Search

Objective. To study the correlations and discrepancies between Child-Pugh system and indocyanine green (ICG) clearance test in assessing liver function reserve and explore the possibility of combining two systems to gain an overall liver function assessment. Design. Retrospective analysis of 2832 hepatocellular carcinoma (HCC) patients graded as Child-Pugh A and Child-Pugh B with ICG clearance test being performed was conducted. Results. ICG retention rate at 15 minutes (ICG15) correlates with Child-Pugh score, however, with a large variance. Platelet count improves the correlation between Child-Pugh score and ICG15. ICG15 can be estimated using the following regression formula: estimated ICG15 (eICG15) = 45.1 + 0.435 × bilirubin − 0.917 × albumin + 0.491 × prothrombin time − 0.0283 × platelet (R2=0.455). Patients with eICG15 >20.0% who underwent major hepatectomy had a tendency towards more posthepatectomy liver failure (4.1% versus 8.0%, p=0.09) and higher in-hospital mortality (3.7% versus 8.0%, p=0.052). They also had shorter median overall survival (5.10±0.553 versus 3.01±0.878 years, p=0.015) and disease-free survival (1.37±0.215 versus 0.707±0.183 years, p=0.018). Conclusion. eICG15 can be predicted from Child-Pugh parameters and platelet count. eICG15 correlates with in-hospital mortality after major hepatectomy and predicts long-term survival.

Background Hepatopancreatoduodenectomy is a complicated and challenging procedure but necessary for curative resection for advanced hepatobiliary malignancies. This retrospective study was to examine the safety and survival outcomes of hepatopancreatoduodenectomy in our center. Methods Prospectively collected data of 12 patients who underwent hepatopancreatoduodenectomy for advanced hepatobiliary malignancies in our hospital from January 1998 to December 2014 were analyzed. The primary endpoints are treatment-related morbidity and mortality and the secondary endpoints are overall survival and disease-free survival. Results Curative resection was achieved in 11 (91.7%) patients. Complications developed in 10 (83.3%) patients. Three hospital deaths resulted from multiorgan failure secondary to postoperative pancreatic fistula or hepaticojejunostomy leakage. Six of the nine remaining patients had disease recurrence. The nine patients had a median survival of 39.8 (5.3–151.8) months. The 1-, 3- and 5-year overall survival rates were 66.7%, 55.6% and 27.8%, respectively. The corresponding disease-free survival rates were 55.6%, 44.4% and 29.6%, respectively. Conclusions Morbidity and mortality after hepatopancreatoduodenectomy were significant. With R0 resection, the 5-year overall survival and disease-free survival rates were 27.8% and 29.6%, respectively.

Acute-phase inflammation plays a critical role in liver graft injury. Inflammasomes, multi-molecular complexes in the cytoplasm, are responsible for initiating inflammation. Here, we aimed to explore the role of inflammasomes in liver graft injury and further to investigate the regulatory mechanism. In a clinical liver transplant cohort, we found that intragraft expression of nucleotide-binding oligomerization domain-like receptor family pyrin domain containing 3 (NLRP3) inflammasomes was significantly up-regulated post-transplantation. Importantly, overexpression of NLRP3 was strongly associated with poor liver function characterized by high levels of ALT, AST, and urea, as well as neutrophil infiltration after transplantation. The significant correlation between NLRP3 and IL-1β mRNA levels led us to focus on one of the associated upstream regulators, telomere-independent repressor activator protein 1 (RAP1), which was further proved to be co-localized with NLRP3 in neutrophils. In the liver of a mouse model (hepatic ischaemia/reperfusion and hepatectomy model) and isolated neutrophils from RAP1-/- mice, the expression levels of NLRP3 and keratinocyte chemoattractant (KC) were significantly down-regulated in contrast to those in wild types. The levels of ALT and AST, as well as the neutrophil infiltration, were also decreased by RAP1 deficiency. In our clinical validation, intragraft KC expression was associated with NLRP3 and co-localized with RAP1 in neutrophils. Furthermore, NLRP3 inflammasomes were up-regulated by recombinant KC in the isolated neutrophils and liver of the mouse model. Our data demonstrated that NLRP3 inflammasomes, activated by the RAP1/KC axis, played a critical role in initiating inflammation during the early stage of liver graft injury. Targeting RAP1/KC/NLRP3 inflammasomes may offer a new therapeutic strategy against liver graft injury. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Background T4 hepatocellular carcinoma (HCC) with invasion to adjacent structure(s) may require resection of not only the tumor but also the invaded structure(s). This study aims to assess whether such combined resection for T4 HCC is justifiable. Methods Adult patients with T4 HCC were divided into three groups. Group 1: tumors and invaded adjacent structures were resected together if histopathologically confirmed tumor invasion; group 2: same as group 1 but histopathologically confirmed tumor adhesion; group 3: tumor resection only. Group comparisons were made. Results Totally 144 patients were included in the study. There were 71, 14 and 59 patients in groups 1, 2 and 3, respectively. The groups were comparable in demographics, complication and survival. Ten hospital deaths occurred (5, 0 and 5 in groups 1, 2 and 3, respectively; P =0.533). The 5-year overall survival (hospital mortality excluded) was 17.8% in group 1, 14.3% in group 2, and 28.9% in group 3 ( P =0.191). The 5-year disease-free survival was 10.4% in group 1 and 14.5% in group 3 (no data for group 2 yet) ( P =0.565). On multivariate analysis, macrovascular invasion and poor differentiation were risk factors for survival whereas combined resection did not impact patients' survival. Conclusions Combined resection achieved survival outcomes similar to tumor resection only. Patients with tumor invasion and those with tumor adhesion had comparable survival after combined resection. At centers with the required expertise, combined resection should be attempted to treat T4 HCCs with clinically suspected invasion of adjacent structures.

