Adult-to-adult living-donor liver transplantation: The experience of the Université catholique de Louvain
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摘要
Background: Liver transplantation is the treatment for end-stage liver diseases and well-selected malignancies. The allograft shortage may be alleviated with living donation. The initial UCLouvain experience of adult living-donor liver transplantation(LDLT) is presented. Methods: A retrospective analysis of 64 adult-to-adult LDLTs performed at our institution between 1998 and 2016 was conducted. The median age of 29(45.3%) females and 35(54.7%) males was 50.2 years(interquartile range, IQR 32.9–57.5). Twenty-two(34.4%) recipients had no portal hypertension. Three(4.7%) patients had a benign and 33(51.6%) a malignant tumor [19(29.7%) hepatocellular cancer, 11(17.2%) secondary cancer and one(1.6%) each hemangioendothelioma, hepatoblastoma and embryonal liver sarcoma]. Median donor and recipient follow-ups were 93 months(IQR 41–159) and 39 months(22–91), respectively. Results: Right and left hemi-livers were implanted in 39(60.9%) and 25(39.1%) cases, respectively. Median weights of right-and left-liver were 810 g(IQR 730–940) and 454 g(IQR 394–534), respectively. Graft-to-recipient weight ratios(GRWRs) were 1.17%(right, IQR 0.98%-1.4%) and 0.77%(left, 0.59%-0.95%). One-and five-year patient survivals were 85% and 71%(right) vs. 84% and 58%(left), respectively. Oneand five-year graft survivals were 74% and 61%(right) vs. 76% and 53%(left), respectively. The patient and graft survival of right and left grafts and of very small( < 0.6%), small(0.6%–0.79%) and large( ≥0.8%) GRWR were similar. Survival of very small grafts was 86% and 86% at 3-and 12-month. No donor died while five(7.8%) developed a Clavien–Dindo complication IIIa, IIIb or IV. Recipient morbidity consisted mainly of biliary and vascular complications; three(4.7%) recipients developed a small-for-size syndrome according to the Kyushu criteria. Conclusions: Adult-to-adult LDLT is a demanding procedure that widens therapeutic possibilities of many hepatobiliary diseases. The donor procedure can be done safely with low morbidity. The recipient operation carries a major morbidity indicating an important learning curve. Shifting the risk from the donor to the recipient, by moving from the larger right-liver to the smaller left-liver grafts, should be further explored as this policy makes donor hepatectomy safer and may stimulate the development of transplant oncology.
Background: Liver transplantation is the treatment for end-stage liver diseases and well-selected malignancies. The allograft shortage may be alleviated with living donation. The initial UCLouvain experience of adult living-donor liver transplantation(LDLT) is presented. Methods: A retrospective analysis of 64 adult-to-adult LDLTs performed at our institution between 1998 and 2016 was conducted. The median age of 29(45.3%) females and 35(54.7%) males was 50.2 years(interquartile range, IQR 32.9–57.5). Twenty-two(34.4%) recipients had no portal hypertension. Three(4.7%) patients had a benign and 33(51.6%) a malignant tumor [19(29.7%) hepatocellular cancer, 11(17.2%) secondary cancer and one(1.6%) each hemangioendothelioma, hepatoblastoma and embryonal liver sarcoma]. Median donor and recipient follow-ups were 93 months(IQR 41–159) and 39 months(22–91), respectively. Results: Right and left hemi-livers were implanted in 39(60.9%) and 25(39.1%) cases, respectively. Median weights of right-and left-liver were 810 g(IQR 730–940) and 454 g(IQR 394–534), respectively. Graft-to-recipient weight ratios(GRWRs) were 1.17%(right, IQR 0.98%-1.4%) and 0.77%(left, 0.59%-0.95%). One-and five-year patient survivals were 85% and 71%(right) vs. 84% and 58%(left), respectively. Oneand five-year graft survivals were 74% and 61%(right) vs. 76% and 53%(left), respectively. The patient and graft survival of right and left grafts and of very small( < 0.6%), small(0.6%–0.79%) and large( ≥0.8%) GRWR were similar. Survival of very small grafts was 86% and 86% at 3-and 12-month. No donor died while five(7.8%) developed a Clavien–Dindo complication IIIa, IIIb or IV. Recipient morbidity consisted mainly of biliary and vascular complications; three(4.7%) recipients developed a small-for-size syndrome according to the Kyushu criteria. Conclusions: Adult-to-adult LDLT is a demanding procedure that widens therapeutic possibilities of many hepatobiliary diseases. The donor procedure can be done safely with low morbidity. The recipient operation carries a major morbidity indicating an important learning curve. Shifting the risk from the donor to the recipient, by moving from the larger right-liver to the smaller left-liver grafts, should be further explored as this policy makes donor hepatectomy safer and may stimulate the development of transplant oncology.
