Living Related Liver Transplantation

Living Related Liver Transplantation （LRLT）is a new strategy, which offers the option of a lifesaving procedure to patients suffering from end - stage liver disease, and the experience indicates that the results are better than cadaveric liver transplantation. It promises to decrease the waiting time for liver transplantation significantly and to reduce the number of patients dying on the waiting list. The selection of a suitable donor and the techniques of operation are of paramount importance for LRLT to minimize the risk for the recipient and the donor, and achieve better outcome for patient. 1 -year recipient survival rate of LRLT is over 90% and 5 - year recipient survival rate of LRLT is about 80%. LRLT has been becoming standard and normal operation in many western transplant centers.     

Postoperative Liver Dysfunction and Future Remnant Liver: Where Is the Limit?

Background The future remnant liver (FRL) limit for safe major hepatectomy with low risk of postoperative liver failure has not yet been well defined. Methods Between April 2000 and September 2004, every patient scheduled for major hepatectomy in our institution underwent CT-volumetry of FRL. Patients with FRL <25% underwent portal vein embolization (PVE). Exclusion criteria were PVE, associated vascular resection and liver cirrhosis. The FRL was correlated with short-term results in patients with normal liver (group A) and those with impaired liver function secondary to neoadjuvant chemotherapy or cholestasis (bilirubin >2 mg/100 ml) (group B). Liver dysfunction was defined as both PT <50% and serum bilirubin level >5 mg/100 ml for three or more consecutive days. Results A total of 119 patients were analyzed, 72 in group A and 47 in group B. The FRL value was the only significant risk factor for postoperative liver dysfunction in the univariate and multivariate analysis (p = 0.009). The FRL did not correlate with postoperative mortality and morbidity. Bilirubin and prothrombin time (PT) on days 3 and 7 were significantly correlated to FRL in both groups. In group A, patients with postoperative liver dysfunction had a FRL<30% (3 versus 0; p = 0.005). According to receiving operator characteristic (ROC) curve analysis, a FRL value of 26.5% predicted postoperative liver dysfunction with 66.7% sensitivity, 97.1% specificity, 50% positive predictive value (PPV), and 98.5% negative predictive value (NPV). In group B, patients with postoperative liver dysfunction had a FRL <35% (4 versus 0; p = 0.027). According to ROC curve analysis, a FRL value of 31.05% predicted postoperative liver dysfunction with 75% sensitivity, 79.1% specificity, 25% PPV, and 97.1% NPV. Conclusions Hepatectomy can be considered safe when FRL is >26.5% in patients with healthy liver and >31% in patients with impaired liver function.     

Progression of Hepatocellular Carcinoma Before Liver Transplantation: Dropout or Liver Transplantation?

Background

Tumor progression before liver transplantation (OLT) is the main cause of dropout from the waiting list (WL) of patients with hepatocellular carcinoma (HCC). The aim of this study was to show a correlation between adopted dropout criteria and dropout/intention-to-treat survival rates of WL HCC patients.

Methods

The study period was 2000 to 2007. The dropout criteria were macroscopic vascular invasion, metastases, or a poorly differentiated tumor. Adult patients with benign chronic liver disease enlisted for primary OLT in the same period represented the control group.

Results

Dropout probability of study (n = 128) versus control group (n = 377) subjects was similar: namely, 12% at 1 year in both groups (P = NS). Intention-to-treat survival curve of the HCC group overlapped that of the benign group (5-year survival rates were 73% and 71%, respectively; P = NS). At the time of listing, 103 study group patients were within the Milan criteria (MC): among these patients, 29 (28%) showed tumor progression beyond MC before OLT. Simulating the dropout of these 29 patients at the time of diagnosis of tumor progression, we compared the dropout probability of the 103 patients within MC with that of the control group. As a result, the 1- and 2-year dropout rates became 37% and 53%, respectively, in the study group, which were significantly higher than those in the controls (P < .01).

