Comparable Short- and Long-term Outcomes in Living Donor and Deceased Donor Liver Transplantations for Patients With Model for End-stage Liver Disease Scores ≥35 in a Hepatitis-B Endemic Area.

OBJECTIVE: To evaluate if living donor liver transplantation (LDLT) should be offered to patients with Model for End-stage Liver Disease (MELD) scores ≥35. BACKGROUND: No data was available to support LDLT of such patients. METHODS: Data of 672 consecutive adult liver transplant recipients from 2005 to 2014 at our center were reviewed. Patients with MELD scores ≥35 were divided into the deceased donor liver transplantation (DDLT) group and the LDLT group and were compared. Univariate analysis was performed to identify risk factors affecting survival. RESULTS: The LDLT group (n = 54) had younger (33 yrs vs 50 yrs, P < 0.001) and lighter (56 Kg vs 65 Kg, P = 0.004) donors, lighter grafts (627.5 g vs 1252.5 g, P < 0.001), lower graft-weight-to-recipient-standard-liver-volume rates (51.28% vs 99.76%, P < 0.001), shorter cold ischemic time (106.5 min vs 389 min, P < 0.001), and longer operation time (681.5 min vs 534 min, P < 0.001). The groups were comparable in postoperative complication, hospital mortality, and graft survival and patient survival at one year (88.9% vs 92.5%; 88.9% vs 94.7%), three years (87.0% vs 86.9%; 87.0% vs 88.8%), and five years (84.8% vs 81.8%; 84.8% vs 83.3%). Univariate analysis did not show inferior survival in LDLT recipients. CONCLUSIONS: At centers with experience, the outcomes of LDLT can be comparable with those of DDLT even in patients with MELD scores ≥35. When donor risks and recipient benefits are fully considered and balanced, an MELD score ≥35 should not be a contraindication to LDLT. In Hong Kong, where most waitlisted patients have acute-on-chronic liver failure from hepatitis B, LDLT is a wise alternative to DDLT.

Excellent outcomes of liver transplantation using severely steatotic grafts from brain-dead donors.

Liver grafts with macrovesicular steatosis of > 60% are considered unsuitable for deceased donor liver transplantation (DDLT) because of the unacceptably high risk of primary nonfunction (PNF) and graft loss. This study reports our experience in using such grafts from brain-dead donors. Prospectively collected data of DDLT recipient outcomes from 1991 to 2013 were retrospectively analyzed. Macrovesicular steatosis > 60% at postperfusion graft biopsy was defined as severe steatosis. In total, 373 patients underwent DDLT. Nineteen patients received severely steatotic grafts (ie, macrovesicular steatosis > 60%), and 354 patients had grafts with ≤ 60% steatosis (control group). Baseline demographics were comparable except that recipient age was older in the severe steatosis group (51 versus 55 years; P = 0.03). Median Model for End-Stage Liver Disease (MELD) score was 20 in the severe steatosis group and 22 in the control group. Cold ischemia time (CIT) was 384 minutes in the severe steatosis group and 397.5 minutes in the control group (P = 0.66). The 2 groups were similar in duration of stay in the hospital and in the intensive care unit. Risk of early allograft dysfunction (0/19 [0%] versus 1/354 [0.3%]; P>0.99) and 30-day mortality (0/19 [0%] versus 11/354 [3.1%]; P = 0.93) were also similar between groups. No patient developed PNF. The 1-year and 3-year overall survival rates in the severe steatosis group were both 94.7%. The corresponding rates in the control group were 91.8% and 85.8% (P = 0.55). The use of severely steatotic liver grafts from low-risk donors was safe, and excellent outcomes were achieved; however, these grafts should be used with caution, especially in patients with high MELD score. Keeping a short CIT was crucial for the successful use of such grafts in liver transplantation.

Outcomes of endo-radiological approach to management of bile leakage after right lobe living donor liver transplantation.

