized disease. On the other hand, ELRAT takes its place among surgical options for carefully selected pCCA patients. In advanced disease, systemic therapy becomes a viable option to prolong survival. This editorial describes current possibilities in chemotherapy and reveals underlying mechanisms and projections in targeted therapy with kinase inhibitors and immunotherapy in both palliative and adjuvant settings. Fibroblast grow factor and fibroblast grow factor receptor, human epidermal growth factor receptor 2, isocitrate dehydrogenase, and protein kinase cAMP activated catalytic subunit alpha (PRKACA) and beta (PRKACB) pathways have been actively investigated in CCA in last years. Several agents were introduced and approved by the Food and Drug Administration. They all demonstrated meaningful activity in CCA patients with no global change in outcomes. That is why every successfully treated patient counts, especially those with advanced disease. In conclusion, pCCA is still hard to treat due to late diagnosis and extremely complicated surgical options. ELRAT also brings some hope, but it could be performed in very carefully selected patients. Advanced disease requires systemic anticancer treatment, which is supposed to be individualized according to the genetic and molecular features of cancer cells. Targeted therapy in combination with chemo-immunotherapy could be effective in susceptible patients.
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Affiliation(s)
- Konstantin Y Tchilikidi
- Department of Surgery with Postgraduate Education, Altai State Medical University, Barnaul 656031, Russia
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3
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Stoltz DJ, Gallo AE, Lum G, Mendoza J, Esquivel CO, Bonham A. Technical Variant Liver Transplant Utilization for Pediatric Recipients: Equal Graft Survival to Whole Liver Transplants and Promotion of Timely Transplantation Only When Performed at High-volume Centers. Transplantation 2024; 108:703-712. [PMID: 37635278 DOI: 10.1097/tp.0000000000004772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Technical variant liver transplantation (TVLT) is a strategy to mitigate persistent pediatric waitlist mortality in the United States, although its implementation remains stagnant. This study investigated the relationship between TVLT utilization, transplant center volume, and graft survival. METHODS Pediatric liver transplant recipients from 2010 to 2020 (n = 5208) were analyzed using the Scientific Registry of Transplant Recipients database. Transplant centers were categorized according to the average number of pediatric liver transplants performed per year (high-volume, ≥5; low-volume, <5). Graft survival rates were compared using Kaplan-Meier curves and log-rank tests. Cox proportional hazards models were used to identify predictors of graft failure. RESULTS High-volume centers demonstrated equivalent whole liver transplant and TVLT graft survival ( P = 0.057) and significantly improved TVLT graft survival compared with low-volume centers ( P < 0.001). Transplantation at a low-volume center was significantly associated with graft failure (adjusted hazard ratio, 1.6; 95% confidence interval, 1.14-2.24; P = 0.007 in patients <12 y old and 1.8; 95% confidence interval, 1.13-2.87; P = 0.013 in patients ≥12 y old). A subset of high-volume centers with a significantly higher rate of TVLT use demonstrated a 23% reduction in waitlist mortality. CONCLUSIONS Prompt transplantation with increased TVLT utilization at high-volume centers may reduce pediatric waitlist mortality without compromising graft survival.
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Affiliation(s)
- Daniel J Stoltz
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Amy E Gallo
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Grant Lum
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Julianne Mendoza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Carlos O Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrew Bonham
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
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Tran TT, Ho PD, Luu NAT, Truong TYN, Nguyen HVK, Bui HT, Pham NT, Tran DA, Pirotte T, Gurevich M, Reding R. Implementing living-donor pediatric liver transplantation in Southern Vietnam: 15-year results and perspectives. Pediatr Transplant 2024; 28:e14441. [PMID: 37294691 DOI: 10.1111/petr.14441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/19/2022] [Accepted: 11/07/2022] [Indexed: 06/11/2023]
Abstract
BACKGROUND ND2 in Ho Chi Minh City is currently the only public center that performs PLT in Southern Vietnam. In 2005, the first PLT was successfully performed, with support from Belgian experts. This study reviews the implementation of PLT at our center and evaluates the results and challenges. METHODS Implementation of PLT at ND2 required medico-surgical team building and extensive improvement of hospital facilities. Records of 13 transplant recipients from 2005 to 2020 were studied retrospectively. Short- and long-term complications, as well as the survival rates, were reported. RESULTS The mean follow-up time was 8.3 ± 5.7 years. Surgical complications included one case of hepatic artery thrombosis that was successfully repaired, one case of colon perforation resulting in death from sepsis, and two cases of bile leak that were drained surgically. PTLD was observed in five patients, of whom three died. There were no cases of retransplantation. The 1-year, 5-year, and 10-year patient survival rates were 84.6%, 69.2%, and 69.2%, respectively. There were no cases of complication or death among the donors. CONCLUSION Living-donor PLT was developed at ND2 for providing a life-saving treatment to children with end-stage liver disease. Early surgical complication rate was low, and the patient survival rate was satisfactory at 1 year. Long-term survival decreased considerably due to PTLD. Future challenges include surgical autonomy and improvement of long-term medical follow-up with a particular emphasis on prevention and management of Epstein-Barr virus-related disease.
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Affiliation(s)
- Thanh Tri Tran
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplant, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Phi Duy Ho
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplant, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Nguyen An Thuan Luu
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplant, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Thi Yen Nhi Truong
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplant, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Hong Van Khanh Nguyen
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplant, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Hai Trung Bui
- Department of Hepato-Pancreato-Biliary Diseases and Liver Transplant, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | | | - Dong A Tran
- Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Thierry Pirotte
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Michael Gurevich
- Department of Surgery, Schneider's Children Hospital, Petah Tikva, Israel
| | - Raymond Reding
- Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Alnagar A, Mirza DF, Muiesan P, G P Ong E, Gupte G, Van Mourik I, Hartley J, Kelly D, Lloyd C, Perera TPR, Sharif K. Long-term outcomes of pediatric liver transplantation using organ donation after circulatory death: Comparison between full and reduced grafts. Pediatr Transplant 2022; 26:e14385. [PMID: 36087024 DOI: 10.1111/petr.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 08/02/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The shortage of donors' livers for pediatric recipients inspired the search for alternatives including donation after cardiac death (DCD). METHODS Retrospective review of pediatric liver transplant (PLT) using DCD grafts. Patients were divided into either FLG or RLG recipients. Pre-transplant recipient parameters, donor parameters, operative parameters, post-transplant recipient parameters, and outcomes were compared. RESULTS Overall, 14 PLTs from DCD donors between 2005 and 2018 were identified; 9 FLG and 5 RLG. All donors were Maastricht category III. Cold ischemia time was significantly longer in RLG (8.2 h vs. 6.2 h; p = .038). Recipients of FLG were significantly older (180 months vs. 7 months; p = .012) and waited significantly longer (168 days vs. 22 days; p = .012). Recipients of RLG tended to be sicker in the immediate pre-transplant period and this was reflected by the need for respiratory or renal support. There was no significant difference between groups regarding long-term complications. Three patients in each group survived more than 5 year post-transplant. One child was re-transplanted in the RLG due to portal vein thrombosis but failed to survive after re-transplant. One child from FLG also died from a non-graft-related cause. CONCLUSIONS Selected DCD grafts are an untapped source to widen the donor pool, especially for sick recipients. In absence of agreed criteria, graft and recipient selection for DCD grafts should be undertaken with caution.
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Affiliation(s)
- Amr Alnagar
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK.,General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Darius F Mirza
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Paolo Muiesan
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Evelyn G P Ong
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Girish Gupte
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Indra Van Mourik
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Jane Hartley
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Deirdre Kelly
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Carla Lloyd
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Thamara P R Perera
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Khalid Sharif
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
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Montgomery JR, Highet A, Brown CS, Waits SA, Englesbe MJ, Sonnenday CJ. Graft Survival and Segment Discards Among Split-Liver and Reduced-Size Transplantations in the United States From 2008 to 2018. Liver Transpl 2022; 28:247-256. [PMID: 34407278 DOI: 10.1002/lt.26271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/08/2021] [Accepted: 08/14/2021] [Indexed: 01/13/2023]
Abstract
Split-liver transplantation has allocation advantages over reduced-size transplantation because of its ability to benefit 2 recipients. However, prioritization of split-liver transplantation relies on the following 3 major assumptions that have never been tested in the United States: similar long-term transplant recipient outcomes, lower incidence of segment discard among split-liver procurements, and discard of segments among reduced-size procurements that would be otherwise "transplantable." We used United Network for Organ Sharing Standard Transplant Analysis and Research data to identify all split-liver (n = 1831) and reduced-size (n = 578) transplantation episodes in the United States between 2008 and 2018. Multivariable Cox proportional hazards modeling was used to compare 7-year all-cause graft loss between cohorts. Secondary analyses included etiology of 30-day all-cause graft loss events as well as the incidence and anatomy of discarded segments. We found no difference in 7-year all-cause graft loss (adjusted hazard ratio [aHR], 1.1; 95% confidence interval [CI], 0.8-1.5) or 30-day all-cause graft loss (aHR, 1.1; 95% CI, 0.7-1.8) between split-liver and reduced-size cohorts. Vascular thrombosis was the most common etiology of 30-day all-cause graft loss for both cohorts (56.4% versus 61.8% of 30-day graft losses; P = 0.85). Finally, reduced-size transplantation was associated with a significantly higher incidence of segment discard (50.0% versus 8.7%) that were overwhelmingly right-sided liver segments (93.6% versus 30.3%). Our results support the prioritization of split-liver over reduced-size transplantation whenever technically feasible.
