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Liou PH, Emond JC. Machine Preservation and the Full Potential of Split Liver Transplantation. Transplantation 2024; 108:1275-1276. [PMID: 38755747 DOI: 10.1097/tp.0000000000005067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
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Barrios O, Dopazo C, López-Boado MA, Gómez-Gavara C, Fundora Suarez Y, Torrents A, Llado L. Optimized results of the liver partition program for split-liver transplantation. Cir Esp 2024; 102:84-89. [PMID: 37980966 DOI: 10.1016/j.cireng.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/27/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION Split liver transplantation is a procedure performed throughout Europe. In 2018 in Catalonia, the distribution of donors was redefined, being potential candidates for SPLIT all those under 35-years and it was made flexible the adult selection for the right graft. The study aim is to evaluate the effect of this modifications on the use of Split donors on the adult/pediatric waiting lists, as well as to evaluate the post-transplant results of adults who received a Split donor. METHODS Observational and retrospective study; 2 data collection periods "PRE" (2013-2017) and "POST" (2018-2021). The adults recipients results were analyzed by a propensity score matching. RESULTS In the first period 3 donors were registered and 3 pediatric patients and 2 adults recieved a transplant. In the POST period, 24 donations with liver bipartition were made, performing the transplant in 19 adults and 24 childrens. When comparing the adults waiting lists, a significant decrease was evidenced, both for adults (p = 0,0001) and on the children's waiting list (p = 0,0004), and up to 3 times there were no recipients on the pediatric waiting list. No significant differences between hospital morbidity or mortality or overall survival were observed in the group of adult recipients of Split grafts. CONCLUSIONS The flexibility in the selection of the adult recipient and the new distribution of donors makes possible to increase the bipartition rate, reducing the pediatric waiting list without worsening the adults results transplant recipients or their permanence on the waiting list.
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Affiliation(s)
- Oriana Barrios
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Universitari de Bellvitge, Barcelona, Spain.
| | - Cristina Dopazo
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Universitari Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Miguel Angel López-Boado
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Clinic Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Concepción Gómez-Gavara
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Universitari Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Yiliam Fundora Suarez
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Clinic Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Abiguei Torrents
- Organización Catalana de Trasplantes (OCATT), Servicio Catalán de Salud, Cataluña, Spain
| | - Laura Llado
- Departamento de Cirugía HBP y Trasplante Hepático, Hospital Universitari de Bellvitge, Barcelona, Spain
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Lauterio A, Cillo U, Spada M, Trapani S, De Carlis R, Bottino G, Bernasconi D, Scalamogna C, Pinelli D, Cintorino D, D'Amico FE, Spagnoletti G, Miggino M, Romagnoli R, Centonze L, Caccamo L, Baccarani U, Carraro A, Cescon M, Vivarelli M, Mazaferro V, Ettorre GM, Rossi M, Vennarecci G, De Simone P, Angelico R, Agnes S, Di Benedetto F, Lupo LG, Zamboni F, Zefelippo A, Patrono D, Diviacco P, Laureiro ZL, Gringeri E, Di Francesco F, Lucianetti A, Valsecchi MG, Gruttadauria S, De Feo T, Cardillo M, De Carlis L, Colledan M, Andorno E. Improving outcomes of in situ split liver transplantation in Italy over the last 25 years. J Hepatol 2023; 79:1459-1468. [PMID: 37516203 DOI: 10.1016/j.jhep.2023.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND & AIMS Split liver transplant(ation) (SLT) is still considered a challenging procedure that is by no means widely accepted. We aimed to present data on 25-year trends in SLT in Italy, and to investigate if, and to what extent, outcomes have improved nationwide during this time. METHODS The study included all consecutive SLTs performed from May 1993 to December 2019, divided into three consecutive periods: 1993-2005, 2006-2014, and 2015-2019, which match changes in national allocation policies. Primary outcomes were patient and graft survival, and the relative impact of each study period. RESULTS SLT accounted for 8.9% of all liver transplants performed in Italy. A total of 1,715 in situ split liver grafts were included in the analysis: 868 left lateral segments (LLSs) and 847 extended right grafts (ERGs). A significant improvement in patient and graft survival (p <0.001) was observed with ERGs over the three periods. Predictors of graft survival were cold ischaemia time (CIT) <6 h (p = 0.009), UNOS status 2b (p <0.001), UNOS status 3 (p = 0.009), and transplant centre volumes: 25-50 cases vs. <25 cases (p = 0.003). Patient survival was significantly higher with LLS grafts in period 2 vs. period 1 (p = 0.008). No significant improvement in graft survival was seen over the three periods, where predictors of graft survival were CIT <6 h (p = 0.007), CIT <6 h vs. ≥10 h (p = 0.019), UNOS status 2b (p = 0.038), and UNOS status 3 (p = 0.009). Retransplantation was a risk factor in split liver graft recipients, with significantly worse graft and patient survival for both types of graft (p <0.001). CONCLUSIONS Our analysis showed Italian SLT outcomes to have improved over the last 25 years. These results could help to dispel reservations regarding the use of this procedure. IMPACT AND IMPLICATIONS Split liver transplant(ation) (SLT) is still considered a challenging procedure and is by no means widely accepted. This study included all consecutive in situ SLTs performed in Italy from May 1993 to December 2019. With more than 1,700 cases, it is one of the largest series, examining long-term national trends in in situ SLT since its introduction. The data presented indicate that the outcomes of SLT improved during this 25-year period. Improvements are probably due to better recipient selection, refinements in surgical technique, conservative graft-to-recipient matching, and the continuous, yet carefully managed, expansion of donor selection criteria under a strict mandatory split liver allocation policy. These results could help to dispel reservations regarding the use of this procedure.
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Affiliation(s)
- Andrea Lauterio
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Marco Spada
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Silvia Trapani
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Riccardo De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; PhD Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Giuliano Bottino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Davide Bernasconi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Chiara Scalamogna
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenico Pinelli
- Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Davide Cintorino
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | | | - Gionata Spagnoletti
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Marco Miggino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Renato Romagnoli
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Leonardo Centonze
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Caccamo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Umberto Baccarani
- Department of Medicine, Liver Transplant Center, University of Udine, Italy
| | - Amedeo Carraro
- Liver Transplant Unit, University and Hospital Trust of Verona, Italy
| | - Matteo Cescon
- Hepatobiliary Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, United Hospital of Ancona, Department of Experimental and Clinical Medicine Polytechnic University of Marche, Ancona, Italy
| | - Vincenzo Mazaferro
- Department of Oncology and Onco-Hematology, University of Milan, Italy; Department of Surgery, Istituto Nazionale Tumori Fondazione IRCCS Milan, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Giovanni Vennarecci
- Division of Hepatobiliary Surgery and Liver Transplant Center, AORN Cardarelli, Naples, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation AOU Pisana, Pisa, Italy
| | - Roberta Angelico
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Salvatore Agnes
- Department of Surgery, Transplantation Service, Catholic University of the Sacred Heart, Foundation A. Gemelli Hospital, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit Azienda Ospedaliera Policlinico, University of Modena and Reggio Emilia Modena, Italy
| | - Luigi Giovanni Lupo
- General Surgery and Liver Transplantation Unit, University of Bari, Bari, Italy
| | - Fausto Zamboni
- Department of Surgery, General and Hepatic Transplantation Surgery Unit, A.O.B. Brotzu, Cagliari, Italy
| | - Arianna Zefelippo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Damiano Patrono
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pietro Diviacco
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Zoe Larghi Laureiro
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Fabrizio Di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Alessandro Lucianetti
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Maria Grazia Valsecchi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy; Department of Surgery and Medical and Surgical Specialties, University of Catania, 95124, Catania, Italy
| | - Tullia De Feo
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cardillo
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Luciano De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Colledan
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Enzo Andorno
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
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da Fonseca EA, Feier FH, Costa CM, Benavides MAR, Vincenzi R, de Oliveira Roda Vincenzi KM, Pugliese RPS, Porta G, Miura IK, de Oliveira CMV, Chapchap P, Neto JS. Hepatic venous reconstruction of the left lateral segment with emphasis on anomalous hepatic vein in pediatric liver transplantation. Liver Transpl 2023; 29:827-835. [PMID: 36847137 DOI: 10.1097/lvt.0000000000000108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/05/2023] [Indexed: 03/01/2023]
Abstract
Left lateral segment grafts have become a suitable option in pediatric liver transplantation (PLT). The correlation between hepatic vein (HV) reconstruction and outcome is relevant when assessing the safe use of these grafts. We retrospectively reviewed the medical records prospectively collected from a pediatric living donor liver transplantation database and conducted a comparative analysis of the different left lateral segment graft types according to HV reconstruction. Donor, recipient, and intraoperative variables were analyzed. Post-transplant outcomes included vascular complications such as hepatic vein outflow obstruction, early (≤30 d) and late (>30 d) PVT, hepatic artery thrombosis, and graft survival. From February 2017 to August 2021, 303 PLTs were performed. According to venous anatomy, the distribution of the left lateral segment was as follows: single HV (type I) in 174 (57.4%), close HVs, simple venoplasty for reconstruction (type II) in 97 (32.01%), anomalous hepatic vein (AHV) with a distance between the HVs orifices that allowed simple venoplasty (type IIIA) in 25 (8.26%) and AHV with a distance between the HVs orifices requiring homologous venous graft interposition (type IIIB) in 07 (2.31%) grafts. Type IIIB grafts came from male donors ( p =0.04) and had a higher mean donor height ( p =0.008), a higher mean graft weight, and a higher graft-to-recipient weight ratio, both p =0.002. The median follow-up time was 41.4 months. The overall cumulative graft survival was 96.3%, and comparative graft survival showed no difference (log-rank p =0.61). No hepatic vein outflow obstructions were observed in this cohort study. There was no statistically significant difference in the post-transplant outcomes between the graft types. The venous reconstruction of the AHV with homologous venous graft interposition had similar outcomes in the short and long term.
