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A group of 118 adults who underwent primary, orthotopic transplantation of the liver over a 4-year period served as the subjects of a detailed examination of their ability to survive the first 6 months as a function of their preoperative condition. As a result, a scoring system was developed empirically in an attempt to separate very high-risk from relatively low-risk patients. The scoring method is based on the high degree of correlation between survival probability and various patient characteristics. It allows for additional scoring to account for the dramatic effect of operative blood loss on the eventual outcome. The curve that best describes the relationship between patient scores and survival probability is sigmoidal in shape. Many patients will have scores located on the curve between the inflection points. They represent a group whose relative risk is difficult to estimate but for whom operative blood loss or the occurrence of surgical complications may prove particularly telling.

During the last 5 years, liver transplantation has become a service as opposed to an experimental operation. The most important factor in making this possible has been the introduction of cyclosporine-steroid therapy. At the same time, liver transplantation has been made more practical by improvements in diagnosing and managing other causes of postoperative hepatic dysfunction. Tissue typing and matching have played no role in improving the results of liver transplantation. With the demonstration that performed antibody states are irrelevant, even avoidance of positive cross-matches caused by cytotoxic antibodies and observance of ABO blood group barriers have become unnecessary if the recipient's needs are great. With the exceptions of malignancy and cirrhosis, the nature of the underlying hepatic disease has not profoundly influenced the results. Retransplantation has played an important role in improving survival, although the costs of retransplantation have been extremely high.

At one time, the operation of orthotopic liver transplantation was viewed as too difficult and dangerous to be practical on a large scale. The image of the procedure as one requiring a virtuoso surgical team has changed during the last few years as the result of technical improvements. These have put the operation within the capability of many competent general and vascular surgeons. In this account, we will discuss various aspects of this still complex undertaking, with emphasis on those recently clarified details that stand above others in importance and significance.

Numerous causes can lead to hepatic dysfunction following orthotopic liver transplantation. The most common cause is rejection, which is usually nonpreventable. The clinical presentation, time of onset, and even treatment are variable. Other causes, such as perioperative ischemic injury, vascular thrombosis, and complications of bile duct reconstruction may be preventable with good surgical technique. Infections can also be minimized by careful adjustment of immunotherapy, avoidance overimmunosuppression, and the judicious use of antibiotics. Hepatic dysfunction following orthotopic liver transplantation requires rapid assessment and proper treatment in order to prevent serious and possibly fatal complications.