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Affiliation(s)
- John R Montgomery
- Department of Surgery, Michigan Medicine, Ann Arbor, MI.,Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI
| | | | - Craig S Brown
- Department of Surgery, Michigan Medicine, Ann Arbor, MI.,Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI
| | - Seth A Waits
- Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI.,Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, MI
| | - Michael J Englesbe
- Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI.,Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, MI
| | - Christopher J Sonnenday
- Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI.,Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, MI
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7
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Alnagar A, Daradka K, Kyrana E, Mtegha M, Palaniswamy K, Rajwal S, Mulla J, O'meara M, Karam M, Shawky A, Hakeem AR, Upasani V, Dhakshinamoorthy V, Prasad R, Attia M. Predictors of patient and graft survival following pediatric liver transplantation: Long-term analysis of more than 300 cases from single centre. Pediatr Transplant 2022; 26:e14139. [PMID: 34545678 DOI: 10.1111/petr.14139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/04/2021] [Accepted: 08/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric liver transplant (PLT) activity has flourished over time although with limited expansion in the graft pool. The study aims to identify pre-transplant factors that predict post-transplant patient and graft survival in the PLT population. METHODS Retrospective review of PLTs at a single tertiary transplant unit from 2000 to 2019. Univariate and multivariate analyses of pre-transplant factors were performed to identify predictors of patient and graft survival. RESULTS Two hundred and seventy-six patients received 320 PLTs. The most common cause of graft loss was hepatic artery thrombosis (n = 13, 29.6%). The most common cause of mortality was sepsis (n = 11, 29.7%). Univariate analysis showed that the following variables had a significant (p < .05) impact on patient survival: recipient age, weight, height, graft type (technical variant graft), transplant category (acute liver failure), the era of transplant, and invasive ventilation. The following variables had a significant (p < .05) impact on graft survival: recipient age, weight, height, transplant category (acute liver failure), and the era of transplant. Multivariate analysis precluded the era of transplant as the only significant factor for patient survival; patients transplanted after 2005 had significantly higher patient survival. No independent factor predicting graft survival was identified. For children transplanted after 2005, the only factor that predicted patient survival was pre-transplant invasive ventilation. CONCLUSIONS Our study suggests that the learning curve and pre-transplant invasive ventilation in the recipient have a significant impact on patient survival. The traditional view of worse outcomes of smaller PLT candidates should be changed.
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Affiliation(s)
- Amr Alnagar
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK.,General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Khaled Daradka
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK.,Department of General Surgery, Jordan University Hospital, The University of Jordan- Queen Rania Street, Amman, Jordan
| | - Eirini Kyrana
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Marumbo Mtegha
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | | | - Sanjay Rajwal
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Jamila Mulla
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Moira O'meara
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Mohamed Karam
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Shawky
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Vivek Upasani
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | | | - Raj Prasad
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
| | - Magdy Attia
- The Leeds Teaching Hospitals, NHS Foundation Trust, Leeds, UK
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8
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Chaudhry S, Bentley-Hibbert S, Stern J, Lobritto S, Martinez M, Vittorio J, Halazun K, Lee H, Emond J, Kato T, Samstein B, Griesemer A. Growth of liver allografts over time in pediatric transplant recipients. Pediatr Transplant 2018; 22:10.1111/petr.13104. [PMID: 29334158 PMCID: PMC5820167 DOI: 10.1111/petr.13104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2017] [Indexed: 01/29/2023]
Abstract
The liver's capacity to grow in response to metabolic need is well known. However, long-term growth of liver allografts in pediatric recipients has not been characterized. A retrospective review of pediatric recipients at a single institution identified patients who had cross-sectional imaging at 1, 5, and 10 years post-transplant. Using volumetric calculations, liver allograft size was calculated and percent SLV were compared across the different time points; 18 patients ranging from 0.3 to 17.7 years old were identified that had imaging at 2 or more time points. Measured liver volumes increased by 59% after 5 years and 170% after 10 years. The measured liver volumes compared to calculated %SLV for these patients were 123 ± 37%, 97 ± 19%, and 118 ± 27% at 1, 5, and 10 years after transplant, respectively. Our data suggest that liver allografts in pediatric recipients increase along with overall growth, and reach SLVs for height and weight by 5 years post-transplantation. Additionally, as pediatric recipients grow, the livers appear to maintain appropriate SLV.
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Affiliation(s)
- S.G. Chaudhry
- Department of Surgery, Columbia University Medical Center, New York, NY
| | | | - J. Stern
- Columbia Center for Translational Immunology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - S. Lobritto
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - M. Martinez
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - J. Vittorio
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - K.J. Halazun
- Department of Surgery, Weill-Cornell Medical Center, New York, NY
| | - H.T. Lee
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - J. Emond
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - T. Kato
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - B. Samstein
- Department of Surgery, Weill-Cornell Medical Center, New York, NY
| | - A. Griesemer
- Department of Surgery, Columbia University Medical Center, New York, NY
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Moorlock G, Neuberger J, Bramhall S, Draper H. An Empirically Informed Analysis of the Ethical Issues Surrounding Split Liver Transplantation in the United Kingdom. Camb Q Healthc Ethics 2016; 25:435-447. [PMID: 27348828 PMCID: PMC5355900 DOI: 10.1017/s0963180116000086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Surgical advances have allowed for the development of split liver transplantation, providing two recipients with the opportunity to potentially benefit from one donated liver by splitting the liver into two usable parts. Although current data suggest that the splitting of livers provides overall benefit to the liver-recipient population, relatively low numbers of livers are actually split in the United Kingdom. This article addresses the question of whether ethical concerns are posing an unnecessary barrier to further increasing the number of life-saving transplantations. Recognizing that an important aspect of exploring these concerns is gaining insight into how transplant staff and patients regard splitting livers, the article presents the findings of a qualitative study examining the views of senior transplant staff and liver transplant patients in the UK and uses these to inform a commentary on the ethical issues relating to split liver transplantation.
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10
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Outcomes of Technical Variant Liver Transplantation versus Whole Liver Transplantation for Pediatric Patients: A Meta-Analysis. PLoS One 2015; 10:e0138202. [PMID: 26368552 PMCID: PMC4569420 DOI: 10.1371/journal.pone.0138202] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 08/27/2015] [Indexed: 02/06/2023] Open
Abstract
Objective To overcome the shortage of appropriate-sized whole liver grafts for children, technical variant liver transplantation has been practiced for decades. We perform a meta-analysis to compare the survival rates and incidence of surgical complications between pediatric whole liver transplantation and technical variant liver transplantation. Methods To identify relevant studies up to January 2014, we searched PubMed/Medline, Embase, and Cochrane library databases. The primary outcomes measured were patient and graft survival rates, and the secondary outcomes were the incidence of surgical complications. The outcomes were pooled using a fixed-effects model or random-effects model. Results The one-year, three-year, five-year patient survival rates and one-year, three-year graft survival rates were significantly higher in whole liver transplantation than technical variant liver transplantation (OR = 1.62, 1.90, 1.65, 1.78, and 1.62, respectively, p<0.05). There was no significant difference in five-year graft survival rate between the two groups (OR = 1.47, p = 0.10). The incidence of portal vein thrombosis and biliary complications were significantly lower in the whole liver transplantation group (OR = 0.45 and 0.42, both p<0.05). The incidence of hepatic artery thrombosis was comparable between the two groups (OR = 1.21, p = 0.61). Conclusions Pediatric whole liver transplantation is associated with better outcomes than technical variant liver transplantation. Continuing efforts should be made to minimize surgical complications to improve the outcomes of technical variant liver transplantation.
