Current advances in liver transplantation.

Advances in the medical and surgical management of patients undergoing liver transplantation have made transplantation the method of choice for dealing with end-stage liver disease. With the availability of anti-viral agents such as interferon and ribavirin, pre and post transplant treatment of hepatitis C, the most common indication for liver transplantation, is now possible. The use of high dose hepatitis B immune globulin (HBIG) and lamivudine has decreased the incidence and severity of recurrence of hepatitis B after liver transplantation. Multimodal therapy including chemoembolization for hepatocellular carcinoma has made liver transplantation a viable option for selected patients with primary liver cancer. The development of more potent immunosuppressive agents has dramatically decreased the incidence of acute rejection, while the search for a solution to the problem of chronic rejection continues. Alcoholic liver disease remains a challenge for transplant physicians and surgeons; however, careful patient selection results in a relatively low rate of recidivism.Surgical advances in liver transplantation have focused on eliminating associated morbidity and mortality as well as expanding the donor pool. Veno-venous bypass (VVB) and T-tube stenting, which were once considered essential techniques in liver transplantation, are now only rarely, if ever, necessary. Operative time, blood product usage, and time to extubation, as well as intensive care unit stay, have all been significantly reduced by elimination of VVB without associated morbidity. Elimination of T-tube usage has also effectively decreased morbidity. Donor expansion has become critical as the need for liver transplants exceeds donor availability. Use of marginal donors, including older donors, donors with up to 40% fat content, and donors with high pressor requirements, has proven to be a safe and effective means of increasing the donor pool. In-situ splitting of donors is the most promising technical advance in liver transplantation. This technique, along with living-related liver transplantation, is very important for providing donors to the pediatric population where donor availability is even more limited.