title: Systematic review of efficacy and outcomes of salvage liver transplantation after primary hepatic resection for hepatocellular carcinoma.
abstract: OBJECTIVE
  Upfront liver transplantation is the gold standard in the treatment of patients with hepatocellular carcinoma (HCC) and cirrhosis, but a shortage of donor organs negatively impacts on survival outcomes, with significant disease progression during long waiting lists. This systematic review evaluates the safety and efficacy of salvage liver transplantation (SLT) as treatment for recurrent HCC after initial hepatic resection.
  
  
  METHODS
  Electronic searches of Pubmed, Embase, and Medline databases identified 130 abstracts, from which 16 eligible studies comprising 319 patients were selected for review. Studies adopting SLT following primary hepatic resection for recurrent HCC with more than five patients were included. Demographic details, morbidity and mortality indices, and survival outcomes were collected from each study and were tabulated.
  
  
  RESULTS
  All patients included in the studies had liver cirrhosis, with the majority being Child-Pugh A (50%) and B (33%). The etiology of liver disease was hepatitis B in the majority of patients (84%). Disease recurrence occurred in 27-80% of patients at a median of 21.4 months (range 14.5-34) following initial resection. SLTs were performed on 41% of recurrences, and were associated with biliary complications (8%), infection (11%), bleeding (8%), and vascular complications (7%). There were 18 perioperative deaths (5.6%). The median 1-, 3-, and 5-year overall and disease-free survival was 89%, 80%, and 62%, and 86%, 68%, and 67%, respectively.
  
  
  CONCLUSIONS
  Synthesis of available observational studies suggests that SLT following primary hepatic resection is a highly applicable strategy with long-term survival outcomes that are comparable to upfront liver transplantation.
authors.affiliation: Hepatobiliary and Surgical Oncology Unit, UNSW Department of Surgery, St George Hospital, Sydney, New South Wales, Australia; St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia; The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, New South Wales, Australia.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Chan
authors.forename: Nayef A
authors.initials: NA
authors.lastname: Alzahrani
authors.forename: David L
authors.initials: DL
authors.lastname: Morris
authors.forename: Terence C
authors.initials: TC
authors.lastname: Chua
mesh_terms: D000328:Adult; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000601:surgery*; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000401:mortality; D008297:Male; D008875:Middle Aged; D039781:PubMed; D016879:Salvage Therapy / Q000401:mortality; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome
keywords: hepatic resection; hepatocellular carcinoma; liver transplantation; outcomes; systematic review; trials