Liver Transplantation Procedures Research Articles

Combined liver transplantation and sleeve gastrectomy: Report of a brief-interval staged approach.

Pretransplantation bariatric surgery in patients with high Model for End-Stage Liver Disease (MELD) score is fraught with risks. Bariatric surgery after liver transplantation (LT) may be complicated by surgical adhesions but could have advantages if performed at the time of transplantation. We investigated a method of brief-interval staging combining LT and sleeve gastrectomy (SG). LT recipients with a body mass index (BMI) > 40 kg/m 2 received an SG during the same hospitalization as the LT (LT/SG), at the same time as a planned brief-interval return to the operating room for biliary anastomosis. Differences in intraoperative attributes of the LT (Stage 1) versus SG (Stage 2) procedures were analyzed using Wilcoxon signed-rank test with significance p < 0.05 and compared with patients with obesity having a two-stage LT without SG. A total of 14 cases {median MELD score 33 (interquartile range [IQR], 18-40)} were compared with 28 controls; 60% were critically ill prior to surgery with mechanical ventilation, vasopressors, or continuous renal replacement therapy. Median interval between procedures was 16.1 (IQR, 12.5-22.7) hours for cases and 12.2 (IQR, 11.1-16.6) hours for controls, p =0.27. Median BMI at LT/SG was 47.0(IQR, 41.7-51.3) kg/m 2 versus 38.1 (IQR, 35.7-39.8) kg/m 2 for controls, p < 0.001. At 1 year, median excess body weight loss was 74.0% (IQR, 46.2%-78.7%) in cases and 15.8% (IQR, -5.4% to 62.6%) in controls, p =0.13; total weight loss was 38.1% (IQR, 23.9-42.9) in cases versus 7.7% (IQR, -2.4% to 27.6%) for controls, p =0.03. Graft survival at 1 year was 92.9% for cases and 89.3% for controls with similar early postoperative outcomes. This proof-of-concept study revealed that a brief-interval SG during LT is feasible in patients with high MELD and resulted in sustained weight loss at 1 year with similar graft survival. Further studies are needed to determine an optimal strategy.

Elevated Pre- and Postoperative ROTEM™ Clot Lysis Indices Indicate Reduced Clot Retraction and Increased Mortality in Patients Undergoing Liver Transplantation.

Background: The ROTEM™ clot lysis index, describing the decrease in firmness of a clot with time, predicts mortality in various settings. The variability of the clot lysis index in surgical procedures and the involved pathophysiological mechanisms are unknown. We therefore compared pre- and postoperative clot lysis indices in liver transplantation (LTX) procedures, determined the eventual association with mortality, and investigated the mechanisms underlying decreased clot lysis index using inhibitors of fibrinolysis and clot retraction, respectively. Methods: In this retrospective cohort study, data on pre- and post-transplant ROTEM™ findings as obtained with EXTEM (tissue factor activation), INTEM (intrinsic system activation), FIBTEM (extrinsic system activation and inhibition of clot retraction), APTEM (extrinsic system activation and fibrinolysis inhibition), conventional laboratory coagulation tests, blood loss, transfusion of blood products, and outcome were registered. Results: Pre-transplant clot lysis indices showed a broad distribution ranging from 75% to 99% independent of the activator used (EXTEM, INTEM). During the surgical procedure, median clot lysis index values markedly increased from 92% to 97% (EXTEM) and 93% to 98% (INTEM), respectively (p < 0.0001 each). Aprotinin had no effect on either pre- or postsurgical clot lysis indices. Inhibition of platelet clot retraction with cytochalasin D (FIBTEM) markedly increased the preoperative clot lysis index. High pre- and post-transplantation clot lysis indices were associated with increased mortality irrespective of the activator used (EXTEM, INTEM) and the inhibition of fibrinolysis (APTEM). Inhibition of clot retraction (FIBTEM) abolished the association of clot lysis index with mortality in both pre- and post-transplantation samples. Conclusion: Both pre- and postoperative ROTEM™ clot lysis indices predict mortality in patients following liver transplantation. Inhibitor experiments reveal that the clot lysis index is not an indicator of fibrinolysis, but indicates platelet clot retraction. The marked increase of clot lysis index during liver transplantation is caused by a decrease in clot retraction with eventual consequences for clot stability, retraction of wound margins, and reperfusion of vessels in case of thrombosis.

Porta hepatis in relation to portal vein among Indians.

