Noncontrast Magnetic Resonance Angiography Clinical Application in Pre-Liver Transplant Recipients With Impaired Renal Function.

Image evaluation of the vascular architecture is essential before living donor liver transplantation (LDLT). However, the use of contrast-enhanced study in recipients with impaired renal function is limited due to the risk of acute kidney injury and nephrogenic systemic fibrosis. Therefore, a contrast medium-free method is both valuable and necessary for preoperative vascular evaluation. Recent literature reported inflow-sensitive inversion recovery (IFIR) magnetic resonance angiography (MRA) without the use of a contrast medium to be a reproducible and noninvasive tool to assess hepatic vasculature with adequate-to-good image quality. The purpose of this study is to clinically apply IFIR MRA preoperatively in LDLT recipients. We retrospectively reviewed 31 LDLT recipients with renal function impairment from March 2013 to August 2018 who received IFIR MRA as a pretransplant vascular architecture evaluation and who underwent a subsequent LDLT. The image findings were assessed for subjective image quality and were compared with intraoperative findings. Our results showed that the pretransplant vascular anatomy was well correlated with intraoperative findings in all recipients. Successful ratings with image quality scores ≥2 for proper hepatic arteries (PHAs), portal veins, and inferior vena cavas (IVCs) were 100.0%, 96.8%, and 93.5%, respectively. Readable ratings with imaging quality score ≥1 for left and right hepatic arteries and gastroepiploic arteries were 83.9%, 96.7%, and 22.6%, respectively. We also found that recipients with higher Model for End-Stage Liver Disease scores (>23) had lower image quality scores for PHAs (P = 0.003) and IVCs (P = 0.046). However, images were still satisfactory for pre-liver transplantation (LT) vascular evaluation. In conclusion, in pre-LT recipients with impaired renal function, IFIR MRA is a feasible and reproducible image modality.

Transarterial Chemoembolization Using 100-µm Drug-Eluting Microspheres in Patients with Hepatocellular Carcinoma: A Prospective Study and Midterm Follow-up.

PURPOSE: The purpose of this study was to assess the safety and efficacy of drug-eluting embolic (DEE) transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients who are ineligible for curative treatment, using doxorubicin-loaded Tandem (Varian Medical) microspheres. MATERIALS AND METHODS: Between October 2015 and December 2017, 98 patients with unresectable HCC (69 males, 29 females; mean age, 60.5 ± 10.0 years of age; and American Joint Committee on Cancer [AJCC] stage ≦T3a) treated with DEE transarterial chemoembolization using 100-µm doxorubicin-loaded microspheres were enrolled prospectively. All studies were reviewed and approved by the Institutional Review Board of Chang Gung Memorial Hospital. Dynamic contrast-enhanced computed tomography or magnetic resonance imaging 1 month after treatment was used for tumor response assessment according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). Outcomes included overall survival (OS), progression-free survival (PFS), and downstaging profile. RESULTS: Median follow-up was 21.2 months. At follow-up examinations at 0.5-, 1-, 1.5- and 2.5-year follow-up, OS rates were 93.8%, 89.5%, 79.4%, and 77.0%, respectively. Complete response (CR), partial response, stable disease, and progressive disease were noted in 50 (51.0%), 23 (23.5%), 18 (18.4%), and 7 (7.1%) patients, respectively, with 93.9% disease control rate and 74.5% objective response rate. Mean OS was 28.7 months, and mean PFS was 19.6 months. Number of nodules >3, bilobar disease, larger tumor, and higher AJCC stage correlated with worse CR. No serious adverse events occurred after DEE transarterial chemoembolization. Successful downstage rate was 73.3% (22 of 30) and number of nodules predicting successful downstaging was 7 nodules (cutoff). CONCLUSIONS: Tandem DEE transarterial chemoembolization provides safe and effective treatment for HCC and a bridge or downstage therapy for liver transplantation.

Quantification of Functional MR Predicts Early Response in Post-doxorubicin Drug-Eluting Beads Chemoembolization for Hepatocellular Carcinoma.

