The currently available indication criteria of living donor liver transplantation (LDLT) for patients with hepatocellular carcinoma (HCC) have high prognostic power but insufficient discriminatory power. On the basis of single-center results from 221 HCC patients undergoing LDLT, we modified the indication criteria for LDLT to expand recipient selection without increasing the posttransplant recurrence of HCC. Our expanded criteria, based on explant pathology, were largest tumor diameter Յ 5 cm, HCC number Յ 6, and no gross vascular invasion. One hundred eighty-six of the 221 HCC patients (84.2%) met our criteria, 10% and 5.5% more than those that met the Milan and University of California at San Francisco (UCSF) criteria, respectively. The overall 5-year patient survival rates were 76.0% and 44.5% within and beyond the Milan criteria, respectively; 75.9% and 36.4% within and beyond the UCSF criteria, respectively; and 76.3% and 18.9% within and beyond our expanded criteria, respectively. Although these 3 sets of criteria had similar prognostic power, our expanded criteria had the highest discriminatory power. Thus, these expanded criteria for LDLT eligibility of HCC patients broaden the indications for patient selection and can more accurately identify patients who will benefit from LDLT. Liver Transpl 14: [935][936][937][938][939][940][941][942][943][944][945] 2008. See Editorial on Page 911Liver transplantation is an effective treatment for unresectable hepatocellular carcinoma (HCC), but posttransplant HCC recurrence is associated with a dismal prognosis. 1-6 Eligibility guidelines for transplantation, such as the Milan and University of California at San Francisco (UCSF) criteria, have been adopted to reduce the posttransplant recurrence of HCC and the wasting of donor organs. 1,3 The Milan criteria were originally established on the basis of pretransplant imaging findings but were reevaluated on the basis of explant liver pathology, whereas the UCSF criteria were based on explant pathology but validated by pretransplant imaging findings. 1,3 Each of these 2 sets of criteria is derived from the experience with deceased donor liver transplantation (DDLT) at a single center. Application of these criteria to living donor liver transplantation (LDLT) has resulted in patient survival outcome very similar to that following DDLT, as shown in large-volume multicenter cohorts from Japan and Korea. 5,6 Moreover, the prognostic powers of the Milan and UCSF criteria are the same in both DDLT and LDLT.Discrepancies between the pretransplant radiological and explant pathologic stagings can occur, and candidates for DDLT should be selected after consideration of the extent of HCC at the time of listing and any further progression of HCC during the waiting period. LDLT, because of its shorter waiting time, is less affected by tumor

Although balloon angioplasty has been accepted as the safe and effective initial treatment to manage hepatic venous outflow abnormalities, it may induce rupture of the fresh anastomosis but also may be ineffective to eliminate various etiologies of venous outflow abnormalities in the early post-transplant period. Therefore, we performed primary stent placement in 108 patients to treat early-onset (Յ4 weeks) post-transplant hepatic venous outflow abnormality. The following parameters were documented retrospectively: technical success and complications: clinical success; recurrence; and patency of stent-inserted hepatic veins.Technical success was achieved in 166 (97.6%) of 170 anastomoses (107 patients). Major complications occurred in 5 (4.6%) patients: partial stent migration (n ϭ 2) and stent malposition (n ϭ 3). Clinical success was achieved in 83 (82.2%) of 101 patients who had abnormal liver enzymes or clinical symptoms. Seven patients without initial clinical symptoms have remained healthy. Restenosis or occlusion of the stent-inserted hepatic veins was documented in 22 patients at a mean of 9.6 Ϯ 8.6 months after stent placement. Four of them underwent stent replacement or retransplantation due to liver function deterioration. Overall 1-, 3-, and 5-year primary patency rates were 82.3 Ϯ 0.3%, 75.0 Ϯ 0.4%, and 72.4 Ϯ 0.5%, respectively. Multivariate Cox regression analysis showed that diameter of stents was an independent factor associated with patency of stents (p ϭ 0.001).Primary stent placement seems to be an effective treatment modality with an acceptable long-term patency to treat early post-transplant hepatic venous outflow obstruction. Liver Transpl 14: 1505-1511, 2008.

PAE is safe and effective for managing primary PPH. Patients with DIC and massive transfusion were likely to have poor results after PAE.

Preoperative sequential application of PVE and HVE seems to be safe and effective in facilitating contralateral liver regeneration by inducing more severe liver damage than PVE alone.

Repeated TACE with additional RT can be performed safely and showed a significant survival benefit in HCC patients with PV branch invasion with conserved liver function.

Repeated TACE could show significant survival benefits in metastatic HCC patients with conserved liver function and intrahepatic HCC T3 stage. The survival data of our study could be used as a historical control for TACE monotherapy in future clinical trials evaluating combination treatments containing TACE in these patients.

Summary Persistance of a large spontaneous splenorenal shunt (SRS) may result in graft failure in adult living donor liver transplantation (LDLT) because it reduces the effective portal perfusion to the partial liver graft by diversion of hepatotrophic portal flow into this hepatofugal pathway. We performed a prospective study to evaluate the efficacy of ligation of left renal vein (LRV) to prevent portal flow steal and the safety of this procedure to the renal function in adult LDLT patients with SRS. Between October 2001 and January 2005, 44 cirrhotic patients with large SRS underwent LDLT with ligation of LRV. Each patient received pre‐ and postoperative computed tomography and Doppler USG to assess the changes of collaterals and portal flow, as well as serial renal and liver function tests. Portal flow after ligation of LRV was statistically and significantly increased when compared with pre‐operative value (P = 0.001). Whereas four patients (9.1%) demonstrated sustained, elevated serum creatinine levels after operation, the renal function tests returned to normal in 40 patients. All patients recovered with satisfactory regeneration of the partial liver graft and there was no procedure‐related permanent renal dysfunction. In conclusion, ligation of LRV to prevent a ‘portal steal phenomenon’ seems to be a safe and effective graft salvage procedure for large spontaneous SRS (>10‐mm diameter) in adult LDLT.

Sequential TACE and PVE before surgery is a safe and effective method to increase the rate of hypertrophy of the FLR and leads to longer overall and recurrence-free survival in patients with HCC.