Skip to main content

Advertisement

SpringerLink
Log in

Grenzbereiche der Lebertransplantation in Indikation und Technik

Frontiers in liver transplantation in indication and techniques

  • Leitthema
  • Published:
Der Chirurg Aims and scope Submit manuscript

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.

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%.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3

Literatur

  1. Bridgewater J, Galle PR, Khan SA, Llovet JM, Park JW, Patel T, Pawlik TM, Gores GJ (2014) Guidelines for the diagnosis and management of intrahepatic cholangiocarcinoma. J Hepatol 60:1268–1289

    Article  PubMed  Google Scholar 

  2. Bundesärztekammer (2017) Richtlinien zur Organtransplantation. Dtsch Arztebl 114:A 2019

    Google Scholar 

  3. Cardoso FS, Karvellas CJ, Kneteman NM, Meeberg G, Fidalgo P, Bagshaw SM (2015) Postoperative resource utilization and survival among liver transplant recipients with Model for End-stage Liver Disease score 〉/= 40: a retrospective cohort study. Can J Gastroenterol Hepatol 29:185–191

    Article  PubMed  PubMed Central  Google Scholar 

  4. Darwish Murad S, Kim WR, Harnois DM, Douglas DD, Burton J, Kulik LM, Botha JF, Mezrich JD, Chapman WC, Schwartz JJ, Hong JC, Emond JC, Jeon H, Rosen CB, Gores GJ, Heimbach JK (2012) Efficacy of neoadjuvant chemoradiation, followed by liver transplantation, for perihilar cholangiocarcinoma at 12 US centers. Baillieres Clin Gastroenterol 143:88–98e3 (quiz e14)

    Google Scholar 

  5. Darwish Murad S, Kim WR, Therneau T, Gores GJ, Rosen CB, Martenson JA, Alberts SR, Heimbach JK (2012) Predictors of pretransplant dropout and posttransplant recurrence in patients with perihilar cholangiocarcinoma. Hepatology 56:972–981

    Article  PubMed  Google Scholar 

  6. De Vreede I, Steers JL, Burch PA, Rosen CB, Gunderson LL, Haddock MG, Burgart L, Gores GJ (2000) Prolonged disease-free survival after orthotopic liver transplantation plus adjuvant chemoirradiation for cholangiocarcinoma. Liver Transpl 6:309–316

    Article  PubMed  Google Scholar 

  7. DSO (2017) DSO Jahresbericht. https://www.dso.de/uploads/tx_dsodl/JB_2017_web_01.pdf. Zugegriffen: 15. September 2018

    Google Scholar 

  8. Dumortier J, Czyglik O, Poncet G, Blanchet MC, Boucaud C, Henry L, Boillot O (2002) Eversion thrombectomy for portal vein thrombosis during liver transplantation. Am J Transplant 2:934–938

    Article  PubMed  Google Scholar 

  9. Englesbe MJ, Kubus J, Muhammad W, Sonnenday CJ, Welling T, Punch JD, Lynch RJ, Marrero JA, Pelletier SJ (2010) Portal vein thrombosis and survival in patients with cirrhosis. Liver Transpl 16:83–90

    Article  PubMed  Google Scholar 

  10. Forner A, Llovet JM, Bruix J (2012) Hepatocellular carcinoma. Lancet 379:1245–1255

    Article  PubMed  Google Scholar 

  11. Francoz C, Belghiti J, Vilgrain V, Sommacale D, Paradis V, Condat B, Denninger MH, Sauvanet A, Valla D, Durand F (2005) Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut 54:691–697

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Francoz C, Valla D, Durand F (2012) Portal vein thrombosis, cirrhosis, and liver transplantation. J Hepatol 57:203–212

    Article  PubMed  Google Scholar 

  13. Gayowski TJ, Marino IR, Doyle HR, Echeverri L, Mieles L, Todo S, Wagener M, Singh N, Yu VL, Fung JJ, Starzl TE (1996) A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation. J Surg Res 60:333–338

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Gonzalez Martinez S, Molina RA, Becerra Massare A, Muffak Granero K, Villegas Herrera T, Villar Del Moral JM, Fundora Suarez Y (2018) Liver transplantation in recipients with high model for end-stage liver disease score. Transplant Proc 50:595–597

    Article  CAS  PubMed  Google Scholar 

  15. Gores GJ, Darwish Murad S, Heimbach JK, Rosen CB (2013) Liver transplantation for perihilar cholangiocarcinoma. Dig Dis 31:126–129