BACKGROUND: The purpose of this study was to assess the value of functional MRI (fMRI) of post-doxorubicin drug-eluting beads transcatheter arterial chemoembolization (DEB-TACE) for hepatocellular carcinoma (HCC) as an early imaging biomarker of response to therapy. METHODS: This prospective analysis included 21 consecutive patients undergoing fMRI before and after DEB-TACE at a single medical center from January 2013 to December 2014. Functional MRI, including relative changes in apparent diffusion coefficient (ADC) and choline levels measured at hydrogen-1 magnetic resonance spectroscopy (MRS) of treated lesions, was recorded at baseline before DEB-TACE, and at 1, 2, and 4 weeks after DEB-TACE therapy. Assessment of tumor response was based on dynamic contrast-enhanced computer tomography imaging response according to modified response evaluation criteria in solid tumors. RESULTS: At post-therapy, 76% (n = 16) of patients demonstrated objective tumor response, 10% (n = 2) had stable disease, and 3 (14%) had progressive disease. Stable disease and progressive disease were designated as non-response. At week 2, the mean change in ADC value of responsive tumors was 0.35 ± 0.24 mm2/s, which was greater than that of non-response tumors (mean 0.01 ± 0.13 × 10-3 mm2/s) (P = 0.006). Significant differences were found in mean choline/water ratio between responsive (7.8 ± 4.9 × 10-3) and non-responsive (17.2 ± 4.9 × 10-3) tumors (P = 0.005). Composite scores of choline/water ratio and relative change of ADC showed significantly better diagnostic accuracy in non-responsive tumors than responsive tumors (area under the curve = 1.0; P < 0.001). CONCLUSIONS: Combined DWI and MRS may be used as an early imaging biomarker of therapy response in HCC patients after chemoembolization therapy.

Urodynamic and Immunohistochemical Evaluation of Intravesical Botulinum Toxin A Delivery Using Low Energy Shock Waves.

PURPOSE: We investigated the feasibility of using low energy shock waves for intravesical botulinum toxin A delivery. We also evaluated its efficacy for acetic acid induced bladder hyperactivity in rats. MATERIALS AND METHODS: In study 1 magnetic resonance imaging with intravesical administration of Gd-DTPA (Gd-diethylenetriamine pentaacetic acid) contrast medium was performed to visualize increased bladder urothelial permeability after low energy shock waves. In study 2 saline (1 ml) or botulinum toxin A (20 U/1 ml saline) was administered in the bladder with or without low energy shock waves (300 pulses at 0.12 mJ/mm(2)) and retained for 1 hour on day 1. Continuous cystometrograms were performed on day 8 by filling the bladder with saline followed by 0.3% acetic acid. The bladder was harvested for histology, and SNAP-25, SNAP-23 and COX-2 expression by Western blot or immunostaining. RESULTS: Magnetic resonance imaging established bladder urothelial leakage of Gd-DTPA after low energy shock waves, which was not seen in controls. The intercontraction interval was decreased 71.9%, 72.6% and 70.6% after intravesical instillation of acetic acid in saline, saline plus low energy shock wave and botulinum toxin A pretreated rats, respectively. However, rats that received botulinum toxin A plus low energy shock waves showed a significantly reduced response (48.6% decreased intercontraction interval) to acetic acid instillation without compromising voiding function. Rats pretreated with botulinum toxin A plus low energy shock waves showed a decreased inflammatory reaction (p <0.05), and decreased expression of SNAP-23 (p <0.05), SNAP-25 (p = 0.061) and COX-2 (p <0.05) compared with the control group. CONCLUSIONS: Low energy shock waves increased urothelial permeability, facilitated intravesical botulinum toxin A delivery and blocked acetic acid induced hyperactive bladder. These results support low energy shock waves as a promising method to deliver botulinum toxin A without the need for injection.

Renal MALT lymphoma associated with Waldenström macroglobulinemia.

Mucosa associated lymphoid tissue lymphoma (MALT lymphoma) is mostly seen in the gastrointestinal tract; origin from the kidney is extremely rare. Waldenström macroglobulinemia (WM) is a clinicopathologic syndrome denoted by the presence of monoclonal gammopathy in the serum, typically caused by lymphoproliferative disorder. Literature review did not find any report of renal MALT lymphoma accompanied by WM. Herein, for the first time, we report a 72 year-old female patient with a history of chronic kidney disease, presenting with solitary renal mass; MALT lymphoma was confirmed by pathological examination. A serology study identified the presence of WM. No manifestation of hyperviscosity syndrome was noted. Bone marrow biopsy disclosed the concurrent systemic involvement. Her treatment response was uneventful and the renal mass responded with regressive change in size after chemotherapy. The renal function remained stable during follow-up. MALT lymphoma should be considered as an underlying pathology of isolated renal mass. Furthermore, patients with MALT lymphoma should be screened for Waldenström macroglobulinemia and hyperviscosity syndrome.

