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Der Chirurg

, Volume 90, Issue 2, pp 102–109 | Cite as

Grenzbereiche der Lebertransplantation in Indikation und Technik

  • W. Schöning
  • R. Öllinger
  • M. Schmelzle
  • J. PratschkeEmail author
Leitthema
  • 169 Downloads

Zusammenfassung

Hintergrund

Die Grenzbereiche der Lebertransplantation liegen vor allem in der Ausweitung der Indikation (hepatozelluläres Karzinom, [perihiläres] Cholangiokarzinom, Empfänger mit gravierenderen Nebendiagnosen bzw. „weichen“ Kontraindikationen) und technisch anspruchsvollen Rekonstruktionsverfahren der vaskulären Strukturen (bei Portalvenenthrombose bzw. schwieriger arterieller Anschlussmöglichkeit) sowie einer Erweiterung des Spenderpools mit suboptimalen Organen (ältere Spender, steatotische Lebern).

Methoden

Anhand persönlicher Erfahrungen im klinischen Alltag und entsprechender Literaturrecherche legen wir in diesem Artikel die aktuelle Situation dar.

Ergebnisse

In Deutschland zeigt sich eine deutliche Abnahme des 1‑Jahres-Überlebens. Der Anteil an „schwer vermittelbaren“ („marginalen“) Spenderorganen verhält sich dabei reziprok zum massiv erniedrigten Spenderaufkommen und parallel zur steigenden Wartelistenmortalität (WL). Gleichzeitig nimmt der Anteil an stationären WL-Patienten mit Mehrorganversagen zu.

Schlussfolgerung

Eine ergebnisorientierte und -kontrollierte Lebertransplantation erlaubt heutzutage kaum noch ein Vordringen in ehemalige Grenzbereiche. Solange sich die aktuellen Bedingungen nicht ändern, wird ein Verschieben der Grenzen des chirurgisch Machbaren kaum möglich sein. Vielmehr kann in der aktuellen Situation durch restriktivere Indikationsstellung und Organakzeptanz nur versucht werden, die ehemals erreichten Erfolge mit exzellentem Kurz- und Langzeitüberleben (1-Jahres-Überleben von 90 %, 20-Jahres-Überleben von 50 %) wieder zu ermöglichen.

Schlüsselwörter

MELD-Patienten Spendermangel Pfortaderthrombose Hepatozelluräes Karzinom Cholangiozelluläres Karzinom 

Frontiers in liver transplantation in indication and techniques

Abstract

Background

The frontiers in liver transplantation are intrinsically expansions of indications, e.g. hepatocellular carcinoma and (perihilar) cholangiocarcinoma, recipients with more severe concomitant diagnoses or “soft” contraindications and technically demanding reconstruction procedures of vascular structures (for portal vein thrombosis or aorto-hepatic conduits). In addition, an extension of the donor pool with suboptimal donor organs (old donors and steatotic livers) is of interest.

Methods

This article presents the current situation based on personal experiences in daily practice and an appropriate literature review.

Results

A significant reduction of 1‑year patient survival has been reported in Germany. The percentage of so-called marginal donor organs is inversely proportional to the very low donation rate and parallel to the waiting list mortality. Simultaneously, the proportion of inpatients with multiple organ failure is rising.

Conclusion

Results-oriented and controlled liver transplantation currently prohibits making inroads into the previously intrinsic frontiers. As long as the current circumstances do not change, a shift in the intrinsic frontiers of that which is surgically feasible will not be possible. The current situation forces the transplant surgeon to apply a more restrictive indications and organ acceptance policy. With this approach we can try to regain the previously excellent short- and long-term results of a 1‑year survival of 90% and a 20-year survival of 50%.

Keywords

MELD patients Donor shortage Portal vein thrombosis Hepatocellular carcinoma Cholangiocellular carcinoma 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

W. Schöning, R. Öllinger, M. Schmelzle und J. Pratschke geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  • W. Schöning
    • 1
  • R. Öllinger
    • 1
  • M. Schmelzle
    • 1
  • J. Pratschke
    • 1
    Email author
  1. 1.Chirurgische Klinik, Campus Charité Mitte/Campus Virchow-KlinikumCharité – Universitätsmedizin BerlinBerlinDeutschland

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