Outcome of split liver transplantation vs living donor liver transplantation:A systematic review and meta-analysis

BACKGROUND The outcomes of liver transplantation(LT)from different grafts have been studied individually and in combination,but the reports were conflicting with some researchers finding no difference in both short-term and long-term outcomes between the deceased donor split LT(DD-SLT)and living donor LT(LDLT).AIM To compare the outcomes of DD-SLT and LDLT we performed this systematic review and meta-analysis.METHODS This systematic review was performed in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.The following databases were searched for articles comparing outcomes of DD-SLT and LDLT:PubMed;Google Scholar;Embase;Cochrane Central Register of Controlled Trials;the Cochrane Database of Systematic Reviews;and Reference Citation Analysis(https://www.referencecitationanalysis.com/).The search terms used were:“liver transplantation;”“liver transplant;”“split liver transplant;”“living donor liver transplant;”“partial liver transplant;”“partial liver graft;”“ex vivo splitting;”and“in vivo splitting.”RESULTS Ten studies were included for the data synthesis and meta-analysis.There were a total of 4836 patients.The overall survival rate at 1 year,3 years and 5 years was superior in patients that received LDLT compared to DD-SLT.At 1 year,the hazard ratios was 1.44(95%confidence interval:1.16-1.78;P=0.001).The graft survival rate at 3 years and 5 years was superior in the LDLT group(3 year hazard ratio:1.28;95%confidence interval:1.01-1.63;P=0.04).CONCLUSION This meta-analysis showed that LDLT has better graft survival and overall survival when compared to DD-SLT.

Graft-to-recipient weight ratio lower to 0.7% is safe without portal pressure modulation in right-lobe living donor liver transplantation with favorable conditions

BACKGROUND: The low graft-to-recipient weight ratio(GRWR) in adult-to-adult living donor liver transplantation(LDLT) is one of the major risk factors affecting graft survival. The goal of this study was to evaluate whether the lower limit of the GRWR can be safely reduced without portal pressure modulation in right-lobe LDLT. METHODS: From 2005 to 2011, 317 consecutive patients from a single institute underwent LDLT with right-lobe grafts without portal pressure modulation. Of these, 23 had a GRWR of less than 0.7%(group A), 27 had a GRWR of ≥0.7%, 【0.8%(group B), and 267 had a GRWR of more than and equal to 0.8%(group C). Medical records, including recipient, donor, operation factors, laboratory findings and complications were reviewed retrospectively. RESULTS: The baseline demographics showed low model for end-stage liver disease score(mean 16.3±8.9) and high percentage of hepatocellular carcinoma(231 patients, 72.9%). Three groups by GRWR demonstrated similar characteristics except recipient body mass index and donor gender. For smallforsize syndrome, there were 3(13.0%) in group A, 1(3.7%) in group B, and 2 patients(0.7%) in group C(P【0.001). Hepatic artery thrombosis was more frequently observed in group A than in groups B and C(8.7% vs 3.7% vs 1.9%, P=0.047). However, among the three groups, graft survival rates at 1 year(100% vs 96.3% vs 93.6%) and 3 years(91.7% vs 73.2% vs 88.1%) were not different(P=0.539). In laboratory measurements,there was no group difference in total bilirubin and albumin. However, prothrombin time was longer in group A within postoperative 1 week and platelet count was lower in groups A and B within postoperative 1 month. CONCLUSION: A GRWR lower to 0.7% is safe and does not need to modulate portal pressure in adult-to-adult LDLT using the right-lobe in favorable conditions including low model for end-stage liver disease score.