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Affiliation(s)
- Eduardo Antunes da Fonseca
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Flavia Heinz Feier
- Hepatology and Liver Transplantation, Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | - Carolina Magalhães Costa
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Marcel Albeiro Ruiz Benavides
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Rodrigo Vincenzi
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Karina Moreira de Oliveira Roda Vincenzi
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Renata Pereira Sustovich Pugliese
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Gilda Porta
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Irene Kazuo Miura
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Caio Marcio Vieira de Oliveira
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Paulo Chapchap
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
| | - João Seda Neto
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
- Hepatology and Liver Transplantation, AC Camargo Cancer Center, São Paulo, SP, Brazil
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Abstract
Liver transplantation (LT) for children results in excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and select genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, appropriate patient selection and evaluation, allocation of organs, transplant surgery including the use of variant grafts, posttransplant care including immunosuppression management, prognosis, and transition of care.
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Affiliation(s)
- Sara Kathryn Smith
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins School of Medicine, 600 N Wolfe Street, Baltimore, MD 21287, USA.
| | - Tamir Miloh
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Miami, Highland Professional Building, 1801 Northwest 9th Avenue, Miami, FL 33136, USA
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6
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Lau NS, Jacques A, McCaughan G, Crawford M, Liu K, Pulitano C. Addressing the challenges of split liver transplantation through technical advances. A systematic review. Transplant Rev (Orlando) 2021; 35:100627. [PMID: 34052472 DOI: 10.1016/j.trre.2021.100627] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/08/2021] [Accepted: 05/17/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Split liver transplantation addresses donor shortages by facilitating the transplant of two recipients using one donor liver. Some still consider these grafts inferior due to prolonged cold ischaemia time and at times difficult vascular reconstruction. Techniques such as in-situ splitting, machine perfusion and interposition grafts may address these challenges and thereby address these concerns. The aim of this review is to assess these technical advances in split liver transplantation, their utility and outcomes. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Keywords included 'split liver transplantation', 'arterial reconstruction', and 'machine perfusion'. Data found was synthesised into sections including: methods of splitting, full-left full-right splitting, donor cholangiography, machine perfusion and arterial reconstruction. RESULTS A total of 78 articles met inclusion criteria after screening of 151 eligible articles. These were subdivided into the following categories: in-situ (25), ex-vivo (25), full-left full-right splitting (15), donor cholangiography (2), machine perfusion (6), and arterial reconstruction (5). The in-situ splitting technique reduces the cold ischaemia time compared to the ex-vivo technique which may improve graft quality and liver splitting during normothermic machine perfusion is a novel technique with the potential to incorporate the best aspects of both techniques. Interposition grafts are often required during split liver transplantation but have an increased risk of hepatic artery thrombosis. CONCLUSION Advancements in technique have allowed many of the unique challenges of split liver transplantation to be overcome. Overall, this supports the use of split liver transplantation in broader and riskier settings and we advocate for liver transplant surgeons to not hesitate in using these grafts liberally and expanding their recipient selection criteria.
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Affiliation(s)
- Ngee-Soon Lau
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Andrew Jacques
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Geoffrey McCaughan
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia
| | - Ken Liu
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales 2050, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia.
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Rogiers X, Broering D, Topp S, Gundlach M. Technical and Physiological Limits of Split Liver Transplantation into Two Adults. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2000.12098565] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- X. Rogiers
- Dept. of Hepatobiliary Surgery, Clinic of Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - D. Broering
- Dept. of Hepatobiliary Surgery, Clinic of Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - S. Topp
- Dept. of Hepatobiliary Surgery, Clinic of Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - M. Gundlach
- Dept. of Hepatobiliary Surgery, Clinic of Surgery, University Hospital Eppendorf, Hamburg, Germany
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8
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Colledan M, Segalin A, Andorno E, Corno V, Lucianetti A, Spada M, Gridelli B. Modified Splitting Technique for Liver Transplantation in Adult-Sized Recipients. Technique and Preliminary Results. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2000.12098571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- M. Colledan
- Liver Transplant Unit, Ospedali Riuniti di Bergamo, Italy
| | - A. Segalin
- Liver Transplant Unit, Ospedali Riuniti di Bergamo, Italy
| | - E. Andorno
- Transplant Unit, Ospedale San Martino, Genova, Italy
| | - V. Corno
- Liver Transplant Unit, Ospedali Riuniti di Bergamo, Italy
| | - A. Lucianetti
- Liver Transplant Unit, Ospedali Riuniti di Bergamo, Italy
| | - M. Spada
- Liver Transplant Unit, Ospedali Riuniti di Bergamo, Italy
| | - B. Gridelli
- Liver Transplant Unit, Ospedali Riuniti di Bergamo, Italy
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9
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First simultaneous and synchronized split-liver transplantation involving two recipients and three surgeons in Costa Rica: A case report. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Spaggiari M, Mashbari H, Di Bella C, Benedetti E, Tzvetanov I. Portojejunostomy in Split Liver Transplantation as a Rescue Technique for Challenging Biliary Reconstruction: A Case Report. Transplant Proc 2019; 51:575-578. [PMID: 30879593 DOI: 10.1016/j.transproceed.2018.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 11/29/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
Cadaveric split liver transplantation (SLT) is a valid option to increase the pool of cadaveric organs, obtaining 2 functioning grafts from a single donor. Typically, SLT is performed for 1 adult and 1 pediatric recipient. However, on the heels of great results achieved in living donor liver transplantation, splitting cadaveric liver into full right graft and full left graft for 2 adults has become a feasible idea. The rate of biliary complications remains the "Achilles heel" in partial graft liver transplantation, either from cadaveric or living donors. In cases of biliary complications, interventional radiology and/or endoscopic procedures are the cornerstone of management. Surgical revision is left as the last option. When surgical revision fails, retransplantation becomes the only rescue option. Herein we describe the case of a cadaveric SLT, complicated by biliary leakage in the presence of multiple bile ducts. A duct-to-duct anastomosis was not feasible. Therefore, a hepaticojejunostomy was performed and resulted in a high-output biliary leak from different sources. Given the anatomy of the biliary tree, radiologic interventional measures were not feasible to address the leak. The idea of performing a portoenterostomy to restore bilioenteric continuity proved to be successful. Portoenterostomy should not be performed in lieu of other alternatives, but rather as the last option to avoid retransplantation in cases of complicated biliary reconstruction after partial graft liver transplant.
