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Liberal Use of Interposition Grafts for Arterial Reconstruction Is Safe and Effective in Adult Split Liver Transplantation. Transplant Direct 2021; 7:e735. [PMID: 34549087 PMCID: PMC8440025 DOI: 10.1097/txd.0000000000001192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 12/28/2022] Open
Abstract
Background. Split liver transplantation (SLT) addresses donor shortages by providing 2 partial grafts from a single donor liver. Arterial reconstruction using an interposition graft facilitates the use of split grafts with difficult recipient anatomy. Its use, however, remains controversial because of a reported increased risk of complications. Methods. A retrospective review of the prospectively maintained Australian National Liver Transplantation Unit database was performed. Donor, recipient, operative, and complications data for adults receiving an SLT between July 2002 and November 2019 were extracted. Results. Arterial reconstruction required an interposition graft in 46 of 155 patients. Overall graft and patient survival were not significantly different between the groups with 1-, 3-, and 5-y graft survivals of 82%, 77%, and 69% for those with interposition grafts and 86%, 79%, and 77% for those without interposition grafts, respectively (P = 0.499). There were more cut liver bile leaks in the interposition graft group (26% versus 9%, P = 0.004), but otherwise, no significant differences in the rate of biliary complications (39% versus 29% P = 0.200), hepatic artery thrombosis (7% versus 10%, P = 0.545), or hepatic artery stenosis (13% versus 10%, P = 0.518). Conclusions. Liberal use of interposition grafts for arterial reconstruction in SLT is safe and does not result in increased complications.
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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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Meurisse N, Monbaliu D, Berlakovich G, Muiesan P, Oliverius M, Adam R, Pirenne J. Heterogeneity of Bile Duct Management in the Development of Ischemic Cholangiopathy After Liver Transplantation: Results of a European Liver and Intestine Transplant Association Survey. Transplant Proc 2019; 51:1926-1933. [PMID: 31301856 DOI: 10.1016/j.transproceed.2019.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical factors and direct cytotoxicity of bile salts on cholangiocytes may play a role in the development of ischemic cholangiopathy (IC) after liver transplantation (LTx). There is no validated consensus on how to protect the bile ducts during procurement, static preservation, and LTx. Meanwhile, IC remains the most troublesome complication after LTx. AIM To characterize bile duct management techniques during the LTx process among European transplant centers in cases of donation after brain death (DBD) and circulatory death (DCD). METHOD An European Liver and Intestine Transplant Association-European Liver Transplant Registry web survey designed to conceal respondents' personal information was sent to surgeons procuring and/or transplanting livers in Europe. RESULTS Sixty-five percent of responses came from large transplant centers (>50 procurements/y). In 8% of DBDs and 14% of DCDs the bile duct is not rinsed. In 46% of DBDs and 52% of DCDs surgeons prefer to remove the gallbladder after graft reperfusion. Protocols concerning preservation solutions (nature, pressure, volume) are extremely heterogeneous. In 54% of DBDs and 61% of DCDs an arterial back table pressure perfusion is performed. Steroids (20%-10%), heparin (72%-60%), prostacyclin (3%-7%), and fibrinolytics (4%-11%) are used as donor-protective interventions in DBD and DCD cases, respectively. In 2% of DBD and 6% of DCD cases a hepatic artery reperfusion is performed first. In 4% of DBD and 6% of DCD cases, fibrinolytics are administered through the hepatic artery during the bench and/or implantation. CONCLUSION This European web survey shows for the first time the heterogeneity in the management of bile ducts during procurement, preservation, and transplantation in Europe. In the context of sharing more marginal liver grafts, an expert meeting must be organized to formulate guidelines to be applied to protect liver grafts against IC.
