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Background With increasing rates of liver transplantation and a stagnant donor pool, the annual wait list removals have remained high. Living donor liver transplantation (LDLT) is an established modality in expanding the donor pool and is the primary method of liver donation in large parts of the world. Marginal living donors, including those with hepatic steatosis, have been used to expand the donor pool. However, due to negative effects of steatosis on graft and recipient outcomes, current practice excludes overweight or obese donors with more than 10% macro vesicular steatosis. This has limited a potentially important source to help expand the donor pool. Weight loss is known to improve or resolve steatosis and rapid weight loss with short-term interventions have been used to convert marginal donors to low-risk donors in a small series of studies. There is, however, a lack of a consensus driven standardized approach to such interventions. Aim To assess the available data on using weight loss interventions in potential living liver donors with steatotic livers and investigated the feasibility, efficacy, and safety of using such donors on the donor, graft and recipient outcomes. The principal objective was to assess if using such treated donor livers, could help expand the donor pool. Methods We performed a comprehensive literature review and meta-analysis on studies examining the role of short-term weight loss interventions in potential living liver donors with hepatic steatosis with the aim of increasing liver donation rates and improving donor, graft, and recipient outcomes. Results A total of 6 studies with 102 potential donors were included. Most subjects were males (71). All studies showed a significant reduction in body mass index post-intervention with a mean difference of -2.08 (-3.06, 1.10, I 2 = 78%). A significant reduction or resolution of hepatic steatosis was seen in 93 of the 102 (91.2%). Comparison of pre- and post-intervention liver biopsies showed a significant reduction in steatosis with a mean difference of -21.22 (-27.02, -15.43, I 2 = 56%). The liver donation rates post-intervention was 88.5 (74.5, 95.3, I 2 = 42%). All donors who did not undergo LDLT had either recipient reasons or had fibrosis/steatohepatitis on post intervention biopsies. Post-operative biliary complications in the intervention group were not significantly different compared to controls with an odds ratio of 0.96 [(0.14, 6.69), I 2 = 0]. The overall post-operative donor, graft, and recipient outcomes in treated donors were not significantly different compared to donors with no steatosis. Conclusion Use of appropriate short term weight loss interventions in living liver donors is an effective tool in turning marginal donors to low-risk donors and therefore in expanding the donor pool. It is feasible and safe, with comparable donor, graft, and recipient outcomes, to non-obese donors. Larger future prospective studies are needed.

Background In the context of liver transplantation for hepatocellular carcinoma (HCC), traditional transplant criteria appear restrictive. The objective of the current study was to determine risk factors for recurrence and improve transplant eligibility in patients with HCC. Materials and methods This was a retrospective study of patients who underwent living donor liver transplant (LDLT) for HCC (n = 219). Largest tumor diameter, tumor number, AFP and neutrophil to lymphocyte ratio were assessed. Multivariate analysis was performed to develop risk scores. The new model was compared with seven previously published transplant criteria using receiver operator curves. Results Largest tumor size >3.7 cm [HR:2.6, P = 0.02], and AFP > 600 ng/ml [HR:4.7, P = 0.001] were independent predictors of recurrence. Patients with risk scores of 0, 1–3, 4–6 and 7–9 had recurrence rate of 5.9%, 12.5%, 25% and 58.4% respectively. When compared with Milan criteria, Metro ticket 2.0, AFP model and Samsung criteria; transplant eligibility increased by 31.5%, 22.9%, 8.7%, and 7% respectively. Recurrence rate with the current model was 16/199 (8%) (P, Highlights • There is an unmet need to expand transplant pool for hepatocellular carcinoma. • We developed a model, based on tumor size cutoff of 3.7 cm, any tumor number, and AFP cutoff of 600 ng/ml; and compared it with other transplant criteria. • There was considerable expansion in transplant pool with comparable outcomes.

Ascaris lumbricoides is one of the most common parasitic infections in developing countries. History of previous biliary tract surgery risks migration of these worms to the biliary tree. Usually, 10% of patients with living donor liver transplants have biliary complications including bile leak and strictures. Here, we present an unusual case of ascariasis being a cause of biliary obstruction and bile leak in the immediate postoperative period of liver transplant.

