The distribution of robotic surgery in general and visceral surgery departments in Switzerland - a nationwide inquiry.

Objectives: Since its introduction as a clinical technique, robotic surgery has been extended to different fields of surgery. However, the indications as well as the number of robotic procedures varied in different institutions. The aim of this investigation was to evaluate the current use of robotic surgery in general and digestive surgery in Switzerland. Methods: All Swiss surgical departments that are recognized training institutes for postgraduate training in surgery by the Swiss Institute of Medical Education (SIWF) were queried with a detailed questionnaire regarding the use of robotic surgery techniques and were analyzed regarding hospital size and type of hospital. Results: Ninety-three departments were queried, and 67 % (n=63) answered the survey. Fifty-eight were public, and five were private institutions. Seventeen (26 %) of the queried departments used robotic surgery in digestive surgery. Four out of 17 (23 %) of the departments that performed robotic surgery were private hospitals, while 13 (77 %) were public institutions. In the majority of departments, robotic surgery of the rectum (n=12; 70.6 %) and colon (n=11; 64.7 %) was performed, followed by hernia procedures (n=8; 47.1 %) and fundoplication (n=7; 41.2 %). Less frequently, pancreatic resections (n=5; 29.4 %), cholecystectomy (n=4; 23.5 %), adrenalectomy (n=4; 23.5 %), gastric bypass (n=3; 17.7 %), gastric sleeve (n=3; 17.7 %), hepatic procedures (n=2; 11.7 %), or small bowel resections (n=1; 5.9 %) were performed as robotic procedures. More than 25 procedures per year per department were performed for hernia surgery (n=5 departments), gastric bypass (n=2 departments), cholecystectomy, fundoplication, and colon surgery (each n=1 department). Conclusions: The number and range of robotic procedures performed in Switzerland varied widely. Higher accreditation for general surgery or subspecialization of visceral surgery of the department was positively associated with the use of robotic techniques, reflecting an unequal availability of robotic surgery.

Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis.

BACKGROUND: Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting. METHODS: This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed. RESULTS: In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2). CONCLUSIONS: Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.

Functional integration of natural killer cells in a microfluidically perfused liver on-a-chip model.

OBJECTIVE: The liver acts as an innate immunity-dominant organ and natural killer (NK) cells, are the main lymphocyte population in the human liver. NK cells are in close interaction with other immune cells, acting as the first line of defense against pathogens, infections, and injury. A previously developed, three-dimensional, perfused liver-on-a-chip comprised of human cells was used to integrate NK cells, representing pivotal immune cells during liver injury and regeneration. The objective of this study was to integrate functional NK cells in an in vitro model of the human liver and assess utilization of the model for NK cell-dependent studies of liver inflammation. RESULTS: NK cells from human blood and liver specimen were isolated by Percoll separation with subsequent magnetic cell separation (MACS), yielding highly purified blood and liver derived NK cells. After stimulation with toll-like-receptor (TLR) agonists (lipopolysaccharides, Pam3CSK4), isolated NK cells showed increased interferon (IFN)-gamma secretion. To study the role of NK cells in a complex hepatic environment, these cells were integrated in the vascular compartment of a microfluidically supported liver-on-a-chip model in close interaction with endothelial and resident macrophages. Successful, functional integration of NK cells was verified by immunofluorescence staining (NKp46), flow cytometry analysis and TLR agonist-dependent secretion of interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha. Lastly, we observed that inflammatory activation of NK cells in the liver-on-a-chip led to a loss of vascular barrier integrity. Overall, our data shows the first successful, functional integration of NK cells in a liver-on-a-chip model that can be utilized to investigate NK cell-dependent effects on liver inflammation in vitro.

Pneumatosis intestinalis with portal, mesenteric and renal gas due to colonic pseudo-obstruction.