The porta hepatis / hilum of liver is a transverse fissure located in the inferior surface, where the major vessels and ducts enter or leave the organ. The major structures traversing the porta hepatis are the portal vein, the hepatic artery and the hepatic duct. Porta hepatis is an area of surgical and radiological significance. The knowledge of variations in structures traversing the porta hepatitis will reduce the risk of surgeries involving this area. Study was conducted in the department of anatomy dissection lab after obtaining ethical clearance. 30 liver specimens were used for these studies which were removed from the cadaver during under graduate teaching. Anatomical knowledge of variations in relations of structures present in porta hepatis is of immense help to surgeons and radiologists when they engage patients for clinical procedures like liver transplant, cholecystectomy and diagnostic procedures. Hence this study was aimed to observe the relations of portal vein in porta hepatis.

A Case of Short- Term Intensive Care Unit-Acquired Weakness Post-Renal Graft Nephrectomy after Liver and Kidney Transplant

Background: In this study, we shed the light on the effect of two short-term ICU admissions within short period in-between admissions and the undesirable results in core muscles, lower limb motor power and physical abilities. We emphasized the importance of early intervention of physical therapy during ICU admission and after. Case Report: This study involved a 58 years old female patient with CKD and liver cirrhosis long years ago, underwent living-donor kidney and liver transplant procedure in September 2021, and was admitted in ICU for one week. Few months later, investigation revealed poor kidney function and renal graft nephrectomy was done in December 2021. Patient was admitted one week in ICU after renal graft nephrectomy. Core muscles, lower limb muscles and physical abilities were measured pre and post ICU admission after renal graft nephrectomy and at the time of discharge from physical therapy service. Result: Motor power was measured before renal graft nephrectomy and ICU admission classified and measured as follows: core muscles, hip flexors, adductors and abductors graded 3/5, hams and quad graded 3+/5, patient was able to stand up from sitting on regular chair and able to walk without assistance. Post renal graft nephrectomy and ICU admission the MRC was as follows: core muscles, hip flexors, adductors and abductors graded 2-/5, hams and quad graded 3-/5, patient was unable to stand up from regular chair and has poor standing balance. Patient was followed up in physical therapy eight weeks in total, four weeks in in-patient setting and four week in OPD. The discharge assessment shows improvement in hams and quad motor power measured 4/5, good core muscles and hip muscles measured 4/5. Patient was ambulatory without assistive device at the time of discharge from physical therapy service. Conclusion: Short-term ICU admission can acquired weakness if patient has repeated ICU admissions within short period

Living donor liver transplant outcomes during the COVID-19 pandemic: does a decrease in case volume impact the overall outcomes?

BackgroundHigh-volume centers (HVCs) are classically associated with better outcomes. During the coronavirus disease 2019 (COVID-19) pandemic, there has been a decrease in the regular liver transplantation (LT) activity at our center. This study analyzed the effect of the decline in LT on posttransplant patient outcomes at our HVC.MethodsWe compared the surgical outcomes of patients who underwent LT during the COVID-19 pandemic lockdown (April 1, 2020 to September 30, 2020) with outcomes in the pre-pandemic calendar year (April 1, 2019 to March 31, 2020).ResultsDuring the 6 months of pandemic lockdown, 60 patients underwent LT (43 adults and 17 children) while 228 patients underwent LT (178 adults and 50 children) during the pre-pandemic calendar year. Patients in the pandemic group had significantly higher model for end-stage liver disease (MELD) scores (24.39±9.55 vs. 21.14±9.17, P=0.034), Child-Turcotte-Pugh scores (11.46±2.32 vs. 10.25±2.24, P=0.03), and incidence of acute-on-chronic liver failure (30.2% vs. 10.2%, P=0.002). Despite performing LT in sicker patients with COVID-19-related challenges, the 30-day (14% vs. 18.5%, P=0.479), 3-month (16.3% vs. 20.2%, P=0.557), and 6-month mortality rates (23.3% vs. 28.7%, P=0.477) were lower, but not statistically significant when compared to the pre-pandemic cohort.ConclusionsDuring the COVID-19 pandemic lockdown the number of LT procedures performed at our HVC declined by half because prevailing conditions allowed LT in very sick patients only. Despite these changes, outcomes were not inferior during the pandemic period compared to the pre-pandemic calendar year. Greater individualization of patient care contributed to non-inferior outcomes in these sick recipients.

Advances in the surgical treatment of liver cancer.

