Book Review

Transplantation of the Liver

N Engl J Med 1996; 335:442-443August 8, 1996

Article

Transplantation of the Liver
Edited by Ronald W. Busuttil and Goran B. Klintmalm. 903 pp., illustrated. Philadelphia, W.B. Saunders, 1996. $250. ISBN: 0-7216-4942-4

More than 6000 liver transplantations are performed annually in the United States and Europe, so the subject has now become important in both medicine and surgery and deserving of this truly magnum opus, which weighs 5 lb (2.3 kg) and has 85 chapters with contributions from 125 authors.

The foreword, by Thomas Starzl, traces the beginnings of liver transplantation, the most complicated organ-transplant operation, and the dreadful early results 30 years ago. Improvement was slow and stuttering, but a sudden change followed the introduction of cyclosporine in 1980. Appropriately, the book is dedicated to Starzl, and he in turn applauds the enormous efforts of the editors in finding suitable authors for each chapter. I am amazed at how clearly the book reads. Each chapter is a short, authoritative statement pertaining to a specific subject, with well-balanced comments on the state of the art and possible future developments.

Starzl's historical review leads into chapters on experimental liver grafting and the hepatotropic physiology of the liver. The second section considers indications for liver transplantation in adults. There is a similar section on pediatric patients and then a section on the immunology of transplantation and the special biologic characteristics of liver transplantation. There are important differences between the liver and other organs. In particular, the liver has an immunosuppressive effect experimentally, which may also be apparent clinically. The assessment of patients before surgery and the details of operations and anesthesia are considered, together with retransplantation; technical variations, including the use of portions of liver; transplantation of the liver together with other organs; and transplantation from living donors. Todo and his Pittsburgh colleagues describe their experience with xenotransplantation. Important sections of the book deal with immediate postoperative care, the later management and recognition of complications, and their correct treatment. The details of practical immunosuppression are described, including the theory and the use of new immunosuppressive drugs. Other chapters speculate on gene therapy, the transplantation of hepatocytes, new approaches to immunosuppression, and extracorporeal xenogeneic livers.

The results of liver transplantation in different disease categories and age groups are reported, together with the details of recurrent disease, including the return to alcohol abuse. The book ends with an extremely interesting section on the ethical and financial aspects of liver transplantation. This operation is among the most expensive; total charges in the first year average more than $300,000. In the allocation of health care resources, the justification for underwriting the expenses of liver transplantation has been questioned. For the individual patient, there can be no doubt that the operation is life-saving and worthwhile, but society may regard liver transplantation somewhat differently.

This will remain a standard textbook and a wonderful reference work on all aspects of liver transplantation. It is really an American effort; of the 125 contributors, only 6 work outside the United States. Nevertheless, there have been important contributions and a wide experience in Western Europe and Australia. Readers around the world who have an interest in liver grafting will need this book. I recommend it enthusiastically.

Roy Calne, F.R.S.
University of Cambridge, Cambridge CB2 2QQ, United Kingdom