Lebertransplantation - chirurgische Techniken

Zusammenfassung

Die Spenderkriterien wurden bei der Lebertransplantation wie bei anderen Organen wegen des persistierenden Organmangels ständig erweitert. Die Schädigung des Transplantats kommt multifaktoriell zustande. Alter, eine mäßige Steatose und andere Faktoren sind allein kein Ablehnungsgrund für ein Transplantat. Obwohl die Technik der Lebertransplantation weitgehend standardisiert ist, sind ca. 10 % der Letalität innerhalb des ersten Monats auf technische Komplikationen zurückzuführen. Die Transplantation erfolgt in Deutschland jeweils zur Hälfte in konventioneller und Huckpacktechnik. Die Komplikationsrate und die Gesamtergebnisse sind gleich. Die Split-Transplantation hat nach dem European Liver Transplant Registry einen hochsignifikanten Einfluss auf das Transplantatüberleben. Probleme mit Arterien- und Gallenwegsanastomosen, Leckagen und Blutungen an der Absetzungsfläche und anatomische Normvarianten sind in 20-30 % nach Split-Transplantation zu erwarten und bedeuten eine besondere Herausforderung für das Transplantationsteam.

Abstract

The increasing shortage of available grafts led to expanding donor criteria. Graft damage in transplantation is a multifactorial process. High donor age or mild to moderate steatosis allone do not justify to refuse a liver graft. Technique of liver transplantation is considered standardized. Nevertheless, according to the European Transplant Registry 10 % of mortality is caused by technical complications. In Germany liver transplantation is performed in equal parts using the conventional and the piggy back technique. Complications and results are comparable. The influence of split liver transplantation on patient survival is low but highly significant. Problems arise in 20 to 30 % from arterial or biliary anastomoses and from leakage or hemorrhage at the cut parenchyma. So fare, split liver transplantation is a challenge for a transplant team and justifies the restriction of this approach to particular centers.