Objectives: Pneumatosis intestinalis is a rare condition with subserosal or submucosal gas-filled cysts of the gastrointestinal tract. It is often associated with acute mesenteric ischemia, but also non-ischemic causes are described. Case presentation: A 27-year-old male patient with severe congenital spastic tetraparesis presented to the emergency room with fever and reduced general condition. The patient was hypotonic and tachycardic, had a fever up to 39.7 °C and reduced peripheral oxygen saturation. The laboratory analyses revealed leukocytosis (16.7 G/L) and elevated CRP (162 mg/L).The patient was admitted to the intensive care unit (ICU) for invasive ventilator treatment because of global respiratory insufficiency and antibiotic therapy due to acute pneumonia and severe acute respiratory distress syndrome (ARDS). In addition, he suffered from colonic pseudo-obstruction but with persistent stool passage. After pulmonary recovery, he was transferred to the normal ward of internal medicine, but signs of colonic pseudo-obstruction were still present.Under therapy with diatrizoic acid and neostigmine, the abdomen was less distended, and the patient had regular bowel movements. After four days, the patient developed sudden acute abdominal pain and suffered sudden pulseless electrical activity. Immediate cardiopulmonary resuscitation was provided. After the return of spontaneous circulation, the patient underwent computed tomography (CT) and was re-admitted to the ICU. The CT scan showed massive dilatation of the colon, including pneumatosis coli, extensive gas formation within the mesenteric veins and arteries, including massive portal gas in the liver, the splenic vein, the renal veins, and disruption of abdominal aortic perfusion. The patient was then first presented for surgical evaluation, but due to futile prognosis, treatment was ceased on the ICU. Conclusions: In conclusion, colonic pseudo-obstruction might have led to colonic necrosis and consecutive massive gas formation within the mesenteric vessels. Therefore, intestinal passage should be restored as soon as possible to avoid possible mortality.

Impact of the first COVID-19 shutdown on traumatological patient volumes in Switzerland.

Background: The coronavirus has caused a worldwide pandemic with serious impacts on our healthcare systems. Many countries experienced a decline in traumatological patient volume. The aim of this study is to evaluate the impact of the first lockdown on traumatological patient volume in Switzerland. Methods: We retrospectively used a prospective national quality measurement database. We compared the period of the first lockdown in Switzerland from March 17 to April 26, 2020 to the same period in the years 2018 and 2019. Included were all adult patients with any S-code (trauma) according to the International Classification of Diseases. Results: In total, we assessed 3874 patients (1779 in the year 2018, 1303 in the year 2019, and 792 in the year 2020) with a mean age of 61 ± 21 years. The patients during the lockdown period had significantly more injuries to the hip and forearm, had more comorbidities, and were more likely to have statutory insurance. During the lockdown period, more thromboembolism prophylaxis or anticoagulation was applied, and more patients needed antibiotic treatment. Conclusions: The present study demonstrated a 40-55% reduction in patient volume during the lockdown period in Switzerland compared to the previous years. The in-hospital mortality and complication rate during the lockdown period remained stable. This study suggests that in-hospital care for trauma patients in Switzerland was not substantially affected by the first lockdown.

The rate of cholangiocarcinoma in Caroli Disease A German multicenter study.

BACKGROUND: Caroli Disease (CD) and Caroli Syndrome (CS) are rare disorders presenting with dilation of the intrahepatic bile ducts. CD/CS are associated with cholangiocarcinoma (CCA). However, the true incidence of CCA is still unclear, although it may serve as an indication for surgery. In this paper, we analyzed (I) the incidence of CCA in German centers, (II) reviewed our single center population together with its clinical presentation and (III) performed a thorough literature review. METHODS: 17 large HPB-centers across Germany were contacted and their patients after surgical treatment due to CD/CS with histopathology were included. Medline search for all studies published in English or German literature was performed. Patients who underwent surgery at our department between 2012 and 2020 due to CD or CS were analyzed. RESULTS: In the multicenter study, 79 patients suffered from CD and 119 patients from CS, with a total number of 198 patients. In 14 patients, CCA was found (Overall: 7,1%; CD: 6,3%, CS 7,6%). Between 2012 and 2020, 1661 liver resections were performed at our department. 14 patients underwent surgery due to CD or CS. Histological examination showed synchronous cholangiocarcinoma in one patient. The literature review revealed a CCA-rate of 7,3% in large series, whereas in case reports a rate of 6,8% was found. CONCLUSION: There is risk of malignant transformation and patients with CD might also benefit from resection due to improvement of symptoms. Therefore, resection is strongly advised. As certain patients with CS require transplantation, treatment should not be guided by the relatively low rate of CCA but by the concomitant diseases that come along with hepatic failure.