Outcome of patients undergoing right lobe living donor liver transplantation with small-for-size grafts

AIM: To investigate the outcome of living donor liver transplantation (LDLT) recipients transplanted with small-for-size grafts (SFSGs). METHODS: Between November 2001 and December 2010, 196 patients underwent LDLT with right lobe liver grafts at our center. Recipients were divided into 2 treatment groups: group A with an actuarial graft-to-recipient weight ratio (aGRWR) < 0.8% (n = 45) and group B with an aGRWR = 0.8% (n = 151). We evaluated serum liver function markers within 4 wk after transplantation. We also retrospectively evaluated the outcomes of these patients for potential effects related to the recipients, the donors and the transplantation procedures based upon a review of their medical records. RESULTS: Small-for-size syndrome (SFSS) developed in 7 of 45 patients (15.56%) in group A and 9 of 151 patients (5.96%) in group B (P = 0.080). The levels of alanine aminotransferase and aspartate aminotransferase in group A were higher than those in group B during early period after transplantation, albeit not sig-nificantly. The cumulative 1-, 3-and 5-year liver graft survival rates were 82.22%, 71.11% and 71.11% for group A and 81.46%, 76.82%, and 75.50% for group B patients, respectively (P = 0.623). However, univariate analysis of risk factors associated with graft survival in group A demonstrated that the occurrence of SFSS after LDLT was the only significant risk factor affecting graft survival (P < 0.001). Furthermore, multivariate analysis of our data did not identify any additional significant risk factors accounting for poor graft survival. CONCLUSION: Our study suggests that LDLT recipients with an aGRWR < 0.8% may have liver graft outcomes comparable to those who received larger size grafts. Further studies are required to ascertain the safety of using SFSGs. (c) 2014 Baishideng Publishing Group Co., Limited. All rights reserved.

Effect of donor age on graft function and longterm survival of recipients undergoing living donor liver transplantation

BACKGROUND： Donor shortage is the biggest obstacle in organ transplantation. Living donor liver transplantation（LDLT） has been considered as a valuable approach to shortening waiting time. The objectives of this study were to investigate the feasibility of utilizing donors older than 50 years in LDLT and to evaluate the graft function and recipient survival.METHODS： All LDLT cases（n=159） were divided into the older（donor age ≥50 years, n=10） and younger（donor age 〈50 years,n=149） donor groups. Donor graft and recipient condition pre-,intra- and post-operation were compared between the two groups.In particular, graft functions and recipient survivals were analyzed.RESULTS： The median donor age was 58.5（52.5-60.0） years in the older donor group and 25.0（23.0-32.0） in the younger donor group. There was no significant difference in cold ischemic time, anhepatic phase and operation time between the older and younger donor groups（P〉0.05）. However, the volume of red blood cell transfused in operation was greater in the older donor group than in the younger donor group（1900 vs 1200 m L, P=0.023）. The 1-, 3- and 5-year graft survival rates were 90%, 80% and 80% for the older donor group, and 92%, 87% and 87% for the younger donor group, respectively（P=0.459）.The 1-, 3- and 5-year survival rates were 100%, 90% and 90% for recipients with older grafts, and 93%, 87% and 87% for those with younger grafts, respectively（P=0.811）.CONCLUSION： It is safe for a LDLT recipient to receive liver from donors older than 50 years, and there is no significant adverse effect on graft function and long-term patients’ survival.

Impact of small-for-size liver grafts on medium-term and long-term graft survival in living donor liver transplantation: A meta-analysis

BACKGROUND Small-for-size grafts (SFSGs) in living donor liver transplantation (LDLT) could optimize donor postoperative outcomes and also expand the potential donor pool. Evidence on whether SFSGs would affect medium-term and long-term recipient graft survival is lacking. AIM To evaluate the impact of small-for-size liver grafts on medium-term and longterm graft survival in adult to adult LDLT. METHODS A systematic review and meta-analysis were performed by searching eligible studies published before January 24, 2019 on PubMed, EMBASE, and Web of Science databases. The primary outcomes were 3-year and 5-year graft survival. Incidence of small-for-size syndrome and short term mortality were also extracted. RESULTS This meta-analysis is reported according to the guidelines of the PRISMA 2009 Statement. Seven retrospective observational studies with a total of 1821 LDLT recipients were included in the meta-analysis. SFSG is associated with significantly poorer medium-term graft survival. The pooled odds ratio for 3-year graft survival was 1.58 [95% confidence interval 1.10-2.29, P = 0.014]. On the other hand, pooled results of the studies showed that SFSG had no significant discriminatory effect on 5-year graft survival with an odds ratio of 1.31 (95% confidence interval 0.87-1.97, P = 0.199). Furthermore, incidence of small-for-size syndrome detected in recipients of SFSG ranged from 0-11.4% in the included studies. CONCLUSION SFSG is associated with inferior medium-term but not long-term graft survival. Comparable long-term graft survival based on liver graft size shows that smaller grafts could be accepted for LDLT with appropriate flow modulatory measures. Close follow-up for graft function is warranted within 3 years after liver transplantation.

