ABSTRACT
RESUMEN Las resecciones hepáticas en dos tiempos se desarrollaron para aumentar la resecabilidad de los tumo res hepáticos en pacientes con futuro remanente hepático insuficiente. El ALPPS, descripto en 2011, ha representado un gran avance en el mundo de la cirugía hepatobiliopancreática. Esta técnica acelera la hipertrofia del futuro remanente hepático y reduce el intervalo de tiempo entre las dos cirugías en comparación con las técnicas clásicas. El ALPPS ha ganado popularidad rápidamente, con más de 1200 pacientes incluidos en el registro mundial. Los comités internacionales de expertos se han reunido en dos ocasiones con el fin de emitir recomendaciones, principalmente sobre las indicaciones, selección de pacientes y estandarización de la técnica quirúrgica. Aunque ha demostrado ser superior en términos de resecabilidad (entre el 80-100% frente al 60-90% de la hepatectomía en dos tiempos), su rápida implementación ha sido penalizada con alta morbi mortalidad en las series publicadas, que llega a alcanzar el 40% y el 9%, respectivamente. Además, la evidencia actual sobre los posibles beneficios y desventajas se basa mayoritariamente en estudios observacionales. Presentamos una revisión histórica, describiendo las diferentes modificaciones técnicas que se han lle vado a cabo desde su inicio y realizando una revisión rigurosa en términos de morbilidad, mortalidad y resultados oncológicos.
ABSTRACT Two-stage liver resections were described to increase the resectability of liver tumors in patients with insufficient future liver remnant. The ALPPS procedure, described in 2011, has represented a breakthrough in the field of hepato-pancreato-biliary surgery. This technique accelerates the hypertrophy of the future liver remnant and reduces the interval between the two surgeries compared with previous techniques. ALPPS has gained popularity rapidly, with more than 1200 patients included in the world registry. Recommendations about indications, patient selection and surgical standardization have been discussed twice in international expert meetings. Although ALPPS has proven to be superior in terms of resectability (80-100% versus 60-90% of two-stage hepatectomy), its rapid implementation has been punished with high morbidity and mortality reaching up to 40% and 9%, respectively, in the published series. The current evidence on the possible benefits and disadvantages is mainly based on observational studies. We present a historical review, describing the different technical modifications that have been carried out since its description, with a rigorous review in terms of morbidity, mortality, and oncological outcomes.
ABSTRACT
Objective To evaluate the efficacy of in-situ split liver transplantation (ISSLT) in children.Methods From June 2015 to August 2018,10 liver grafts from DBD were split in-situ.All the donors were male,and the median age of the donors was 28.5 year old (18-48 year).One left half graft and 9 left lateral lobe grafts (including 2 reduced size grafts) were transplanted to 10 pediatric recipients.Four grafts were transplanted in our center,and the rest 6 grafts were shared to other two transplant center.The primary diseases of the recipients included biliary atresia (8/10),hepatic sinus obstruction syndrome (1/10) and Alagille syndrome (1/10).The median age of the recipients was 10 month (7 month-11 year),and the mean body weight was 9.8 ± 6.6 kg (5-28 kg).Results All liver grafts were split in-situ.The mean split time of liver grafts was 88.5 ± 18.9 min.The mean weight of split grafts was 336.7-± 85.4 g.All recipients were subjected to piggyback liver transplantation.Operation time was 542.5 ± 112.1 min.Anhepatic time was 52.0 ±-13.5 min.GRWR was (3.98 ±0.96)％.GRWR of two cases was more than 5％,so segment Ⅲ was partially reduced.During the follow-up period,9 cases were alive and 1 case died due to multiple organ failure 1 day after liver transplantation.Conclusions ISSLT can enlarge the graft pool for children and achieve good results.
ABSTRACT
BACKGROUND/AIMS: The shortage of cadaveric liver donor is particularly critical for children. Split liver transplantation, not only overcomes the drawbacks of reduced size grafts and living donor transplantation for children but also increases the total number of donor organs. The purpose of this study is to examine the technical feasibility of split liver transplantation in pig. METHODS: Nine pigs(3 donors and 6 recipients weighing 19-33Kg) were used. In donor pigs, the liver was divided between right medial lobe and left medial lobe without inflow occlusion under general anesthesia. Left liver was harvested first and then right liver was harvested as usual manner. One recipient pig underwent left lobectomy and left graft were transplanted orthotopically (auxiliary partial orthotopic liver transplantation(APOLT)). For right graft, conventional orthotopic liver transplantation were done. Veno-venous bypass was not performed. Instead, superior and inferior mesenteric arteries were clamped temporarily. RESULT: There was no anhepatic time when using left graft. Cold ischemic time were 2hr 35min, 1hr 21min, and 1hr 5min, respectively. When using right graft, anhepatic time was 72min, 54min, and 49min, respectively. Cold ischemic time was 5hr 17min, 6hr 32min, and 4hr 18min, respectively. Biochemical laboratory data(WBC, hemoglobin, platelet, ALT/AST, LDH, prothrombin time) after reperfusion 1 hour showed good graft function in all transplant pigs and were better in the recipient pigs taking left graft than right graft. Histologic findings at 4 hours after reperfusion show normal appearance except mild ischemic change around central vein. All transplant pigs survived over 24 hours without any major complication. CONCLUSION: APOLT for left graft and conventional liver transplantation for right graft without venovenous bypass were successful in pig. In situ split liver transplantation in pig is technically feasible procedure and this model is suitable for future studies of split liver transplantation.