Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Liver transplantation in children: Indications and outcomes

Historic overview Thomas Starzl attempted the first human liver transplantation (LT) in 1963 in a 3-year-old child with biliary atresia (BA; see Chapter 125 ). Unfortunately, the child died in the operating room from uncontrollable hemorrhage. Just a few years later, however, Starzl successfully performed eight LTs in eight children. In contrast to his first attempt, all survived the operation and half survived for more than…

Orthotopic liver transplantation: Standard donation after brain death, donation after cardiac death, and live donor – indications and outcomes

Since the initial descriptions of successful deceased donor liver transplantation (LT) in the 1960s by Dr. Thomas Starzl (see Chapter 125 ), there has been tremendous change and growth in the field of transplantation. Advancements in organ preservation, immunosuppression, perioperative management, and refinements in surgical technique have contributed to an increased number of patients undergoing LT and growing indications for the procedure (see Chapter 105 ).…

Liver transplantation for nonhepatocellular malignant disease

Overview Liver transplantation (LT) is considered standard of care for select patients with hepatocellular carcinoma (HCC) arising in the setting of cirrhosis (see Chapter 108A ). The role of LT in treatment of other malignancies arising in the liver such as hilar and intrahepatic cholangiocarcinoma (CCA), hepatic epithelioid hemangioendothelioma (HEHE), or tumors metastatic to the liver such as neuroendocrine cancer (NEC) and colorectal cancer (CRC) continues…

Liver transplantation for hepatocellular carcinoma

Cancer of a solid organ is an uncommon indication for organ transplantation, but hepatocellular carcinoma (HCC) is an important exception to that general rule (see Chapters 89 and 105 ). HCC is the most common tumor treated with whole-organ transplantation, and it is listed as the primary indication in approximately 25% of liver transplantations (LTs). The existing treatment options for HCC include hepatic resection, local ablation,…

Liver transplantation in patients with fulminant hepatitis

Acute liver failure (ALF), formally known as fulminant hepatic failure, is a rare and devastating condition characterized by the development of encephalopathy and impaired synthetic liver function (international normalized ratio [INR] > 1.5) occurring within 26 weeks of acute-onset jaundice and elevated transaminases (see Chapters 77 and 78 ). Stemming from a broad range of etiologies, ALF is the direct result of the overwhelming death of…

Liver transplantation: Perioperative anesthetic considerations

Introduction The Global Observatory on Donation and Transplantation estimates that more than 35,000 liver transplantations are performed annually worldwide, but the number of patients on the waiting list continues to exceed donor organ availability. Because of the continuous donor shortage, dramatic changes in recipient and donor selection have emerged in the past decade, leading to an amplification of clinical challenges for perioperative liver transplant physicians. United…

Liver transplantation: Indications and general considerations

The first human orthotopic liver transplant was carried out by Starzl in 1963. In the subsequent two decades, only a relatively small number of patients received grafts, usually those who were moribund with end-stage disease, and survival results were disappointing. However, with increasing surgeon experience and confidence, better anesthesia, and improved microbiologic and immunologic treatments, results started to improve. Increasingly more patients were grafted, with a…

Liver and pancreas transplantation immunobiology

Allotransplantation, defined as the transfer of tissues between genetically nonidentical individuals, has evolved into a highly successful therapy for end-stage organ failure in the modern era. However, unless some modification of the recipient immune system is made, transplanted organs are invariably destroyed through a process broadly known as rejection . Over the last several decades, the ability to manipulate the immune response has become increasingly selective…

Adjuncts to hepatic resection: From ultrasound guidance to new oncologic and technical horizons

Introduction Adequate oncologic margins and enough future liver remnant (FLR) with proper inflow and outflow are the pillars for any successful strategy in liver surgery (see Chapter 101 ). Given that tumor-free margin remains the mainstream of any oncologic surgery, liver regeneration has been considered the most suitable path to address successfully both surgical radicality and safety for advanced oncologic liver involvement. By treating the diseased…

Associating liver partition and portal vein ligation for staged hepatectomy: Indications and outcomes