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11
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Dar FS, Bhatti ABH, Dogar AW, Zia H, Amin S, Rana A, Nazer R, Khan NA, Khan EUD, Rajput MZ, Salih M, Shah NH. The travails of setting up a living donor liver transplant program: Experience from Pakistan and lessons learned. Liver Transpl 2015; 21:982-990. [PMID: 25891412 DOI: 10.1002/lt.24151] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/07/2015] [Indexed: 02/05/2023]
Abstract
Living donor liver transplantation (LDLT) is the only treatment option for patients with end-stage liver disease (ESLD) where cadaveric donors are not available. In developing countries, the inception of LDLT programs remains a challenge. The first successful liver transplantation program in Pakistan started transplantation in 2012. The objective of this study was to report outcomes of 100 LDLT recipients in a developing country and to highlight the challenges encountered by a new LDLT program in a resource-limited setting. We retrospectively reviewed recipients who underwent LDLT between April 2012 and August 2014. Demographics, etiology, graft characteristics, and operative variables were assessed. Outcome was assessed on the basis of morbidity and mortality. All complications of ≥ 3 on the Clavien-Dindo grading system were included as morbidity. Estimated 1-year survival was calculated using Kaplan-Meier curves, and a Log-rank test was used to determine the significance. Outcomes between the first 50 LDLTs (group 1) and latter 50 LDLTs (group 2) were also compared. Median age was 46.5 (0.5-72) years, whereas the median MELD score was 15.5 (7-37). The male to female ratio was 4:1. ESLD secondary to hepatitis C virus was the most common indication (73% patients). There were 52 (52%) significant (≥ grade 3) complications. The most common morbidities were bile leaks in 9 (9%) and biliary strictures in 14 (14%) patients. Overall mortality in patients who underwent LDLT for ESLD was 10.6%. Estimated 1-year survival was 87%. Patients who underwent transplantation in the latter period had a significantly lower overall complication rate (36% versus 68%; P = 0.01). Comparable outcomes can be achieved in a new LDLT program in a developing country. Outcomes improve as experience increases.
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Affiliation(s)
- Faisal Saud Dar
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | | | - Abdul-Wahab Dogar
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | - Haseeb Zia
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | - Sadaf Amin
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | | | | | | | | | | | - Muhammad Salih
- Transplant Hepatology, Shifa International Hospital, Islamabad, Pakistan
| | - Najmul Hassan Shah
- Transplant Hepatology, Shifa International Hospital, Islamabad, Pakistan
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12
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Hansel MC, Gramignoli R, Skvorak KJ, Dorko K, Marongiu F, Blake W, Davila J, Strom SC. The history and use of human hepatocytes for the treatment of liver diseases: the first 100 patients. CURRENT PROTOCOLS IN TOXICOLOGY 2014; 62:14.12.1-23. [PMID: 25378242 PMCID: PMC4343212 DOI: 10.1002/0471140856.tx1412s62] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Orthotopic liver transplantation remains the only curative treatment for many end-stage liver diseases, yet the number of patients receiving liver transplants remains limited by the number of organs available for transplant. There is a need for alternative therapies for liver diseases. The transplantation of isolated hepatocytes (liver cells) has been used as an experimental therapy for liver disease in a limited number of cases. Recently, the 100th case of hepatocyte transplantation was reported. This review discusses the history of the hepatocyte transplant field, the major discoveries that supported and enabled the first hepatocyte transplants, and reviews the cases and outcomes of the first 100 clinical transplants. Some of the problems that limit the application or efficacy of hepatocyte transplantation are discussed, as are possible solutions to these problems. In conclusion, hepatocyte transplants have proven effective particularly in cases of metabolic liver disease where reversal or amelioration of the characteristic symptoms of the disease is easily quantified. However, no patients have been completely corrected of a metabolic liver disease for a significant amount of time by hepatocyte transplantation alone. It is likely that future developments in new sources of cells for transplantation will be required before this cellular therapy can be fully implemented and available for large numbers of patients.
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Affiliation(s)
- Marc C Hansel
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania
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Cheng YF, Ou HY, Tsang LLC, Yu CY, Huang TL, Chen TY, Concejero A, Wang CC, Wang SH, Lin TS, Liu YW, Yang CH, Yong CC, Chiu KW, Jawan B, Eng HL, Chen CL. Vascular stents in the management of portal venous complications in living donor liver transplantation. Am J Transplant 2010; 10:1276-1283. [PMID: 20353467 DOI: 10.1111/j.1600-6143.2010.03076.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To evaluate the efficacy of stent placement in the treatment of portal vein (PV) stenosis or occlusion in living donor liver transplant (LDLT) recipients, 468 LDLT records were reviewed. Sixteen (10 PV occlusions and 6 stenoses) recipients (age range, 8 months-59 years) were referred for possible interventional angioplasty (dilatation and/or stent) procedures. Stent placement was attempted in all. The approaches used were percutaneous transhepatic (n = 10), percutaneous transsplenic (n = 4), and intraoperative (n = 2). Technical success was achieved in 11 of 16 patients (68.8%). The sizes of the stents used varied from 7 mm to 10 mm in diameter. In the five unsuccessful patients, long-term complete occlusion of the PV with cavernous transformation precluded catherterization. The mean follow-up was 12 months (range, 3-24). The PV stent patency rate was 90.9% (10/11). Rethrombosis and occlusion of the stent and PV occurred in a single recipient who had a cryoperserved vascular graft to reconstruct the PV during the LDLT operation. PV occlusion of >1 year with cavernous transformation seemed to be a factor causing technical failure. In conclusion, early treatment of PV stenosis and occlusion by stenting is an effective treatment in LDLT. Percutaneous transhepatic and transsplenic, and intraoperative techniques are effective approaches depending on the situation.
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Affiliation(s)
- Y-F Cheng
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, [corrected] Taiwan
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14
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Cheng YF, Ou HY, Tsang LLC, Yu CY, Huang TL, Chen TY, Concejero A, Yong CC, Chen CL. Interventional percutaneous trans-splenic approach in the management of portal venous occlusion after living donor liver transplantation. Liver Transpl 2009; 15:1378-80. [PMID: 19790159 DOI: 10.1002/lt.21813] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Yu-Fan Cheng
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Polak WG, Peeters PM, Slooff MJ. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant 2009; 23:546-64. [DOI: 10.1111/j.1399-0012.2009.00994.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ethics Committees at Work. Camb Q Healthc Ethics 2009. [DOI: 10.1017/s096318010000548x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The Research Center for Surgery (RCS) in Moscow is recognized as one of the largest and most prestigious surgical institutions in Russia. In this 400-bed facility more than 3,000 surgical procedures are performed annually, including heart, liver, and pancreas interventions and the reimplantation of limbs. The main focus of the research program at the RCS is on the transplantation of organs and reconstructive surgery. All procedures are free of charge to the patient.
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Farmer DG, Venick RS, McDiarmid SV, Ghobrial RM, Gordon SA, Yersiz H, Hong J, Candell L, Cholakians A, Wozniak L, Martin M, Vargas J, Ament M, Hiatt J, Busuttil RW. Predictors of outcomes after pediatric liver transplantation: an analysis of more than 800 cases performed at a single institution. J Am Coll Surg 2007; 204:904-14; discussion 914-6. [PMID: 17481508 DOI: 10.1016/j.jamcollsurg.2007.01.061] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 01/24/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pediatric liver transplantation (PLTx) is the standard of care for treatment of liver failure in children. Unfortunately, there are few studies with substantial numbers of patients that identify outcomes predictors. The goal of this study was to determine factors that influence outcomes in a large, single-center cohort of PLTx. STUDY DESIGN This retrospective review between 1984 to 2006 included all recipients 18 years of age and younger undergoing PLTx. Multiorgan graft recipients were excluded (n = 48). Data sources included transplantation center database and hospital medical records. Outcomes measures were overall patient and graft survival. Demographic, laboratory, and perioperative variables were analyzed. Univariate and multivariate statistical analysis was undertaken using log-rank test and Cox's proportional hazards model. A p value < 0.05 was considered significant at the multivariate level. RESULTS Eight hundred fifty-two PLTx were performed in 657 children; 55% were girls, 45% were Hispanic, and median age was 29.5 months. Biliary atresia and acute liver failure were the most common causes of liver disease. Fifty-two percent were hospitalized before PLTx. Graft types were whole (75%) and segmental (25%). Indications for re-PLTx (n = 195) included graft nonfunction (22%), immunologic (34%), and vascular complications (35%). Overall 1-, 5-, and 10-year survival rates were 85%, 81%, and 78% (patient), and 78%, 72%, and 67% (graft). Independent significant predictors of worse patient survival were renal function, pretransplantation ventilator dependence, and causes of liver disease. Independent significant predictors of worse graft survival were renal function and warm ischemia time. CONCLUSIONS As one of the largest, single-center analyses of PLTx, this study enables accurate statistical analysis and demonstrates excellent longterm outcomes. Independent prognosticators of graft survival were renal function and warm ischemia time, and those for patient survival were renal function, mechanical ventilation, and causes of liver disease. These factors can aid in the medical decision making required for optimal use of scarce donor organs.