Conclusion

HCC patients on the WL showed a significantly greater dropout rate than subjects with benign cirrhosis when too restrictive radiologic dropout criteria were used. The adoption of criteria more related to biological aggressiveness of a tumor decreased the dropout risk for HCC patients without impairing their intention-to-treat survival rates.     

“State of the Art” in Liver Resection and Living Donor Liver Transplantation: A Worldwide Survey of 100 Liver Centers

Background  New strategies have been developed to expand indications for liver surgery. The objective was to evaluate the current practice worldwide regarding critical liver mass and manipulation of the liver volume. Methods  A survey was sent to 133 liver centers worldwide, which focused on (a) critical liver volume, (b) preoperative manipulation of the liver mass, and (c) use of liver biopsy and metabolic tests. Results  The overall response rate to the survey was 75%. Half of the centers performed more than 100 resections per year; 86% had an associated liver transplant program. The minimal remnant liver volume for resection was 25% (15–40%) in cases of normal liver parenchyma and 50% (25–90%) in the presence of underlying cirrhosis. The minimal remnant liver volume for living donors was 40% (30–50%), whereas the accepted graft body weight ratio was 0.8 (0.6–1.2). Portal vein occlusion to manipulate the liver volume before resection was performed in 89% of the centers. Conclusions  Limits of liver volume and the current practice of liver manipulation before resection were comparable among different centers and continents. The minimal remnant liver volume in normal liver was 25%, and more than 80% of the centers performed portal vein occlusion. S. Breitenstein and C. Apestegui contributed equally to this work. Henrik Petrowsky is the recipient of the Novartis fellowship in Hepato-Pancreato-Biliary surgery and liver transplantation at the Swiss HPB Center at the University of Zurich.     

Liver surgery: what is feasible?

BACKGROUND: Bilobar hepatic metastases, a small residual liver volume, de-novo and recurrent lesions, simultaneous pulmonary metastases and infiltration of vascular structures are often limiting factors in the surgical treatment of primary and secondary liver tumors. Nevertheless surgery is the "gold standard" with the chance of long-term survival, not possible to achieve with locally ablation and chemotherapy. METHODS: The combination with neoadjuvant chemotherapy and radiofrequency ablation, extended liver resection after selective portal vein embolization, two-stage hepatectomy, resection and reconstruction of vascular structures in deep hypothermia and simultaneous resection of pulmonary metastases, increase the resectability even in patients with poor prognosis achieving 5-year-survival rates between 26-46 % in colorectal liver metastases, 40 % in primary liver tumors and a median survival of 42 months after resection of liver and lung metastases. CONCLUSION: Interdisciplinary treatment and aggressive surgical resection seem to be justified, when performed safely as a curative option.     

Can Patients Who Develop Cerebral Death in Fulminant Liver Failure Despite Liver Transplantation Be Previously Forseen?

Background

The outcome of medical treatment is worse in fulminant liver failure (FLF) developing on acute or chronic ground. Recently, liver transplantations with the use of living and cadaveric donors have been performed in these diseases and good results obtained. In this study, we aimed to present the factors affecting the recovery of cerebral functions after liver transplantation in hepatic encephalopathy (HE) developing in FLF, to identify irreversible patient groups and to prevent unnecessary liver transplantation.

Liver transplantation — State of the art

Background: It is 30 years since the first human liver transplantation (LT) took place in Denver, Colorado. Many advances have taken place since that date. This paper examines the current state of LT. Methods: The present indications and results of LT are reviewed, organ supply, organ preservation and technical innovations are discussed. Results: LT is now widely accepted as the only curative treatment for end stage liver disease. Indications are continuing to expand with increasing application in fulminant hepatic failure and inborn errors of metabolism. Results have improved steadily over the years with 80% one-year patient survival now being a realistic target. An adequate supply of donor organs will without doubt become an increasing problem in the coming years. Surgical innovation has seen the introduction of reduced size liver grafts for children, split liver grafts to allow the use of a single liver for 2 patients and even the use of living related liver grafts in selected cases. Conclusions: Many challenges still exist in the fields of immunosuppression and organ preservation but steady improvement and refinement of our techniques sill result in a continuing improvement in the coming years in terms of both patient and graft survival.     

