The surgical challenges of salvage living donor liver transplantation for Hepatocellular carcinoma; The cumulative experience of 100 cases - A retrospective cohort study and a propensity score analysis

Background: Hepatocellular carcinoma (HCC) is increasingly managed by liver resection first then salvage liver transplantation in case of recurrence within accepted criteria. Many reports compared the safety of the salvage against the primary surgery in the setting of deceased donation but the difference in case of living donation is not sufficiently defined. Salvage living donor liver transplantation (SLDLT) is believed to be a more challenging surgery than primary living donor liver transplantation (PLDLT) due to operative field adhesions, in addition to the inherent difficulties particularly short vasculobiliary stumps. In this report, we compared both pathways from a surgical perspective in a homogenous LDLT-only cohort. Materials and methods: Over 15 years, 448 LDLTs for HCC were performed in a single liver transplant institution in Taiwan, including PLDLT (n = 348) and SLDLT (n = 100). A retrospective comparative review of the surgical outcomes of both pathways using a propensity score matching model (1-1, 100 pairs) was performed with adjustment for age, Child score and MELD score. The surgical outcome and survival were compared across 2 time eras. Results: The operative data showed that SLDLT surgery encountered more extensive adhesions (57% vs. 0%, p < 0.001), longer operative duration (650 vs. 618 min, p = 0.04), and was followed by more incidence of reexploration (16% vs. 5%, p = 0.01), than the PLDLT surgery. There was no significant difference regarding the incidence of in-hospital mortality, vascular and biliary complications, or overall survival (OS). The 1-year OS of SLDLT was inferior to PLDLT in the first 50 cases (90% vs. 98%, p = 0.03), then the same OS was found in the 2nd 50 cases (96% vs. 96%, p = 0.9). Conclusions: The SLDLT surgery is a demanding lengthy procedure with extensive adhesions and possibility of frequent re-explorations. Significant case load and high centre volume are important factors for safe practice of SLDLT and better cumulative OS.