Liver resection is the standard curative treatment for liver cancer. Advances in surgical techniques over the last 30 years, including the preoperative assessment of the future liver remnant, have improved the safety of liver resection. In addition, advances in nonsurgical multidisciplinary treatment have increased the opportunities for tumor downstaging. Consequently, the indications for resection of more advanced liver cancer have expanded. Laparoscopic and robot-assisted liver resections have also gradually become more widespread. These techniques should be performed in stages, depending on the difficulty of the procedure. Advances in preoperative simulation and intraoperative navigation technology may have also lowered the threshold for their performance and may have promoted their widespread use. New insights and experiences gained from laparoscopic surgery may be applicable in open surgery. Liver transplantation, which is usually indicated for patients with poor liver function, has also become safer with advances in perioperative management. The indications for liver transplantation in liver cancer are also expanding. Although the coronavirus disease 2019 pandemic has forced the postponement of liver resection and transplantation procedures, liver surgeons should appropriately tailor the surgical plan to the individual patient as part of multidisciplinary treatment. This review may provide an entry point for future clinical research by identifying currently unresolved issues regarding liver cancer, and particularly hepatocellular carcinoma.

Financial problems for underprivileged people undergoing liver transplantation procedure in Pakistan

Financial problems for underprivileged people undergoing liver transplantation procedure in Pakistan

Hepatic pannexin-1 mediates ST2+ regulatory T cells promoting resolution of inflammation in lipopolysaccharide-induced endotoxemia.

Sepsis remains the most lethal infectious disease and substantially impairs patient prognosis after liver transplantation (LT). Our previous study reported a role of the pannexin 1 (PANX1)–interleukin‐33 (IL‐33) axis in activating innate immunity to protect against methicillin‐resistant Staphylococcus aureus infection; however, the role of PANX1 in regulating adaptive immunity in sepsis and the underlying mechanism are unclear. In this study, we examined the role of the PANX1–IL‐33 axis in protecting against sepsis caused by a gram‐negative bacterial infection in an independent LT cohort. Next, in animal studies, we assessed the immunological state of Panx1−/‐ mice with lipopolysaccharide (LPS)‐induced endotoxemia and then focused on the cytokine storm and regulatory T cells (Tregs), which are crucial for the resolution of inflammation. To generate liver‐specific Panx1‐deficient mice and mimic clinical LT procedures, a mouse LT model was established. We demonstrated that hepatic PANX1 deficiency exacerbated LPS‐induced endotoxemia and dysregulated the immune response in the mouse LT model. In hepatocytes, we confirmed that PANX1 positively regulated IL‐33 synthesis after LPS administration. We showed that the adenosine triphosphate‐P2X7 pathway regulated the hepatic PANX1–IL‐33 axis during endotoxemia in vitro and in vivo. Recombinant IL‐33 treatment rescued LPS‐induced endotoxemia by increasing the numbers of liver‐infiltrating ST2+ Tregs and attenuating the cytokine storm in hepatic PANX1‐deficient mice. In conclusion, our findings revealed that the hepatic PANX1–IL‐33 axis protects against endotoxemia and liver injury by targeting ST2+ Tregs and promoting the early resolution of hyperinflammation.

Vascular Complications in Pediatric Liver Transplants and Their Management.

The blood supply of the liver occurs through the hepatic artery and portal vein. Outflow of blood circulation in the liver is via the hepatic veins. Any disruption in this blood circulation results in deterioration of liver functions. In this study, we evaluated early vascular complications in pediatric liver transplant recipients seen at our center. From November 1988 to December 2021, our team has performed 701 liver transplant procedures, which have included 334 pediatric liver transplants. Among these pediatric liver transplant recipients (mean age of 7.34 y), 176 were male patients. Nineteen patients (5.7%) were recipients of deceased donors. Reason for liver failure was mainly biliary atresia (n = 169). Mean weight of recipients was 23.3 kg. Most graft types were left lateral grafts (n = 204). Three patients had hepatic vein complications. All 3 patients were successfully treated with interventional radiological methods by placing a stent in the anastomosis region. Portal vein complications occurred in 3 patients. One patient had hemostasis performed surgically. The second patient had surgically revision of the anastomosis because of thrombus formation. Because of stenosis of more than 50% in the portal vein anastomosis, the third patient required stent placement in the anastomosis region. Hepatic artery complications occurred in 54 patients: 31 patients had hepatic artery thrombosis, 13 patients had hepatic artery stenosis, 7 patients had bleeding from hepatic artery anastomosis, 2 patients had hepatic artery dissection, and 1 patient had pseudoaneurysm in the hepatic artery. Forty-three of these patients were successfully treated with interventional radiological methods and 11 required surgical treatment. Vascular complications after liver transplant can cause deterioration in hepatic functions and acute liver failure. Vascular complications can be successfully treated in experienced organ transplant centers.

