Adult liver transplantation: the Paul Brousse experience

During the past 3 decades, more than 2,250 liver transplants were performed at Paul Brousse Hospital. Overall patient survival was 82% at one year, 71% at 5 years and 64% at 10 years. Our group has developed a variety of approaches to liver transplantation, including: 1. Anti HBs immunoglobulin prophylaxis for the prevention of HBV recurrence. Combination prophylaxis with lamivudine and anti HBs immunoglobulins reduced the rate of HBV re-infection to 20%. 2. Transplantation of HIV-HCV and HIV-HBV infected patients. These transplants are feasible and we achieved 2- year survival rates of 70% and 90%, respectively. The main problem was HCV recurrence which was more severe in HIV co-infected patients. 3. Transplantation for hepatocellular carcinoma on a cirrhotic liver with a single tumor <5 cm or <3 tumors <3 cm. 4. Transplantation for familial amyloidotic polyneuropathy (FAP). The 5- and 10-year survival rates were 76% and 72%, respectively. More than 100 livers obtained after hepatectomy from FAP patients were transplanted as "domino" living donor livers to patients with unresectable liver cancers with a 5-year survival rate of 64%. In some domino recipients, symptoms of FAP disease occurred more rapidly than expected and this could be an indication for a second transplantation of a non FAP-liver. 5. Split-liver transplantation for pediatric patients. This has increased the number of transplantable livers for children by 28%. 6. Split-liver transplantation for 2 adults. The grafts were prepared by ex-vivo or in-situ splitting and the overall 5-year survival rate was 56%. 7. Adult -to-adult living-related liver transplantation. There has been no mortality nor late complications in donors and the overall 5-year survival rate among recipients was 73%. 8. Liver retransplantation with good results in the elective situation. Retransplantation should be used with discretion in the emergency setting.

[Two tapes to control the main fissure of the liver]

Herein we report a technique that allows a rapid and selective clamping of the left and right glissonian sheats and that secures the opening of the main fissure. The posterior face of segment IV capsula is opened immediately above the hilum on the left side of the gallbladder fossa. The tip of a right angled dissector is gently pushed in the liver substance from front to back while maintained against the hilar plate, until it arises in the caudate process just below the pedicle. A tape is used to encircle the Glisson sheath. Its inferior extremity can be picked up either on the right or the left side of the liver pedicle in order to clamp the right or the left portal pedicle, respectively. Both clamping precisely mark the anterior limit of the main fissure. Using a Kelly forceps, a second tape is introduced in the Couinaud space, between the inferior vena cava and segment one. The inferior extremity of this tape is then picked up above the Glisson sheat and allows to hang the posterior limit of the main fissure which can be securely approached. The two tapes technique cannot be applied when liver is fibrotic or when biliary ducts are dilated.

[Adult to adult living-related liver transplantation. The Paul-Brousse Hospital preliminary experience]

AIM

Liver-graft shortages justify the development of adult living-related liver transplantation. The preliminary experience with this technique at Paul-Brousse Hospital is reported. PATIENTS ET METHODES: From January to July 2000, 7 adult to adult living-related liver transplantations were performed. Donors were 5 females and 2 males aged 20 to 53 years old (median: 41). A right liver graft was harvested in all cases. Recipients were 5 males and 2 females aged from 17 to 58 years old (median: 50) transplanted for viral cirrhosis (4 cases including 2 with hepatocellular carcinoma), subfulminant hepatitis (1 case), hepatocellular carcinoma on a healthy liver (1 case), and epithelioid hemangioendothelioma (1 case). Follow-up ranged from 41 to 157 days (median: 117 days).

RESULTS

One donor had a biliary fistula that healed spontaneously. One donor had asterixis for 24 hours. The 7 donors are alive at home without any late complications. One recipient was retransplanted for hepatic artery thrombosis and 2 recipients had a biliary fistula that healed spontaneously. The 7 recipients are alive at home with normal liver function.

CONCLUSION

Our experience and other reports suggest that adult to adult living-related liver transplantation is feasible with rare mortality and low morbidity in donors. Results in recipients are comparable to those obtained with cadaveric grafts. For a given patient the possibility of living related donation might extend the indications for transplantation without penalizing patients waiting for a cadaveric graft.