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Affiliation(s)
- Douglas G Farmer
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA 90095-7054, USA
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19
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Morioka D, Egawa H, Kasahara M, Ito T, Haga H, Takada Y, Shimada H, Tanaka K. Outcomes of adult-to-adult living donor liver transplantation: a single institution's experience with 335 consecutive cases. Ann Surg 2007; 245:315-25. [PMID: 17245187 PMCID: PMC1876999 DOI: 10.1097/01.sla.0000236600.24667.a4] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine outcomes for both donors and recipients of adult-to-adult living donor liver transplantation (AALDLT) and independent factors impacting those outcomes. SUMMARY BACKGROUND DATA Deceased donors for organ transplantation remain extremely rare, making living donor liver transplantation (LDLT) practically the sole therapeutic modality for patients with end-stage liver disease in Japan. METHODS Retrospective analysis of initial LDLT for 335 consecutive adult (>or=18 years) patients performed between November 1994 and December 2003. RESULTS : Of the 335 recipients, 275 received right-liver grafts and the remaining 60 recipients received non-right-liver grafts. Three of the 335 liver grafts were domino-splitting livers. Sixty of the 332 donors other than the domino-donors showed major postoperative complications. Multivariate analysis indicated that accumulation of case experience significantly and advantageously affected the surgical outcomes of these living liver donors, and right-liver donation and prolonged donor operation time were shown to be independent risk factors of major complications in the donors. Post-transplant patient and graft survival estimates were 73.1% and 72.5% at 1 year, 67.7% and 66.3% at 4 years, and 64.7% and 61.9% at 7 years, respectively. Obvious pretransplant encephalopathy, a higher (>or=31) modified Model for End-stage Liver Disease score (including points for persistent ascites and low serum sodium) and higher donor age (>or=50 years) were indicated as independent factors predictive of graft failure (graft loss or death) in the multivariate analysis. CONCLUSIONS Graft type and degree of experience exerted a significant impact on the surgical outcomes of AALDLT donors but did not significantly affect the survival outcomes of AALDLT recipients. Better pretransplant conditions and younger age (<50 years) among the living donors appeared to be advantageous in terms of gaining better survival outcomes of patients undergoing AALDLT.
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Affiliation(s)
- Daisuke Morioka
- Organ Transplant Unit, Kyoto University Hospital, Kyoto, Japan.
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Carnevale FC, Borges MV, Moreira AM, Cerri GG, Maksoud JG. Endovascular Treatment of Acute Portal Vein Thrombosis After Liver Transplantation in a Child. Cardiovasc Intervent Radiol 2006; 29:457-61. [PMID: 16502164 DOI: 10.1007/s00270-005-0046-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Although operative techniques in hepatic transplantation have reduced the time and mortality on waiting lists, the rate of vascular complications associated with these techniques has increased. Stenosis or thrombosis of the portal vein is an infrequent complication, and if present, surgical treatment is considered the traditional management. This article describes a case of acute portal vein thrombosis after liver transplantation from a living donor to a child managed by percutaneous techniques.
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Affiliation(s)
- Francisco Cesar Carnevale
- Division of Interventional Radiology, Radiology Institute, Hospital das Clínicas, University of São Paulo, Brazil.
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21
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Nadalin S, Bockhorn M, Malagó M, Valentin-Gamazo C, Frilling A, Broelsch C. Living donor liver transplantation. HPB (Oxford) 2006; 8:10-21. [PMID: 18333233 PMCID: PMC2131378 DOI: 10.1080/13651820500465626] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT). First introduced for children in 1989, its adoption for adults has followed only 10 years later. As the demand for LT continues to increase, LDLT provides life-saving therapy for many patients who would otherwise die awaiting a cadaveric organ. In recent years, LDLT has been shown to be a clinically safe addition to deceased donor liver transplantation (DDLT) and has been able to significantly extend the scarce donor pool. As long as the donor shortage continues to increase, LDLT will play an important role in the future of LT.
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Affiliation(s)
- S. Nadalin
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - M. Bockhorn
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - M. Malagó
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - C. Valentin-Gamazo
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - A. Frilling
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - C.E. Broelsch
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
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Abstract
The increasing awareness of liver diseases and their early detection have led to an increase in the number of transplant waiting list candidates over the past decade. This need has not been matched by the actual number of orthotopic liver transplantations performed. Live donor liver transplantation (LDLT) is an innovative surgical technique intended to expand the available organ donor pool. Although LDLT offers definite advantages to the recipient, it offers none to the donor except for the possibility of psychological well-being. Clinical research studies aimed at the prospective collection of data for donors and recipients need to be conducted.
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Affiliation(s)
- Lawrence U Liu
- Division of Liver Diseases, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10039, USA
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Yan JQ, Becker T, Neipp M, Peng CH, Lueck R, Lehner F, Li HW, Klempnauer J. Surgical experience in splitting donor liver into left lateral and right extended lobes. World J Gastroenterol 2005; 11:4220-4. [PMID: 16015693 PMCID: PMC4615446 DOI: 10.3748/wjg.v11.i27.4220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To outline the surgical experience with donor liver splitting in split liver transplantation.
METHODS: From March 1 to September 1 in 2004, 10 donor livers were split ex situ into a left lateral lobe (segments II and III) and a right extended lobe (segments I, IV - VIII) in Medical School of Hannover, and thereafter split liver transplantation was performed successfully in 19 cases. The average age, weight and ICU staying period of the donors were 32.7 years (15 - 51 years), 64.5 kg (45 - 75 kg) and 2.4 d (1 - 8 d) respectively.
RESULTS: The average weight of the whole graft and the left lateral lobe was 1 322.6 g (956 - 1 665 g) and 281.8 g (198 - 373 g) respectively, and the average ratio of left lateral lobe to the whole graft was 0.215 (0.178 - 0.274). The average graft to recipient weight ratio (GRWR) of the left lateral lobe and the right extended lobe reached 2.44% (1.22 - 5.41%) and 1.73% (1.31 - 2.30%) respectively. On average it took approximately 105 min (85 - 135 min) to split the donor liver. Five donor organs showed anatomic variation including the left hepatic vein variation in two cases, the left hepatic artery variation in two cases and the bile duct variation in one case.
CONCLUSION: Split liver transplantation has become a mature surgical technique to expand the donor pool with promising results. In the process of graft splitting, close attention needs to be paid to potential anatomic variations, especially to variations of the left hepatic vein, the left hepatic artery, and the bile duct.
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Affiliation(s)
- Ji-Qi Yan
- Department of Surgery, Ruijin Hospital Affiliated to Shanghai Second Medical University, Shanghai 200025, China.
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Kim JS, Grotelüschen R, Mueller T, Ganschow R, Bicak T, Wilms C, Mueller L, Helmke K, Burdelski M, Rogiers X, Broering DC. Pediatric transplantation: the Hamburg experience. Transplantation 2005; 79:1206-1209. [PMID: 15880071 DOI: 10.1097/01.tp.0000160758.13505.d2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since starting our program in 1989, 455 pediatric orthotopic liver transplantations have been performed using all techniques. In April 2001, we experienced our last in-hospital death of a pediatric liver-transplant recipient. Since then, all our liver-transplant children (n=170) were able to be discharged from the hospital. The aim of this study is to analyze the actual status of pediatric liver transplantation at the University of Hamburg and to find future perspectives to improve the results after pediatric liver transplantation. METHODS From May 4, 2001 until September 8, 2004, 22 (13%) whole organs, 18 (11%) reduced-size organs, 79 (47%) split organs, and 51 (30%) organs from living donors were transplanted into 142 patients. One hundred forty-one were primary liver transplants, 25 retransplants, 3 third, and 1 fourth liver transplants. Of the 170 orthotopic liver transplantations (OLT), 31 (18%) were highly urgent (United Network of Organ Sharing [UNOS] I). RESULTS After 170 consecutive pediatric liver transplants, no patients died during the hospital course (100% patient survival<3 months), but overall, 5 (2.9%) recipients died during further follow-up. The 3-month and actual graft survival rates are 93% and 85%, respectively. Twenty (11.8%) children had to undergo retransplantation. However, patient survival was not sustained by longer graft survival. Analyzing our series, we see that graft survival after reduced-size liver transplantation showed a significantly lower rate versus living-donor liver transplantation. CONCLUSION The learning curve in pediatric liver transplantation has reached a turning point where immediate patient survival is considered the rule. The challenge is to increase graft survival to the same level. The long-term management of the transplant patients, with the aim of avoiding late graft loss and achieving excellent quality of life, will become the center of the debate.