BACKGROUND AND AIM: Bile leakage is a major complication after right lobe living donor liver transplantation (RLDLT). It can result in significant morbidities and, occasionally, mortalities. Endo-radiology is a non-surgical means that has been used to manage this complication. This study reviews the outcomes of the endo-radiological approach to the management of bile leakage after RLDLT with duct-to-duct anastomosis (DDA) at a high-volume center. METHOD: A retrospective study was conducted on all adult patients who received RLDLT at our center between January 2001 and December 2013. There were 496 RLDLTs performed during the study period. Only patients who had DDA as the only bile duct reconstruction method were included in the study. RESULTS: Twelve (3.7%) out of the 328 study subjects developed bile leakage after RLDLT. Six out of these 12 patients were successfully treated with the endo-radiological approach without the need for laparotomy. They had endoscopic retrograde cholangiography with stenting followed by percutaneous drainage of biloma. One of the 12 patients died from recurrence of hepatocellular carcinoma 37 months after transplantation. The remaining 11 patients are all alive. CONCLUSION: The endo-radiological approach should be the first-line management for bile leakage for selected patients with DDA as the bile duct reconstruction method.

Radiofrequency ablation versus transarterial chemoembolization for unresectable solitary hepatocellular carcinomas sized 5-8 cm.

OBJECTIVES: This retrospective review was conducted to compare the efficacy of radiofrequency ablation (RFA) with that of transarterial chemoembolization (TACE) in treating large (5-8 cm) unresectable solitary hepatocellular carcinomas (HCCs). METHODS: Patients with large unresectable solitary HCCs primarily treated by RFA or TACE were reviewed. The primary endpoint was overall survival. Secondary endpoints were tumour response, time to disease progression, and treatment-related morbidity and mortality. RESULTS: There were 15 patients in the RFA group. Of these, 12 achieved complete ablation, one had ablation site recurrence, and five developed complications. Median disease-free survival in this group was 13.0 months (range: 2.8-38.0 months). The TACE group included 26 patients, of whom four obtained a partial response, none achieved a complete response, and five developed complications. The median time to disease progression in this group was 8.0 months (range: 1.0-68.0 months). There were no hospital deaths in this series. Median survival was 39.8 months in the RFA group and 19.8 months in the TACE group (P = 0.257). Rates of 1-, 2- and 5-year survival were 93.3%, 86.2% and 20.9%, respectively, in the RFA group and 73.1%, 40.6% and 18.3%, respectively, in the TACE group. CONCLUSIONS: Both RFA and TACE are feasible treatments for large unresectable solitary HCCs. Both modes show comparable rates of complications and longterm survival, but RFA achieves better initial tumour control and results in better short-term survival.

A retrospective study on risk factors associated with failed endoscopic treatment of biliary anastomotic stricture after right-lobe living donor liver transplantation with duct-to-duct anastomosis.

OBJECTIVE: This aim of this study is to determine the risk factors in failed endoscopic retrograde cholangiography (ERC). BACKGROUND: Endoscopic treatment is considered the first-line intervention for biliary anastomotic stricture (BAS) after right-lobe living donor liver transplantation with duct-to-duct anastomosis. METHODS: A retrospective study was performed on 287 patients who received right-lobe living donor liver transplantation with duct-to-duct anastomosis. The morphology of BAS was defined according to the shape of the distal side of duct-to-duct anastomosis shown on cholangiogram and was categorized into 3 types: pouched, intermediately pouched, and triangular. All cases of ERC were performed by operating surgeons. RESULTS: Fifty-nine patients (20.6%) had BAS and received ERC and balloon dilatation with or without stenting. The success rate was 73.2%. The median number of sessions needed for successful ERC was 3. In the 15 patients with failed ERC, 4 were successfully treated with percutaneous transhepatic biliary drainage and balloon dilatation and 11 underwent conversion hepaticojejunostomy (6 had external percutaneous transhepatic biliary drainage as a temporizing measure). On multivariate analysis, recipient age [odds ratio (OR): 0.922; 95% confidence interval (CI): 0.85-1.00; P = 0.049], operation time (OR: 1.007; 95% CI: 1.001-1.013; P = 0.025), and morphology of stricture (OR: 6.722; 95% CI: 1.31-34.48; P = 0.022) were independent risk factors associated with failed ERC. The success rates for the 3 types of BAS-pouched, intermediately pouched, and triangular-were 42.9%, 63.6%, and 88.9%, respectively (P = 0.021). Association was found between bile leak and pouched BAS (P = 0.008). CONCLUSIONS: ERC is highly effective in treating BAS. A success rate of 73%, the highest ever reported, has been achieved. Morphology of stricture is associated with outcome of ERC. Radiological or surgical intervention should be considered for patients with pouched BAS after endoscopic treatment fails for the first time.

