Live donor liver transplantation in adults

Vascular Complications After Liver Transplantation

OBJECTIVES

Vascular complications after liver transplant can be lethal. High levels of suspicion and aggressive use of diagnostic tools may help with early diagnosis and treatment. Here, we share our experiences regarding this topic.

MATERIALS AND METHODS

Adult and pediatric patients who had liver transplant between February 1997 and June 2018 in our clinic were included in the study. Patients were grouped according to age (pediatric patients were those under 18 years old), male versus female, indication for transplant, type of liver transplant, type of vascular complication, treatment, and survival aftertreatment.We analyzed the statistical incidence of vascular complications according to age, male versus female, and type of liver transplant.

RESULTS

Our analyses included 607 liver transplant procedures, including 7 retransplants, with 349 (57.4%) from living donors and 258 (42.6%) from deceased donors. Of total patients, 539 were adults (89.8%) and 61 were children (10.2%). Vascular complications occurred in 25 patients (4.1%), with hepatic artery complications seen in 13 patients (2.1%) (10 adults [1.8%] and 3 children [4.9%]), portal vein complications seen in 9 patients (1.5%) (6 adults [1.1%] and 3 children [4.9%]), and hepatic vein complications seen in 3 patients (0.5%) (2 adults [0.36%] and 1 child [1.6%]). Rate of vascular complications was statistically higher in pediatric patients (11.4% vs 3.3%; P = .007) and higher but not statistically in recipients of livers from living donors (5.2% vs 2.7%; P = .19). Twelve patients (48.8%) were treated with endovascular approach, and 11 (0.44%)required surgicaltreatment. Two patients underwent immediate retransplant due to hepatic artery thrombosis.

CONCLUSIONS

Because vascular complications are the most severe complications afterlivertransplant,there must be close follow-up of vascular anastomoses, particularly early postoperatively, with radiologic methods. In cases of vascular complications, emergent treatment, including endovascular interventions, surgery, and retransplant, must be performed.

Intraoperative Factors Associated With Early Recipient Death After Adult-to-Adult Living Donor Liver Transplant

OBJECTIVES

Living donor liver transplant is the gold standard therapy for patients with terminal hepatic disorders for whom no alternative therapy is available. The primary aim was to assess different intraoperative factors that may predict early death after adult-to-adult living donor liver transplant. The secondary aim was to assess the effect of small-for-size syndrome on mortality.

MATERIALS AND METHODS

This retrospective multicenter cohort study was performed on records from 145 adults with cirrhosis who had received a right lobe living donor liver transplant. Patients were divided according to the occurrence of short-term mortality (death within the first month after transplant). The primary intraoperative parameters included graft weight, surgical duration, mean blood pressure, serum lactate and sodium bicarbonate, transfusions, durations of cold and warm ischemia and anhepatic phase, input and output during surgery, and portal venous pressures.

RESULTS

There were statistically significant variations between both cohorts for number of units of packed red blood cells, durations of cold and warm ischemia and anhepatic phase, preclamp and postreperfusion portal venous pressures, average urine output, mean serum lactate, mean blood pressure, and surgical duration (P ⟨ .001). Also, there were significant differences in the number of platelets, units of fresh frozen plasma, and mean sodium bicarbonate (P = .025, .003, and .035, respectively). Of the 25 patients who died within the early postoperative period, 20 had developed small-for-size syndrome (P ⟨ .001).

CONCLUSIONS

A variety of intraoperative risk factors may affect early posttransplant mortality, which suggests the high complexity of living donor liver transplants and the need for well-trained experienced teams to perform these surgeries.

Deportalization, Venous Congestion, Venous Deprivation: Serial Measurements of Volumes and Functions on Morphofunctional 99mTc-Mebrofenin SPECT-CT

The objective was to assess the changes in regional volumes and functions under venous-impaired vascular conditions following liver preparation. Twelve patients underwent right portal vein embolization (PVE) (n = 5) or extended liver venous deprivation (eLVD, i.e., portal and right and middle hepatic veins embolization) (n = 7). Volume and function measurements of deportalized liver, venous-deprived liver and congestive liver were performed before and after PVE/eLVD at days 7, 14 and 21 using 99mTc-mebrofenin hepatobiliary scintigraphy with single-photon emission computed tomography and computed tomography (99mTc-mebrofenin SPECT-CT). Volume and function progressed independently in the deportalized liver (p = 0.47) with an early decrease in function (median −18.2% (IQR, −19.4–−14.5) at day 7) followed by a decrease in volume (−19.3% (−22.6–−14.4) at day 21). Volume and function progressed independently in the venous deprived liver (p = 0.80) with a marked and early decrease in function (−41.1% (−52.0–−12.9) at day 7) but minimal changes in volume (−4.7% (−10.4–+3.9) at day 21). Volume and function progressed independently in the congestive liver (p = 0.21) with a gradual increase in volume (+43.2% (+38.3–+51.2) at day 21) that preceded a late and moderate increase in function at day 21 (+34.8% (−8.3–+46.6)), concomitantly to the disappearance of hypoattenuated congestive areas in segment IV (S4) on CT, initially observed in 6/7 patients after eLVD and represented 35.3% (22.2–46.4) of whole S4 volume. Liver volume and function progress independently whatever the vascular condition. Hepatic congestion from outflow obstruction drives volume increase but results in early impaired function.

Gender Imbalance and the Relationship Between Living Donors and Recipients in Liver Transplantations in an Organ Transplant Center in Turkey

OBJECTIVES

Because of the scarcity of publications on gender differences and the relationship between living donors and recipients in liver transplant procedures, we carried out this study with the objective to examine the gender distribution of donors and recipients and the relationships between donors and recipients in living related-donor liver transplants performed in a university hospital in Ankara, Turkey.

MATERIALS AND METHODS

We retrospectively evaluated the data of 549 patients who underwent living related-donor and deceased-donor liver transplant procedures conducted in a university hospital between 1988 and 2017 and the 409 living donors.

RESULTS

Males constituted 53.1% of the 409 living related liver donors and 63.6% of the living liver recipients. We found that 72.9% of the deceased-donor liver transplant recipients were also male. Of living related donors, 91.4% were blood relatives, with 74.8% being first-degree relatives. The most common donor-recipient relation was mother to son. Analyses of interspousal donations showed a significant difference between husband to wife and vice versa (7 vs 17; P < .05).