Background Prediction of hepatorenal syndrome (HRS) remains difficult in advanced cirrhotic patients. Aims To evaluate use of serum and urine biomarkers to predict HRS. Methods We prospectively recruited Child’s B or C cirrhotic patients with normal serum creatinine, and followed them for 12 weeks for the development of HRS. Serum Cystatin C (CysC), serum and urine Neutrophil Gelatinase-Associated Lipocalin (NGAL), serum and urine IL-18, serum N-acetyl-β- d glucosaminidase (NAG), urine kidney injury molecule-1 (KIM-1) and urine liver-type fatty acid binding protein (LFABP) were measured at recruitment (baseline), and their relationship with subsequent HRS investigated. Results 43 patients were included. 12 (27.9%) developed HRS at 7.3 ± 5.1 weeks from baseline. Logistic regression analysis showed that baseline urinary NGAL and urinary KIM-1 were significantly associated with the development of HRS (RR 1.007, 95% CI 1.001–1.012, p = 0.014; RR 1.973, 95% CI 1.002–3.886, p = 0.049). The cut-off values for NGAL and KIM-1 to predict HRS were 18.72 ng/mL and 1.499 ng/mL respectively (AUCs 0.84, p = 0.005; and 0.78, p = 0.008). Conclusion Urinary NGAL and KIM-1 could serve as biomarkers to predict HRS in advanced cirrhotic patients.

To evaluate if living donor liver transplantation (LDLT) should be offered to patients with Model for End-stage Liver Disease (MELD) scores ≥35.No data was available to support LDLT of such patients.Data of 672 consecutive adult liver transplant recipients from 2005 to 2014 at our center were reviewed. Patients with MELD scores ≥35 were divided into the deceased donor liver transplantation (DDLT) group and the LDLT group and were compared. Univariate analysis was performed to identify risk factors affecting survival.The LDLT group (n = 54) had younger (33 yrs vs 50 yrs, P0.001) and lighter (56 Kg vs 65 Kg, P = 0.004) donors, lighter grafts (627.5 g vs 1252.5 g, P0.001), lower graft-weight-to-recipient-standard-liver-volume rates (51.28% vs 99.76%, P0.001), shorter cold ischemic time (106.5 min vs 389 min, P0.001), and longer operation time (681.5 min vs 534 min, P0.001). The groups were comparable in postoperative complication, hospital mortality, and graft survival and patient survival at one year (88.9% vs 92.5%; 88.9% vs 94.7%), three years (87.0% vs 86.9%; 87.0% vs 88.8%), and five years (84.8% vs 81.8%; 84.8% vs 83.3%). Univariate analysis did not show inferior survival in LDLT recipients.At centers with experience, the outcomes of LDLT can be comparable with those of DDLT even in patients with MELD scores ≥35. When donor risks and recipient benefits are fully considered and balanced, an MELD score ≥35 should not be a contraindication to LDLT. In Hong Kong, where most waitlisted patients have acute-on-chronic liver failure from hepatitis B, LDLT is a wise alternative to DDLT.

Objective:To investigate the long-term outcomes of pure laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma (HCC) with background cirrhosis.Background:Laparoscopic hepatectomy has been gaining popularity, but has not been widely accepted, because published data were gathere

Background/objective: One thousand liver transplantations have been performed at the only liver transplant center in Hong Kong over a period of 22 years, which covered the formative period of living donor liver transplantation. These 1000 transplantations, which marked the journey of liver transplantation from development to maturation at the center, should be educational. This research was to study the experience and to reflect on the importance of technical innovations and case selection. Methods: The first 1000 liver transplantations were studied. Key technical innovations and surgical therapeutics were described. Recipient survival including hospital mortality was analyzed. Recipient survival comparison was made for deceased donor liver transplantation and living donor liver transplantation indicated by hepatocellular carcinoma and other diseases. Results: Among the 1000 transplantations, 418 used deceased donor grafts and 582 used living donor grafts. With the accumulation of experience, hospital mortality improved to < 2% in the past 2 years. In the treatment of diseases other than hepatocellular carcinoma, living donor liver transplantation was superior to deceased donor liver transplantation, with a 10-year recipient survival around 90%. Conclusion: Transplant outcomes have been improving consistently over the series, with a very low hospital mortality and a predictably high long-term survival.

// Kevin Tak-Pan NG 1, 2 , Chung Mau Lo 1, 2 , Nathalie Wong 3 , Chang Xian Li 1, 2 , Xiang Qi 1, 2 , Xiao Bing Liu 1, 2 , Wei Geng 1, 2 , Oscar Wai-Ho Yeung 1, 2 , Yuen Yuen Ma 1, 2 , See Ching Chan 1 , Kwan Man 1, 2 1 Department of Surgery, The University of Hong Kong, Hong Kong 2 Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, China 3 Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong Correspondence to: Kwan Man, e-mail: kwanman@hku.hk Keywords: miR-1246, early-phase, liver transplantation, HCC recurrence, macrophage activation Received: October 27, 2015 Accepted: February 16, 2016 Published: February 23, 2016 ABSTRACT Post-liver transplantation tumor recurrence is a major challenge for hepatocellular carcinoma (HCC) recipients. We aimed to identify early-phase circulating microRNAs after liver transplantation for predicting tumor recurrence and survival of HCC recipients. Circulating microRNA profiles at early-phase (2-hour after portal vein reperfusion) after liver transplantation were compared between HCC recipients with (n=4) and without tumor recurrence (n=8) by microarray analyses. Candidate microRNAs were validated in 62 HCC recipients by quantitative RT-PCR. The prognostic values of microRNAs for tumor recurrence and survival were examined. Simulated in vitro ischemia-reperfusion injury models were employed to characterize the possible mechanism of up-regulation of circulating microRNAs. Our results showed that up-regulation of circulating miR-148a, miR-1246 or miR-1290 at early-phase was significantly associated with HCC recurrence after liver transplantation. Among them, miR-148a ( p =0.030) and miR-1246 ( p =0.009) were significant predictors of HCC recurrence. MiR-1246 was an independent predictor of overall ( p =0.023) and disease-free survival ( p =0.020) of HCC recipients. The level of early-phase circulating miR-1246 was positively correlated with serum AST and ALT levels in HCC recipients after liver transplantation. The expression of hepatic miR-1246 was positively correlated with TNF α mRNA. In vitro experiments indicated that injury-induced activation and differentiation of macrophages significantly elevated the expression and secretion of miR-1246. In conclusion, early-phase circulating miR-1246 is an indicator of hepatic injury and a novel prognostic biomarker for tumor recurrence and survival of HCC recipients after liver transplantation.

