Role of pre-transplant 18F-FDG PET/CT in predicting hepatocellular carcinoma recurrence after liver transplantation.

The last two decades have seen a paradigm shift in the selection of patients with hepatocellular carcinoma (HCC) for liver transplantation. Microvascular invasion and differentiation have been the most significant factors affecting post-transplant recurrence; however, because of inherent disadvantages of pre-transplant biopsy, histological criteria never gained popularity. Recently, the selection criteria evolved from morphological to biological criteria, such as biomarkers and response to loco-regional therapy. With the introduction of multimodality imaging, combination of computed tomography with nuclear medicine imaging, particularly, 18F-fluorodeoxyglucose positron emission tomography fulfilled an unmet need and rapidly became a critical component of HCC management. This review article will focus on the use of 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography in the pre-transplant evaluation of HCC patients with special discussion on its ability to predict HCC recurrence after liver transplantation.

Major complications of adult right lobe living liver donors.

BACKGROUND: The right lobe of the liver is generally preferred for living donor liver transplantation in adult patients with end-stage liver disease. It is important to know the preoperative factors relating to the major postoperative complications. We therefore evaluated the possible risk factors for predicting postoperative complications in right lobe liver donors. METHODS: Data from 378 donors who had undergone right lobe hepatectomy at our center were evaluated retrospectively. The factors we evaluated included donor age, gender, body mass index (BMI), remnant liver volume, operation time, history of previous abdominal surgery, inclusion of the middle hepatic vein and variations in the portal and bile systems. RESULTS: Of the 378 donors, 219 were male and 159 female. None of the donors died, but 124 (32.8%) donors experienced complications including major complications (Clavien scores III and IV) in 27 (7.1%). Univariate analysis showed that complications were significantly associated with male gender and higher BMI (P<0.05), but not with donor age, remnant liver volume, operation time, graft with middle hepatic vein, variations in the portal and bile systems and previous abdominal surgery (P<0.05). Multivariate logistic regression analysis showed that major complications were significantly associated with male gender (P=0.005) and higher BMI (P=0.029). Moreover, the Chi-square test showed that there were significant relationships between major complications and male gender (P=0.010, X2=6.614, df=1) and BMI >25 kg/m2 (P=0.031, X2=8.562, df=1). Of the 96 male donors with BMI >25 kg/m2, 14 (14.6%) with major complications had significantly smaller mean remnant liver volume than those (82, 85.4%) without major complications (32.50%+/-4.45% vs 34.63%+/-3.11%, P=0.029). CONCLUSION: Male donors with BMI >25 kg/m2 and a remnant liver volume ≤32.50% had a significantly increased risk for major complications.

Living donor right lobe liver transplantation as a treatment for hepatic alveolar echinococcosis: report of three cases.

Echinococcus alveolaris is a parasite from tenia family which causes tumor-like lesions in the livers of infected people. If it is not diagnosed in the early stage of the disease, it frequently causes multiple cysts in the liver. The clinical importance of the disease is rapid progression, infiltration into different tissues like a malignant tumor and capacity of creating metastatic masses. The disease could be treated either by surgical resection or liver transplantation. The resection of the cystic disease is the preferred treatment method. In cases where resection is not possible, liver transplantation is the choice of treatment. Here we present three cases which were admitted to the hospital with unresectable hepatic alveolar echinococcosis and treated by liver transplantation successfully. Patients for whom surgical resection is not possible, we recommend liver transplantation as the treatment method.

Living Donor Liver Transplantation in Patients 70 Years or Older.