CONCLUSIONS

Most recipients and donors in living related-donor liver transplants were males with a young predominance. It is not known whether this might be related to biologic, psychologic, or socio cultural features of patients, gender issues, or economic factors. Further research with qualitative components on the influential factors, including gender, is needed.

A portal pressure cut-off of 15 versus a cut-off of 20 for prevention of small-for-size syndrome in liver transplantation: A comparative study

AIM

Portal hypertension has recently been implicated in the pathogenesis of small-for-size syndrome (SFSS) in adult-to-adult living-donor liver transplantation (A-LDLT). The aim of our study is to compare the portal venous pressure (PVP) cut-off values of 15 mmHg and 20 mmHg in terms of prevention of SFSS in A-LDLT.

METHODS

Seventy-six patients underwent A-LDLT. A PVP <20 mmHg at the end of the operation was targeted using graft inflow modulation. Patients were divided into two groups: group A, final PVP <15 mmHg; and group B, final PVP 15-19 mmHg. Peak serum bilirubin and peak international normalized ratio in the first month after A-LDLT, as well as hepatic encephalopathy, SFSS, 90-day morbidity, and mortality were observed in both groups.

RESULTS

Final PVP was well controlled below 20 mmHg in all patients (group A, n = 39; group B, n = 37). Six patients suffered SFSS in group B (16.2%) compared to one patient (2.6%) in group A (P = 0.04). Nine patients died in group B (24.3%), four of whom died of SFSS, compared to three patients in group A (7.7%) (P = 0.047).

CONCLUSION

A PVP cut-off of 15 mmHg seems to be a more appropriate target level than a cut-off of 20 mmHg for prevention of postoperative SFSS in A-LDLT.

Endoscopic Management of Biliary Leaks and Strictures After Living Donor Liver Transplantation: Optimizing Techniques for Successful Management

BACKGROUND AND AIMS

Biliary complications (BCs) occur in up to 40% of living donor liver transplant (LDLT) recipients. The aim of this study was to evaluate the efficacy of endoscopic therapy in the management of LDLT-related BCs.

METHODS

A retrospective study of 100 LDLT recipients at a single transplant center over a 9-year period was conducted. BC was defined as a biliary leak and/or a stricture. Patient records were used to identify time to diagnosis, type of intervention, and time to resolution.

RESULTS

BCs occurred in 46 (46%) patients; median follow-up was 4.6 years (range 5 days-9.3 years); and median time to diagnosis was 37.5 days (range 1 day-3.5 years). BCs were classified as a leak in 6 (6%), stricture in 22 (22%), and a leak + stricture in 18 (18%). ERCP was the initial treatment modality in 43/46 (93%) patients and was completed in 42/43 (98%). Three (6.5%) patients with a leak underwent surgery as the primary treatment approach. The median time to resolution of BCs was 91.5 days (range 21-367). Thirteen patients had a recurrence which was managed with endoscopic therapy alone.

CONCLUSIONS

Endoscopic therapy was successful in almost all patients (98%) and ERCP alone resulted in successful treatment in a higher proportion of patients (93%) than traditionally reported. Advanced endoscopic techniques obviate the need for PTC and/or surgery and allow successful management in almost all LDLT recipients presenting with BC and in patients with recurrence of strictures.

Predictive Value of Unenhanced Computerized Tomography for Detecting Hepatosteatosis in Living Liver Donors

OBJECTIVE

Macrovesicular hepatosteatosis is related to post-transplantation complications, so preoperative hepatosteatosis determination plays a critical role in donor selection. The aim of this study was to evaluate the efficacy of unenhanced computerized tomography (CT) in determining hepatosteatosis in liver donor candidates.

METHODS

Information about donor candidates was retrospectively reviewed. In this screening, 27 donor candidates who underwent liver biopsy because of suspected hepatosteatosis in routine abdominal CT examination before transplantation, were reviewed. Liver biopsies and CT images were reevaluated by an experienced pathologist and radiologist. Macrovesicular hepatosteatosis was graded according to percentage and divided into 3 groups. Three radiologic liver attenuation indices were used: 1) hepatic attenuation value (CT(L)); 2) the difference between hepatic attenuation and spleen attenuation (CT(L-S)); and 3) the ratio of hepatic attenuation to splenic attenuation (CT(L/S)).

RESULTS

CT(L), CT(L-S), and CT(L/S) values of donors with hepatosteatosis were significantly higher than the donors without hepatosteatosis. In receiver operating characteristic analysis, the optimal cutoff value of these indices for determining hepatosteatosis were; 42.5, -5, and 0.98, respectively. At these cutoff values, the sensitivity and specificity of these indices were calculated to be 80% and 75%, 93.3% and 83.3%, and 93.3% and 83.3%, respectively. There were no statistical differences between their diagnostic performances. When these 3 indices were used for detect significant hepatosteatosis (>20%) it was observed that hepatosteatosis of only one donor could not be determined whereas it was seen that specificity was decreased markedly.

CONCLUSIONS

Despite the high diagnostic yield of unenhanced CT, it is not suitable to use alone for assessment of hepatosteatosis in clinical practice.

Vascular complications after adult living donor liver transplantation: Evaluation with ultrasonography

Living donor liver transplantation (LDLT) has been widely used to treat end-stage liver disease with improvement in surgical technology and the application of new immunosuppressants. Vascular complications after liver transplantation remain a major threat to the survival of recipients. LDLT recipients are more likely to develop vascular complications because of their complex vascular reconstruction and the slender vessels. Early diagnosis and treatment are critical for the survival of graft and recipients. As a non-invasive, cost-effective and non-radioactive method with bedside availability, conventional gray-scale and Doppler ultrasonography play important roles in identifying vascular complications in the early postoperative period and during the follow-up. Recently, with the detailed vascular tracing and perfusion visualization, contrast-enhanced ultrasound (CEUS) has significantly improved the diagnosis of postoperative vascular complications. This review focuses on the role of conventional gray-scale ultrasound, Doppler ultrasound and CEUS for early diagnosis of vascular complications after adult LDLT.

