Liver transplantation in a patient with unresectable colorectal liver metastases -- a case report.

BACKGROUND: Due to the lower survival rates achieved, in the early period of liver transplantation era, in patients with colorectal liver metastases, and because of the organ shortage,in the last two decades colorectal liver metastases are considered a contraindication for liver transplantation. However, the increasing number of marginal donors, and the improvements in posttransplant immunossuppresion, chemotherapy and methods to assess the extrahepatic disseminationof colorectal cancer, opened the perspective of liver transplantation to certain patients with malignancies (such as HCC beyond Milan criteria, and selected patients with cholangiocarcinomaor liver metastases from neuroendocrine tumors).Since some of these patients experienced favorable outcomes,in the last years, there were authors that considered a rationalerevisitation of the benefits of liver transplantation in patients with unresectable colorectal liver metastases. Thus, in 2006, a Norwegian group started a study which aims to assess the results of liver transplantation in patients with unresectable colorect alliver metastases. Their results were unexpectedly favorable, revealing that 5-year overall survival rate was 60%, and the quality of life was excellent in the first year following transplantation.However, all the patients presented relapse of the disease in the first two years following transplantation. In the present paper we present the clinico-pathologic characteristics,the pre- and postoperative management and the outcome of a patient with unresectable colorectal liver metastases who underwent liver transplantation in a very advanced state of the disease (when he developed subacute liver failure due to insufficient functional liver parenchyma and toxicity of chemotherapy).We consider useful to present such observations,because collecting the data presented by different centers maybe contributive to identification of a selected group of patients who could benefit from liver transplantation. CASE REPORT: A 42-year old male patient, it was diagnosed with upper rectum cancer and multiple bilobar liver metastases in April 2009. Chemotherapy was started (in another hospital),and because the disease was stable after 7 cycles of FOLFOX and Bevacizumab, the patient was reffered to surgery (for a "two stage" liver resection). In October 2009 it was performed primary tumor resection associated with left lateral section ectomy and segment 4 metastasectomy. Because in November 2009 CT scan re-evaluation revealed progression of liver metastases, the second stage hepatectomy was precluded. Subsequent therapy consisted in radio embolization, multiple lines of chemotherapy,and targeted therapies. After more than 2 years, the liver metastases progressed and the patient developed progressive cholestatic subacute liver failure due to insufficient functional liver parenchyma and chemotherapy toxicity. In this state of the disease, he was admitted in our hospital, being dependant by liver dialysis and plasma exchange procedures. Due to the patients' age, and because the MDCT scan revealed the absence of extrahepatic disease (after almost three years of disease progression), and he could not benefited from any type of antineoplastic treatment due to progressive cholestatic subacute liver failure, liver transplantation with an organ from amarginal donor was considered and performed in January 2012.The postoperative course was uneventful, and the quality of his life improved (being fully reinserted social and professional).The immunosuppressive regimen consisted in Sirolimus and Mycophenolate mofetil, and the adjuvant chemotherapy started two months following liver transplantation. However,the patient developed extrahepatic relapse of the disease (lung metastases and retroperitoneal recurrence), but now, at morethan 20 months following transplantation, he is still alive in agood clinical condition. CONCLUSIONS: In patients with multiple unresectable liver onlycolorectal metastases, liver transplantation may improve overallsurvival and quality of life, by using marginal grafts whichcannot be allocated to the patients with standard indicationsfor liver transplantation. The advent of MDCT and PET CT scan and the use of m-TOR inhibitors may improve the resultsachieved by liver transplantation in patients with CLMs.Further studies could be useful in an attempt to disclosewhether a selected group of patients with unresectable liveronly colorectal metastases could become acceptable candidatesfor liver transplantation.

Outcome of liver transplantation for hepatocellular carcinoma -- a single center experience.

