Overall Bottom Line

There are four key components of the surgical evaluation of patients for LT based on necessity, suitability, strategy and informed consent:

1. Necessity: does this patient need LT?

2. Suitability: is this patient a good candidate for LT?

3. Strategy: how do we get a liver for this patient or are there other alternative options?

4. Informed consent (choice): a detailed discussion of the risks and benefits of the procedure.

Section 1: Background

Evaluation of patients for LT is a multidisciplinary process that involves medical, surgical, cardiac, infectious disease and psychosocial assessment.
Surgical evaluation is an essential part of the process and it is the first bond between a patient and a surgeon.
Four key components should be addressed in the surgical evaluation:

1. Necessity.

2. Suitability.

3. Strategy.

4. Informed consent (choice).

The overall surgical risk must be considered and evaluated by a surgeon and an anesthesiologist in high risk cases.
It is essential to physically see the patient as an “eye ball” test is frequently more useful than information reported from your colleagues or laboratory results when assessing the patient’s surgical risk.
Anatomical evaluation and a surgical plan need to be made well in advance of surgery.

Section 2: Prevention

Not applicable for this topic.

Does the patient need liver transplantation?
Does this patient have significant complications due to irreversible liver disease?
Is this patient too early for transplantation? Well-compensated liver cirrhosis?
If the MELD score is <15, what is the indication for the transplantation? Is this due to HCC? Is this patient sicker than the calculated MELD score (e.g. a patient with recurrent ascites who requires large volume paracentesis every week?).
Does the patient have an alternative treatment such as TIPS?
Does the patient have an alternative treatment such as liver resection for HCC?
Does the patient need one organ, or more organs such as liver/kidney or multi-visceral transplantation?

The patient is a 55-year-old obese (BMI 35) male with history of HCV liver cirrhosis /HCC who came here to be seen by a surgeon for LT evaluation. Screening US showed a 2 cm mass in segment VIII. CT scan showed that the mass had arterial enhancement and portal phase wash out. Platelet count was 55. His natural MELD score was 7. No ascites or encephalopathy was noted. He was treatment-naïve for hepatitis C. Should he have a LT or liver resection?
The patient is a 27-year-old otherwise healthy female who took one bottle of Tylenol and NSAIDs to commit suicide. N-acetylcysteine was administered within 24 hours after taking these drugs. She is encephalopathic. Total bilirubin is 15 mg/dL, lactate is 3 mmol/L, phosphorous is 2 mg/dL and creatinine is 2 mg/dL. She is on levophed 4 μg/minute. Could this patient recover without liver transplantation? What are risk factors for fulminant liver failure?

MELD score 15–17 is the cut-off for liver transplantation risk/benefit: the benefit of LT will overweigh its risk when a patient’s MELD score exceeds 15–17.
If a patient with lower MELD (<15) needs LT, the patient should have strong indications such as HCC, refractory ascites or very poor quality of life.

Hepatoportal sclerosis and other causes of non-cirrhotic portal hypertension can sometimes mimic liver cirrhosis. If the patient has hepatoportal sclerosis with portal vein thrombosis, the treatment of choice may be the shunt surgery rather than LT.
Liver resection might be the better or equivalent option, if feasible (single tumor without significant portal hypertension) for the patients with HCC in regions of the country where a very high MELD score is required for DDLT.

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