Post-Operative Complications in Living Liver Donors: A Single-Center Experience in China

The gap between the growing demand for available organs and the cadaveric organs facilitates the adoption of living donor liver transplantation. We retrospectively identified and evaluated the post-operative complications as per the modified Clavien classification system in 152 living liver donors at at the First Affiliated Hospital, College of Medicine, Zhejiang University between December, 2006 and June, 2014. Post-operative complications were observed in 61 patients (40.1%) in the present study, but no mortality was reported. Complications developed in 58 (40.0%) right, 1 (33.3%) left, and 2 (66.7%) lateral left hepatectomy donors. The prevalence of re-operation was 1.3%. Grade I and II complications were observed in 38 (25.0%) and 11 (7.2%) donors, respectively. Grade IIIa complications developed in 9 (5.9%) donors and only 3 (2.0%) patients reported grade IIIb complications. The most common complication was pleural effusion that occurred in 31 (20.4%) donors. No significant prognostic baseline factor was identified in this study. In conclusion, living donors experienced various complications, which were usually mild and had a good prognosis.

Risk of venous congestion in live donors of extended right liver graft

AIM: To investigate middle hepatic vein (MHV) management in adult living donor liver transplantation and safer remnant volumes (RV).

METHODS: There were 59 grafts with and 12 grafts without MHV (including 4 with MHV-5/8 reconstructions). All donors underwent our five-step protocol evaluation containing a preoperative protocol liver biopsy Congestive vs non-congestive RV, remnant-volume-body-weight ratios (RVBWR) and postoperative outcomes were evaluated in 71 right graft living donors. Dominant vs non-dominant MHV anatomy in total liver volume (d-MHV/TLV vs nd-MHV/TLV) was constellated with large/small congestion volumes (CV-index). Small for size (SFS) and non-SFS remnant considerations were based on standard cut-off- RVBWR and RV/TLV. Non-congestive RVBWR was based on non-congestive RV.

RESULTS: MHV and non-MHV remnants showed no significant differences in RV, RV/TLV, RVBWR, total bilirubin, or INR. SFS-remnants with RV/TLV < 30% and non-SFS-remnants with RV/TLV ≥ 30% showed no significant differences either. RV and RVBWR for non-MHV (n = 59) and MHV-containing (n = 12) remnants were 550 ± 95 mL and 0.79 ± 0.1 mL vs 568 ± 97 mL and 0.79 ± 0.13, respectively (P = 0.423 and P = 0.919. Mean left RV/TLV was 35.8% ± 3.9%. Non-MHV (n = 59) and MHV-containing (n = 12) remnants (34.1% ± 3% vs 36% ± 4% respectively, P = 0.148. Eight SFS-remnants with RVBWR < 0.65 had a significantly smaller RV/TLV than 63 non-SFS-remnants with RVBWR ≥ 0.65 [SFS: RV/TLV 32.4% (range: 28%-35.7%) vs non-SFS: RV/TLV 36.2% (range: 26.1%-45.5%), P < 0.009. Six SFS-remnants with RV/TLV < 30% had significantly smaller RVBWR than 65 non-SFS-remnants with RV/TLV ≥ 30% (0.65 (range: 0.6-0.7) vs 0.8 (range: 0.6-1.27), P < 0.01. Two (2.8%) donors developed reversible liver failure. RVBWR and RV/TLV were concordant in 25%-33% of SFS and in 92%-94% of non-SFS remnants. MHV management options including complete MHV vs MHV-4A selective retention were necessary in n = 12 vs n = 2 remnants based on particularly risky congestive and non-congestive volume constellations.

CONCLUSION: MHV procurement should consider individual remnant congestive- and non-congestive volume components and anatomy characteristics, RVBWR-RV/TLV constellation enables the identification of marginally small remnants.

Living donor liver transplantation does not increase tumor recurrence of hepatocellular carcinoma compared to deceased donor transplantation

AIM: To compare the recurrence-free survival (RFS) and overall survival (OS) of hepatitis B virus (HBV)-positive hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT).

METHODS: We retrospectively collected clinical data from 408 liver cancer patients from February 1999 to September 2012. We used the chi-squared test or Fisher’s exact test to analyze the characteristics of LDLT and DDLT. Kaplan-Meier analysis was used to compare the RFS and OS in HCC.

RESULTS: Three hundred sixty HBV-positive patients (276 DDLT and 84 LDLT) were included in this study. The mean follow-up time was 27.1 mo (range 1.1-130.8 mo). One hundred eighty-five (51.2%) patients died during follow-up. The 1-, 3-, and 5-year RFS rates for LDLT were 85.2%, 55.7%, and 52.9%, respectively; for DDLT, the RFS rates were 73.2%, 49.1%, and 45.3% (P = 0.115). The OS rates were similar between the LDLT and DDLT recipients, with 1-, 3-, and 5-year survival rates of 81.8%, 49.5%, and 43.0% vs 69.5%, 43.0%, and 38.3%, respectively (P = 0.30). The outcomes of HCC according to the Milan criteria after LDLT and DDLT were not significantly different (for LDLT: 1-, 3-, and 5-year RFS: 94.7%, 78.7%, and 78.7% vs 89.2%, 77.5%, and 74.5%, P = 0.50; for DDLT: 86.1%, 68.8%, and 68.8% vs 80.5%, 62.2%, and 59.8% P = 0.53).

CONCLUSION: The outcomes of LDLT for HCC are not worse compared to the outcomes of DDLT. LDLT does not increase tumor recurrence of HCC compared to DDLT.

Living donor liver transplantation

PURPOSE OF REVIEW

Living donor liver transplantation (LDLT) continues to evolve, generating interesting issues on the applicability and safety of new techniques.

RECENT FINDINGS

Specific selection criteria and standardized surgical techniques with high ethical and medical standards are needed to minimize donor risk. In this aspect, minimally invasive donor hepatectomy has caused controversies. The reproducibility and safety of pure laparoscopic major hepatectomy in LDLT remains uncertain. Therefore, a stepwise approach is needed to avoid unnecessary donor risk. To expand the living donor pool, dual graft and ABO-incompatible LDLT have emerged as well tolerated and effective methods. The extended selection criteria for hepatocellular carcinoma in LDLT appear acceptable to balance donor risk and recipient outcome. However, these criteria should be validated based on the risk-benefit ratio. Despite technical advances, technical challenges persist such as Budd-Chiari syndrome and portal vein thrombosis. To address these issues, several innovative surgical techniques have been proposed and have shown promising results.

SUMMARY

LDLT is associated with donor safety concerns, technical complexity, and small-for-size issues. Nonetheless, accumulated experience and technical know-how from large-volume Asian LDLT centers have led to progress in LDLT. Further technical refinement and investigation to overcome the disadvantages of partial grafts will broaden the applicability of LDLT.

