Liver transplant

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A liver transplant (LTX) is the transplantation of a healthy liver from a deceased person or part of a liver from a healthy person into the body of a patient with liver disease. In children, malformations of the biliary tract are usually the cause of a transplant , in adolescents metabolic diseases and in adults terminal cirrhosis . In 2017, 760 liver transplants were performed in Germany following post-mortem organ donation and 61 following living donation. In 2017, 1,213 new patients were registered for liver transplantation.

Indications

Factors that may require a transplant include:

In contrast to other organs such as the kidneys , heart or lungs , replacement therapy such as dialysis , heart-lung machine or ECMO for the liver is not yet possible today. Thus, irreversible liver failure without a transplant means rapid death of the patient. For this reason, people with highly acute illnesses can be given priority on the waiting list.

Due to the lack of donors, not a few patients die on the waiting list today (see organ donation ). For this reason, procedures such as living liver donation and split livers are performed. The urgency of the transplant and the order on the waiting list are determined using the MELD score . The more detailed indications are regulated in Germany by the guidelines of the German Medical Association.

execution

After a suitable donor organ has been found for the person waiting, time is the most important factor. The organ must be transplanted into the recipient's body within 16–24 hours of removal, as its functionality quickly deteriorates. During this time, the organ is checked for its ability to be transplanted and taken to the transplant center of the organ recipient. If the recipient is not there, he will be picked up. This time window is also shortened by the duration of the actual operation, which often amounts to over 8 hours.

In contrast to other organs such as the kidney or pancreas, a liver transplant is an orthotopic transplant . This means that the new organ is implanted in the same place in the body as the previously removed old organ (abbreviation OLT = Orthotopic Liver Transplant). This more complicated procedure is necessary because the vascular supply to the liver with its three vessels ( inferior vena cava , portal vein , hepatic artery ) and the bile duct can only be guaranteed at this point in the body.

The blood vessels that are directly connected to the liver are first exposed through a large incision in the upper abdomen . The cirrhotic disease often causes portal hypertension , which, like the coagulation disorders that often occur in liver disease, can aggravate the subsequent explantation of the old organ.

First, a portocaval shunt is created, in which the blood, which normally flows from the portal vein into the liver, is diverted into the inferior vena cava (inferior vena cava). Then the hepatic artery, the bile duct and finally the hepatic vein are severed, the liver is removed at this point. The donor liver is being prepared for implantation while it is being removed. The four central steps after the insertion of the new organ are the connection of the inferior suprahepatic vena cava of the donor with the cava of the recipient, then the reconstruction of the portal vein takes place. After this anastomosis, the portal vein is opened. At this point, the blood flows through the opened thigh of the donor's inferior vena cava into the abdomen. This serves to remove the preservation solution from the organ. After the preservation solution has been removed, the lower donor vena cava is closed. Now the anastomoses between the donor's hepatic artery and the gastroduodenal artery take place, the bile duct is reconstructed last.

Complications

There are some risks involved in liver transplantation that make this procedure one of the most difficult organ transplants, such as:

  • Infections
  • increased bleeding tendency (due to metabolic disorders)
  • initial dysfunction and severe graft dysfunction
  • Thrombosis
  • Leaks in the bile duct connection
  • Rejection reactions
  • Bilioma (a real or false cyst filled with bile, or a bile leak with an intra-abdominal accumulation of bile)
  • Ischemic Type Biliary Lesion (ITBL)
  • Hepatitis C reinfections
  • Fibrosing Cholestatic Hepatitis (FCH)

Some of these complications may require retransplantation.

Aftercare

Postoperative monitoring is essential for liver transplantation; the average postoperative length of stay in acute care facilities is about one month. It is important to suppress the immune system with drugs , otherwise rejection reactions can occur quickly. However, liver transplantation is slightly less critical than other transplants in terms of immunosuppression. Intensive psychological support is also almost indispensable.

The pre-existing symptoms of liver disease, such as tiredness, weakness and yellowing, usually recede, allowing the patient a new life. After the transplant, the organ recipients can often lead a normal life, taking into account the increased susceptibility to infections due to the immunosuppression .

Success rate

Liver transplantation is the therapy of choice for the diseases mentioned above. With constant improvement in technology and research in the field of immunotherapy, the survival rate is steadily increasing. In 2005, one-year survival rates of over 90%, 5-year survival rates of over 80% and 10-year survival rates of over 70% were achieved. The survival rates, however, are heavily dependent on the underlying disease as well as the overall condition, secondary and concomitant diseases of the patient. With a long-term survival of over 90%, the best prognosis is for patients who have been transplanted for primary biliary cirrhosis.

