APPROCCIO MINIINVASIVO NELLA DONAZIONE DORGANO A SCOPO TRAPIANTO

APPROCCIO MINIINVASIVO NELLA DONAZIONE D’ORGANO A SCOPO TRAPIANTO PEDIATRICO Roberta Angelico MD, Ph. D, FEBS Chirurgia Epatobiliopancreatica e dei Trapianti Addominali Ospedale Pediatrico Bambino Gesù, IRCCS, Roma CHIRURGIA ROBOTICA vs CHIRURGIA LAPAROSCOPICA TRADIZIONALE Chieti, 5 Aprile 2019

LIVING DONOR TRANSPLANTATION IN CHILDREN Why? ü Lack of size-match donor ü No waiting on the transplant list ü Elective procedure ideal timing for transplantation ü No deterioration / drop out / mortality on the waiting list Excellent outcomes! 2

LIVING DONOR TRANSPLANTATION IN CHILDREN 3 Limits ü Availability of donor ü Donor morbidity and mortality ü Technical complexity and difficult organization LIVER TRANSPLANTATION KIDNEY TRANSPLANTATION UNOS Data 2018

4 HOW TO IMPROVE LIVE DONATION? Donor mini-invasive surgery

5 PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION Extended right lobe: segments I+IV-VIII Left lateral segment: segments II-III 70%-75% whole liver volume IDEAL GRAFT-TO-RECIPIENT-WEIGHT-RATIO: 1. 5 -3% 20%-25% whole liver volume

ADULT-TO-CHILD LDLT 6 mini-invasive donor surgery ü ≅ 200 laparoscopic donor procedures ü Donor morbidity: 0 -25% ü Donor mortality: 0% ü Conversion rate: 0 -6% ü Standardized technique Pan Au K et al. WJG, 2018 Han H et al. Dig Surgery, 2018

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PEDIATRIC LIVER TRANSPLANTATION ACTIVITY 8 Ospedale Pediatrico Bambino Gesù 100% 95% 34 28 26 27 24 15 15 3 -77% 30% Living donor liver transplantation

9 Donor Mini-Invasive Left Lateral Sectionectomy OPBG experience Donor Recipients No. Age (yrs) Sex (M/F) Operation time (min) Ischemia Tot-Warm (min) Morbidity Age Sex (M/F) Diagnosis Morbidity 1 40 M 490 84 -5 No 12 m F Biliary atresia No 2 41 M 497 78 -4 No 1 y 4 m F Criptogenetic cholestasis Biliary stenosis 3 29 F 455 43 -5 IVC thrombosis 7 m M Biliary atresia PV thrombosis 4 37 F 480 78 -6 No 9 m M Biliary atresia PV stenosis 5* 44 M 465 60 -5 No 2 y 8 m F Intrahepatic familiar cholestsis No 6 32 M 440 45 -3 No 1 y 6 m M PH 1 No 7 35 F 482 123 -6 No 6 m F Biliary atresia No 8 35 F 540 83 -4 No 5 m F Biliary atresia No 9* 41 M 390 194 -5 No 2 y 10 m M PH 1 IVC thrombosis 10 34 M 420 69 -3 Biliary leak 2 y 8 m F Biliary atresia No 11 35 F 500 162 -6 No 6 m M Biliary atresia Outflow stenosis 12 43 M 475 82 -5 No 2 y 9 m F Ductopenic cirrhosis No 13 47 M 505 50 -4 No 5 y F Alagille’s syndrome No Period: July 2016 -April 2019 * Sequential living-related kidney transplantation

10 Donor Mini-Invasive Left Lateral Sectionectomy OPBG experience Donor Recipients No. Age (yrs) Sex (M/F) Operation time (min) Ischemia Tot-Warm (min) Morbidity Age Sex (M/F) Diagnosis Morbidity 1 40 M 490 84 -5 No 12 m F Biliary atresia No 2 41 M 497 78 -4 No 1 y 4 m F Criptogenetic cholestasis Biliary stenosis 3 29 F 455 43 -5 IVC thrombosis 7 m M Biliary atresia PV thrombosis 480 78 -6 No 9 m M Biliary atresia PV stenosis 465 60 -5 No 2 y 8 m F Intrahepatic familiar cholestsis No M 440 45 -3 No 1 y 6 m M PH 1 No Clavien Grade 1: 0% F Grade 2: 15% M Grade 3: 0% Grade 4: 0% 4 37 5* 44 6 32 7 35 F 482 123 -6 No 6 m F Biliary atresia No 8 35 F 540 83 -4 No 5 m F Biliary atresia No 9* 41 M 390 194 -5 No 2 y 10 m M PH 1 IVC thrombosis 10 34 M 420 69 -3 Biliary leak 2 y 8 m F Biliary atresia No 11 35 F 500 162 -6 No 6 m M Biliary atresia Outflow stenosis 12 43 M 475 82 -5 No 2 y 9 m F Ductopenic cirrhosis No 13 47 M 505 50 -4 No 5 y F Alagille’s syndrome No Period: July 2016 -April 2019 * Sequential living-related kidney transplantation

LIVING DONOR KIDNEY TRANSPLANTATION 11 Gold standards: ü Pure laparoscopic nephrectomy ü Hand-assisted nephrectomy Walther AE et al. Pediatric Transpl. , 2015

12 PEDIATRIC RENAL TRANSPLANTATION Ospedale Pediatrico Bambino Gesù 96% 28 26 Log-Rank= 0. 292 83% 2018 43% living donor kidney transplantation Log-Rank= 0. 273

13 Sequential laparoscopic liver-kidney procurement in the same living donor Donor Age (yrs) 1 2 32 40 Sex (M/F) Liver surgery Kidney surgery F Laparoscopic left lateral sectionectomy Laparoscopic left nephrectomy M Laparoscopic left lateral sectionectomy Hand-assisted right nephrectomy A C B D Recipients Morbidity No No Time between L-K surgery 8 m 4 m Age 15 m 34 m Sex (M/F) Diagnosis Morbidity M primary hyperoxaluria type 1 No M primary hyperoxaluria type 1 IVC thrombosis

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15 Conclusions ü Mini-invasive approaches in donor liver resection might improve donor outcome and potentially increase the donor pool ü Laparoscopic LLS for pediatric LDLT is considered a safe and feasible procedure with potential advantages when performed in expert centres ü Pure laparoscopic and hand-assisted nephrectomy are the gold standard for living donor liver nephrectomy ü The referral to pediatric transplant center with expertise in living donation and laparoscopic surgery is essential for good outcome

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