Clinical implications of preoperative and intraoperative liver biopsies for evaluating donor steatosis in living related liver transplantation

The role of liver biopsy in selecting optimal donors is an area of continuing controversy in living donor liver transplantation (LDLT). Our aim was to assess the potential implications of preoperative and intraoperative biopsies for evaluating donor liver fat content. Three thousand eight hundred fifty-nine consecutive subjects underwent predonation needle biopsy of the right lobe, and 1766 of these subjects actually donated their livers for LDLT and underwent intraoperative wedge biopsies of paired right and left lobes. The preoperative workup protocol also included abdominal ultrasonography (USG) and computed tomography (CT). Intersample agreement on steatosis grades (<5%, 5% to <15%, 15% to <30%, and ≥30%) was calculated, and clinicometabolic factors related to sampling variability were evaluated. For detecting ≥30% steatosis in the 3859 potential donors, USG and CT had sensitivities of 84.9% and 57.3%, specificities of 76.3% and 92.7%, positive predictive values of 29.6% and 48.0%, and negative predictive values of 97.7% and 94.8%, respectively. Analyses of the 1766 actual donors showed that with respect to the total steatosis grades of intraoperative right and left biopsies versus preoperative biopsy, 36.7% and 36.0% of the pairs, respectively, differed from the weighted κ values of 0.44 and 0.40. Similar agreement levels existed for macrovesicular and microvesicular steatosis subtypes. The per-subject agreement rate for the total steatosis grade between intraoperative right and left biopsies was 83.6%. According to a multivariate analysis, independent factors affecting the variability of the total steatosis results from preoperative and intraoperative biopsies (major features) were higher systolic blood pressure, body mass index, and alanine aminotransferase values and lower high-density lipoprotein cholesterol values. In conclusion, imaging may be insufficiently sensitive for evaluating donor hepatic steatosis. Preoperative and selective intraoperative liver biopsies are mandatory for assessing donor steatosis in LDLT unless preoperative imaging demonstrates no fat.

Correlation between 3D-MRCP and intra-operative findings in right liver donors

A correct preoperative definition of the hepatic duct confluence anatomy of right liver living donors is a pivotal step in determining their candidacy for donation and planning the surgery. The purposes of this study are to evaluate the accuracy of three-dimensional Magnetic Resonance Cholangiography (3D MRCP) when compared with intraoperative cholangiography (IOC) in assessing biliary anatomy and to identify imaging characteristics that may help predict the yield of hepatic duct orifices in the right liver graft. Twenty consecutive right liver donors were imaged with 3D MRCP and IOC. The MRCP and IOC findings were compared, and the results confirmed against actual donor anatomy. Three-D MRCP accurately predicted the biliary anatomy in 18 of 20 cases. Specificity and positive predictive value of 3D MRCP in defining normal biliary anatomy was 100%. In 2 patients, 3D MRCP failed to indentify abnormal anatomy. The yield of more than one hepatic duct was associated with: (I) The presence of abnormal biliary anatomy, (II) The length of the main right hepatic duct, and (III) The presence of an acute angle at the confluence of right and left hepatic duct. In conclusion, 3D MRCP reliably represents normal biliary anatomy. The presence of anatomical variations decreases MRCP sensitivity and makes IOC or duct probing a necessary tool for accurately performing the transection of the right hepatic duct.

Intraoperative predictors of short-term mortality in living donor liver transplantation due to acute liver failure

BACKGROUND

Acute liver failure (ALF) is a rare and fatal disease with rapidly deteriorating clinical features. Many predictive models for ALF outcomes have been tested, but none have been adopted as definitive guidelines for prognosis because of inconsistencies in accuracy. Most prognostic models for ALF are based on preoperative patient conditions, thus ignoring various specific intraoperative features relevant to postoperative outcomes. We investigated whether intraoperative factors predicted short-term mortality due to ALF in living donor liver transplantations (LDLT).

METHODS

We retrospectively collected intraoperative data, including surgical time, fluctuations in mean blood pressure (MBP) and heart rate, mean pulmonary arterial pressure (PAP), central venous pressure (CVP), urine output, laboratory data, oxygen indices (PaO(2)/FiO(2)), administered drugs, and transfusion of packed red blood cells (PRBCs) from 101 patients with ALF who underwent LDLT. After simple relationships of individual intraoperative variables with 1-month posttransplant mortality were analyzed, we examined potentially significant intraoperative variables (P < .10) by a multivariate adjustment process with preoperative indicators of ALF prognosis.

RESULTS

Intraoperative MBP fluctuations, first mean PAP and CVP, last oxygen index, administered calcium chloride, and PRBC transfusion showed individual associations with posttransplant mortality of ALF patients (P < .05). After multivariate adjustment, PRBC transfusion of ≥ 10 pints (odds ratio 4.73; 95% confidence interval [CI] 1.06-21.16) and MBP fluctuations (odds ratio 1.26; 95% CI 1.00-1.58) were identified to be independent predictors of 1-month posttransplant mortality, together with preoperative factors, including severe hepatic encephalopathy, and a Model for End-stage Liver Disease score ≥ 30 points (area under the curve 0.82, P < .001).

CONCLUSION

MBP fluctuations and large blood transfusions were intraoperative predictors of short-term mortality after LDLT due to ALF. Increased attention to intraoperative manifestations should provide valuable prognostic information for ALF.

Steatosis among living liver donors without evidence of fatty liver on ultrasonography: potential implications for preoperative liver biopsy

BACKGROUND

The degree of steatosis is an important factor that determines the graft function in the recipient and the recovery of the remnant liver in the living donor. To date, there is no consensus regarding how to assess steatosis among potential living liver donors. We evaluate the prevalence and risk factors for steatosis in living liver donors with normal serum aminotransferase levels and without fatty liver on ultrasonography (US-negative).

METHODS

The degree of steatosis was assessed for a total of 492 US-negative living liver donors with normal aminotransferase levels (age 30.1±9.9; male 301 [61.2%]). Total steatosis was defined by adding the degree of macrosteatosis and microsteatosis.

RESULTS

No liver donor had a severe degree (≥60%) of macrosteatosis or microsteatosis. A moderate degree (30-59%) of macrosteatosis and microsteatosis was seen in 4 (0.8%) and 26 (5.3%) subjects, respectively. Severe and moderate degrees of total steatosis were seen in 3 (0.6%) and 53 (10.8%) subjects, respectively. Body mass index and serum triglyceride levels were independent factors associated with the moderate or greater degree of total steatosis.