The Impact of Donor Risk Index, Recipients’ and Operative Characteristics on Post Liver Transplant One-Year Graft Failure: A Cohort Analysis

Background and Aims: The donor risk index (DRI) quantifies donor-related characteristics potentially associated with increased risk of early graft failure. We aimed to assess the impact of the DRI, recipient and perioperative factors on post liver transplant (LT) outcomes. Methods: This was a single-center retrospective cohort study including all adult (≥18 years) patients who underwent LT from 01/2019 to 12/2019 at Curry Cabral Hospital, Lisbon, Portugal. Primary endpoint was 1-year graft failure post LT. Associations were studied with logistic regression. Results: A total of 131 cadaveric donor LT procedures were performed in 116 recipients. Recipients’ median (IQR) age was 57 (47–64) years and 101/131 (77.1%) were males. Cirrhosis was the underlying etiology in 95/131 (81.2%) transplants. Based on 8 predefined donors’ characteristics, median (IQR) DRI was 1.96 (1.67–2.16). Following adjustment for MELDNa score pre LT and SOFA score (adjusted odds ratio [aOR], 95% confidence interval [CI] = 0.91 [0.56–1.47]) or lactate (aOR [95% CI] = 2.76 [0.71–10.7]) upon intensive care unit (ICU) admission post LT, DRI was not associated with 1-year graft failure. However, higher SOFA score (aOR [95% CI] = 1.20 [1.05–1.37]) or lactate (aOR [95% CI] = 1.27 [1.10–1.46]) upon ICU admission post LT were independently associated with higher odds of 1-year graft failure. Conclusions: In a recent cohort of patients who underwent LT, DRI, despite being high, was not associated with 1-year graft failure, but SOFA score or lactate upon ICU admission post LT were.

Sinusoidal obstruction syndrome after liver transplantation: A multicenter observational study.

Sinusoidal obstruction syndrome after liver transplantation: A multicenter observational study.

The Effects of Growth Factors and Cytokines on Hepatic Regeneration: A Systematic Review.

The incidence of liver disease increases throughout the years due to many lifestyle factors; thus, the only definite treatment available for chronic liver disease is a liver transplant. However, the liver has a natural ability to repair itself and regenerate its hepatic tissue from stem cells. It is hypothesized that by inducing the liver with specific growth factors and cytokines such as interleukin 6 (IL-6) compared to general growth factors like growth differentiation factor 15 (GDF-15), it can regenerate, decreasing the need for liver transplant procedures. MEDLINE, the Journal of Hepatology, and Google Scholar were used to find articles. Various studies, including epidemiological studies dated from the year 2000 and greater, were used for the introduction. The results used only randomized control trials, experimental studies, and primary articles published since 2000. This compared the results of manipulating variables to determine the effects of hepatic regeneration by either specific hepatocyte growth factors or general growth factors like GDF-15. A total of 10 collected studies showed increased levels of gene expression and function, improved gross morphology, and histological appearance of the liver when induced by cytokines and specific growth factors versus general growth factors. Overall, the hypothesis was proven. The effects of GDF-15 were not significant compared to the effects of hepatocyte-specific growth factors and cytokines like IL-6 because they have two different effects on the liver after liver injury. Future studies should investigate this topic on the human hepatic regenerative ability, plus compare the effects of general growth factors like GDF-15 and specific hepatocyte growth factors and cytokines such as IL-6 in human liver tissue.

En bloc excision of giant polycystic liver with hepatic cava and its auto-transplant caval reconstruction as a safe surgical procedure for liver transplantation.

Safely excising a giant liver while leaving the hepatic inferior vena cava intact is difficult. Hata et al. present images and videos describing their novel technique consisting of total hepatectomy including the hepatic cava; extracorporeal retrieval; and auto-transplant inferior vena cava reconstruction, for an extremely enlarged polycystic liver weighing 24 kg.

Abrogation of graft ischemia-reperfusion injury in ischemia-free liver transplantation.

