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Transplantation for Primary Hepatic Malignancy

Fifty years have passed since the first liver transplantation was performed by Thomas E. Starzl. Orthotopic liver transplantation (OLT) has become the recommended treatment in patients with hepatocellular carcinoma (HCC) and cirrhosis, as well as for other selected tumors. This was not always straightforward; the first cases, performed starting in 1967, resulted in early recurrence of tumor in the first months after transplantation, with early mortality…

Transplantation for Autoimmune Hepatitis

Autoimmune hepatitis (AIH) is a chronic necroinflammatory liver disease of unknown etiology characterized by the presence of various circulating autoantibodies, hypergammaglobulinemia, and interface hepatitis of predominant lymphoplasmacytic necroinflammatory infiltration on histological examination. AIH reflects a complex interaction between triggering factors, autoantigens, genetic predispositions, and immunoregulatory networks. There is a higher prevalence among females, an immunogenetic connection with the human leukocyte antigen (HLA) A1-B8-DR3 or DR4 haplotype,…

Transplantation for Sclerosing Cholangitis

Sclerosing cholangitis is characterized by chronic biliary duct inflammation, subsequently resulting in fibrotic stricturing and duct obliteration. Biliary cirrhosis follows, with progression to complications of end-stage liver disease, liver failure, and the need for liver transplantation. Primary sclerosing cholangitis (PSC) is likely an immune-mediated chronic and progressive cholestatic liver condition characterized by inflammation and fibrosis of both intrahepatic and extrahepatic bile ducts. Secondary sclerosing cholangitis is…

Transplantation for Primary Biliary Cirrhosis

Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease of unknown etiology characterized by lymphocytic cholangitis and segmental destruction of intralobular bile ducts within the liver. Patients with PBC may progress gradually to cirrhosis, liver failure, and ultimately death or liver transplantation (LT). Survival free of liver transplantation can be prolonged by ursodeoxycholic acid (UDCA) in the majority of patients receiving therapy. However, in patients…

Transplantation for Fulminant Hepatic Failure

Data from the Scientific Registry of Transplant Recipients (SRTR) and the European Liver Transplant Registry (ELTR) indicate comparable levels of liver transplantation for fulminant hepatic failure (FHF), representing around 8% of overall organ utilization. A single-center (King’s College Hospital) experience of 2095 patients with FHF and at least grade 2 encephalopathy had a 19% transplantation rate, but this increased to 53% of nonacetaminophen cases and 35%…

Transplantation for Hepatitis C

Advances in medical management and surgical techniques have resulted in significant improvements in posttransplant survival rates for patients with transplants from both deceased and living donors, with 74% and 79% of patients, and 60% and 74% of patients, respectively, alive 5 and 10 years following transplantation ( ). Cirrhosis secondary to chronic hepatitis C virus (HCV) infection is the most common disease indication for liver…

Natural History of Hepatitis C

Hepatitis C is a major cause of chronic liver disease worldwide and remains the leading indication for liver transplantation in the United States and western Europe. The epidemiological characteristics of chronic hepatitis C infection are evolving and leading to more advanced liver disease; this has significant implications for liver transplantation. Recent trends reveal an increasing prevalence of cirrhosis and hepatocellular carcinoma associated with hepatitis C. This…

Transplantation for Hepatitis A and B

In the United States and Europe 5% to 10% of patients undergoing liver transplantation (LT) have hepatitis B virus (HBV)-associated chronic or fulminant liver disease. In Asia it is the most common indication for LT. Results of LT have been hampered by recurrent infection. Historically the spontaneous risk for HBV reinfection was about 80% when related to the initial liver disease (i.e., acute versus chronic) and…

Current Indications, Contraindications, Delisting Criteria, and Timing For Transplantation

Liver transplantation (LT) is now a widely accepted lifesaving therapy for the complications of cirrhosis and acute liver failure. Before the availability of LT, medical management provided a temporizing measure but not a definitive cure for the complications of end-stage liver disease (ESLD). Chronic liver disease accounts for more than 2 million outpatient visits and more than 750,000 hospitalizations per year in the United States. More…

