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

These results suggest that the prognostic impact of tumor size may be underestimated in the current version of the AJCC staging system and that solitary HCC staging could be improved with inclusion of tumor size cutoff of 5 cm in HBV-associated patients. Further validation is necessary with multicenter studies.

A considerable proportion of adult living donor liver transplantation (LDLT) recipients experience biliary complication (BC), but there are few reports regarding BC based on long-term studies of a large LDLT population. The present study examined BC incidence, risk factors and management using single-center data from 259 adult patients (225 right liver and 34 left liver grafts) between 2000 and 2002. The mean follow-up period was 46 Ϯ 14 months. Biliary reconstruction included single duct-to-duct anastomosis (DD, n ϭ 141), double DD (n ϭ 19), single hepaticojejunostomy (HJ, n ϭ 67), double HJ (n ϭ 28), and combined DD and HJ (n ϭ 4). There were 12 episodes of anastomotic bile leak and 42 episodes of anastomotic stenosis in 50 recipients. Most leaks occurred within the first month, whereas stenosis occurred over 3 yr. Most stenoses were successfully treated using radiological intervention. Cumulative 1-, 3-, and 5-yr BC rates were 12.9%, 18.2%, and 20.2%, respectively. BC occurred much more frequently in right liver grafts compared to left liver grafts (P ϭ 0.024). Stenosis-free survival curves for right liver graft recipients were similar for all reconstruction groups. When right liver graft recipients with single biliary reconstructions were grouped according to graft duct size and type of biliary reconstruction, DD involving a small-sized duct (less than 4 mm in diameter) was found to be a BC risk factor (P ϭ 0.015), whereas HJ involving such duct sizes was not found to be associated with a higher risk (P ϭ 0.471). In conclusion, close surveillance for BC appears necessary for at least the first 3 yr after LDLT. We found that most BC could be successfully controlled using radiological intervention. In terms of anastomotic stenosis risk, HJ appears a better choice than DD for right liver grafts involving ducts less than 4 mm in diameter. Liver Transpl 12: 831-838, 2006. © 2006 AASLD. Received October 19, 2005 accepted November 29, 2005. Patient survival rates for living donor liver transplantation (LDLT) to adult recipients became favorable due to innovative surgical techniques that have overcome the anatomical limitations associated with such partial liver grafts. However, a high incidence of biliary complication (BC) remains the most intractable problem associated with LDLT.

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Salvage liver transplantation has been performed for recurrent hepatocellular carcinoma (HCC) or deterioration of liver function after primary liver resection. Because prior liver resection per se is an unfavorable condition for living donor liver transplantation (LDLT), we assessed the technical feasibility of LDLT after prior hepatectomy, and we compared the outcome of salvage LDLT with that of primary LDLT in HCC patients. Of 342 patients with HCC, 17 (5%) underwent salvage LDLT, with 5 having undergone prior major liver resection and 12 prior minor resection. During salvage LDLT, 12 patients received right lobe grafts, 3 received left lobe grafts, and 2 received dual grafts. There was 1 incident (5.9%) of perioperative mortality. Recipient operation time was not prolonged in patients undergoing salvage LDLT, but bleeding complications occurred more frequently than in patients undergoing primary LDLT. Overall survival rates after salvage LDLT were similar to those after primary LDLT, especially when the extent of recurrent tumor was within the Milan criteria. These results indicate that every combination of prior hepatectomy and living donor liver graft is feasible for patients undergoing salvage LDLT, and the acceptable extent of HCC for salvage LDLT is equivalent to that for primary LDLT. Liver Transpl 13:741-746, 2007. © 2007 AASLD.Received May 31, 2006; accepted February 9, 2007. See Editorial on Page 636Salvage liver transplantation (LT) has been performed for recurrence of hepatocellular carcinoma (HCC) or for deterioration of liver function after primary liver resection for HCC. Questions arise, however, regarding the technical feasibility of salvage LT in patients who have undergone prior liver surgery. Because initial liver resections in these patients are usually minor in extent, performing deceased donor whole liver graft implantation is not regarded as a contraindication. In contrast, prior performance of a major liver resection, such as right lobectomy, makes subsequent recipient hepatectomy technically difficult. To date, only a small number of salvage LT operations after major liver resection have been reported. 1,2 Living donor liver transplantation (LDLT) can also be performed for salvage. Although prior minor hepatectomy is acceptable for salvage LDLT, there have been no reports to date of salvage LDLT after major hepatectomy. Moreover, the extent of recurrent HCC eligible for salvage LT is not known.To assess the technical feasibility and indication of salvage LDLT for recurrent HCC, we retrospectively assessed our experience performing these surgical procedures over 10 years. We especially analyzed the outcome of various combinations of prior major hepatectomy and graft types in patients undergoing LDLT for recurrent HCC after prior liver resection. MATERIALS AND METHODS Patient SelectionFrom February 1997 to March 2006, a total of 1,049 cases of adult LDLT have been performed in our institution, 3,4 with 342 recipients (32.6%) diagnosed as havAbbreviations: HCC, hepatocellular carcino...