Background and aim Bile leakage is a major complication after right lobe living donor liver transplantation (RLDLT). It can result in significant morbidities and, occasionally, mortalities. Endo-radiology is a non-surgical means that has been used to manage this complication. This study reviews the outcomes of the endo-radiological approach to the management of bile leakage after RLDLT with duct-to-duct anastomosis (DDA) at a high-volume center. Method A retrospective study was conducted on all adult patients who received RLDLT at our center between January 2001 and December 2013. There were 496 RLDLTs performed during the study period. Only patients who had DDA as the only bile duct reconstruction method were included in the study. Results Twelve (3.7%) out of the 328 study subjects developed bile leakage after RLDLT. Six out of these 12 patients were successfully treated with the endo-radiological approach without the need for laparotomy. They had endoscopic retrograde cholangiography with stenting followed by percutaneous drainage of biloma. One of the 12 patients died from recurrence of hepatocellular carcinoma 37 months after transplantation. The remaining 11 patients are all alive. Conclusion The endo-radiological approach should be the first-line management for bile leakage for selected patients with DDA as the bile duct reconstruction method.

Laparoscopic left lateral sectionectomy has been proven to be a safe and effective treatment for liver lesions. However, most of the literatures only reported this treatment method on benign lesion or colorectal metastases. The data on long-term outcome of laparoscopic left lateral section resection in patients with HCC and cirrhosis are still limited. The aim of this study is to analyze the survival outcome of laparoscopic left lateral sectionectomy when compared to open approach in patients with HCCs.Between January 2004 and September 2014, 967 patients had primary HCC with hepatectomy performed. Twenty-four patients had undergone pure laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC). Twenty-nine patients with case-matched tumor characteristics and liver functions but received open left lateral sectionectomy for HCC were included for comparison.Comparing laparoscopic group to open resection group, the median operation time was 190.5 versus 195 min (P = 0.734); the median blood loss was 100 versus 300 ml (P0.001). Hospital stay was 5 days in laparoscopic group versus 6 days in the open group (P = 0.057). There was no difference between the two groups in terms of complications (P = 0.495). The median survival in laparoscopic group was115 months versus125 months in the open group (P = 0.853).Laparoscopic left lateral sectionectomy for HCC is a safe and simple procedure associated with less blood loss. The survival outcome is comparable with conventional open approach. It is becoming a more favorable treatment option even for patients with HCC and cirrhosis.

With improvements in survival, liver transplant recipients now suffer more morbidity from long-term immunosuppression. Considerations were given to develop individualized immunosuppression based on their risk of rejection.We retrospectively analyzed the data of 788 liver transplants performed during the period from October 1991 to December 2011 to study the relationship between acute cellular rejection (ACR) and various clinical factors.Multivariate analysis showed that older age (P=0.04, OR=0.982), chronic hepatitis B virus infection (P=0.005, OR= 0.574), living donor liver transplantation (P=0.02, OR=0.648) and use of interleukin-2 receptor antagonist on induction (P0.001, OR=0.401) were associated with fewer ACRs. Patients with fulminant liver failure (P=0.004, OR=4.05) were more likely to develop moderate to severe grade ACR.Liver transplant recipients with older age, chronic hepatitis B virus infection, living donor liver transplantation and use of interleukin-2 receptor antagonist on induction have fewer ACR. Patients transplanted for fulminant liver failure are at higher risk of moderate to severe grade ACR. These results provide theoretical framework for developing individualized immunosuppression.

This study was presented at the 11th World IHPBA Congress, 22–27 March 2014, Seoul., BACKGROUND: Hepatocellular carcinoma (HCC) with bile duct tumour thrombus (BDTT) is rare. The aim of the present study was to determine the prognosis of HCC with BDTT after a hepatectomy. METHODS: A retrospective analysis was performed on all HCC patients with BDTT having a hepatectomy from 1989 to 2012. The outcomes in these patients were compared with those in the control patients matched on a 1:6 ratio. RESULTS: Thirty-seven HCC patients with BDTT having a hepatectomy (the BDTT group) were compared with 222 control patients. Patients in the BDTT group had poorer liver function (43.2% had Child-Pugh B disease). More patients in this group had a major hepatectomy (91.9% versus 27.5%, P = 0.001), portal vein resection (10.8% versus 1.4%, P = 0.006), en-bloc resection with adjacent structures (16.2% versus 5.4%, P = 0.041), hepaticojejunostomy (75.7% versus 1.6%, P < 0.001) and complications (51.4% versus 31.1%, P = 0.016). The two groups had similar hospital mortality (2.7% versus 5.0%, P = 0.856), 5-year overall survival (38.5% versus 34.6%, P = 0.59) and 5-year disease-free survival (21.1% versus 20.8%, P = 0.81). Multivariate analysis showed that lymphovascular permeation, tumour size and post-operative complication were significant predictors for worse survival whereas BDTT was not. DISCUSSION: A major hepatectomy, extrahepatic biliary resection and hepaticojejunostomy should be the standard for HCC with BDTT, and long-term survival is possible after radical surgery. © 2014 International Hepato-Pancreato-Biliary Association., link_to_OA_fulltext

SummaryThe suitable size of a graft is a key element in the success of liver transplantation. A small-for-size liver graft is very likely to sustain a significant degree of injury as a result of ischemia, preservation, reperfusion, and rejection. Usually, small-for-size grafts are a concern in living-donor liver transplantation rather than in deceased-donor liver transplantation. Here, we describe the successful transplantation of a liver from a 2-year-old deceased donor to a 61-year-old male recipient who suffered from liver failure related to hepatitis B. No report of successful deceased-donor liver transplantation with discrepancies between donor and recipient age and size to such an extent has been found in the literature. Despite unusually large discrepancies, with effort in minimizing the ischemic time, revised surgical techniques, and strong regenerative power of the “young” graft, the old patient's liver function gradually returned to normal. This again proves that the definition of a “suitable graft” evolves with time and experience.