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Affiliation(s)
- Nicolas Meurisse
- Department of Abdominal Transplant Surgery, University of Liege Academic Hospital, ULg CHU, Liege, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Gabriela Berlakovich
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Paolo Muiesan
- Liver Unit, University of Birmingham, Birmingham, United Kingdom
| | - Martin Oliverius
- Department of Surgery of the 3rd Faculty of Medicine Charles University and Kralovske Vinohrady Hospital, Prague, Czech Republic
| | - René Adam
- APHP Hospital Paul Brousse, Inserm U985, University Paris Sud, Paris, France
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
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Order of liver graft revascularization in deceased liver transplantation: A systematic review and meta-analysis. Surgery 2019; 166:237-246. [PMID: 31085045 DOI: 10.1016/j.surg.2019.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/15/2019] [Accepted: 03/29/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The ideal order for liver graft revascularization during liver transplantation remains unknown. The majority of liver transplant centers prefer portal venous reperfusion followed by arterial reperfusion to shorten the warm ischemia time. The aim of this study was to review the different revascularization techniques used in clinical liver transplantation to identify any potential clinical benefits. METHODS A systematic search of 5 databases was performed to identify all available original articles that reported liver transplantation and compared different techniques of reperfusion. The primary outcomes were patient and graft survival. Secondary outcomes were defined by postreperfusion syndrome, primary nonfunction, vascular complications, biliary complications, and retransplantation. RESULTS A total of 1,160 patients undergoing liver transplantation from 15 studies were included in this review and meta-analysis. There were no differences regarding the 1-year patient and graft survival for the revascularization techniques. The incidence of primary nonfunction, vascular complications, and retransplantation did not differ between the groups. Although there were no differences regarding biliary complications between the different groups, there were more nonanastomotic strictures in patients with initial portal revascularization (9%) compared with those with simultaneous revascularization (2%; risk ratio 1.07; 95% confidence interval, 1.00-1.14; P = .05; I2 = 51%). CONCLUSION The order of liver graft revascularization does not influence patient and graft survival. Each revascularization technique offers potential benefits that can be used under specific clinical situations.
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Kwak BJ, Kim DG, Han JH, Choi HJ, Bae SH, You YK, Choi JY, Yoon SK. Clinical outcome of 1,000 consecutive cases of liver transplantation: a single center experience. Ann Surg Treat Res 2018; 95:267-277. [PMID: 30402445 PMCID: PMC6204322 DOI: 10.4174/astr.2018.95.5.267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/19/2018] [Accepted: 06/01/2018] [Indexed: 12/16/2022] Open
Abstract
Purpose The aim of this study was to analyze survival outcomes in 1,000 consecutive liver transplantations (LTs) performed at a single institution from 1993 to April 2017. Methods The study population was divided into 2 groups based on donor type: deceased donor LT (DDLT; n = 181, 18.1%) and living donor LT (LDLT; n = 819; 81.9%), and into 3 periods based on the number of cases (first 300 cases, middle 300 cases, last 400 cases). Results Infection was the most common cause of death, accounting for 34.8% (95 of 273). Mortality due to hepatocellular carcinoma recurrence occurred most frequently between 1 and 5 years after transplantation. Mortality rate by graft rejection was highest between 5 and 10 years after transplantation. And mortality by de novo malignancy occurred most frequently after 10 years after transplantation. The patient survival rates for the entire population at 5 and 10 years were 74.7%, and 68.6%, respectively. There was no difference in survival rate between the LDLT and DDLT groups (P = 0.188). Cause of disease, disease severity, case period, and retransplantation had a significant association with patient survival (P = 0.002, P = 0.031, P = 0.003, and P = 0.024, respectively). Conclusion Surgical techniques and perioperative management for transplant patients have improved and undergone standardization. Controlling perioperative infection and managing patients with HCC as LT candidates will result in better outcomes.
