Split liver transplantation in adults

Split liver transplantation(SLT),while widely accepted in pediatrics,remains underutilized in adults. Advancements in surgical techniques and donor-recipient matching,however,have allowed expansion of SLT from utilization of the right trisegment graft to now include use of the hemiliver graft as well. Despite less favorable outcomes in the early experience,better outcomes have been reported by experienced centers and have further validated the feasibility of SLT. Importantly,more than two decades of experience have identified key requirements for successful SLT in adults. When these requirements are met,SLT can achieve outcomes equivalent to those achieved with other types of liver transplantation for adults. However,substantial challenges,such as surgical techniques,logistics,and ethics,persist as ongoing barriers to further expansion of this highly complex procedure. This review outlines the current state of SLT in adults,focusing on donor and recipient selection based on physiology,surgical techniques,surgical outcomes,and ethical issues.

Hepatocellular carcinoma beyond Milan criteria: Management and transplant selection criteria

Liver transplantation(LT) for hepatocellular carcinoma(HCC) has been established as a standard treatment in selected patients for the last two and a half decades. After initially dismal outcomes, the Milan criteria(MC)(single HCC ≤ 5 cm or up to 3 HCCs ≤ 3 cm) have been adopted worldwide to select HCC patients for LT, however cumulative experience has shown that MC can be too strict. This has led to the development of numerous expanded criteria worldwide. Morphometric expansions on MC as well as various criteria which incorporate biomarkers as surrogates of tumor biology have been described. HCC that presents beyond MC initially can be downstaged with locoregional therapy(LRT). Post-LRT monitoring aims to identify candidates with favorable tumor behavior. Similarly, tumor marker levels as response to LRT has been utilized as surrogate of tumor biology. Molecular signatures of HCC have also been correlated to outcomes; these have yet to be incorporated into HCC-LT selection criteria formally. The ongoing discrepancy between organ demand and supply makes patient selection the most challenging element of organ allocation. Further validation of extended HCCLT criteria models and pre-LT treatment strategies are required.

Radiologic-histological correlation of hepatocellular carcinoma treated via pre-liver transplant locoregional therapies

BACKGROUND:Locoregional therapies(LRTs) are treatments to achieve local control of hepatocellular carcinoma(HCC).Correlation between radiologic response to LRT and degree of induced tumor necrosis is not well understood.The aim of this study was to evaluate different levels of radiologic response after pre-liver transplant(LT) LRT and its correlation with percentage of tumor necrosis on explanted histopathology.METHODS:Institutional Review Board approved LT database was queried for treated HCC in patients undergoing LT.Radiologic response was evaluated to predict tumor necrosis in the explanted liver.Tumor response was evaluated 1 to 3 months after LRT with computed tomography or MRI via Response Evaluation Criteria in Solid Tumors(RECIST),and European Association for the Study of the Liver(EASL) guidelines.LRT was repeated as needed until time of LT.Histological tumor necrosis was graded as complete(100%),partial(50%-99%),or poor(【50%).RESULTS:Between 2002 and 2011,128 patients(97 men and 31 women) received pre-LT LRT including transarterial therapy(93),radiofrequency ablation(20),or combination of both(15).The mean age of the patients was 58±9 years.Their mean follow-up was 35±27 months.The median waitlist time was 55 days.One hundred(78%) patients had HCC within the Milan criteria at the initial radiologic diagnosis.Nineteen(15%) of the patients had complete tumor necrosis on histopathology analysis.Fifty(39%) of the patients exhibited partial necrosis,52(41%) showed poor or no necrosis and 7(5%) showed progressive disease.The overall pre-LT radiologic staging was correlated with explant pathology in 73(57%) of the patients.Underestimated tumor stage was noted in 49(38%) patients,and overestimated tumor stage in 6(5%) patients.The post-LT 3-year overall survival and disease free survival were 82% and 80%,and the rates for complete and partial tumor necrosis were 100% vs 78%(P=0.02) and 100% vs 75%(P=0.03),respectively.CONCLUSIONS:In the current era,interpretation of radiologic response after LRT for HCC does not correlate accurately with histologic tumor necrosis.Total tumor necrosis is the goal of LRT;therefore,evolution in its performance is needed.Similarly,ways to predict therapy induced tumor necrosis via radiological investigation need to be improved.

Ohio solid organ transplantation consortium criteria for liver transplantation in patients with alcoholic liver disease

AIM To evaluate risk of recidivism on a case-by-case basis.METHODS From our center's liver transplant program,we selected patients with alcoholic liver disease who were listed for transplant based on Ohio Solid Organ Transplantation Consortium(OSOTC) exception criteria.They were considered to have either a low or medium risk of recidivism,and had at least one or three or more months of abstinence,respectively.They were matched based on gender,age,and Model for End-Stage Liver Disease(MELD) score to controls with alcohol-induced cirrhosis from Organ Procurement and Transplant Network data.RESULTS Thirty six patients with alcoholic liver disease were approved for listing based on OSOTC exception criteria and were matched to 72 controls.Nineteen patients(53%) with a median [Inter-quartile range(IQR)] MELD score of 24(13) received transplant and were followed for a median of 3.4 years.They were matched to 38 controls with a median(IQR) MELD score of 25(9).At one and five years,cumulative survival rates(± standard error) were 90% ± 7% and 92% ± 5% and 73% ± 12% and 77% ± 8% in patients and controls,respectively(Log-rank test,P = 0.837).Four(21%) patients resumed drinking by last follow-up visit.CONCLUSION Compared to traditional criteria for assessment of risk of recidivism,a careful selection process with more flexibility to evaluate eligibility on a case-by-case basis can lead to similar survival rates after transplantation.