Feasibility of using marginal liver grafts in living donor liver transplantation

Liver transplantation(LT) is one of the most effective treatments for end-stage liver disease caused by related risk factors when liver resection is contraindicated. Additionally,despite the decrease in the prevalence of hepatitis B virus(HBV) over the past two decades,the absolute number of HBs Ag-positive people has increased,leading to an increase in HBV-related liver cirrhosis and hepatocellular carcinoma. Consequently,a large demand exists for LT. While the wait time for patients on the donor list is,to some degree,shorter due to the development of living donor liver transplantation(LDLT),there is still a shortage of liver grafts. Furthermore,recipients often suffer from emergent conditions,such as liver dysfunction or even hepatic encephalopathy,which can lead to a limited choice in grafts. To expand the pool of available liver grafts,one option is the use of organs that were previously considered "unusable" by many,which are often labeled "marginal" organs. Many previous studies have reported on the possibilities of using marginal grafts in orthotopic LT; however,there is still a lack of discussion on this topic,especially regarding the feasibility of using marginal grafts in LDLT. Therefore,the present review aimed to summarize the feasibility of using marginal liver grafts for LDLT and discuss the possibility of expanding the application of these grafts.

Outcomes of right-lobe and left-lobe living-donor liver transplantations using small-for-size grafts

AIM To analyze the outcomes of living-donor liver transplantation(LDLT) using left-lobe(LL) or right-lobe(RL) small-for-size(SFS) grafts.METHODS Prospectively collected data of adult patients who underwent LDLT at our hospital in the period from January 2003 to December 2013 were reviewed. The patients were divided into the RL-LDLT group and the LL-LDLT group. The two groups were compared in terms of short-and long-term outcomes, including incidence of postoperative complication, graft function, graft survival, and patient survival. A SFS graft was defined as a graft with a ratio of graft weight(GW) to recipient standard liver volume(RSLV)(GW/RSLV) of < 50%. The Urata formula was used to estimate RSLV.RESULTS Totally 218 patients were included for analysis, with 199 patients in the RL-LDLT group and 19 patients in the LL-LDLT group. The two groups were similar in terms of age(median, 53 years in the RL-LDLT group and 52 years in the LL-LDLT group, P = 0.997) but had significantly different ratios of men to women(165:34 in the RL-LDLT group and 8:11 in the LL-LDLT group, P < 0.0001). The two groups were also significantly different in GW(P < 0.0001), GW/RSLV(P < 0.0001), and graft cold ischemic time(P = 0.007). When it comes to postoperative complication, the groups were comparable(P = 0.105). Five patients died in hospital,4(2%) in the RL-LDLT group and 1(5.3%) in the LLLDLT group(P = 0.918). There were 38 graft losses, 33(16.6%) in the RL-LDLT group and 5(26.3%) in the LL-LDLT group(P = 0.452). The 5-year graft survival rate was significantly better in the RL-LDLT group(95.2% vs 89.5%, P = 0.049). The two groups had similar 5-year patient survival rates(RL-LDLT: 86.8%, LL-LDLT: 89.5%, P = 0.476).CONCLUSION The use of SFS graft in LDLT requires careful tailormade surgical planning and meticulous operation. LLLDLT can be a good alternative to RL-LDLT with similar recipient outcomes but a lower donor risk. Further research into different patient conditions is needed in order to validate the use of LL graft.