BACKGROUND & AIMS: Liver transplantation (LT) is a promising treatment for patients with liver cirrhosis associated with hepatocellular carcinoma (HCC). The aim of our study was to evaluate our experience regarding the clinical and pathological staging of HCC in patients who underwent LT, as well as recurrence free and overall survival. METHODS: From January 2006 to December 2011, 38 patients with diagnosis of HCC, underwent LT in our Center. Demographic, clinical, imaging and pathologic information were recorded. A Cox proportional hazards survival analysis was performed in order to identify significant predictors of tumor recurrence and patient's death after LT. RESULTS: Eighteen patients (47.4%) in our study group were within Milan criteria. The mean follow-up was 22 months and the recurrence rate of HCC after LT was 13.2%. The 1, 3- year recurrence free survival rates were 85%, 74.3% respectively. The 1 and 3-year overall survival rates were 83.5% and 63.6% respectively. No significant predictor for HCC recurrence was identified in our study group by survival analysis, taking into account 13 different variables. As independent predictors of patient'ss death after LT for HCC however, the presence of diabetes mellitus (p=0.001), presence of more than 3 HCC nodules (p=0.03) and tumor recurrence after LT (p=0.03) were identified by multivariate Cox proportional hazards survival analysis. CONCLUSION: In our cohort HCC recurrence rate after LT was 13.2%. Diabetes mellitus, presence of more than 3 HCC nodules and HCC recurrence were significant predictors of poor overall survival after LT.

Simultaneous resection of the primary colorectal tumor and liver metastases--a safe and effective operation.

BACKGROUND: The aim of this retrospective study was to compare the results achieved by simultaneous resection (SR) vs. delayed resection (DR) in patients with synchronous colorectal liver metastases (SCRLM). METHODS: In "Dan Setlacec" Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute, between 1995 and 2010, 117 patients underwent SR and 25 patients underwent DR. It was compared the outcome of the patients in the two groups. It was also assessed if certain subgroups of patients present a better outcome after DR than after SR. RESULTS: The location of the primary tumor, the number and diameter of liver metastases, and the proportion of major hepatectomies were similar in the two groups (p value > 0.05). For all patients, the morbidity, mortality, disease-free and overall surrvival rates were not statistically significant different between the two groups (p value > 0.05). In subgroups of patients with rectal tumors, with multiple liver metastases, and undergoing major hepatectomies, the morbidity, mortality and survival rates achieved by SR were similar to those achieved by DR. CONCLUSION: Simultaneous resection of SCRLM is similarly safe and efficient as the delayed resection, even in patients with rectal tumors, with multiple liver metastases, or undergoing major hepatectomies.

Intrahepatic cholangiocarcinoma--a rare indication for liver transplantation. Case report and review of the literature.

BACKGROUND: While hepatocellular carcinoma is a common indication for liver transplantation, intrahepatic cholangiocarcinoma represents a controversial indication for this procedure, due to lower disease-free and overall survival rates achieved by liver transplantation in such patients. Hence, in the last years, few centers reported satisfactory survival rates after liver transplantation for cholangiocarcinoma, in highly selected groups of patients. Herein we present the clinicopathological characteristics, the pre- and postoperative management and the favorable outcome of a patient undergoing liver transplantation for an unresectable intrahepatic cholangiocarcinoma. We consider that reporting the patients with such favorable outcomes is useful, since collecting the data presented by different centers may contribute to identification of a selected group of patients with cholangiocarcinoma who may benefit from liver transplantation. CASE REPORT: A 62-year old female patient with a primary liver tumor developed on HBV liver cirrhosis, was admitted in our center for therapeutical management. Since preoperative work-up suggested that the tumor is an unresectable hepatocellular carcinoma (due to its location and underlying liver disease), we decided to perform liver transplantation. The pathological examination of the explanted liver revealed that the tumor was a stage I intrahepatic cholangiocarcinoma. The postoperative course was uneventful, and in present, 15 months after transplantation, the patient is alive, without recurrence. CONCLUSIONS: Liver transplantation may represent a valid therapeutical option in selected patients with intrahepatic cholangiocarcinoma. Patients with early stage intrahepatic cholangiocarcinomas unresectable due to the underlying liver cirrhosis seem to benefit mostly by liver transplantation. Further studies are needed to identify the favorable prognostic factors in order to select the most appropriate candidates for liver transplantation. The most suitable immunosuppressive and (radio)chemotherapic regimens should be identified in the future, in order to improve the disease-free and overall survival rates of the patients undergoing liver transplantation for intrahepatic cholangiocarcinoma.

[Biliary complications following liver transplantation]. / Complicatiile biliare post transplant hepatic.

