Classical piggyback liver transplantation (CPBLT) is an advanced technique based on standard orthotopic liver transplantation (SOLT),which has more advantages compared to the SOLT.However,there are still some problems with CPBLT to be solved,such as complicated surgical procedures,postoperative hepatic venous outflow obstruction and thrombosis.Recently,in order to solve these problems,modifications have been made,being named ameliorated piggyback liver transplantation (APBLT).The APBLT solved above-mentioned problems,and expanded the application of PBLT.Therefore,this article describes the technique of these ameliorations,and discusses their individual characteristics.

Objective A classification for hepatic venous outflow obstruction after piggyback liver transplantation (PBLT) and its clinical significance.Methods We conducted a retrospective study on 248 patients who underwent liver transplantation from May 2000 to August 2006.The aims were to elucidate the causes and treatment of postoperative venous outflow obstruction.Results Venous outflow obstruction occurred in 38 patients after transplantation.Among those,2 (5.26％) had superior hepatic inferior vena cava (IVC) stenosis,13 (34,21％) had the hepatic vein anastomosis twisted at an angle,7 (18.42％) had IVC stenosis at the posthepatic segment,and 16 (42.10％) had outflow obstruction at the hepatic veins.In these 38 patients,34 underwent PBLT,2 underwent APBLT,and 2 COLT.Most patients with hepatic venous outflow obstruction improved with surgical treatment and interventional therapy.Conclusions Hepatic vein outflow obstruction was associated with the technique of hepatic vein anastomosis,the type of cavocaval anastomosis and graft size mismatch between the donor and the recipient.Performing piggyback liver transplantation according to the classification of hepatic vein and appropriate treatments could improve the prognosis of venous outflow obstruction in clinical practice.

Marginal liver donor,a way to expand the liver pool,has been maximized in the unique position due to the shortage of donors.But the definition of marginal donor liver varies from center to center and the standard is very complex.With the enhancement of organ perfusion solution,preservation methods and surgical techniques,the edge donor criteria are also gradually expanding.What decision should we make,facing such clinical controversies.This paper makes a review on the marginal liver donor in the donation after citizen deceased,so as to improve its clinical application.

Liver transplantation,a unique effective treatment for end-stage liver diseases,has already been applied in clinical practice for more than half a century.But the shortage of donor liver source has been the bottleneck limiting its development.How to determine the tiny minority donor liver quality to guarantee the prognosis of transplant patients becomes a hot focus for current research.Brain death causes patho-physiological changes of body organs,including liver.How to carry out related pathological and serologic tests to determine the safety of the donor liver is a very important issue.In this paper,the articles published in recent years were overviewed and analyzed to summarize the evaluation index of donating organ quality.We hope this paper may benefit the treatment through ensuring an effective evaluation on the donor liver in the future.

China donation after Citizen's death (CDCD) has been organized since 2010,and now has been synchronized with the international organ transplantation.At present,liver transplantation has become the only safe and curative treatment for the end-stage liver diseases.Nevertheless,there is much restriction over further exploration of this technique.This article will mainly focus on donation after brain death (DBD),and summarize the four dominating injuries of donor liver,including the donor's primary injury,cut and perfusion injury,graft preservation injury,and ischemia-reperfusion injury.

China donation after citizens' death (CDCD) has already entered a new historical era,and the donation after brain death plus cardiac death (DBCD),which refers to the transition from brain death to cardiac death,is most widely used.The various pathological and physiological changes have an influence on donor organs,which could not be ignored.So the research on the effects of donor brain death for CDCD liver transplantation will be of great significance.Here we discussed the CDCD initiation and its classification,and the necessity and application of establishing a donation after brain death (DBD) animal model to clarify the relationship between DBD and CDCD liver transplantation and thus to enlighten future studies.

Vascular complications after liver transplantation can seriously threaten the survival of patients.In the preoperative assessment and postoperative monitoring of patients' vascular conditions,although the digital subtraction angiography (DSA) is the golden standard for vascular lesion diagnosis,but not the first choice due to traumatic lesions.In some clinical circumstances,DSA can only be used when Doppler ultrasound,spiral CT,and MRI are not applicable,and in most cases DSA is used for treatment rather than diagnosis.This article reviewed the current interventional treatment of vascular complications to stress the important role of DSA in diagnosis and treatment of related complications after liver transplantation.

Patients who suffer from HBV-related endstage liver disease are the majority of liver transplantation (LT) recipients,and hence HBV recurrence post-LT is the key for the treatment success.HBIG was no longer solely used in clinical practice because of high cost and unavoidable drug-resistance.Nowadays,the standard prophylaxis regimen is the combination of low-dose HBIG and nucleoside analogues (NAs).Recently,the necessity of HBIG usage has been often questioned,and the novel prophylaxis of HBIG-withdrawn and HBIG-free regimen have been carried out in several transplant centers with encouraging results.In this review,we summarized the application of HBIG in the prophylaxis of HBV recurrence,and then evaluated the prospect of the prophylaxis of HBIG-withdrawn and HBIG-free regimen.

Biliary complication (BC) after liver transplantation has attracted increased attention from a clinical and research perspective.BC,which affects the long-term outcome of the liver transplant,includes diseases of biliary stricture,biliary obstruction,biliary fistula,and many more that need an operation or interventional therapy.The occurrence of these diseases is related to the surgical operation,biliary tract variation,vessel injury,and quality of the donor graft.This article reviews BC and its etiology,diagnosis,and therapy in order to help future clinical and experimental studies.

Objective To compare the outcome of donation after cardiac death (DCD) versus donation after brain death (DBD) for liver transplantation.Method Such databases as PubMed,Cochrane Central Register of Controlled Trials (CENTRAL),EMbase,the ISI Web of Knowledge databases and CBMdisk were searched from Month 1990 to March 2011 for collecting the randomized controlled trials (RCTs),case control studies and cohort analysis about DCD versus DBD for liver transplantation,and the references of those trials were also searched by hand.After study selection,assessment and data extraction conducted by two reviewers independently,meta-analyses were performed by using the RevManS.1 software.The quality of evidence was assessed by using the GRADEpro software.Result DCD group had similar MELD of recipients with DBD group before operation [Z =1.37,95％ CI(-2.25,0.26),P =0.17],and DCD group got shorter cold ischemia time than DBD group [Z=2.26,95％CI(-1.76,-0.12),P =0.02].DCD group had higher hiliary complication incidence [Z =6.37,95％ CI(1.89,3.31),P＜0.000 01],higher vascular complication incidence [Z =2.14,95％ CI(1.03,2.17),P =0.03],higher liver primary non-function (PNF) incidence [Z =4.43,95％ CI (2.02,6.17),P＜0.000 01],lower 1-year graft survival rate [Z =3.78,95％ CI(0.84,0.94),P =0.0002] and lower 3 year graft survival rate[Z=2.54,95％ CI(0.73,0.96),P =0.01] than DBD group.The quality of the result was verified from low to moderate.Conclusion Liver transplantation using DCD had higher incidence of complications and lower 1-year and 3-year graft survival rate than DBD.For the poor quality of the original studies,a prudent choice is suggested.More randomized controlled trials are needed.