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that long-term survival following transplantation for HCV is compromised by the reoccurrence of the disease in the transplanted liver.9 While intense efforts are underway to find medical therapies that treat viral replication post transplant, the decision whether to retransplant for this condition, which is likely to again reoccur in the second graft, is a subject of much debate. For the recipient dying of graft failure from recurrent HCV the benefit is obvious even if only a reduced survival compared with a first graft in a non-HCV patient is anticipated. When considered in terms of equitable and efficient use of a scarce resource the correct decision is less clear.

Operative complications can clearly impact the success of hepatic transplantation and retransplantation. 10 Liver retransplantation when done early in the postoperative period presents less of a technical challenge than the original operation owing to the relative simplicity of the recipient hepatectomy. However, when performed after a significant delay, these patients represent an arduous technical challenge. But, despite the greater technical complexity, patients transplanted late generally have shown better survival. An important exception is the finding that adults transplanted within the first week post transplant have survival rates equal to first grafts. Since those that succumb later often do so as the result of infection, the better survival in those retransplanted early may be a consequence of intervention before the patient become too ill and infected.

Several other technical considerations are important in hepatic retransplantation. Vascular grafts, usually of donor iliac artery and vein obtained at the time of liver procurement, have proven useful as an alternate method of arterial or portal venous reconstruction when there are difficulties with the standard anastomosis to the recipients own artery or portal vein. The use of an arterial graft is significantly more common in the retransplant setting (9.5% vs. 28.2 %). In addition, the biliary reconstruction can also present a challenge. If a duct-to-duct anastomosis is planned, all donor duct tissue must be removed while still ensuring that the recipient bile duct is viable and long enough to allow for a new anastomosis that is without tension. If any doubts exist, a choledochodochostomy should be abandoned in favor of an anastomosis to a Roux limb of jejunum. The need for enteric biliary drainage is required in approximately 18.8% of first time grafts compared with 47.7% in retransplants. If a jejunal limb is to be reused, the first site of duct anastomosis should be excised or closed primarily and a new site prepared

In addition to operative contributions, it is also possible that inferior patient survival after retransplantation may reflect an inherently sicker population. It is well documented that the outcome after a primary hepatic transplant correlates well with the patient's UNOS status and it is reasonable to assume that this might also apply to retransplantation. Moreover, sicker patients who are desperately awaiting retransplantation may be more apt to receive marginal grafts, thus further reducing their survival potential. In addition to being critically ill at the time they are undergoing major surgery, retransplanted patients are also highly immu-nosuppressed. In the case of intractable or chronic rejection, where immunosup-pression is often increased, the further loss of immunocompetence and the

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