CONCLUSIONS

Noninvasive preoperative assessment for liver steatosis (US-negative with normal aminotransferase level) was sufficient to exclude severe macrosteatosis or microsteatosis and moderate macrosteatosis but not sufficient to exclude moderate microsteatosis or total steatosis in living liver donors.

Safety and feasibility of diet-treated donors with steatotic livers at the initial consultation for living-donor liver transplantation

BACKGROUND

The purpose of this study was to evaluate both safety of diet-treated donors and the feasibility of their use for living-donor liver transplantation (LDLT).

METHODS

A total of 128 living donors were enrolled in this study between April 2003 and March 2010. Of them, 41 were diagnosed with hepatic steatosis at the initial consultation. Donor selection was based on the findings of liver biopsy accompanied with normalization of liver function tests after diet treatment consisting of an 800 to 1400 kcal/day diet and a 100 to 400 kcal/day exercise without drug treatment, targeting body mass index of 22 kg/m².

RESULTS

Body mass index of diet-treated donors was significantly reduced with diet from 23.3 ± 0.6 to 21.9 ± 0.4 kg/m² (P<0.0001). Liver function tests associated with fatty liver, including alanine aminotransferase, gamma-glutamyl transpeptidase, and total cholesterol levels, also improved with diet (P=0.0128, 0.0016, and 0.0004, respectively). The liver biopsy results of most of these donors showed stage 0/1 fibrosis and minimal/mild steatosis after the diet therapy. Surgical outcomes, including postoperative liver function tests, perioperative complications, and liver regeneration rates, did not significantly differ between nondiet-treated and diet-treated donors. Surgical outcomes and the overall survival did not significantly differ between recipients of grafts from nondiet-treated and diet-treated donors.

CONCLUSION

The use of diet-treated donors for living-donor liver transplantation is feasible with respect to donor safety and the outcome of the recipient when strict selection criteria are used.

Liver transplantation: issues and nursing care requirements

Liver transplantation has evolved into an accepted treatment for many suffering from end-stage liver failure. The complex nature of the liver results in every organ system being impacted by either the failing or the transplanted liver. Organ shortage remains problematic, and work to ensure maximizing the organ donor pool as well as the success of each organ transplant continues. The clinical care and condition of the patient before transplant can impact the outcome after transplant. Nurses can play an integral role in early identification of graft dysfunction, rejection, or infection. Because of the intimate and large amount of time that the nurse is at the patient’s bedside, he or she is often in a position to monitor for potential risks to the patient and take corrective action.

Convergence process of volumetric liver regeneration after living-donor hepatectomy

BACKGROUND

We investigated the long-term profiles of liver regeneration after living-donor hepatectomy.

METHODS

Thirty-three donors participated in the study. Preoperative and postoperative liver volume was calculated using computed tomography. Volume assessment was repeated at 1 week, 2 weeks, 1 month, 3 months, 6 months, 12 months, and 4 years postoperatively.

RESULTS

Donors were divided into the right (n = 23; residual liver volume, 42%) and left (n = 10; residual liver volume, 63%) groups according to the operative procedures. The restoration ratio to the preoperative liver volume (right vs. left groups) were 51%, 57%, 64%, 74%, 77%, 81%, and 88% vs. 69%, 72%, 76%, 79%, 83%, 84%, and 91% at 1 week, 2 weeks, 1 month, 3 months, 6 months, 12 months, and 4 years, respectively; the interindividual variation in the restoration ratio to the preoperative liver volume became narrower with time.

CONCLUSION

Liver resection in humans resulted in rapid regeneration during the first 3 months, followed by a more moderate rate of regeneration thereafter, in proportion to the amount of liver mass resected. The volume of the regenerating liver appeared to converge towards the individual preoperative volume with time. However, the liver volume was not restored to the preoperative volume at 4 years after the resection.

Modification of right hepatectomy results in improvement outcome: a retrospective comparative study

OBJECTIVE

To evaluate any change in the operative and survival outcomes in patients undergoing a right hepatectomy after adoption of the no-clamp technique using a radiofrequency dissecting sealer (TissueLink™) in liver resection.

METHODS

In all, 58 consecutive patients who underwent a right hepatectomy from July 2003 to December 2007 (Group 1) were compared with 66 consecutive patients who underwent a right hepatectomy from January 1999 to June 2003 (Group 2). In group 1, a liver transection was performed with a cavitron ultrasonic surgical aspirator (CUSA) and TissueLink™ without hilar clamping whereas in group 2, a liver transection was performed with CUSA and diathermy with routine continuous hilar clamping.

RESULTS

For the operative outcomes, there was significantly less blood loss (median 450 vs. 900 ml, P < 0.001) in group 1. The complication rate was also significantly lower in group 1 (22.4% vs. 47.0%, P = 0.004). In subgroup analysis for patients with hepatocellular carcinoma (HCC), the overall survival rate was significantly better in group 1; 1-, 3- and 5-year survival rates were 78%, 72% and 57% in group 1 vs. 72%, 44% and 39% in group 2, respectively (P = 0.048).

CONCLUSIONS

When compared with the retrospective cohort, a right hepatectomy utilizing TissueLink™ without hilar clamping was feasible with potential benefits in surgical outcomes.

Uncontrolled organ donation following prehospital cardiac arrest: a potential solution to the shortage of organ donors in the United Kingdom?

Uncontrolled donation after cardiac death (DCD) could increase the donor pool in the UK. Air ambulance (AA) teams may be well placed to recruit these donors. They cover large geographical areas, have short transfer times and tasked predominantly to life-threatening cases. The potential to recruit from this pool of donors was reviewed. Seventy-five month activity of an AA unit was analysed identifying patients who entered prehospital cardiac arrest (PHCA). Patients over 70 years of age were excluded as were those whose cardiac arrest was unwitnessed. A minimum potential donor pool was estimated based upon patients dying of medical causes. Rates of bystander resuscitation, mechanism of death and patient demographic data were observed. During 10,022 missions 534 patients entered PHCA. A total of 106 patients met inclusion criteria. There were 12 paediatric cases; 39 cases of 17-50 year olds and 55 cases of 50-70 year olds. Medical and traumatic causes of death accounted for 60 and 46 cases respectively. Bystander resuscitation efforts were provided in 47% of cases. A regional AA could contribute to a national uncontrolled DCD programme. Given that there are 31 AA's in England and Wales, we estimate that there could be a minimum of 300 additional potential donors annually.