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Affiliation(s)
- M Spaggiari
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA.
| | - H Mashbari
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA
| | - C Di Bella
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA
| | - E Benedetti
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA
| | - I Tzvetanov
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA
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12
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Gavriilidis P, Roberts KJ, Azoulay D. Right lobe split liver graft versus whole liver transplantation: A systematic review by updated traditional and cumulative meta-analysis. Dig Liver Dis 2018; 50:1274-1282. [PMID: 30236766 DOI: 10.1016/j.dld.2018.08.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 08/20/2018] [Accepted: 08/22/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Advancements in surgical techniques and experience of donor-recipient pairing has led to a wider use of right split liver grafts in adults. An update meta-analysis was conducted to compare right split liver graft (RSLG) and whole liver transplantation (WLT) using traditional and cumulative approaches. METHODS Databases were searched for relevant articles over the previous 20 years (MEDLINE, Embase, Cochrane Library, and Google Scholar). Meta-analyses were performed using both fixed and random effects models. Patient and graft survival were obtained using the inverse variance hazard ratio method. RESULTS Donors were significantly younger in the RSLG group than in the WLT group (MD = -12.06 [-16.29 to -7.83]; P < .001). In addition, the model for end-stage liver disease (MELD) score was significantly lower in the RSLG group than in the WLT group (MD = -2.45 [-4.61 to -.28]; P = .03). However, cold ischaemia time was significantly longer by 1 h in the RSLG group than in the WLT group (MD = 57 [20.63-92.73]; P = .002). Overall biliary, vascular, and outflow tract complications and hepatic artery thrombosis were significantly lower in the WLT group than in the RSLG group (odds ratio [OR] = 1.75 [1.35-2.27], P < .001; OR = 1.91 [1.37-2.65], P = .006; Peto OR = 1.83 [1.19-2.82], P = .006; and Peto OR = 2.07 [1.39-3.10], P = .004, respectively). However, no difference in patient and graft survival was noted between the two cohorts. CONCLUSIONS Although the RSLG group had a higher postoperative complication rate than the WLT group, equal patient and graft survival benefits were observed.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, UK; Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, Créteil, France.
| | - Keith J Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, UK
| | - Daniel Azoulay
- Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, Créteil, France
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13
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Abstract
Liver transplantation (LT) for children has excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and a few genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, patient selection and evaluation, allocation, transplant surgery and organ selection, posttransplant care, prognosis, adherence, and transition of care.
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Affiliation(s)
- Yen H Pham
- Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Texas Children's Hospital, 18200 Katy Freeway, Suite 250, Houston, TX 77094, USA
| | - Tamir Miloh
- Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA.
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14
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Zamora-Valdes D, Leal-Leyte P, Kim P, Testa G. Fighting Mortality in the Waiting List: Liver Transplantation in North America, Europe, and Asia. Ann Hepatol 2018; 16:480-486. [PMID: 28612751 DOI: 10.5604/01.3001.0010.0271] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.
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Affiliation(s)
- Daniel Zamora-Valdes
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Pilar Leal-Leyte
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Peter Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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15
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Testa G, Anthony T, McKenna GJ, Koon EC, Wallis K, Klintmalm GB, Reese JC, Johannesson L. Deceased donor uterus retrieval: A novel technique and workflow. Am J Transplant 2018; 18:679-683. [PMID: 28858421 DOI: 10.1111/ajt.14476] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/03/2017] [Accepted: 08/18/2017] [Indexed: 01/25/2023]
Abstract
Uterus transplantation has proven successful when performed with a living donor. Subsequently, interest in the novel field of reproductive transplantation is growing. The procedure is still considered experimental, with fewer than 25 cases performed worldwide, and the techniques of both uterus procurement and transplantation are still developing. We detail a new approach to deceased donor uterus procurement. In contrast to reported techniques and our own initial experience, in which the deceased donor uterus was procured post cross-clamp and after other organs were procured, our approach now is to perform the uterus procurement prior to the procurement of other organs in a multiorgan donor and hence prior to cross-clamp. We describe our practical experience in developing and implementing the logistical workflow for deceased donor uterus procurement in a deceased multiorgan donor setting.
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Affiliation(s)
- G Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - T Anthony
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - E C Koon
- Obstetrics and Gynecology/Gynecologic Oncology, Baylor University Medical Center, Dallas, TX, USA
| | - K Wallis
- Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - J C Reese
- Southwest Transplant Alliance, Dallas, TX, USA
| | - L Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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16
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Andrassy J, Wolf S, Lauseker M, Angele M, van Rosmalen MD, Samuel U, Rogiers X, Werner J, Guba M. Higher retransplantation rate following extended right split-liver transplantation: An analysis from the eurotransplant liver follow-up registry. Liver Transpl 2018; 24:26-34. [PMID: 29144580 DOI: 10.1002/lt.24980] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/19/2017] [Accepted: 10/11/2017] [Indexed: 12/13/2022]
Abstract
Split-liver transplantation has been perceived as an important strategy to increase the supply of liver grafts by creating 2 transplants from 1 allograft. The Eurotransplant Liver Allocation System (ELAS) envisages that the extended right lobes (ERLs) after splitting (usually in the pediatric center) are almost exclusively shipped to a second center. Whether the ELAS policy impacts the graft and patient survival of extended right lobe transplantation (ERLT) in comparison to whole liver transplantation (WLT) recipients remains unclear. Data on all liver transplantations performed between 2007 and 2013 were retrieved from the Eurotransplant Liver Follow-up Registry (n = 5351). Of these, 5013 (269 ERL, 4744 whole liver) could be included. The impact of the transplant type on patient and graft survival was evaluated using univariate and multivariate proportional hazard models adjusting for demographics of donors and recipients. Cold ischemia times were significantly prolonged for ERLTs (P < 0.001). Patient survival was not different between ERLT and WLT. In the univariate analysis, ERLT had a significantly higher risk for retransplantation (P = 0.02). For WLT, the risk for death gradually and significantly increased with laboratory Model for End-Stage Liver Disease (MELD) scores of >20. For ERLT, this effect was seen already with laboratory MELD scores of >14. These results mandate a discussion on how to refine the splitting policy to avoid excess retransplant rates in ERL recipients and to further improve transplant outcomes of these otherwise optimal donor organs. Liver Transplantation 24 26-34 2018 AASLD.
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Affiliation(s)
- Joachim Andrassy
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Sebastian Wolf
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Michael Lauseker
- Institute for Biometrics and Epidemiology, Ludwig-Maximilian University, Munich, Germany
| | - Martin Angele
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
| | | | - Undine Samuel
- Eurotransplant International Foundation, Leiden, the Netherlands
| | - Xavier Rogiers
- Eurotransplant International Foundation, Leiden, the Netherlands
| | - Jens Werner
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Markus Guba
- Department of Surgery, Ludwig-Maximilian University, Munich, Germany
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17
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Assalino M, Majno P, Toso C, Berney T, Giraud R, Dutkowski P, Andres A, Wildhaber B, Elkrief L. In situ liver splitting under extracorporeal membrane oxygenation in brain-dead donor. Am J Transplant 2018; 18:258-261. [PMID: 28801937 DOI: 10.1111/ajt.14461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/21/2017] [Accepted: 08/01/2017] [Indexed: 01/25/2023]
Abstract
Hemodynamic instability is generally considered as a contraindication to liver splitting, in particular when using an in situ technique. We describe the cases of two young donors with brain death in whom refractory cardiac arrest and hemodynamic instability were supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), allowing uneventful in situ splitting. Two adult and two pediatric liver recipients were successfully transplanted with immediate graft function. Favorable outcomes were also observed for the other transplanted organs, including one heart, two lungs, and four kidneys. Refractory cardiac arrest and hemodynamic instability corrected by VA-ECMO should not be considered as a contraindication to in situ liver splitting.
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Affiliation(s)
- Michela Assalino
- Division of Transplantation, Department of Surgery, University Hospitals, Geneva, Switzerland
| | - Pietro Majno
- Division of Transplantation, Department of Surgery, University Hospitals, Geneva, Switzerland.,HPB Center, University Hospitals of Geneva, Geneva, Switzerland
| | - Christian Toso
- Division of Transplantation, Department of Surgery, University Hospitals, Geneva, Switzerland
| | - Thierry Berney
- Division of Transplantation, Department of Surgery, University Hospitals, Geneva, Switzerland
| | - Raphaël Giraud
- Intensive Care University Hospitals, Geneva, Switzerland
| | - Philipp Dutkowski
- Division of Transplantation, University Hospital, Zurich, Switzerland
| | - Axel Andres
- Division of Transplantation, Department of Surgery, University Hospitals, Geneva, Switzerland
| | - Barbara Wildhaber
- University Center of Pediatric Surgery of Western Switzerland, University Hospitals, Geneva, Switzerland
| | - Laure Elkrief
- Division of Transplantation, Department of Surgery, University Hospitals, Geneva, Switzerland
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18
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Nacoti M, Cazzaniga S, Colombo G, Corbella D, Fazzi F, Fochi O, Gattoni C, Zambelli M, Colledan M, Bonanomi E. Postoperative complications in cirrhotic pediatric deceased donor liver transplantation: Focus on transfusion therapy. Pediatr Transplant 2017; 21. [PMID: 28681471 DOI: 10.1111/petr.13020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 12/28/2022]
Abstract
Intraoperative transfusions seem associated with patient death and graft failure after PLTx. A retrospective analysis of recipients' and donors' characteristics and transplantation data in a cohort of patients undergoing PLTx from 2002 to 2009 at the Bergamo General Hospital was performed. A two-stage hierarchical Cox proportional hazard regression with forward stepwise selection was used to identify the main risk factors for major complications. In addition, propensity score analysis was used to adjust risk estimates for possible selection biases in the use of blood products. Over the 12-year period, 232 pediatric cirrhotic patients underwent PLTx. One-year patient and graft survival rates were 92.3% and 83.7%, respectively. The Kaplan-Meier shows that the main decrease in both graft and patient survival occurs during the first months post-transplantation. At the same time, it appears that most of the complications occur during the first month post-transplantation. One-month and 1-year patient complication-free survival rates were 24.8% and 12.1%, respectively. Our study shows that intraoperative red blood cells and platelet transfusions are independent risk factors for developing one or more major complications in the first year after PLTx. Decreasing major complications will improve the health status and overall long-term patient survival after pediatric PLTx.