Synergistic effect of the TLR5 agonist CBLB502 and its downstream effector IL-22 against liver injury.

The toll-like receptor 5 (TLR5) agonist, CBLB502/Entolimod, is a peptide derived from bacterial flagellin and has been shown to protect against radiation-induced tissue damage in animal models. Here we investigated the protective mechanism of CBLB502 in the liver using models of ischemia-reperfusion injury and concanavalin A (ConA) induced immuno-hepatitis. We report that pretreatment of mice with CBLB502 provoked a concomitant activation of NF-κB and STAT3 signaling in the liver and reduced hepatic damage in both models. To understand the underlying mechanism, we screened for cytokines in the serum of CBLB502 treated animals and detected high levels of IL-22. There was no transcriptional upregulation of IL-22 in the liver, rather it was found in extrahepatic tissues, mainly the colon, mesenteric lymph nodes (MLN), and spleen. RNA-seq analysis on isolated hepatocytes demonstrated that the concomitant activation of NF-κB signaling by CBLB502 and STAT3 signaling by IL-22 produced a synergistic cytoprotective transcriptional signature. In IL-22 knockout mice, the loss of IL-22 resulted in a decrease of hepatic STAT3 activation, a reduction in the cytoprotective signature, and a loss of hepatoprotection following ischemia-reperfusion-induced liver injury. Taken together, these findings suggest that CBLB502 protects the liver by increasing hepatocyte resistance to acute liver injury through the cooperation of TLR5-NF-κB and IL-22-STAT3 signaling pathways.

COVID-19 lock-down significantly reduced number of surgical presentations in an emergency department.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an acute virus infection, which was declared by the World Health Organization (WHO) as a pandemic. As a consequence, the Swiss government decreed a public lock-down to reduce and restrict further infections. The aim of this investigation was to provide the impact of the COVID-19 lock-down on the presentations of patients in an interdisciplinary emergency department (ED). PATIENTS, MATERIAL AND METHODS: A retrospective study was performed at an interdisciplinary Swiss ED during the lock-down period. All patients who presented to the ED were enrolled in this investigation and compared to a control cohort during the same time period in 2019. Data regarding patients' characteristics, medical specialty, time course of presentations during the observation period, outpatient or hospital admission were analyzed. RESULTS: In total 7072 patients were included in the final analysis. During the lock-down period the number of ED presentations significantly decreased by 29% in comparison to the control period in the previous year (p < 0.0001). The analysis of the time course revealed that in each week the number of patients was lower with 13-43% reduction. Irrespective of the medical specialty, the number of presentations decreased during the COVID-19 situation, whereas this decrease was higher in surgical diseases (31%, p < 0.0001) than in non-surgical presentations (3.6%, p = 0.4). CONCLUSION: The socioeconomic lock-down was associated with reduced number of presentations in an ED. Mainly, surgical diseases and injuries were affected in terms of a reduction of presentations during the COVID-19 lock-down period.

Risk of malignancy in Caroli disease and syndrome: A systematic review.