[Alcoholic liver cirrhosis. Treatment of hepatocellular carcinoma]

TRANSPLANTATION AND RESECTION: Surgery is still the only curative treatment of hepatocellular carcinoma (HCC). For patients with cirrhosis, liver transplantation for HCC with one nodule less than 5 cm in diameter, or no more than three nodules each less than 3 cm, gives the best results with a 5-year survival rate of 70%. Resection of a single tumor for patients with good liver function may also be performed with curative intent but the rate of recurrence is high. OTHER TECHNIQUES: Cryotherapy and radiofrequency are in-situ destruction methods used for small tumors. In the future, these procedures may compete with hepatic resection. When used alone, intra-arterial treatments, such as chemoembolisation, have only a palliative intent, but they also may be combined with other procedures. The treatment of advanced HCC is still limited and there is no standard approach for its management. HCC WITHOUT CIRRHOSIS: For those with HCC without cirrhosis, the same treatments are available but resection is more often performed because of the ability of the liver to regenerate. The management of patients with HCC with or without cirrhosis may combine several treatment modalities and needs a multi-disciplinary approach.

[Multistage liver resections in colorectal liver metastases. The Paul Brousse concept]

Hepatic resection is currently the only form of treatment that offers a chance of long-term survival, with rates ranging from 25% to 39%. However, a curative operation can be performed in only 10% of patients with colorectal metastases to the liver. Our policy is to increase the number of patients that can benefit from liver resection. Liver metastases can be considered as irresectable mainly in three different situations (sometimes associated): (I) large and/or poorly located tumors; (II) bilateral tumors in both liver lobes; (III) tumors technically resectable, but not operable because the liver remnant is too small, which is associated with a prohibitive risk of postoperative severe liver failure. The aim of this paper is to report the strategies we use in our center to achieve curative resection in these three schematic situations despite initial contraindications.

[Peroperative exploration of the liver in hepatic tumor surgery]

Intraoperative exploration of the liver and complete abdominal examination are essential before hepatic resection for patients with liver tumors. The surgeon's eye and hand, traditional methods of exploration, are still accurate for abdominal exploration, screening of small superficial liver tumors and evaluation of non-tumoral liver parenchyma. Intraoperative ultrasonography is often superior to preoperative screening methods in diagnosing small liver tumors. Intraoperative ultrasonography identifies variations of intrahepatic vascular structures and reveals exact location of tumors according to functional anatomy. The surgeon's eye and hand and intraoperative ultrasound are complementary for a complete exploration, and may affect operative decision making. Laparoscopy and laparoscopic ultrasonography, when diagnosing non resectable tumors, reduce the number of unnecessary laparotomies. However, the effectiveness of exploration by laparoscopy and laparoscopic ultrasonography is lower than that of laparotomy, which remains indispensable before hepatic resection for malignant tumors.

[Dose adaptation during training of intracavernous self-injections of prostaglandin E1]

OBJECTIVE

Dose adaptation in self-administered intracavernous PGE1 injections is poorly defined in learning protocols and its degree of difficulty depends on the aetiology of the erectile dysfunction. The authors tried to standardize this phase by studying the results and complications of a protocol using an identical initial dose of PGE1 regardless of the aetiology of erectile dysfunction.

MATERIAL AND METHODS

101 patients consulting for erectile dysfunction participated in a learning protocol of self-administered intracavernous PGE1 injections, consisting of 3 injections systematically starting with 10 micrograms of PGE1, following assessment of the aetiology.

RESULTS

For an efficacy of 58.4%, 79.2% and 88.1% after one, two or three injections, respectively, the prolonged erection rate (> or = 6 hours) was 2.7% after the first injection and 0% after the other injections. However, erection durations of 2 to 6 hours have frequently been reported in neurological patients. Discontinuations during the learning phase were only observed in patients presenting with tumescence without rigidity after one injection (5.4%) or two injections (21%).

CONCLUSION

In the light of these results and to minimize prolonged erections and discontinuations, while ensuring efficacy, PGE1 dose adaptation can be simply performed by starting with 10 micrograms in all patients except for neurogenic patients (5 micrograms) with an increase to 20 or 30 micrograms in the case of failure.