INTRODUCTION: Previous published studies have shown that age is not a contraindication for deceased donor liver transplantation. The data about elderly recipient after living donor liver transplantation (LDLT) is unsatisfactory. The aim of this study was to evaluate the outcome of the LDLT with recipients aged 70 years or older. PATIENTS AND METHODS: Between 2005 and 2013, 469 patients underwent LDLTs. The clinical characteristics, preoperative, intraoperative, and postoperative data, graft, and patients' survival of these patients were retrospectively analyzed. All recipients who were 70 years or older at the time of liver transplantation were indentified. The results were compared to the results of the patients younger than 70 years. RESULTS: There were 12 patients (2%) 70 years or older. All patients received the right lobe of their donor in a standard technique. One patient died postoperatively because of pulmonary infection, and one patient died 6 months after the operation because of graft failure after cardiac infarction. The comorbidity score of these two patients were significantly higher compared to the other ten patients without any complications (8.5 vs. 4.6, P = 0.01). The 1-year and 3-year patient and graft survival was 84%. There were no significant differences in complications, hospital stay, perioperative mortality, or median survival compared to the younger group. CONCLUSION: Although the number of the patients is small, our study emphasizes that LDLT of patients 70 years or older can be performed safely in patients without major comorbidities. Elderly patients with increased risk for postoperative complications should be excluded from LDLT.

Living Donor Liver Transplantation Outcomes for Hepatocellular Carcinoma Beyond Milan or UCSF Criteria.

Liver transplantation (LT) is the most effective treatment for hepatocellular carcinoma (HCC) that arises from cirrhosis. The Milan and the University of California, San Francisco (UCSF) selection criteria have resulted in major improvements in patient survival. We assessed our outcomes for patients with HCC that were beyond the Milan and UCSF criteria after living donor liver transplantation. We reviewed the data for 109 patients with cirrhosis and HCC who underwent living donor right lobe liver transplantation (living donor liver transplantation; LDLT) during the period from July 2004 to July 2012. Sixteen (14.7 %) patients had HCC recurrences during a mean follow-up of 35.4 ± 26.2 months (range 4-100 months). The mean time to recurrence was 11 ± 9.4 months (range 4-26 months). Survival rates were not significantly different between patients with HCC that met and were beyond the Milan and UCSF criteria (p = 0.761 and p = 0.861, respectively). The Milan and UCSF criteria were not independent risk factors for HCC recurrence or patient survival. Only poorly differentiated tumors were associated with a lower survival rate (OR = 8.656, 95 % confidence interval (CI) 2.01-37.16; p = 0.004). Survival rates for patients with HCC that were beyond conventional selection criteria should encourage reconsidering the acceptable thresholds of these criteria so that more HCC patients may undergo LT without affecting outcomes.

Living donor liver transplantation for obese patients: challenges and outcomes.

Living donor liver transplantation (LDLT) is an accepted option for end-stage liver disease, particularly in countries in which there are organ shortages. However, little is known about LDLT for obese patients. We sought to determine the effects of obesity on pretransplant living donor selection for obese recipients and their outcomes. On the basis of body mass index (BMI) values, 148 patients were classified as normal weight (N), 148 were classified as overweight (OW), and 74 were classified as obese (O). O recipients had significantly greater BMI values (32.1 ± 1.6 versus 23.2 ± 1.9 kg/m(2), P < 0.001) and received larger actual grafts (918.9 ± 173 versus 839.4 ± 162 g, P = 0.002) than recipients with normal BMI values. Donors who donated to O recipients had a greater mean BMI (26.3 ± 3.8 kg/m(2)) than those who donated to N recipients (24.4 ± 3.2 kg/m(2), P = 0.001). Although O recipients were more likely to face some challenges in finding a suitable living donor, there were no differences in graft survival [hazard ratio (HR) = 0.955, 95% confidence interval (CI) = 0.474-1.924, P = 0.90] or recipient survival (HR = 0.90, 95% CI = 0.56-1.5, P = 0.67) between the 3 groups according to an adjusted Cox proportional hazards model. There were no significant differences in posttransplant complication rates between the 3 recipient groups or in the morbidity rates for the donors who donated to O recipients versus the donors who donated to OW and N recipients (P = 0.26). Therefore, we recommend that obese patients undergo pretransplant evaluations. If they are adequately evaluated and selected, they should be considered for LDLT.

Glasgow coma scale and APACHE-II scores affect the liver transplantation outcomes in patients with acute liver failure.