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Affiliation(s)
- Jong-Sun Kim
- Department of Surgery, University Hospital Eppendorf, University of Hamburg, Hamburg, Germany
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Broering DC, Wilms C, Bok P, Fischer L, Mueller L, Hillert C, Lenk C, Kim JS, Sterneck M, Schulz KH, Krupski G, Nierhaus A, Ameis D, Burdelski M, Rogiers X. Evolution of donor morbidity in living related liver transplantation: a single-center analysis of 165 cases. Ann Surg 2004; 240:1013-1026. [PMID: 15570207 PMCID: PMC1356517 DOI: 10.1097/01.sla.0000146146.97485.6c] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE During the last 14 years, living donor liver transplantation (LDLT) has evolved to an indispensable surgical strategy to minimize mortality of adult and pediatric patients awaiting transplantation. The crucial prerequisite to performing this procedure is a minimal morbidity and mortality risk to the healthy living donor. Little is known about the learning curve involved with this type of surgery. PATIENTS AND METHODS From January 1991 to August 2003, a total of 165 LDLTs were performed in our center. Of these, 135 were donations of the left-lateral lobe (LL, segments II and III), 3 were of the left lobe (L, segments II-IV), 3 were full-left lobes (FL, segments I-IV), and 24 were of the full-right lobe (FR, segments V-VIII). We divided the procedures into 3 periods: period 1 included the years 1991 to 1995 (LL, n = 49; L, n = 2; FR, n = 1), period 2 covered 1996 to 2000 (LL, n = 47), and period 3 covered 2001 to August 2003 (LL, n = 39; FR, n = 23; FL, n = 3; L, n = 1). Perioperative mortality and morbidity were assessed using a standardized classification. Length of stay in intensive care unit, postoperative hospital stay, laboratory results (bilirubin, INR, and LFTs), morbidity, and the different types of grafts in the 3 different periods were compared. RESULTS One early donor death was observed in period 1 (03/07/93, case 30; total mortality, 0.61.%). Since 1991, the perioperative morbidity has continually declined (53.8% vs. 23.4% vs. 9.2%). In period 1, 28 patients had 40 complications. In period 2, 11 patients had 12 complications, and in period 3, 6 patients had 9 complications. Within the first period, 1 donor underwent relaparotomy because of bile leakage. Postoperative hospital stay was 10 days, 7 days, and 6 days, respectively. Donation of the full right lobe, in comparison with that of the left lateral lobe, resulted in a significantly diminished liver function (bilirubin and INR) during the first 5 days after donation but did not increase morbidity. One donor from period 1 experienced late death caused by amyotrophic lateral sclerosis. CONCLUSIONS In a single center, morbidity after living liver donation strongly correlates to center experience. Despite the additional risks associated with temporary reduction of liver function, this experience enabled the team to bypass part of the learning curve when starting right lobe donation. Specific training of the surgical team and coaching by an experienced center should be implemented for centers offering this procedure to avoid the learning curve.
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Affiliation(s)
- Dieter C Broering
- Department of Hepatobiliary Surgery and Transplantation, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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Carnevale FC, Borges MV, Pinto RADP, Oliva JL, Andrade WDC, Maksoud JG. Endovascular treatment of stenosis between hepatic vein and inferior vena cava following liver transplantation in a child: a case report. Pediatr Transplant 2004; 8:576-80. [PMID: 15598327 DOI: 10.1111/j.1399-3046.2004.00213.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The liver transplantation technique advances have allowed the endovascular treatment of stenosis between hepatic vein and inferior vena cava, and this has become an established and widely acceptable method for the treatment of patients with end-stage liver disease. However, in spite of the advances in the surgical technique of liver transplantation there is relatively still a high incidence of postoperative complications, especially those related to vascular complications. One technical variant of orthotopic liver transplantation is the piggyback technique with conservation of the recipient vena cava, which is anastomosed to the graft hepatic veins. As a consequence of the increased number of liver transplants in children, there is a higher demand for endovascular treatment of vascular stenosis, such as those at the level of the hepatic veins. This leads to more consistent experience of endovascular treatment of the surgical vascular complications following liver transplantation. This article describes the case of a child submitted to liver transplantation with reduced graft (left lateral segment) who presented stenosis of the anastomosis between the hepatic vein and IVC 6 months later which was successfully treated by PTA.
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Affiliation(s)
- Francisco Cesar Carnevale
- Department of Radiology, Instituto da Criança Prof. Pedro de Alcântara, University of São Paulo, São Paulo, Brazil.
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Broering DC, Kim JS, Mueller T, Fischer L, Ganschow R, Bicak T, Mueller L, Hillert C, Wilms C, Hinrichs B, Helmke K, Pothmann W, Burdelski M, Rogiers X. One hundred thirty-two consecutive pediatric liver transplants without hospital mortality: lessons learned and outlook for the future. Ann Surg 2004; 240:1002-1012. [PMID: 15570206 PMCID: PMC1356516 DOI: 10.1097/01.sla.0000146148.01586.72] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Orthotopic liver transplantation (OLT) has become an established procedure for the treatment of pediatric patients with end-stage liver disease. Since starting our program in 1989, 422 pediatric OLTs have been performed using all techniques presently available. Analyzing our series, we have concluded that the year of transplantation is the most important prognostic factor in patient and graft survival in a multivariate analysis. METHODS From April 2001 to December 1, 2003, 18 whole organs (14%), 17 reduced-size organs (13%), 53 split organs (42%; 46 ex situ, 7 in situ), and 44 organs from living donors (33%) were transplanted into 115 patients (62 male and 53 female). One hundred twelve were primary liver transplants, 18 were retransplants, one third and one fourth liver transplants. Of the 132 OLTs, 26 were highly urgent (19.7%). The outcome of these 132 OLTs was retrospectively analyzed. RESULTS Of 132 consecutive pediatric liver transplants, no patients died within the 6 months posttransplantation. Overall, 3 recipients (2%) died during further follow-up, 1 child because of severe pneumonia 13 months after transplantation and the second recipient with unknown cause 7 months postoperatively, both with good functioning grafts after uneventful transplantation. The third had a recurrence of an unknown liver disease 9 months after transplantation. The 3-month and actual graft survival rates are 92% and 86%, respectively. Sixteen children (12%) had to undergo retransplantation, the causes of which were chronic rejection (3.8%), primary nonfunction (3.8%), primary poor function (PPF; 1.5%), and arterial thrombosis (3%). The biliary complication rate was 6%; arterial complications occurred in 8.3%; intestinal perforation was observed in 3%; and in 5%, postoperative bleeding required reoperation. The portal vein complication rate was 2%. CONCLUSIONS Progress during the past 15 years has enabled us to perform pediatric liver transplantation with near perfect patient survival. Advances in posttransplant care of the recipients, technical refinements, standardization of surgery and monitoring, and adequate choice of the donor organ and transplantation technique enable these results, which mark a turning point at which immediate survival after transplantation will be considered the norm. The long-term treatment of the transplanted patient, with the aim of avoiding late graft loss and achieving optimal quality of life, will become the center of debate.
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Affiliation(s)
- Dieter C Broering
- Department of Hepatobiliary Surgery, University Hospital Eppendorf, University of Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.
