Prospective study on the outcome of patients with hepatocellular carcinoma registered for living donor liver transplantation: how long can they wait? Transplantation. 2010;89:650-654. [PMID: 20048691 DOI: 10.1097/TP.0b013e3181cd4ae9]

Biliary complications in 108 consecutive recipients with duct-to-duct biliary reconstruction in living-donor liver transplantation

BACKGROUND

Biliary complications remain the leading cause of postoperative complications after living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy. The aim of this study was to analyze the causes of these complications.

METHODS

One hundred eight patients who underwent LDLT with duct-to-duct biliary reconstruction at Mie University Hospital were enrolled in this study. The mean follow-up time was 58.4 months (range, 3-132). The most recent 18 donors underwent indocyanine green (ICG) fluorescence cholangiography for donor hepatectomy. The development of biliary complications was retrospectively analyzed. Biliary complications were defined as needing endoscopic or radiologic treatment.

RESULTS

Biliary leakages and strictures occurred in 6 (5.6%) and 15 (13.9%) of the recipients, respectively, and 3 donors (2.7%) experienced biliary leakage. However, since the introduction of ICG fluorescence cholangiography, we have not encountered any biliary complications in either donors or recipients. Biliary leakage was an independent risk factor for the development of biliary stricture (P = .013). Twelve (80%) of the 15 recipients with biliary stricture had successful nonoperative endoscopic or radiologic management, and 3 patients underwent surgical repair with hepaticojejunosotomy.

CONCLUSIONS

Biliary leakage was an independent factor for biliary stricture. ICG fluorescence cholangiography might be helpful to reduce biliary complications after LDLT in both donors and recipients.

Evaluating the validity of model for end-stage liver disease exception points for hepatocellular carcinoma patients with multiple nodules <2 cm

Liver transplant allocation policy does not give model for end-stage liver disease (MELD) exception points for patients with a single hepatocellular carcinoma (HCC) <2 cm in size, but does give points to patients with multiple small nodules. Because standard-of-care imaging for HCC struggles to differentiate HCC from other nodules, it is possible that a subset of patients receiving liver transplant for multiple nodules <2 cm in size does not have HCC. We evaluate risk of post-transplant HCC recurrence and wait-list dropout for patients with multiple small nodules using competing risks regression based on the Fine and Gray model. We identified 5002 adult HCC patients in the OPTN/UNOS dataset diagnosed and transplanted between January 2006 and September 2010. Compared to patients with >1 tumor <2 cm, risk of developing recurrence was significantly higher in patients with one or more tumors with only one tumor ≥2 cm (SHR 1.63, p = 0.009), as well as in patients with 2-3 tumors ≥2 cm (SHR 1.84, p = 0.02). Dropout risk was not significantly different among size categories. HCC recurrence risk was significantly lower in patients with multiple nodules <2 cm in size than in those with larger tumors, supporting the possibility that some patients received unnecessary transplants. The priority given to these patients must be re-examined.

Living-donor or deceased-donor liver transplantation for hepatic carcinoma: A case-matched comparison

AIM: To compare the surgical outcomes between living-donor and deceased-donor liver transplantation in patients with hepatic carcinoma.

METHODS: From January 2007 to December 2010, 257 patients with pathologically confirmed hepatic carcinoma met the eligibility criteria of the study. Forty patients who underwent living-donor liver transplantation (LDLT) constituted the LDLT group, and deceased-donor liver transplantation (DDLT) was performed in 217 patients. Patients in the LDLT group were randomly matched (1:2) to patients who underwent DDLT using a multivariate case-matched method, so 40 patients in the LDLT group and 80 patients in the DDLT group were enrolled into the study. We compared the two groups in terms of clinicopathological characteristics, postoperative complications, long-term cumulative survival and relapse-free survival outcomes. The modified Clavien-Dindo classification system of surgical complications was used to evaluate the severity of perioperative complications. Furthermore, we determined the difference in the overall biliary complication rates in the perioperative and follow-up periods between the LDLT and DDLT groups.