    Article  PubMed  Google Scholar 

  16. Gotthardt DN, Weiss KH, Rupp C, Bode K, Eckerle I, Rudolph G, Bergemann J, Kloeters-Plachky P, Chahoud F, Buchler MW, Schemmer P, Stremmel W, Sauer P (2013) Bacteriobilia and fungibilia are associated with outcome in patients with endoscopic treatment of biliary complications after liver transplantation. Endoscopy 45:890–896

    Article  PubMed  Google Scholar 

  17. Heimbach JK, Gores GJ, Haddock MG, Alberts SR, Nyberg SL, Ishitani MB, Rosen CB (2004) Liver transplantation for unresectable perihilar cholangiocarcinoma. Semin Liver Dis 24:201–207

    Article  PubMed  Google Scholar 

  18. Henson JB, Patel YA, King LY, Zheng J, Chow SC, Muir AJ (2017) Outcomes of liver retransplantation in patients with primary sclerosing cholangitis. Liver Transpl 23:769–780

    Article  PubMed  PubMed Central  Google Scholar 

  19. Herzer K, Gerken G, Kroy D, Tacke F, Plewe J, Eurich D, Spengler U, Strassburg CP, Welker MW, Pischke S, Sterneck M, Mehrabi A, Weiss KH, Herber A, Berg T, Zimmermann T, Galle PR, Heinzow H, Schmidt H, Markova A, Serfert Y, Manns MP, Zeuzem S, Wedemeyer H (2018) Impact of direct-acting antiviral therapy on the need for liver transplantation related to hepatitis C in Germany. J Hepatol 69:982–984

    Article  PubMed  Google Scholar 

  20. Hessheimer AJ, Cardenas A, Garcia-Valdecasas JC, Fondevila C (2016) Can we prevent ischemic-type biliary lesions in donation after circulatory determination of death liver transplantation? Liver Transpl 22:1025–1033

    Article  PubMed  Google Scholar 

  21. Hibi T, Nishida S, Levi DM, Selvaggi G, Tekin A, Fan J, Ruiz P, Tzakis AG (2014) When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases. Ann Surg 259:760–766

    Article  PubMed  Google Scholar 

  22. IQTIG (2017) Qualitätsreport. https://iqtig.org/downloads/berichte/2017/IQTIG_Qualitaetsreport-2017_2018_09_21.pdf. Zugegriffen: 15. September 2018

    Google Scholar 

  23. Kim H, Lee KW, Yi NJ, Lee HW, Choi Y, Suh SW, Jeong J, Suh KS (2015) Outcome and technical aspects of liver retransplantation: analysis of 25-year experience in a single major center. Transplant Proc 47:727–729

    Article  CAS  PubMed  Google Scholar 

  24. Krenzien F, Schmelzle M, Struecker B, Raschzok N, Benzing C, Jara M, Bahra M, Ollinger R, Sauer IM, Pascher A, Pratschke J, Andreou A (2018) Liver transplantation and liver resection for cirrhotic patients with Hepatocellular carcinoma: comparison of long-term survivals. J Gastrointest Surg 22:840–848

    Article  PubMed  Google Scholar 

  25. Lim C, Salloum C, Compagnon P, Laurent A, Azoulay D (2015) Liver transplantation and portal vein thrombosis: an unfinished saga. Ann Surg 262:e90

    Article  PubMed  Google Scholar 

  26. Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, Montalto F, Ammatuna M, Morabito A, Gennari L (1996) Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 334:693–699

    Article  CAS  PubMed  Google Scholar 

  27. Mazzaferro V, Llovet JM, Miceli R, Bhoori S, Schiavo M, Mariani L, Camerini T, Roayaie S, Schwartz ME, Grazi GL, Adam R, Neuhaus P, Salizzoni M, Bruix J, Forner A, De Carlis L, Cillo U, Burroughs AK, Troisi R, Rossi M, Gerunda GE, Lerut J, Belghiti J, Boin I, Gugenheim J, Rochling F, Van Hoek B, Majno P, Metroticket Investigator Study G (2009) Predicting survival after liver transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a retrospective, exploratory analysis. Lancet Oncol 10:35–43

    Article  PubMed  Google Scholar 

  28. Mazzaferro V, Sposito C, Zhou J, Pinna AD, De Carlis L, Fan J, Cescon M, Di Sandro S, Yi-Feng H, Lauterio A, Bongini M, Cucchetti A (2018) Metroticket 2.0 model for analysis of competing risks of death after liver transplantation for hepatocellular carcinoma. Baillieres Clin Gastroenterol 154:128–139

    Google Scholar 

  29. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, Sanchez EQ, Gogel B, Levy MF, Goldstein RM, Fasola CG, Elliott EE, Bursac N, Mulligan D, Gonwa TA, Klintmalm GB (2002) Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg 235:292–296