This study was presented at the 11th World Congress of the IHPBA, 22–27 March 2014, Seoul as 'Outcomes of unresectable solitary hepatocellular carcinomas China sized 5 to 8cm treated by radiofrequency ablation versus transarterial chemoembolization' by WC Dai., OBJECTIVES: This retrospective review was conducted to compare the efficacy of radiofrequency ablation (RFA) with that of transarterial chemoembolization (TACE) in treating large (5-8 cm) unresectable solitary hepatocellular carcinomas (HCCs). METHODS: Patients with large unresectable solitary HCCs primarily treated by RFA or TACE were reviewed. The primary endpoint was overall survival. Secondary endpoints were tumour response, time to disease progression, and treatment-related morbidity and mortality. RESULTS: There were 15 patients in the RFA group. Of these, 12 achieved complete ablation, one had ablation site recurrence, and five developed complications. Median disease-free survival in this group was 13.0 months (range: 2.8-38.0 months). The TACE group included 26 patients, of whom four obtained a partial response, none achieved a complete response, and five developed complications. The median time to disease progression in this group was 8.0 months (range: 1.0-68.0 months). There were no hospital deaths in this series. Median survival was 39.8 months in the RFA group and 19.8 months in the TACE group (P = 0.257). Rates of 1-, 2- and 5-year survival were 93.3%, 86.2% and 20.9%, respectively, in the RFA group and 73.1%, 40.6% and 18.3%, respectively, in the TACE group. CONCLUSIONS: Both RFA and TACE are feasible treatments for large unresectable solitary HCCs. Both modes show comparable rates of complications and longterm survival, but RFA achieves better initial tumour control and results in better short-term survival. © 2014 International Hepato-Pancreato-Biliary Association.

SummaryLiver transplantation is a standard treatment for patients with familial amyloidotic polyneuropathy (FAP) with disease progression. Given the multiorgan involvement by amyloidosis, the heart is often involved. When poor cardiac function becomes prohibitive to liver transplantation, a combined heart-liver transplantation (CHLT) is the only realistic treatment. This article records a CHLT for a patient with FAP whose removed liver was immediately transplanted as an amyloidotic hepatic allograft (AHA) to a patient having hepatocellular carcinoma and cirrhosis in a sequential liver transplantation. In the CHLT, the heart and liver are donated by a deceased donor. The newly implanted heart did not tolerate cross clamping of the inferior vena cava (IVC), so a side-to-side anastomosis was performed to connect the IVC and that of the liver graft. Therefore, the AHA was devoid of an IVC. The infrarenal cava procured from the deceased donor was used for reconstruction of the AHA to match a whole graft used in routine deceased-donor liver transplantation. Venoplasty was performed using the graft right hepatic vein and the middle and left hepatic vein stump to form a single cuff. The reconstructed AHA was implanted to the recipient conveniently like a usual whole graft.

ObjectivesThere is controversy over whether hepatocellular carcinoma (HCC) should be primarily treated with living donor liver transplantation (LDLT) if liver resection (LR) can be effective. This retrospective study was conducted to compare survival outcomes in patients treated with either modality for solitary HCC measuring ≤8cm in diameter.MethodsOutcomes in patients with solitary HCC primarily treated by LDLT were analysed. Patients with solitary HCC of similar sizes with or without microvascular invasion primarily treated with LR were selected at a ratio of 6:1 for comparison.ResultsIn-hospital mortality amounted to 0% and 1.3% in the LDLT (n = 50) and LR (n = 300) groups, respectively (P = 0.918). Complication rates were 34% and 20% in the LDLT and LR groups, respectively (P = 0.027). Rates of 1-, 3-, 5- and 10-year overall survival were 98%, 94%, 89% and 83%, respectively, in the LDLT group and 95%, 85%, 76% and 56%, respectively, in the LR group (P = 0.013). Rates of 1-, 3-, 5- and 10-year disease-free survival were 96%, 90%, 87% and 81%, respectively, in the LDLT group and 81%, 64%, 57% and 40%, respectively, in the LR group (P < 0.0001).ConclusionsLiving donor liver transplantation surpassed LR in survival outcomes, achieving a 10-year overall survival rate 1.5 times as high and a 10-year disease-free survival rate twice as high as those facilitated by LR. However, it entailed more complications, in addition to the inevitable risks to the donor.

Background We aimed to assess if simultaneous resection conferred any survival benefit in resection of synchronous colorectal liver metastases. Methods From January 1990 to December 2008, 116 patients with synchronous colorectal liver metastases were identified. Among these 116 patients, 88 underwent staged resection (SR), while the remaining 28 patients underwent simultaneous resection (SIMR). Patients’ follow-up data were reviewed. Results There were no significant differences between the groups in terms of patient and tumour characteristics. Major hepatectomy was performed in 54 patients (61%) undergoing SR, and 12 patients (43%) undergoing SIMR (P = 0.09). The median blood loss (SR 0.7 L versus SIMR 0.8 L) was similar. Post-operative morbidity rates and hospital mortality rates were not statistically different. The total length of hospital stay was shorter in SIMR patients (18.0 versus 11.5 days, P = 0.009). The 1-, 3- and 5-year overall survival for SR were 90.7%, 47.1% and 33.3%, whilst the corresponding survival rates for SIMR were 75.0%, 25.0% and 0%, respectively (P = 0.003). However, when the disease-free survival (DFS) was stratified according to the number of hepatic metastases, the survival benefit of SR and SIMR for solitary CRM were similar (3-year DFS: 28.3% versus 11.1%, P = 0.089). Conclusions Our study showed that an operative strategy of SR generally offered better survival outcome than SIMR in the surgical management of CRM.

The objective of this study was to investigate the outcomes of high-intensity focused ultrasound (HIFU) ablation as a bridging therapy for patients with hepatocellular carcinoma (HCC) who had been wait-listed for deceased donor liver transplantation (DDLT). Adult patients with unresectable and unablatable HCCs within the University of California San Francisco criteria who had been wait-listed for DDLT were screened for their suitability for HIFU ablation as a bridging therapy if they were not suitable for transarterial chemoembolization (TACE). Treatment outcomes for patients receiving HIFU ablation, TACE, and best medical treatment (BMT) were compared. Fifty-one patients were included in the analysis. Before the introduction of HIFU ablation, only 39.2% of the patients had received bridging therapy (TACE only, n = 20). With HIFU ablation in use, the rate increased dramatically to 80.4% (TACE + HIFU, n = 41). The overall dropout rate was 51% (n = 26). Patients in the BMT group had a significantly higher dropout rate (P = 0.03) and significantly poorer liver function as reflected by higher Model for End-Stage Liver Disease scores and higher Child-Pugh grading. Clinically relevant ascites was found in 5 patients in the HIFU group and 2 patients in the BMT group, but none was found in the TACE group (P = 0.01 and P = 0.03, respectively). The TACE and HIFU groups had comparable percentages of tumor necrosis in excised livers (P = 0.35), and both were significantly higher than that in the BMT group (P = 0.01 and P = 0.02, respectively). In conclusion, HIFU ablation was safe even for HCC patients with Child-Pugh C disease. Its adoption increased the percentage of patients receiving bridging therapy from 39.2% to 80.4%. A randomized controlled trial for further validation of its efficacy is warranted. Liver Transpl 20:912–921, 2014. © 2014 AASLD.