BACKGROUND: Congenital intrahepatic bile duct dilatation without fibrosis is called Caroli disease (CD), and is called Caroli syndrome (CS) when it has fibrotic and cirrhotic liver morphology. The development of intrahepatic carcinoma is described in both conditions, but the reported incidence varies extensively. Potential risk factors for the malignant transformation were not described. Furthermore, conservative or surgical treatment is performed depending on the extent of cystic malformation, hepatic dysfunction and structural hepatic changes, but little is known about which treatment should be offered to patients with CD or CS and cancer. AIM: To further investigate the malignant transformation in these conditions. METHODS: A systematic review of the current literature until January 2019 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A search using Medline (PubMed) was performed using a combination of Medical Subject Headings terms "caroli disease", "caroli syndrome", "tumor", "malignant", and "cholangiocarcinoma". Only human studies published in English were used for this systematic review. The following parameters were extracted from each article: year of publication, type of study, number of patients, incidence of malignant tumor, duration of symptoms, age, sex, diagnostics, identification of tumor, surgical therapy, survival and tumor recurrence. RESULTS: Twelve retrospective studies reporting the courses of 561 patients (53% females) were included in this systematic review. With a mean age of 41.6 years old (range 23 to 56 years old), patients were younger than other populations undergoing liver surgery. Depending on the size of the study population the incidence of cholangiocarcinoma varied from 2.7% to 37.5% with an overall incidence of 6.6%. There were only few detailed reports about preoperative diagnostic work-up, but a multimodal work-up including ultrasound of the liver, computed tomography, magnetic resonance imaging and endoscopic retrograde cholangiopancreatography was used in most studies. Disease duration was variable with up to several years. Most patients had episodes of cholangitis, sepsis, fever or abdominal pain. Tumor detection was an incidental finding of the surgical specimen in most cases because it is currently often impossible to detect tumor manifestation during preoperative diagnostics. Liver resection or liver transplantation was performed depending on the extent of the biliary pathology and additional alterations of the liver structure or function. No postoperative adjuvant chemotherapy was reported, but chemotherapy was administered in selected cases of tumor recurrence. Overall survival rates after one year were low at 36% and a high recurrence rate of up to 75% during the observation period. CONCLUSION: Only few retrospective studies reported a low tumor incidence. Despite the high rate of mortality and tumor recurrence, definite surgical treatment should be offered as soon as possible.

[Acute appendicitis - recent controversies in diagnostic and therapy]. / Akute Appendizitis ­ Aktuelle Kontroversen in der Diagnostik und Therapie.

Acute appendicitis - recent controversies in diagnostic and therapy Abstract. Acute appendicitis is one of the most frequent surgically treated gastrointestinal diseases. For most of the patients it is supposed to be easily diagnosed and treated, but there are cases with complex diagnosis and indistinct treatment. For correct diagnosis an elaborated patients' history and clinical examination by an experienced surgeon is necessary. In many countries, patients undergo additional extensive radiological diagnostics beside of ultrasound. This fact leads to an unjustified risk of x-ray exposure and increased costs in the health care system. In contrast, delay during diagnosis and treatment and consecutive complications are often the trigger for legal dispute and the accusation of malpractice of the responsible surgeon. In addition, the treatment of acute appendicitis has undergone changes towards a non-surgical therapy, so that the routinely performed urgent appendectomy has been displaced by conservative therapy using antibiotics, percutaneous drainage, and interval surgery after a certain time in a non-inflammatory state. So far, no distinct guideline is available, as profound prospective and randomized results and subgroup analysis are still missing. In this article these problems and controversies are enlightened. Particularly, legal aspects and potential conflicts between family doctors, surgeons, relatives, and patients are discussed. Finally, nothing is easy to diagnose or treat, even potentially simple diseases as acute appendicitis is considered to be.

Robotic hepatic surgery in malignancy: review of the current literature.

The use of minimally invasive liver surgery, such as laparoscopic and robotic surgery, is increasing worldwide. Robot-assisted laparoscopy is a new surgical technique that improves surgical handling. The advantage of this technique is improved dexterity, which leads to increased surgical precision and no tremor or fatigue. Comparable oncological results were documented for laparoscopic and open surgery. Currently, "conventional" laparoscopic liver surgery has limitations with respect to the treatment of lesions in the posterior-superior segments, and there are limited technical features for the reconstruction steps. These limitations might be overcome with the use of robotic surgery. The use of robotic surgery for hepatic procedures originated because of the technical potential to overcome several of the major technical limitations known from conventional laparoscopy and the possibility of performing more extended liver resections. Additionally, there is increasing evidence indicating that robotic hepatic surgery is feasible and safe in resections of the posterior segments. Studies showed that using the robotic technique is associated with a decreased or at least equal amount of intraoperative blood loss compared to that of the conventional laparoscopic or open technique. There is increasing evidence that robotic liver surgery might be as safe as conventional laparoscopic procedures in cancer cases in terms of resection margins, disease-free and overall survival. Furthermore, robotic surgery might be more favorable with respect to postoperative patient recovery. Despite promising results, still large, multicenter, randomized and prospective studies are needed to analyze the exact value of robotic liver surgery in patients with malignant liver tumors.