Potential etiopathogenesis of seventh day syndrome following living donor liver transplantation:ischemia of the graft?

BACKGROUND: Seventh-day syndrome (7DS) is an early serious complication following liver transplantation with a high mortality because of its unknown etiopathogenesis. This study aimed to analyze the potential etiopathogenesis of 7DS. METHODS: A retrospective analysis of 98 consecutive living donor liver transplants performed from 2001 to 2007 at our center revealed that 5 patients had suffered from 7DS; their age, MELD score, portal vein inflow and other parameters were compared with those of the other recipients. RESULTS: The 5 patients showed common features: (a) initial uneventful recovery, and a dramatic rise of serum liver enzyme levels I to 2 weeks later; (b) decreased inflow in the portal vein accompanied by augmentation of serum creatinine and urea nitrogen level; and (c) serial liver biopsy findings of apoptosis and ischemic necrosis of hepatocytes. Four of the 5 patients died. Age, waiting time to transplantation, MELD score, operation time, cold ischemic time, portal interceptive time and diameter of the portal vein were not significantly different between the 2 groups, but a difference was found in the flow rate of the portal vein (t=3.234, P<0.001). CONCLUSIONS: The 5 patients suffered from a decreased portal vein inflow, ischemic liver necrosis, and renal failure. Hence, hypoperfusion of the liver graft was considered to be the etiopathogenesis of 7DS, for which, however sufficient evidence is lacking. More studies of 7DS are needed.

Pediatric living donor liver transplantation for congenital hepatic fibrosis using a mother's graft with von Meyenburg complex: A case report

This is the first report of living donor liver transplantation(LDLT) for congenital hepatic fibrosis(CHF) using a mother's graft with von Meyenburg complex. A 6-year-old girl with CHF, who suffered from recurrent gastrointestinal bleeding, was referred to our hospital for liver transplantation. Her 38-year-old mother was investigated as a living donor and multiple biliary hamartoma were seen on her computed tomography and magnetic resonance imaging scan. The mother's liver function tests were normal and she did not have any organ abnormality, including polycystic kidney disease. LDLT using the left lateral segment(LLS) graft from the donor was performed. The donor LLS graft weighed 250 g; the graft recipient weight ratio was 1.19%. The operation and post-operative course of the donor were uneventful and she was discharged on post-operative day(POD) 8. The graft liver function was good, and the recipient was discharged on POD 31. LDLT using a graft with von Meyenburg complex is safe and useful. Long-term follow-up is needed with respect to graft liver function and screening malignant tumors.

Measures for increasing the safety of donors in living donor liver transplantation using right lobe grafts

BACKGROUND: The safety of donors in living donor liver transplantation (LDLT) should be the primary consideration. The aim of this study was to report our experience in increasing the safety of donors in LDLTs using right lobe grafts. METHODS: We retrospectively studied 37 living donors of right lobe grafts from January 2002 to March 2006. The measures for increasing the safety of donors in LDLT included carefully selected donors, preoperative evaluation by ultrasonography, angiography and computed tomography; and necessary intraoperative cholangiography and ultrasonography. Right lobe grafts were obtained using an ultrasonic dissector without inflow vascular occlusion on the right side of the middle hepatic vein. The standard liver volume and the ratio of left lobe volume to standard liver volume were calculated. RESULTS: There was no donor mortality in our group. Postoperative complications only included bile leakage (I donor), biliary stricture (1) and portal vein thrombosis (1). All donors recovered well and resumed their previous occupations. In recipients, complications included acute rejection (2 patients), hepatic artery thrombosis (1), bile leakage (1), intestinal bleeding (1), left subphrenic abscess (1) and pulmonary infection (1). The mortality rate of recipients was 5.4% (2/37); one recipient with pulmonary infection died from multiple organ failure and another from occurrence of primary disease. CONCLUSIONS: The first consideration in adult-to-adult LDLT is the safety of donors. The donation of a right lobe graft is safe for adults if the remnant hepatic vasculature and bile duct are ensured, and the volume-of the remnant liver exceeds 35% of the total liver volume.