BACKGROUND: The timing and selection of patients for liver transplantation in acute liver failure are great challenges. This study aimed to investigate the effect of Glasgow coma scale (GCS) and APACHE-II scores on liver transplantation outcomes in patients with acute liver failure. METHOD: A total of 25 patients with acute liver failure were retrospectively analyzed according to age, etiology, time to transplantation, coma scores, complications and mortality. RESULTS: Eighteen patients received transplants from live donors and 7 had cadaveric whole liver transplants. The mean duration of follow-up after liver transplantation was 39.86+/-40.23 months. Seven patients died within the perioperative period and the 1-, 3-, 5-year survival rates of the patients were 72%, 72% and 60%, respectively. The parameters evaluated for the perioperative deaths versus alive were as follows: the mean age of the patients was 33.71 vs 28 years, MELD score was 40 vs 32.66, GCS was 5.57 vs 10.16, APACHE-II score was 23 vs 18.11, serum sodium level was 138.57 vs 138.44 mmol/L, mean waiting time before the operation was 12 vs 5.16 days. Low GCS, high APACHE-II score and longer waiting time before the operation (P<0.01) were found as statistically significant factors for perioperative mortality. CONCLUSION: Lower GCS and higher APACHE-II scores are related to poor outcomes in patients with acute liver failure after liver transplantation.

Anatomical variations of donor portal vein in right lobe living donor liver transplantation: the safe use of variant portal veins.

In right lobe (RL) living donor liver transplantation (LDLT), portal vein (PV) variations are of immense clinical significance. In this study, we describe in detail our PV reconstruction techniques in RL grafts with variant PV anatomy and evaluate the impact of accompanying biliary variations on the recipient outcomes. In a total of 386 RL LDLTs performed between July 2004 and July 2012, the clinical data on 52 (13%) transplants using RL grafts with variant PV anatomy were retrospectively analyzed. Portal vein anatomy was classified as type 2 in 20 patients, type 3 in 24 patients, and type 4 in eight patients. The PV reconstruction techniques utilized included back-wall plasty (n = 21), back-wall plasty with saphenous vein graft interposition (n = 6), saphenous vein graft interposition (n = 5), cryopreserved iliac vein Y-graft interposition (n = 6), and quiltplasty (n = 3). There was no donor mortality. In a median follow-up of 29 months, none of the recipients had vascular complications. Anomalous PV anatomy was associated with a high (54%) incidence of biliary variations; however, these variations did not result in increased biliary complication rate. Overall, the 1- and 3-year patient survival rates of recipients were 91% and 81%, respectively. Vascular and biliary variations in RL grafts render LDLT technically more challenging. By employing appropriate reconstruction techniques, it is possible to successfully use RL grafts with PV variations without endangering recipient and donor safety.

The Predictive and Prognostic Significance of c-erb-B2, EGFR, PTEN, mTOR, PI3K, p27, and ERCC1 Expression in Hepatocellular Carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is the fifth most common fatal cancer and an important healthcare problem worldwide. There are many studies describing the prognostic and predictive effects of epidermal growth factor receptor 2 (c-erb-B2) and epidermal growth factor receptor 1 (EGFR), transmembrane tyrosine kinases that influence cell growth and proliferation in many tumors. OBJECTIVES: The current study aimed to investigate the expression levels of c-erb-B2, EGFR, PTEN, mTOR, PI3K, p27, and ERCC1 in hepatocellular carcinoma (HCC) and their correlation with other clinicopathologic features. PATIENTS AND METHODS: Fifty HCC cases were stained immunohistochemically with these markers. Correlations between the markers and clinicopathologic characteristics and survival rates were analyzed. RESULTS: No membranous c-erb-B2 staining was seen, whereas cytoplasmic positivity was present in 92% of HCC samples, membranous EGFR was observed in 40%, PI3K was found in all samples, and mTOR was seen in 30%, whereas reduced or absent PTEN expression was observed in 56% of samples and loss of p27 was seen in 92% of the cases. c-erb-B2 and mTOR overexpression, as well as reduced expression of p27, all correlated with multiple tumors (P = 0.041, P < 0.001, and P < 0.001, respectively). P27 loss, and mTOR and EGFR positivity were significantly correlated with AFP (P = 0.047, P = 0.004, and P = 0.008, respectively). Angiolymphatic invasion was more commonly seen in EGFR- and ERCC1-positive cases (P = 0.003 and P = 0.005). EGFR was also correlated with histological grade (P = 0.039). No significant correlations were found among PTEN , PI3K, and the clinicopathological parameters. Disease-free or overall survival rates showed significant differences among therapy modalities, AFP levels, angiolymphatic or lymph node invasions, and ERCC1 and p27 expression levels (P < 0.05). CONCLUSIONS: c-erb-B2, EGFR, mTOR, ERCC1 overexpression levels, and loss of p27 may play roles in hepatocarcinogenesis and may be significant predictors of aggressive tumor behavior. These markers were found to be correlated with certain clinicopathologic features, therapy modalities, and survival rates in the current study. These findings may help in planning new, targeted treatment strategies .