Liver Transplant for Perihilar Cholangiocarcinoma (Klatskin Tumor): The Essential Role of Patient Selection.

OBJECTIVES: Perihilar cholangiocarcinoma (Klatskin tumor) is a rare tumor entity, which is diagnosed late due to uncharacteristic symptoms. The therapeutic strategy for cure is still liver resection. Liver transplant in cases of locally irresectable tumors represents an alternative potential curative therapy for a select group of patients. MATERIALS AND METHODS: We present our data of 22 patients with irresectable Klatskin tumors who received transplants between 1996 and 2015. We analyzed relevant prognostic factors for the selection of patients to be transplanted to ensure an acceptable overall survival and reviewed known and established selection criteria. RESULTS: Four factors (age, tumor size, serum level of carbohydrate antigen 19-9, percutaneous transhepatic cholangiodrainage) could be detected for possible patient selection. Positive lymph node status and advanced tumor stage according to the Union for International Cancer Control were confirmed as negative prognostic factors for survival after transplant. CONCLUSIONS: Liver transplant is a curative therapy for selected patients with irresectable Klatskin tumors, but further prospective studies are urgently needed.

Posttraumatic venous gas in the liver - a case report and review of the current literature.

BACKGROUND: There are numerous causes of hepatic gas formation that range from serious pathologies to incidental findings, including mesenteric infarction, liver abscess, inflammatory bowel disease or minimally invasive hepatic interventions. CASE PRESENTATION: We report a case of a 50-year-old man who was admitted to the emergency room after a car accident. The clinical examination and further diagnostics revealed a craniocerebral injury with a fracture of the skull, concomitant soft tissue lesions and subarachnoidal bleeding. Furthermore, a blunt thoracic trauma with hemopneumothorax due to rib fractures was treated with a chest tube. No obvious abdominal pathology was seen. While in the operating theatre for the surgical revision of the cranial soft tissue lesions, a femoral venous catheter was inserted without any complications. A routine ultrasound of the abdomen six hours after the trauma revealed unclear hepatic gas formation. A contrast-enhanced computer tomography (CT) scan of the abdomen was performed, and the gas formation was found to be localized within the left hepatic vein. Afterwards, there was no specific treatment of the hepatic venous gas formation, as no alterations of liver function or liver enzymes were seen. The further course of the patient was uneventful regarding the gas formation in the liver, and another ultrasound two days later revealed no further gas in the liver. CONCLUSIONS: The placement of a femoral venous catheter is a risk factor for gas formation in liver veins. No further treatment is needed in cases with stable liver function. To rule out serious pathologies, diagnostic findings (e.g., ultrasound, CT), clinical history and underlying diseases need to be analyzed carefully after the detection of intrahepatic gas formation. With contrast-enhanced CT, the localization of the gas and its potential causes might be detectable.

Short-term treatment with taurolidine is associated with liver injury.

BACKGROUND: Taurolidine has been used for peritonitis, oncological and catheter-lock treatment because of its anti-inflammatory properties. It has been suggested that taurolidine has no severe side-effects, but after long-term use morphological and functional changes of the liver were reported. The aim of this study was to investigate the effect of short-term use of taurolidine on the liver. METHODS: In HepaRG cell cultures and on a novel liver biochip dose-dependent effects of taurolidine treatment on hepatocyte adherence and cell viability was investigated. Furthermore, liver enzymes and interleukin- (IL-) 6 were measured in supernatants. Male rats were treated with low- or high-dose taurolidine, respectively, and compared to controls with physiological saline solution administration regarding blood serum parameters and histology. RESULTS: In HepaRG cell cultures, hepatocyte adherence was significantly decreased, cell death and cleaved caspase-3 were significantly increased after administration of taurolidine in a dose-dependent manner. High-dose application of taurolidine led to elevated liver enzymes and IL-6 secretion in hepatic organoid. After 24 h a significant increase of serum GLDH and ASAT was observed in rats treated with high-dose taurolidine treatment. CONCLUSIONS: Our results suggest that taurolidine caused liver injury after short-term use in in vitro and in vivo models probably due to direct toxic effects on hepatocytes. Therefore, the taurolidine dose should be titrated in further investigations regarding liver injury and inflammation.