Background: Liver transplantation is the treatment for end-stage liver diseases and well-selected malignancies. The allograft shortage may be alleviated with living donation. The initial UCLouvain experience of adult living-donor liver transplantation(LDLT) is presented. Methods: A retrospective analysis of 64 adult-to-adult LDLTs performed at our institution between 1998 and 2016 was conducted. The median age of 29(45.3%) females and 35(54.7%) males was 50.2 years(interquartile range, IQR 32.9–57.5). Twenty-two(34.4%) recipients had no portal hypertension. Three(4.7%) patients had a benign and 33(51.6%) a malignant tumor [19(29.7%) hepatocellular cancer, 11(17.2%) secondary cancer and one(1.6%) each hemangioendothelioma, hepatoblastoma and embryonal liver sarcoma]. Median donor and recipient follow-ups were 93 months(IQR 41–159) and 39 months(22–91), respectively. Results: Right and left hemi-livers were implanted in 39(60.9%) and 25(39.1%) cases, respectively. Median weights of right-and left-liver were 810 g(IQR 730–940) and 454 g(IQR 394–534), respectively. Graft-to-recipient weight ratios(GRWRs) were 1.17%(right, IQR 0.98%-1.4%) and 0.77%(left, 0.59%-0.95%). One-and five-year patient survivals were 85% and 71%(right) vs. 84% and 58%(left), respectively. Oneand five-year graft survivals were 74% and 61%(right) vs. 76% and 53%(left), respectively. The patient and graft survival of right and left grafts and of very small( < 0.6%), small(0.6%–0.79%) and large( ≥0.8%) GRWR were similar. Survival of very small grafts was 86% and 86% at 3-and 12-month. No donor died while five(7.8%) developed a Clavien–Dindo complication IIIa, IIIb or IV. Recipient morbidity consisted mainly of biliary and vascular complications; three(4.7%) recipients developed a small-for-size syndrome according to the Kyushu criteria. Conclusions: Adult-to-adult LDLT is a demanding procedure that widens therapeutic possibilities of many hepatobiliary diseases. The donor procedure can be done safely with low morbidity. The recipient operation carries a major morbidity indicating an important learning curve. Shifting the risk from the donor to the recipient, by moving from the larger right-liver to the smaller left-liver grafts, should be further explored as this policy makes donor hepatectomy safer and may stimulate the development of transplant oncology.
引文
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[4]Ikegami T,Shirabe K,Yoshizumi T,Aishima S,Taketomi YA,Soejima Y,et al.Primary graft dysfunction after living donor liver transplantation is characterized by delayed functional hyperbilirubinemia.Am J Transplant2012;12:1886-1897.
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[7]Rossler F,Sapisochin G,Song G,Lin YH,Simpson MA,Hasegawa K,et al.Defining benchmarks for major liver surgery:a multicenter analysis of 5202 living liver donors.Ann Surg 2016;264:492-500.
[8]Uemura T,Wada S,Kaido T,Mori A,Ogura Y,Yagi S,et al.How far can we lower graft-to-recipient weight ratio for living donor liver transplantation under modulation of portal venous pressure?Surgery 2016;159:1623-1630.
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[12]Gorgen A,Goldaracena N,Zhang W,Rosales R,Ghanekar A,Lilly L,et al.Surgical complications after right hepatectomy for live liver donation:largest single-center Western world experience.Semin Liver Dis 2018;38:134-144.