The associating liver partition and portal vein (PV) ligation for staged hepatectomy (ALPPS) procedure is a modification of the two-staged liver resection combining two established surgical techniques: right portal vein ligation (PVL) and in situ splitting of the liver (ISS). , The first large series introducing this novel technique of two-stage hepatectomy was published as a multicenter experience of German surgeons. Dr. Hans Schlitt initiated the…

Preoperative portal vein embolization: Indications, technique, and results

Introduction Portal vein embolization (PVE) is the most common portal flow modulation procedure performed preoperatively to reduce the risk of extensive liver resection in patients with a small anticipated future liver remnant (FLR). PVE redirects portal blood flow to the intended FLR and is expected to produce a shift in hepatic functional reserve resulting from atrophy of the embolized liver and compensatory hypertrophy of the FLR…

Segment-oriented anatomic liver resections: Indications and outcomes

Overview Segment-oriented hepatectomy is defined as the removal of one or more of the eight anatomic segments of the liver. The techniques of segment-oriented anatomic liver resection are based on the pioneering work of Claude Couinaud, who identified intrahepatic anatomy by creating vascular and biliary casts of the liver (see Introduction and Chapter 2 ) Couinaud established that the liver is subdivided into eight autonomous segments,…

Parenchymal preservation in hepatic resectional surgery: Rationale, indications and outcomes

Introduction Advances in patient selection, surgical technique, and perioperative management have improved the outcomes of patients undergoing hepatic resection in recent years. As a result, the utilization of liver resection for patients with both benign and malignant disease has increased worldwide , (see Chapter 101A ). Marked improvements in operative and anesthetic techniques, improved patient selection, and the emergence of hepatobiliary surgery have reduced mortality rates…

Hepatic resection for benign and malignant liver and biliary tract disease: Indications and outcomes

Introduction A wide variety of diseases affect the liver that can potentially be addressed with hepatectomy. They range from benign and asymptomatic, as in the case of simple liver cysts (see Chapter 88 ), to premalignant (biliary cystadenomas) and malignant. Malignant tumors can further be classified as primary liver tumors, such as hepatocellular carcinoma (HCC; see Chapter 89 ) and intrahepatic cholangiocarcinoma (IHC; see Chapter 50…

Isolated hepatic perfusion for unresectable hepatic metastases

Each year, isolated hepatic metastases from a variety of primary malignancies pose a significant clinical dilemma for tens of thousands of patients (see Chapters 90 , 91 , and 92 ). For a small percentage of patients, surgical resection or ablation is effective in controlling clinically apparent disease, but for many patients with colorectal, gastrointestinal neuroendocrine tumors, and ocular melanoma, the number of tumors and volume…

Advances in systemic therapy for hepatocellular carcinoma

Overview Hepatocellular carcinoma (HCC) represents a challenging malignancy of global importance (see Chapter 89 ). It is the fifth most common solid tumor in terms of incidence and the third leading cause of cancer-related death worldwide. Its incidence mirrors that of chronic liver injury, which is predominantly attributable to viral hepatitis infection, both hepatitis B and C (see Chapter 68 ). Other etiologic factors that cause…

Systemic chemotherapy for colorectal liver metastasis: Impact on surgical management

Introduction Over the past decades, the management of colorectal liver metastases (CLM) has been transformed by several improvements in both medical and surgical fields (see Chapters 90 , 97 , 101 , and 102 ). The development of modern and efficient chemotherapeutic regimens has increased tumor response rates as well as overall prognosis of metastatic patients. A better knowledge of tumor biology has allowed tailoring indications…

Regional chemotherapy for liver tumors

Overview The liver is a unique organ with a rich dual blood supply (see Chapter 2 ) and serves as a target organ for many tumor metastases. As the portal vein drains the gastrointestinal (GI) tract, malignancies arising from these organs frequently give rise to hematogenous liver metastases. Because colorectal cancer most frequently results in distant metastatic spread to the liver, most hepatic arterial infusion (HAI)…

Cryotherapy and ethanol injection

Cryotherapy Introduction Hepatic ablative techniques remain an important tool in the armamentarium against both primary and metastatic liver tumors. Liver resection continues to be the gold standard in management; however, ablative therapies are useful for patients with limited disease and compromised liver function, and in some cases they can be curative. Because the majority of malignant liver tumors present as unresectable disease, there has been an…