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Siegler J, Siegler M, Cronin DC. Recipient Death During a Live Donor Liver Transplantation: Who Gets the “Orphan” Graft? Transplantation 2004; 78:1241-4. [PMID: 15548958 DOI: 10.1097/01.tp.0000138095.44770.17] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The limited availability of deceased organ donors, prolongation of waiting time, and increasing number of patients dying awaiting transplantation have contributed to the increased use of adult-to-adult living-donor liver transplant. In the event that the intended recipient dies after the donor graft has been procured but before it has been transplanted, what should be done with the graft? A structured, nine-item oral survey of 26 experts in liver transplantation was conducted in June and July 2003. Respondents were selected primarily because of their extensive experience with liver transplantation, especially adult-to-adult living-donor transplant. All respondents said the surgical team should try to use the available graft for another recipient. Twenty-one respondents believed consent from the donor or the donor's family was required for allocation, whereas 19% believed consent desirable but not required. Nine respondents recommended an allocation organization place the graft, whereas 17 respondents recommended placement within the donor hospital. Two of the respondents had previously encountered this situation, whereas four had experienced an intraoperative recipient death before procurement of a live donor graft. On the basis of the responses, we offer the following recommendations for handling orphan liver grafts: (1) obtain predonation informed consent from all donors that indicates what the donor would want to have done with the "orphan graft" in all cases of living-donor liver transplantation; (2) avoid the premature removal of the donor graft until the recipient hepatectomy and survival are likely; (3) if a live donor graft has been procured and cannot be transplanted into the intended recipient, and if informed consent has been obtained before the donor operation, the organ should be reallocated without delay to minimize cold ischemia time and maximize the utility of the graft.
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Affiliation(s)
- Jessica Siegler
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Renz JF, Yersiz H, Reichert PR, Hisatake GM, Farmer DG, Emond JC, Busuttil RW. Split-liver transplantation: a review. Am J Transplant 2003; 3:1323-35. [PMID: 14525591 DOI: 10.1046/j.1600-6135.2003.00254.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Split-liver transplantation (SLT), a procedure where one cadaver liver is divided to provide for two recipients, offers immediate expansion of the existing cadaver donor pool. To date, the principal beneficiaries of SLT have been adult/pediatric recipient pairs with excellent outcomes reported; however, the current scarcity of cadaver organs has renewed interest in expanding these techniques to include two adult recipients from one adult cadaver donor. Significant obstacles to the widespread application of SLT exist and must be resolved by the transplant community before greater utilization can be realized. This manuscript reviews the historic background, surgical techniques, current results, and obstacles impeding further application of SLT.
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Affiliation(s)
- John F Renz
- Center for Liver Disease and Transplantation, College of Physicians and Surgeons of Columbia University, New York Presbyterian Hospital, New York, NY, USA.
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Gridelli B, Spada M, Petz W, Bertani A, Lucianetti A, Colledan M, Altobelli M, Alberti D, Guizzetti M, Riva S, Melzi ML, Stroppa P, Torre G. Split-liver transplantation eliminates the need for living-donor liver transplantation in children with end-stage cholestatic liver disease. Transplantation 2003; 75:1197-203. [PMID: 12717203 DOI: 10.1097/01.tp.0000061940.96949.a1] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND End-stage cholestatic liver disease (ESCLD) is the main indication for liver replacement in children. Pediatric cadaver-organ-donor shortage has prompted the most important evolutions in the technique of liver transplantation, in particular living-donor liver transplantation (LDLT) and split-liver transplantation (SLT). METHODS Between November 1997 and June 2001, 127 children with ESCLD were evaluated for liver transplantation, and 124 underwent 138 liver transplantations after a median time of 40 days. Causes of liver disease were congenital biliary atresia (n=96), Alagille's syndrome (n=12), Byler's disease (n=8), and other cholestatic diseases (n=8). RESULTS Ninety (73%) patients received a split-liver graft, 28 (23%) a whole liver, and 6 (4%) a reduced-size liver. Overall 2- and 4-year patient survival rates were 93% and 91%, respectively; the 2- and 4-year graft-survival rates were 84% and 80%, respectively. In split-liver recipients, 4-year patient and graft-survival rates were 91% and 83%, respectively; these were 93% and 78%, respectively, in whole-liver recipients and 67% and 63%, respectively, in reduced-size liver recipients. Retransplantation rate was 11%, whereas mortality rate was 8%. Overall incidence of vascular and biliary complication were 16% and 27%, respectively. CONCLUSIONS SLT can provide liver grafts for children with ESCLD with an outcome similar to the one reported following LDLT, eliminating mortality while they are on a transplantation wait list. The need for pediatric LDLT should be reevaluated and programs of SLT strongly encouraged and supported at a national and international level.
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Affiliation(s)
- Bruno Gridelli
- Department of General and Transplantation Surgery, Ospedali Riuniti di Bergamo, Largo Barozzi 1, 24100 Bergamo, Italy
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Ding YT, Qiu YD, Chen Z, Xu QX, Zhang HY, Tang Q, Yu DC. The development of a new bioartificial liver and its application in 12 acute liver failure patients. World J Gastroenterol 2003. [PMID: 12679942 DOI: 10.1016/s1091-255x(02)00290-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM Bioartificial liver is a hope of supporting liver functions in acute liver failure patients. Using polysulfon fibers, a new bioartificial liver was developed. The aim of this study was to show whether this bioartificial liver could support liver functions or not. METHODS Hepatocytes were procured from swine using Seglen's methods. The bioartificial liver was constructed by polysulfon bioreactor and more than 10(10) hepatocytes. It was applied 14 times in 12 patients, who were divided into 7 cases of simultaneous HBAL and 5 cases of non-simultaneous HBAL. Each BAL treatment lasted 6 hours. The general condition of the patients and the biochemical indexes were studied. RESULTS After treatment with bioartificial liver, blood ammonia, prothrombin time and total bilirubin showed significant decrease. 2 days later, blood ammonia still showed improvment. within one month period, 1 case (1/7) in simultaneous group died while in non-simultaneous group 2 cases (2/5) died. The difference was significant. Mortality rate was 25 %. CONCLUSION The constructed bioartificial liver can support liver functions in acute liver failure. The simultaneous HBAL is better than non-simultaneous HBAL.
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Affiliation(s)
- Yi-Tao Ding
- Hepatobiliary Surgical Department, Affiliated Drum Tower Hospital of Medical College in Nanjing University, Zhongshan road, 321, Nanjing, 210008, Jiangsu Province, China.
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Ding YT, Qiu YD, Chen Z, Xu QX, Zhang HY, Tang Q, Yu DC. The development of a new bioartificial liver and its application in 12 acute liver failure patients. World J Gastroenterol 2003; 9:829-832. [PMID: 12679942 PMCID: PMC4611459 DOI: 10.3748/wjg.v9.i4.829] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2002] [Revised: 09/05/2002] [Accepted: 09/12/2002] [Indexed: 02/06/2023] Open
Abstract
AIM Bioartificial liver is a hope of supporting liver functions in acute liver failure patients. Using polysulfon fibers, a new bioartificial liver was developed. The aim of this study was to show whether this bioartificial liver could support liver functions or not. METHODS Hepatocytes were procured from swine using Seglen's methods. The bioartificial liver was constructed by polysulfon bioreactor and more than 10(10) hepatocytes. It was applied 14 times in 12 patients, who were divided into 7 cases of simultaneous HBAL and 5 cases of non-simultaneous HBAL. Each BAL treatment lasted 6 hours. The general condition of the patients and the biochemical indexes were studied. RESULTS After treatment with bioartificial liver, blood ammonia, prothrombin time and total bilirubin showed significant decrease. 2 days later, blood ammonia still showed improvment. within one month period, 1 case (1/7) in simultaneous group died while in non-simultaneous group 2 cases (2/5) died. The difference was significant. Mortality rate was 25 %. CONCLUSION The constructed bioartificial liver can support liver functions in acute liver failure. The simultaneous HBAL is better than non-simultaneous HBAL.
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Affiliation(s)
- Yi-Tao Ding
- Hepatobiliary Surgical Department, Affiliated Drum Tower Hospital of Medical College in Nanjing University, Zhongshan road, 321, Nanjing, 210008, Jiangsu Province, China.
