Liver transplantation

A liver transplantation ( LTX ) is the transplantation of a healthy liver of a deceased person or part of a liver of a healthy person in a liver disease patient's body. In children, most bile duct abnormalities in adolescents usually metabolic diseases and cirrhosis in adults, a endgradige the reason for a transplant. In Germany, 1,199 liver transplants were performed in 2011, were registered for a transplant 1,729 patients.

Indications

Factors that may make a transplant necessary are for example:

• Congenital biliary atresia, the most common indication for liver transplantation in childhood
• Cirrhosis of the liver, caused by Alcoholic liver cirrhosis in chronic alcohol abuse
• Hepatitis B
• Combined hepatitis B and hepatitis D
• Hepatitis C
• Autoimmune hepatitis
• Primary biliary cirrhosis ( PBC)
• Primary sclerosing cholangitis ( PSC)

In contrast to other organs such as kidney, heart or lung replacement therapy such as dialysis, heart -lung machine, or ECMO for the liver is not yet possible. Thus means definitive liver failure without transplantation quickly the patient's death. For this reason, people can be pre- coated with highly acute disease on the waiting list.

Because of the donor shortage today do not die a few patients on the waiting list (see organ donation ). For this reason, methods such as living liver donation and split livers are done. Urgency of transplantation and order on the waiting list will be determined by the MELD score. The detailed indication positions are regulated in Germany by the guidelines of the German Medical Association

Implementation

After a suitable donor organ for the waiting was found, time is the most important factor. The institution must be transplanted within 16-24 hours of collection in the recipient's body, since the function deteriorates quickly. During this time the organ is examined for its ability transplantation and taken to the transplant center of the organ recipient. Should the recipient not be present, he is picked up. This time window is also shortened by the length of the actual surgery, which often amounts to about 8 hours.

In contrast to other organs such as kidney or pancreas is in liver transplantation to orthotopic transplantation. This means that the new organ in the same place is implanted in the body as the previously removed old ( Abbreviated = OLT Orthotopic Liver Transplant Plant). This complicated procedure is necessary because the vascular supply of the liver with its three vessels ( inferior vena cava, portal vein, hepatic artery ) and the bile duct can only be guaranteed at this point in the body.

Through a large upper abdominal incision, the blood vessels are first disclosed, which are directly connected with the liver. Often, the disease causes a cirrhotic portal hypertension, which, as well as the coagulation disorders that frequently occur in liver disease, complication can affect the then following explantation of the old organ.

First, a portacaval shunt is applied in the blood, which normally flows from the portal vein to the liver, in the inferior vena cava ( inferior vena cava ) is redirected. Thereafter, the hepatic artery, common bile duct and the hepatic vein is finally cut, the liver is taken at that moment. Even during the removal, the donor liver is prepared for implantation. The four key steps after the onset of the new body, the junction of the superior vena cava of the donor with the cava of the recipient, then the reconstruction of the portal vein takes place. After this anastomosis, the portal vein is opened. At this moment the blood flow to the open arms of the inferior vena cava of the donor into the abdomen, this serves to remove the preservation solution from the organ. After the preservative solution has been removed, the lower Spenderhohlvene is closed. Now the anastomoses between the hepatic artery of the donor and the gastroduodenal artery are held, the last of the bile duct is reconstructed.

Complications

In liver transplantation occur some risks that make this procedure one of the most difficult organ transplants, such as:

• Infections (of the patient that is dying after liver transplantation in 70 % of cases the cause of an infectious disease )
• Increased bleeding tendency ( by metabolic disorders)
• Initial non function and severe dysfunction of the graft
• Thrombosis
• Leaks in the bile duct connection
• Rejection
• Biliom ( one filled with bile true or false cyst or a bile leak with intra-abdominal bile collection)
• Ischemic Type Biliary Lesion ( ITBL )
• Re-infection of hepatitis C
• Fibrosing Cholestatic hepatitis ( FCH )

Some of these complications can make a retransplantation necessary.

Follow-up

Postoperative monitoring is essential in liver transplantation, the average postoperative length of stay in acute care facilities is approximately one month. Important is the medical suppression of the immune system, otherwise can quickly occur rejection reactions. However, liver transplantation in terms of immune suppression is somewhat less critical than other transplants. Also, an intensive psychological care is almost indispensable.

The pre-existing symptoms of liver disease such as fatigue, weakness, and yellowing go back to the rule, which allows the patient to a new life. After the transplant organ recipients can lead a normal life, taking into account the increased susceptibility to infection by immunosuppression often.

Success rate

Liver transplantation is the treatment of choice for the above-mentioned diseases. Through constant improvements in technology and research in the field of immunotherapy, the survival rate is steadily increasing. In 2005, one-year survival rates of over 90 %, 5 - year survival rates of over 80 % and 10 - year survival rates of over 70 % has been achieved. However, the survival rates are highly dependent on the underlying disease as well as the overall condition, follow-up and comorbidities of the patient. The best by a long-term survival of more than 90 % prognosis patients who were transplanted due to a primary Biliary cirrhosis.

For various reasons, it may cause failure of the transplant and re- transplantation ( " retransplantation ").

Living liver donation

The biggest problem is, as with all transplants, the imbalance between patients who are on a waiting list, and potential organ donors.

Since the liver is able to regenerate itself, so to grow back, come as the kidney and liver donations of matching donors in question. Here ethical considerations play a major role: the donor must be healthy so that it can be ensured that he bears them no damage from the surgery.

The ability of the liver to regenerate itself, also the method of the split liver makes use of. Here, a donor organ to two receivers is divided. This method is often used in children, as there are not many (size matters) matching organs for children. The procedure was first performed by Rudolf Pichlmayr 1988 at the Hannover Medical School and has since become established as standard procedure in pediatric liver transplantation.

History

The first liver transplant in humans worldwide conducted in Denver on March 1, 1963, the U.S. Surgeon Thomas E. Starzl. On June 19, 1969 Alfred Gütgemann attended the University of Bonn for the first time before such an operation in Germany. In 1988, Rudolf Pichlmayr the first successful division of the liver into two halves performed ( split liver transplantation). In 1989, Christoph Broelsch out the first successful live liver donation for transplantation of a child.