Background Laparoscopic liver resection is associated with less perioperative blood loss, shorter hospital stay, and fewer postoperative complications in younger patients. However, it remains unclear if these short-term benefits could also be applicable to elderly patients with medical comorbidities. Aim To evaluate the perioperative outcomes of laparoscopic liver resection in patients with advanced age. Materials and Methods Patients aged ≥ 70 years old who received liver resections for malignant liver tumors between January 2002 and December 2012 were included. The perioperative outcomes of 17 patients with laparoscopic approach were matched and compared with 34 patients with conventional open approach in a 1:2 ratio. Results There was no significant difference with regard to age, gender, incidence of comorbid illness, hepatitis B positivity, and Child grading of liver function. The median tumor size was 3 cm for both groups. The types of liver resection were similar between the two groups with no significant difference in the duration of operation (laparoscopic: 195 min vs open: 210 min, P = 0.436). The perioperative blood loss was 150 mL in the laparoscopic group and 330 mL in the open group (P = 0.046) with no significant difference in the number of patients with blood transfusion. The duration of hospital stay was 6 days (3–15 days) for the laparoscopic group and 8 days (5–105 days) for the open group (P = 0.005). Conclusion Laparoscopic liver resection is safe and feasible for elderly patients. The short-term benefits of laparoscopic approach continued to be evident for geriatric oncological liver surgery.

This aim of this study is to determine the risk factors in failed endoscopic retrograde cholangiography (ERC).Endoscopic treatment is considered the first-line intervention for biliary anastomotic stricture (BAS) after right-lobe living donor liver transplantation with duct-to-duct anastomosis.A retrospective study was performed on 287 patients who received right-lobe living donor liver transplantation with duct-to-duct anastomosis. The morphology of BAS was defined according to the shape of the distal side of duct-to-duct anastomosis shown on cholangiogram and was categorized into 3 types: pouched, intermediately pouched, and triangular. All cases of ERC were performed by operating surgeons.Fifty-nine patients (20.6%) had BAS and received ERC and balloon dilatation with or without stenting. The success rate was 73.2%. The median number of sessions needed for successful ERC was 3. In the 15 patients with failed ERC, 4 were successfully treated with percutaneous transhepatic biliary drainage and balloon dilatation and 11 underwent conversion hepaticojejunostomy (6 had external percutaneous transhepatic biliary drainage as a temporizing measure). On multivariate analysis, recipient age [odds ratio (OR): 0.922; 95% confidence interval (CI): 0.85-1.00; P = 0.049], operation time (OR: 1.007; 95% CI: 1.001-1.013; P = 0.025), and morphology of stricture (OR: 6.722; 95% CI: 1.31-34.48; P = 0.022) were independent risk factors associated with failed ERC. The success rates for the 3 types of BAS-pouched, intermediately pouched, and triangular-were 42.9%, 63.6%, and 88.9%, respectively (P = 0.021). Association was found between bile leak and pouched BAS (P = 0.008).ERC is highly effective in treating BAS. A success rate of 73%, the highest ever reported, has been achieved. Morphology of stricture is associated with outcome of ERC. Radiological or surgical intervention should be considered for patients with pouched BAS after endoscopic treatment fails for the first time.

Background & Aims High-intensity focused ultrasound (HIFU) ablation is a non-invasive treatment for unresectable hepatocellular carcinomas (HCCs), but long-term survival analysis is lacking. This study was to analyse its outcome compared to that of transarterial chemoembolization (TACE). Methods From October 2003 to September 2010, 113 patients received HIFU ablation as a treatment of HCCs at our hospital. Twenty-six patients had HCCs sized 3–8 cm. Fifty-two patients with matched tumour characteristics having TACE as primary treatment were selected for comparison. Short-term outcome and long-term survival were analysed. Results In the HIFU group (n = 26), 46 tumours were ablated. The median age of the patients was 69 (49–84) years. The median tumour size was 4.2 (3–8) cm. In the TACE group (n = 52), the median age of the patients was 67 (44–84) years. The median tumour size was 4.8 (3–8) cm. There was no hospital mortality in any of the groups. In the HIFU group, the rates of complete tumour response, partial tumour response, stable disease and progressive disease were 50%, 7.7%, 25.6% and 7.7% respectively, according to the modified Response Evaluation Criteria in Solid Tumours. The TACE group had the corresponding rates at 0%, 21.2%, 63.5% and 15.4% respectively (P

Background. Liver is the commonest site for metastasis in patients with neuroendocrine tumour (NET). A vast majority of treatment strategies including liver directed nonsurgical therapy, liver directed surgical therapy, and nonliver directed therapy have been proposed. In this study we aim to investigate the outcome of liver resection in neuroendocrine tumour liver metastases (NELM). Method. 293 patients had hepatectomy for liver metastasis in our hospital between June 1996 and December 2010. Twelve patients were diagnosed to have NET in their final pathology and their data were reviewed. Results. The median ages of the patients were 48.5 years (range 20-71 years). Eight of the patients received major hepatectomy. Four patients received minor hepatectomy. The median operation time was 418 minutes (range 195-660 minutes). The median tumor size was 8.75 cm (range 0.9-21 cm). There was no hospital mortality. The overall one-year and three-year survivals were 91.7% and 55.6%. The one-year and three-year disease-free survivals were 33.3% and 16.7%. Conclusion. Hepatectomy is an effective and safe treatment for NELM. Reasonable outcome on long term overall survival and disease-free survival can be achieved in this group of patients with a low morbidity rate. © 2014 Tan To Cheung et al., published_or_final_version

Liver transplant for biliary atresia (BA) has been reported to be associated with worse outcome, but this remains controversial. The objective of this study is to compare the outcomes of BA and non-BA recipients.Recipients with age18years were reviewed except cases of retransplantation. Intratransplant and posttransplant complications as well as survivals were evaluated.119 patients, with median follow-up period 8.5years, were studied (DDLT=33; LDLT=86/M:F=56:63), and 68% (n=81) were BA patients. While demographic data were comparable between two groups of recipients, BA patients had a worse pretransplant PELD/MELD score (15.2 vs 4.0, p=0.021). Transplantation takes a longer time in the BA group (580min vs 400min, p=0.065) with more blood loss (720ml vs 500ml, p=0.072). The incidence of transplant-related complications was 30.3% (36/119) (Table 1). There was no significant difference between incidences of vascular complication, but biliary complication was more common in the BA group. Overall, the survivals between the two groups were comparable.Liver transplant is an effective surgical treatment for BA patients. When compared to other indications, results are not inferior. Previous Kasai operation is not necessarily associated with adverse outcomes.