For various reasons, the transplant can fail and the transplant can be re-transplanted ("retransplantation").

Living liver donation

However, as with all transplants, the biggest problem is the imbalance between patients who are on a waiting list and potential organ donors .

Since the liver is able to regenerate, i.e. to grow back, living donations from suitable donors are also possible, as is the case with kidney transplants. Ethical considerations play a major role here: the donor must be healthy so that it can be guaranteed that he will not be harmed by the procedure.

The liver's ability to regenerate is also exploited by the split liver process. A donor organ is divided between two recipients. This procedure is often used with children because there are not many organs that fit children (in terms of size). The procedure was first carried out by Rudolf Pichlmayr in 1988 at the Hannover Medical School and has since established itself as the standard procedure in child liver transplantation.

history

The US surgeon Thomas E. Starzl performed the world's first successful liver transplant on humans in 1967 in Denver, Colorado. Starzl had tried a liver transplant as early as 1963, but the patient died during the operation. The patient, who was transplanted in 1967, lived for a year after the operation. In Germany and Europe, the first successful liver transplant took place on 19 June 1969 by the from South Korea originating Chong-Su Lie (international and Jong-Soo Lee written) under the leadership of then chief physician Alfred Gütgemann at the Surgical University Hospital Bonn. This patient survived the operation by 205 days. In 1988 Rudolf Pichlmayr performed the first successful division of the liver in two halves (split liver transplant). In 1989, Christoph Broelsch carried out the first successful live liver donation for a child's transplant.

Web links

Individual evidence

  1. ^ R. Pichlmayr: Transplantationschirurgie Springer Verlag, Berlin 1981
  2. ^ Siewert: Surgery. 8th edition.
  3. ^ German Foundation for Organ Transplantation: Liver Transplantation .
  4. ↑ Guidelines for waiting lists and organ placement for liver transplantation (RiliOrgaLeber)
  5. ^ P. Neuhaus et al.: Current aspects of liver transplantation. Uni-Med-Verlag, Bremen et al. 2005, ISBN 3-89599-774-9 .
  6. ↑ R. Pichlmayr, B. Rings, G. Gubernatis, J. Hauss, H. Bunzendahl: [Transplantation of a donor liver to 2 recipients (splitting transplantation) - a new method in the further development of segmental liver transplantation]. In: Langenbeck's archive for surgery . Volume 373, Number 2, 1988, pp. 127-130, ISSN  0023-8236 . PMID 3287073 .
  7. ↑ Starzl TE, Groth CG, Brettschneider L, Penn I, Fulginiti VA, Moon JB, Blanchard H, Martin AJ Jr, Porter KA Orthotopic homotransplantation of the human liver. Ann Surg. 1968 Sep; 168 (3): 392-415.
  8. ↑ Jachertz, Norbert: Organ transplantation: Daring decision . In: Dtsch Arztebl . tape 106 , no. 25 , 2009, p. A-1294 / B-1102 / C-1074 ( online ).
  9. ↑ Jachertz, Norbert: TS Lie: Pioneer and bridge builder . In: Dtsch Arztebl . tape 106 , no. 8 , 2009, p. A-351 / B-299 / C-291 ( online ).
  10. ↑ Jachertz, Norbert: TS Lie: trailblazers of liver transplantation . In: Dtsch Arztebl . tape 116 , no. 25 , 2019, pp. A-1245 / B-1021 / C-1009 ( online ).
  11. ↑ CE Broelsch, PF Whitington, JC Emond, TG Heffron, JR Thistlethwaite, L. Stevens, J. Piper, SH Whitington, JL Lichtor: Liver transplantation in children from living related donors. Surgical techniques and results. In: Annals of Surgery . Volume 214, Number 4, October 1991, pp. 428-437, ISSN  0003-4932 . PMID 1953097 . PMC 1358542 (free full text).
  12. ↑ PA Singer, M. Siegler, JD Lantos, JC Emond, PF Whitington, JR Thistlethwaite, CE Broelsch: The ethical assessment of innovative therapies: liver transplantation using living donors. In: Theoretical medicine. Volume 11, Number 2, June 1990, pp. 87-94, ISSN  0167-9902 , PMID 2203179 .