The biliary complications (BC) were always considered the "Achilles heel" of liver transplantation, being one of the leading causes of postoperative morbidity. The technique of the biliary reconstruction depends on the surgical procedure and it has a major impact on the patients and the graft evolution. The most frequent types of BC were stenoses, leaks, bilomas, cholangitis, etc. As an incidence, there is a peak of BC in the first 6 months after the transplant, a third of them appearing in the first month. Among the major BC risk factors, the most important are: hepatic artery pathology, the use of partial liver graft, bilioplasty and the number of biliary ducts and anastomoses. The BC management can be conservative, interventional or surgical depending on the type of BC. Along with the improvement of the interventional radiological and endoscopic methods, a large number of BCs are successfully treated non-surgically. There are still a few circumstances in which surgery is mandatory such as important persistent biliary leaks, even more when a partial liver graft was used or in association with hepatic artery pathology when re-transplantation is required. Multiple or serial biliary stenoses can lead to surgical revision. Although BC plays an important role in the patients postoperative morbidity, by early diagnosis and through numerous therapeutic methods promptly applied, there is no major impact on mortality.

[Liver transplantation--indications, surgical technique, results--the analysis of a clinical series of 200 cases]. / Transplantul hepatic--indicati, tehnica, rezultate-analiza unei serii clinice de 200 de cazuri.

INTRODUCTION: Initially considered experimental, liver transplantation (LT) has become the treatment of choice for the patients with end-stage liver diseases. MATERIAL AND METHODS: Between April 2000 and October 2009, 200 LTs (10 reLTs) were performed in 190 patients, this study being retrospective. There were transplanted 110 men and 80 women, 159 adults and 31 children with the age between 1 and 64 years old (mean age--39.9). The main indication in the adult group was represented by viral cirrhosis, while the pediatric series the etiology was mainly glycogenosis and biliary atresia. There were performed 143 whole graft LTs, 46 living donor LTs, 6 split LTs, 4 reduced LTs and one domino LT RESULTS: The postoperative survival was 90% (170 patients). The patient and graft one-year and five-year survivals were 76.9%, 73.6% and 71%, 68.2%, respectively. The early complications occurred in 127 patients (67%). The late complications were recorded in 71 patients (37.3%). The intraoperative and early postoperative mortality rate was 9.5% (18 patients). CONCLUSIONS: The Romanian liver transplantation program from Fundeni includes all types of current surgical techniques and the results are comparable with those from other international centers.

MELD exceptions and new predictive score of death on long waiting lists for liver transplantation.

BACKGROUND: Cirrhosis related complications, considered MELD exceptions, proved to add prognostic value to the MELD score in predicting waiting list mortality. AIM: To identify the predictive value for death on a long waiting list (WL) for the complications of liver disease. METHODS: During 2004-2007, 372 consecutive adult patients were listed for liver transplantation (LT). To identify the potential predictors of patient death, univariate and multivariate Cox's proportional hazards regression model was used. RESULTS: In the univariate survival analysis the following variables were significant: spontaneous bacterial peritonitis, refractory ascites, hyponatremia, hepatic encephalopathy, hepatorenal syndrome, initial and current MELD score, initial and current Child-Pugh score. The independent predictors of death on our WL were: refractory ascites (p=0.002) and hepatorenal syndrome (p=0.002). Based on a logistic regression analysis a new score has been developed: Score = 1/(1+ exp(-(-4.38 + 1.34 x Refractory ascites + 0.9 x Hepatorenal syndrome + 0.15 x Current MELD). The c-statistic for the new score for prediction of death on the WL was 0.85 compared to 0.80 for current MELD score. CONCLUSION: Refractory ascites and hepatorenal syndrome should add valuable points to the current MELD in order to better prioritize for LT patients included on long WL. ABBREVIATIONS: Liver transplantation (LT), Model for End-Stage Liver Disease (MELD), waiting list (WL), United Network for Organ Sharing (UNOS), standard deviation (SD), receiver operating characteristic (ROC), hepatitis B virus (HBV), hepatocellular carcinoma (HCC), positive predictive value (PPV), negative predictive value (NPV), Child-Turcotte-Pugh (CTP), hepatic venous pressure gradient (HVPG).

Laparoscopic hand-assisted adrenalectomy for a 20 cm benign tumor.

