Living donor liver transplantation for hepatocellular carcinoma: long-term results compared with deceased donor liver transplantation.

OBJECTIVE: Living donor liver transplantation (LDLT) may represent a valid therapeutic option allowing several advantages for patients affected by hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT). However, some reports in the literature have demonstrated worse long-term and disease-free survivals among patients treated by LDLT than deceased donor liver transplantation (DDLT) for HCC. Herein we have reported our long-term results comparing LDLT with DDLT for HCC. PATIENTS AND METHODS: Among 179 patients who underwent OLT from January 2000 to December 2007, 25 (13.9%) received LDLT with HCC 154 (86.1%) received DDLT. Patients were selected based on the Milan criteria. Transarterial chemoembolization, radiofrequency ablation, percutaneous alcoholization, or liver resection was applied as a downstaging procedure while on the waiting list. Patients with stage II HCC were proposed for LDLT. RESULTS: The overall 3- and 5-year survival rates were 77.3% and 68.7% versus 82.8% and 76.7% for LDLT and DDLT recipients, respectively, with no significant difference by the log-rank test. Moreover, the 3- and 5-year recurrence-free survival rates were 95.5% and 95.5% (LDLT) versus 90.5% and 89.4% (DDLT; P = NS). CONCLUSIONS: LDLT guarantees the same long-term results as DDLT where there are analogous selection criteria for candidates. The Milan criteria remain a valid tool to select candidates for LDLT to achieve optimal long-term results.

Liver adenomatosis: a rare indication for living donor liver transplantation.

Liver adenomatosis (LA) is a rare benign disease of the liver with unclear pathogenesis, which is characterized by multiple hepatic adenomas. The management of LA remains controversial. Herein we have reported a case of LA treated by living donor liver transplantation (LDLT). A 48-year-old woman developed multiple liver adenomas. In view of the sizes and localizations of the lesions, the patient underwent right hepatic resection and segment II nodulectomy. Thirty-four months later, she developed recurrence of multiple hepatic adenomas and 2 nodules were highly suspect for hepatocellular carcinoma. Re-resection was not indicated due to the whole liver being involved with adenomas. The patient underwent LDLT. At 45 months thereafter she is alive and disease-free. In conclusion, LDLT is indicated in cases of nonresectability; it may offer optimal results in view of the absence of portal hypertension and the elimination of waiting list time.

Adult living donor liver transplantation with right lobe graft: the venous outflow management in the Milan-Niguarda experience.

In right lobe living donor liver transplantation (ALDLT), reconstruction of middle hepatic vein (MHV) tributaries is often necessary to avoid severe graft congestion. From March 2001, we performed 36 right lobe ALDLT (segments 5, 6, 7, and 8) without MHV and one pediatric transplant (segments 2 and 3). In the presence of MHV tributaries larger than 5 mm, we intraoperatively evaluated the need for reconstruction. At a mean follow-up of 848 days (range=8-2412), 33/37 transplanted patients are alive with overall patient and graft survivals of 89.2% and 83.8%, respectively. Large MHV tributaries (>5 mm) were present in 10 cases, and inferior right hepatic veins (IRHV) draining segment 6 in 11 cases. In 10 cases, we performed an end-to-side anastomosis between the IRHV and the side of the recipient vena cava. In three cases, the MHV tributaries were end-to-end anastomosed to the stump of the recipient MHV. In all other cases, the vein tributaries were not reconstructed. A computed tomography scan performed from 1 to 3 months after surgery did not show any congested area in the liver parenchyma. In our experience, reconstruction of the MHV tributaries was not always necessary when graft-to-recipient weight ratio is >0.8. Pre- and intraoperative evaluation of the segmental branches of the hepatic vein is crucial to decide about reconstructing these collaterals. Anastomosis of V5 or V8 to the stump of the recipient MHV reduces the number of vascular anastomosis and maintains a physiological angle between these collaterals and the caval vein.

Right hemiliver transplant: results from living and cadaveric donors.

UNLABELLED: Although right hemiliver transplant from living donors (LD) is gaining acceptance as a way to overcome the critical organ shortage, splitting a liver for two adults from cadaveric donor (CD) is still controversial. METHODS: From May 1999 to August 2004 we performed nine right hemiliver transplants using segments 5-6-7-8 from CD and 18 from LD. RESULTS: We compared the two procedures to evaluate both the technical aspects and the patients' outcomes. In the CD group, three recipients died (33%), two of whom were UNOS Status 2A. Patient and graft survivals were 67% (median follow-up: 23 months). Among the LD group, three recipients died (17%) and two were retransplanted; one because of arterial thrombosis and the other as a consequence of small-for-size syndrome. Patient and graft survivals were 83% and 72%, respectively (median follow-up: 8 months). There were five early complications in the CD group (55%) and five (27%) in the LD group. Two patients in the LD group experienced a late stenosis of the biliary anastomosis. DISCUSSION: Data from our early experience show that better results are achieved by right hemiliver transplants from LD; the morbidity and mortality are higher among the CD group. We believe that this finding is probably a consequence of better preoperative donor evaluation, shorter ischemia time, better logistics, and learning curve. Recipient selection is crucial; this kind of graft is at high risk of poor function, technical complications, and infections. Further experience will help to clarify the reliability of right hemiliver transplants from CD.

[Surgical treatment of hepatocellular carcinoma: resection or transplantation? Results of a multivariate analysis]. / Trattamento chirurgico del carcinoma epatocellulare: resezione o trapianto? Risultati di un'analisi multivariata.