Sonographic evaluation of vessel grafts in living donor liver transplantation recipients of the right lobe

AIM： To evaluate the vessel grafts （VG） used to reconstruct the middle hepatic vein （MHV） tributaries with ultrasonography. METHODS： Twenty-four patients undergone living donor liver transplantation were enrolled in our study. MHV tributaries larger than 5 mm in diameter were reconstructed with interposition VG. Blood flow of the graft and interposition VG was checked by Doppler ultrasonography daily in the first 2 postoperative weeks and monthly followed up after discharge. The sensitivity of VG detected by ultrasonography was assessed using surgical records as references. Student＇s t test was used to compare the velocity of VG and occluded VG in chronic patents （〉 3 mo）. RESULTS： Thirty-one VG were used to reconstruct the MHV tributaries. Ultrasonography identified 96.7% （30/31） of large MHV tributaries and 90.3% （28/31） of VG. The diameter of VG was 5.6 ± 0.8 mm and the velocity of VG was 19.7 ± 8.1 cm/s. Two VG （2/31, 6.5%） were occluded on the first postoperative day in one patient who suffered from persistent ascites and had a prolonged recovery of liver function. Twenty-six VG （26/31, 83.9%） were patent 2 wk after operation. Six （6/31, 19.4%） VG were patent over 3 mo after operation. Intrahepatic venous collaterals were detected in 29.2% （7/24） patients. The velocity of VG and occluded VG was 30.1 ± 5.6 cm/s, 16.5 ± 5.8 cm/s, respectively, in chronic patents. The difference between two groups was statistically significant （P 〈 0.001）. CONCLUSION： Our results indicate that most VG are patent in the first postoperative week while only a small portion with a higher velocity remains patent after 3 mo. Intrahepatic venous collaterals can be observed in some patients after occlusion of VG.

Outcomes of adult patients adopting small-for-size grafts in living donor liver transplantation: A systematic review and meta-analysis

Background: Small-for-size graft(SFSG) has emerged as one of the very contentions in adult-to-adult living donor liver transplantation(LDLT) as a certain graft size is related to recipients’ prognosis. Graftto-recipient weight ratio(GRWR)≥0.8% was considered as a threshold to conduct LDLT. However, this also has been challenged over decades as a result of technique refinements. For a better understanding of SFSG in practice, we conducted this meta-analysis to compare the perioperative outcomes and long-term outcomes between patients adopting the grafts with a lower volume(GRWR < 0.8%, SFSG group) and sufficient volume(GRWR ≥ 0.8%, non-SFSG group) in adult-to-adult LDLT. Data sources: The studies comparing recipients adopting graft with a GRWR < 0.8% and ≥ 0.8% were searched by three authors independently in Pub Med, Web of Science, Embase, the Cochrane Library, MEDLINE and Google Scholar databases until September 2018 and data were analyzed by RevMan 5.3.5. Results: Sixteen studies with a total of 3272 subjects were included in this meta-analysis. In terms of small-for-size syndrome(SFSS), no significant difference was found in subjects enrolled after year 2010(before 2010, OR = 3.00, 95% CI: 1.69–5.35, P = 0.0002;after 2010, OR = 1.23, 95% CI: 0.79–1.90, P = 0.36;P for interaction: 0.02). There was no significant difference in operative duration, blood loss, cold ischemia time, biliary complications, acute rejection, postoperative bleeding, hospitalization time, perioperative mortality, and 1-, 3-and 5-year overall survival rates between two groups. Conclusions: This meta-analysis suggested that adopting SFSG in adult LDLT has comparable outcomes to those with non-SFSG counterparts since 2010.