Repeated resection via an open approach is an effective treatment for post-operative recurrent hepatocellular carcinoma (HCC). However, there are limited data on the application of laparoscopic approach for recurrent HCC in patients with prior liver resections. The aim of this study was to review our experience of laparoscopic re-resection in patients with postoperative tumor recurrence.A total of 11 patients received laparoscopic re-resections for postoperative tumor recurrence in our center. Data were reviewed for demographics, tumor characteristics, and perioperative outcomes. Case-match analysis with the open approach was performed in a 1:2 ratio.Six patients had their first liver resection carried out via the open approach and the remaining five patients received the laparoscopic approach. The recurrent tumor size was 20 mm (12-50 mm) and ten patients had a solitary recurrence. Two patients had laparoscopic left lateral sectionectomy and the remaining nine patients had sub-segmentectomies. There was no significant difference in patient characteristics, preoperative liver function, and tumor features between the laparoscopic and open groups. Perioperative blood loss was significantly reduced in the laparoscopic group (100 vs. 314 mL; p = 0.014) but the morbidity rate (18.2 vs. 4.5 %; p = 0.199) and length of hospitalization were comparable (6 vs. 5 days; p = 0.831). The 3-year overall survival rates for the laparoscopic and open groups were 60.0 and 89.3 %, respectively (p = 0.279).Our study showed that laparoscopic re-resection for recurrent HCC was feasible with satisfactory postoperative and oncological outcomes, even in patients with previous major liver resections.

Different approaches to surgical treatment of portal vein tumor thrombosis (PVTT) have been advocated. This study investigated the outcomes of different surgical approaches in hepatocellular carcinoma (HCC) patients with PVTT. We reviewed prospectively collected data for all patients who underwent hepatectomy for HCC at our hospital between December 1989 and December 2010. Patients were excluded from analysis if they had extrahepatic disease, PVTT reaching the level of the superior mesenteric vein, or hepatectomy with a positive resection margin. The remaining patients were divided into three groups for comparison: group 1, with ipsilateral PVTT resected in a hepatectomy; group 2, with PVTT extending to or beyond the portal vein bifurcation, treated by en bloc resection followed by portal vein reconstruction; group 3, with PVTT extending to or beyond the portal vein bifurcation, treated by thrombectomy. A total of 88 patients, with a median age of 54 years, were included in the analysis. Group 2 patients were younger, with a median age of 43.5 years versus 57 in group 1 and 49 in group 3 (p = 0.017). Group 1 patients had higher preoperative serum alpha-fetoprotein levels, with a median of 8,493 ng/mL versus 63.25 in group 2 and 355 in group 3 (p = 0.004), and shorter operation time, with a median of 467.5 min versus 663.5 in group 2 and 753 in group 3 (p = 0.018). No patient had thrombus in the main portal vein. Two (2.8 %) hospital deaths occurred in group 1 and one (10 %) in group 2, but none in group 3 (p = 0.440). The rates of complication in groups 1, 2, and 3 were 31.9, 50.0, and 71.4 %, respectively (p = 0.079). The median overall survival durations were 10.91, 9.4, and 8.58 months, respectively (p = 0.962), and the median disease-free survival durations were 4.21, 3.78, and 1.51 months, respectively (p = 0.363). The groups also had similar patterns of disease recurrence (intrahepatic: 33.8 vs. 28.6 vs. 40.0 %; extrahepatic: 16.9 vs. 14.3 vs. 0 %; both: 28.2 vs. 42.9 vs. 40.0 %; no recurrence: 21.1 vs. 14.3 vs. 20.0 %; p = 0.836). The three approaches have similar outcomes in terms of survival, complication, and recurrence. Effective adjuvant treatments need to be developed to counteract the high incidence of recurrence.

Background This study aimed to investigate whether re-resection can achieve a good survival outcome in the treatment of recurrent liver metastases of colorectal cancer. Methods Prospectively collected data of patients who underwent hepatectomy for liver tumours were reviewed. Patients whose liver tumours were metastases of colorectal cancer were included in the study provided that they had no extrahepatic metastases and received no loco-ablative treatment simultaneous with hepatectomy. Patients who did not have recurrent liver metastasis after their first liver resection (group R) and patients who underwent re-resection for recurrent liver metastasis (group RR) were compared. Results In total, 321 patients were included in the study, with 307 in group R and 14 in group RR. The two groups had comparable demographics. Insignificantly more patients in group R received major resection (55.6% versus 30.8%, P = 0.079). The median blood loss volume was 0.6 (0–12.7) L in group R and 0.35 (0–15) L in group RR (P = 0.202). Group RR had a significantly smaller median tumour size (2.5 cm versus 3.5 cm, P = 0.020) and resection margin width (0.3 cm versus 0.7 cm, P = 0.037). On univariate analysis, re-resection was not a risk factor in overall survival. On multivariate analysis, post-operative complication (hazard ratio (HR) 1.66, 95% confidence interval (CI) 1.15–2.39, P = 0.007), microscopic margin involvement (HR 1.95, 95% CI 1.26–3.04, P = 0.003) and multiple tumours (HR 1.58, 95% CI 1.17–2.14, P = 0.003) were risk factors in overall survival. The two groups had no significant differences in disease-free survival and overall survival. Conclusion Re-resection for recurrent colorectal liver metastases can achieve a favourable survival outcome at centres with expertise.