Background/aims Bile leak is one of the most common complications of liver transplantation. The treatment options for bile leaks include conservative management, surgical re-intervention, percutaneous drainage and endoscopic drainage. We aimed to perform a systematic review to identify the efficacy of endoscopic treatment in the resolution of post-transplant bile leaks. Methods Two independent reviewers performed systematic literature search in PubMed, ISI Web of Science, grey literature and relevant references in May 2017. Human studies in English with documented post-liver transplant bile leaks were included. Results Thirty-four studies were included in the final analysis. The pooled efficacy of biliary stents for the resolution of post-transplant bile leaks was 82.43% compared with 87.15% efficacy of nasobiliary tubes. The efficacy of biliary stents was lower for anastomotic leaks (69.23%) compared to T-tube (90.9%) or cut-surface/ cystic duct stump related leaks (92.8%). Similarly, the efficacy of nasobiliary tube was also lower for anastomotic leaks (58.33%) compared to T-tube or cut-surface related leaks (100%). Conclusion In this systematic review, the overall efficacy was 82.43% in biliary stent group, and 87.15% in nasobiliary tube group. Both biliary stent and nasobiliary tube were more effective in managing non-anastomotic leaks compared to anastomotic leaks.

Background Routine use of (MBR) by Roux en Y in adult Orthotopic Liver Transplantation (OLT) has not been elucidated. The usual choice of enteric drainage got expected morbidities of biliary enteric anastomosis. Patients of liver transplant clinical differences are compared. Choices, current status, efficacy, application, short and long term outcome of biliary reconstruction by (MBR) roux en Y anastomosis in adult liver transplant was compared to Conventional roux en y. Aim The primary aim of the study is to clarify the influence to the diseased liver recipient duct to the future graft biliary drainage. Methods Study of consecutive liver transplant patients was retrieved. Total Number of 1234 OLT, By the End of July 2014. Group A 16 patients of Conventional Period up to 22 March, 2006. Group B 50 patients of (MBR) up to 31 JULY 2014. Results In group A 8/16 got short and long term complication. However, in group B only 4/50 got short term problems, with no death. Conclusion In Spite of the drawback of adult OLT roux en Y hepatico-jejunal anastomosis including anatomical challenges and graft position, we developed graft survival in adults liver transplant with widened application of (MBR). There is accessible and durable intact biliary drainage choice by (MBR) hepatica enteric anastomosis for adults OLT patients that can be encouraged and advised by microscopic surgery.

Background/aims: an increased post-operative mortality risk has been reported among patients who undergo living donor liver transplantation (LDLT) with higher model for end-stage liver disease (MELD) scores. In this study, we investigated the effect of MELD score reduction on post-operative outcomes in patients with a high MELD (>= 20) score by pre-transplant management. Materials and methods: we retrospectively analyzed 386 LDLT cases, and patients were divided into low-MELD (= 20, n=93) groups according to their MELD score at the time of index hospitalization. Patients in the high-MELD group were managed specifically according to a treatment algorithm in an effort to decrease the MELD score. Patients in the high-MELD group were further divided into 2 subgroups: (1) responders (n=34) to pre-transplant treatment with subsequent reduction of the MELD score by a minimum of I point vs. (2) non-responders (n=59), whose MELD score remained unchanged or further increased on the day of LDLT. Responders vs. non-responders were compared according to etiology, demographics, and survival., NA

Hepatocellular carcinoma (HCC) recurrence after liver transplant is associated with a poor prognosis and significantly increases morbidity and mortality among liver transplant patients. Therefore, this meta-analysis aims to evaluate the overall prevalence of HCC recurrence following liver transplant. Medline and Embase databases were searched, and a meta-analysis of proportions was conducted. Observational studies reporting the prevalence of recurrent hepatocellular carcinoma (HCC) after liver transplant were included, with the analysis being stratified by adherence to Milan criteria, ethnicity, socio-economic status, alpha fetoprotein (AFP) levels, living donor vs. deceased donor, and the underlying aetiology of the liver disease. A meta-regression on the date of the study completion was also performed. Of a total 40,495 patients, 3888 developed an HCC recurrence. The overall prevalence of recurrent HCC was 13% (CI: 0.12–0.15). Patients beyond the Milan criteria (MC) were more likely to recur than patients within MC. Asian populations had the greatest prevalence of HCC recurrence (19%; CI: 0.15–0.24) when compared to Western (12%; CI: 0.11–0.13) and Latin American populations (11%; CI: 0.09–0.14). The prevalence of recurrent HCC was the highest in patients infected with hepatitis B virus (HBV) (18%; CI: 0.11–0.27) compared to other aetiologies. A higher AFP also resulted in an increased recurrence. This highlights interesting differences based on ethnicity, income, and aetiology, and further studies are needed to determine the reasons for the disparity.

