成人对成人活体肝移植：鲁汶天主教大学的经验。
Adult-to-adult living-donor liver transplantation: The experience of the Université catholique de Louvain.
机构信息
Starzl Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrates 10, 1200 Brussels, Belgium; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
Hepatobiliopancreatic Unit, Las Higueras Hospital, Talcahuano, Chile.
出版信息
Hepatobiliary Pancreat Dis Int. 2019 Apr;18(2):132-142. doi: 10.1016/j.hbpd.2019.02.007. Epub 2019 Feb 28.
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. One- and 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.
背景
肝移植是治疗终末期肝病和精选恶性肿瘤的方法。活体供肝移植可缓解供肝短缺问题。本文报告了鲁汶大学成人活体肝移植（LDLT）的初步经验。
方法
对 1998 年至 2016 年在我院进行的 64 例成人对成人 LDLT 进行回顾性分析。29 例（45.3%）女性和 35 例（54.7%）男性的中位年龄为 50.2 岁（四分位间距 IQR 32.9-57.5）。22 例（34.4%）受者无门静脉高压。3 例（4.7%）患者为良性肿瘤，33 例（51.6%）为恶性肿瘤[19 例（29.7%）肝细胞癌，11 例（17.2%）继发癌，1 例（1.6%）分别为肝血管内皮细胞瘤、肝母细胞瘤和胚胎性肝肉瘤]。中位供肝和受者随访时间分别为 93 个月（IQR 41-159）和 39 个月（22-91）。
结果
39 例（60.9%）和 25 例（39.1%）分别植入右半肝和左半肝。右半肝和左半肝的中位重量分别为 810g（IQR 730-940）和 454g（IQR 394-534）。供肝与受者体重比（GRWR）分别为 1.17%（右，IQR 0.98%-1.4%）和 0.77%（左，0.59%-0.95%）。1 年和 5 年患者生存率分别为 85%和 71%（右）与 84%和 58%（左），1 年和 5 年移植物生存率分别为 74%和 61%（右）与 76%和 53%（左）。右半肝和左半肝、非常小（<0.6%）、小（0.6%-0.79%）和大（≥0.8%）GRWR 移植物的患者和移植物存活率相似。非常小移植物的 3 个月和 12 个月存活率分别为 86%和 86%。无供者死亡，5 例（7.8%）发生 Clavien-Dindo 并发症 IIIa、IIIb 或 IV 级。受者的发病率主要为胆漏和血管并发症；3 例（4.7%）根据九州标准发生小肝综合征。
结论
成人对成人 LDLT 是一种要求很高的手术，扩大了许多肝胆疾病的治疗可能性。供肝手术具有较低的发病率，可以安全进行。受者手术的发病率较高，表明存在重要的学习曲线。通过从较大的右半肝向较小的左半肝移植物转移风险，将风险从供者转移到受者，可以进一步探索这种策略，因为这种策略使供肝切除术更安全，并可能刺激移植肿瘤学的发展。
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