Laparoscopic vs. Open Liver Resection for Hepatocellular Carcinoma of Cirrhotic Liver: A Case–Control Study

Background

Laparoscopic liver resection is considered a safe and feasible alternative to open surgery for malignant liver lesions. However, laparoscopic surgery in cirrhotic patients remains challenging. The aim of this retrospective case–control study was to compare morbidity, mortality, and long-term patient survival between laparoscopic liver resections (LLR) and open liver resections (OLR) for hepatocellular carcinoma (HCC) in patients with histologically proven cirrhosis.

Methods

A total of 45 patients treated with LLR were matched by cause of cirrhosis, Child-Pugh score, type of surgical resection (subsegmentectomy, segmentectomy, and bisegmentectomy), tumor number, tumor size, and alpha-fetoprotein value with 45 patients treated with OLR. Pre-, intra-, and post-operative variables were compared between groups.

Results

Compared with OLR, the LLR group displayed a significantly shorter operative time (140 vs. 180 min; p = 0.02), shorter hospital stay (7 vs. 12 days; p < 0.0001), and lower morbidity rate (20 vs. 45 % of patients; p = 0.01). A higher rate of R0 resection was observed in the LLR group than in the OLR group (95 vs. 85 %; p = 0.03). Postoperative ascites was more frequently observed in the OLR group (18 vs. 2 %; p = 0.01). Mortality, patient, and disease-free survival rates were similar between groups. The 1-, 5-, and 10-year survival rates were 88, 59, and 12 %, respectively, in the LLR group and 63, 44, and 22 % in the OLR group (p = 0.27).

Conclusions

Significantly shorter operative times, better resection margins, lower postoperative complications, and shorter hospital stay were observed in the LLR group compared with the OLR group. LLR and OLR have similar overall and disease-free survival rates in cirrhotic HCC patients.     

Is Liver Transplantation Without Abdominal Drainage Safe?

This observational, analytical cohort consisted of 35 consecutive liver transplant (OLT) patients with no intra-abdominal drain and a control cohort of 35 subjects operated immediately before the former who had placement of an intra-abdominal drain. We sought to assess the impact of abdominal drainage on the diagnosis and prevention of early postoperative complications: hemoperitoneum, reinterventions, biliary leaks, or percutaneous drainage. We assessed variables related to the recipient (age, indication, pretransplant ascites, body mass index, Model for End-Stage Liver Disease score and rejection), the donor (age, steatosis, ischemia time) and intra- and postoperative factors (surgery time, blood product use, and coagulopathy). The end point was defined as the need for a reintervention, paracentesis, appearance, and drainage of collections as well as lengths of hospital and intensive care unit (ICU) stays. The postoperative ICU and in-hospital stays were similar between groups (3.7 vs 3.9 days and 12 vs 14 days, respectively). Two patients in the group with drainage were reoperated due to hemoperitoneum, whereas we did not reoperate any patients in the group without drainage. No patient from either group developed a biliary fistula or required drainage of an intra-abdominal collections. The need for paracentesis was greater among the group without drainage (23% vs 5.7%; P < .04) and among those with a prior history of severe ascites. Patients with drainage displayed a greater incidence of perihepatic hematomas by ultrasound (53% vs 21%; P < .08) and required more postoperative blood products, especially platelets (P > .04) and plasma (P < .01).

Conclusion

OLT without intra-abdominal drainage is safe, not increasing morbidity. It seems likely that drainage may be responsible for intra-abdominal hematomas and greater consumption of blood products.     

Portal Hypertension: Contraindication to Liver Surgery?

