Combined liver-thoracic transplantation: single-center experience with introduction of the‘Liver-first’principle

Abstract

Combined liver/thoracic transplantation (cLiThTx) is a complex procedure for end-stage/advanced liver and heart(H)/lung(Lu) disease. To avoid futile use of multiple organs in single recipients, results should be scrutinously analyzed. Single-center cLiThTx (04/2000-12/2015) were reviewed for the following: demographics, indications, surgical technique, complications, rejection, and five-year patient survival. Results are reported as median (range). Fourteen consecutive patients underwent cLiThTx: 3 cLiHTx, 10 cLiLuTx, and 1 cLiHLuTx. Recipient age was 42 years (17-63 years). Most frequent indications were cystic fibrosis (n = 5), hepatopulmonary fibrosis (n = 2), amyloidosis (n = 2), and epithelioid hemangio-endothelioma (n = 2). Thoracic organs were transplanted first, except in three where LiTx preceded LuTx. In the latter, lungs were preserved by normothermic ex vivo lung perfusion. Stenting was performed for stenosis of bile duct (n = 4), hepatic artery (n = 2), and bronchus (n = 2). Abdominal interventions were required for bleeding (n = 3), evisceration (n = 1), and adhesiolysis (n = 1). One liver (cLiLuTx) was lost to hepatic artery thrombosis 3 months post-transplant and successfully retransplanted. One patient (cLiHTx) died 4 months post-transplant (myocardial infarction). Follow-up was 4 years (2 months-16 years). One liver and 5 pulmonary rejections occurred, all mild and reversible. Two patients developed bronchiolitis obliterans, one is clinically well 16 years post-transplant, and the other successfully retransplanted. Estimated 5-year patient survival is 90%. CLiThTx is safe with excellent short-/long-term surgical and immunological results.

A Multidisciplinary Approach to Pretransplant and Posttransplant Management of Cystic Fibrosis–Associated Liver Disease

“…Patient survival following lung transplantation significantly decreases after 6 hours of ischemic time to the liver . However, a transplant center in Europe recently endorsed a “liver‐first” principle following a small series of 5 CF patients who had good midterm survival with this approach . Additionally, advances in ex vivo machine perfusion allow for longer preservation of donated lungs, which may further assist in the liver‐first approach and offer the potential benefit of decreasing bleeding complications associated with lung transplant …”

“…(50) However, a transplant center in Europe recently endorsed a "liver-first" principle following a small series of 5 CF patients who had good midterm survival with this approach. (51) Additionally, advances in ex vivo machine perfusion allow for longer preservation of donated lungs, which may further assist in the liver-first approach and offer the potential benefit of decreasing bleeding complications associated with lung transplant. (52) Using age at transplant as a surrogate marker of organ failure demonstrates that the peak incidence of LT for CF in the United States occurs in adolescence and is uncommon after 35 years.…”

First report of a living liver graft in combined lung and liver transplantation

“…To our knowledge, there are no previous reports of simultaneous CLLDLT in the literature. Small case series of combined lung and liver transplantation from deceased donors showed longer wait times for these patients than for patients awaiting single organ trans-plantation, with reported median wait times of 40-700 days [1][2][3][4][5][6]. Considering the severe shortage of deceased donors, the combination of living and deceased donor grafts is a feasible treatment option if a successful team approach can be utilized to minimize the risks of this technically and logistically challenging scenario to the recipient and living donor alike.…”

Liver-first versus lung-first: a new dilemma in combined organ transplantation

“…In addition, the incidence of grade 2/3 PGD at 72 h post-transplant was much lower in the liver-first than in the lung-first group [10]. To fully elucidate the potential of an inversed-liver-firstsequence, further research and multicenter collaboration is needed, as more patients are being referred, following the increasing success of this complex transplant procedure [1].…”

“…Dear Editors, One-staged combined liver-lung transplantation (cLi-LuTx) is a life-saving procedure for patients with dual organ failure [1]. The classic sequence dictates LuTx priority over LiTx, due to the tolerable cold ischemic time, which is considered shorter for the lungs (6-8 h) than for the liver (8-10 h).…”