    Article  PubMed  PubMed Central  Google Scholar 

  30. Muller X, Marcon F, Sapisochin G, Marquez M, Dondero F, Rayar M, Doyle MMB, Callans L, Li J, Nowak G, Allard MA, Jochmans I, Jacskon K, Beltrame MC, van Reeven M, Iesari S, Cucchetti A, Sharma H, Staiger RD, Raptis DA, Petrowsky H, de Oliveira M, Hernandez-Alejandro R, Pinna AD, Lerut J, Polak WG, de Santibanes E, de Santibanes M, Cameron AM, Pirenne J, Cherqui D, Adam RA, Ericzon BG, Nashan B, Olthoff K, Shaked A, Chapman WC, Boudjema K, Soubrane O, Paugam-Burtz C, Greig PD, Grant DR, Carvalheiro A, Muiesan P, Dutkowski P, Puhan M, Clavien PA (2018) Defining benchmarks in liver transplantation: a multicenter outcome analysis determining best achievable results. Ann Surg 267:419–425

    Article  PubMed  Google Scholar 

  31. Pichlmayr R, Weimann A, Tusch G, Schlitt HJ (1997) Indications and role of liver transplantation for malignant tumors. Oncologist 2:164–170

    CAS  PubMed  Google Scholar 

  32. Ravaioli M, Zanello M, Grazi GL, Ercolani G, Cescon M, Del Gaudio M, Cucchetti A, Pinna AD (2011) Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg 253:378–384

    Article  PubMed  Google Scholar 

  33. Razumilava N, Gores GJ (2014) Cholangiocarcinoma. Lancet 383:2168–2179

    Article  PubMed  PubMed Central  Google Scholar 

  34. Reese T, Raptis DA, Oberkofler CE, de Rougemont O, Gyori GP, Gosteli-Peter M, Dutkowski P, Clavien PA, Petrowsky H (2018) A systematic review and meta-analysis of rescue revascularization with arterial conduits in liver transplantation. Am J Transplant. https://doi.org/10.1111/ajt.15018

    Article  PubMed  PubMed Central  Google Scholar 

  35. Sapisochin G, Bruix J (2017) Liver transplantation for hepatocellular carcinoma: outcomes and novel surgical approaches. Nat Rev Gastroenterol Hepatol 14:203–217

    Article  PubMed  Google Scholar 

  36. Sapisochin G, Fidelman N, Roberts JP, Yao FY (2011) Mixed hepatocellular cholangiocarcinoma and intrahepatic cholangiocarcinoma in patients undergoing transplantation for hepatocellular carcinoma. Liver Transpl 17:934–942

    Article  PubMed  Google Scholar 

  37. Sapisochin G, Rodriguez de Lope C, Gastaca M, Ortiz de Urbina J, Suarez MA, Santoyo J, Castroagudin JF, Varo E, Lopez-Andujar R, Palacios F, Sanchez AG, Perez B, Guiberteau A, Blanco G, Gonzalez-Dieguez ML, Rodriguez M, Varona MA, Barrera MA, Fundora Y, Ferron JA, Ramos E, Fabregat J, Ciria R, Rufian S, Otero A, Vazquez MA, Pons JA, Parrilla P, Zozaya G, Herrero JI, Charco R, Bruix J (2014) “Very early” intrahepatic cholangiocarcinoma in cirrhotic patients: should liver transplantation be reconsidered in these patients? Am J Transplant 14:660–667

    Article  CAS  PubMed  Google Scholar 

  38. Sapisochin G, de Lope CR, Gastaca M, de Urbina JO, Lopez-Andujar R, Palacios F, Ramos E, Fabregat J, Castroagudin JF, Varo E, Pons JA, Parrilla P, Gonzalez-Dieguez ML, Rodriguez M, Otero A, Vazquez MA, Zozaya G, Herrero JI, Antolin GS, Perez B, Ciria R, Rufian S, Fundora Y, Ferron JA, Guiberteau A, Blanco G, Varona MA, Barrera MA, Suarez MA, Santoyo J, Bruix J, Charco R (2014) Intrahepatic cholangiocarcinoma or mixed hepatocellular-cholangiocarcinoma in patients undergoing liver transplantation: a Spanish matched cohort multicenter study. Ann Surg 259:944–952

    Article  CAS  PubMed  Google Scholar 

  39. Sapisochin G, Facciuto M, Rubbia-Brandt L, Marti J, Mehta N, Yao FY, Vibert E, Cherqui D, Grant DR, Hernandez-Alejandro R, Dale CH, Cucchetti A, Pinna A, Hwang S, Lee SG, Agopian VG, Busuttil RW, Rizvi S, Heimbach JK, Montenovo M, Reyes J, Cesaretti M, Soubrane O, Reichman T, Seal J, Kim PT, Klintmalm G, Sposito C, Mazzaferro V, Dutkowski P, Clavien PA, Toso C, Majno P, Kneteman N, Saunders C, Bruix J, iCCAIC (2016) Liver transplantation for “very early” intrahepatic cholangiocarcinoma: International retrospective study supporting a prospective assessment. Hepatology 64:1178–1188