Portal inflow and pressure changes in right liver living donor liver transplantation including the middle hepatic vein

The middle hepatic vein may be included in right liver living donor liver transplantation (LDLT) to optimize hepatic venous outflow. We studied the graft's ability to relieve portal hypertension and accommodate portal hyperperfusion with portal manometry and ultrasonic flowmetry. Surgical outcomes with respect to portal hemodynamometry were also investigated. The ages of the recipients and donors for 46 consecutive LDLT procedures were 50 (range, 16-66 years) and 31 years (range, 18-54 years), respectively. The graft to standard liver volume ratio was 47.4% (range, 32.4%-69.0%). The hospital mortality rate was 4.4% as 2 recipients died from a subarachnoid hemorrhage and sepsis. The portal pressure dropped by 8 mm Hg (range, -7 to 19 mm Hg) from 23 (range, 8-37 mm Hg) to 14 mm Hg (range, 10-26 mm Hg) after graft implantation. The portal inflow positively correlated with the portal pressure before native liver hepatectomy (R(2) = 0.305, P = 0.001) and not with the graft size. The portal inflow increased from 81 mL/minute/100 g (range, 35-210 mL/minute/100 g) before donor right hepatectomy to 318 mL/minute/100 g (range, 102-754 mL/minute/100 g) after graft implantation. The graft portal inflow had a positive linear correlation with the recipient portal pressure before native liver total hepatectomy (R(2) = 0.261, P = 0.001) but not after graft implantation, and it had a negative correlation with the graft to standard liver volume ratio (R(2) = 0.247, P = 0.001). Only 1 of the graft biopsies showed moderate sinusoidal congestion. Twelve recipients had Clavien grade 2+ complications that were not related to the portal inflow and pressure or graft size. Right liver LDLT including the middle hepatic vein effectively lowered the recipient portal pressure by allowing unimpeded venous outflow.

Prospective evaluation of biliary reconstruction with duct-to-duct continuous suture in adult live donor liver transplantation

Purpose

Biliary reconstruction remains the Achilles’ heel of adult live donor liver transplantation (LDLT). The study aims to investigate the feasibility of duct-to-duct hepaticocholedochostomy in LDLT.

Methods

Perioperative data from 30 consecutive LDLT aiming at duct-to-duct reconstruction of the biliary tract using a continuous suture technique were prospectively collected. Nineteen recipients (63.3%) had one graft bile duct. Eleven recipients (36.7%) had two or three graft bile ducts. The median follow-up was 50 months.

Results

The overall biliary complication rate was 23.3%. Two recipients developed biliary stricture (6.7%), and two recipients (6.7%) presented with biliary leakage in early posttransplant phase (<90 days). One recipient suffered from bilioma (3.3%), and two recipients (6.7%) presented with biliary stricture in later posttransplant phase (>90 days). No correlation was found between the number of graft bile ducts and the incidence of biliary complications. No biliary complication-associated necessity for re-transplantation or mortality was observed. On multivariate analysis, no single risk factor associated with biliary complication could be identified. All biliary complications were successfully treated with Roux-en-hepaticojejunostomy and/or with endoscopic interventions.

Conclusion

Duct-to-duct hepaticocholedochostomy with continues suture represents a safe and feasible procedure for biliary reconstruction in LDLT. Recipients may benefit from aggressive management of biliary complications with Roux-en-hepaticojejunostomy as compared with repeated endoscopic interventions in early posttransplant phase.

Genomic and proteomic biomarkers for diagnosis and prognosis of hepatocellular carcinoma

Hepatocellular carcinoma is one of the most deadly liver malignancies found worldwide, with hepatitis virus infection being the prominent risk factor for this lesion. Patients with hepatocellular carcinoma are usually first diagnosed when in the advanced stage; thus, long-term clinical outcomes are poor and patients have limited treatment options. Currently, surveillance of hepatocellular carcinoma relies upon serological testing of alpha-fetoprotein levels and hepatic ultrasonography, which have low sensitivity and specificity, and are sometimes operator-dependent, respectively. Therefore, discovery of new biomarkers for early and accurate detection of hepatocellular carcinoma would be of great clinical value. Genomic and proteomic approaches are two major laboratory platforms for the identification of candidate hepatocellular carcinoma biomarkers based on profiling and validating with tumor and nontumor clinical samples. Frequently, these diagnostic markers have been found in association with genetic aberrations, protein-level alterations, post-translational modifications and immune functions. With the discovery of these biomarkers, earlier detection of hepatocellular carcinoma in high-risk subjects (e.g., cirrhosis and hepatitis carriers) becomes possible, which will enable clinicians to offer patients better clinical management and more effective treatment modalities.

Impact of preoperative serum sodium concentration in living donor liver transplantation

BACKGROUND AND AIMS

The importance of hyponatremia in deceased donor liver transplantation (DDLT) has been recently discussed frequently. However, its impact on the outcomes in living donor liver transplantation (LDLT) has not yet been elucidated. The current study was designed to demonstrate the impact of pre-transplant sodium concentration on postoperative clinical outcomes.

METHODS

One hundred and thirty-four patients who underwent LDLT for end-stage liver diseases were examined to evaluate the significance of pre-transplant hyponatremia (Na < or = 130 mEq/L) on the short-term clinical outcomes and the efficacy of the Model for End-Stage Liver Disease and serum sodium (MELD-Na) score using the sodium concentration and original MELD score.

RESULTS

The preoperative sodium and MELD score for all patients were 133.9 mEq/L (range: 109-142) and 16.2 (range: 6-38), respectively. According to a multivariate analysis, not only the MELD score (P = 0.030) but also the sodium concentration (P = 0.005) were found to be significant predictive factors for short-term graft survival. Preoperative hyponatremia was a significant risk factor for the occurrence of sepsis (P < 0.001), renal dysfunction (P < 0.001) and encephalopathy (P = 0.026). The MELD-Na score was 19.6 (range: 6-51) and the area under the receiver-operator curve of that (c-statistics: 0.867) was higher than MELD score and sodium concentration (c-statistics: 0.820 and 0.842, respectively).

CONCLUSION

Preoperative hyponatremia was a significant risk for postoperative complications and short-term graft loss. The addition of sodium concentration to MELD score might therefore be an effective predictor for post-transplant short-term mortality in LDLT.