Homogeneous phenomenon of the graft when using different genotype characteristic of recipients/donors in living donor liver transplantation

AIM:To investigate the evidence of homogeneous phenomenon on CYP3A5*3 MDR1-3435 and CYP3A4*18of the liver graft after living donor liver transplantation(LDLT).METHODS:We identified the proportional change of the CYP3A5*3,MDR1-3435 and CYP3A4*18 from the peripheral blood mononuclear cell of 41 pairs recipient/donor with different genotype polymorphisms and 119liver graft biopsy samples used with the pyrosequencing technique after LDLT.Polymerase chain reaction/ligase detection reaction assay and restriction fragment length polymorphism was employed for genotyping the CYP3A5*3 and CYP3A4*18 single nucleotide poly-morphisms(SNPs).All of the recipients and donors expressed with the similar SNP genotype of CYP3A5*3,MDR1-3435 or CYP3A4*18 were excluded.RESULTS:The final genetic polymorphisms of the liver graft biopsy samples of CYP3A5*3,MDR1-3435 and CYP3A4*18 was predominated depends on the donor with restriction fragment length polymorphism and seems to be less related to the recipient.The proportional changes of G to A alleles of the 119 samples of CYP3A5*3(included A】A/G,A/G】A,A/G】G,G】A,G】A/G and A】G),C to T alleles of the 108 samples of MDR1-3435(included C】C/T,C/T】C,C/T】T,T】C/T and T】C),and T to C alleles of 15 samples of CYP3A4*18(included T/C】T and T】C/T)were significant different between the recipients and the liver graft biopsy samples(P【0.0001)and less difference when compared with the donors in the pyrosequencing analysis after LDLT.CONCLUSION:The CYP3A5*3,MDR1-3435 and CYP3A4*18 of the recipient could be modified by the donor so-called homogenous phenomenon when the recipient’s blood drained into the liver graft.

Pediatric living donor liver transplantation using liver allograft after ex vivo backtable resection of hemangioma: A case report

BACKGROUND Use of liver allograft with hepatic hemangioma after in vivo resection of hemangioma in living donor liver transplantation(LDLT)has been previously reported.However,there are few reports describing ex vivo backtable resection of hemangioma from liver allografts in LDLT.CASE SUMMARY A 55-year-old male was evaluated as a donor for an 8-month-year old patient with acute hepatic failure due to biliary atresia.Pre-operative contrast enhanced computed tomography revealed a 9 cm hemangioma in segment 4 with vascular variations in the donor.During LDLT,an intra-operative intrahepatic cholangiography was performed to ensure no variation in the anatomy of the intrahepatic bile duct.After intra-operative pathological diagnosis,ex vivo backtable resection of the hemangioma was performed and the liver allograft was transplanted into the recipient.The donor’s and recipient’s post-operative course were uneventful.At the 2-year follow-up,the liver allograft showed good regeneration without any recurrence of hemangioma.CONCLUSION Liver allografts with hemangiomas are an acceptable alternative strategy for LDLT.Ex vivo backtable resection of hemangioma from the donor liver during pediatric LDLT is safe and feasible,and can effectively reduce the operative time and intra-operative bleeding for the donor.

Some aspects of adult living donor liver transplantation:small-for-size graft and ABO mismatch

Living donor liver transplantation (LDLT) was first performed for pediatric patients, for whom the gap between demand and supply of

Is right lobe liver graft without main right hepatic vein suitable for living donor liver transplantation?

BACKGROUND Since the first living donor liver transplantation(LDLT)was performed by Raia and colleagues in December 1988,LDLT has become the gold standard treatment in countries where cadaveric organ donation is not sufficient.Adequate hepatic venous outflow reconstruction in LDLT is essential to prevent graft congestion and its complications including graft loss.However,this can be complex and technically demanding especially in the presence of complex variations and congenital anomalies in the graft hepatic veins.CASE SUMMARY Herein,we aimed to present two cases who underwent successful right lobe LDLT using a right lobe liver graft with rudimentary or congenital absence of the right hepatic vein and describe the utility of a common large opening drainage model in such complex cases.CONCLUSION Thanks to this venous reconstruction model,none of the patients developed postoperative complications related to venous drainage.Our experience with venous drainage reconstruction models shows that congenital variations in the hepatic venous structure of living liver donors are not absolute contraindications for LDLT.