Pilot study of high-intensity focused ultrasound ablation as a bridging therapy for hepatocellular carcinoma patients wait-listed for liver transplantation.

The objective of this study was to investigate the outcomes of high-intensity focused ultrasound (HIFU) ablation as a bridging therapy for patients with hepatocellular carcinoma (HCC) who had been wait-listed for deceased donor liver transplantation (DDLT). Adult patients with unresectable and unablatable HCCs within the University of California San Francisco criteria who had been wait-listed for DDLT were screened for their suitability for HIFU ablation as a bridging therapy if they were not suitable for transarterial chemoembolization (TACE). Treatment outcomes for patients receiving HIFU ablation, TACE, and best medical treatment (BMT) were compared. Fifty-one patients were included in the analysis. Before the introduction of HIFU ablation, only 39.2% of the patients had received bridging therapy (TACE only, n = 20). With HIFU ablation in use, the rate increased dramatically to 80.4% (TACE + HIFU, n = 41). The overall dropout rate was 51% (n = 26). Patients in the BMT group had a significantly higher dropout rate (P = 0.03) and significantly poorer liver function as reflected by higher Model for End-Stage Liver Disease scores and higher Child-Pugh grading. Clinically relevant ascites was found in 5 patients in the HIFU group and 2 patients in the BMT group, but none was found in the TACE group (P = 0.01 and P = 0.03, respectively). The TACE and HIFU groups had comparable percentages of tumor necrosis in excised livers (P = 0.35), and both were significantly higher than that in the BMT group (P = 0.01 and P = 0.02, respectively). In conclusion, HIFU ablation was safe even for HCC patients with Child-Pugh C disease. Its adoption increased the percentage of patients receiving bridging therapy from 39.2% to 80.4%. A randomized controlled trial for further validation of its efficacy is warranted.

Low-volume deceased donor liver transplantation alongside a strong living donor liver transplantation service.

BACKGROUND: At our center, living donor liver transplantation (LDLT) is the main workload supported by a strong, mature service. Deceased donor liver transplantation (DDLT) is performed but in small volume. This study aimed to review the results of a low-volume DDLT service alongside a strong LDLT service. METHODS: Consecutive DDLTs for adults performed from 1991 to 2009 were reviewed. The 1st to the 50th DDLTs were categorized as Era I cases, and the rest were Era II cases. The outcomes of the DDLTs were analyzed and compared with those achieved overseas. RESULTS: Eras I and II consisted of 59 and 183 DDLTs, respectively. All donors were brain-dead and heart-beating with a median age of 49 years (range 7-76 years). Among the 242 DDLTS, 30.2 % were on a high-urgency basis and 15.3 % were for hepatocellular carcinoma. The patients had a median model for end-stage liver disease score of 21 (range 6-40), and most (67.8 %) were hepatitis B virus carriers. Before transplantation, 16.1 % of the patients were in the intensive care unit and 30.2 % were in the hospital. The hospital mortality rate dropped from 13.6 % (8/59) during Era I to 3.8 % (7/183) during Era II (p = 0.012). For Era I, the 1-, 3-, and 5-year survival rates were 84.7, 79.7, and 76.3 %, respectively, which improved to 92.9, 89.0 and 87.2 % for Era II (p = 0.026). CONCLUSIONS: The recipient survival of this series compares favorably with contemporary series. It is shown that a low-volume DDLT service alongside a strong LDLT service can have excellent results.

Samaritan donor interchange in living donor liver transplantation.

BACKGROUND: In order to overcome ABO blood group incompatibility, paired donor interchange has been practised in living donor liver transplantation. Liver transplantations using grafts donated by Samaritan living donors have been performed in Europe, North America, South Korea, and Hong Kong. Such practice is clearly on strong biological grounds although social and psychological implications could be far-reaching. Local experience has been satisfactory but is still limited. As few centers have this arrangement, its safety and viability are still being assessed under a clinical trial setting. METHODS: Here we report a donor interchange involving an ABO-compatible pair with a universal donor and an ABO-incompatible pair with a universal recipient. This matching was not only a variation but also an extension of the donor interchange scheme. RESULTS: The four operations (two donor hepatectomies and two recipient operations) were successful. All the two donors and the two recipients recovered well. Such donor interchange further supports the altruistic principle of organ donation in contrast to exchange for a gain. CONCLUSIONS: Samaritan donor interchange certainly taxes further the ethical challenge of donor interchange. Although this practice has obvious biological advantages, such advantages have to be weighed against the potential increase in potential psychological risks to the subjects in the interchange. Further ethical and clinical evaluations of local and overseas experiences of donor interchange should guide future clinical practice in utilizing this potential organ source for transplantation.

