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, 180 (1), 1-9

Assessment of Five-Year Experience With Abdominal Organ Cluster Transplantation

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Assessment of Five-Year Experience With Abdominal Organ Cluster Transplantation

M Alessiani et al. J Am Coll Surg.

Abstract

Background: Upper abdominal exenteration (resection of the liver, stomach, spleen, pancreaticoduodenal complex, and part of the colon) for the treatment of otherwise unresectable tumors is one of the more radical operations in oncology. This study was done to analyze retrospectively a five-year experience with exenteration in 57 patients treated with variations of resectional and transplant reconstructive techniques.

Study design: Sixty-one transplantations were performed upon 57 patients. Three different organ replacement techniques were used: liver-pancreas-duodenum en bloc (original procedure), liver only (modified procedure), and liver plus pancreatic islets. The diagnoses were cholangiocarcinoma (20 patients), hepatocellular carcinoma (12 patients), endocrine neoplasms (14 patients), sarcoma (six patients), and adenocarcinoma of the pancreas (two patients), colon (two patients), or gallbladder (one patient). Analyses of survival and tumor recurrence were stratified by procedure variations, type and extent of tumor, and immunosuppressive regimen.

Results: The three month and one, two, three, and five year actuarial patient survival rates were 82, 56, 38, 33, and 30 percent, respectively. Eighteen (31.5 percent) of the 57 patients are alive after 425 15 (standard deviation) months (range of 17 to 61 months) and 12 patients are tumor free. The actuarial survival rates stratified by transplantation procedure, immunosuppression, and tumor diagnosis and extent showed no statistically significant differences beyond the three different transplantation groups. Endocrine tumors had a better three-year survival rate (64 percent) than sarcoma (44 percent), hepatocellular carcinoma (25 percent), cholangiocarcinoma (20 percent), and the other adenocarcinomas (20 percent). Twenty-three patients (40 percent) died as a result of tumor recurrence. Patients with combined factors of no lymph node involvement, absence of vascular invasion, and metastases to the liver only (11 patients) had the lowest incidence of recurrence (27 compared to 73.5 percent, p = 0.006).

Conclusions: Patients with unresectable endocrine neoplasms, fibrolamellar hepatocellular carcinoma, and selected cholangiocarcinoma confined to the liver can benefit from this radical operative approach. Patients with sarcoma can achieve long survival periods but have a high recurrence rate.

Figures

Fig. 1
Fig. 1
a, Original cluster procedure with transplantation of liver-pancreas-duodenum en bloc. In two cases, part of the stomach was preserved and the transplanted duodenum was placed in continuity with the stomach and jejunum of the patient (inset). b, Modified cluster procedure with transplantation of the liver only. In eight patients, one-third or more of the recipient stomach was preserved (inset, right), including three patients in whom the body and the tail of the pancreas also were retained (inset, left). c, Islet cluster procedure with transplantation of the liver and pancreatic islets injected into the portal vein of the transplanted liver. In two patients, part of the recipient stomach was preserved (inset).
Fig. 2
Fig. 2
The overall actuarial patient survival rate curve.
Fig. 3
Fig. 3
The actuarial patient survival rate stratified by transplantation procedure: original cluster (liver-pancreas-duodenum), modified cluster (liver only), and liver plus pancreatic islets.
Fig. 4
Fig. 4
The actuarial patient survival rate stratified by immunosuppression with cyclosporine or FK 506.
Fig. 5
Fig. 5
The actuarial patient survival rate stratified by histologic diagnosis. HCC, Hepatocellular carcinoma, and Cholangioca, cholangiocarcinoma.
Fig. 6
Fig. 6
Incidence of recurrence within each tumor diagnosis group. Patients who died within the first three months from technical or nontumor complications (ten cases), as well as those in whom gross tumor remained (two cases) were excluded from this analysis. HCC, Hepatocellular carcinoma, and cholangioca, cholangiocarcinoma.
Fig. 7
Fig. 7
Transplantation technique in a patient with gastrinoma invading the upper vena cava and the right atrium. The entire upper vena cava and part of the wall of the right atrium were excised and replaced with both donor structures. This patient, whose entire pancreas was removed, had donor pancreatic islets infused into the portal vein and is insulin free after four years.
Fig. 8
Fig. 8
The mean percent of weight loss in the surviving are tumor free who had part of the stomach preserved (GP=7 cases) and those in whom total gastrectomy was performed (NGP=5 cases). GP, Gastric preservation, and NGP, nongastric preservation.

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