Yttrium-90 Radioembolization as the Major Treatment of Hepatocellular Carcinoma.

Background: The purpose of this study was to assess the safety and efficacy of Yttrium-90 radioembolization using in unresectable hepatocellular carcinoma. Methods: From 2017 to 2021, 32 patients with unresectable hepatocellular carcinoma, with mean tumor diameter about 7cm (21 males, 11 females; median age, 57.5 years of age), treated with Yttrium-90 radioembolization using resin microspheres were reviewed at pre-Yttrium-90 and post-Yttrium-90 follow-up. Tumor response was assessed according to the modified Response Evaluation Criteria in Solid Tumors. Outcomes including overall survival and progression-free survival were reported. Results: Median follow-up was 18 months. At follow-up examinations at 3-, 6-, and 12-months follow-up, the overall survival rates were 94%, 87% and 59%, and the progression-free survival rates were 78%, 64% and 60%, respectively. Complete response, partial response, stable disease, and progressive disease were noted in 7 (21.9%), 14 (43.7%), 4 (12.5%), and 7 (21.9%) patients, respectively. The disease control rate was 78.1%, the objective response rate was 65.6%, and the successful downstage rate was 34.4% (11 of 32). Nine of thirty-two patients underwent resection or transplantation after Yttrium-90 radioembolization with 2-year overall survival being 100%. No serious adverse events occurred after Yttrium-90 treatment. Worse overall survival was related to the larger tumor, higher stage, Eastern Cooperative Oncology Group performance status, and Child-Pugh score. And worse progression-free survival was related to the higher tumor burden, and pre-Yttrium-90 serum α-fetoprotein level >100. Conclusion: Yttrium-90 Radioembolization can control hepatocellular carcinoma well even in advanced diseases. Patients successfully downstaging/bridging to resection or transplantation have excellent overall survival.

Segmental regeneration in right-lobe liver grafts in adult living donor liver transplant.

Our aim is to evaluate the relationship and impact of right-lobe (RL) liver grafts procured with or without the middle hepatic vein (MHV) trunk and MHV tributary reconstruction on segmental regeneration of these grafts in adult living donor liver transplantation (ALDLT). Patients underwent primary ALDLT using a RL liver graft were divided into three groups according to graft type: with MHV tributary reconstruction (group I), without MHV tributary reconstruction (group II), and with inclusion of the MHV trunk (group III). The overall graft volume and the volumes of the anterior and posterior segments of the grafts six months post-transplant, evaluated using computed tomography, were calculated as the regeneration indices. Optimal regeneration of the RL liver graft was achieved in the three groups of patients. There was no significant difference in the regeneration indices between groups I (149.4%) and III (143.6%). However, in group II (112.4%) without MHV or tributary reconstruction, the anterior regenerative index was lower than the other two groups and exhibited transient prolonged hyperbilirubinemia. Segmental graft regeneration is maximized by adequate venous drainage. Inclusion of the MHV trunk or MHV tributary reconstruction influences segmental liver regeneration and preclude transient hyperbilirubinemia in the early post-liver transplant phase.

Regeneration and outcome of dual grafts in living donor liver transplantation.

In living donor liver transplantation (LDLT), the essential aims are to provide an adequate graft volume to the recipient and to keep a sufficient remnant liver volume in the donor. In some instances, these aims cannot be met by a single donor and LDLT using dual grafts from two donors is a good solution. From 2002 to 2009, five recipients in our hospital received dual graft LDLT. Two recipients received one right lobe and one left lobe grafts; the other three received two left lobe grafts. The mean final liver regeneration rate was 91.2%. Left lobe graft atrophy in the long term was observed in recipients who received a right and a left lobe grafts. The initial bigger volume graft in all recipients was noted to have better regeneration than the smaller volume grafts. Portal flow and bilateral grafts volume size discrepancy were considered as two major factors influencing graft regeneration in this study. We also noted that the initial graft volume correlated with portal flow in the separate grafts and finally contribute to individual graft regeneration. Because of compensatory hypertrophy of the other graft, recipients who experienced atrophy of one graft did not show signs of liver dysfunction.

