Seoul, Korea

Salvage living-donor liver transplantation to previously hepatectomized hepatocellular carcinoma patients: is it a reasonable strategy?

Sung-Gyu Lee

Seoul, Korea

Salvage liver transplantation (LT) has been performed for recurred hepatocellular carcinoma (HCC) or for deterioration of liver function after resection of HCC. Controversies arise, however, over the technical feasibility of salvage LT in patients who underwent liver surgery, especially concerning recipient's remnant hepatectomy with torrential amount of bleeding.[1,2]Heavy adhesions are often encountered after prior liver resection, and numerous collateral veins penetrate into these adhesions in patients with portal hypertension. This technical diff i culty is one of the reasons why many transplant surgeons are unwilling to perform salvage LT, especially after major hepatectomy.

Salvage living donor liver transplantation (LDLT) is a more demanding procedure than deceased donor liver transplantation (DDLT) using the whole-size graft donor with a long vascular pedicle. It has high morbidity and mortality by more blood loss, short vascular pedicles (HA, BD, PV, HV), and co-existing HA injury and/or ischemic BD injury by repeated transarterial chemoembolization. It is more demanding if patients have portal hypertension (+)/previous major hepatectomy. Indications for salvage LT have been reported to be different in the hepatic functional basis (1.Evidence of hepatic dysfunction: Child-Pugh score ≥7 and MELD ≥10; 2.Major complication: ascites, variceal bleeding, encephalopathy), the availability of the alternative forms of HCC treatment (1.No effective alternate therapy; 2.Previous treatmentshown to be ineffective), and the acceptable extent of recurrent HCC determining the potential for successful outcome (1.Within the Milan criteria; 2.Expansion of inclusion criteria in LDLT should be careful). Selection criteria of salvage LDLT for HCC recurrence should be more strict than DDLT, because the live-donor's benef i t solely comes from the recipient's good outcome.[3]Basically, HCC selection criteria for salvage LDLT are the same as those for primary LT. When the histology of the previously resected HCC demonstrated poor prognostic signs of early HCC recurrence after LT such as vascular invasion, poorly-differentiated tumor, combined HCC, cholangiocarcinoma (CCC), and satellite nodules, salvage LDLT should be cautiously considered.

Fig. 1.DDLT is no-touch tumor operation withen-blocremoval of IVC (vena cava), whereas LDLT with Piggy-Back preservation of IVC may spread tumor by surgical manipulation. LDLT can be a no-touch tumor operation when IVC is en-blocresected and reconstructed with artif i cial (Dacron graft) vascular graft.

Fig. 2.Hepatocellular carcinomas that were surgically treated cases at the Asan Medical Center, Ulsan University.

LDLT can theoretically provide an unlimited resource of liver grafts and eliminate the uncertainty of prolonged waiting time and the risk of drop-out due to tumor progession compared to DDLT.[4]Despite of theoretical survival benef i t of LDLT over DDLT, enthusiasm for LDLT has been waned in many centers,[5]because it is technically demanding, increased surgery-related recipient morbidity,[6]and it results in the higher HCC recurrence than DDLT since DDLT is a non-touch tumor operation withen-blocremoval of the vena cava. However, LDLT with Piggy-Back technique may spread tumor by more surgical manipulation. Since 2009, we have applied the non-touchen-blocremoval of the vena cava in LDLT for HCC in the caudate lobe/hepatic vein-IVC conf l uence to decrease HCC recurrence (Fig. 1). Currently, near 50% of our adult LDLTs have been performed for HCC patients with or without hepatic decompensation. At the Asan Medical Center, 2778 adult LDLTs were performed from February 1997 to October 2012, and 100 salvage LDLTs (8.7% of adult LDLT for HCC) for recurred HCC were performed with an in-hospital mortality of 5.1% that was 2.5 times higher than that for LDLTs for primary HCC. The technical concern of salvage right-lobe LDLT in previously right hepatectomized recipient is to secure the reconstruction of hepatic venous outf l ow, but the formation of new right hepatic vein outf l ow with fencing of the great saphenous vein is technically feasible in any circumstances.[7]The overall 5-year survival rate of salvage LDLT for HCC patients within the Milan/UCSF criteria was comparable to that of primary LDLT (76.9% vs 79.5%). HCC is the sixth most common cancer worldwide, and is the third most common cause of cancerrelated death. Its incidence is 5 or 6 fold higher in Asia than North America and Europe. So, HCC is a disease of Asia. In our practice, the annual number of hepatic resections for HCC has been over 700, with more than 150 LDLTs for HCC.[8]Accordingly, salvage LDLT for recurred HCC is increasing with an in-hospital mortality of less than 2.5% (Fig. 2).

In conclusion, salvage LDLT after major liver resection is still technically demanding with more blood loss, especially in portal hypertensive patients, but with recent technical ref i nement, the postoperative complication rate and in-hospital mortality have been lowered. Our experiences have shown that any combination of recipients' prior liver resections and various forms of LDLT, even in dual grafts transplantation, is feasible for salvage LDLT, and that the long-term survival of HCC patients within the Milan/UCSF criteria is similar between primary LDLT and salvage LDLT.

1 Belghiti J, Cortes A, Abdalla EK, Régimbeau JM, Prakash K, Durand F, et al. Resection prior to liver transplantation for hepatocellular carcinoma. Ann Surg 2003;238:885-893.

2 Adam R, Azoulay D, Castaing D, Eshkenazy R, Pascal G, Hashizume K, et al. Liver resection as a bridge to transplantation for hepatocellular carcinoma on cirrhosis: a reasonable strategy? Ann Surg 2003;238:508-519.

3 Lo CM, Fan ST, Liu CL, Chan SC, Wong J. The role and limitation of living donor liver transplantation for hepatocellular carcinoma. Liver Transpl 2004;10:440-447.

4 Moon DB, Lee SG. Adult-to-adult living donor liver transplantation at the Asan Medical Center. Yonsei Med J 2004;45:1162-1168.

5 Poon RT, Fan ST, Lo CM, Liu CL, Wong J. Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function: implications for a strategy of salvage transplantation. Ann Surg 2002;235:373-382.

6 Hwang S, Lee SG, Moon DB, Ahn CS, Kim KH, Lee YJ, et al. Salvage living donor liver transplantation after prior liver resection for hepatocellular carcinoma. Liver Transpl 2007; 13:741-746.

7 Lee SG. Techniques of reconstruction of hepatic veins in living-donor liver transplantation, especially for right hepatic vein and major short hepatic veins of right-lobe graft. J Hepatobiliary Pancreat Surg 2006;13:131-138.

8 Lee SG, Moon DB. Living donor liver transplantation for hepatocellular carcinoma. Recent Results Cancer Res 2013; 190:165-179.

Received December 31, 2012

Accepted after revision January 15, 2013

AuthorAff i liations:Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, College of Medicine, Ulsan University, Seoul, Korea (Lee SG)

Sung-Gyu Lee, MD, FACS, Professor of Surgery, Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, College of Medicine, Ulsan University, 88, Olympic-ro 43-Gil, Singpa-Gu, Seoul 138-736, Korea (Email: sglee2@amc.seoul.kr)

? 2013, Hepatobiliary Pancreat Dis Int. All rights reserved.

10.1016/S1499-3872(13)60001-6