Since its introduction in 1992, laparoscopic adrenalectomy (LA) has become the technique of choice in the surgical treatment of both secreting or non-secreting benign adrenal pathology. Although traditionally, laparoscopic approach was recommended only for tumor sizes less than 6-8 cm--as larger tumors were known to have an increased risk of malignancy--the currently growing experience and improvement of surgical techniques has allowed for an extension of the therapeutic indication, as shown by the recent case report of LA use for a benign 22 cm tumor (1). We report the case of a young patient operated in our Department for a benign 20 cm adrenal tumor for which laparoscopic "hand-assisted" adrenalectomy yielded a good postoperative outcome and minimal complications.

[Human pancreas procurement for pancreas and islet transplantation]. / Prelevarea pancreasului uman pentru transplantul de pancreas si de insule pancreatice.

Insulin-dependent diabetes mellitus is a disease characterized by a deficiency of insulin secretion by beta islet cells. Integral pancreatic transplantation and islet cell transplantation represent two possibilities of replacing the beta islet cells. The aim of this paper is to analyze the main aspects of selection criteria of the pancreas donor and surgical methods of preservation for integral pancreas or islet cell transplantation. There are described the pancreas procurements realized by the Center of General Surgery and Liver Transplantation team from Fundeni Clinical Institute between December 2005-December 2006 and correlation between the donor's and pancreas features and the quality of islet cell isolation. The selection of pancreas donor and the accomplishment of pancreas procurement represent important factors in the post-transplantation course of the graft. The data from pancreas/islet cell transplantation centers suggest that the factors that influence positively the course of graft are: the donor's age, body mass index, cold ischemia time.

Two-stage hepatectomy: an analysis of a single center's experience.

Hepatic resection remains the only potential curative treatment for either primary or secondary liver tumors. In order to increase the resectability of initially unresectable tumors and to decrease the posthepatectomy morbidity and mortality, ligation and section of a portal branch with consecutive hepatic resection is recommended. Between September 1st 1999 and January 1st 2006, in the Department of General Surgery and Liver Transplantation of Clinical Institute Fundeni (Bucharest), the ligation of a portal branch was performed in 15 patients with gross hepatic tumors: hepatocellular carcinoma (2 cases), peripheral cholangiocarcinoma (6 cases) and hepatic metastases for colorectal cancer (7 cases). Two-stage hepatectomy was performed in 8 cases. The interval between the two operations ranged between 4 weeks and 2 months (except one case that returned to us only after 6 months, when was reevaluated and resected). Hepatic resection could not be performed in 7 cases due to the local and regional progression of the disease (4 cases) or to the absence of the hypertrophy-atrophy process (3 cases). In the 8 resected cases, hepatic failure occurred posthepatectomy in 2 patients, resulting in the death of one patient; that means a mortality of 12.5%. Other two patients died at 4 and 10 months respectively, as a result of distant metastases. The rest of 5 patients are alive, free of recurrence; two of them have more than 5 years from the operation. CONCLUDING: portal vein ligation can be performed in selected cases of unresectable gross hepatic tumors. Two-staged hepatectomy is not always feasible. Moreover, the hypertrophy of the contralateral lobe does not always prevent the postoperative hepatic failure. For the cases that can be resected, both survival and quality of life are significantly improved.

[Therapy of malignant liver tumors using microwave and radiofrequency ablation]. / Terapia tumorilor hepatice maligne cu microunde si unde de radiofrecventa.

The aim of our study was to evaluate the efficiency for thermo-ablation with microwave and radiofrequency on patients with malignant liver tumors. From January 2002 to January 2005, in our Center of General Surgery and Liver Transplantation in 53 patients 70 sessions of thermoablation were carried out. The mean age was 58 years (25-79 years). Sex ratio men: women was 1.8 (34:19). The diagnosis was hepatocarcinoma in 38 patients (72%), liver metastases from colorectal cancer in 9 (17%) and from non-colorectal cancer (6-11%). The most tumors were single (36-68%). The mean diameter was 39.5 mm (9-94 mm). Percutaneous approach was used in 14 interventions (20%), laparoscopic in 2 (3%) and open approach in 54 cases (77%). We performed 54 sessions of microwave ablation in 42 patients and 8 sessions of radiofrequency ablation in 5 patients. Both methods were applied in 6 patients during 8 sessions. Tumor ablation was done together with liver resection in 10 patients (19%) and resections of other organs in other 8 patients (15%). Morbidity was 12%. The encountered complications were ascites, right pleural effusion and liver abscesses. There was no death. Total and partial necrosis was observed in 27, respectively 20 patients. Local recurrence occurred in one patient but distal liver recurrences were diagnosed in 13 patients. After thermoablation for partial necrosis, local or distal recurrences patients received arterial chemoembolization (5), systemic chemotherapy (23), liver resection (1) and transplantation (1). The mean survival at 1 year and 3 years was 77% and respectively 38%. Microwave or radiofrequency ablation is a simple treatment method, with proved efficiency and minimal risks whose main indication is unresectable tumor.

