A COMPARISON OF LIVING DONOR AND DECEASED DONOR LIVER TRANSPLANTATION FOR HILAR CHOLANGIOCARCINOMA - PowerPoint PPT Presentation

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A COMPARISON OF LIVING DONOR AND DECEASED DONOR LIVER TRANSPLANTATION FOR HILAR CHOLANGIOCARCINOMA

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Mayo Clinic Approach. 1993 to Present. CCA appears resectable ... Mayo Clinic Treatment Protocol. External beam radiation therapy. Brachytherapy ... – PowerPoint PPT presentation

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Title: A COMPARISON OF LIVING DONOR AND DECEASED DONOR LIVER TRANSPLANTATION FOR HILAR CHOLANGIOCARCINOMA


1
A COMPARISON OF LIVING DONOR AND DECEASED DONOR
LIVER TRANSPLANTATION FOR HILAR CHOLANGIOCARCINOMA
  • C. BURCIN TANER, JULIE K. HEIMBACH, JOHN J.
    POTERUCHA,
  • DAVID J. BRANDHAGEN, SCOTT L. NYBERG, MICHAEL B.
    ISHITANI,
  • GREGORY J. GORES, CHARLES B. ROSEN
  • William J. von Liebig Transplant Center,
  • Mayo Clinic Rochester and Mayo Clinic College of
    Medicine

2
Hilar Cholangiocarcinoma
  • Standard surgical resection has limited efficacy
  • Few tumors are resectable
  • Long term survival
  • Results with liver transplantation alone are poor
  • Lymph node metastases portend poor prognosis
  • Radiation with chemosensitization affords
    palliation

3
Hilar CholangiocarcinomaMayo Clinic
Approach1993 to Present
  • CCA appears resectable
  • Resection with excision of extrahepatic bile
    duct, regional lymphadenectomy, and right or left
    hepatectomy ( caudate)
  • CCA appears unresectable
  • Liver transplantation protocol
  • CCA arising in setting of PSC
  • Liver transplantation protocol

4
Eligibility Criteria
  • Patients with unresectable hilar CCA or hilar CCA
    arising in setting of PSC
  • No clinical evidence of metastases
  • Diagnosis
  • Intraluminal brush cytology / biopsy
  • CA 19.9 level 100ng/ml with radiographically
    malignant stricture
  • Confirmatory DIA and FISH analysis
  • EUS and Staging operation prior to transplantation

5
Exclusion Criteria
  • Uncontrolled infection
  • Prior radiation
  • Prior biliary resection or attempted resection
  • Intrahepatic metastases
  • Evidence of extrahepatic disease
  • History of other malignancy within 5 years

6
Mayo Clinic Treatment Protocol
External beam radiation therapy Brachytherapy Prot
racted venous infusion of 5-FU / Xeloda Abdominal
exploration for staging Liver transplantation
7
Staging Laparotomy
  • Complete abdominal exploration
  • Biopsy of regional lymph nodes (hepatic artery
    and CBD lymph nodes)
  • Examination of tumor to assess complete removal
    with total hepatectomy
  • Assigned MELD20
  • Increase in MELD score equivalent to 10 risk of
    pre-transplant mortality every 6 months (Per
    agreement in Region 7)

8
Liver Transplantation
  • Avoiding hilus during dissection
  • Low division of CBD, HA, and PV
  • Frozen section of CBD margin
  • Interposition graft off aorta for HA
  • Interposition graft for PV in LDLT
  • Mycophenolate mofetil, steroid, tacrolimus

9
Aim
  • To review recent experience of living donor and
    deceased donor liver transplantation for hilar
    cholangiocarcinoma

10
Methods
  • Review of all patients treated between January
    2004 December 2004 with liver transplantation
  • Follow-up through June 2005

11
Results
12
Results
  • Waiting Time mean (median)
  • Living Donor 111 (104) days
  • Deceased Donor 271 (181) days
  • Hospital Stay
  • Living Donor 11.5 (11) days
  • Deceased Donor 16.1 (9) days

13
Results
  • Preservation Time mean (median)
  • Living Donor 175 (175) minutes
  • Deceased Donor 435 (480) minutes
  • Anhepatic Time mean (median)
  • Living Donor 75 (72.5) minutes
  • Deceased Donor 67 (64) minutes

14
Results
  • Explant Pathology
  • Living Donor
  • 1 patient with residual tumor
  • Deceased Donor
  • 6 patients with residual tumor

15
Results
  • Vascular Complications
  • Living Donor 0
  • Deceased Donor 2 HA thromboses
  • 1 PV thrombosis
  • 1 HA pseudoaneurysm

16
Results
  • Biliary Complications
  • Living Donor 2 Strictures
  • 1 Bile Leak
  • Deceased Donor 1 Stricture
  • 1 Bile Leak

17
Results
  • Other Complications
  • Living Donor 1 Incisional Hernia
  • Deceased Donor 1 Jejunal Perforation
  • 1 Graft Failure
  • 1 Death
  • Disease Recurrence 0

18
Conclusion
  • Early results with living donor liver
    transplantation are comparable to deceased donor
    liver transplantation for cholangiocarcinoma.
  • Compared to our results in 2000, our latest data
    suggests better perioperative morbidity and
    mortality for living donor liver transplant
    group.
  • Longer follow-up is necessary to determine
    whether living donor recipients will have less
    tumor recurrence associated with decrease in
    waiting time.
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