Effect of the Steric Hindrance and Branched Substituents on Visible Phenylamine Oxime Ester Photoinitiators: Photopolymerization Kinetics Investigation through Photo-DSC Experiments.

In this work, free radical photopolymerization (FRP) kinetics for series of different phenylamine oxime ester structures (DMA-P, DEA-P, DMA-M, TP-2P, TP-2M and TP-3M) was investigated. Steric hindrance and branched substituents were prepared to realize the corresponding electronic and photopolymerization effects. The photophysical, electrochemical, thermal properties and radical concentration were investigated by UV-visible spectroscopy, cyclic voltammetry (CV), thermogravimetric analysis (TGA), differential scanning calorimetry (DSC) and electron paramagnetic resonance (EPR). Furthermore, the structure-reactivity relationships were also studied in detail through photo-DSC experiment. We demonstrate that the introduction of alkyl chains and/or numbers of oxime esters affects significantly the photoreactivity. Under the same weight ratio of formulation and irradiated condition, TP-3M containing three oxime esters in its structure and methyl group in the periphery exhibits the highest double-bond conversion efficiency. TP-3M-based formulation also shows a wide operation window under different contents and light intensities. Importantly, the photoreactivity of the TP-3M-based system was found to be better than the commercial photoinitiator (OXE-01) under LED@405 nm at a low concentration. This work could provide some significance to the design of oxime esters with enhanced photoreactivity.

Hepatic arterial embolization for massive bleeding from an intrahepatic artery pseudoaneurysm using N-butyl-2-cyanoacrylate after living donor liver transplantation.

Parenchymal pseudoaneurysm of the hepatic arteries with massive intraperitoneal bleeding is rare but a serious life-threatening complication when it occurs following liver transplantation. We report a case of an adult postliving donor liver transplant recipient who developed massive subcapsular bleeding combined with massive right pleural effusion from ruptured multiple small intrahepatic arteries, which developed from a pseudoaneurysm that was treated by hepatic arterial embolization. Successful embolization was performed via a percutaneous trans-catheter approach by depositing 20-25%N-butyl-2-cyanoacrylate (NBCA) through the multiple small intrahepatic arteries into the pseudoaneurysm. Complete occlusion of the feeding arteries and pseudoaneurysm cavity resulted to immediate cessation of bleeding. There was no re-bleeding; and normal liver graft function was noted postembolization. Hepatic arterial embolization with NBCA can be used as treatment for postliver transplant peripheral intrahepatic artery pseudoaneurysm bleeding.

Ketone Number and Substitution Effect of Benzophenone Derivatives on the Free Radical Photopolymerization of Visible-Light Type-II Photoinitiators.

Three novel visible-light absorbing benzophenone-based hydrogen acceptors (BPD-D, BPDM-D and BPDP-D) were designed on the basis of a donor-benzophenone-donor structural backbone. Mono or diketone units and double diphenylamine electron-donating groups in para-or meta-positions were introduced to comprehend the electronic and structural effects on free radical photopolymerization (FRPP). Such a structural change leads not only to a red-shift of the absorption maxima but strongly enhances their molar extinction coefficients compared to the commercial phototinitiators such as benzophenone (BP) and 4,4'-bis(diethylamino) benzophenone (EMK). In addition, excellent melting points and thermal decomposition temperatures were achieved for those novel compounds. Further, the photochemical reaction behavior was studied by cyclic voltammograms (CV), photolysis and electron spin resonance (ESR) spectroscopy. Finally, benzophenone derivatives in combination with an amine (TEA, triethylamine) as a co-initiator were prepared and initiated the FRPP of trimethylolpropane trimethacrylate (TMPTMA) using a UV lamp as a light source. When used in stoichiometric amounts, the BPDP-D/TEA had the best double bond conversion efficiency among all the compounds studied, and were even superior to the reference compounds of BP/TEA and EMK/TEA. The results and conclusions could provide the fundamental rules applicable for the structural design of benzophenone derivative-based photoinitiators.