Background In the treatment of liver metastasis of gastrointestinal stromal tumour (GIST), the role of hepatectomy is controversial. This study tried to identify such role by investigating the immediate and long-term surgical outcomes. Methods Data of patients who underwent hepatectomy to treat their metastatic disease were reviewed. Patients whose liver tumours were confirmed to be metastatic GISTs were included for analysis. Clinicopathological characteristics of the primary disease, time of metastasis development and modes of treatment were recorded. Immediate outcome and long-term survival after hepatectomy were analysed. Results Ten patients were confirmed to have isolated liver metastasis of GIST. Their median age was 61 (42–74) years. All of them had normal liver function and no cirrhosis. Seven patients received major hepatectomy and three patients received minor hepatectomy. The median operation time was 319.5 (122–735) min. The median tumor size was 5.5 (1.5–15) cm. No hospital death occurred. The 1-, 3- and 5-year overall survival rates were 100, 75 and 50%, respectively and the corresponding disease-free survival rates were 70, 42 and 14%, respectively. Conclusion Treating isolated liver metastasis of GIST with hepatectomy is effective and safe. Favourable long-term overall survival and disease-free survival can be achieved.

To evaluate our preliminary experience of high-intensity focused ultrasound (HIFU) for the treatment of recurrent hepatocellular carcinoma (HCC).HIFU is a new thermal ablative therapy for HCC. Whether it incurs survival benefit similar to that of radiofrequency ablation (RFA) remains uncertain.Clinicopathological data of 27 patients who received HIFU ablation and 76 patients who received RFA for recurrent HCC from October 2006 to October 2009 were reviewed. Survival outcomes between the 2 groups were compared using the log-rank test. A value of P0.05 was considered significant.The median follow-up was 27.9 months. There was no difference in tumor size (HIFU, 1.7 cm; RFA, 1.8 cm; P = 0.28) between the 2 groups. Procedure-related morbidity rate was 7.4% in the HIFU group and 6.5% in the RFA group (P = 1.00). Skin burn and pleural effusion were the 2 morbidities associated with HIFU. There was no hospital mortality in the HIFU group, whereas 2 deaths occurred in the RFA group. The 1-, 2-, and 3-year disease-free survival rates were 37.0%, 25.9%, and 18.5%, respectively, for the HIFU group, and 48.6%, 32.1%, and 26.5%, respectively for the RFA group (P = 0.61). The 1-, 2-, and 3-year overall survival rates were 96.3%, 81.5%, and 69.8%, respectively, for the HIFU group, and 92.1%, 76.1%, and 64.2%, respectively, for the RFA group (P = 0.19).Our preliminary experience in using HIFU for recurrent HCC is promising. Further studies are needed to explore its treatment value for primary HCC.

The objective of this study was to evaluate the efficacy of salvage liver transplantation (SLT), repeated hepatic resection (RR), and repeated radiofrequency ablation (rRFA) for patients with postoperative tumor recurrence. The optimal treatment strategy for patients with recurrent hepatocellular carcinoma (HCC) remains unclear. From January 1993 to September 2009, 532 patients underwent either hepatic resection or radiofrequency ablation (RFA) for HCC within the Milan criteria. In all, 219 patients experienced intrahepatic recurrence, and 87 were selected for SLT (n=19), RR (n=24), or rRFA (n=44). Their clinicopathological data were reviewed, and their survival outcomes were assessed with Kaplan-Meier methods. Seventy-four of 220 patients (33.6%) developed recurrent HCC within the Milan criteria. The median Model for End-Stage Liver Disease (MELD) scores for SLT, RR, and rRFA were 10.7, 7.2, and 8.3, respectively (P

INTRODUCTION Laparoscopic liver resection has been reported as a safe and effective approach to the management of liver cancer. However, studies of long-term outcomes regarding tumor recurrence and patient survival in comparison with the conventional open approach are limited. The aim of this study was to analyze the survival outcome of laparoscopic liver resection versus open liver resection. PATIENTS AND METHODS Between October 2002 and September 2009, 32 patients underwent pure laparoscopic liver resection for hepatocellular carcinoma (HCC). Case-matched control patients (n = 64) who received open liver resection for HCC were included for comparison. Patients were matched in terms of cancer stage, tumor size, location of tumor, and magnitude of resection. Immediate operation outcomes, operation morbidity, disease-free survival, and overall survival were compared between groups. RESULTS With the laparoscopic group compared with the open resection group, operation time was 232.5 minutes versus 204.5 minutes (P = 0.938), blood loss was 150 mL versus 300 mL (P = 0.001), hospital stay was 4 days versus 7 days (P < 0.0001), postoperative complication was 2 (6.3%) versus 12 (18.8%) (P = 0.184), disease-free survival was 78.5 months versus 29 months (P = 0.086), and overall survival was 92 months versus 71 months (P = 0.142). The disease-free survival for stage II HCC was 22.1 months versus 12.4 months (P = 0.075). CONCLUSIONS Laparoscopic liver resection for HCC is associated with less blood loss, shorter hospital stay, and fewer postoperative complications in selected patients with no compromise in survival.

Background Conversion hepaticojejunostomy is considered the salvage intervention for biliary anastomotic stricture, a common complication of right-liver living donor liver transplantation with duct-to-duct anastomosis, after failed endoscopic treatment. The aim of this study is to compare the outcomes of side-to-side hepaticojejunostomy with those of end-to-side hepaticojejunostomy. Methods Prospectively collected data of 402 adult patients who had undergone right-liver living donor liver transplantation with duct-to-duct anastomosis were reviewed. Diagnosis of biliary anastomotic stricture was made based on clinical, biochemical, histological and radiological results. Endoscopic treatment was the first-line treatment of biliary anastomotic stricture. Results Interventional radiological or endoscopic treatment failed to correct the biliary anastomotic stricture in 13 patients, so they underwent conversion hepaticojejunostomy. Ten of them received end-to-side hepaticojejunostomy and three received side-to-side hepaticojejunostomy. In the end-to-side group, two patients sustained hepatic artery injury requiring repeated microvascular anastomosis, two developed re-stenosis requiring further percutaneous transhepatic biliary drainage and balloon dilatation, and two required revision hepaticojejunostomy. In the side-to-side group, one patient developed re-stenosis requiring further endoscopic retrograde cholangiography and balloon dilatation. No re-operation was needed in this group. Otherwise, outcomes in the two groups were similar in terms of liver function and graft survival. Conclusions Despite the similar outcomes, side-to-side hepaticojejunostomy may be a better option for bile duct reconstruction after failed interventional radiological or endoscopic treatment because it can decrease the chance of hepatic artery injury and allows future endoscopic treatment if re-stricture develops. However, more large-scale studies are warranted to validate the results.