Experiences with surgically treated primary or secondary hepatic sarcoma.

PURPOSE: Liver resection in hepatic sarcoma is rare, but other alternative treatment options are scarce. Surgery offers the only aggressive approach to achieve a tumour-free state. The aim of this investigation was to evaluate the outcome and survival of these patients at a single hepato-biliary university hospital. METHODS: Between January 2004 and July 2013, 896 anatomical liver resections were performed. Eleven liver resections (1.2%) were performed due to primary hepatic sarcoma or hepatic sarcoma metastases. The demographic and clinical parameters were collected from the institutional patients' records. RESULTS: In eight patients (83%), liver resection was performed due to hepatic sarcoma metastases. The surgical procedures were as follows: two patients (18%) had segmentectomy, six patients (55%) had hemihepatectomy or extended hemihepatectomy and three patients (27%) had multivisceral resections. In nine patients (82%), the resection margins were tumour free. In 55% (n = 6) of the patients, the maximal tumour diameter was greater than 10 cm. The postoperative morbidity was low with a Clavien-Dindo score of 2 (range 0-5). One patient died on postoperative day 2 after multivisceral resection. During the follow-up of 932 days (range 2-2.220 days) the 1-, 2- and 3-year survival rates were 91, 63 and 45%, respectively. Tumour recurrence was detected in seven patients (63%). CONCLUSIONS: Liver resections in patients with primary or secondary hepatic sarcoma are rare. The main goal in these patients is to achieve complete tumour resection because chemotherapy offers no suitable alternative, but the long-term survival rates are limited because of high a recurrence rate even after aggressive surgical approaches.

Treatment options for spontaneous and postoperative sclerosing mesenteritis.

Sclerosing mesenteritis is a rare pathology with only a few described cases in the literature. The etiology is unclear; however, several potential triggers, including abdominal surgery and abdominal trauma, have been discussed. The pathology includes a benign acute or chronic inflammatory process affecting the adipose tissue of the mesenterium. Despite it being a rare disease, sclerosing mesenteritis is an important differential diagnosis in patients after abdominal surgery or patients presenting spontaneously with signs of acute inflammation and abdominal pain. We present here three cases with sclerosing mesenteritis. In two cases, sclerosing mesenteritis occurred postoperatively after abdominal surgery. One patient was treated because of abdominal pain and specific radiological signs revealing spontaneous manifestation of sclerosing mesenteritis. So far there are no distinct treatment algorithms, so the patients were treated differently, including steroids, antibiotics and watchful waiting. In addition, we reviewed the current literature on treatment options for this rare disease.

Role of NK, NKT cells and macrophages in liver transplantation.

Liver transplantation has become the treatment of choice for acute or chronic liver disease. Because the liver acts as an innate immunity-dominant organ, there are immunological differences between the liver and other organs. The specific features of hepatic natural killer (NK), NKT and Kupffer cells and their role in the mechanism of liver transplant rejection, tolerance and hepatic ischemia-reperfusion injury are discussed in this review.

Liver transplantation for hepatocellular carcinoma - factors influencing outcome and disease-free survival.

Hepatocellular carcinoma is one of the leading causes of cancer-related death worldwide. Liver transplantation can be a curative treatment in selected patients. However, there are several factors that influence disease-free survival after transplantation. This review addresses the pre-, intra- and postoperative factors that influence the risk of tumor recurrence after liver transplantation.