Background
Although piggyback technique has gained widespread acceptance for liver transplantation in general, there is an exceptional lack of data on the choice of appropriate surgical technique for patients with hepatocellular carcinoma (HCC). The purpose of this study was to evaluate the impact of surgical technique on outcomes after liver transplantation for HCC.
Material and Methods
We conducted a retrospective cohort study on 90 HCC patients who underwent liver transplantation with the conventional (n=19) or piggyback (n=71) technique. Both techniques were compared with respect to intraoperative variables and long-term outcomes, determined by 3-year overall (OS) and recurrence-free (RFS) survival. The potential role of confounding factors was excluded in a series of Cox proportional regression models.
Results
The piggyback technique was associated with shorter procedure duration (p=0.0005), shorter anatomical anhepatic phase (p<0.0001), shorter duration of total (p=0.018) and warm ischemia (p<0.0001), and fewer blood transfusions (p=0.006). Three-year OS was 89.1% after piggyback and 49.9% after conventional transplantation (p=0.0008), with 3-year RFS of 89.4% and 56.0% (p=0.0006), respectively. Piggyback transplantations provided outcomes superior to conventional procedures both in patients within (p=0.019 for OS; p=0.003 for RFS) and beyond (p=0.023 for OS; p=0.031 for RFS) Milan criteria. Multivariate analysis of the risks of death and recurrence confirmed the benefits of piggyback technique.
Conclusions
Given its superior long-term outcome, piggyback transplantation might be considered primarily for HCC patients.

Keywords: Liver Transplantation, Hepatocellular carcinoma (HCC), Neoplasm recurrence, surgical technique, outcomes, piggyback technique