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Affiliation(s)
- M Nacoti
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | | | - G Colombo
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - D Corbella
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | - F Fazzi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | - O Fochi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - C Gattoni
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - M Zambelli
- Liver Transplant Unit, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - M Colledan
- Liver Transplant Unit, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - E Bonanomi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
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19
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Brockmann JG, Vogel T, Coussios C, Friend PJ. Liver splitting during normothermic organ preservation. Liver Transpl 2017; 23:701-706. [PMID: 28006866 DOI: 10.1002/lt.24693] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/29/2016] [Indexed: 01/01/2023]
Affiliation(s)
- Jens G Brockmann
- Organ Transplant Center King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia
| | - Thomas Vogel
- Department of Surgery University Clinics Muenster, Muenster, Germany
| | - Constantin Coussios
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
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20
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21
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Contemporary Pediatric Liver Transplantation: Complex Challenges, Evolving Solutions. Int Anesthesiol Clin 2017; 55:148-161. [PMID: 28221170 DOI: 10.1097/aia.0000000000000138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Komatsu S, Vicentine FPP, El Mouhadi S, Brustia R, Perdigao F, Sepulveda A, Soubrane O, Scatton O. Improving graft survival by understanding the mechanism of segment 4 complications after split liver transplantation. Clin Transplant 2016; 30:1165-72. [PMID: 27422029 DOI: 10.1111/ctr.12812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study was designed to assess the actual mechanism of segment 4 (S4)-related complications after split liver transplantation (SLT) and their impact on graft and overall survival with reference to those of left lateral sectionectomy for pediatric living donor liver transplantation (LLSLD). METHODS Clinical data from 53 SLT recipients and 62 LLSLD patients were assessed to determine the mechanism of S4-related complications. The postoperative parameters of SLT and their impact on graft and overall survival were also evaluated. RESULTS Although two biliary leakages were noted (3.2%), no necrosis of S4 developed after LLSLD. S4-related complications were seen in 15 (28.3%) patients after SLT. Radiological volumetry of S4 and the ischemic area after SLT showed no significant difference between those with and without S4-related complications. There were no significant differences between the patients with and without S4-related complications regarding both overall and graft survival rates. Significant better overall and graft survival rates were observed in patients treated during the later period. CONCLUSIONS S4-related complications after SLT are totally independent of the S4 volume, and biliary leakage is inherently an actual mechanism. Adequate intervention with early identification leads to better graft and overall survival, which validates SLT as a treatment option.
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Affiliation(s)
- Shohei Komatsu
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Fernando Pompeu Piza Vicentine
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Sanaâ El Mouhadi
- Department of Radiology, Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Raffaele Brustia
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Fabiano Perdigao
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Ailton Sepulveda
- Department of Hepatobiliary and Liver Transplantation, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris, France.,Université Paris VII, Paris, France
| | - Olivier Soubrane
- Department of Hepatobiliary and Liver Transplantation, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris, France.,Université Paris VII, Paris, France
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France.
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23
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Abstract
Liver transplantation (LT) is an important component in the therapeutic armamentarium of managing end-stage liver disease. In North American children, biliary atresia remains the most common indication for LT compared to hepatitis C in adults, while hepatoblastoma is the most common liver tumor requiring LT, versus Hepatocellular carcinoma in adults. Rejection, lymphoproliferative disease, renal insufficiency, metabolic syndrome, recurrent disease, 'de novo' autoimmune hepatitis and malignancy require careful surveillance and prompt action in adults and children after LT. In children, specific attention to EBV viremia, growth, development, adherence and transition to the adult services is also required. Antibody mediated rejection and screening for donor specific antibodies is becoming important in managing liver graft dysfunction. Biomarkers to identify and predict tolerance are being developed. Machine perfusion and stem cells (iPS) to synthesize organs are generating interest and are a focus for research.
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Affiliation(s)
- Nanda Kerkar
- a Keck School of Medicine, Medical Director Liver/Intestinal and Hepatology Transplant Program, Children's Hospital of Los Angeles , University of Southern California , Los Angeles , CA , USA
| | - Arathi Lakhole
- b Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Los Angeles , University of Southern California , Los Angeles , CA , USA
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24
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Lauterio A, Di Sandro S, Concone G, De Carlis R, Giacomoni A, De Carlis L. Current status and perspectives in split liver transplantation. World J Gastroenterol 2015; 21:11003-15. [PMID: 26494957 PMCID: PMC4607900 DOI: 10.3748/wjg.v21.i39.11003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/27/2015] [Accepted: 08/30/2015] [Indexed: 02/06/2023] Open
Abstract
Growing experience with the liver splitting technique and favorable results equivalent to those of whole liver transplant have led to wider application of split liver transplantation (SLT) for adult and pediatric recipients in the last decade. Conversely, SLT for two adult recipients remains a challenging surgical procedure and outcomes have yet to improve. Differences in organ shortages together with religious and ethical issues related to cadaveric organ donation have had an impact on the worldwide distribution of SLT. Despite technical refinements and a better understanding of the complex liver anatomy, SLT remains a technically and logistically demanding surgical procedure. This article reviews the surgical and clinical advances in this field of liver transplantation focusing on the role of SLT and the issues that may lead a further expansion of this complex surgical procedure.
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25
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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: 1.7] [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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26
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Wan P, Li Q, Zhang J, Xia Q. Right lobe split liver transplantation versus whole liver transplantation in adult recipients: A systematic review and meta-analysis. Liver Transpl 2015; 21:928-43. [PMID: 25832308 DOI: 10.1002/lt.24135] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/24/2015] [Accepted: 03/29/2015] [Indexed: 02/06/2023]
Abstract
Split liver transplantation (SLT) has proven to be an effective technique to reduce the mortality of children on the waiting list, but whether creating 2 split grafts from 1 standard-criteria whole liver would compromise outcomes of adult recipients remains uncertain. We conducted this meta-analysis to compare outcomes of right lobe SLT and whole liver transplantation (WLT) in adult patients. PubMed, Embase, and the Cochrane Library were searched for relevant articles published before December 2014. Outcomes assessed were patient survival (PS), graft survival (GS), and major surgical complications after transplantation. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to synthesize the results. Seventeen studies with a total of 48,457 patients met the full inclusion criteria. PS and GS rates were all found to be equivalent between SLT and WLT recipients. However, SLT was associated with higher rates of overall biliary complications (OR = 1.66; 95% CI = 1.29-2.15; P < 0.001), bile leaks (OR = 4.30; 95% CI = 2.97-6.23; P < 0.001), overall vascular complications (OR = 1.81; 95% CI = 1.29-2.53; P < 0.001), hepatic artery thromboses (OR = 1.71; 95% CI = 1.17-2.50; P = 0.005), and outflow tract obstructions (OR = 4.17; 95% CI = 1.75-9.94; P = 0.001). No significant difference was observed in incidences of biliary stricture, portal vein complications, postoperative bleeding requiring surgical treatments, primary nonfunction, and retransplantations. In subgroup analyses, biliary and vascular complications only increased after ex vivo SLT rather than in situ SLT, and SLT recipients had more retransplantations if they matched with WLT recipients in terms of urgent status. In conclusion, adult right lobe SLT was associated with increased biliary and vascular complications compared with WLT, but it did not show significant inferiority in PSs and GSs.