Drug-eluting bead transarterial chemoembolization for hepatocellular carcinoma: does size really matter?

PURPOSE: We aimed to compare the safety and effectiveness of 100-300 µm versus 300-500 µm drug-eluting bead transarterial chemoembolization (DEB-TACE) and to investigate the impact of tumor and feeding artery size on treatment outcome of different particle sizes in the treatment of hepatocellular carcinoma (HCC). METHODS: This retrospective cohort study enrolled 234 consecutive patients who underwent TACE using 100-300 µm DEB (Group A, n=75) and 300-500 µm DEB (Group B, n=159) in a tertiary center between August 2012 and March 2017. Initial treatment response and adverse events were assessed using modified Response Evaluation Criteria in Solid Tumors (mRECIST) and National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 5.0, respectively. RESULTS: A total of 704 HCCs in 234 patients were evaluated. The average index tumor size was 3.8 cm. Multivariate analysis showed that tumor size, lobe involvement, particle size, and tumor location were significant predictive factors of complete response. The overall rate of complete response in groups A and B were 56.0% and 33.3% (P = 0.001), respectively. Group A had higher complete response rate than group B in the subgroup of BCLC B with tumor <3 cm (57.9% vs. 21.1%; P = 0.020) and subgroup of feeding artery ≥0.9 mm (55.2% vs. 30.9%; P = 0.014). There were fewer major complications in group A compared with group B (0% vs. 6.9%, P = 0.018). CONCLUSION: TACE with 100-300 µm DEB is associated with better initial treatment response and fewer major complications compared with 300-500 µm. Our study also highlights the impact of tumor characteristics on treatment outcome of different DEB size, which might help to select the optimal sphere size for TACE in the treatment of HCC.

Management of Biliary Stricture in Pediatric Living Donor Liver Transplantation Recipients.

OBJECTIVE: Evaluation of the efficiency of percutaneous transhepatic cholangial drainage (PTCD) for biliary stricture after living donor liver transplantation (LDLT) in pediatric patients. MATERIALS AND METHODS: We retrospectively analyzed biliary stricture observed in pediatric biliary atresia. LDLT patients were studied between June 1994 and November 2017. A total of 291 patients were observed, 10 of whom were found to have biliary strictures. RESULTS: Among the 291 patients, we observed 10 patients with biliary stricture, which were divided into 2 groups: group A were patients who have biliary stricture with vascular complication (n = 4), and group B were patients who have biliary stricture without vascular complication (n = 4). Two children without vascular complications received PTCD to bridge the time for Rou-en-Y hepaticojejunostomy. A total of 12 procedures were carried out: only 1 patient (10%) underwent the procedure 3 times. The average interval between liver transplantation and percutaneous transhepatic drainage was 63.2 months in group A and 156.9 months in group B, and no significant difference between the 2 groups (P = .127). Clinical success was achieved in all patients. The PTCD was removed from 3 of 4 patients (75%) in group B with clinical success at a mean follow-up of 32.2 months. Higher PTCD removal rate (75%, P < .05) was found in the patients without vascular complication. All of the patients in group A were tube dependent during follow-up. No major complications were observed among all procedures. CONCLUSION: PTCD is an effective rescue therapy in pediatric LDLT patients, especially in nonvascular complication patients. Successful internal-external drainage and stenting can prevent a second operation for bile duct reconstruction.

Intensive Doppler Ultrasonography for Early Detection of Hepatic Artery Thrombosis After Adult Living Donor Liver Transplantation.

BACKGROUND Early hepatic artery thrombosis (eHAT) is a severe arterial complication leading to biliary complications and graft failure in living donor liver transplantation (LDLT). This study sought to early identify the abnormal waveforms of eHAT by using intensive Doppler ultrasonography (DUS) after LDLT and to assess the clinical outcome in these eHAT patients. MATERIAL AND METHODS DUS for 419 adult LDLT recipients was performed twice after vascular anastomosis during liver transplantation and once a day at the bedside for at least 2 weeks. RESULTS Nine adult LDLT recipients with eHAT were identified by using bedside DUS with subsequent computed tomography angiography (CTA). All eHAT cases were noted in the first 2 weeks. Five patients with CTA findings of partial thrombus with the small visualized intrahepatic hepatic artery (HA) were treated with intravenous thrombolysis (IVT) (medical group). Another 4 patients with CTA findings of extrahepatic HA occlusion and nonvisualization of intrahepatic HAs were treated by arterial re-anastomosis (surgical group). The prevalence of long-term non-anastomotic biliary strictures was 33.3% in the surgical group. Intensive post-LDLT DUS is a convenient and sensitive tool for eHAT detection. CONCLUSIONS Subsequent CTA gives valid information on occluded arteries and associated findings, which impact decision-making and are correlated with patient outcome. Our protocol of DUS has high sensitivity and diagnostic accuracy for use in in eHAT patients with partial occlusion, and it can be applied for IVT treatment, avoiding the need for reoperation and preventing long-term biliary complications.

