Living Donor Liver Transplantation for Perihilar Cholangiocarcinoma: Outcomes and Complications

Abstract

BACKGROUND: Neoadjuvant therapy and liver transplantation is an effective treatment for perihilar cholangiocarcinoma (pCCA). Living donor liver transplantation (LDLT) addresses the problem of organ shortage, but has higher risk of technical complication that can be aggravated by radiotherapy. We investigated the incidence of vascular and biliary complication in pCCA compared with non-pCCA patients and their impact on patient and graft survival. STUDY DESIGN: All consecutive LDLTs (n ¼ 247) performed between 2000 and 2017 were reviewed, including demographics, donor variables, operative details, and postoperative outcomes. Logistic regression models were used to investigate the relationship between variables and outcomes. RESULTS:Seventy-four LDLTs (30.0%) were performed for pCCA and 173 for other indications. Forty-nine patients (66.2%) had primary sclerosing cholangitis-associated pCCA; the remainder had de novo pCCA. LDLT for pCCA was associated with nonstandard arterial (p ¼ 0.001) or portal vein reconstruction (p < 0.001) and Roux-en-Y choledochojejunostomy (p < 0.001). The incidence of early hepatic artery thromboses was similar (5.4% vs 7.6%; p ¼ 0.54). Late hepatic artery (18.9% vs 4.1%; p < 0.001) and portal vein (37.8% vs 8.7%; p < 0.001) complication was more common in the pCCA group. Anastomotic biliary complications occurred in 39.2% vs 54.1% (p ¼ 0.032) of patients. Overall survival for pCCA at 1, 5, and 10 years was 84.9%, 66.5%, and 55.6%, respectively. Cancer recurred in 12.3%. Residual tumor on explant prognosticated inferior survival (hazard ratio 5.69; 95% CI, 1.97 to 16.35) and vascular and biliary complications did not. CONCLUSIONS: Late vascular complication is common after LDLT for pCCA, but do not adversely affect long-term survival. LDLT provides excellent survival, particularly for patients with no residual disease at the time of transplantation.

Liver Transplantation in Malignancies: A Comprehensive and Systematic Review on Oncological Outcome

“…All of these patients underwent LT for PSC, while pCCC was found incidentally posttransplant, not detected in the preoperative findings due to a small tumor size of a median of 3 cm with <5% positive lymph nodes. Similar good results were presented by Tan et al [46] in PSC patients with pCCC with an OS of 89.8, 75.9, 75.9, and 73.2%, much better than the survival of de novo pCCC patients without PSC of 75.0, 58.0, 47.5, and 35.2% at 1, 3, 5, and 10 years, respectively. This difference however vanished if residual tumor was present after LT and survival was comparable inferior in both groups (Table 2).…”

“…Most recent studies have shown that LT is justified for patients with unresectable very early iCCC and combined HCC/iCCC, with survival outcomes comparable to those of HCC (62) (Table 2). Best results however are clearly obtained in patients who underwent LT for PSC with incidentally found pCCC, while comparable results can be obtained in PSC patients with pCCC diagnosed before LT [45, 46](Table 2). Further, there appears no difference in outcome if patients with small iCCC and combined HCC/iCCC undergo LT [47] (Table 2).…”

Recent developments and ongoing trials in transplant oncology

“…While waiting time is not a predictor for drop‐out, the role of living‐donor LT (LDLT) remains to be clarified and may potentially represent a route for expanding the current selection criteria. The neoadjuvant radiotherapy contributes to the technical complexity of LDLT 98 . Late hepatic artery thrombosis was found to be 18.9% and portal vein complications 37.8% in a recent experience from the Mayo clinic 98 .…”

“…The neoadjuvant radiotherapy contributes to the technical complexity of LDLT 98 . Late hepatic artery thrombosis was found to be 18.9% and portal vein complications 37.8% in a recent experience from the Mayo clinic 98 . Nonetheless, these complications do not impair long‐term survival 98 .…”

“…Late hepatic artery thrombosis was found to be 18.9% and portal vein complications 37.8% in a recent experience from the Mayo clinic 98 . Nonetheless, these complications do not impair long‐term survival 98 . Moreover, LDLT may represent a strategy for patients who may be either upfront resectable or who exceed current national listing criteria.…”