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Affiliation(s)
- Ping Wan
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qigen Li
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianjun Zhang
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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27
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Maggi U, De Feo TM, Andorno E, Cillo U, De Carlis L, Colledan M, Burra P, De Fazio N, Rossi G. Fifteen years and 382 extended right grafts from in situ split livers in a multicenter study: Are these still extended criteria liver grafts? Liver Transpl 2015; 21:500-11. [PMID: 25545700 DOI: 10.1002/lt.24070] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/02/2014] [Accepted: 12/14/2014] [Indexed: 12/13/2022]
Abstract
In situ split liver extended right grafts (SL-ERGs) are still considered marginal grafts. Our aim was to verify this statement at the present time. From 1997 to 2011, a multicenter, retrospective study based on a prospective database was performed at 9 liver transplantation (LT) centers in northern Italy; it included 382 in situ SL-ERG transplants in adults. There were 358 primary LTs and 24 retransplantations (RETXs). The 1-, 3-, and 5-year overall graft survival rate for LT with in situ SL-ERGs were 73.5%, 63.3%, and 60.7%, respectively, from 1997 to 2004 and 83.5%, 80.3%, and 80.3%, respectively, thereafter (P=0.0001). A shorter total ischemia time and fewer RETX grafts were the main differences between the characteristics of the 2 periods. From 1997 to 2011, the 1-, 3-, and 5-year graft survival rates showed a significant difference between the 358 primary LT in situ SL-ERGs and the 24 RETX in situ SL-ERGs (P<0.001). In a multivariate analysis, the main prognostic factor for 60-day graft survival was a total ischemia time<8 hours for the 358 primary in situ SL-ERGs. From 2005 to 2011, in 2473 LTs, the 5-year graft survival for 184 in situ SL-ERGs and 2289 whole grafts was 75% and 80% (P=0.3), respectively. Univariate and multivariate studies alike failed to indicate that the type of graft was a prognostic factor for graft survival. A donor age>60 years, RETX grafts, and urgency were the main prognostic factors for failure for all of the grafts. Although caution should be taken regarding the choice of appropriate donors, in situ SL-ERGs should no longer be considered marginal grafts for experienced LT centers. SL-ERGs should not be used in RETX settings, and when SL-ERGs are used as primary grafts, the total ischemia time should be less than 8 hours.
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Affiliation(s)
- Umberto Maggi
- UO Chirurgia Generale e Trapianti di Fegato, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy; Department of Digestive and Hepatobiliary Surgery, AP-HP, U.F.R. de Médecine de l'Université Paris XII-Créteil, Paris, France
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Yamada N, Sanada Y, Hirata Y, Okada N, Wakiya T, Ihara Y, Miki A, Kaneda Y, Sasanuma H, Urahashi T, Sakuma Y, Yasuda Y, Mizuta K. Selection of living donor liver grafts for patients weighing 6kg or less. Liver Transpl 2015; 21:233-8. [PMID: 25422258 DOI: 10.1002/lt.24048] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/04/2014] [Accepted: 10/20/2014] [Indexed: 12/12/2022]
Abstract
In the field of pediatric living donor liver transplantation (LDLT), physicians sometimes must reduce the volume of left lateral segment (LLS) grafts to prevent large-for-size syndrome. There are 2 established methods for decreasing the size of an LLS graft: the use of a segment 2 (S2) monosegment graft and the use of a reduced LLS graft. However, no procedure for selecting the proper graft type has been established. In this study, we conducted a retrospective investigation of LDLT and examined the strategy of graft selection for patients weighing ≤6 kg. LDLT was conducted 225 times between May 2001 and December 2012, and 15 of the procedures were performed in patients weighing ≤6 kg. We selected S2 monosegment grafts and reduced LLS grafts if the preoperative computed tomography (CT)-volumetry value of the LLS graft was >5% and 4% to 5% of the graft/recipient weight ratio, respectively. We used LLS grafts in 7 recipients, S2 monosegment grafts in 4 recipients, reduced S2 monosegment grafts in 3 recipients, and a reduced LLS graft in 1 recipient. The reduction rate of S2 monosegment grafts for use as LLS grafts was 48.3%. The overall recipient and graft survival rates were both 93.3%, and 1 patient died of a brain hemorrhage. Major surgical complications included hepatic artery thrombosis in 2 recipients, bilioenteric anastomotic strictures in 2 recipients, and portal vein thrombosis in 1 recipient. In conclusion, our graft selection strategy based on preoperative CT-volumetry is highly useful in patients weighing ≤6 kg. S2 monosegment grafts are effective and safe in very small infants particularly neonates.
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Affiliation(s)
- Naoya Yamada
- Department of Transplant Surgery, Tochigi, Japan
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29
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Mabrouk Mourad M, Liossis C, Kumar S, Gunson BK, Mergental H, Isaac J, Bramhall SR, Muiesan P, Mirza DF, Thamara P R Perera M. Vasculobiliary complications following adult right lobe split liver transplantation from the perspective of reconstruction techniques. Liver Transpl 2015; 21:63-71. [PMID: 25302412 DOI: 10.1002/lt.24015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 12/11/2022]
Abstract
Split liver transplantation (SLT) compensates for the organ shortage and provides an alternative solution for recipients disadvantaged by a smaller body size. Variations in the hepatic arterial anatomy and reconstructive techniques may lead to more technical complications, and we sought to analyze the incidence and risk factors of vasculobiliary complications with respect to reconstructive techniques. We identified 171 adult right lobe SLT procedures and 1412 whole liver transplantation (WLT) procedures between January 2000 and June 2012 and compared the results of these 2 groups. In the SLT group, arterial reconstruction techniques were classified into 4 subgroups (I-IV), and biliary reconstruction was classified into 2 groups [duct-to-duct (DD) anastomosis and Roux-en-Y hepaticojejunostomy (RH)]. Specific surgical complications were analyzed against reconstruction techniques. The overall incidence of vascular and biliary complications in the SLT group was greater than that in the WLT group (P = 0.009 and P = 0.001, respectively). There was no difference in hepatic artery thrombosis (HAT), but we saw a tendency toward early HAT in the presence of multiple hepatic arteries supplying the right lobe graft (group IV; 20%) in comparison with the other arterial reconstruction groups (P = 0.052). No difference was noticed in the overall incidence of biliary complications in either DD or RH recipients across 4 arterial reconstruction groups. When the arterial reconstruction involved a right hepatic artery (groups II and III) combined with a DD biliary anastomosis, there was a significant preponderance of biliary complications (P = 0.04 and P = 0.01, respectively). There was no survival difference between SLT and WLT grafts. In conclusion, the complications of SLT are directly related to arterial and biliary reconstruction techniques, and this classification helps to identify high-risk reconstructive techniques.
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30
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Nickkholgh A, Contin P, Abu-Elmagd K, Golriz M, Gotthardt D, Morath C, Schemmer P, Mehrabi A. Intestinal transplantation: review of operative techniques. Clin Transplant 2014; 27 Suppl 25:56-65. [PMID: 23909503 DOI: 10.1111/ctr.12190] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2013] [Indexed: 01/01/2023]
Abstract
The improvement of outcomes in intestinal transplantation (ITx) over the last two decades has been made possible through standardization in surgical techniques, improvements in immunosuppressive and induction protocols, and post-operative patient care. From a surgical technical point of view, all different types of small bowel containing transplants can be categorized into three main prototypes, including isolated small bowel, liver-small bowel, and multivisceral transplantations. In this review, we describe these three main prototypes and discuss the most important technical modifications of each type, as well as donor and recipient procedures, and highlight the more recent operative technical topics of discussion in the literature.
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Affiliation(s)
- Arash Nickkholgh
- Department of General, Visceral and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
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31
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Feasibility of split liver transplantation for 2 adults in the model of end-stage liver disease era. Ann Surg 2013; 258:306-11. [PMID: 23108123 DOI: 10.1097/sla.0b013e3182754b8e] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the results of split liver transplantation for 2 adults in the model of end-stage liver disease (MELD) era. BACKGROUND In the MELD era, liver allografts are first allocated to recipients with the highest MELD scores. However, the application of split liver transplantation for 2 adults in urgent condition has doubled and has become a matter of concern. METHODS Twenty-one deceased liver grafts were split into full right and full left lobes for 42 adult recipients. One of the hemiliver grafts was allocated to the recipient with the highest MELD score in the waiting list. The results of split liver transplantation were examined and compared with those of living donor liver transplantation. RESULTS Among 42 recipients, 24 (57.1%) had MELD scores higher than 20. The median (interquartile) MELD score for the recipients with split liver transplantation was 22 (15-30), which was higher than that for the recipients with living donor liver transplantation (P < 0.001). The 1-, 3-, and 5-year survival rates for split liver transplantation were comparable with those of living donor transplantation (P = 0.489). Nevertheless, 10 of 42 split liver recipients died within 3 months after transplantation. By receiver operating characteristic curve analysis, the safe graft-recipient weight ratio was better more than 1% to avoid early patient death for split liver transplantation. CONCLUSIONS Although most of the recipients with split liver transplantation had high MELD scores, the results were comparable with those of living donor liver transplantation. Split liver transplantation for 2 adults is still feasible in the MELD era.