Good longterm survival after primary living donor liver transplantation for solitary hepatocellular carcinomas up to 8 cm in diameter.

OBJECTIVES: There is controversy over whether hepatocellular carcinoma (HCC) should be primarily treated with living donor liver transplantation (LDLT) if liver resection (LR) can be effective. This retrospective study was conducted to compare survival outcomes in patients treated with either modality for solitary HCC measuring ≤8 cm in diameter. METHODS: Outcomes in patients with solitary HCC primarily treated by LDLT were analysed. Patients with solitary HCC of similar sizes with or without microvascular invasion primarily treated with LR were selected at a ratio of 6 : 1 for comparison. RESULTS: In-hospital mortality amounted to 0% and 1.3% in the LDLT (n = 50) and LR (n = 300) groups, respectively (P = 0.918). Complication rates were 34% and 20% in the LDLT and LR groups, respectively (P = 0.027). Rates of 1-, 3-, 5- and 10-year overall survival were 98%, 94%, 89% and 83%, respectively, in the LDLT group and 95%, 85%, 76% and 56%, respectively, in the LR group (P = 0.013). Rates of 1-, 3-, 5- and 10-year disease-free survival were 96%, 90%, 87% and 81%, respectively, in the LDLT group and 81%, 64%, 57% and 40%, respectively, in the LR group (P < 0.0001). CONCLUSIONS: Living donor liver transplantation surpassed LR in survival outcomes, achieving a 10-year overall survival rate 1.5 times as high and a 10-year disease-free survival rate twice as high as those facilitated by LR. However, it entailed more complications, in addition to the inevitable risks to the donor.

Outcomes of side-to-side conversion hepaticojejunostomy for biliary anastomotic stricture after right-liver living donor liver transplantation.

BACKGROUND: Conversion hepaticojejunostomy is considered the salvage intervention for biliary anastomotic stricture, a common complication of right-liver living donor liver transplantation with duct-to-duct anastomosis, after failed endoscopic treatment. The aim of this study is to compare the outcomes of side-to-side hepaticojejunostomy with those of end-to-side hepaticojejunostomy. METHODS: Prospectively collected data of 402 adult patients who had undergone right-liver living donor liver transplantation with duct-to-duct anastomosis were reviewed. Diagnosis of biliary anastomotic stricture was made based on clinical, biochemical, histological and radiological results. Endoscopic treatment was the first-line treatment of biliary anastomotic stricture. RESULTS: Interventional radiological or endoscopic treatment failed to correct the biliary anastomotic stricture in 13 patients, so they underwent conversion hepaticojejunostomy. Ten of them received end-to-side hepaticojejunostomy and three received side-to-side hepaticojejunostomy. In the end-to-side group, two patients sustained hepatic artery injury requiring repeated microvascular anastomosis, two developed re-stenosis requiring further percutaneous transhepatic biliary drainage and balloon dilatation, and two required revision hepaticojejunostomy. In the side-to-side group, one patient developed re-stenosis requiring further endoscopic retrograde cholangiography and balloon dilatation. No re-operation was needed in this group. Otherwise, outcomes in the two groups were similar in terms of liver function and graft survival. CONCLUSIONS: Despite the similar outcomes, side-to-side hepaticojejunostomy may be a better option for bile duct reconstruction after failed interventional radiological or endoscopic treatment because it can decrease the chance of hepatic artery injury and allows future endoscopic treatment if re-stricture develops. However, more large-scale studies are warranted to validate the results.

Retrohepatic vena cava deroofing in living donor liver transplantation for caudate hepatocellular carcinoma.