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Vicente E, López-Santamaría M, Nuño J, Gámez M, Murcia J, Quijano Y, López-Hervás P, Tovar JA, Jara P, Frauc E, Honrubia A, Monge G, Bárcena R, García M, Martínez A, Puente A, Domínguez A, Zarzosa G. Bipartición hepática. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72132-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Buell JF, Funaki B, Cronin DC, Yoshida A, Perlman MK, Lorenz J, Kelly S, Brady L, Leef JA, Millis JM. Long-term venous complications after full-size and segmental pediatric liver transplantation. Ann Surg 2002; 236:658-66. [PMID: 12409673 PMCID: PMC1422625 DOI: 10.1097/00000658-200211000-00017] [Citation(s) in RCA: 198] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To assess the long-term incidence of venous complications, including portal vein and hepatic vein stenoses, in both whole cadaveric and reduced-size cadaveric and living related liver transplants in a pediatric population, and to assess the therapeutic modalities in the treatment of these lesions. SUMMARY BACKGROUND DATA A shortage in appropriate-sized liver grafts for pediatric patients led to the use of segmental liver grafts, which became the predominant graft used in 325 of 600 (54%) transplants at the authors' institution. To assess the long-term impact of this strategy, the authors examined the incidence of late (>90 days) venous complications and the efficacy of all therapeutic interventions. METHODS Six hundred pediatric liver transplants were performed in 325 patients, with reduced-size or split (RSS; n = 207), living related (LRD; n = 118), or full-size cadaveric grafts (FS; n = 275) from 1988 to 2000. All transplants identified with late portal vein or vena caval stenoses or thromboses from a cohort of 524 grafts with survival greater than 90 days were reviewed for demographics, symptoms, therapeutic intervention, recurrence, morbidity, and mortality. RESULTS Fifty lesions were identified in 49 patients (38 portal vein and 12 hepatic vein-cava stenoses). Sex distribution was similar between portal vein and hepatic vein to cava, as was the mean patient age. Portal vein stenoses occurred in 32 LRD, 3 RSS, and 3 FS, while hepatic vein-cava stenoses occurred in 2 LRD, 8 RSS, and 2 FS. In the 38 portal vein stenoses, 9 had prior perioperative portal vein and/or 5 hepatic artery thrombectomies. Portal vein stenoses were identified after bleeding (17/38), ascites (6/38), increased liver function tests (6/38), splenomegaly (5/38), or screening ultrasound (4/38). Portal vein stenosis was associated most often with cryopreserved vein for portal conduits. Excluding conduits, the incidence of late portal vein complications was reduced to 1%. Lesions became symptomatic at a mean of 50.8 +/- 184.2 months posttransplant. All patients underwent venous angioplasty with a 66% (25/38) success rate, while 7 of 25 required further angioplasty and stenting. In the 13 unsuccessful angioplasties, 8 required surgical shunts for complete portal vein thrombosis. Recurrence occurred in 9 patients: all were amenable to stenting. Nine patients (24%) eventually died of sepsis (4) and surgical deaths at shunt or retransplant (5). Hepatic vein-cava stenoses occurred after a mean of 37.2 +/- 35.2 months, presenting with ascites (n = 10), increased liver function tests (n = 2), and splenomegaly (n = 2). All patients were diagnosed by venogram and managed by balloon dilatation alone (n = 6) or stented (n = 4), with an 80% (10/12) success, with two late recurrences amenable to repeat angioplasty or stenting. Long-term survival was 80% at 1 year. CONCLUSIONS The use of segmental grafts without venous conduits is not associated with a significant rate of long-term venous complication. When late venous complications do occur, venous angioplasty and stenting are both a safe and effective management modality. If necessary, venous angioplasty may be repeated with the placement of a stent. When this is required, care must be taken to place the stent in a position where the metallic object will not interfere with future surgical manipulations should retransplantation be necessary.
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Affiliation(s)
- Joseph F Buell
- Department of Transplantation Surgery, Pediatrics and Interventional Radiology, The University of Chicago, Pritzker School of Medicine, Chicago, Illinois 60637, USA
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Broering DC, Topp S, Schaefer U, Fischer L, Gundlach M, Sterneck M, Schoder V, Pothmann W, Rogiers X. Split liver transplantation and risk to the adult recipient: analysis using matched pairs. J Am Coll Surg 2002; 195:648-657. [PMID: 12437252 DOI: 10.1016/s1072-7515(02)01339-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The technique of liver splitting is an effective way of increasing the donor pool and reducing pediatric waiting list mortality. But the procedure is still not fully accepted because of concerns that it may cause complications in adult recipients. STUDY DESIGN Fifty-nine adult recipients of primary extended right split liver transplantations (SLTs) were matched to recipients of whole liver transplantations (WLTs) according to the following criteria: 1) United Network for Organ Sharing (UNOS) status, 2) donor age, 3) recipient age, 4) total cold ischemic time, 5) indication for liver transplantation, 6) Child-Pugh class, and 7) year of transplantation. A WLT-recipient match was identified in 40 adult recipients of primary SLT. RESULTS Fifteen percent of the recipients in our study were highly urgent cases (UNOS 1), and 85% were UNOS status 3-4. The 3- and 12-month patient survival rates after SLT and WLT were 82.5% and 77.1%, and 92.5% and 87.5%, respectively (log rank p = 0.358). The 3- and 12-month graft survival rates showed no significant difference in either group (80% and 74% in SLT and 87.5% and 77.4% in WLT [log rank p = 0.887]). The rates of primary nonfunction, primary poor function, biliary and vascular complications, intra- and postoperative blood transfusion, and intensive care stay were comparable for SLT and WLT. CONCLUSIONS SLT, using the extended right hepatic lobe, does not notably differ from WLT with regard to initial graft function, postoperative complications, or patient and graft survival. Based on this, the liver can be considered a paired organ, and mandatory splitting of good-quality livers can be recommended.
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Affiliation(s)
- Dieter C Broering
- Department of Hepatobiliary Surgery and Transplantation, University Hospital-Eppendorf, University of Hamburg, Germany
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Emond JC, Freeman RB, Renz JF, Yersiz H, Rogiers X, Busuttil RW. Optimizing the use of donated cadaver livers: analysis and policy development to increase the application of split-liver transplantation. Liver Transpl 2002; 8:863-72. [PMID: 12360426 DOI: 10.1053/jlts.2002.34639] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The American Society of Transplant Surgeons and the American Society of Transplantation jointly sponsored a conference in Crystal City, Virginia, on March 28th and 29th, 2001, to explore mechanisms for maximizing the cadaver-organ donor pool. Participants from transplantation medicine, surgery, organ procurement organizations, the general public, and government convened to address expanding utilization of each organ type. The committee assigned to review liver organ utilization identified multiple practices that could expand the potential donor pool including non-heart beating donors, marginal grafts, efficient allocation of cadaver organs, and wider application of split-liver transplantation. This article details the data reviewed by the liver committee and their recommendations on policy development for the expanded application of split-liver transplantation.
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Affiliation(s)
- Jean C Emond
- Center for Liver Diseases and Transplantation, New York Presbyterian Hospital, New York, NY 10032, USA.
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Abstract
INTRODUCTION This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation. REFERRAL AND ASSESSMENT This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice. DONOR ORGANS The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed. OPERATIVE TECHNIQUE The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols. RETRANSPLANTATION The role of retransplantation is reviewed. OUTCOME AND SURVIVAL The results of liver transplantation are reviewed with specific emphasis on our own experience. FUTURE The future of liver transplantation is addressed.
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Affiliation(s)
- S R Bramhall
- Department of Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
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Affiliation(s)
- H P Grewal
- Department of Surgery, University of Tennessee, Memphis, TN 38163, USA.
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40
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Kogan-Liberman D, Emre S, Shneider BL. Recent advances in pediatric liver transplantation. Curr Gastroenterol Rep 2002; 4:84-97. [PMID: 11825546 DOI: 10.1007/s11894-002-0042-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pediatric liver transplantation has matured into a well-established, highly successful treatment for advanced pediatric liver disease. Recent 1-year success rates range from 85% to 95%. This unprecedented achievement is the result of careful selection criteria and optimal timing of transplantation, technical advances in surgical technique, and improved treatment following transplant. This report highlights many recent published findings representing advances that have led to current successful approaches.
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Affiliation(s)
- Debora Kogan-Liberman
- Department of Pediatrics, Recanati/Miller Transplantation Institute, Mount Sinai School of Medicine, Box 1656, One Gustave L. Levy Place, New York, NY 10029, USA
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Abstract
In many clinical scenarios, liver imaging does not differ as greatly in children as in adults. Common indications for liver imaging in children include trauma, suspected mass, pre-transplantation studies, monitoring after liver transplantation, jaundice, or liver dysfunction. This article highlights areas in which pathology or imaging approach in children differs from that seen in adults. Topics covered include imaging of a suspected hepatic mass, neonatal jaundice, and segmental liver transplantation.
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Affiliation(s)
- Lane F Donnelly
- Department of Radiology, Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA.
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Rigsby CK, Superina R, Alonso EM, Mueller PR, Donaldson JS. Interventional Radiology in the Pediatric Liver Transplant Patient. Semin Intervent Radiol 2002; 19:59-72. [PMID: 38444433 PMCID: PMC10911270 DOI: 10.1055/s-2002-25140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Liver transplantation now plays a major role in the treatment of end-stage liver disease in children. Reduced-size liver transplant surgical techniques have allowed increasing numbers of children to undergo liver transplantation. As more children are undergoing liver transplantation, there is a growing need for radiologic diagnosis of and intervention in post-transplantation complications in these patients.