Biliary complications in living liver donors

With the increasing use of living donor liver transplantation (LDLT), the morbidity and mortality of the donors have thus become inevitable problems associated with this procedure. The most common postoperative complications among donors for LDLT involve the biliary tract. The incidence of biliary complications in donors tends to be about 5% based on recent publications. Anatomical variations in the biliary tract, higher predonation alkaline phosphatase levels, and intraoperative blood transfusions are also risk factors for biliary complications in the donors after donation. Donors with biliary complications often show unspecific symptoms and most of the biliary complications can be normally treated by nonsurgical methods. Interventional procedures such as percutaneous placement of a peritoneal drain, percutaneous/endoscopic biliary drainage, and combinations of balloon dilatation and/or stenting are effective in the treatment of bile leakage and biliary stricture. A clear understanding of the biliary anatomy of each donor and refined surgical techniques will help to minimize risk of biliary complications for living liver donors.

Small-for-size liver graft injury--impact on tumor behavior

The success of liver transplantation has led to an ever-increasing demand for liver grafts. Since the first successful living donor liver transplantation, this surgical innovation has been well established in children and has significantly relieved the crisis of donor organ shortage for children. However, the extension of living donor liver transplantation to adult recipients is limited by the graft volume. The major concern of adult-to-adult living donor liver transplantation is the adequate graft that can be harvested from a living donor. Small-for-size graft injury is frequently observed. To develop novel effective treatments attenuating small-for-size liver graft injury during living donor liver transplantation, it is important to explore the precise mechanism of acute phase small-for-size graft damage. Recently, a number of clinical studies and animal experiments have been conducted to investigate the possible key issues on acute phase small-for-size liver graft injury, such as mechanical injury from shear stress, subsequent inflammatory responses, and imbalance of vasoregulatory factors. This review focuses on the mechanism of small-for-size liver graft injury based on the number of clinical and experimental studies. The latest research findings of the significance of acute phase liver graft injury on late phase tumor recurrence and metastasis are also addressed.

Flowmetry-based portal inflow manipulation for a small-for-size liver graft in a recipient with spontaneous splenorenal shunt

We report a case of living donor liver transplantation using a small-for-size graft (SFSG) with graft to estimated standard liver volume of only 28% in a recipient with spontaneous splenorenal shunt and demonstrate the value of intraoperative ultrasonic flowmetry. Despite an SFSG, the graft was underperfused. This was recognized by flowmetry and was rectified by ligation of the splenorenal shunt.

Liver transplantation

Liver transplantation has become a lifesaving procedure for patients who have chronic end-stage liver disease and acute liver failure. The satisfactory outcome of liver transplantation has led to insufficient supplies of deceased donor organs, particularly in East Asia. Hence, East Asian surgeons are concentrating on developing and performing living-donor liver transplantation (LDLT). This review article describes an update on the present status of liver transplantation, mainly in adults, and highlights some recent developments on indications for transplantation, patient selection, donor and recipient operation between LDLT and deceased-donor liver transplantation (DDLT), immunosuppression, and long-term management of liver transplant recipients. Currently, the same indication criteria that exist for DDLT are applied to LDLT, with technical refinements for LDLT. In highly experienced centers, LDLT for high-scoring (>30 points) Model of End-Stage Liver Disease (MELD) patients and acute-on-chronic liver-failure patients yields comparably good outcomes to DDLT, because timely liver transplantation with good-quality grafting is possible. With increasing numbers of liver transplantations and long-term survivors, specialized attention should be paid to complications that develop in the long term, such as chronic renal failure, hypertension, diabetes mellitus, dyslipidemia, obesity, bone or neurological complications, and development of de novo tumors, which are highly related to the immunosuppressive treatment.

The Clavien-Dindo classification of surgical complications: five-year experience

BACKGROUND AND AIMS

The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception.

MATERIAL AND METHODS

Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication.

RESULTS

We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test).

CONCLUSIONS

This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.

Liver transplantation: from Child to MELD

The widespread availability of transplantation in most major medical centers in the United States, together with a growing number of transplant candidates, has made it necessary for primary care providers, especially internal medicine and family practice physicians to be active in the clinical care of these patients before and after transplantation. This review provides an overview of the liver transplantation process, including indications, contraindications, time of referral to a transplant center, the current organ allocation system, and briefly touches on the expanding field of living donor liver transplantation.

Adult right-lobe living liver donors: quality of life, attitudes and predictors of donor outcomes

To refine selection criteria for adult living liver donors and improve donor quality of care, risk factors for poor postdonation health-related quality of life (HRQOL) must be identified. This cross-sectional study examined donors who underwent a right hepatectomy at the University of Toronto between 2000 and 2007 (n = 143), and investigated predictors of (1) physical and mental health postdonation, as well as (2) willingness to participate in the donor process again. Participants completed a standardized HRQOL measure (SF-36) and measures of the pre- and postdonation process. Donor scores on the SF-36 physical and mental health indices were equivalent to, or greater than, population norms. Greater predonation concerns, a psychiatric diagnosis and a graduate degree were associated with lower mental health postdonation whereas older donors reported better mental health. The majority of donors (80%) stated they would donate again but those who perceived that their recipient engaged in risky health behaviors were more hesitant. Prospective donors with risk factors for lower postdonation satisfaction and mental health may require more extensive predonation counseling and postdonation psychosocial follow-up. Risk factors identified in this study should be prospectively evaluated in future research.

Report of the Paris consensus meeting on expanded criteria donors in liver transplantation

Because of organ shortage and a constant imbalance between available organs and candidates for liver transplantation, expanded criteria donors are needed. Experience shows that there are wide variations in the definitions, selection criteria, and use of expanded criteria donors according to different geographic areas and different centers. Overall, selection criteria for donors have tended to be relaxed in recent years. Consensus recommendations are needed. This article reports the conclusions of a consensus meeting held in Paris in March 2007 with the contribution of experts from Europe, the United States, and Asia. Definitions of expanded criteria donors with respect to donor variables (including age, liver function tests, steatosis, infections, malignancies, and heart-beating versus non-heart-beating, among others) are proposed. It is emphasized that donor quality represents a continuum of risk rather than "good or bad." A distinction is made between donor factors that generate increased risk of graft failure and factors independent of graft function, such as transmissible infectious disease or donor-derived malignancy, that may preclude a good outcome. Updated data concerning the risks associated with different donor variables in different recipient populations are given. Recommendations on how to safely expand donor selection criteria are proposed.

Donor morbidity after living donation for liver transplantation

BACKGROUND & AIMS

Reports of complications among adult right hepatic lobe donors have been limited to single centers. The rate and severity of complications in living donors were investigated in the 9-center Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL).