Schlüsselwörter

Lebertransplantation - Technik - Splitting - Spender

Key words

Liver transplantation - technique - split - donor

Literatur

• 1 Welch C S. A note on transplantation of the whole liver in dogs.  Transplant Bull. 1955;  2 54
• 2 Cannon J A. Brief report.  Transplant Bull. 1956;  3 7
• 3 Starzl T E, Kaupp H A, Brock D R, Lazarus R E, Johnston R V. Reconstructive problems in canine liver homotransplantation with spezial reference to the postoperative role of hepatic venous flow.  Surg Gynecol Obstet. 1960;  111 733-743
• 4 Starzl T E, Marchioro T L, von Kaulla K N, Hermann G, Brittain R S, Waddell W R. Homotransplantation of the liver in humans.  Surg Gynecol Obstet. 1963;  117 659-676
• 5 Starzl T E, Iwatsuki S, van Thiel D H. et al . Evolution of liver transplantation.  Hepatology. 1982;  2 614-636
• 6 Bismuth H, Houssin D. Reduced-sized orthotopic liver graft in hepatic transplantation in children.  Surgery. 1984;  95 367-370
• 7 Pichlmayr R, Ringe B, Gubernatis G, Hauss J, Bunzendahl H. Transplantation einer Spenderleber auf zwei Empfänger (splitting-transplantation): eine neue Methode in der Weiterentwicklung der Lebersegmenttransplantation.  Langenbecks Arch Chir. 1988;  373 127-130
• 8 Bismuth H, Morino M, Castaing D. et al . Emergency orthotopic liver transplantation in two patients uring one donor liver.  Br J Surg. 1989;  76 722-724
• 9 Filipponi F, Romagnoli J, Urbani L. et al . Transplantation of ninety-three-year-old donor liver. Case report.  Hepatogastroenterology. 2003;  50 510-511
• 10 Montalti R, Nardo B, Bertelli R. et al . Donor pool expansion in liver transplantation.  Transplant Proc. 2004;  36 520-522
• 11 Rull R, Vidal O, Momblan D. et al . Evaluation of potential liver donors: limits imposed by donor variables in liver transplantation.  Liver Transpl. 2003;  9 389-393
• 12 Tisone G, Manzia T M, Zazza S. et al . Marginal donors in liver transplantation.  Transplant Proc. 2004;  36 525-526
• 13 Imber C J, Peter S DS, Lopez I, Guiver L, Friend P J. Current practice regarding the use of fatty livers: a trans-atlantic survey.  Liver Transpl. 2002;  8 545-549
• 14 Verran D, Kusyk T, Painter D. et al . Clinical experience gained from the use of 120 steatotic donor livers for orthotopic liver transplantation.  Liver Transpl. 2003;  9 500-505
• 15 Zamboni F, Franchello A, David E. et al . Effect of macrovesicular steatosis and other donor and recipient characteristics on the outcome of liver transplantation.  Clin Transplant. 2001;  15 53-57
• 16 Adam R, Cailliez V, Majno P. et al . Normalised intrinsic mortality risk in liver transplantation: European Liver Transplant Registry study.  Lancet. 2000;  356 621-627
• 17 European Liver Transplant Registry .Data Analysis 1968-2003. Hopital Paul Brousse, Paris-Villejuif 2004
• 18 Müller A R, Platz K P, Krause P. et al . Perioperative factors influencing patient outcome after liver transplantation.  Transpl Int. 2000;  13 S 158-S 161
• 19 Schnülle P, Berger S, de Boer J. et al . Effects of catecholamine application to brain-dead donors on graft survival in solid organ transplantation.  Transplantation. 2001;  72 455-463
• 20 Briceno J, Marchal T, Padillo J, Solorzano G, Pera C. Influence of marginal donors on liver preservation injury.  Transplantation. 2002;  27 522-526
• 21 Emond J C, Reeman R B, Renz J F. et al . Optimizing the use of donated cadaver livers: analysis and policy development to increase the application of split-liver transplantation.  Liver Transpl. 2002;  8 863-872
• 22 Ploeg R F, D'Alessandro A M, Knechtle S J. et al . Risk factors for primary dysfunction after liver transplantation - a multivariate analysis.  Transplantation. 1993;  55 807-813
• 23 Myron Kauffman H, Mc Bride M A, Cherikh W S. et al . Transplant tumor registry: donor related malignancies.  Transplantation. 2002;  74 358-362
• 24 Buell J F, Trofe J, Hanaway M J. et al . Transmission of donor cancer into cardiothoracic transplant recipients.  Surgery. 2001;  130 660-666
• 25 Starzl T E, Hakal T R, Shaw B W. et al . A flexible procedure for multiple cadaveric organ procurement.  Surg Gynecol Obstet. 1984;  158 223-230
• 26 Gubernatis G, Abendroth D, Haverich A. et al . Technik der Mehrorganentnahme.  Chirurg. 1988;  59 461-468
• 27 Moench C, Moench K, Lohse A W, Thies J, Otto G. Prevention of ischemic-type biliary lesions by arterial back-table pressure perfusion.  Liver Transpl. 2003;  9 285-289
• 28 Griffith B P, Shaw B W, Hardesty R L. et al . Veno-venous bypass without systemic anticoagulation for human liver transplantation.  Surg Gynecol Obstet. 1985;  160 270-272
• 29 Tzakis A G, Kirkegaard P, Pinna A D. et al . Liver transplantation with cavoportal hemitransposition in the presence of diffuse portal vein thrombosis.  Transplantation. 1998;  65 619-624
• 30 Massarollo P C, Mies S, Raia S. Simultaneous arterial and portal revascularization in liver transplantation.  Transplant Proc. 1998;  30 2883-2884
• 31 Post S, Bleyl J, Golling M, Herfarth C, Otto G. Modes of reperfusion in clinical liver transplantation.  Langenbecks Arch Chir. 1995;  380 53-57
• 32 Gordon R D, Shaw B W, Iwatsuki S. et al . A simplified technique for revascularization of homografts of the liver with a variant right hepatic artery from the superior mesenteric artery.  Surg Gynecol Obstet. 1985;  160 474-476
• 33 Todo S, Makowka S, Tzakis A G. et al . Hepatic artery in liver transplantation.  Transplant Proc. 1987;  19 (Suppl 1) 2406-2411
• 34 Nussler N C, Settmacher U, Haase R, Stange B, Heise M, Neuhaus P. Diagnosis and treatment of arterial steal syndromes in liver transplant recipients.  Liver Transpl. 2003;  9 596-602