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32
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Saidi RF. Utilization of expanded criteria donors in liver transplantation. Int J Organ Transplant Med 2013; 4:46-59. [PMID: 25013654 PMCID: PMC4089311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Improvements in surgical techniques, immunosuppression, and post-transplantation patient care have led to the optimization of liver transplantation outcomes. However, the waiting list for liver transplantation is increasing at a greater pace. The large gap between the growing pool of patients waiting for liver transplantation and the scarcity of donor organs has fueled efforts to maximize existing donors and identify new sources. This article will be focused on the current state of liver transplantation using grafts from extended criteria donors (elderly donors, steatotic donors, donors with malignancies, donors with viral hepatitis) and from donation after cardiac death (DCD), as well as the use of partial grafts (split grafts and living-donor liver transplantation) and other suboptimal donors (donors with hypernatremia, infections, hypotension and inotropic support). Overall, broadened criteria for acceptable donor livers appear to lessen graft survival rates somewhat compared with rates for standard criteria organs.
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Emre S, Umman V, Cimsit B, Rosencrantz R. Current concepts in pediatric liver transplantation. ACTA ACUST UNITED AC 2012; 79:199-213. [PMID: 22499491 DOI: 10.1002/msj.21305] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation is the definitive treatment for end-stage liver disease in both children and adults. Advances over the last 2 decades have resulted in excellent patient and graft survival rates in what were previously cases of fatal disorders. These developments have been due to innovations in surgical technique, increased surgical experience, refinements in immunosuppressive regimens, quality improvements in intraoperative anesthetic management, better understanding of the pathophysiology of the liver diseases, and better preoperative and postoperative care. Remarkably, the use of split-liver and living-related liver transplantation surgical techniques has helped mitigate the well-recognized national organ shortage. This review will discuss the major aspects of pediatric liver transplantation as it pertains to indication for transplantation, recipient selection and listing for orthotopic liver transplantation, pre-orthotopic liver transplantation care of children, optimal timing of orthotopic liver transplantation, surgical technical considerations, postoperative care and complications, and patient and graft survival outcomes.
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Affiliation(s)
- Sukru Emre
- Yale University School of Medicine, New Haven, CT, USA.
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34
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Clinical experience of more than 200 cases of pediatric liver transplantation at a single center: improved patient survival. Transplant Proc 2012; 44:484-6. [PMID: 22410052 DOI: 10.1016/j.transproceed.2012.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of this study was to present our experience with more than 200 cases of orthotopic liver transplantation (OLT) at a single center. We conducted a retrospective, single-center assessment of the demographic and clinical factors in children who underwent OLT from 1994 to 2010. Two hundred children younger than 18 years of age underwent 200 primary and 9 liver re-transplantations. The overall patient survival rates before 2003 at 1, 5, and 10 years were 86.4%, 79.5%, and 78.4%, respectively; whereas after 2003 they were 95.4% and 95.4% at 1 and 5 years, respectively (P<.05). Our center's results showed durable, improved outcomes in recent years.
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35
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Sepulveda A, Scatton O, Tranchart H, Gouya H, Perdigao F, Stenard F, Bernard D, Conti F, Calmus Y, Soubrane O. Split liver transplantation using extended right grafts: the natural history of segment 4 and its impact on early postoperative outcomes. Liver Transpl 2012; 18:413-22. [PMID: 22144403 DOI: 10.1002/lt.22479] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Split liver transplantation (SLT) using extended right grafts is associated with complications related to ischemia of hepatic segment 4 (S4), and these complications are associated with poor outcomes. We retrospectively analyzed 36 SLT recipients so that we could assess the association of radiological, biological, and clinical features with S4 ischemia. The overall survival rates were 84.2%, 84.2%, and 77.7% at 1, 3, and 5 years, respectively. The recipients were mostly male (24/36 or 67%) and had a median age of 52 years (range = 13-63 years), a median body mass index of 22.9 kg/m(2) (range = 17.3-29.8 kg/m(2) ), and a median graft-to-recipient weight ratio of 1.3% (range = 0.9%-1.9%). S4-related complications were diagnosed in 22% of the patients (8/36) with a median delay of 22 days (range = 10-30 days). Secondary arterial complications were seen in 3 of these patients and led to significantly decreased graft survival in comparison with the graft survival of patients without complications (50.0% versus 85.6%, P = 0.017). Patients developing S4-related complications had significantly elevated aspartate aminotransferase (AST) levels (>1000 IU/L) on postoperative day (POD) 1 and elevated gamma-glutamyl transpeptidase (GGT) levels (>300 IU/L) on PODs 7 and 10 (P < 0.05). These AST and GGT elevations conferred a significantly high risk of developing these complications (odds ratio = 42, 95% confidence interval = 4-475, P < 0.05). The ischemic volume of S4 was extremely variable (0%-95%) and did not correlate with S4-related complications. In conclusion, our results suggest that S4-related complications are risk factors for worse graft survival, and the development of these complications can be anticipated by the early identification of a specific biological profile and a routine radiological examination.
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Affiliation(s)
- Ailton Sepulveda
- Hepatobiliary Surgery and Liver Transplantation Service, Saint Antoine Hospital, Assistance Public-Hôpitaux de Paris, Paris, France
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36
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Nesher E, Island E, Tryphonopoulos P, Moon J, Nishida S, Selvaggi G, Tekin A, Levi DM, Tzakis A. Split liver transplantation. Transplant Proc 2011; 43:1736-41. [PMID: 21693268 DOI: 10.1016/j.transproceed.2010.11.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 10/29/2010] [Accepted: 11/03/2010] [Indexed: 11/24/2022]
Abstract
We analyzed the results of 55 patients who underwent split liver transplantation at our center between September 1996 and December 2008, 30 adults (54.5%) and 25 children (45.5%). Median follow-up was 12 years. Overall patient survival was 71%, adult 70% and pediatric 72%. Mean patient survival was 61.58 months, and mean graft survival was 44.35 months. Pediatric survival and pediatric graft survival after 1 and 5 years were 84% and 72% and 72% and 52.4%, respectively. Adult survival and adult graft survival after 1 and 5 years were 75% and 66.2% and 60.7% and 51.5%, respectively. Twelve patients required retransplantation, 6 for primary nonfunction, 3 for chronic rejection, and 3 for vascular complications. Blood groups of the recipient patients were: 34 O, 14 A, 7 B, and 0 AB. The use of split liver for adult and pediatric populations allows us to expand the cadaveric donor pool and has the potential to significantly reduce waiting list mortality, especially for certain blood groups.
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Affiliation(s)
- E Nesher
- Division of Transplantation, Department of Surgery, University of Miami School of Medicine, Miami, Florida 33136, USA.
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37
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Abstract
Liver transplantation (OLT) has become the only treatment modality for patients with end-stage liver diseases. Establishment of standard liver transplantation technique, development of better immunosuppressive medications and accumulated experience using them safely, and improvement of intensive care and anesthesia played major role to have current 88%-90% 1-year survival after liver transplantation. As liver transplantations became more successful with the growing experience and development in the field, the increased demand for liver allografts could not match the available supply of donor organs. As a result of this imbalance, each year nearly 3000 patients die in the United States awaiting liver transplantation on the national waiting list. Split liver transplantation (SLT) has been perceived as an important strategy to increase the supply of liver grafts by creating 2 transplants from 1 allograft. The bipartition of a whole liver also carries utmost importance by increasing the available grafts for the pediatric patients, where size-matched whole liver allografts are scarce, leading increased incidence of waiting list mortality in this group. In the common approach of the split liver procedure, liver is divided into a left lateral segment graft (LLS) to be transplanted to a child and a right extended liver lobe graft for an adult recipient. In a technically more challenging variant of this procedure, the principle is to split the liver into 2 hemigrafts and use the left side for a small adult or a teenager and the right for a medium-sized adult patient. Donor selection for splitting, technical expertise in both OLT and hepatobiliary surgery, logistics to decrease total ischemia time, and manpower of the transplantation team are important factors for successful outcomes after SLT. The liver can be split on the back table (ex situ) or in the donor hospital before the donor cross-clamp using in situ splitting technique, which was developed directly from living donor liver transplantation. The most important advantage of in situ splitting is to decrease the total ischemia time and increased the possibility of inter-center sharing. The in situ technique of splitting has other advantages, including evaluation of the viability of segment IV in case of LLS splitting and better control of bleeding from cut surface upon reperfusion on the recipient. Recipient selection for split liver grafts is also crucial for success after SLT. In this review, we aim to summarize the advances that have occurred in SLT. We also discuss anatomic and technical aspects, including both approaches to SLT, which is now considered by many centers to be a routine operation.