RESULTS: The clinicopathological characteristics of the enrolled patients were comparable between the two groups. The duration of operation was significantly longer (553 min vs 445 min, P < 0.001) in the LDLT group than in the DDLT group. Estimated blood loss (1188 mL vs 1035 mL, P = 0.055) and the proportion of patients with intraoperative transfusion (60.0% vs 43.8%, P = 0.093) were slightly but not significantly greater in the LDLT group. In contrast to DDLT, LDLT was associated with a lower rate of perioperative grade II complications (45.0% vs 65.0%, P = 0.036) but a higher risk of overall biliary complications (27.5% vs 7.5%, P = 0.003). Nonetheless, 21 patients (52.5%) in the LDLT group and 46 patients (57.5%) in the DDLT group experienced perioperative complications, and overall perioperative complication rates were similar between the two groups (P = 0.603). No significant difference was observed in 5-year overall survival (74.1% vs 66.6%, P = 0.372) or relapse-free survival (72.9% vs 70.9%, P = 0.749) between the LDLT and DDLT groups.

CONCLUSION: Although biliary complications were more common in the LDLT group, this group did not show any inferiority in long-term overall survival or relapse-free survival compared with DDLT.

Outcomes of living donor liver transplantation using elderly donors

Purpose

Living donor liver transplantation (LDLT) using elderly donors is increasing in frequency in response to organ shortage. However, elderly donor graft has been reported to negatively affect graft patency and patient survival.

Methods

We retrospectively reviewed the medical records of 604 patients who underwent LDLT at Seoul St. Mary's Hospital, The Catholic University of Korea between May 1999 and September 2012. Elderly donors were defined as those ≥55 years of age. Here, we evaluate the survival differences and causes of death of recipients of elderly donor grafts.

Results

The overall mortality rate of the recipients was significantly higher in the elderly donor group (group A) than in the younger donor group (group B: 46.2% vs. 18.1%, P = 0.004). The survival length of group A was significantly shorter than that of group B (31.2 ± 31.3 and 51.4 ± 40.8 months, P = 0.014). The significantly common causes of death in group A were biliary (41.7%) and arterial complication (16.7%), and it was higher than those in group B (P = 0.000 and P = 0.043, respectively).

Conclusion

LDLT using elderly donors could induce more serious complications and higher mortality rates than those at using younger donors. As such, careful donor selection is needed, especially with regard to assessing the condition of potential elderly donor livers. Furthermore, a large-volume and multicenter study of complications and outcomes of LDLT using elderly donor liver is required.

Long-term outcomes after resection versus transplantation for hepatocellular carcinoma within UCSF criteria

PURPOSE

We compared the long-term outcomes of resection and transplantation for hepatocellular carcinoma (HCC) while satisfying the University of California at San Francisco criteria.

METHODS

HCC patients who underwent liver resection (n = 746) and transplantation (n = 54) between 2001 and 2007 were reviewed. Overall and disease-free survival rates were evaluated using the Kaplan-Meier estimator, and independent prognostic factors were determined using the Cox proportional regression model. The presence of cirrhosis was used to divide the patients into groups. The patients who received primary transplantation were further analyzed.

RESULTS

Nine years after surgery, the patients' overall survival was similar in the resection and transplantation groups (75.9 and 77.2%, respectively). Furthermore, the recurrence rate in the resection group was higher than that in the transplantation group (65 vs. 34.4%; adjusted hazard ratio, 3.27; range, 1.76-6.08), especially for cirrhosis patients (adjusted hazard ratio, 4.28; range, 2.14-8.56). The results suggested that noncirrhotic patients who underwent resection had a better survival advantage than primary liver transplant recipients did (adjusted hazard ratio, 0.46; range, 0.18-1.21). However, noncirrhotic patients had higher recurrence rates (59.2 vs. 15.8%; adjusted hazard ratio, 3.98; range, 1.26-12.58). Similar trends were noted in patients with hepatitis B virus infection and/or a single tumor.

CONCLUSIONS

Long-term survival rates after liver transplantation and resection were similar, but the latter was associated with a higher recurrence rate.