The success of liver transplantation (LT) for hepatocellular carcinoma (HCC) is enhanced by careful patient selection on the basis of the Milan criteria. The criteria are traditionally assessed by contrast CT, which is known to be affected by structural or architectural changes in cirrhotic livers. We aimed to compare dual-tracer ((11)C-acetate and (18)F-FDG) PET/CT with contrast CT for patient selection on the basis of the Milan criteria.Patients who had HCC and had undergone both preoperative dual-tracer PET/CT and contrast CT within a 1-mo interval were retrospectively studied. They then underwent either LT (n = 22) or partial hepatectomy (PH) (n = 21; HCC of ≤ 8 cm). Imaging data were compared with data from postoperative pathologic analysis for accuracy in assessment of parameters specified by the Milan criteria (tumor size and extent, vascular invasion, and metastasis), TNM staging, and patient selection for LT.Dual-tracer PET/CT performed equally well in both LT and PH groups for HCC detection (94.1% vs. 95.8%) and TNM staging (90.9% vs. 90.5%). Contrast CT performed reasonably well in the LT group but not in the PH group for HCC detection (67.6% vs. 37.5%) and TNM staging (54.5% vs. 28.6%). In the LT group, the sensitivity and specificity of contrast CT for patient selection on the basis of the Milan criteria were 43.8% and 66.7%, respectively (comparable to values in the literature); the sensitivity and specificity of dual-tracer PET/CT were 93.8% and 100%, respectively (both Ps0.05). From the surgeon's perspective, we tended to perform transplantation for patients with higher diagnostic certainty (stricter CT criteria) because of a shortage of donor grafts. Patients who were not transplant candidates usually underwent up-front hepatectomy without the benefit of reassessment contrast CT, resulting in lower accuracies for the PH group. The overall sensitivity (96.8%) and specificity (91.7%) of dual-tracer PET/CT for patient selection for LT were significantly higher than those of contrast CT (41.9% and 33.0%, respectively) (both Ps0.05). Sources of error for contrast CT were related to cirrhosis or previous treatment and included difficulty in differentiating cirrhotic nodules from HCC (39%) and estimation of tumor size (14%). Overstaging of vascular invasion (4.6%) and extrahepatic metastases (4.6%) was infrequent. The rate of false-negative results of dual-tracer PET/CT was 4.7%.Dual-tracer PET/CT was significantly less affected by cirrhotic changes than contrast CT for HCC staging and patient selection for LT on the basis of the Milan criteria. The inclusion of dual-tracer PET/CT in pretransplant workup may warrant serious consideration.

Aim In the present study, we discuss the surgical management, complications and clinical outcomes of patients with renal cell carcinoma (RCC) extending into the inferior vena cava (IVC), who were treated with surgical resection at a teaching hospital from 1997 to 2011. Patients and Methods Twelve patients diagnosed with RCC and IVC tumour thrombus underwent radical nephrectomy and IVC tumour thrombectomy during the study period. Results Of the 12 patients (male : female: 1:1), the mean age was 65 years (range: 48–82 years). All had good premorbid performance status and no distant metastasis at the time of operation. Employing the Mayo Clinic classification, the tumour thrombus extension was level I in four cases (33 per cent), level II in four cases (33 per cent), level III in two cases (17 per cent) and level IV in two cases (17 per cent). In one patient, the renal tumour extended into the right atrium and had a solitary right pulmonary artery tumour embolus, which subsequently underwent a simultaneous right pulmonary artery tumour embolectomy. In our series, the mean blood loss in levels I–IV tumour thrombus were 1050 mL, 2075 mL, 4152 mL and 11 500 mL, respectively. Complications occurred in three cases (25 per cent), and one (8.3 per cent) required re-laparotomy for haemostasis. There was no hospital mortality. The median follow up was 45.5 months (range: 6–125 months). Median disease-free and overall survivals were 29 and 76 months, respectively. Five-year disease-free and overall survivals were 35.5 per cent and 62.5 per cent, respectively. Conclusion Radical nephrectomy and IVC tumour thrombectomy remain a challenging procedure. With detailed perioperative planning and multidisciplinary efforts, surgical resection is the definitive treatment of choice for patients with RCC and IVC tumour thrombus. The perioperative and survival outcomes of the present series were comparable to contemporary series.

Liver failure following major hepatectomy for hepatocellular carcinoma is a known but uncommon mode of early treatment failure. When post-hepatectomy liver failure becomes progressive, the only effective treatment for rescuing the patient is liver transplantation. Deceased-donor liver transplantation in this situation is often not feasible because of the shortage of deceased-donor liver grafts. Proceeding with living-donor liver transplantation is an ethical challenge because of the possibility of donor coercion. In addition, tumor status, as confirmed by histopathological examination of the resected specimen, may indicate aggressive cancer that warns against rescue transplantation because of the increased chance of tumor recurrence. Here we describe four cases of rescue living-donor liver transplantation for liver failure after hepatectomy for hepatocellular carcinoma. The patients all survived the transplantation and were free from tumor recurrence after follow-up periods ranging from 6 months to 9 years. Our experience has shown that rescue living-donor liver transplantation for post-hepatectomy liver failure is feasible. Tumor status should be considered carefully because large tumors and tumors with macrovascular invasion are strong contraindications to rescue living-donor liver transplantation.

Hepatitis B is endemic in many regions of Asia, including China, Korea and India. This results in a heavy burden of hepatocellular carcinoma (HCC) because hepatitis B virus is a major risk factor in the development of the disease. In addition, the incidence of hepatitis-C-related HCC is on the rise in the United States. HCC patients with poor liver function reserve are not suitable candidates for resection, and liver transplantation (LT) has emerged as the treatment of choice for small unresectable HCCs. To treat more HCC patients with LT, the standard patient selection criteria have been expanded at a number of centers. Careful and well-considered selection of patients is the key to success in LT for HCC. Although tumor size and tumor number are used to predict whether transplantation is likely to be successful, the weighting that should be attached these two parameters has not been determined. In addition to the size and number of lesions, the morphology of HCC is also predictive of its behavior. Well-circumscribed lesions, in general, are less aggressive than those with poorly defined borders. On the waiting list for LT, HCC patients compete with liver failure patients. It is essential that the criteria used for selecting HCC patients for LT should be easily applicable and fair to other transplant candidates. In the face of the scarcity of deceased-donor livers and the inevitable risks for living liver donors, a predictably low rate of recurrence of HCC after LT is mandatory.