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[22]Man K,Fan ST,Lo CM,Liu CL,Fung PC,Liang TB,et al.Graft injury in relation to graft size in right lobe live donor liver transplantation:a study of hepatic sinusoidal injury in correlation with portal hemodynamics and intragraft gene expression.Ann Surg 2003;237:256-264.
[23]Wu YJ,Wang SH,Elsarawy AM,Chan YC,Chen CL,Cheng BC,et al.Prediction of the development of persistent massive ascites after living donor liver transplantation using a perioperative risk score.Transplantation2018;102:e275-e281.
[24]Ikegami T,Shirabe K,Nakagawara H,Yoshizumi T,Toshima T,Soejima Y,et al.Obstructing spontaneous major shunt vessels is mandatory to keep adequate portal inflow in living-donor liver transplantation.Transplantation2013;95:1270-1277.
[25]Yamada T,Tanaka K,Uryuhara K,Ito K,Takada Y,Uemoto S.Selective hemiportocaval shunt based on portal vein pressure for small-for-size graft in adult living donor liver transplantation.Am J Transplant 2008;8:847-853.
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[27]Fan ST,Lo CM,Liu CL,Wang WX,Wong J.Safety and necessity of including the middle hepatic vein in the right lobe graft in adult-to-adult live donor liver transplantation.Ann Surg 2003;238:137-148.
[28]Rao HB,Prakash A,Sudhindran S,Venu RP.Biliary strictures complicating living donor liver transplantation:problems,novel insights and solutions.World J Gastroenterol 2018;24:2061-2072.
[29]Baker TB,Zimmerman MA,Goodrich NP,Samstein B,Pomfret EA,Pomposelli JJ,et al.Biliary reconstructive techniques and associated anatomic variants in adult living donor liver transplantations:the adult-to-adult living donor liver transplantation cohort study experience.Liver Transplant 2017;23:1519-1530.
[30]Lin TS,Chen CL,Concejero AM,Yap AQ,Lin YH,Liu CY,et al.Early and long-term results of routine microsurgical biliary reconstruction in living donor liver transplantation.Liver Transplant 2013;19:207-214.
[31]Lin TS,Chen CL,Concejero AM,Yap AQ,Lin YH,Liu CY,et al.Section 9.Technical details of microsurgical biliary reconstruction in living donor liver transplantation.Transplantation 2014;97:S34-S36.
[32]Kim SH,Lee KW,Kim YK,Cho SY,Han SS,Park SJ.Tailored telescopic reconstruction of the bile duct in living donor liver transplantation.Liver Transpl2010;16:1069-1074.
[33]Uchiyama H,Shirabe K,Yoshizumi T,Ikegami T,Harimoto N,Itoh S,et al.Living donor liver transplantation for intrahepatic arteriovenous fistula with hepatic artery reconstruction using the right gastroepiploic artery.Liver Transplant2016;22:552-556.
[34]Chen CL,Concejero AM,Cheng YF.More than a quarter of a century of liver transplantation in Kaohsiung Chang Gung Memorial Hospital.Clin Transpl2011:213-221.
[35]Ikegami T,Yoshizumi T,Uchiyama H,Soejima Y,Harada N,Maehara Y.Hepatic artery reconstruction in living donor liver transplantation using surgical loupes:achieving low rate of hepatic arterial thrombosis in 741 consecutive recipients-tips and tricks to overcome the poor hepatic arterial flow.Liver Transplant 2017;23:1081-1082.
[36]Takatsuki M,Chiang YC,Lin TS,Wang CC,Concejero A,Lin CC,et al.Anatomical and technical aspects of hepatic artery reconstruction in living donor liver transplantation.Surgery 2006;140:824-829.
[37]Li PC,Thorat A,Jeng LB,Yang HR,Li ML,Yeh CC,et al.Hepatic artery reconstruction in living donor liver transplantation using surgical loupes:achieving low rate of hepatic arterial thrombosis in 741 consecutive recipients-tips and tricks to overcome the poor hepatic arterial flow.Liver Transplant 2017;23:887-898.
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[2]Dahm F,Georgiev P,Clavien PA.Small-for-size syndrome after partial liver transplantation:definition,mechanisms of disease and clinical implications.Am J Transplant 2005;5:2605-2610.