BackgroundIschemia‐reperfusion injury (IRI) is considered an inherent component of organ transplantation that compromises transplant outcomes and organ availability. The ischemia‐free liver transplantation (IFLT) procedure has been developed to avoid interruption of blood supply to liver grafts. It is unknown how IFLT might change the characteristics of graft IRI.MethodsSerum and liver biopsy samples were collected from IFLT and conventional liver transplantation (CLT) recipients. Pathological, metabolomics, transcriptomics, and proteomics analyses were performed to identify the characteristic changes in graft IRI in IFLT.ResultsPeak aspartate aminotransferase (539.59 ± 661.76 U/L versus 2622.28 ± 3291.57 U/L) and alanine aminotransferase (297.64 ± 549.50 U/L versus 1184.16 ± 1502.76 U/L) levels within the first 7 days and total bilirubin levels by day 7 (3.27 ± 2.82 mg/dl versus 8.33 ± 8.76 mg/dl) were lower in the IFLT versus CLT group (all p values < 0.001). The pathological characteristics of IRI were more obvious in CLT grafts. The antioxidant pentose phosphate pathway remained active throughout the procedure in IFLT grafts and was suppressed during preservation and overactivated postrevascularization in CLT grafts. Gene transcriptional reprogramming was almost absent during IFLT but was profound during CLT. Proteomics analysis showed that “metabolism of RNA” was the major differentially expressed process between the two groups. Several proinflammatory pathways were not activated post‐IFLT as they were post‐CLT. The activities of natural killer cells, macrophages, and neutrophils were lower in IFLT grafts than in CLT grafts. The serum levels of 14 cytokines were increased in CLT versus IFLT recipients.ConclusionsIFLT can largely avoid the biological consequences of graft IRI, thus has the potential to improve transplant outcome while increasing organ utilization.

Changes in the Serum Fatty Acid Profile After Anhepatic Phase of Orthotopic Liver Transplantation Procedure.

During orthotopic liver transplantation (OLT), the patients’ body remains deprived of this organ for some time, which could cause critical changes in the levels of various metabolites in the circulation, including fatty acids. Thus, the aim of this study was to determine whether the liver transplantation procedure leads to significant changes in the FA profile in serum lipids after the anhepatic phase. Our gas chromatography–mass spectrometry analysis revealed that after transplantation, serum levels of myristic and palmitic acids significantly decreased, whereas serum levels of very long-chain FAs containing 20 or more carbons in their chains were increased. These results indicate that the anhepatic phase during liver transplantation produces significant changes in serum fatty acid levels, and emphasizes the role of the liver in the metabolism of very long-chain fatty acids.

Combined open-heart surgery and living donor liver transplantation in a 4-year-old child with Alagille syndrome - A case report

Alagille syndrome (ALGS) is a complex multisystem genetic disorder. Patients with ALGS usually require liver transplantation (LT). Congenital heart diseases are also common in ALGS patients. ALGS patients may become ineligible for LT procedure due to cardiac abnormalities whereas any corrective cardiac surgeries are precluded due to the Child C cirrhosis of the liver in these patients. We report a unique case of a 4-year- and 10-month-old girl who underwent open-heart surgery and living donor liver transplantation (LDLT). She had significant hepatic and cardiopulmonary involvement, and Child C cirrhosis with portal hypertension and complex cardiac defects, and was ineligible for up-front LT. An open-cardiac surgery was performed and after 12 h she received LDLT using a left lateral hepatic graft. This is the first report of a case of successful combined open-heart surgery and LDLT in a child with ALGS with cardiac defects and Child C liver cirrhosis.

Combined Heart – Liver – Kidney Transplantation: A Pioneer Experience in South America

Multiorgan dysfunction is common in population with heart failure, particularly, hepatic dysfunction. A heart or liver transplantation procedure performed in isolation itself presents multiple challenges for the perioperative team. Accordingly, combining both transplants yields a vastly more complicated surgery, with many unique multisystem and multidisciplinary considerations. Although combined heart and liver transplantations are being performed with increasing frequency. Case report: Male patient, 56 years old, diagnosed with dilated cardiomyopathy with biventricular dysfunction and cardiac cirrhosis associated with cardiorenal syndrome. He evolved with progressive dyspnea, undergoing frequent paracentesis and hemodialysis, being listed for transplantation, which took place in April 2021. The uptake occurred in a single-piece block consisting of the heart and liver, with the kidneys removed afterwards. The procedure was performed using the block technique, with simultaneous heart and liver implants, with extracorporeal circulation. Orthotopic kidney transplantation occurred after completion of the other two implants. After surgery, the patient was referred to the intensive care unit, where he remained for 6 days and was discharged after 17 days. Hemodialysis was not necessary at any time after surgery. Conclusion: Due to the high morbidity and mortality rates of cardiac surgery in patients with liver cirrhosis, especially those with Child-Pugh C disease, the combined transplantation may be a promising. However, patients should be carefully selected for this complex procedure, especially in these times of organ shortages.