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Affiliation(s)
- S Emre
- Yale University School of Medicine, New Haven, CT, USA.
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38
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Abstract
Partial liver transplantation, including reducedsize liver transplantation, split liver transplantation, and living donor liver transplantation, has been developed with several innovative techniques because of donor shortage. Reduced-size liver transplantation is based on Couinaud's anatomical classification, benefiting children and small adult recipients but failing to relieve the overall donor shortage. Split liver transplantation provides chances to two or even more recipients when only one liver graft is available. The splitting technique must follow stricter anatomical and physiological criteria either ex situ or in situ to ensure long-term quality. The first and most important issue involving living donor liver transplantation is donor safety. Before surgery, a series of donor evaluations-including anatomical, liver volume, and liver function evaluations-is indispensable, followed by ethnic agreement. At different recipient conditions, auxiliary liver transplantation and auxiliary partial orthotopic liver transplantation, which employ piggyback techniques, are good alternatives. Partial liver transplantation enriches the practice and knowledge of the transplant society.
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Colledan M, Segalin A, Spada M, Lucianetti A, Corno V, Gridelli B. Liberal policy of split liver for pediatric liver transplantation. A single centre experience. Transpl Int 2011. [DOI: 10.1111/j.1432-2277.2000.tb02001.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Maggi U, Caccamo L, Reggiani P, Lauro R, Bertoli P, Camagni S, Paterson IM, Rossi G. Hypoperfusion of segment 4 in right in situ split-liver transplantation. Transplant Proc 2010; 42:1240-3. [PMID: 20534271 DOI: 10.1016/j.transproceed.2010.03.110] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
To expand the donor pool, split-liver transplantation has been implemented in recent years. In the classic technique, the arterial axis with the artery for segment 4 (S4) coming from the left hepatic artery (HA) is included with the right graft. To give a surgical advantage to pediatric recipients in our center, the left HA, the common HA, and the celiac trunk are generally retained with the left liver. Thus the artery for S4 is sacrificed. We compared the outcomes of S4 in 290 whole grafts (WG; group A) with 28 right in situ split-liver grafts (SSLG; group B), which were transplanted over the past 10 years (January 1999-December 2009). The rates of major biliary and of hemorrhagic complications were similar. In most of cases (16/24, 66%) S4, on computerized tomographic scan appeared to show signs of hypoperfusion, sometimes with a peripheral aspect of hyperperfusion in the arterial phase. S1 showed signs of hypoperfusion in only 2 cases. A biliary collection near the resection line present in 8 cases was treated in 6 of them with percutaneous drainage and in 2 with laparotomy. These complications did not influence graft or patient survival. Graft survivals at 1, 5, and 10 years for WG and SSLG were not different among the groups: 85%, 74%, and 66% vs 89%, 79%, and 63%, respectively (P = .8). Although our technique cannot be considered to be anatomically correct, the ischemia of S4 did not influence the outcome. The rate of retransplantations for hepatic artery thrombosis was 17.9% in RSSG and 3.4% in WG (P = .001), which was probably due at least in part to the insertion of interposition grafts.
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Affiliation(s)
- U Maggi
- Unitá Operativa di Chirurgia Generale e dei Trapianti di Fegato, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena di Milano v Francesco Sforza 35 - 20121, Milano, Italy.
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41
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Viganò L, Laurent A, Tayar C, Merle JC, Lauzet JY, Hurtova M, Decaens T, Duvoux C, Cherqui D. Outcomes in adult recipients of right-sided liver grafts in split-liver procedures. HPB (Oxford) 2010; 12:195-203. [PMID: 20590887 PMCID: PMC2889272 DOI: 10.1111/j.1477-2574.2009.00147.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The split-liver technique provides a good left lateral graft in children, but its results in adults remain controversial. METHODS From 1992 to 2007, 37 patients received 38 cadaveric right-sided grafts. Donors and recipients were selected for good quality grafts and elective indications; the latter included a high proportion of tumour cases and primary sclerosing cholangitis. Grafts included 31 extended right grafts (ERGs; segments IV-VIII and I and the inferior vena cava [IVC]) and seven right grafts (RGs; segments V-VIII) including five without the IVC and middle hepatic vein (MHV). RESULTS Mortality was 5% (two patients). There were four retransplantations (11%) for arterial thrombosis (1), portal vein thrombosis (2) and primary non-function (1). The retransplantation rate was higher in RG than in ERG (three vs. one patient; P= 0.015). Of the five patients without MHV, three were retransplanted and one had small-for-size syndrome leading to late death. After a mean follow-up of 5 years, 1-, 3- and 5-year graft and patient survival rates were 84%, 80% and 71%, and 91%, 88% and 78%, respectively. One-year patient and graft survival rates after ERG transplantation were 96% and 92%, respectively. CONCLUSIONS Split-liver transplantation is a safe alternative to whole organ transplantation when an ERG is carried out. Right graft is associated with increased risk of graft loss, especially if the MHV is omitted. Split-liver transplantation with an ERG offers excellent outcomes and should be encouraged when good quality grafts are available.
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Affiliation(s)
- Luca Viganò
- Departments of Digestive and Hepatobiliary Surgery, Henri Mondor Hospital-University of Paris 12Créteil, France
| | - Alexis Laurent
- Departments of Digestive and Hepatobiliary Surgery, Henri Mondor Hospital-University of Paris 12Créteil, France
| | - Claude Tayar
- Departments of Digestive and Hepatobiliary Surgery, Henri Mondor Hospital-University of Paris 12Créteil, France
| | - Jean-Claude Merle
- Departments of Anaesthesiology, Henri Mondor Hospital-University of Paris 12Créteil, France
| | - Jean-Yves Lauzet
- Departments of Anaesthesiology, Henri Mondor Hospital-University of Paris 12Créteil, France
| | - Monica Hurtova
- Departments of Hepatology, Henri Mondor Hospital-University of Paris 12Créteil, France
| | - Thomas Decaens
- Departments of Hepatology, Henri Mondor Hospital-University of Paris 12Créteil, France
| | - Christophe Duvoux
- Departments of Hepatology, Henri Mondor Hospital-University of Paris 12Créteil, France
| | - Daniel Cherqui
- Departments of Digestive and Hepatobiliary Surgery, Henri Mondor Hospital-University of Paris 12Créteil, France
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Gruttadauria S, Francesco FD, Pagano D, Petri SL, Cintorino D, Spada M, Gridelli B. Liver resections for liver transplantations. World J Gastrointest Surg 2010; 2:51-6. [PMID: 21160850 PMCID: PMC2999215 DOI: 10.4240/wjgs.v2.i3.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 02/22/2010] [Accepted: 03/01/2009] [Indexed: 02/06/2023] Open
Abstract
Split-Liver and living-related donor liver transplantation are the newest and both technically and ethically most challenging developments in liver transplantation and have contributed to a reduction in donor shortage. We report the technical aspects of surgical procedures performed to achieve a partial graft from a cadaveric and a live donor.
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Affiliation(s)
- Salvatore Gruttadauria
- Salvatore Gruttadauria, Fabrizio di Francesco, Duilio Pagano, Sergio Li Petri, Davide Cintorino, Marco Spada, Bruno Gridelli, Mediterranean Institute for Transplantation and High Specialization Therapies, University of Pittsburgh Medical Center in Italy, Palermo 90127, Italy
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43
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Innovative surgical techniques address the organ donation crisis, ... don't they? Curr Opin Organ Transplant 2010; 14:507-14. [PMID: 19623071 DOI: 10.1097/mot.0b013e32833067f3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Retrospectively analysing the role that innovative technique and strategies have played to face organ shortage during the last decades, and elaborating rationally about their potential contribution to expand organ availability in the coming future. RECENT FINDINGS Current organ donation crisis proceeds from both decreasing offers, qualitatively and quantitatively, and steadily increasing demand. Innovative surgical techniques using the existing donor pool have been extensively used for paediatric transplantation, but these techniques both have been insufficiently implemented in overall transplant activity to meet the demand, and are less usable on the emerging potential pool of donors ('extended-criteria' and nonheart-beating donors), as combining both approaches could carry a higher risk of complications. SUMMARY The future is emerging through complementary approaches and strategies in which innovative techniques have a role to play to match the existing pool with the paediatric demand, with an increasing attention to donor management and organ care and with development of preprocurement and postprocurement new therapies.
