Adult liver transplantation: UCL experience

Objective : to evaluate the impact of standardized operative and peri-opera tive care on the outcome of liver transplantation in a single center series of 395 adult patients. Method and Material : between February 1984 and December 31, 1998, 451 orth otopic liver transplantations were performed in 395 adult patients (greater than or equal to 15 years) at the University Hospitals St-Luc in Brussels. Morbidity and mortality of the periods 1984-1990 (Gr I -174 pat.) and 1991 -1998 were compared (Gr II - 221 pat.). During the second period anti-fecti ous chemotherapy and perioperative care were standardized and surgical tech nique changed from classical orthotopic liver transplantation with recipien ts' vena cava resection (and use of veno-venous bypass) towards liver impla ntation with preservation of the vena cava (without use of bypass). Immunosuppression was cyclosporine based from 1984 up to 1996 and tacrolimu s based during the years 1997 and 1998. Immunosuppression was alleviated du ring the second period due to change from quadruple to triple and even doub le therapy and due to the introduction of low steroid dosing and of steroid withdrawal, once stable graft function was obtained. Indications for liver grafting were chronic liver disease (284 pat - 71,9%) , hepatobiliary tumor (52 pat - 13,2%), acute liver failure (40 pat - 10.1% ) and metabolic disease (19 pat - 4,8%). Regrafting was necessary because o f graft dysfunction (21 pat), technical failure (12 pat), immunological fai lure (18 pat) and recurrent viral allograft disease (5 pat) ; three of thes e patients were regrafted at another institution. Follow-up was complete fo r all patients with a minimum of 9 months. Results : actuarial 1, 5 and 10 years survival rates for the whole group we re 77,9%, 65,7% and 58,3%. These survival rates were respectively 77,3%, 69 ,7%, 62,5% and 73,2%, 59,6% 51,4% for benign chronic liver disease and acut e liver failure ; those for malignant liver disease were 80.6%, 44,3% and 3 6,7%. Early (< 3 months) and late 21.2% (84 pat). Early mortality lowered f rom 20% in Gr I to 9,4% in Gr II (p < 0.02) ; this was due to a significant reduction during the second period of bacterial (99/174 pat. -56.9% vs 82/ 221 pat. -37.1%). fungal (14 pat. - 8% vs 7 pat. - 3.2%) and viral (87 pat. - 50% vs 49 pat. - 22.2%) infections (p < 0.05) as well as of perioperativ e bleeding (92 pat. - 52.9% vs 39 pat. - 17.6% - p < 0.001). Late mortality remained almost identical throughout the two periods as lethal outcome was mainly caused by recurrent allogroft diseases, cardio-vascular and tumor p roblems. Morbidity in these series was important considering that almost, h alf of the patients has a technical complication, mostly related to bleedin g (131 pat - 33,2%) and biliary problems (66 pat - 16.7%). Retransplantatio n index was 1.1 (54 pat. - 14%). Early retransplantation mortality was 24% ; it lowered, although not yet significantly, during the secong period (8/2 5 pat. - 32% vs 5/29 pat. - 17.2%). Conclusion : Despite a marked improvement of results, liver transplantation remains a major medical and surgical undertaking. Standardization of opera tive and perioperative care, less haemorraghic surgery and less agressive i mmunosuppression are the keys for further improvement.