**7.1 Technical considerations of liver transplantation for HCC**

Patients undergoing liver transplantation for HCC do not usually have the same degree of liver dysfunction than their counterparts. This difference can be explained for example by the use of allocations systems such as the UNOS (United Network for Organ Sharing), where patients with HCC are prioritized based upon tumor criteria rather than the MELD score. As a result, patients undergoing liver transplantation for HCC can have a lesser degree of portal hypertension and the *hepatectomy* phase of the operation is usually less demanding (Table 2). For this reason, cell savers are usually not needed and should be avoided in case any tumor cells are present in the blood. From the technical standpoint, a few aspects should be considered. Every patient should have a recent staging no older than 3 months when brought in for the transplant. A thorough evaluation of the abdomen and hilum should be performed prior to dividing vital structures and if needed, lymph node biopsies should be obtained to rule out the possibility of metastatic disease. The patients should be informed of the possibility of incidental metastatic disease and no patient should be transplanted with known metastatic disease as this represents a contraindication. The possibility of a back up recipient should be considered in cases where patients are transplanted with criteria exceeding Milan or when the imaging is suggestive of possible metastatic or multifocal disease. Because the hepatectomy involves significant manipulation of the liver, pre-transplant tumor therapies are considered to be 'preventive' in releasing cancer cells in the circulation and are encouraged as a mean to prevent early recurrence of HCC. The survival benefit of pretransplant locoregional therapies has been demonstrated for trans-arterial chemoembolization (Maddala, 2004) and radiofrequency ablation (Pompili, 2005).


Table 2. Basic technical principles in Liver Transplantation for HCC

Several techniques are available for the *implantation* of the liver: veno-veno bypass, standard technique with clamp and sew, piggy-back technique and caval preservation with or without temporary portocaval shunt. Different techniques have been compared but no study has proven superiority of any particular technique over the others (Sakai, 2010; Gurusamy, 2011; Viera de Melo, 2011). The caval preservation technique (piggy-back) is the preferred technique at many centers but should be avoided in cases where tumors are close to the retrohepatic inferior vena cava or adjacent to the hepatic vein-caval confluence. In cases where pre-transplant therapies have been performed such as chemo- or radio-

considered in the context of a multidisciplinary approach to the individual patient's tumor,

Patients undergoing liver transplantation for HCC do not usually have the same degree of liver dysfunction than their counterparts. This difference can be explained for example by the use of allocations systems such as the UNOS (United Network for Organ Sharing), where patients with HCC are prioritized based upon tumor criteria rather than the MELD score. As a result, patients undergoing liver transplantation for HCC can have a lesser degree of portal hypertension and the *hepatectomy* phase of the operation is usually less demanding (Table 2). For this reason, cell savers are usually not needed and should be avoided in case any tumor cells are present in the blood. From the technical standpoint, a few aspects should be considered. Every patient should have a recent staging no older than 3 months when brought in for the transplant. A thorough evaluation of the abdomen and hilum should be performed prior to dividing vital structures and if needed, lymph node biopsies should be obtained to rule out the possibility of metastatic disease. The patients should be informed of the possibility of incidental metastatic disease and no patient should be transplanted with known metastatic disease as this represents a contraindication. The possibility of a back up recipient should be considered in cases where patients are transplanted with criteria exceeding Milan or when the imaging is suggestive of possible metastatic or multifocal disease. Because the hepatectomy involves significant manipulation of the liver, pre-transplant tumor therapies are considered to be 'preventive' in releasing cancer cells in the circulation and are encouraged as a mean to prevent early recurrence of HCC. The survival benefit of pretransplant locoregional therapies has been demonstrated for trans-arterial chemoembolization (Maddala, 2004) and radiofrequency ablation (Pompili,

liver reserve and potential transplant candidacy.

Recent Staging imaging (within 3 months)

No caval preservation if tumor close to cava

Explore abdomen and hilar nodes before dividing vital structures

Table 2. Basic technical principles in Liver Transplantation for HCC

Dissect artery carefully in cases with prior embolization procedures and be prepared for

Several techniques are available for the *implantation* of the liver: veno-veno bypass, standard technique with clamp and sew, piggy-back technique and caval preservation with or without temporary portocaval shunt. Different techniques have been compared but no study has proven superiority of any particular technique over the others (Sakai, 2010; Gurusamy, 2011; Viera de Melo, 2011). The caval preservation technique (piggy-back) is the preferred technique at many centers but should be avoided in cases where tumors are close to the retrohepatic inferior vena cava or adjacent to the hepatic vein-caval confluence. In cases where pre-transplant therapies have been performed such as chemo- or radio-

Back-up recipient available

**7.1 Technical considerations of liver transplantation for HCC** 

**7. Liver transplantation for HCC** 

2005).

No cell saver

vascular grafts

embolization, the gastroduodenal artery has usually been embolized and significant arterial inflammation and fragility can be encountered for the arterial anastomosis. For this reason, arterial grafts should always be available as an alternative mean for reconstruction. The portal vein should be inspected for the presence of thrombus and frozen sections of any large or suspicious clot should be obtained intraoperatively as tumor thrombus is an ominous finding that portends a poor prognosis and is a contraindication for transplantation.