A new technique for the reconstruction of complex portal vein anomalies in right lobe living liver donors.

Living donor liver right lobe transplantation using donors with variation of the right sectorial portal vein is considered a challenging procedure in terms of the donor's safety and the complexity of reconstruction in the recipient. We describe an innovative technique to reconstruct double portal vein orifices via a deceased donor iliac vein graft. The postoperative course of the recipient was uneventful. Doppler ultrasound on the fourth postoperative month revealed equivalent flow in both portal vein branches. Reconstruction of double right portal vein branches using a cryopreserved iliac vein is a valuable technique for utilizing right lobe grafts with challenging portal vein anatomy.

Ratio of remnant to total liver volume or remnant to body weight: which one is more predictive on donor outcomes?

BACKGROUND: Right lobe donations are known to expose the donors to more surgical risks than left lobe donations. In the present study, the effects of remnant volume on donor outcomes after right lobe living donor hepatectomies were investigated. METHODS: The data on 262 consecutive living liver donors who had undergone a right hepatectomy from January 2004 to June 2011 were retrospectively analysed. The influence of the remnant on the outcomes was investigated according to the two different definitions. These were: (i) the ratio of the remnant liver volume to total liver volume (RLV/TLV) and (ii) the remnant liver volume to donor body weight ratio (RLV/BWR). For RLV/TLV, the effects of having a percentage of 30% or below and for RLV/BWR, the effects of values lower than 0.6 on the results were investigated. RESULTS: Complication and major complication rates were 44.7% and 13.2% for donors with RLV/TLV of ≤30%, and 35.9% and 9.4% for donors with RLV/BWR of < 0.6, respectively. In donors with RLV/TLV of ≤30%, RLV/BWR being below or above 0.6 did not influence the results in terms of liver function tests, complications and hospital stay. The main impact on the outcome was posed by RLV/TLV of ≤30%. CONCLUSION: Remnant volume in a right lobe living donor hepatectomy has adverse effects on donor outcomes when RLV/TLV is ≤30% independent from the rate of RLV/BWR with a cut-off point of 0.6.

AFP level and histologic differentiation predict the survival of patients with liver transplantation for hepatocellular carcinoma.