Fluorescence spectroscopy for clinical transplantation liver grafts monitoring: possibilities offered by 408 nm excitation

Fluorescence spectroscopy techniques have been investigated aiming to reduce the invasiveness of methods for investigation of tissue. In transplantation procedures, it may offer the possibility of a complementary technique for the monitoring of liver grafts' conditions prior to and during the transplantation procedure stages involving cold perfusion. The objective of this study was to evaluate fluorescence spectroscopy under violet light excitation (408 nm) for the monitoring of clinical hypothermic liver transplantation procedures. Organ grafts were monitored from before the removal of the donor's body to 1 h after the implant into the receptor's body. Fluorescence spectroscopy was assessed over five stages within these transplant stages. The study provided evidence of a correlation between fluorescence information collected during liver grafts transplantation and the survival of patients. Fluorescence spectroscopy can become a tool to monitor transplantation grafts, providing objective information for the final decision of surgeons to use organs.

European Liver Transplant Registry: Donor and transplant surgery aspects of 16,641 liver transplantations in children.

The European Liver Transplant Registry (ELTR) has collected data on liver transplant procedures performed in Europe since 1968. Over a 50-year period (1968-2017), clinical and laboratory data were collected from 133 transplant centers and analyzed retrospectively (16,641 liver transplants in 14,515 children). Data were analyzed according to three successive periods (A, before 2000; B, 2000-2009; and C, since 2010), studying donor and graft characteristics and graft outcome. The use of living donors steadily increased from A to C (A, n=296 [7%]; B, n=1131 [23%]; and C, n=1985 [39%]; p=0.0001). Overall, the 5-year graft survival rate has improved from 65% in group A to 75% in group B (p<0.0001) and to 79% in group C (B versus C, p<0.0001). Graft half-life was 31 years, overall; it was 41 years for children who survived the first year after transplant. The late annual graft loss rate in teenagers is higher than that in children aged <12 years and similar to that of young adults. No evidence for accelerated graft loss after age 18 years was found. Pediatric liver transplantation has reached a high efficacy as a cure or treatment for severe liver disease in infants and children. Grafts that survived the first year had a half-life similar to standard human half-life. Transplantation before or after puberty may be the pivot-point for lower long-term outcome in children. Further studies are necessary to revisit some old concepts regarding transplant benefit (survival time) for small children, the role of recipient pathophysiology versus graft aging, and risk at transition to adult age.

Auxiliary Liver Transplantation for Cirrhosis: From APOLT to RAPID: A Scoping Review.

To survey the available literature regarding the use of auxiliary liver transplantation (ALT) in the setting of cirrhosis. ALT is a type of liver transplantation (LT) procedure in which part of the cirrhotic liver is resected and part of the liver graft is transplanted. The cirrhotic liver left in situ acts as an auxiliary liver until the graft has reached sufficient volume. Recently, a 2-stage concept named RAPID (Resection and Partial Liver segment 2/3 transplantation with Delayed total hepatectomy) was developed, which combines hypertrophy of the small graft followed by delayed removal of the native liver. A scoping review of the literature on ALT for cirrhosis was performed, focusing on the historical background of RAPID and the status of RAPID for this indication. The new comprehensive nomenclature for hepatectomy ("New World" terminology) was used in this review. A total of 72 cirrhotic patients underwent ALT [heterotopic (n = 34), orthotopic (Auxiliary partial orthotopic liver transplantation, n = 34 including 5 followed by resection of the native liver at the second stage) and RAPID (n = 4)]. Among the 9 2-stage LTs (APOLT, n = 5; RAPID, n = 4), portal blood flow modulation was performed in 6 patients by deportalization of the native liver (n = 4), portosystemic shunt creation (n = 1), splenic artery ligation (n = 3) or splenectomy (n = 1). The delay between the first and second stages ranged from 18 to 90 days. This procedure led to an increase in the graft-to-recipient weight ratio between 33% and 156%. Eight patients were alive at the last follow-up. Two-stage LT and, more recently, the RAPID procedure are viable options for increasing the number of transplantations for cirrhotic patients by using small grafts.