Background Recently, benchmarks for pancreatic surgery have been proposed. Living donor liver transplantation (LDLT) is thought to have a positive impact on PD outcomes. The objective of the current study was to determine if the proposed benchmark cutoffs are achievable in an LDLT program with low to medium volumes for PD. Methods We retrospectively reviewed patients who underwent PD between 2011 and 2018 (N = 116). Their outcomes were assessed and compared with benchmark cutoffs for pancreatic surgery based on results from high volume centers (HVC) for PD. During the same period, 759 LDLTs were performed in our center. Outcomes were further compared based on whether PD was performed in low volume (≤76/year) (Group 1) or high volume (>76/year) (Group 2) transplant years. Results Out off 20 benchmarks, 15 (75%) were met while 19/20 (95%) were within range reported from HVC-PD. Benchmarks remained within range for biochemical leak (15.5% vs 13%, 1.3–22.7%), grade 4 complications (12.1% vs 5%, (0–14%), hospital mortality (3.8% vs 1.6%, 0–4%) and failure to rescue (24.4% vs 9%, 0–25%). There was a significant reduction in blood transfusion rate (69% vs 39.5%, P = 0.003) in group 2 while patients with at least one complication (45.5% vs 66.7%) (P = 0.04), median hospital stay (9 vs 11, P = 0.004), and median comprehensive complication index (CCI) (0 vs 20.9, P = 0.005) increased. Conclusion Best achievable results for PD can be reproduced in LDLT programs with low to moderate PD volumes. Transition to a high volume transplant center does not confer additional improvement in outcomes., Highlights ∙ This is the first study to objectively assess impact of living donor liver transplant (LDLT) experience on pancreaticdoudenectomy (PD) outcomes. ∙Even with low to moderate PD volumes, LDLT programs can achieve outcomes comparbale to high volume centers. ∙Transition from low to high annual LDLT volume does not confer any additional improvement in PD outcomes.

Background: Prospective recipients of liver transplant (LT) have a high prevalence rate of coronary artery disease (CAD) requiring revascularization. In patients of Child Turcot Pugh Class B and C performing LT prior to cardiac revascularization on cardiopulmonary bypass leads to a high risk of major adverse cardiovascular events (MACE). Whereas, isolated cardiac surgery prior to LT has perioperative risk of coagulopathy, sepsis, and hepatic decompensation. We present four cases of end stage liver disease who underwent concomitant living donor liver transplant (LDLT) with off pump coronary artery bypass graft (OPCAB) in an effort to decrease the morbidity and mortality. Methods: The cases were performed in a tertiary care centre over two years. Four patients scheduled for LDLT, who were diagnosed with significant CAD, underwent single sitting OPCAB and LDLT. Cardiac surgery was performed first and once patient was stable, it was followed by LDLT. The morbidity parameters in terms of duration of intubation, blood transfusion, hospital stay, ICU stay, requirement of dialysis, atrial fibrillation and sepsis was compared with similar studies. Results: The blood transfusion requirement (median 8 units PRBC), incidence of atrial fibrillation (25%), sepsis (25%), and renal dysfunction (0%) was less than the combined surgery conducted on cardiopulmonary bypass. The rate of median intubation time, length of ICU stay, hospital stay, and one year mortality rate was comparable with other studies. Conclusions: Morbidity with combined OPCAB and LDLT is less than combined on pump coronary artery bypass surgery with LDLT. Combined CABG with LDLT may be performed with acceptable outcomes in CTP class B and C cirrhosis.

Over the last 17 years, liver transplant in India has evolved from a rarity to a common procedure available along the length and breadth of the country with survival data comparable to the best centres in the world. India is now in the forefront of Living donor liver transplant (LDLT) in the world, led by the team of the principal author. LDLT is possible for all types of recipients and indications with 95% success, with low incidence of vascular complications and biliary complications. While Deceased donor liver transplants (DDLTs) have picked up steam in Southern India, there is still a large gap between demand and supply of organs. LDLT is essential to bridge this gap and continues to be the main curative option for the majority of patients in India suffering from end-stage liver disease and Hepato cellular carcinoma (HCC) confined to the liver.

Aim: Over the last decade, the number of liver transplantations and centers that provide this service in India have grown exponentially. However, not all practices relevant to liver transplantation are uniform across the country. We decided to get the opinion from living donor liver transplant (LDLT) centers across the country on four specific aspects relating to LDLT. Methods: We formulated four specific questions that were carefully worded to incorporate aspects of “routine practice” and also answerable in the negative or affirmative, so as to make comparison possible. We collected the data of LDLT centers in India from popular resources such as MOHAN Foundation, from our institutional memory, and also by inquiring with respondents. The following questions were asked: (1) Do you routinely use N-acetyl cysteine for LDLT donors? (2) Do you use routinely use prostaglandin E1 (alprostadil) to facilitate hepatic artery flow in recipients? (3) Do you routinely use antiplatelets to prevent hepatic artery thrombosis in adult LDLT recipients? (4) Do you routinely use low molecular weight heparin for deep vein thrombosis prophylaxis after donor hepatectomy? Results: We received a total of 38 responses, of which 34 were complete. Conclusions: There is no consensus among practitioners regarding the studied aspects of the practice pertinent to immediate postoperative care in liver transplantation. This is primarily because there is neither evidence nor clear guidance from learned societies regarding these issues.