BACKGROUND: In liver transplantation or resection for hepatocellular carcinoma (HCC), patient selection depends on morphological features. In patients with HCC, we performed a clinicopathological analysis of risk factors that affected survival after liver transplantation. METHODS: In 389 liver transplantations performed from 2004 to 2010, 102 were for HCC patients. Data were collected retrospectively from the Organ Transplantation Center Database. Variables were as follows: age, gender, preoperative alpha-fetoprotein (AFP) levels, Child-Pugh and MELD scores, prognostic staging criteria (Milan and UCSF), etiology, number of tumors, the largest tumor size, total tumor size, multifocality, intrahepatic portal vein tumor thrombosis, bilobarity, and histological differentiation. RESULTS: One hundred and two patients were evaluated. The 5-year overall survival rate was 56.5%. According to the UCSF criteria, 63% of the patients were within and 37% were beyond UCSF (P=0.03). Ten patients were excluded (one with fibrolamellary HCC and 9 because of early postoperative death without HCC recurrence), and 92 patients were assessed. The mean age of the patients was 56.5+/-6.9 years. Sixty-two patients underwent living donor liver transplantations. The mean follow-up time was 29.4+/-22.6 months. Fifteen patients (16.3%) died in the follow-up period due to HCC recurrence. Univariate analysis showed that AFP level, intrahepatic portal vein tumor thrombosis, histologic differentiation and UCSF criteria were significant factors related to survival and tumor recurrence.The 5-year estimated overall survival rate was 62.2% in all patients. According to the UCSF criteria, and the 5-year overall survival rate was 66.7% within and 52.7% beyond the criteria (P=0.04). Multivariate analysis showed that AFP level and poor differentiation were independent factors. CONCLUSIONS: For proper patient selection in liver transplantation for HCC, prognostic criteria related to tumor biology (especially AFP level and histological differentiation) should be considered. Poor differentiation and higher AFP levels are indicators of poor prognosis after liver transplantation.

Living-donor liver transplant in 3 patients with Budd-Chiari syndrome: case report.

Budd-Chiari syndrome is a rare but life-threatening disorder characterized by obstruction of the hepatic venous outflow. Treatment depends on the underlying cause, the location, and extent of the obstruction, and the functional capacity of the liver. A stepwise therapeutic approach is commonly accepted. When all other therapy options are unsuccessful, or in case of end-stage liver disease, transplant should be considered. We present case reports of 3 patients with Budd-Chiari syndrome who underwent living-donor liver transplant. Characteristic features of Budd-Chiari syndrome, diagnostic and therapeutic interventions, complications, and overall outcomes are discussed. We believe that when a deceased donor graft is unavailable, a living-donor liver transplant can be a safe option for patients with end-stage liver disease associated with Budd-Chiari syndrome.

Right-lobe liver transplant from donors with Gilbert syndrome.

OBJECTIVES: Donor safety is one of the most important aspects of living-donor liver transplant. The preoperative evaluation of candidates for such transplants essentially starts with serologic and biochemical analyses. However, some potential liver donors with normal liver function test results may have isolated mild hyperbilirubinemia (serum indirect bilirubin level > 20.5 µmol/L [1.2 mg/dL]). Gilbert syndrome is an autosomal recessive condition that is a common cause of nonhemolytic unconjugated hyperbilirubinemia, and its prevalence is 3% to 10% in the healthy US population. Mild hyperbilirubinemia episodes are expected in people with Gilbert syndrome when they are exposed to physical stress, such as operative intervention or low energy intake. The liver morphologic findings of these individuals are normal; however, there is a debate on the use of people with Gilbert syndrome as living-liver donors. The purpose of this study was to assess the results of right-lobe living-donor hepatectomy of liver donors with Gilbert syndrome. MATERIALS AND METHODS: Between 2004 and 2010, two hundred twenty-five living-donor liver transplants using right-lobe grafts were performed in our hospital. Donors with Gilbert syndrome were defined as those whose serum bilirubin level was greater than 20.5 µmol/L (1.2 mg/dL). Six of 225 right-lobe living-donor liver transplants were performed using donors with Gilbert syndrome. RESULTS: The median follow-up after transplant was 34 months (range, 18 to 51 mo). One week after the operation, the median bilirubin level for right-lobe liver donors was 34.5 µmol/L (2.02 mg/dL) (range, 17.1 to 51.3 µmol/L [1 to 3 mg/dL]), and the median prothrombin time (international normalized ratio) was 1.36 (range, 1.1 to 1.7). The median bilirubin level of the donors after 6 months was 29 µmol/L (1.7 mg/dL) (range, 20.5 to 41 µmol/L [1.2 to 2.4 mg/dL]). CONCLUSIONS: Living-donor liver transplant from Gilbert syndrome donors can be safely performed.