Introduction In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients. Methods Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it. Results Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P < 0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P = 0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P = 0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P = 0.004; 77.8% vs. 57.6%, P = 0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P = 0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival. Conclusions Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.     

Primary Castleman’s Disease of the Liver

Journal of Gastrointestinal Surgery - Castleman's disease is a rare lymphoproliferative disorder that may affect the liver as part of mutlicentric disease or, rarely, as unicentric hepatic...     

Single HCC in Cirrhotic Patients: Liver Resection or Liver Transplantation? Long-term Outcome According to an Intention-to-treat Basis

Background

Compensated cirrhotic patients with single hepatocellular carcinoma (HCC) ≤5 cm may benefit from both liver resection (LR) and liver transplantation (LT); however, the better 10-year actuarial survival of the two treatments remains unclear. We aimed to assess the long-term outcome of cirrhotic patients with single HCC ≤5 cm treated either with LR or LT on an intention-to-treat basis.

Methods

A total of 217 cirrhotic patients with single HCC ≤5 cm were evaluated at our department: 95 were treated with LR (LR group), and 122 were included on the waiting list for LT (LT group). Patients in the LR group were divided into very early HCC (tumor size ≤2 cm) and early HCC (tumor size >2 cm). Median follow-up was 5.3 (range 0.1–18) years.

Results

Tumor recurrence was 72 % in the LR group versus 16 % in the LT group (p < 0.001). 1-, 5-, and 10-year cumulative risk of recurrence was 18, 69, and 83 % in the LR group versus 4, 18, and 20 % in the LT group (p < 0.001). Ten-year actuarial survival was 33 % in the LR group versus 49 % in the LT group (p = 0.002). At HCC recurrence, 27.3 % were included on the waiting list for salvage transplantation (very early HCC group) versus 15.1 % (early HCC group) (p = 0.2). After salvage transplantation, HCC recurrence was 0 % (very early HCC group) versus 40 % (early HCC group) (p = 0.2). No significant differences were observed in 1-, 5-, and 10-year actuarial survival between the very early HCC group and the LT group (95, 55, and 50 % vs. 82, 62, and 50 %).

Conclusions

LR should be the treatment of choice for cirrhotic patients with very early HCC.     

Living Donor and Deceased Donor Liver Transplantation for Autoimmune and Cholestatic Liver Diseases—An Analysis of the UNOS Database

Introduction

Autoimmune hepatitis and cholestatic liver diseases have more favorable outcomes after liver transplantation as compared to viral hepatitis and alcoholic liver diseases. However, there are only few reports comparing outcomes of both living donor liver transplants (LDLT) and deceased donor liver transplants (DDLT) for these conditions.

Aim

We aim to study the survival outcomes of patients undergoing LT for autoimmune and cholestatic diseases and to identify possible risk factors influencing survival. Survival outcomes for LDLT vs. DDLT are also to be compared for these diseases.

Patients and Methods

A retrospective analysis of the UNOS database for patients transplanted between February 2002 until October 2006 for AIH, PSC, and PBC was performed. Survival outcomes for LDLT and DDLT patients were analyzed and factors influencing survival were identified.

Results

Among all recipients the estimated patient survival at 1, 3, and 5 years for LDLT was 95.5%, 93.6%,and 92.5% and for DDLT was 90.9%, 86.5%, and 84.9%, respectively (p?=?0.002). The estimated graft survival at 1, 3, and 5 years for LDLT was 87.9%, 85.4%, and 84.3% and for DDLT 85.9%, 80.3%, and 78.6%, respectively (p?=?0.123). On multivariate proportional hazard regression analysis after adjusting for age and MELD score, the effect of donor type was not found to be significant.

Conclusion

The overall survival outcomes of LDLT were similar to DDLT in our patients with autoimmune and cholestatic liver diseases. It appears from our study that after adjusting for age and MELD score donor type does not significantly affect the outcome.