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Affiliation(s)
- Cynthia K Rigsby
- Department of Radiology, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
| | - Riccardo Superina
- Department of Surgery, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
| | - Estella M Alonso
- Department of Pediatrics, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
| | - Peter R Mueller
- Department of Radiology, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
- Department of Surgery, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
| | - James S Donaldson
- Department of Radiology, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
- Department of Surgery, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University School of Medicine, Children's Memorial Hospital, Chicago, Illinois
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Farmer DG, Yersiz H, Ghobrial RM, McDiarmid SV, Gornbein J, Le H, Schlifke A, Amersi F, Maxfield A, Amos N, Restrepo GC, Chen P, Dawson S, Busuttil RW. Early graft function after pediatric liver transplantation: comparison between in situ split liver grafts and living-related liver grafts. Transplantation 2001; 72:1795-802. [PMID: 11740391 DOI: 10.1097/00007890-200112150-00015] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The systematic application of living-related and cadaveric, in situ split-liver transplantation has helped to alleviate the critical shortage of suitable-sized, pediatric donors. Undoubtedly, both techniques are beneficial and advantageous; however, the superiority of either graft source has not been demonstrated directly. Because of the potential living-donor risks, we reserve the living donor as the last graft option for pediatric recipients awaiting liver transplantation. Inasmuch as no direct comparison between these two graft types has been performed, we sought to perform a comparative analysis of the functional outcomes of left lateral segmental grafts procured from these donor sources to determine whether differences do exist. METHODS A retrospective analysis of all liver transplants performed at a single institution between February 1984 and January 1999 was undertaken. Only pediatric (<18 years) recipients of left lateral segmental grafts procured from either living-related (LRD) or cadaveric, in situ split-liver (SLD) donors were included. A detailed analysis of preoperative, intraoperative, and postoperative variables was undertaken. Survival was estimated using the Kaplan-Meier method, and comparison of variables between groups was undertaken using the t test of Wilcoxon rank sum test. RESULTS There were no significant differences in the preoperative variables between the 39 recipients of SLD grafts and 34 recipients of LRD grafts. The donors did differ significantly in mean age, ABO blood group matching, and preoperative liver function testing. Postoperative liver function testing revealed significant early differences in aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, prothrombin time, and alkaline phosphatase, with grafts from LRD performing better than those from SLD. SLD grafts also had significantly longer ischemia times and a higher incidence of graft loss owing to primary nonfunction and technical complications (9 vs. 2, P<0.05). However, six of these graft losses in the SLD group were because of technical or immunologic causes, which, theoretically, should not differ between the two groups. Furthermore, these graft losses did not negatively impact early patient survival as most patients were successfully rescued with retransplantation (30-day actuarial survival, 97.1% SLD vs. 94.1% LRD, P=0.745). In the surviving grafts, the early differences in liver function variables normalized. CONCLUSIONS Inherent differences in both donor sources exist and account for differences seen in preoperative and intraoperative variables. Segmental grafts from LRD clearly performed better in the first week after transplantation as demonstrated by lower liver function variables and less graft loss to primary nonfunction. However, the intermediate function (7-30 days) of both grafts did not differ, and the early graft losses did not translate into patient death. Although minimal living-donor morbidity was seen in this series, the use of this donor type still carries a finite risk. We therefore will continue to use SLD as the primary graft source for pediatric patients awaiting liver transplantation.
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Affiliation(s)
- D G Farmer
- Division of Liver and Pancreas Transplantation, Dumont-UCLA Transplant Center, 90095-7054, USA.
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Broering DC, Mueller L, Ganschow R, Kim JS, Achilles EG, Schäfer H, Gundlach M, Fischer L, Sterneck M, Hillert C, Helmke K, Izbicki JR, Burdelski M, Rogiers X. Is there still a need for living-related liver transplantation in children? Ann Surg 2001; 234:713-722. [PMID: 11729377 PMCID: PMC1422130 DOI: 10.1097/00000658-200112000-00002] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess and compare the value of split-liver transplantation (SLT) and living-related liver transplantation (LRT). SUMMARY BACKGROUND DATA The concept of SLT results from the development of reduced-size transplantation. A further development of SLT, the in situ split technique, is derived from LRT, which itself marks the optimized outcome in terms of postoperative graft function and survival. The combination of SLT and LRT has abolished deaths on the waiting list, thus raising the question whether living donor liver transplantation is still necessary. METHODS Outcomes and postoperative liver function of 43 primary LRT patients were compared with those of 49 primary SLT patients (14 ex situ, 35 in situ) with known graft weight performed between April 1996 and December 2000. Survival rates were analyzed using the Kaplan-Meier method. RESULTS After a median follow-up of 35 months, actual patient survival rates were 82% in the SLT group and 88% in the LRT group. Actual graft survival rates were 76% and 81%, respectively. The incidence of primary nonfunction was 12% in the SLT group and 2.3% in the LRT group. Liver function parameters (prothrombin time, factor V, bilirubin clearance) and surgical complication rates did not differ significantly. In the SLT group, mean cold ischemic time was longer than in the LRT group. Serum values of alanine aminotransferase during the first postoperative week were significantly higher in the SLT group. In the LRT group, there were more grafts with signs of fatty degeneration than in the SLT group. CONCLUSIONS The short- and long-term outcomes after LRT and SLT did not differ significantly. To avoid the risk for the donor in LRT, SLT represents the first-line therapy in pediatric liver transplantation in countries where cadaveric organs are available. LRT provides a solution for urgent cases in which a cadaveric graft cannot be found in time or if the choice of the optimal time point for transplantation is vital.
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Affiliation(s)
- D C Broering
- Department of Surgery, University Hospital Eppendorf, University of Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.
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Guarrera JV, Emond JC. Advances in segmental liver transplantation: can we solve the donor shortage? Transplant Proc 2001; 33:3451-5. [PMID: 11750478 DOI: 10.1016/s0041-1345(01)02488-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- J V Guarrera
- Department of Surgery and The Center for Liver Disease and Transplantation, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA
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Bramhall SR, Minford E, Gunson B, Buckels JA. Liver transplantation in the UK. World J Gastroenterol 2001; 7:602-11. [PMID: 11819840 PMCID: PMC4695560 DOI: 10.3748/wjg.v7.i5.602] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2001] [Revised: 06/06/2001] [Accepted: 06/15/2001] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation. REFERRAL AND ASSESSMENT This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice. DONOR ORGANS The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed. OPERATIVE TECHNIQUE The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols. RETRANSPLANTATION The role of retransplantation is reviewed. OUTCOME AND SURVIVAL The results of liver transplantation are reviewed with specific emphasis on our own experience. FUTURE The future of liver transplantation is addressed.
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Affiliation(s)
- S R Bramhall
- Department of Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
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47
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Abstract
Living donor liver transplantation was developed in response to a shortage of full-size grafts for children. The progression from reduced-size cadaveric grafts to use of living donors occurred subsequent to expansion of liver anatomy knowledge and practical use of hepatic segments. A major benefit of pediatric live donor liver transplantation is the grafting of children without using livers from the cadaver donor pool. A major drawback of the procedure relates to the need to perform surgery and assign risk to an otherwise healthy individual. The ethical challenge has been discussed in detail and, although not ideal, the procedure "passes muster" on grounds of informed consent and the good of helping another human being. Formidable success appears to have been attained with the adult-to-adult procedure thus far; however, the transplant community still awaits center-specific and compiled data to determine whether the procedure truly reduces adult waiting list times for liver transplant recipients with minimal donor risk.
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Affiliation(s)
- D S Seaman
- Abdominal Organ transplantation, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio 44106, USA.
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Abstract
Liver transplantation from living related donors was unthinkable until recently, when the safety of modern hepatic surgery became widely appreciated. The first step was the successful demonstration that parts of livers could be transplanted. This technique, termed reduced-size liver transplantation, evolved into reliable procedures to allow parents to donate small parts of their livers to small children. More recently, right hepatectomy, in which up to 70% of the liver is resected for donation, has been performed in adults. As the demand for liver transplantation continues to increase, the development of ethically sound, medically and surgically optimal programs for routine use of living donors has become essential. This chapter provides a broad overview of the evolution and current state of liver transplantation with living donors.
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Affiliation(s)
- B Samstein
- The Center for Liver Disease and Transplantation, New York Presbyterian Hospital, Columbia College of Physicians and Surgeons, New York, New York 10032
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