Resection And Partial LIver Transplantation With Delayed Hepatectomy for Hepatocellular Carcinoma

In France, the liver transplant allocation is based on the severity of liver failure, but patients with hepatocellular carcinoma (HCC) usually do not have hepatocellular failure, resulting in reduced access to liver transplantation. Two years after registration on the LT list, only 66% of those registered are transplanted due to tumor progression. This observation leads to the paradoxical conclusion that better access to transplantation is an absolute priority, but remains limited by the shortage of grafts.

The split surgical of one graft into two grafts is the most effective way to increase the number of transplantable organs. This technique is performed daily as part of pediatric TH where the child receives the left lobe/liver, adapted to his morphology. However, in adults, transplantation of the left lobe (segments 2+3) or of the left liver (segments 2+3+4) associated with complete excision of the native liver generates a high rate of complications (small-for-size syndrome) and compromises graft and recipient survival. For these reasons, this type of procedure has been almost abandoned in France.

One of the ways to increase the organ pool without risking liver failure is therefore to perform an auxiliary transplant with a partial graft from an organ harvested in its entirety and then shared.

The investigators therefore wish to evaluate the feasibility and tolerance, the results and the "gain" of grafts after a standardized RAPID procedure ( Resection And Partial LIver Transplantation with Delayed Hepatectomy) allowing to transplant an adult with a left lobe (very small graft) from a shared whole graft (deceased donor in brain death) , and to compare the results with standard management (orthotopic HT with whole organ for HCC).

The population is 50 major patients (in order to realize the RAPID procedure for 34 patients) with HCC requiring LT according to the usual transplantability criteria, with preserved liver function. The study lasts a maximum of 70 months (24 months of inclusion period, 6 months between selection and inclusion, <12 months between inclusion and the 1st RAPID time, 4 months maximum between the 2 RAPID Steps, 24 months of patient follow-up post 2nd step of RAPID). The study will proceed as described below :

• Pre-selection, information and consent of the patient by the local team.
• After validation by the scientific committee of the inclusion/exclusion criteria, the patient will be prioritized with the Biomedicine Agency (800 points at 6 months)
• If necessary, he will receive a waiting treatment for the CHC
• Step 1 of RAPID : During the first operation, he will have a left hepatectomy and then LT with a left lobe/liver in an orthotopic position. During this operation, a treatment (resection/destruction) of a possible HCC of the right liver can be proposed in order to not to leave active nodule(s).
• Step 2 of RAPID : Within a maximum of 4 months, after graft hypertrophy, right hepatectomy of the remaining native liver will be realized.
• The oncological and post-LT follow-up will then be no different from a standard out-of-protocol patient. Standard immunosuppression
• At the end of the study, a comparative analysis will be made with the control group, the anonymous data of which will be transmitted by the ABM.

The expected benefits for participants are :

• Rapid access to LT thanks to prioritization by the Biomedicine Agency at 6 months. Moreover, prioritization on the list could make it possible to limit the use of waiting treatments (surgery, radiation therapy, chemoembolization, immunotherapy, etc.) with non-negligible side effects/morbidity (e.g. arterial dissection jeopardizing the future graft) and high costs.
• reduction in the risk of leaving the list, of death on the list,
• access to an excellent quality graft (strict donor selection criteria) while patients with HCC frequently receive marginal organs, known as "out of turn", in an attempt to reduce their wait,
• possible improvement in intention-to-treat survival.

The expected benefits for society are :

• Overall increase in the organ pool = partial response to the shortage of organs from which all recipients will be able to benefit (reduction of waiting time),
• reduction of costs related to waiting treatments in CHCs (patients registered on the list),
• reduction of costs related to hospitalization in the event of acute decompensation of chronic liver disease (ACLF).

The risks added by research :

• The main risk is that caused by two successive interventions, close together. The international literature on orthotopic auxiliary grafting using a small graft shows that the morbidity is real but the medium and long-term results are good (4 postoperative deaths reported only).
• The risk of small for size syndrome is not ruled out in the RAPID protocol but will be limited to a minimum by appropriate portal modulation measures, a surgical technique refined and implemented by the experience of each center + literature, and finally postoperative follow-up close.