Purpose This study was designed to analyze factors related to the success of salvage liver transplantation (SLT) in hepatocellular carcinoma (HCC). While liver resection (LR) is considered the best locoregional therapy in HCC, there is a high recurrence rate. SLT may be the best treatment option when feasible. Methods Patients who underwent living donor SLT for recurrent HCC after LR from November 1996 to May 2017 were included. Patient demographic data, clinical and pathologic characteristics, operative data, hospital course, and follow-up data regarding initial LR, locoregional therapy after recurrence and SLT were reviewed. Prognostic factors for recurrence were analyzed using Cox proportional hazard ratio. Results Eighty-five of 123 SLT patients were included. Patients who had five or more locoregional therapies prior to SLT (hazard ratio [HR], 3.74; 95% confidence interval [CI], 1.45–9.64, P = 0.006), hepatitis B (HR, 9.20; 95% CI, 1.13–74.89; P = 0.04), outside Milan criteria at the time of SLT (HR, 2.66, 95% CI, 1.26–5.63; P = 0.011) and an alpha-fetoprotein level above 1,000 ng/mL at the time of recurrence after initial LR (HR, 6.48; 95% CI, 1.83–22.92; P = 0.004) and at the time of transplantation (HR, 3.43; 95% CI, 1.26–5.63; P = 0.011) were related to significant risk of recurrence. Conclusion Continuing five or more locoregional therapies for recurrent HCC after LR is related to poor recurrence-free survival after SLT.

Objectives To compare long-term survival of living donor liver transplant (LDLT) at experienced transplant centers with outcomes of deceased donor liver transplant and identify key variables impacting patient and graft survival. Background The Adult-to-Adult Living Donor Liver Transplantation Cohort Study is a prospective multicenter National Institutes of Health study comparing outcomes of LDLT and deceased donor liver transplant and associated risks. Methods Mortality and graft failure for 1427 liver recipients (963 LDLT) enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study who received transplant between January 1, 1998, and January 31, 2014, at 12 North American centers with median follow-up 6.7 years were analyzed using Kaplan-Meier and multivariable Cox models. Results Survival probability at 10 years was 70% for LDLT and 64% for deceased donor liver transplant. Unadjusted survival was higher with LDLT (hazard ratio = 0.76, P = 0.02) but attenuated after adjustment (hazard ratio = 0.98, P = 0.90) as LDLT recipients had lower mean model for end-stage liver disease (15.5 vs 20.4) and fewer received transplant from intensive care unit, were inpatient, on dialysis, were ventilated, or with ascites. Posttransplant intensive care unit days were less for LDLT recipients. For all recipients, female sex and primary sclerosing cholangitis were associated with improved survival, whereas dialysis and older recipient/donor age were associated with worse survival. Higher model for end-stage liver disease score was associated with increased graft failure. Era of transplantation and type of donated lobe did not impact survival in LDLT. Conclusions LDLT provides significant long-term transplant benefit, resulting in transplantation at a lower model for end-stage liver disease score, decreased death on waitlist, and excellent posttransplant outcomes. Recipient diagnosis, disease severity, renal failure, and ages of recipient and donor should be considered in decision making regarding timing of transplant and donor options.Clinical Trials ID: NCT00096733.

Background This study was carried out in Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan, with the aim of reviewing the characteristics and the outcome of liver transplantation (LT) in children with Alagille syndrome (AGS). Methods We performed a retrospective analysis of transplant records of children diagnosed with AGS and undergoing LT between 1987 and 2010. Results Nine patients underwent living donor LT. Cholestasis and characteristic facies were seen in all patients. Posterior embryotoxon was seen in 4/9 (44.4%), butterfly vertebrae in 3/9 (33.3%), heart defect (pulmonary stenosis in 2) in 3/9 (33.3%), and renal disease in 2/9 (22.2%) patients. Five cases had cholestasis prior to the age of 60 days, whereas four cases had cholestasis after 60 days of age. Iminodiacetic acid scans showed no excretion of isotope into the bowel in four cases and suggested a false diagnosis of biliary atresia. All patients underwent diagnostic laparotomy and liver biopsy. Results of liver biopsy showed characteristic features of paucity of interlobular bile ducts in all patients. Kasai portoenterostomy was not performed in any patient prior to being referred for LT. The mean age at the time of LT was 4.6 years. The 5-year overall survival rate after living donor LT was 88.9%. Conclusion Our conclusion is that the clinical features of AGS are informative. In addition, histological confirmation is important in the diagnosis. AGS children with severe liver disease had good prognoses with LT.