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Abstract
Pediatric LT has evolved into an accepted treatment modality for children with end-stage liver disease with excellent long-term graft and patient survival. A number of factors have been critical in the improvement in recipient outcomes including a change in organ donation from donation after cardiac death, to donation after brain death, and more recently live donor LT and a better appreciation of hepatic anatomy allowing for split LT, LDLT, auxiliary partial orthotopic LT, and laparoscopic donor hepatectomy. In this review we summarize the surgical advances that have occurred in pediatric LT that have been important in shaping what is now considered by many to be a routine operation.
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Affiliation(s)
- Adam Bartlett
- Kings College London School of Medicine at Denmark Hill, Institute of Liver Studies, Kings College Hospital, Denmark Hill, Camberwell, London, UK
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45
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Máthé Z, Kóbori L, Görög D, Fehérvári I, Nemes B, Gerlei Z, Doros A, Németh A, Mándli T, Fazakas J, Járay J. The first successful adult right-lobe living donor liver transplantation in Hungary. Orv Hetil 2010; 151:3-7. [DOI: 10.1556/oh.2010.28782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A világszerte fennálló szervdonorhiány csökkentésének egyik lehetősége az élő donoros májtranszplantáció. A szerzők beszámolnak a Magyarországon először végzett felnőttkori élő donoros májtranszplantációval szerzett tapasztalataikról. Az átültetés testvérek között történt, 2007. november 19-én. A 33 éves egészséges férfi donor májának jobb lebenye (V–VIII. szegmentum) került eltávolításra és beültetésre az autoimmun hepatitis talaján kialakult cirrhosisban szenvedő, egy éve májtranszplantációs várólistán levő, 23 éves nőbetegbe. A jobb májlebeny beültetése saját hepatectomia után orthotopicus helyzetben történt. A májfunkció gyorsan javult a transzplantációt követően. A donort szövődménymentes posztoperatív szak után, stabil májfunkciós paraméterekkel, a 10. napon otthonába bocsátottuk. Dolgozik, aktív életet él, a kontrollvizsgálatok a máj jelentős regenerációját mutatták. A recipiens két évvel a májátültetés után, kompenzált májfunkcióval szintén aktív életet él és rendszeres ellenőrzés alatt áll. A felnőttkori élő donoros májtranszplantáció előnye a lerövidíthető várakozási idő és a tervezhető műtét. Az eljárás a donor biztonságának maximális előtérbe helyezésével, jól szelektált esetekben, alkalmas lehet a szervhiány csökkentésére.
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Affiliation(s)
| | - László Kóbori
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Dénes Görög
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Imre Fehérvári
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Balázs Nemes
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Zsuzsa Gerlei
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Attila Doros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Andrea Németh
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Tamás Mándli
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - János Fazakas
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
| | - Jenő Járay
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Csermák A. u. 25/G 1038
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Misra MV, Smithers CJ, Krawczuk LE, Jenkins RL, Linden BC, Weldon CB, Kim HB. Reduced size liver transplantation from a donor supported by a Berlin Heart. Am J Transplant 2009; 9:2641-3. [PMID: 19775315 DOI: 10.1111/j.1600-6143.2009.02818.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Patients on cardiac assist devices are often considered to be high-risk solid organ donors. We report the first case of a reduced size liver transplant performed using the left lateral segment of a pediatric donor whose cardiac function was supported by a Berlin Heart. The recipient was a 22-day-old boy with neonatal hemochromatosis who developed fulminant liver failure shortly after birth. The transplant was complicated by mild delayed graft function, which required delayed biliary reconstruction and abdominal wall closure, as well as a bile leak. However, the graft function improved quickly over the first week and the patient was discharged home with normal liver function 8 weeks after transplant. The presence of a cardiac assist device should not be considered an absolute contraindication for abdominal organ donation. Normal organ procurement procedures may require alteration due to the unusual technical obstacles that are encountered when the donor has a cardiac assist device.
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Affiliation(s)
- M V Misra
- Department of Surgery, Children's Hospital Boston, Boston, MA, USA
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47
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Strauss A, Grabhorn E, Sornsakrin M, Briem-Richter A, Fischer L, Nashan B, Ganschow R. Liver transplantation for fulminant hepatic failure in infancy: a single center experience. Pediatr Transplant 2009; 13:838-42. [PMID: 19067912 DOI: 10.1111/j.1399-3046.2008.01071.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
FHF is characterized by a high percentage of unknown causes leading to acute liver failure and furthermore by an increased morbidity and mortality prior to and post-Ltx. In different transplant centers, the reasons leading to FHF differ significantly as well as outcome. We report our single center experience with 30 pediatric patients receiving a liver transplant for FHF, out of a total of 83 children presenting with FHF. The time to transfer patients to the transplant center after the diagnosis of FHF was long, with a median of 14 days (Ltx group) and 12 days (controls), respectively. In nearly half of the patients (n = 14) in the Ltx group, we were not able to establish an exact diagnosis prior to Ltx: 50% suffered from encephalopathy, and 13 patients were treated in the intensive care unit prior to transplant. Because of the availability of different surgical techniques, all children received a timely transplant [split (n = 18), living donor (n = 9), whole organ (n = 2), and reduced liver (n = 1)]. Patient survival was 93.4%, and graft survival was 83.4% for at least one yr follow-up. Severe complications following Ltx included three cases with aplastic anemia and one child suffering from systemic mitochondrial depletion syndrome. The survival of patients treated medically was 83%. We conclude that a strong focus should be made on early referral to a specialized center and on improvement of diagnostic tools to timely detect the underlying reason for FHF. Results following Ltx for FHF are good.
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Affiliation(s)
- Annette Strauss
- Department of Pediatrics, Pediatric Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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48
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Sandroussi C, Crawford M, Lockwood DS, Tang P, Gallagher JP, Pleass H, Strasser SI, Shackel NA, McCaughan GW, Verran DJ. Donor and recipient selection leads to good patient and graft outcomes for right lobe split transplantation versus whole graft liver transplantation in adult recipients. Liver Transpl 2009; 15:1586-93. [PMID: 19877214 DOI: 10.1002/lt.21849] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The outcomes of right lobe split (RLS) liver transplantation are variable in adult recipients. This report is an analysis of outcomes of our initial 5-year experience with the right lobe trisegment split graft. A retrospective analysis was performed of the recipient and graft outcomes from July 2002 to March 2007 of all adult recipients of RLS grafts versus recipients of whole grafts (WGs). All data were analyzed with Stata version 8 (Stata Corp., Texas). There were 43 (19.1%) RLS recipients and 182 (80.9%) WG recipients. The median Model for End-Stage Liver Disease score was 13 (7-23) in the RLS group and 18 (6-50) in the WG group (P < 0.001). Hepatocellular carcinoma and primary sclerosing cholangitis were more common in the RLS group (P < 0.05), whereas alcoholic cirrhosis and chronic hepatitis C were more common in the WG group. The median donor age was lower in the RLS group at 39 (13-61) years versus the WG group at 47 (12-79) years (P < 0.001). Primary nonfunction occurred in 1.6% of the WG patients only. Biliary complications occurred in 28% of the RLS patients versus 28% of the WG patients. Vascular complications occurred in 18% of the RLS patients versus 14% of the WG patients. The retransplantation rate was similar at 2.3% in the RLS group versus 4.9% in the WG group (P = not significant). Overall 3-year recipient survival was 92.7% in the RLS group versus 82.7% in the WG group (P = 0.284). Graft survival was 88.4% in the RLS group at 3 years versus 78.5% in the WG group (P = 0.304). In conclusion, good outcomes can be achieved with RLS liver transplantation in adult recipients without a detrimental effect on recipient or graft survival.
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Affiliation(s)
- Charbel Sandroussi
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, Australia.
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49
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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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50
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Santori G, Andorno E, Morelli N, Casaccia M, Bottino G, Di Domenico S, Valente U. A 20-Year Period of Orthotopic Liver Transplantation Activity in a Single Center: A Time Series Analysis Performed Using the R Statistical Software. Transplant Proc 2009; 41:1286-9. [DOI: 10.1016/j.transproceed.2009.03.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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