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.

Even in patients with cirrhosis, pure LRH is not less safe than the traditional open approach. The oncological outcomes of HCC were also comparable between the two groups. In selected patients, pure LRH for HCC appears to represent a viable alternative to ORH.

Cryopreserved iliac vein grafts (IVGs) have often been used for reconstruction of middle hepatic vein (MHV) branches in right liver grafts, but their storage pool has often been exhausted in our institution due to the low incidence of deceased donor organ procurement. To overcome this shortage of IVG, we started to use cryopreserved iliac artery graft (IAG). During September and October 2004, we carried out 41 cases of adult living donor liver transplantation, including 29 right lobe grafts with MHV reconstruction. Interposition vessel grafts were autologous vein (n ‫؍‬ 6), IVG (n ‫؍‬ 13), and IAG (n ‫؍‬ 10). IAG was used in 3 (21%) of 13 cases during the first month. For the next month, it was more frequently used (7 [44%] of 16) because handling of cryopreserved IAG was not difficult and its outcome was favorable. On follow-up with computed tomography for 3 months, outflow disturbance occurred in 1 (17%) of 6 autologous vein cases, in 2 (15%) of 13 IVG cases, and in 1 (10%) of 10 IAG cases. Twomonth patency rate of IAG was not lower than that of IVG. In conclusion, we feel that cryopreserved IAG can be used as an interposition vessel graft for MHV reconstruction of right liver graft when cryopreserved IVG is not available. (Liver Transpl 2005;11:644-649.) H epatic venous congestion (HVC) from deprivation of middle hepatic vein (MHV) outflow in the right lobe (RL) graft can be prevented by interposition of a vein graft between the major tributaries of MHV and recipient inferior vena cava. 1 In addition to the recipient's autologous vein grafts, such as greater saphenous vein (GSV), left portal vein, and paraumbilical vein, homologous vein grafts such as cryopreserved iliac vein graft (IVG) also have been used for this purpose. 2,3 Recently, cryopreserved IVG became the most preferred vessel graft for MHV reconstruction in our institution, because it did not require time-consuming dissection of recipient tissues and it was usually large and long enough to use for any variant type of MHV branch. However, this IVG preference often exhausted the cryopreserved IVG pool in our situation, because the number of living donor liver transplantations (LDLTs) requiring MHV reconstruction exceeded the low incidence of deceased donor organ procurement. On the other hand, a number of iliac artery grafts (IAGs) always were left in storage because they were never previously used. Although there was no reference to IAG use as a vein graft substitute to our knowledge at that time, we tried to use the cryopreserved IAG in order to overcome the disproportionate shortage of vein grafts. Only after application of several RL grafts did we feel that it was possible to replace IVG with IAG without any serious problem. We herein describe our early experience of MHV reconstruction using IAG for RL grafts. Patients and Methods Recipients and Living DonorsDuring the months of September and October 2004, we have performed 41 cases of adult-to-adult LDLT using 29 RL grafts, 2 left lobe grafts, and 9 dual grafts. As there was one dual LDLT case...