The removal of tumor together with the native liver in living donor liver transplantation for hepatocellular carcinoma is challenged by a very close resection margin if the tumor abuts the inferior vena cava. This is in contrast to typical deceased donor liver transplantation where the entire retrohepatic inferior vena cava is included in total hepatectomy. Here we report a case of deroofing the retrohepatic vena cava in living donor liver transplantation for caudate hepatocellular carcinoma. In order to ensure clear resection margins, the anterior portion of the inferior vena cava was included. The right liver graft was inset into a Dacron vascular graft on the back table and the composite graft was then implanted to the recipient inferior vena cava. Using this technique, we observed the no-touch technique in tumor removal, hence minimizing the chance of positive resection margin as well as the chance of shedding of tumor cells during manipulation in operation.

Outcomes of living donor liver transplantation for patients with preoperative type 1 hepatorenal syndrome and acute hepatic decompensation.

This study investigated the outcomes of living donor liver transplantation (LDLT) for patients with preoperative type 1 hepatorenal syndrome (HRS) and acute hepatic decompensation. Prospectively collected data for 104 patients who had fulminant hepatic failure, acute decompensation of cirrhosis, or an acute flare of chronic hepatitis B were analyzed. Thirty-three patients (31.7%) had HRS (the HRS group), and 71 patients (68.3%) did not (the non-HRS group). The median follow-up period was 60 months. The HRS group had significantly more preoperative intensive care unit (ICU) admissions (84.8% versus 60.6%, P = 0.01), worse preoperative blood test results (creatinine, 248 versus 88 µmol/L, P < 0.001; total bilirubin, 630 versus 555 µmol/L, P = 0.001), more hemodialysis (48.5% versus 0%, P < 0.001), more blood transfusions (9 versus 4 U, P < 0.001), longer postoperative ICU stays (8 versus 4 days, P < 0.001), worse postoperative blood test results (creatinine at 1 year, 108 versus 96 µmol/L, P = 0.006), and poorer overall survival (P < 0.001). In a multivariate analysis, only HRS was associated with poorer overall survival (hazard ratio = 8.592, 95% confidence interval = 1.782-41.431, P = 0.007). In conclusion, HRS patients had worse postoperative renal function and overall survival than non-HRS patients. However, their 5-year overall survival rate was still nearly 80%, which is satisfactory. Therefore, LDLT can be considered for patients who have acute hepatic decompensation with or without HRS.

Increasing the recipient benefit/donor risk ratio by lowering the graft size requirement for living donor liver transplantation.

In living donor liver transplantation (LDLT), a right liver graft is larger than a left liver graft and hence leads to better recipient survival. However, in comparison with donor left hepatectomy, donor right hepatectomy carries a higher donor risk. We estimated the expansion of the applicability of left liver living donor liver transplantation (LLDLT) by lowering the graft weight (GW)/standard liver volume (SLV) ratio in increments of 5%. Consecutive LDLT cases were included in this study. The results of computed tomography volumetry provided the graft volume measurements, and the GW was derived from the graft volume with the conversion factor of 1.19 mL/g. We tried to estimate how many more times LLDLT would have been feasible if the GW/SLV requirement had been lowered to 40%, 35%, 30%, or 25%. In all, 361 consecutive donor-recipient pairs underwent LDLT. Right liver living donor liver transplantation (RLDLT) accounted for 95% of the LDLT cases. Most recipients were male (74.2%), and most donors were female (60.4%). The median GW/SLV ratio was 46% (47% for RLDLT and 37% for LLDLT, P < 0.001). Two of the 218 female donors donated the left liver, and 12 of the 93 female recipients received a left liver. In 147 of the 173 cases (85%) when the donor was female and the recipient was male, the GW/SLV ratio did not reach 30%. LLDLT could have been performed more often than 5% of the time if a lower GW/SLV requirement had been adopted. With GW/SLV ratios ≥ 40%, ≥ 35%, ≥ 30%, and ≥ 25%, the proportion of LLDLT cases would have risen from 5% to 5.8%, 12.5%, 29.1%, and 62.3%, respectively. LLDLT could have been performed approximately twice as often with every 5% reduction of the GW/SLV requirement. In conclusion, lowering the graft size requirement could improve the applicability of LLDLT and hence reduce donor risk.

Radiological prognosticators of hepatocellular carcinoma treated by hepatectomy.

