[Impact of the COVID-19 pandemic on hepato-pancreato-biliary surgery and organ transplantation]

Hintergrund und Ziel der Arbeit

Im Rahmen der COVID-19(„coronavirus disease 2019“)-Pandemie wurden weitreichende Ressourceneinschränkungen und -umverteilungen innerhalb des Gesundheitssystems notwendig. Diese Übersichtsarbeit beleuchtet die direkten und indirekten Folgen der COVID-19-Pandemie auf die Bereiche der hepatopankreatobiliären (HPB)-Chirurgie und Organtransplantation unter Berücksichtigung aktueller Literatur und veröffentlichter Expertenmeinungen nationaler und internationaler Fachgesellschaften. Entwicklungen der Operationszahlen wurden über die Eurotransplant Statistics Report Library und eine zentrumsinterne Auswertung HPB-chirurgischer Eingriffe analysiert.

Ergebnisse

In den Bereichen der HPB-Chirurgie und Organtransplantation zeigte sich vor allem in der ersten Pandemiewelle an vielen Zentren ein deutlicher Einbruch der Eingriffszahlen. Interessanterweise konnte meist kein kompensatorischer Zuwachs der Operationen in den Folgemonaten verzeichnet werden. Im Jahrestrend zeigen sich somit leicht rückläufige Zahlen. Ob dieser Trend auf eine erhöhte Sterblichkeit durch verschobene Operationen und geänderte Therapieregimes zurückzuführen ist, lässt sich derzeit zumindest nicht ausschließen. Eine SARS-CoV-2(„severe acute respiratory syndrome coronavirus 2“)-Infektion ist auf jeden Fall mit einem komplikativen Verlauf assoziiert, insbesondere im perioperativen Verlauf und nach Transplantation.

Diskussion

Aufgrund des erhöhten Risikoprofils der genannten Patientengruppen besteht ein erhöhtes Risiko für einen schweren COVID-19-Verlauf. Dies muss bei der Abwägung von Therapiealternativen, der Schutzempfehlungen und der Priorisierung bei Impfungen in Betracht gezogen werden.

Hepatocyte Transplantation to the Liver via the Splenic Artery in a Juvenile Large Animal Model

Hepatocyte transplantation (HcTx) is a promising approach for the treatment of metabolic diseases in newborns and children. The most common application route is the portal vein, which is difficult to access in the newborn. Transfemoral access to the splenic artery for HcTx has been evaluated in adults, with trials suggesting hepatocyte translocation from the spleen to the liver with a reduced risk for thromboembolic complications. Using juvenile Göttingen minipigs, we aimed to evaluate feasibility of hepatocyte transplantation by transfemoral splenic artery catheterization, while providing insight on engraftment, translocation, viability, and thromboembolic complications. Four Göttingen Minipigs weighing 5.6 kg to 12.6 kg were infused with human hepatocytes (two infusions per cycle, 1.00E08 cells per kg body weight). Immunosuppression consisted of tacrolimus and prednisolone. The animals were sacrificed directly after cell infusion (n=2), 2 days (n=1), or 14 days after infusion (n=1). The splenic and portal venous blood flow was controlled via color-coded Doppler sonography. Computed tomography was performed on days 6 and 18 after the first infusion. Tissue samples were stained in search of human hepatocytes. Catheter placement was feasible in all cases without procedure-associated complications. Repetitive cell transplantations were possible without serious adverse effects associated with hepatocyte transplantation. Immunohistochemical staining has proven cell relocation to the portal venous system and liver parenchyma. However, cells were neither present in the liver nor the spleen 18 days after HcTx. Immunological analyses showed a response of the adaptive immune system to the human cells. We show that interventional cell application via the femoral artery is feasible in a juvenile large animal model of HcTx. Moreover, cells are able to pass through the spleen to relocate in the liver after splenic artery infusion. Further studies are necessary to compare this approach with umbilical or transhepatic hepatocyte administration.

[High donor age for liver transplantation : Tackling organ scarcity in Germany]

BACKGROUND

Liver transplantation is the only curative treatment option for patients with end-stage liver disease; however, the 40% decline of available organ donors in recent years in Germany necessitates the optimization of available resources and possibly extending the criteria to older donors.

MATERIAL AND METHODS

All 2652 livers made available to the Charité Universitätsmedizin Berlin from 2010 to 2016 were retrospectively analyzed and the clinical outcome of 526 liver transplantations during this time frame were evaluated.

RESULTS

The median age of donors of transplanted organs increased from 49.3 years in 2010 to 57.3 years in 2016 (p = 0.02). Organs from donors ≥65 years were more frequently discarded than organs from younger donors (n = 344, 18.4% vs. n = 220, 28.1%; p = 0.005). Moreover, the older donors had higher rates of diabetes mellitus and hepatic steatosis. Organs from older donors had a higher donor risk index (2.8 vs. 2.2; p < 0.001) and were transplanted more often in patients with preserved liver function and hepatocellular carcinoma and liver cirrhosis (n = 121, 74.7% of indications). The 3‑year survival after liver transplantation from donors ≥65 and ≥80 years old was not significantly reduced in comparison to younger donors; however, there was an increased retransplantation rate (28.6%; p = 0.005) after transplantation of organs from donors ≥80 years old.

CONCLUSION

Despite conservative organ acceptance there were higher rates of retransplantation after transplantation from very old donors. In the light of an increasing scarcity of suitable organs this mandates caution and highlights the need for adequate assessment instruments for marginal donor organs before transplantation.