Liver Transplantation in the World: Present Conditions of Liver Transplantation from Cadaver Donors in USA. (1995)

The potential usefulness of orthotopic liver transplantation (OLTx) in the treatment of end-stage liver diseases was recognized in the 1950s, and the first clinical attempt was carried out at the University of Colorado in Denver, on March 1, 1963 [1,2]. It was unsuccessful: the 3 year old patient, affected by extrahepatic biliary atresia, exsanguinated on the operating table. Among the next 8 patients, transplanted in Denver (6 patients), Boston (1 patient), and Paris (1 patient), the longest survival was 23 days [2]. The first long-term survivor was a child transplanted for hepatoma on July 23, 1967, who died of carcinomatosis 400 days later [3].

The late 1960's and early 1970's saw very slow progress in this field, with patients suffering from frequent and disabling complications, and an overall one-year patient survival of only 35 % [4]. By then, the technical steps of the standard procedure had already been precisely described (Figure 1), and the surgical technique that is currently used at the Pittsburgh Transplantation Institute, and in most of the world transplant centers, is essentially the one developed at the University of Colorado in the 1960's [1,2]. On the other hand, the indications for OLTx were much more limited in those early days, and the list of the diseases being treated with this procedure has grown significantly in the past 30 years. For example, post-necrotic cirrhosis of any etiology is today the most common indication for OLTx in most liver transplant centers, while only one patient in the original Denver series had post-necrotic cirrhosis [2]. The reason for the paucity of cirrhotic patients (other than biliary atresia) in the early trials was that, while the fate of patients with a liver malignancy or extrahepatic biliary atresia was easy to predict, the prognosis of a stable patient with cirrhosis could not be predicted as readily. Therefore, given the uncertainty surrounding the operation, most candidates were first considered only when they were already moribund, usually as a consequence of recent or ongoing variceal hemorrhage, and most died while awaiting for a suitable donor. It was the routine achievement of long-term survival (the longest surviving recipient was transplanted 25 years ago), several major immunological advances [5-8], and the progress in donor surgery, and organ preservation, what led to an expansion of the indications for OLTx. As a consequence, diseases that were not considered before are now successfully treated with OLTx, and the procedure could be used for virtually any patient suffering from a lethal hepatic disease.



FIGURE 1

Top: The recipient cirrhotic liver is excised. Bottom: The new donor liver is placed in the field by the second assistant, and the implantation is started with the end-to-end anastomosis of the suprahepatic vena cava. The right and left corner stitches ...



In 1982 it was estimated that the annual need for OLTx was 15 per million population [9], but this is probably now higher, as the advances of the past decade allow us to treat patients that not long ago would have been considered not transplantable. In fact, depending on the criteria used to determine what are appropriate indications, we can estimate that between 4,000 and 50,000 OLTx may be needed in the United States every year, with a similar number in Europe. But, while in the past the appropriateness of the decision to proceed with transplantation was judged largely on the basis of technical and medical factors related to the recipient, nowadays it is the supply of organs that increasingly shapes these decisions.