[3]Ikegami T,Yoshizumi T,Sakata K,Uchiyama H,Harimoto N,Harada N,et al.Left lobe living donor liver transplantation in adults:what is the safety limit?Liver Transplant 2016;22:1666-1675.
[4]Ikegami T,Shirabe K,Yoshizumi T,Aishima S,Taketomi YA,Soejima Y,et al.Primary graft dysfunction after living donor liver transplantation is characterized by delayed functional hyperbilirubinemia.Am J Transplant2012;12:1886-1897.
[5]Hernandez-Alejandro R,Sharma H.Small-for-size syndrome in liver transplantation:new horizons to cover with a good launchpad.Liver Transplant2016;22:33-36.
[6]Roll GR,Parekh JR,Parker WF,Siegler M,Pomfret EA,Ascher NL,et al.Left hepatectomy versus right hepatectomy for living donor liver transplantation:shifting the risk from the donor to the recipient.Liver Transplant2013;19:472-481.
[7]Rossler F,Sapisochin G,Song G,Lin YH,Simpson MA,Hasegawa K,et al.Defining benchmarks for major liver surgery:a multicenter analysis of 5202 living liver donors.Ann Surg 2016;264:492-500.
[8]Uemura T,Wada S,Kaido T,Mori A,Ogura Y,Yagi S,et al.How far can we lower graft-to-recipient weight ratio for living donor liver transplantation under modulation of portal venous pressure?Surgery 2016;159:1623-1630.
[9]Troisi RI,Berardi G,Tomassini F,Sainz-Barriga M.Graft inflow modulation in adult-to-adult living donor liver transplantation:a systematic review.Transpl Rev(Orlando)2017;31:127-135.
[10]Lerut J,Mathys J,Verbaandert C,Talpe S,Ciccarelli O,Lemaire J,et al.Tacrolimus monotherapy in liver transplantation:one-year results of a prospective,randomized,double-blind,placebo-controlled study.Ann Surg2008;248:956-967.
[11]Hashikura Y,Makuuchi M,Kawasaki S,Matsunami H,Ikegami T,Nakazawa Y,et al.Successful living-related partial liver transplantation to an adult patient.Lancet 1994;343:1233-1234.
[12]Gorgen A,Goldaracena N,Zhang W,Rosales R,Ghanekar A,Lilly L,et al.Surgical complications after right hepatectomy for live liver donation:largest single-center Western world experience.Semin Liver Dis 2018;38:134-144.
[13]Pinheiro RS,Waisberg DR,Nacif LS,Rocha-Santos V,Arantes RM,Ducatti L,et al.Living donor liver transplantation for hepatocellular cancer:an(almost)exclusive Eastern procedure?Transl Gastroenterol Hepatol 2017;2:68.
[14]Suh KS,Suh SW,Lee JM,Choi Y,Yi NJ,Lee KW.Recent advancements in and views on the donor operation in living donor liver transplantation:a singlecenter study of 886 patients over 13 years.Liver Transplant 2015;21:329-338.
[15]Lee SG.A complete treatment of adult living donor liver transplantation:a review of surgical technique and current challenges to expand indication of patients.Am J Transplant 2015;15:17-38.
[16]Jeon YM,Lee KW,Yi NJ,Lee JM,Hong G,Choi Y,et al.The right posterior bile duct anatomy of the donor is important in biliary complications of the recipients after living-donor liver transplantation.Ann Surg 2013;257:702-707.
[17]Uchiyama H,Shirabe K,Nakagawara H,Ikegami T,Toshima T,Soejima Y,et al.Revisiting the safety of living liver donors by reassessing 441 donor hepatectomies:is a larger hepatectomy complication-prone?Am J Transplant2014;14:367-374.
[18]Yoon JH,Lee JM,Suh KS,Lee KW,Yi NJ,Lee KB,et al.Combined use of MRfat quantification and MR elastography in living liver donors:can it reduce the need for preoperative liver biopsy?Radiology 2015;276:453-464.
[19]Simpson MA,Verbesey JE,Khettry U,Morin DS,Gordon FD,Burns DL,et al.Successful algorithm for selective liver biopsy in the right hepatic lobe live donor(RHLD).Am J Transplant 2008;8:832-838.
