Further Details From the First Human Liver Transplantation in Europe

Although there is general agreement that the first liver transplantation (LT) in humans in the United States was performed by T.E. Starzl and his team, there is still some uncertainty concerning who and how the first clinical LT was performed in Europe. Jean Demirleau reported at the French “Academie de Chirurgie” (Academy of Surgery), on February 5, 1964 (1), a first attempt at LT that he performed at the Hospital St. Antoine in Paris (Fig. 1) probably in January of the same year. It was the first LT in Europe. The recipient was a 75-year-old man, with hepatic metastases from small bowel and colon cancer. The liver had been harvested from a 71-year-old cardiac death donor. In the donor operation, which lasted 25 min, the abdomen was filled with ice. The liver was then perfused on a back table. In the recipient, an extracorporeal circulation between the infrahepatic vena cava and the atrial appendage was put in place during clamping of the inferior vena cava. After the two end-to-end caval anastomoses, caval clamps were released and the portal and then arterial anastomoses were performed. A biliary end-to-end anastomosis on a T-tube was performed. The operation lasted 4 hr, but the patient died 3 hr after surgery due to fibrinolysis.FIGURE 1: Jean Demirleau report at the French “Academie de Chirurgie” (Academy of Surgery) (1964).In 1963, Starzl attempted three human liver replacements (2, 3). Some aspects of Demirleau’s LT can be considered peculiar for that time and they were rediscovered afterwards. (a) The donor of the first Demirleau’s LT was what we would call today a “marginal donor.” (b) Whereas Starzl used an extracorporeal perfusion apparatus provided with an oxygenator and a heat exchanger when harvesting the liver from the donor (2), Demirleau performed a “topical cooling” and a “fast technique” lasting 25 min without any perfusion until the back table. (c) In the first recipient, Starzl performed a one-step procedure and a two-step procedure in patients 2 and 3: during the first stage, “dissection and skeletonization of structures” were performed; then, the patient returned to the recovery room to be brought back to the theater later for the transplant. Demirleau performed the operation in one time. (d) Starzl used a passive bypass to decompress the lower part of the recipient body; in the first transplantation, he tried similarly to decompress the portal tree. Demirleau used a small-diameter plastic tubing between the right atrium and the vena cava to decompress the caval circulation and clamped the portal vein. (e) Vascular anastomoses were performed by Demirleau as in modern LTs: the artery after the portal vein. In Starzl’s first attempts, the arterial flow was reestablished before the portal circulation. (f) Starzl’s biliary reconstruction (2) was a cholecystojejunostomy in the first transplant, a choledocho-choledochostomy in the second transplant, and from 1967 a cholecystoduodenostomy (4), whereas Demirleau performed a choledocho-choledochostomy on a T-tube. Prof. Roy Calne performed the first LT in humans in the UK in April 1968 (5), but the first human LT in Europe was performed in 1964 by Demirleau. We thought interesting to describe some technical details of this first European attempt at LT. Obscure pioneers of surgery such as Demirleau in France deserve a wider place in the history of LT. Umberto Maggi 1,2 Daniel Azoulay1 1 Department of Digestive and Hepatobiliary Surgery, AP-HP U.F.R. de médecine de l’Université Paris XII-Créteil Paris, France 2 UO Chirurgia Generale e Trapianti di Fegato - Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano Milan, Italy