[Orthotopic liver transplantation in adult patients with cadaveric grafts. Experience of the Fundeni Center of General Surgery and Liver Transplantation]. / Transplantul hepatic ortotopic de la donator cadavru la adult. Experienta Centrului de Chirurgie Generalai si Transplant Hepatic Fundeni.

We analyze the experience of the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest, Romania) regarding orthotopic liver transplantation (OLT) in adult recipients, with whole liver grafts from cadaveric donors, between April 2000 (when the first successful LT was performed in Romania) and December 2004. This series includes 37 OLTs in adult recipients (16 women and 21 men, aged between 29-57 years--average 46 years). Other two LT with whole liver cadaveric grafts and two reduced-size LT were performed in children; also, in the same period, due to the acute organ shortage, other methods of LT were performed in 28 patients (21 living donor LT, 6 split LT and one "do mino" LT), that were not included in the present series. The indications for OLT were HBV cirrhosis--10, HBV+HDV cirrhosis--4, HCV cirrhosis--11, HBV+HCV cirrhosis--2, biliary cirrhosis--5, Wilson disease--2, alcoholic cirrhosis--1, non-alcoholic liver disease--1, autoimmune cirrhosis--1. With three exceptions, in which the classical transplantation technique was used, the liver was grafted following the technique described by Belghiti. Local postoperative complications occurred in 15 patients (41%) and general complications in 17 (46%); late complications were registered in 18 patients (49%) and recurrence of the initial disease in 6 patients (16%). Intrao- and postoperative mortality was 8% (3/37). There were two patients (5%) who died because of immunosuppressive drug neurotoxicity at more than 30 days following LT. Four patients (11%) died lately because of PTLD, liver venoocclusive disease, recurrent autoimmune hepatitis and liver venoocclusive disease, myocardial infarction, respectively. Thirty-four patients survived the postoperative period (92%); according to Kaplan-Meier analysis, actuarial patient-survival rate at month 31 was 75%.

Liver hemangioma revisited: current surgical indications, technical aspects, results.

BACKGROUND/AIMS: New developments regarding the diagnosis of liver hemangiomas, surgical indication and therapeutic options emerged recently. We reviewed our experience from the point of view of these modern developments. METHODOLOGY: Fifty-seven patients with liver hemangiomas were retrospectively studied. The relationship between size, symptoms and treatment was assessed. RESULTS: Indication for surgery was the size of the lesion in 5 patients, symptomatology in 48 and uncertain diagnosis in 4. Increase in size was noted in four patients. Six patients had associated intraabdominal benign or malignant pathology. The treatment of choice was enucleation. Postoperative complications were noted in 6 patients and mortality was nil. In 3 patients the hemangiomas recurred and were reresected in 2. CONCLUSIONS: Hemangiomas should be resected when larger than 10 cm and when they become symptomatic. With the modern diagnostic work-up, uncertainty of diagnosis as an indication for surgery should be rare. Surgery remains the main treatment, with a low morbidity and mortality if performed in a specialized hepatobiliary unit. Enucleation is the surgical option of choice. In selected cases laparoscopic enucleation can be performed with good results.

[Laparoscopic liver surgery: analyze the experience on 36 cases]. / Chirurgia laparoscopica a ficatului: analiza unei experiente de 36 de cazuri.

