How Can Machine Perfusion Change the Paradigm of Liver Transplantation for Patients with Perihilar Cholangiocarcinoma?

Abstract

Perihilar cholangiocarcinomas (pCCA) are rare yet aggressive tumors originating from the bile ducts. While surgery remains the mainstay of treatment, only a minority of patients are amenable to curative resection, and the prognosis of unresectable patients is dismal. The introduction of liver transplantation (LT) after neoadjuvant chemoradiation for unresectable pCCA in 1993 represented a major breakthrough, and it has been associated with 5-year survival rates consistently >50%. Despite these encouraging results, pCCA has remained a niche indication for LT, which is most likely due to the need for stringent candidate selection and the challenges in preoperative and surgical management. Machine perfusion (MP) has recently been reintroduced as an alternative to static cold storage to improve liver preservation from extended criteria donors. Aside from being associated with superior graft preservation, MP technology allows for the safe extension of preservation time and the testing of liver viability prior to implantation, which are characteristics that may be especially useful in the setting of LT for pCCA. This review summarizes current surgical strategies for pCCA treatment, with a focus on unmet needs that have contributed to the limited spread of LT for pCCA and how MP could be used in this setting, with a particular emphasis on the possibility of expanding the donor pool and improving transplant logistics.

Liver transplantation for tumor entities

“…However, the adoption of this feasible yet challenging protocols remains limited to few selected centers. In contrast, machine perfusion (MP) is gaining global traction and has demonstrated its ability to expand donor pool (ECD) [21–23]. Patients not meeting SECA II criteria were included in a distinct trial arm (SECA-II arm D), and 9 out of 10 were transplanted using ECD grafts [24].…”

“…This issue might be tackled by recurring to LDLT [88] or a more deliberate use of livers from ECDs. By increasing organ utilization, and therefore the number of available grafts, and facilitating transplant logistics, LT for pCCA may represent an ideal setting for implementation of MP techniques [89][90][91]. For example, in LT for both iCCA and pCCA, use of MP could allow performing lymphadenectomy at the time of LT while simultaneously avoiding the increased technical difficulty due to adhesion formation and the detrimental effects of prolonging cold ischemia time (Fig.…”

Liver transplantation for intrahepatic cholangiocarcinoma: who, when and how

“…NMP increases preservation time for the staging laparotomy, frozen section sampling, dissection of adhesions, and preparation for complex vascular reconstructions. Up to one-third of the patients with resectable disease on imaging will have occult metastatic or locally advanced disease during diagnostic laparotomy [70 ▪ ,71]. In the MMAJCCC series, two patients were aborted during transplant due to extrahepatic disease, and two had positive microscopic margins.…”

Early outcome of machine perfusion vs static cold storage of liver graft: A systemic review and meta-analysis of randomized controlled trials

“…In an effort to expand the donor pool, transplant surgeons have increasingly used extended criteria grafts, domino liver grafts and living donor grafts. [1][2][3] The use of extended criteria grafts is very challenging and it is associated with more complications such as post reperfusion syndrome, early allograft dysfunction (EAD), primary non function (PNF), vascular and biliary complications among others. These complications may be associated with graft loss or even mortality of patients.…”