[Control and care structures at transplant centers for patients with ethyltoxic cirrhosis while waiting for a liver transplant: A qualitative survey of practitioners.]

OBJECTIVE

The aim of this study was to record the current care and control structures in place for patients with ethyltoxic liver cirrhosis while being prepared for a liver transplant (LTX) at German transplant centers. In addition, it was also intended to analyze the associated barriers as well as the view of the practitioners on ways to improve care of this patient group.

METHODS

In an exploratory descriptive qualitative design, 11 interviews with practitioners from 10 of the 22 German LTX centers were conducted and analyzed using qualitative content analysis.

RESULTS

There were considerable differences in the care and control structures in place at the LTX centers. Addiction therapy counseling or treatment were not integrated into the treatment concept at all centers. Structural barriers arose from insufficient funding and staffing. Practitioners recommended expansion of treatment options as well as standardizing treatment concepts.

DISCUSSION

The results of our study point to a need for action both in the area of the structures of the individual LTX centers and overall at the system level. Taking into account current standards of addiction medicine, our results could serve as a basis for the development of treatment concepts and recommendations for optimizing standard care before LTX.

Liver transplantation for HCC in cirrhosis: Are Milan criteria outdated?

In Germany, organ allocation is based on the MELD-system and lab-MELD is usually low in patients with hepatocellular carcinoma (HCC) in cirrhosis. Higher medical urgency can be achieved by standard exception for HCC (SE-HCC), if Milan criteria (MC) are met. Noteworthy, UNOS T2 reflects MC, but excludes singular lesions < 2 cm. Thus, SE-HCC is awarded to patients with one lesion between 2 and 5 cm or 2 to 3 lesions between 1 and 3 cm. These criteria are static and do not reflect biological properties of HCC.We present a retrospective cohort of 111 patients, who underwent liver transplantation at UKSH, Campus Kiel between 2007 and 2017. No difference was found in overall survival for patient cohorts using Milan, UCSF, up-to-seven, and French-AFP criteria. However, there was a significantly reduced survival, if microvascular invasion was detected in the explanted organ and in patients with HCC-recurrence. The exclusive use of static selection criteria including MC appear to limit the access to liver transplantation.

Living-Donor Liver Transplantation for a Large Hepatocellular Carcinoma in a Genetically Identical Twin Sister

Hepatocellular carcinoma (HCC) is, to date, the most common malignant tumor of the liver and is commonly staged with the Milan criteria. While deceased-donor liver transplantations (DDLT) are reserved for patients within the Milan criteria, living-donor liver transplantation (LDLT) might be a curative option for patients outside the Milan criteria. We here report a case of a 32-year-old woman who developed a giant, unresectable HCC out of a hepatocellular adenoma (HCA) after a pregnancy. The genetically identical twin sister donated her left hemi-liver after ethical approval and preoperative screening. No long-term immunosuppressive therapy was necessary, and after more than eight years, both are in perfect health and the recipient gave birth to a second child. This case shows that in certain situations large HCCs outside the standard criteria can be cured by LT. Careful evaluation of both donor and recipient should be performed for indications like this to assure optimal clinical outcome.

Versorgung von Lebertransplantierten während der COVID-19-Pandemie

Hintergrund

Die Pandemie durch Coronavirus Disease 2019 (COVID-19) stellt eine anhaltende Herausforderung für das gesamte Gesundheitssystem dar, darunter auch für die Versorgung von Lebertransplantierten, die eine besondere Risikogruppe darstellen.

Fragestellung

Ziel der Arbeit ist es, einen praxisnahen Überblick über die aktualisierte S1-Leitlinie zur Versorgung von Lebertransplantierten während der COVID-19-Pandemie zu geben.

Material und Methoden

Basis dieser Übersicht ist die aktualisierte Leitlinie (Stand 15.06.2022) der Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV).

Ergebnisse

Während der Pandemie sollen Lebertransplantationsprogramme inklusive Evaluation, Organspenden und Nachsorge möglichst unverändert fortgeführt werden, da sie eine lebensrettende Therapieoption darstellen. Je nach Pandemielage sind jedoch Anpassungen möglich. Die Impfungen gegen „severe acute respiratory syndrome coronavirus type 2“ (SARS-CoV-2) sollen entsprechend den Empfehlungen der Ständigen Impfkommission (STIKO) erfolgen, und Antikörperbestimmungen sind sinnvoll. Im Fall einer Infektion stehen verschiedene Therapieoptionen zur Verfügung. Eine präventive Anpassung der Immunsuppression soll nicht erfolgen, eine Anpassung von Mycophenolat-Mofetil-haltigen Regimen sowie eine Anpassung bei SARS-CoV-2-Infektion kann jedoch sinnvoll sein.

Schlussfolgerungen

Die mittlerweile zur Verfügung stehende Immunisierung sowie die antivirale/immunmodulierende Therapie erlauben eine deutlich verbesserte Prävention und Therapie von COVID-19 bei Lebertransplantierten. Eine frühzeitige Erkennung durch engmaschige Testung ist von hoher Wichtigkeit. Die verbesserten pharmakologischen Optionen ermöglichen unter Risiko-Nutzen-Abwägung auch eine Transplantation von positiven Spendern oder Empfängern.

[Innovations in liver surgery through transplantation from living donors]

Living-donor liver transplantation was introduced into clinical practice in the early 1990s. At first the results were unsatisfactory, but today's results after living donation are as good as those obtained after conventional liver transplantation with full-sized organs. With minimally invasive diagnostic methods, it is now possible to determine the quality of potential donor livers and exclude focal lesions and anatomical variants which influence the strategy of organ retrieval procedures. Donor liver resection is done without hilar occlusion after determining the anatomical variants of the bile system (especially for right lobes) and localizing of the course of the middle hepatic vein. Microsurgical techniques are used for reconstruction of the biliary system and hepatic vessels. Living-donor liver transplantation allows us to investigate the complex changes after liver resection. The surgical techniques and pathophysiological postoperative changes can be adapted unconventionally to complex oncological liver resections. Therapeutic optimization and better risk management are becoming possible for liver resections.