Immunohistochemical evaluation for outflow reconstruction using opened round ligament in living donor right posterior sector graft liver transplantation: A case report

Utilizing the opened round ligament as venous grafts during liver transplantation is useful but controversial,and there are no pathological analyses of this procedure. Herein,we describe the first reported case of a pathological analysis of an opened round ligament used as a venous patch graft in a living donor liver transplantation(LDLT). A 13-year-old female patient with biliary atresia underwent LDLT using a posterior segment graft from her mother. The graft had two hepatic veins(HVs),which included the right HV(RHV; 15 mm) and the inferior RHV(IRHV; 20 mm). The graft RHV and IRHV were formed into a single orifice using the donor's opened round ligament(60 mm × 20 mm) as a patch graft during bench surgery; it was then anastomosed end-to-side with the recipient inferior vena cava. The recipient had no post-transplant complications involving the HVs,but she died of septic shock with persistent cholangitis and jaundice 86 d after LDLT. The HV anastomotic site had no stenosis or thrombus on autopsy. On pathology,there was adequate patency and continuity between the recipient's HV and the donor's opened round ligament. In addition,the stains for CD31 and CD34 on the inner membrane of the opened round ligament were positive. Hepatic venous reconstruction using the opened round ligament as a venous patch graft is effective in LDLT,as observed on pathology.

Liver transplantation and resection in patients with hepatocellular cancer and portal vein tumor thrombosis: Feasible and effective?

Patients with locally advanced hepatocellular cancer(HCC)and portal vein tumor thrombosis(PVTT)have a dismal prognosis since limited treatment options are available for them.In recent years,effective systemic therapy,and advances in the understanding of technicalities and effectiveness of ablative therapies especially radiotherapy,have given some hope to prolong survival in them.This review summarized recent evidence in literature regarding the possible role of liver resection(LR)and liver transplantation(LT)in patients with locally advanced HCC and PVTT with no extrahepatic disease.Downstaging therapies have helped make curative resection or LT a reality in selected patients.This review emphasizes on the key points to focus on when considering surgery in these patients,who are usually relegated to palliative systemic therapy alone.Meticulous patient selection based on tumor biology,documented downstaging based on imaging and decrease in tumor marker levels,and an adequate waiting period to demonstrate stable disease,may help obtain satisfactory long-term outcomes post LR or LT in an intention to treat strategy in patients with HCC and PVTT.

Successful living donor liver transplantation with a graft-to-recipient weight ratio of 0.41 without portal flow modulation:A case report

BACKGROUND There have been numerous efforts to lower the limit of minimum graft size to meet the metabolic demand of recipients in adult-to-adult living donor liver transplantation(LDLT).We experienced a successful case of LDLT using a verysmall-for-size graft without portal flow modulation such as splenectomy or portocaval shunt.CASE SUMMARY A 49-year-old man(weighing 91 kg)suffering hepatocellular carcinoma accompanied with hepatitis B virus related cirrhosis underwent LDLT.The one and only voluntary donor was his 17-year-old daughter whose body weight was 50 kg with a body mass index(BMI)of 18.3.The procured right liver graft was 411 g with a real graft-to-recipient weight ratio(GRWR)of 0.41%,the smallest to be reported in the literature.Both the recipient and donor had an uneventful recovery and were discharged on days 15 and 8,respectively,with normal liver function.The father and daughter have had no complication so far and are still in good health with normal liver function 81 mo after LDLT.CONCLUSION Satisfactory outcomes can be achieved in LDLT with a GRWR as low as 0.41%even without using portal flow modulation in highly selected patients.

Role of biliary complications in chronic graft rejection after living donor liver transplantation

Postoperative biliary complications remain a substantial challenge after living donor liver transplantation,especially due to its heterogeneous clinical presentation.