Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA.
Department of Immunology, Mayo Clinic, Rochester, MN, USA.
J Gastrointest Surg. 2020 Nov;24(11):2679-2685. doi: 10.1007/s11605-020-04721-4. Epub 2020 Jul 15.
Liver transplantation for peri-hilar cholangiocarcinoma (pCCA) following neoadjuvant chemoradiation achieves excellent long-term survival in carefully selected patients with early-stage unresectable pCCA and patients with primary sclerosing cholangitis (PSC)-associated pCCA. Strict adherence to selection criteria, aggressive neoadjuvant therapy, operative staging prior to transplantation, and several technical accommodations during the transplant operation are necessary for success. In this review, we provide a contemporaneous overview of liver transplantation for pCCA, including selection criteria, neoadjuvant therapy, operative staging, and technical aspects of liver transplantation unique to patients with pCCA and an irradiated operative field. We also discuss several evolving trends intended to improve patient outcomes.
Intention-to-treat and patient outcomes after liver transplantation for PSC-associated pCCA are superior to de novo pCCA. Outcomes between living donor liver transplantation (LDLT) and deceased donor liver transplantation are similar for patients with PSC-associated pCCA. However, LDLT for de novo pCCA shows a trend toward more disease recurrence and worse patient survival. A period of waiting time before transplant may be beneficial in selecting for patients with superior outcomes after transplant. Compared with liver transplantation for other indications, there is an increased risk of late arterial and portal vein complications, presumably due to the radiation. However, with close follow-up and prompt intervention for vascular complications, graft loss can be avoided. Neoadjuvant therapy and liver transplantation can achieve results comparable with resection for patients with early-stage unresectable pCCA and is the treatment of choice for patients with pCCA arising in the setting of PSC.
对于新辅助放化疗后的肝门周围胆管癌（pCCA）患者，经严格选择的早期不可切除的 pCCA 患者和原发性硬化性胆管炎（PSC）相关 pCCA 患者，行肝移植可获得优异的长期生存。成功的关键在于严格遵循选择标准、积极的新辅助治疗、移植前的手术分期，以及在移植手术过程中进行的几项技术适应。在本综述中，我们提供了 pCCA 肝移植的当代概述，包括选择标准、新辅助治疗、手术分期以及 pCCA 患者和受照射手术野的肝移植的独特技术方面。我们还讨论了一些旨在改善患者预后的新趋势。
PSC 相关 pCCA 患者接受肝移植的意向治疗和患者结局优于原发性 pCCA。PSC 相关 pCCA 患者接受活体供肝移植（LDLT）和尸体供肝移植（DDLT）的结局相似。然而，对于原发性 pCCA，LDLT 有疾病复发和患者生存较差的趋势。在移植前等待一段时间可能有利于选择移植后结局更好的患者。与其他适应证的肝移植相比，发生动脉和门静脉并发症的风险增加，这可能是由于辐射所致。然而，通过密切随访和及时干预血管并发症，可以避免移植物丢失。新辅助治疗和肝移植可达到与切除相当的结果，适用于早期不可切除的 pCCA 患者，并且是 PSC 相关 pCCA 患者的治疗选择。
