The feasibility of hepatic homotransplantation has been clearly established in principle inasmuch as several animals are still alive almost 3 years after complete hepatectomy and liver replacement. Both orthotopic and auxiliary operations are complicated surgical techniques. Nevertheless, the results in dogs are comparable to those which can be obtained with homotransplantation of the kidney.In man the problem is more difficult. In patients who have a need for such operations, there is invariably a metabolic disorder more complex than that caused by renal failure. In addition, the new organ must function efficiently from the beginning since its complete functional failure leads to death within a few hours. There is no recourse to an artificial liver to maintain life until the reversal of an injury which is caused by either ischemia or rejection.Nevertheless, research of several kinds may soon make possible the successful use of hepatic transplantation procedures for the definitive treatment of human liver disease as exemplified by the reports in this symposium concerning new techniques of organ preservation, histocompatibility analysis, and immunosuppression.

UNTIL last year, the kidney was the only organ which had been transplanted with subsequent significant prolongation of life. There had been nine reported attempts at orthotopic liver transplantation; seven in Denver 2 2 + 2 3 and one each in Bostonle and P a r i~.~ Two of these patients had succumbed within a few hours after operat i~n ,~, 22 and none had lived for longer than 23 days.This dismal picture has changed within the last 9 months, inasmuch as seven consecutive patients treated with orthotopic liver transplantation from July 23, 1967 to March 17, 1968 all passed through this previously lethal operative and postoperative period. Three of the recipients are still alive after 9, 23$, and 1 months; the others died after 2, 3%, 454, and 6 months. MethodsThe Recipients. Summary information for the seven patients is given in Table 1. Their ages were 13 months to 16 years. Six were females. The indications for transplantation, which had been established by earlier explorations at other hospitals, were

UNTIL last year, the kidney was the only organ which had been transplanted with subsequent significant prolongation of life. There had been nine reported attempts at orthotopic liver transplantation; seven in Denver 2 2 + 2 3 and one each in Bostonle and P a r i~.~ Two of these patients had succumbed within a few hours after operat i~n ,~, 22 and none had lived for longer than 23 days.This dismal picture has changed within the last 9 months, inasmuch as seven consecutive patients treated with orthotopic liver transplantation from July 23, 1967 to March 17, 1968 all passed through this previously lethal operative and postoperative period. Three of the recipients are still alive after 9, 23$, and 1 months; the others died after 2, 3%, 454, and 6 months. MethodsThe Recipients. Summary information for the seven patients is given in Table 1. Their ages were 13 months to 16 years. Six were females. The indications for transplantation, which had been established by earlier explorations at other hospitals, were

FOR the most part, the surgical technics of kidney transplantation have been standardized. 3 , 8, 10, 11,11,25 The least satisfactory aspect of this operation is provision of urinary drainage as will be demonstrated by an analysis of the urologic complications encountered in 216 consecutive recipients of renal grafts at the Colorado General and Denver Veterans Administration Hospitals.The Denver series is a useful one with which to study the attributes and deficiencies of urinary drainage procedures, not only because of the large numbers of patients, but also because all operations reported were performed at least one year ago, thereby assuring reasonably long fol-

There have been 9 reported attempts of orthotopic homotransplantation of the human liver-7 in Denver 16,21,22 and one each in Boston 11 and Paris. 5 Survival time was 0 to 23 days. There were multiple reasons for death in each case, but in most an important factor was either the failure to obtain good immediate liver function or the inability to subsequently maintain such function.On July 23 and 31, Sept. 5, and Oct. 8, 1967, 4 more orthotopic liver transplantations were performed in our institutions. The recipients are at the time of this writing 94, 86, 49, and 14 days postoperative. This report is concerned with the first 3 of these patients and with the improvements in therapy which were brought to these cases. In addition, attention will be directed to a number of serious and previously unrecognized problems which were encountered. The diagnosis and treatment of these complications will be presented, as well as some thoughts about how they might be prevented in future cases. OBSERVATIONS Case materialThe 3 recipients (hereafter called Patients 1 to 3) were 19, 20½, and 13 months old and weighed 10.8, 8.7, and 9.4 kilograms. All were girls. The diagnosis of nonresectable hepatic-cell carcinoma was made in Patient 1 at an abdominal exploration when she was 13 months old. During the next 5 months, the tumor had grown inexorably despite liver irradiation with a total of 975 r and systemic therapy with actinomycin-D, cyclophosphamide, methotrexate, and 5-fluorouracil. Liver function was normal. ADDENDUMTwo of the 3 patients in this series are still alive as of January 27, 1968. Patient 1 has now survived for more than 6 months. Liver function remains excellent, but she has developed slow-growing pulmonary metastases. Patient 3 will be 5 months postoperative in 1 week. Patient 2, who had poor liver function at the time the report was submitted, died after 134 days. The immediate cause of death was massive intestinal gangrene. Two more infants with biliary atresia have received orthotopic homotransplantation. The first died 61 days after transplantation as a consequence of thrombosis of the right hepatic artery and gangrene of the liver lobe. The second child is more than 2 months postoperative and has not had any of the complications described in the text. Drs. Pierre Daloze of Montreal and Claude Huguet of Paris were important members of the operating teams. Drs. Anthony Aldrete, Theodore Gingrich, and David LeVine provided the anesthesia. Three medical students made important contributions to the postoperative care of the patients; The homograft donorsThe donors for Patients 1 to 3 were 18 months, 4 years, and 18 months old and weighed 6.4, 13.0, and 8.2 kilograms. The first was a boy and the second and third were girls. The red-cell types of the 3 donors were the same as those of the recipients, namely O, O, and A.The condition of the donors was hopeless at the time of admission to the hospital because of brain damage and apnea. One was a microcephalic who had been resuscitated from a postaspiration cardiac ...