Successful treatment of severe hepatorenal syndrome with living donor liver transplantation.

Hepatorenal syndrome is defined as renal failure caused by acute or chronic liver failure without any laboratory or histological reasons. The exact etiology of this syndrome is unknown. However, vasodilatation in the splanchnic area as a result of cirrhosis and portal hypertension, reflex systemic and splanchnic vasoconstriction are the basic pathophysiological reasons of this syndrome. The decrease of renal perfusion, decrease in glomerular filtration rate, sodium retention and deterioration of excretion of free water are the major renal problems and these remain progressive according to the stage of liver disease. The treatment of this syndrome is correction of the underlying problem. Here, we report a patient who was having hemodialysis due to renal failure as a consequence of liver cirrhosis for three months and returned back to his normal life without a need for dialysis after liver transplantation.

Recipient splenic artery utilization for arterial re-anastomosis in living donor liver transplantation: single-center experience.

Thrombosis of recipient hepatic artery is a life threatening complication for liver transplantation. The etiology of hepatic arterial thrombosis is multi-factorial and can be caused by intimal dissection, poor surgical technique and coagulopathies. The patency of hepatic arterial flow is very important for both graft survival and patient survival. Intraoperative diagnosis of inadequate hepatic arterial flow found with Doppler ultrasonography is essential in order to achieve good results after liver transplantation. Urgent re-anastomosis is necessary when the arterial blood flow is insufficient. We performed 317 living donor liver transplantations from July 2004 to July 2011. We used recipient splenic artery for hepatic artery reconstruction in six patients. These six patients were included in this study. Using the recipient splenic artery is a simple, safe and practical alternative for hepatic artery re-anastomosis in living donor liver transplantations.

Biliary complications after right lobe living donor liver transplantation: a single-centre experience.

BACKGROUND: Biliary complications that developed after right lobe liver transplantation from living donors were studied in a single centre. METHODS: From 2004 to 2010, 200 consecutive living donor right lobe liver transplantations were performed. The database was evaluated retrospectively. Biliary complications were diagnosed according to clinical, biochemical and radiological tests. The number of biliary ducts in the transplanted graft, the surgical techniques used for anastomosis, biliary strictures and bile leakage rates were analysed. RESULTS: Of a total of 200 grafts, 117 invloved a single bile duct, 77 had two bile ducts and in six grafts there were three bile ducts. In 166 transplants, the anastomosis was performed as a single duct to duct, in 21 transplants double duct to ducts, in one transplant, three duct to ducts and in 12 transplants as a Roux-en-Y reconstruction. In all, 40 bile leakages (20%) and 17 biliary strictures (8.5%) were observed in 49 patients resulting in a total of 57 biliary complications (28.5%). Seventeen patients were re-operated (12 as a result of bile leakages and five owing to biliary strictures). CONCLUSION: Identification of more than one biliary orifice in the graft resulted in an increase in the complication rates. In grafts containing multiple orifices, performing multiple duct-to-duct (DD) or Roux-en-Y anastomoses led to a lower number of complications.

General evaluation of hepatectomy and hepatocellular carcinoma cases.

