Extended survival in 3 cases of orthotopic homotransplantation of the human liver

Abstract

Orthotopic homotransplantation of cadaver livers was carried out in 3 children, aged 13 to 20½ months, for the treatment of primary liver-cell carcinoma or extrahepatic biliary atresia. The donor-recipient lymphocyte antigen compatibility ranged from good to poor. Immunosuppressive therapy was with azathioprine, prednisone, and heterologous antilymphocyte globulin (ALG). In all 3 recipients, the right phrenic nerve was paralyzed during operation, probably by crushing it with the vascular clamp that was applied to the suprahepatic inferior vena cava. Normal diaphragmatic movement returned from 2 to 10 weeks later. During the anhepatic phase of the procedure, it was found that decompression of the occluded vena caval and portal venous systems with external bypasses was not necessary. In the process of transplantation, the homografts sustained from minor to moderate ischemic injury. The anoxia probably contributed to a moderately severe intraoperative metabolic acidosis following revascularization, but the livers provided satisfactory early postoperative function. Subsequently, infected liver infarctions and consequent gram-negative septicemia developed in each patient. In one this was evidently due to a technical complication with resultant thrombosis of part of the hepatic arterial supply, but in the other two the infarctions occurred after more than 3 weeks. In the latter cases, a blood flow reduction caused by clinically inevident rejection or other unknown factors may have been responsible. The septic infarcts were excised or debrided under appropriate antibiotic coverage. The possible etiologic role of rejection was supported by histologic evidence of this process in all 3 of the patients. Regeneration subsequently contributed to a variable filling in of the intrahepatic defects. Late function has ranged from completely satisfactory to subnormal, as judged by multiple function tests of synthesis and excretion. Only one patient has clinical evidence of liver failure, manifested by persistent jaundice and ascites. All 3 children are alive after 94, 86, and 49 days, as well as a fourth patient, who is now 2 weeks postoperative.