We analyze the experience in laparoscopic liver surgery in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute between september 1998 and march 2003. This study includes 36 patients, 24 females (66.7%) and 12 males (33.3%) with ages between 25 and 67 and a mean age of 46 years. From the group of 36 patients with liver pathology considered for laparoscopic treatment 6 cases had multiple hepatic lesions with no preop diagnosis. The postoperative diagnosis was neoplasia in 4 cases, noncellular necrosis with chronic inflammation in one case and focal nodular hyperplasia in another case. The fenestration and drainage were used as laparoscopic treatment in case of 7 patients with nonparasitic liver cysts. Nine patients from our group had hydatid cysts. In 7 patients the treatment consisted in partial pericystectomy after inactivation and parasite evacuation. In 2 patients an ideal pericystectomy was performed for cysts located in segments II and III. The solid lesions selected for laparoscopic treatment were in 3 cases benign symptomatic tumors with no preoperative diagnosis, in 9 cases symptomatic hemangioma and in 2 cases malignant lesions. From these 14 patients in only 2 cases the lesions were located in the right antero lateral segments. Only in the case of metastasis a left lateral sectorectomy was performed, in all other cases a nonanatomical resection being performed. Conversion to open surgery was necessary in 11.11% of cases (2 hemangioma, 2 partial pericystectomies) for bleeding control. In our study we had no mortality and 11.11% morbidity. The follow-up was available in all patients for a mean time of 18 months (10 to 36). A CT scan was made in all patients with solid lesions 6 months after surgery and an ultrasound examination in all other cases. All patients were nonsymptomatic at repeated reevaluations. We are now at the beginning of laparoscopic liver surgery and these results need to be confirmed. The benefits seem to be those of any miniinvasive surgery: reduced trauma to the abdominal wall, early mobilization, shorter hospital stay, better aesthetics.

[Pyogenic liver abscess]. / Abcese hepatice piogene. Evaluarea schimbarilor aparute în etiologie, diagnostic, tratament si evolutie.

The objective of this study was to investigate and report changes in presentation, management and outcome of patients with pyogenic liver abscess (PLA). Between 01.01.1995-31.12.1999, 27 patients with PLA were treated in the General Surgical Service of the Fundeni Clinical Hospital. The incidence of cryptogenic abscesses was dominant (55.5%). The symptoms and the biological status are frequently nonspecific. The CT scan and echographic examination sensibility in the diagnosis of the PLA was 89.5% and 78.3%. The aerobe germs are most involved. All patients received antibiotic treatment in preoperative as in postoperative period. The surgical treatment was performed in 24 patients: in 9 patients (33.3%), the abscess was surgically evacuated and drained and in 15 patients (55.5%), a liver resection was performed. Percutaneous catheter drainage under CT or echo-guidance was performed in three patients (11.1%). The clinical evolution was good in 21 patients (77.7%). There was four complications (14.8%) and two death (7.4%). Although with a better prognostic, the PLA remains an important pathology.

[Video-assisted thoracoscopic thymectomy--preliminary results]. / Timectomia pe cale toracoscopica--rezultate preliminare.

Video-assisted thoracoscopic surgery (VATS) provides a new approach to thymectomy. From April 1999 to December 1999, we performed a total of 10 video-assisted thoracoscopic thymectomies for myasthenia gravis (MG). There were one male and nine female patients with ages ranging from 8 to 59 years. Thymoma was present in one of the ten patients. We considered that complete thymectomy was accomplished in all cases by examination of the thymic bed and of the resected specimen. There was no mortality or intraoperative complications. The median postoperative hospital stay was 4 days. Clinical improvement was observed in all patients after this short follow-up. Compared with a similar historical group of patients with MG who underwent transsternal thymectomy, the VATS group was associated with significantly less analgesic requirement and shortened hospital stay. We conclude that VAT thymectomy is technically feasible and is associated with a favorable postoperative course compared with the transsternal approach. We believe that complete thymectomy can be achieved by this approach. Further investigation with long-term follow-up is needed to further clarify the role of VAT thymectomy in thoracic surgery.

[Liver transplantation--considerations over 8 cases operated in the year 2000]. / Transplantul hepatic--consideratii asupra a 8 cazuri operate în anul 2000.

In the year 2000, at the Department for General Surgery and Liver Transplantation from The Fundeni Clinical Institute Bucharest, seven OLTs and one living-related transplantation were performed in 6 adults and 2 children. Postoperative complications were: bile leakage, hemoperitoneum, lower gastrointestinal hemorrhage, parietoabdominal hematoma. There was only one postoperative death due to septic complications in the 18th p.o.d. and one late death due to pneumonia of unknown origin. After the results in the year 2000 there was an increased number of donors and referrals. We consider that now in Romania this is an established program that will continue depending on the number of donors and financing.