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Liver transplantation for primary tumors originating in the liver or biliary tree, not suitable because of location of extent for subtotal hepatic resection, has been disappointing. So has liver transplantation for tumors metastatic to the liver. Although many patients receiving a liver transplant for malignant disease are technically easier to operate on than patients with cirrhosis and such patients often make a swift postoperative recovery, disease recurrences within 6 to 18 months is common despite the additional field of resection a transplant hepatectomy can provide. Patients with disease extending beyond the liver capsule, into regional lymph nodes, or into major vascular structures such as the portal vein or vena cava, have a particularly poor prognosis and are probably not suitable candidates for liver transplantation alone.

For many years it was thought that transplantation of the liver was not subject of the common prohibitive barriers that must routinely be observed in renal transplantation. For example, incompatibility for ABO blood group antigens and the presence of preformed anti-lymphocytotoxic antibody directed against HLA specificies are prohibitive for kidney transplants but were not considered to be so for liver transplantation. However, as the expanded case experience of the last decade became available for analysis, we have come to learn that some of the factors not previously considered important in liver transplantation are indeed relevant.

Since the introduction of cyclosporine-steroid therapy in 1980 for liver transplantation, 1 year clinical survival rates have approached 70% for most of the common indications for liver replacement and 5 year survival rates are better than 60%. Nevertheless, allograft rejection continues to be a significant cause of retransplantation or death. Clinical rejection occurs in 70% of liver allograft recipients on cyclosporine-steroid therapy. Many patients require treatment with polyclonal or monoclonal antibody preparations to control acute cellular rejection. An increased risk of opportunistic infection, especially from cytomegalovirus, is associated with such therapy.

I have been asked to address the current status of liver transplantation. To understand the current state of the art in this field, one must appreciate what has gone on before, so building on the historical foundation which Dr Lee has provided, I will review with you from a historical perspective where we are today in liver transplantation. I have been greatly assisted by and relied heavily on earlier reviews of the history of developments in liver transplantation provided by my mentor, the man who has paved the path for all working in this field, Thomas Starzl (1).

The modern techniques for liver preservation evolved from work over many years in Thomas Starzl’s lab in Denver, Sir Roy Calne’s lab in Cambridge, and Folkert Belzer’s laboratory in Madison. In 1963 Marchioro, working in Starzl’s laboratory, reported the first systematic attempt to preserve organs by continuous hypothermic perfusion, using the cadaver as the perfusion chamber and providing flow and oxygenation with a mechanical heart-lung machine (1). The method was used clinically in the mid-60’s before brain death became a condition of organ donation. Cadavers with no heart beat could be effectively and quickly cooled with this technique. This experience provided the basis for the in situ cooling techniques that are now in standard use for modern multiple organ procurement.