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Affiliation(s)
- Bong Jun Kwak
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Goo Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyun Han
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Si Hyun Bae
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoung You
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Young Choi
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Kew Yoon
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Elsabbagh AM, Williams C, Girlanda R, Hawksworth J, Kroemer A, Matsumoto CS, Fishbein TM. The impact of intercenter sharing on the outcomes of pediatric split liver transplantation. Clin Transplant 2017; 31. [PMID: 29032604 DOI: 10.1111/ctr.13138] [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: 10/08/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Split liver transplantation allows for expansion of the pool of organs available for pediatric liver transplantation. The impact of sharing segments of the same liver between centers has not been studied. STUDY DESIGN Retrospective analysis of 24 pediatric split liver transplant cases in a recent cohort. We evaluated the outcomes of pediatric recipients who shared organs with adult patients in our own center (group A) compared to recipients who shared organs with adult patients in other centers. (group B). RESULTS One-, 3-, and 5-year graft survival for group A was 100%, 100%, and 100% vs 83%, 71%, and 57% for group B (P = .039). Postoperative complications included biliary complications (41.7% in group A vs 50% in group B, P = .682), vascular complications (8.3% in group A vs 41.7% in group B, P = .059), and postoperative bleeding (16.7% in group A vs 25% in group B, P = .615). High-grade Clavien-Dindo complications were 0% in group A vs 33.3% in group B, P = .028. CONCLUSIONS Organ sharing between centers appears to be associated with significantly poorer graft survival. Possible explanations include greater procurement-related injury or suboptimal vessel distribution. Future larger studies focused on this area may be helpful to formulate policy considerations.
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Affiliation(s)
- Ahmed M Elsabbagh
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Cassie Williams
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Raffaele Girlanda
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Cal S Matsumoto
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
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Yassen AM, Elsarraf WR, Elmorshedi MA, Abdel Wahab M, Salah T, Sultan AM, Elghawalby AN, Elshobari MM, Elsadany M, Zalata K, Shiha U. Short-term effects of extracorporeal graft rinse versus circulatory graft rinse in living donor liver transplantation. A prospective randomized controlled trial. Transpl Int 2017; 30:725-733. [PMID: 28403531 DOI: 10.1111/tri.12968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/12/2016] [Accepted: 04/06/2017] [Indexed: 12/20/2022]
Abstract
Living donor liver transplantation has shorter cold ischemia time, less preservative volume, and lower metabolic load compared to transplantation from deceased donors. We investigated the impact of rinsing the graft contents into the systemic circulation on operative course and postoperative outcomes. Donors had right hepatectomy, and grafts were preserved with cold histidine-tryptophan-ketoglutarate solution. On ending portal vein anastomosis, grafts were flushed by patient's portal blood either through incompletely anastomosed hepatic vein (extracorporeal rinse group, EcRg, n = 40) or into systemic circulation (circulatory rinse group, CRg, n = 40). The primary outcome objective was the lowest mean arterial blood pressure within 5 min after portal unclamping as a marker for postreperfusion syndrome (PRS). Secondary objectives included hemodynamics and early graft's and patient's outcomes. Within 5 min postreperfusion, mean arterial blood pressure was significantly lower in the CRg compared to the EcRg, yet this was clinically insignificant. Postoperative graft functions, early biliary and vascular complications, and three-month survival were comparable in both groups. Rinsing the graft into the circulation increased the incidence of PRS without significant impact on early graft or patient outcome in relatively healthy recipients.