[20]Doyle A,Adeyi O,Khalili K,Fischer S,Dib M,Goldaracena N,et al.Treatment with Optifast reduces hepatic steatosis and increases candidacy rates for living donor liver transplantation.Liver Transplant 2016;22:1295-12300.
[21]Kiuchi T,Kasahara M,Uryuhara K,Inomata Y,Uemoto S,Asonuma K,et al.Impact of graft size mismatching on graft prognosis in liver transplantation from living donors.Transplantation 1999;67:321-327.
[22]Man K,Fan ST,Lo CM,Liu CL,Fung PC,Liang TB,et al.Graft injury in relation to graft size in right lobe live donor liver transplantation:a study of hepatic sinusoidal injury in correlation with portal hemodynamics and intragraft gene expression.Ann Surg 2003;237:256-264.
[23]Wu YJ,Wang SH,Elsarawy AM,Chan YC,Chen CL,Cheng BC,et al.Prediction of the development of persistent massive ascites after living donor liver transplantation using a perioperative risk score.Transplantation2018;102:e275-e281.
[24]Ikegami T,Shirabe K,Nakagawara H,Yoshizumi T,Toshima T,Soejima Y,et al.Obstructing spontaneous major shunt vessels is mandatory to keep adequate portal inflow in living-donor liver transplantation.Transplantation2013;95:1270-1277.
[25]Yamada T,Tanaka K,Uryuhara K,Ito K,Takada Y,Uemoto S.Selective hemiportocaval shunt based on portal vein pressure for small-for-size graft in adult living donor liver transplantation.Am J Transplant 2008;8:847-853.
[26]Reddy MS,Rela M.Portosystemic collaterals in living donor liver transplantation:what is all the fuss about?Liver Transplant 2017;23:537-544.
[27]Fan ST,Lo CM,Liu CL,Wang WX,Wong J.Safety and necessity of including the middle hepatic vein in the right lobe graft in adult-to-adult live donor liver transplantation.Ann Surg 2003;238:137-148.
[28]Rao HB,Prakash A,Sudhindran S,Venu RP.Biliary strictures complicating living donor liver transplantation:problems,novel insights and solutions.World J Gastroenterol 2018;24:2061-2072.
[29]Baker TB,Zimmerman MA,Goodrich NP,Samstein B,Pomfret EA,Pomposelli JJ,et al.Biliary reconstructive techniques and associated anatomic variants in adult living donor liver transplantations:the adult-to-adult living donor liver transplantation cohort study experience.Liver Transplant 2017;23:1519-1530.
[30]Lin TS,Chen CL,Concejero AM,Yap AQ,Lin YH,Liu CY,et al.Early and long-term results of routine microsurgical biliary reconstruction in living donor liver transplantation.Liver Transplant 2013;19:207-214.
[31]Lin TS,Chen CL,Concejero AM,Yap AQ,Lin YH,Liu CY,et al.Section 9.Technical details of microsurgical biliary reconstruction in living donor liver transplantation.Transplantation 2014;97:S34-S36.
[32]Kim SH,Lee KW,Kim YK,Cho SY,Han SS,Park SJ.Tailored telescopic reconstruction of the bile duct in living donor liver transplantation.Liver Transpl2010;16:1069-1074.
[33]Uchiyama H,Shirabe K,Yoshizumi T,Ikegami T,Harimoto N,Itoh S,et al.Living donor liver transplantation for intrahepatic arteriovenous fistula with hepatic artery reconstruction using the right gastroepiploic artery.Liver Transplant2016;22:552-556.
[34]Chen CL,Concejero AM,Cheng YF.More than a quarter of a century of liver transplantation in Kaohsiung Chang Gung Memorial Hospital.Clin Transpl2011:213-221.
[35]Ikegami T,Yoshizumi T,Uchiyama H,Soejima Y,Harada N,Maehara Y.Hepatic artery reconstruction in living donor liver transplantation using surgical loupes:achieving low rate of hepatic arterial thrombosis in 741 consecutive recipients-tips and tricks to overcome the poor hepatic arterial flow.Liver Transplant 2017;23:1081-1082.
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