• 35 Manner M, Otto G, Senninger N, Kraus T, Goerich J, Herfarth C. Arterial steal: an unusual cause for hepatic hypoperfusion after liver transplantation.  Transpl Internat. 1991;  4 122-124
• 36 Goss J A, Shackleton C R, Farmer D G. et al . Orthotopic liver transplantation for primary sclerosing cholangitis. A 12-year single center experience.  Ann Surg. 1997;  225 472-481
• 37 Davidson B R, Rai R, Kurzawinski T R. et al . Prospective randomized trial of end-to-end versus side-to-side biliary reconstruction after orthotopic liver transplantation.  Br J Surg. 1999;  86 447-452
• 38 Neuhaus P, Blumhardt G, Bechstein W O, Steffen R, Keck H. Side-to-side anastomosis of the common bile duct is the method of choice for biliary tract reconstruction after liver transplantation.  Transplant Proc. 1990;  22 1571
• 39 Wolff H, Otto G, David H. Biliary tract reconstruction in liver transplantations.  Transplantation Proc. 1985;  17 274-275
• 40 Krom R AF, Kingma L M, Haagsma E B, Wesenhagen H, Sloof J M, Gips C H. Choledochocholedochostomy, a relatively safe procedure in orthotopic liver transplantation.  Surgery. 1985;  97 552-556
• 41 Rouch D A, Emond J C, Thistlethwaite J R, Mayes J T, Broelsch C E. Choledochocholedochostomy without a T tube or internal stent in transplantation of the liver.  Surg Gynecol Obstet. 1990;  170 239-244
• 42 Scatton O, Meunier B, Cherqui D. et al . Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation.  Ann Surg. 2001;  233 432-437
• 43 Northover J M, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications.  Br J Surg. 1979;  66 379-384
• 44 Calne R Y, Williams R. Liver transplantation in man: observations on technique and organization in five cases.  Brit Med J. 1968;  4 535
• 45 Bismuth H, Castaing D, Sherlock D J. Liver transplanation by face-à-face vena cavaplasty.  Surgery. 1992;  111 151
• 46 Meunier B, Bardaxoglou E, Chareton B. et al . “Piggyback” method in hepatic transplantation.  Chirurgie. 1993;  119 682-685
• 47 Lerut J, Ciccarelli O, Roggen F. et al . Cavocaval adult liver transplantation and retransplantation without venovenous bypass and without portocaval shunting: a prospective feasibility study in adult liver transplantation.  Transplantation. 2003;  75 1740-1745
• 48 Jovine E, Mazziotti A, Grazi G L. et al . Piggy-back versus conventional technique in liver transplantation: report of a randomized trial.  Transpl Int. 1997;  10 109-112
• 49 Moreno-Gonzalez E, Meneu-Diaz J G, Fundora Y. et al . Advantages of the piggy back technique on intraoperative transfusion, fluid consumption, an vasoactive drugs requirements in liver transplantation: a comparative study.  Transplant Proc. 2003;  35 1918-1919
• 50 Parrilla P, Sanchez-Bueno F, Figueras J. et al . Analysis of the complications of the piggy-back technique in 1,112 liver transplants.  Transplantation. 1999;  67 1214-1217
• 51 Broelsch C E, Emond J C, Whitington P F. Application of reduced-size liver transplants or split grafts, auxiliary orthotopic grafts and living related segmental transplants.  Ann Surg. 1990;  214 368-377
• 52 Cohen B, Persijn G G. Eurotransplant Annual Report 2003. Leiden 2004
• 53 Heaton N. Small-for-size liver syndrome after auxiliary and split liver transplantation: donor selection.  Liver Transpl. 2003;  9 26-28
• 54 European Liver Transplant Registry .Data Analysis 1968-2003. Hopital Paul Brousse, Paris-Villejuif 2004
• 55 Renz J F, Emond J C, Yersiz H, Ascher N L, Busuttil R W. Split liver transplantation in the United States. Outcomes of a National Survey.  Ann Surg. 2004;  239 172-181
• 56 Rogiers X, Malago M, Gawad K. et al . In situ splitting of cadveric livers. The ultimate expansion of a limited donor pool.  Ann Surg. 1996;  224 331-339
• 57 Sommacale D, Farges O, Ettorre G M. et al . In situ split liver transplantation for two adult recipients.  Transplantation. 2000;  15 1005-1007
• 58 Yersiz H, Renz J F, Farmer D G, Hisatike G M, McDiarmid S V, Busuttil R W. One hundred in situ split-liver transplantations: a single-center experience.  Ann Surg. 2003;  238 496-505
• 59 Noujaim H, Gunson B, Mayer D A. et al . Worth continuing doing ex situ liver graft splitting? A single-center analysis.  Am J Transpl. 2003;  3 318-323
• 60 Reyes J, Gerber D, Mazariegos G V. et al . Split-liver transplantation: a comparison of ex vivo and in situ techniques.  J Pediatr Surg. 2000;  35 283-289
• 61 Azoulay D, Marin-Hargreaves G, Castaing D, Bismuth H. Ex situ splitting of the liver. The versatile Paul Brousse Technique.  Arch Surg. 2001;  136 956-961
• 62 Rela M, Vougas V, Muiesan P. et al . Split liver transplantation. King's College Hospital experience.  Ann Surg. 1998;  227 282-288
• 63 Rogiers X, Topp S, Broering D C. Split liver transplantation: split in-situ or ex-situ?.  Curr Opin Transpl. 2000;  5 57-63
• 64 Humar A, Khwaja K, Sielaff T D, Lake J R, Payne W D. Technique of split-liver transplant for two adult recipients.  Liver transpl. 2002;  8 725-729
• 65 Gundlach M, Broering D, Topp S, Sterneck M, Rogiers X. Split-cava technique: liver splitting for two adult recipients.  Liver Transpl. 2000;  6 703-706
• 66 Emond J C, Whitington P F, Thistlethwaite J R. et al . Transplantation of two patients with one liver. Analysis of a preliminary experience with ‘split-liver’ grafting.  Ann Surg. 1990;  212 14-22
• 67 Shaw B W, Wood R P, Stratta R J. et al . Management of arterial anomalies encountered in split-liver transplantation.  Transpl Proc. 1990;  22 420-422
• 68 Otte J B, de Ville de Goyet J, Alberti D. et al . The concept and technique of the split liver in clinical transplantation.  Surgery. 1990;  107 605-612
• 69 Emond J C, Heffron T G, Whitington P F. et al . Reconstruction of the hepatic vein in reduced size hepatic transplantation.  Surg Gynecol Obstet. 1993;  176 11-17