BACKGROUND: Hepatectomy is the main curative treatment for hepatocellular carcinoma (HCC), but postoperative long-term survival is poor. Preoperative radiological features of HCC displayed by computed tomography or magnetic resonance imaging could serve as additional prognostic factors. This study aimed to identify preoperative radiological features of HCC that may be of prognostic significance in hepatectomy. METHODS: Ninety-two patients who underwent hepatectomy for HCC were included in this study. Preoperative radiological features including tumor number, size, location (peripheral, middle, central), portal vein invasion, hepatic vein invasion, and presence of pseudo-capsule were analyzed in relation to survival. RESULTS: With a median follow-up period of 41.7 months, the 1-, 3- and 5-year overall survival rates were 85%, 65% and 58%, respectively. Univariate analysis showed that portal vein invasion and absence of pseudo-capsule were significant prognostic factors for overall survival, while all the examined radiological features were prognostic factors for disease-free survival. Multivariate analysis for overall survival found no significant factor. On multivariate analysis for disease-free survival, patients who had tumors with portal vein invasion had poorer survival with a hazard ratio of 2.26 (95% CI, 1.05-4.91; P=0.038) and patients with single nodular HCC or pseudo-capsulated HCC had better survival with a hazard ratio of 0.50 (95% CI, 0.27-0.94; P=0.032) and 0.38 (95% CI, 0.14-0.99; P=0.048), respectively. CONCLUSIONS: Demonstrable pseudo-capsule of HCC and solitary HCC on imaging and absence of portal vein invasion are features associated with better disease-free survival after hepatectomy. These features may guide treatment planning for HCC.

High-intensity focused ultrasound ablation as a bridging therapy for hepatocellular carcinoma patients awaiting liver transplantation.

The scarcity of liver grafts in Asia leads to a significant dropout of patients from liver transplant waiting lists, particularly patients with hepatocellular carcinoma and a low model for end-stage liver disease score. In order to reduce dropping out, different bridging therapies are employed. We report the use of high-intensity focused ultrasound ablation as a bridging therapy for a patient with hepatocellular carcinoma of stage two and an extremely low platelet count (20X109/L). The ablation was successful. Blood tests showed that his liver function was similar before and after the treatment. No adhesion was encountered in the liver transplantation performed six months later.

Modulation of graft vascular inflow guided by flowmetry and manometry in liver transplantation.

BACKGROUND: Survival of the partial graft after living donor liver transplantation owes much to its tremendous regenerative ability. With excellent venous outflow capacity, a graft within a wide range of graft-to-standard-liver-volume ratios can cope with portal hypertension that is common in liver transplant recipients. However, when the ratio range is exceeded, modulation of graft vascular inflow becomes necessary for graft survival. The interplay between graft-to-standard-liver-volume ratio and portal pressure, in the presence of portosystemic shunt or otherwise, requires individualized modulation of graft portal and arterial inflows. Boosting of portal inflow by shunt ligation can be guided by transonic flowmetry, whereas muting of portal inflow by splenic artery ligation can be monitored by portal electronic manometry. METHOD: We describe four cases to illustrate the above. RESULTS: One patient had hepatic artery thrombosis resulting from splenic artery steal syndrome which was the sequela of small-for-size syndrome. Emergency splenic artery ligation and re-anastomosis of the hepatic artery successfully muted the portal inflow and boosted the hepatic arterial inflow. Another patient with portal vein thrombosis underwent thrombendvenectomy. Portal inflow was boosted with ligation of portosystemic shunt, which is often present in these patients with portal hypertension. The coexistence of splenic aneurysm and splenorenal shunt required ligation of both in the third patient. The fourth patient, with portal pressure and flow monitoring, avoided ligation of a coronary vein which became a main portal inflow after portal thrombendvenectomy. CONCLUSION: Management of graft inflow modulation guided selectively by transonic flowmetry or portal manometry was described.

New insights after the first 1000 liver transplantations at The University of Hong Kong.

