Surgical dilemma: liver resection or liver transplantation for hepatocellular carcinoma and cirrhosis. Intention-to-treat analysis in patients within and outwith Milan criteria

AbstractBackgroundThe optimal role of surgery in the management of hepatocellular carcinoma (HCC) is in continuous evolution.ObjectiveThe objective of this study was to analyse survival rates after liver resection (LR) and orthotopic liver transplantation (OLT) for HCC within and outwith Milan criteria in an intention-to-treat analysis.MethodsDuring 1997–2007, 179 patients with cirrhosis and HCC either underwent LR (n= 60) or were listed for OLT (n= 119). Patients with incidental HCC after OLT, preoperative macrovascular invasion before LR, non-cirrhosis and Child–Pugh class C cirrhosis prior to OLT were eliminated, leaving 51 patients primarily treated with LR and 106 patients listed for primary OLT (84 of whom were transplanted) to be included in this analysis. A total of 66 patients fell outwith Milan criteria (26 LR, 40 OLT) and 91 continued to meet Milan criteria (25 LR, 66 OLT).ResultsThe median length of follow-up was 26 months. The mean waiting time for OLT was 7 months. During that time, 21 patients were removed from the waiting list as a result of tumour progression. Probabilities of dropout were 2% and 13% at 6 and 12 months, respectively, for patients within Milan criteria, and 34% and 57% at 6 and 12 months, respectively, for patients outwith Milan criteria (P < 0.01). Tumour size >3cm was found to be the independent factor associated with dropout (hazard ratio [HR] 6.0). Postoperative survival was slightly higher after OLT, but this was not statistically significant (64% for OLT vs. 57% for LR). Overall survival from time of listing for OLT or LR did not differ between the two groups (P= 0.9); for patients within Milan criteria, 1- and 4-year survival rates after LR were 88% and 61%, respectively, compared with 92% and 62%, respectively, after OLT (P= 0.54). For patients outwith Milan criteria, 1- and 4-year survival rates after LR were 69% and 54%, respectively, compared with 65% and 40%, respectively, after OLT (P= 0.42). Tumour size >3cm was again found to be an independent factor for poor outcome (HR 2.4) in the intention-to-treat analysis.ConclusionsSurvival rates for patients with HCC are similar in LR and OLT. Liver resection can potentially decrease the dropout rate and serve as a bridge for future salvage LT, particularly in patients with tumours >3cm

The International Liver Transplant Society Guideline on Living Liver Donation.

The following guideline represents the position of the International Liver Transplantation Society (ILTS) on key preoperative, operative, and postoperative aspects surrounding living liver donation. These recommendations were developed from experts in the field from around the world. The authors conducted an analysis of the National Library of Medicine indexed literature on "living donor liver transplantation" [Medline search] using Grading of Recommendations Assessment, Development and Evaluation methodology. Writing was guided by the ILTS Policy on the Development and Use of Practice Guidelines (www.ilts.org). ILTS members, and many more nonmembers, were invited to comment. Recommendations have been based on information available at the time of final submission (March 2016). The lack of randomized controlled trials in this field to date is acknowledged and is reflected in the grading of evidence. Intended for use by physicians, these recommendations support specific approaches to the diagnostic, therapeutic, and preventive aspects of care

Right hepatectomy for living donation: Role of remnant liver volume in predicting hepatic dysfunction and complications

BACKGROUND: Extensive attention has been placed on remnant liver volume (RLV) above other factors to ensure donor safety. METHODS: We performed a retrospective review of 137 right hepatectomies in live donors between June 1999 and November 2010. RESULTS: Median right lobe volume was 1,029 cm(3), which correlated with its actual weight (r = 0.63, P 3 mg/dL or prothrombin time >18 s on postoperative day 4). RLV did not predict postoperative hepatic dysfunction (P = .9), but it was associated with peak international normalized ratio (INR) (P = .04). Donor age and male gender were predictors of increased bilirubin at postoperative day 4 (age, P = .03; gender, P = .02). Of the donors, 45 (33%) experienced complications, and 24 donors had RLVs <30%; 42% experienced complications compared to 31% of donors whose RLVs were greater than 30% (P = .3). Cell-saver utilization and aspartate-aminotransferase (AST) levels (OR = 3) were associated with complications. Volumetric assessment can predict RLV accurately. CONCLUSION: Although no demonstrable association between RLV <30% and complications was found, an RLV of 30% should remain the threshold for donor safety. Age and gender should be balanced in donors with a near threshold RLV of 30%. Surgical complexity, suggested by the need for intraoperative autoinfusion of blood and postoperative levels of AST, remained the independent predictor of complications.Fil: Facciuto, Marcelo. Mount Sinai Medical Center; Estados UnidosFil: Contreras Saldivar, Alan. Mount Sinai Medical Center; Estados UnidosFil: Singh, Manoj K.. Mount Sinai Medical Center; Estados UnidosFil: Rocca, Juan Pablo. Mount Sinai Medical Center; Estados UnidosFil: Taouli, Bachir. Mount Sinai Medical Center; Estados UnidosFil: Oyfe, Irina. Columbia University; Estados UnidosFil: LaPointe Rudow, Dianne. Mount Sinai Medical Center; Estados UnidosFil: Gondolesi, Gabriel Eduardo. Fundación Favaloro; Argentina. Universidad Favaloro; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Schiano, Thomas. Mount Sinai Medical Center; Estados UnidosFil: Kim Schluger, Leona. Mount Sinai Medical Center; Estados UnidosFil: Schwartz, Myron E.. Mount Sinai Medical Center; Estados UnidosFil: Miller, Charles M.. Cleveland Clinic. Digestive Disease Institute. Department of Hepato-Pancreato-Biliary and Transplant Surgery ; Estados UnidosFil: Florman, Sander. Mount Sinai Medical Center; Estados Unido