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Affiliation(s)
- Amr M Yassen
- Department of Anesthesia and Intensive Care, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Waleed R Elsarraf
- Department of Anesthesia and Intensive Care, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Mohamed A Elmorshedi
- Department of Anesthesia and Intensive Care, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Mohamed Abdel Wahab
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Tarek Salah
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Ahmed M Sultan
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Ahmed N Elghawalby
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Mohamed M Elshobari
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Mohamed Elsadany
- Department of Hepatology, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Khaled Zalata
- Department of Pathology, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Usama Shiha
- Department of Radiology, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
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Uribe M, Alba A, Hunter B, González G, Godoy J, Ferrario M, Buckel E, Cavallieri S, Heine C, Rebolledo R, Auad H, Acuña C. Liver transplantation in children weighing less than 10 kg: Chilean experience. Transplant Proc 2014; 45:3731-3. [PMID: 24315011 DOI: 10.1016/j.transproceed.2013.08.092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Orthotopic liver transplantation is the treatment of choice for most terminal liver diseases in children. In small children (≤ 10 kg), this procedure is challenging and has special considerations. The aim of this study is to describe the experience of a Chilean liver transplantation program in this subgroup of patients. METHODS The liver transplant database of Hospital Luis Calvo Mackenna and Clinica Las Condes was reviewed. All children less than 10 kg undergoing liver transplantation between January 1994 and July 2011 were included. Patient and graft outcomes and main complications were analyzed. RESULTS We have performed 230 pediatric liver transplantations, 49 of them in 41 patients weighing less than 10 kg. The first indication for transplantation was biliary atresia in 25 patients (61%). A living related donor was used in 23 cases (51%). Actuarial survival was 75.7% at 1 year and 67.1% at 5 years. The main cause of death was infection, and the leading cause of graft loss was vascular complication. DISCUSSION Our transplant program includes 2 centers that perform more than 90% of pediatric liver transplantations in Chile, including public health pediatric patients from all around the country. Patients weighing less than 10 kg represent the most challenging group in pediatric liver transplantation due to higher rates of vascular and biliary complications and postoperative infections.
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Affiliation(s)
- M Uribe
- Hospital Luis Calvo Mackenna, Santiago, Chile.
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A prospective policy development to increase split-liver transplantation for 2 adult recipients: results of a 12-year multicenter collaborative study. Ann Surg 2014; 259:157-65. [PMID: 23422004 DOI: 10.1097/sla.0b013e31827da6c9] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To analyze in a multicenter study the potential benefit of a new prospective policy development to increase split-liver procedures for 2 adult recipients. BACKGROUND Split-liver transplantation is an important means of overcoming organ shortages. Division of the donor liver for 1 adult and 1 pediatric recipient has reduced the mortality of children waiting for liver transplantation but the benefits or disadvantages to survival when the liver is divided for 2 adults (adult-to-adult split-liver transplant, AASLT) compared with recipients of a whole graft have not been fully investigated. METHODS We developed a computerized algorithm in selected donors for 2 adult recipients and applied it prospectively over a 12-year period among 7 collaborative centers. Patient and graft outcomes of this cohort receiving AASLT either as full right grafts or full left grafts were analyzed and retrospectively compared with a matched cohort of adults who received a conventional whole-liver transplant (WLT). Univariate and multivariate analysis was done for selected clinical variables in the AASLT group to assess the impact on the patient outcome. RESULTS Sixty-four patients who received the AASLT had a high postoperative complication rate (64.1% grade III and IV) and a lower 5-year survival rate than recipients of a WLT (63.3% and 83.1%) CONCLUSIONS AASLT should be considered a surgical option for selected smaller-sized adults only in experimental clinical studies in experienced centers.
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Franz C, Hoffmann K, Hinz U, Singer R, Hund E, Gotthardt DN, Ganten T, Kristen AV, Hegenbart U, Schönland S, Hinderhofer K, Büchler MW, Schemmer P. Modified body mass index and time interval between diagnosis and operation affect survival after liver transplantation for hereditary amyloidosis: a single-center analysis. Clin Transplant 2013; 27 Suppl 25:40-8. [DOI: 10.1111/ctr.12193] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2013] [Indexed: 12/19/2022]
Affiliation(s)
- Clemens Franz
- Department of General and Transplant Surgery; Ruprecht-Karls-University Heidelberg; Heidelberg; Germany
| | - Katrin Hoffmann
- Department of General and Transplant Surgery; Ruprecht-Karls-University Heidelberg; Heidelberg; Germany
| | - Ulf Hinz
- Department of General and Transplant Surgery; Ruprecht-Karls-University Heidelberg; Heidelberg; Germany
| | | | | | | | | | | | | | | | | | - Markus W. Büchler
- Department of General and Transplant Surgery; Ruprecht-Karls-University Heidelberg; Heidelberg; Germany
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