BACKGROUND/OBJECTIVE: One thousand liver transplantations have been performed at the only liver transplant center in Hong Kong over a period of 22 years, which covered the formative period of living donor liver transplantation. These 1000 transplantations, which marked the journey of liver transplantation from development to maturation at the center, should be educational. This research was to study the experience and to reflect on the importance of technical innovations and case selection. METHODS: The first 1000 liver transplantations were studied. Key technical innovations and surgical therapeutics were described. Recipient survival including hospital mortality was analyzed. Recipient survival comparison was made for deceased donor liver transplantation and living donor liver transplantation indicated by hepatocellular carcinoma and other diseases. RESULTS: Among the 1000 transplantations, 418 used deceased donor grafts and 582 used living donor grafts. With the accumulation of experience, hospital mortality improved to < 2% in the past 2 years. In the treatment of diseases other than hepatocellular carcinoma, living donor liver transplantation was superior to deceased donor liver transplantation, with a 10-year recipient survival around 90%. CONCLUSION: Transplant outcomes have been improving consistently over the series, with a very low hospital mortality and a predictably high long-term survival.

Transplantation of a 2-year-old deceased-donor liver to a 61-year-old male recipient.

The suitable size of a graft is a key element in the success of liver transplantation. A small-for-size liver graft is very likely to sustain a significant degree of injury as a result of ischemia, preservation, reperfusion, and rejection. Usually, small-for-size grafts are a concern in living-donor liver transplantation rather than in deceased-donor liver transplantation. Here, we describe the successful transplantation of a liver from a 2-year-old deceased donor to a 61-year-old male recipient who suffered from liver failure related to hepatitis B. No report of successful deceased-donor liver transplantation with discrepancies between donor and recipient age and size to such an extent has been found in the literature. Despite unusually large discrepancies, with effort in minimizing the ischemic time, revised surgical techniques, and strong regenerative power of the "young" graft, the old patient's liver function gradually returned to normal. This again proves that the definition of a "suitable graft" evolves with time and experience.

Perpetuating proficiency in donor right hepatectomy for living donor liver transplantation.

BACKGROUND/OBJECTIVE: Donor right hepatectomy (DRH) was developed by master liver surgeons and has been applied in many liver transplant centers as the mainstay for adult living donor liver transplantation. It is a major and complex surgical operation performed on living liver donors for the benefit of liver recipients. The donors deserve the lowest though inevitable morbidity and mortality. In this study, the surgical outcomes of DRH performed by newer surgeons at an established center were studied to assess the transferability of the techniques of this standardized procedure. METHODS: We studied 450 consecutive DRHs performed by 11 surgeons. Three surgeons initiated and developed the transplant program and performed the first 200 DRHs (Era I). The role of chief surgeon in the following 250 DRHs (Era II) was gradually taken up by four newer surgeons with close guidance initially. RESULTS: Blood loss and operation time at the end of Era I versus the beginning of Era II were 251 vs. 341 mL and 391 vs. 497 minutes. The learning curve effect in Era I did not occur in Era II. The complication rates of the last 50 cases in Era I and Era II were 16% and 24%, respectively. Era I had one donor death whereas Era II had no donor death. CONCLUSION: At an established center, DRH can be carried out safely by newer surgeons with good outcomes.

Retransplantation using living-donor right-liver grafts.

BACKGROUND: This study reviews the outcomes of retransplantation using living-donor right-liver grafts. METHODS: A retrospective study of liver retransplants performed between 1996 and 2013 was conducted. The retransplants were divided into the DD group (with deceased donors) and the LD group (with living donors). Survival outcomes were analyzed. RESULTS: The DD group contained 23 patients and 27 retransplants using whole-liver grafts and the LD group contained 11 patients and 11 retransplants using right-liver grafts. Vascular and biliary complications were the main indications for retransplantation in both groups. The LD group had significantly younger donors, lighter grafts, shorter cold ischemia and longer operations. The two groups were comparable in age, preoperative liver function, warm ischemia, blood loss, transfusion, intensive care unit stay, hospital stay, hospital mortality, complication and graft loss. The 1-year, 3-year and 5-year patient survival rates were 78.3%, 73.7% and 63.8%, respectively, in the DD group. The LD group had the corresponding rates all at 90.9% (P = 0.246). The 1-year, 3-year and 5-year graft survival rates were 74.1%, 65.8% and 61.5%, respectively, in the DD group. The LD group had the corresponding rates all at 90.9% (P = 0.132). CONCLUSION: Excellent long-term survival after retransplantation using living-donor right-liver grafts can be achieved.