OBJECTIVE: Although the clinical and histopathological findings of hepatocellular carcinoma are well described, there are few national studies. In this study, we aimed to investigate the relationship between these findings in total or partial hepatectomy specimens in our series. MATERIAL AND METHOD: We first collected 190 cases of total or partial hepatectomies performed because of hepatocellular carcinoma, cirrhosis or other disorders from the archives of Pathology. After re-examining the histopathological and clinical features such as age, gender and etiology, the relationship between them and serology results were statistically analyzed using the chi square and Multiple Comparison Tests. RESULTS: Among 190 cases, there were 168 (88.5%) total and 18 (9.5%) partial hepatectomies and 4 (2%) tumorectomy or metastasectomy cases. After gross and microscopic examination, 170 (89.5%) cases had a diagnosis of cirrhosis, 85 (44.7%) hepatocellular carcinoma, 3 parasitic cyst, 7 metastasis, 1 hepatoblastoma, 1 hepatocellular adenoma, 2 cholangiocarcinoma, 2 Budd Chiari Syndrome, 1 focal nodular hyperplasia, 1 cavernous hemangioma, and 2 acute fulminant hepatitis. Among the hepatocellular carcinoma cases, 53 had Hepatitis B virus, 15 Hepatitis C virus , 3 Hepatitis B virus and Hepatitis C virus, and 3 Hepatitis B virus and Hepatitis delta virus etiology, while 6 were alcoholic and 4 were due to other causes. Among cirrhosis patients, 84 (49.4%) had hepatocellular carcinoma. The male to female ratio of hepatocellular carcinoma cases was 74/11. The mean age was 55 and the median age 56.7. CONCLUSION: The results of this study demonstrated that the most common hepatic disorder was cirrhosis due to Hepatitis B virus in the hepatectomy specimens of our series that mostly consisted of total hepatectomies performed for transplantation where 50% had hepatocellular carcinoma.

Living donor liver hilar variations: surgical approaches and implications.

BACKGROUND: Varied vascular and biliary anatomies are common in the liver. Living donor hepatectomy requires precise recognition of the hilar anatomy. This study was undertaken to study donor vascular and biliary tract variations, surgical approaches and implications in living liver transplant patients. METHODS: Two hundred living donor liver transplantations were performed at our institution between 2004 and 2009. All donors were evaluated by volumetric computerized tomography (CT), CT angiography and magnetic resonance cholangiography in the preoperative period. Intraoperative ultrasonography and cholangiography were carried out. Arterial, portal and biliary anatomies were classified according to the Michels, Cheng and Huang criteria. RESULTS: Classical hepatic arterial anatomy was observed in 129 (64.5%) of the 200 donors. Fifteen percent of the donors had variation in the portal vein. Normal biliary anatomy was found in 126 (63%) donors, and biliary tract variation in 70% of donors with portal vein variations. In recipients with single duct biliary anastomosis, 16 (14.4%) developed biliary leak, and 9 (8.1%) developed biliary stricture; however more than one biliary anastomosis increased recipient biliary complications. Donor vascular variations did not increase recipient vascular complications. Variant anatomy was not associated with an increase in donor morbidity. CONCLUSIONS: Living donor liver transplantation provides information about variant hilar anatomy. The success of the procedure depends on a careful approach to anatomical variations. When the deceased donor supply is inadequate, living donor transplantation is a life-saving alternative and is safe for the donor and recipient, even if the donor has variant hilar anatomy.

Living donor liver transplantation for hepatocellular carcinoma: a single center analysis of outcomes and impact of different selection criteria.

We examined the outcomes of patients who received living donor liver transplantation (LDLT) for HCC comparing the impact of up-to-seven criteria and Asan Criteria (AC) with Milan Criteria (MC). Between July 2004 and July 2009, of 175 consecutive LDLT, there were 45 consecutive patients with HCC. Forty patients who completed 12 months follow-up were enrolled. In search for the highest number of expansion, we selected AC as the extended criteria. Patients were divided into having tumors within MC, beyond MC within AC and Beyond Criteria (BC) groups. With a median follow-up of 46 months, overall 1, 3, and 5 years survival was -90%, -81%, and -70%, respectively. In patients within AC, estimated mean survival was 49.8 vs. 40.5 months for BC group (P = 0.2). Disease-free survival was significantly higher in patients within AC comparing with BC group; 48.0 vs. 38.6 months (P = 0.04). Preoperative AFP level >400 and poor tumor differentiation were factors adversely effecting recipient survival. On multivariate analysis, the presence of poor tumor differentiation (P = 0.018 RR: 2.48) was the only independent predictor of survival. Extension of tumor size and number to AC is feasible, without significantly compromising outcomes; however, the presence of poor tumor differentiation was associated with worse outcomes after LDLT.