Donation After Cardiac or Brain Death: Regulatory and Ethical Principles

The Interesting Intersection of Procurement Regulation and Ethics Some of the most fascinating aspects in the practice of medicine are the dilemmas that can arise at the intersections where laws, or for the purposes of this chapter, transplant regulations and policy, can collide with one’s personal ethical values and responsibilities as a physician. The conflicts and inconsistencies between what physicians are told to do and what…

Organ Allocation: The European Models

Liver Transplantation in Europe The number of liver transplants performed in Europe has increased, reaching a plateau of close to 6000 liver transplants performed annually ( Fig. 6-1 ). The number of listed patients waiting for a liver transplant continues to increase, and the gap is widening between them and the number of available liver grafts. Table 6-1 lists the liver transplant activity and organ donation…

Organ Allocation: The U.S. Model

Historical Perspective and Legislation The process of liver allocation in the United States has evolved significantly over the past 4 decades. At the time of the first transplants there was no formal allocation system. There were no established criteria defining brain death, and donor surgery proceeded only after cardiac death. Transplants were limited to a few centers and a few select recipients. Donors were usually identified…

Influence of Transplantation on Liver Surgery

Liver transplantation is the gold standard treatment for patients with end-stage liver disease. The great success of liver transplantation has produced a ripple effect on many other medical and scientific disciplines and, in particular, on general and hepatobiliary surgery. The anatomical principles, technical refinements, and basic scientific underpinnings of liver transplantation have immediate relevance to the work of surgeons with interests in nontransplant hepatobiliary surgery, trauma…

Molecular and Cellular Basis of Liver Failure

Liver failure is the inability of the liver to perform its normal synthetic and metabolic function as part of normal physiology and arises from the loss of functional hepatic parenchyma from either acute or chronic injury. More than 30 million people in the United States have liver disease—1 in 10 Americans. Cirrhosis affects hundreds of millions of patients worldwide. In the United States the overall prevalence…

Surgical Anatomy of the Liver

The increasing organ shortage observed since the previous edition of Transplantation of the Liver mandates expert knowledge of partial allograft transplantation by the practicing clinician. The maturation of hepatobiliary surgery has expanded the role and safety of major hepatic resection, permitting the expanded application of partial-liver allografts derived from living or deceased donors to adults and children. In this past decade, partial-liver allografts have become the…

The History of Liver Transplantation

The history of liver transplantation is a complicated story to tell—it is a story of great successes and tragic failures. It is a story of both individual heroics and the power of collaboration. It is a story that has many overlapping themes that all evolved simultaneously—there were developments in immunosuppression, creation of animal models, advances in organ preservation, and the results from human trials. Each of…

Posttraumatic Reconstruction

Introduction As discussed in Chapter 5 , the surgical management of tibial plateau fractures relies primarily on open reduction and internal fixation (ORIF) using various fracture fixation principles. Reconstruction, however, does serve an important role in select cases in the acute fracture setting. Additionally, arthroplasty is the primary surgical treatment for addressing posttraumatic end-stage arthrosis after tibial plateau fractures. Unicompartmental and total knee arthroplasty (TKA) for…

Complications

Introduction Tibial plateau fractures occur when a varus or valgus stress is applied to the knee in conjunction with axial loading. Younger individuals sustain this fracture through high-energy mechanisms such as motor vehicle accidents, pedestrian strikes, or falls from heights. In older individuals, it typically occurs due to their poor bone quality and a low-energy fall. , This section will focus on the sequelae and complications…

Postoperative Care/Rehabilitation

Introduction Postoperative care and rehabilitation for tibial plateau fractures remain areas of surgical management with little standardization. While a significant amount of research has focused on diagnosis, classification, surgical techniques, and operative outcomes of tibial plateau fractures, far less has evaluated appropriate postoperative care. Hence, there are a wide range of postoperative management protocols implemented by orthopedic trauma surgeons worldwide. An ideal postoperative regimen would minimize…

Treatment of Associated Soft-Tissue Injuries

Introduction Historically, restoring the bony architecture in tibial plateau fractures has been the focus of surgical management. While this remains the primary objective in treatment algorithms, management of the soft-tissue structures around the knee has become a secondary objective. Failure to address soft-tissue compromise can lead to continued pain or instability to the knee. This chapter focuses on the nature of the soft-tissue problem, recognizing the…