This retrospectively study presents the results of a large series of transplanted or resected patients, with the aim of defining the characteristics of those patients who may benefit from resection or transplantation in an era in which these two surgical options can both be offered with low risks and extremely satisfactory results. Two hundred and seventy-five patients (154 resected and 121 transplanted) with hepatocellular carcinoma were submitted to surgical treatment in our department from December 1985 to December 1999. Age, sex, presence of cirrhosis, aetiology of liver disease, Child-Pugh classification, and alpha-fetoprotein levels were considered. Twenty-two of the 121 (18.1%) transplanted patients and 7 of the 154 (4.5%) resected patients died within 3 months of surgery. All curves show an evident trend towards increased mortality or recurrence rates in the resected group after prolonged follow-up. Liver transplantation appears to offer better survival and recurrence-free rates than liver resection in patients with hepatocellular carcinoma. Liver resection should be considered a good therapeutic alternative in patients who do not fulfill the transplant criteria.

Hepatocellular carcinoma: comparison between liver transplantation, resective surgery, ethanol injection, and chemoembolization.

Between January 1989 and June 1997, 533 patients (423 male, 110 female, mean age 61 years, range 22-89 years) with hepatocellular carcinoma (HCC) were observed at our center. We report on 419 patients retrospectively compared for different treatments: liver transplantation (LT; 55 patients), resective surgery (RS; 41 patients), transarterial chemoembolization (TACE; 171 patients) and percutaneous ethanol injection (PEI; 152 patients). The 3- and 5-year actuarial survival rates were, respectively, 72% and 68% for LT, 64 and 44% for RS, 54 and 36% for PEI, and 32 and 22% for TACE. Survival curves were compared for sex, age, tumor characteristics, alphafetoprotein level, Child class, and etiology of cirrhosis. All patient-related characteristics examined (sex, age) are not significantly related to patient survival. Tumor-related variables and associated liver disease variables significantly conditioned survival in relation to different treatments. LT seems to be the treatment of choice for monofocal HCC less then 5 cm in diameter and in selected cases of plurifocal HCC.

Left thoracic approach for cancer of cardia: early and late results.

BACKGROUND: The surgical treatment of cancer of the cardia is controversial and results are often disappointing. Concern exists not only with regards to the surgical approach but also to the extent of the resection. The authors analyze their experience over a 20-year period adopting almost exclusively a "limited" esophagogastrectomy with a wide regional lymphadenectomy through a left thoracotomy. The aim of the study is to determine if this approach actually plays a role in the treatment of this tumor. METHODS: 148 patients were evaluated for cardial cancer. Of these 22 (14.8%) were not resectable and 6 (4%) received other types of resections for technical reasons. 120 patients are the basis of the present analysis. More than 75% of patients were in stage III or IV. Follow-up was completed in 92.5% of cases; all surviving patients had at least 5 years of follow-up. RESULTS: Four (3.3%) patients died in the postoperative period. In 6 cases (5%) an anastomotic leakage occurred and this caused the death of 2 patients. Nine (7.5%) patients had severe pulmonary complications. Dysphagia was relieved in all non complicated patients. 13 (10.8%) patients had anastomotic recurrence. Overall survival rate after 5 years was 25.62 +/- 6.1%. A significant difference in survival was noted in patients at stages II and III after 5 years (61.3% vs 18.6, p < 0.02). CONCLUSIONS: This operation has proved to be a good option providing satisfying long-term results and a lower incidence of complications if compared with more extended procedures. It can be performed in the majority of patients with carcinoma of the cardia with a low mortality and morbidity and with excellent palliation of dysphagia. In our opinion it remains an optimum treatment for cardial cancer.

Hepatic adenoma and focal nodular hyperplasia: diagnosis and criteria for treatment.

UNLABELLED: Focal nodular hyperplasia (FNH) and adenoma are rare benign hepatic tumors, and the standards for diagnosis and treatment still remain controversial. Usually adenoma is an indication for resection, due to its tendency to bleed and to degenerate; FNH, on the contrary, may be treated conservatively. Preoperation differential diagnosis is, however, difficult, often impossible. MATERIALS AND METHODS: Thirty-eight patients with presumed hepatic adenoma and/or FNH were studied at our department from 1984 to 1996. Preoperative assessment included clinical evaluation and symptoms, laboratory tests, liver biopsy, ultrasound scan, computed tomography scan, magnetic resonance imaging, scintigraphy, and angiography. Thirteen patients had a presumed diagnosis of FNH, 16 of adenoma, and 9 of undetermined benign lesions; 27 had hepatic resections (3 with laparoscopic technique), and 11 were not operated on and are actually under a strict follow-up observation. RESULTS: The final diagnosis was 19 FNH and 19 adenomas (2 of which contained areas of hepatocarcinoma). Presumed diagnosis was confirmed in 71% of cases. Use of oral contraceptives, abdominal symptoms, and pathologic liver test results were frequent in patients with adenomas. There were no deaths after surgery. All resected patients were tumor free during the follow-up, and in 10 of the 11 nonoperated cases, the size of the nodules remained unchanged. We conclude that precise diagnosis of these benign liver tumors remains difficult and sometimes impossible, despite new imaging techniques. Hepatic resections can be performed under very safe conditions; laparoscopic surgery may play a role in selected cases. Adenomas and uncertain cases are clear indications for surgery. Only when a diagnosis of FNH can be firmly confirmed in asymptomatic patients is strict observation without surgery recommended.