METHODS

A retrospective observational study design was used. Participants included all potential living donors evaluated between 1998 and 2003. Complication severity was graded using the Clavien scoring system.

RESULTS

Of 405 donors accepted for donation, 393 underwent donation, and 12 procedures were aborted. There were 245 donors (62%) who did not experience complications; 82 (21%) had 1 complication, and 66 (17%) had 2 or more. Complications were scored as grade 1 (minor; n = 106, 27%), grade 2 (potentially life threatening; n = 103, 26%), grade 3 (life threatening; n = 8, 2%), and grade 4 (leading to death; n = 3, 0.8%). Common complications included biliary leaks beyond postoperative day 7 (n = 36, 9%), bacterial infections (n = 49, 12%), incisional hernia (n = 22, 6%), pleural effusion requiring intervention (n = 21, 5%), neuropraxia (n = 16, 4%), reexploration (n = 12, 3%), wound infections (n = 12, 3%), and intraabdominal abscess (n = 9, 2%). Two donors developed portal vein thrombosis, and 1 had inferior vena caval thrombosis. Fifty-one (13%) donors required hospital readmission, and 14 (4%) required 2 to 5 readmissions.

CONCLUSIONS

Adult living liver donation was associated with significant donor complications. Although most complications were of low-grade severity, a significant proportion were severe or life threatening. Quantification of complication risk may improve the informed consent process, perioperative planning, and donor care.

Nitric oxide reduces organ injury and enhances regeneration of reduced-size livers by increasing hepatic arterial flow

Background

Reduced-size livers suffer from portal hyperperfusion, diminished arterial blood flow and the risk of postoperative liver injury. The aim of this experimental study was to unravel the role of nitric oxide in this setting.

Methods

Rats underwent 85 per cent partial hepatectomy and either substitution of nitric oxide with molsidomine or inhibition of nitric oxide synthase (NOS) with NG-nitro-l-arginine methyl ester. Untreated hepatectomized animals served as controls and unresected animals as the sham group.

Results

Ultrasonic flowmetry following partial hepatectomy revealed a marked increase in portal venous inflow with a concomitant decrease in hepatic arterial inflow. Nitric oxide substitution counteracted the decline in hepatic arterial inflow and caused a significantly greater increase in cell proliferation after partial hepatectomy compared with control or NOS-inhibited animals. Hepatectomized animals further profited from nitric oxide substitution, as indicated by reduced aminotransferase release and improved liver function.

Conclusion

Nitric oxide improves the postoperative course of rats with reduced-size livers by modulating hepatic macrohaemodynamics and mediating regeneration and cytoprotection, but not by reducing hepatic hyperperfusion and the accompanying sinusoidal shear stress.

Historical perspective of living donor liver transplantation

Living donor liver transplantation (LDLT) has gone through its formative years and established as a legitimate treatment when a deceased donor liver graft is not timely or simply not available at all. Nevertheless, LDLT is characterized by its technical complexity and ethical controversy. These are the consequences of a single organ having to serve two subjects, the donor and the recipient, instantaneously. The transplant community has a common ground on assuring donor safety while achieving predictable recipient success. With this background, a reflection of the development of LDLT may be appropriate to direct future research and patient-care efforts on this life-saving treatment alternative.

Current indications and contraindications for liver transplantation

Survival rates after liver transplantation have improved steadily because of earlier referral and timely evaluation, judicious patient selection, improved surgical techniques, superior immunosuppressive regimens, and effective prevention of perioperative opportunistic infections. Indications and contraindications for liver transplantation are undergoing constant modifications with the goal of improving survival and functional status of patients who have end-stage liver disease or acute liver failure. Potential candidates for liver transplantation should meet minimal listing criteria and not have contraindications to liver transplantation. Currently, the Model for End-stage Liver Disease score is used for organ allocation, but it may have future application in patient-selection criteria.

Adult living donor liver transplantation: living donation of the right liver lobe

BACKGROUND

Adult living donor liver transplantation (LDLT) has become a routine treatment option for patients waiting for liver transplantation. In European and North American countries, LDLT for adult recipients is mainly performed with right lobe grafts. Indications, when compared to deceased donor liver transplantation, are controversial.

MATERIALS AND METHODS

In our institution, patients suffering from hepatocellular carcinoma in cirrhosis, non-resectable hilar cholangiocarcinoma, viral hepatitis associated cirrhosis, as well as cholestatic liver and biliary disease are considered good candidates for LDLT.

RESULTS

In this overview, donor evaluation, graft selection, and the donor operation with special regard to operative techniques and strategies are discussed. For visualization, a 5-min video sequence of the standard donor operation as performed in our institution is attached.

CONCLUSION

Given the ongoing shortage of donor organs, adult LDLT has become a routine treatment option for patients waiting for liver transplantation. The associated inevitable risk for the healthy donor, however, remains ethically controversial.

Liver surgery and transplantation in China: Progress and Challenges

From the limited but available information, we traced the history of developments of liver surgery and transplantation in China. Liver surgery first started in the late 1950s in China, and it soon flourished mainly because of the great demand in liver surgery and the emergence of a number of giants in liver surgery. We recognized and honoured the important contributions of these Chinese pioneers in portal hypertension, recurrent pyogenic cholangitis, hepatocellular carcinoma and liver transplantation.

Liver transplantation for hepatocellular carcinoma beyond the Milan criteria: the controversies continue

Liver transplantation has now become a favored option for patients with early-stage hepatocellular carcinoma (HCC) with or without impaired hepatic function as a complication of underlying cirrhosis. To overcome the persistent donor organ shortage, the use of adult-to-adult living donor liver transplantation (LDLT) has recently increased, especially in Asian countries. In the use of LDLT, several controversies remain including the safety of living donation and expanding the current Milan criteria. Most physicians agree that criteria for transplanting patients with HCC should be expanded beyond the Milan criteria because the Milan criteria miss a number of patients who may benefit from LDLT; however, the expanded criteria proposed were different (the size and number of HCCs and the biologic markers) from one center to the other. When we consider LDLT as a treatment option for patients with HCC, donor safety should be kept in mind first, and the wishes of both patient and donor should be weighed against the potential (if small) risk for the donor. In contrast to deceased donor liver transplantation, the benefit of LDLT is better appreciated in terms of gain in life expectancy than in terms of survival when the wishes of both patient and donor outweigh the donor risk. Further research on the predictors of benefit of LDLT to HCC patients other than the size and number of HCC such as molecular profiling of HCC are necessary to finally reach a consensus.