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

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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

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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

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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

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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

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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

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Mayo Clinic Treatment Protocol
External beam radiation therapy Brachytherapy Prot
racted venous infusion of 5-FU / Xeloda Abdominal
exploration for staging Liver transplantation
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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)

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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

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Aim

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

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Methods

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

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Results
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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

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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

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Results

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

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Results

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

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Results

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

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Results

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

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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.