Актуальные этические и технические вопросы пересадки печени от живого донора (Current ethical and technical issues in live liver donation)

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Introduction

Liver surgery has undergone dramatic changes ever since the first successful liver transplantation procedures by Dr. Starzl in 1963-1968. Removing parts of the liver to serve the need for smaller recipients followed twenty years later (1989) [1-3]. Although lobar liver anatomy has been well described since ancient times, the exact functional details and the specific segmental anatomy have only been described within the last few decades [4-9].

For transplant candidates, specifically for children and small infants, the graft needs to match the size of the individual`s abdomen and allow for reconnection of vascular and biliary pedicles. Facing a mortality rate of up to 40 % on a waitlist for children, surgical diminutions of liver grafts have become widely accepted [3,10,11]. The procedure was declared “Reduced Size Grafting„ and provided an appropriate sized lobe for an infant, while the remnant liver lobes were discarded. Thus, preferential allocation and transplantation of children turned into a disadvantage for adult recipients.

In 1988, the first attempt to split a whole liver into two transplantable lobes for one adult and one child was performed [12].

Independently, the first prospective series of 20 patients sharing one donor liver and receiving either a right or left liver lobe originated at the University of Chicago [13]. However, the results turned out to be inferior to standard full size transplants and were reluctantly performed for a few more years by other centers (Fig. 1) [14]. One of the main reasons for failure of an isolated left lobe graft, which was splitted „ex situ“ was the unpredictable perfusion and drainage quality which became detectable only following reperfusion. Hypoperfusion of segment IV of the left lobe graft resulted in ischemia, necrosis and sepsis. Although anatomical sectors were followed during transparenchymal dissection of the explanted liver, great varieties within its parenchymal vascular perfusion and biliary drainage became evident. Thus, a logical ramification was to harvest the graft still under regular perfusion in the brain dead organ donor. This major step was initiated by Rogiers et al, who performed the first „in situ“ split procedures [15].

This refined procedure allowed shortening of cold and warm ischemia times, improved logistics and avoiding avascular segments. The vital prerequisite was circulatory stability of the donor and excellent graft quality.

The downside, however, was an extended harvesting time for the liver, while other explant teams had to remain in waiting position in fear of a potential crash of the donor circulation.

Moreover, transplant centers needed to accept a partial graft instead of a non-traumatized whole liver, thus, deviating from a standard protocol with a risky outcome [16]

The techniques, learned by performing „in situ“ harvesting paved the way for further developments in live liver donation as well as in recent ALPPS (Associating Liver Partitioning with Portal Vein Ligation for Staged hepatectomy) procedures for treatment of advanced cancer or metastases of the liver [17-19]. While lobe harvesting procedures were under great scrutiny, the demand for cadaveric donor organs grew even larger. Favorable indications expanded together with increasing death rates on the waitlists in particular for adults.

In 1989, the advent for a new dimension of liver surgery was reached when the first procedures of live donor liver transplants were reported from Brasil, Australia and Japan. In these countries, alternatives for cadaveric donors were either scarce or not available. Therefore, the necessity for harvesting a portion of a live donor had arrived to serve individual patients.

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0 #1 2 27.10.2017 07:15
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