    Article  CAS  PubMed  Google Scholar 

  40. Schlitt HJ, Loss M, Scherer MN, Becker T, Jauch KW, Nashan B, Schmidt H, Settmacher U, Rogiers X, Neuhaus P, Strassburg C (2011) Current developments in liver transplantation in Germany: MELD-based organ allocation and incentives for transplant centres. Z Gastroenterol 49:30–38

    Article  CAS  PubMed  Google Scholar 

  41. Schmelzle M, Krenzien F, Schoning W, Pratschke J (2018) Treatment of hepatocellular carcinoma in the cirrhotic and non-cirrhotic liver. Chirurg. https://doi.org/10.1007/s00104-018-0690-6

    Article  PubMed  Google Scholar 

  42. Schoening W, Helbig M, Buescher N, Andreou A, Schmitz V, Bahra M, Puhl G, Pascher A, Pratschke J, Seehofer D (2016) Eurotransplant donor-risk-index and recipient factors: influence on long-term outcome after liver transplantation—a large single-center experience. Clin Transplant 30:508–517

    Article  PubMed  Google Scholar 

  43. Schoening WN, Buescher N, Rademacher S, Andreou A, Kuehn S, Neuhaus R, Guckelberger O, Puhl G, Seehofer D, Neuhaus P (2013) Twenty-year longitudinal follow-up after orthotopic liver transplantation: a single-center experience of 313 consecutive cases. Am J Transplant 13:2384–2394

    Article  CAS  PubMed  Google Scholar 

  44. Schulte K, Borzikowsky C, Rahmel A, Kolibay F, Polze N, Frankel P, Mikle S, Alders B, Kunzendorf U, Feldkamp T (2018) Decline in organ donation in Germany. Dtsch Arztebl Int 115:463–468

    PubMed  PubMed Central  Google Scholar 

  45. Sudan D, DeRoover A, Chinnakotla S, Fox I, Shaw B Jr., McCashland T, Sorrell M, Tempero M, Langnas A (2002) Radiochemotherapy and transplantation allow long-term survival for nonresectable hilar cholangiocarcinoma. Am J Transplant 2:774–779

    Article  PubMed  Google Scholar 

  46. Terrault NA, Pageaux GP (2018) A changing landscape of liver transplantation: king HCV is dethroned, ALD and NAFLD take over! J Hepatol 69:767–768

    Article  PubMed  Google Scholar 

  47. Weismuller TJ, Fikatas P, Schmidt J, Barreiros AP, Otto G, Beckebaum S, Paul A, Scherer MN, Schmidt HH, Schlitt HJ, Neuhaus P, Klempnauer J, Pratschke J, Manns MP, Strassburg CP (2011) Multicentric evaluation of model for end-stage liver disease-based allocation and survival after liver transplantation in Germany—limitations of the „sickest first“-concept. Transpl Int 24:91–99

    Article  PubMed  Google Scholar 

  48. Xia VW, Taniguchi M, Steadman RH (2008) The changing face of patients presenting for liver transplantation. Curr Opin Organ Transplant 13:280–284

    Article  PubMed  Google Scholar 

  49. Yao FY, Ferrell L, Bass NM, Watson JJ, Bacchetti P, Venook A, Ascher NL, Roberts JP (2001) Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Hepatology 33:1394–1403

    Article  CAS  PubMed  Google Scholar 

  50. Yerdel MA, Gunson B, Mirza D, Karayalcin K, Olliff S, Buckels J, Mayer D, McMaster P, Pirenne J (2000) Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation 69:1873–1881

    Article  CAS  PubMed  Google Scholar 

  51. Zarrinpar A, Hong JC (2012) What is the prognosis after retransplantation of the liver? Adv Surg 46:87–100

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Chirurgische Klinik, Campus Charité Mitte/Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland

    W. Schöning, R. Öllinger, M. Schmelzle &  J. Pratschke

Authors
  1. W. Schöning
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. R. Öllinger
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Schmelzle
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. Pratschke
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. Pratschke.

Ethics declarations

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.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schöning, W., Öllinger, R., Schmelzle, M. et al. Grenzbereiche der Lebertransplantation in Indikation und Technik. Chirurg 90, 102–109 (2019). https://doi.org/10.1007/s00104-018-0761-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-018-0761-8

Schlüsselwörter

Keywords

Search

Navigation