Preoperative imaging evaluation of the hepatic vasculature in biliary atresia patients undergoing LDLT: comparison of MDCT and MRI.

LT is the definitive treatment option in the management of end-stage liver disease. Preoperative vascular evaluation plays an important role for a safe and successful operation in LDLT. The purpose of this study is to assess the usefulness and accuracy of CTA and MRA in evaluating vascular anomalies in BA patients undergoing LDLT. Images of CTA and MRA for preoperative vascular evaluation in 57 BA patients undergoing LDLT were reviewed with the operative and pathologic findings. All underwent preoperative CTA and MRA. Pathologic PV (n = 20), interruption of the retro-hepatic vena cava (n = 1), aberrant right HA from the SMA (n = 2) were confirmed during the transplant operation. The success rate of CTA and MRA in identifying vascular anomalies was 96% and 82%, respectively (p = 0.01). The IQR scores were 3.25 +/- 0.53 for CTA and 2.91 +/- 0.70 for MRA (p = 0.001). The sensitivity, specificity and accuracy of CTA were 85%, 97% and 93%, respectively; and for MRA, were 65%, 95% and 84%, respectively. CTA is superior than MRA in the preoperative evaluation of the vascular anatomy in pediatric BA LDLT candidates.

Diffusion-weighted imaging for identifying patients at high risk of tumor recurrence following liver transplantation.

BACKGROUND: Tumor recurrence is the major risk factor affecting post-transplant survival. In this retrospective study, we evaluate the prognostic values of magnetic resonance (MR) diffusion-weighted imaging (DWI) in liver transplantation for hepatocellular carcinoma (HCC). METHODS: From April 2014 to September 2016, 106 HCC patients receiving living donor liver transplantation (LDLT) were enrolled. Nine patients were excluded due to postoperative death within 3 months and incomplete imaging data. The association between tumor recurrence, explant pathologic findings, and DWI parameters was analyzed (tumor-to-liver diffusion weighted imaging ratio, DWIT/L; apparent diffusion coefficients, ADC). The survival probability was calculated using the Kaplan-Meier method. RESULTS: Sixteen of 97 patients (16%) developed tumor recurrence during the follow-up period (median of 40.9 months; range 5.2-56.5). In those with no viable tumor (n = 65) on pretransplant imaging, recurrence occurred only in 5 (7.6%) patients. Low minimum ADC values (p = 0.001), unfavorable tumor histopathology (p <  0.001) and the presence of microvascular invasion (p <  0.001) were risk factors for tumor recurrence, while ADCmean (p = 0.111) and DWIT/L (p = 0.093) showed no significant difference between the groups. An ADCmin ≤ 0.88 × 10- 3 mm2/s was an independent factor associated with worse three-year recurrence-free survival (94.4% vs. 23.8%) and overall survival rates (100% vs. 38.6%). CONCLUSIONS: Quantitative measurement of ADCmin is a promising prognostic indicator for predicting tumor recurrence after liver transplantation.

Living donor liver transplantation for hepatocellular carcinoma: a single-center experience in Taiwan.

BACKGROUND: Living donor liver transplantation (LDLT) demonstrates certain survival benefits over deceased donor liver transplantation for hepatocellular carcinoma (HCC) but there is no consensus on criteria for the use of LDLT for HCC for hepatocellular carcinoma (HCC) taking into account strategies to improve survival. METHODS: Thirty-five patients (89% men) underwent LDLT for HCC. The mean age was 51 years (range, 22-61). The median disease severity scores were B, 11-20, and 2B for Child-Turcotte-Pugh, Model for End-stage Liver Disease, and United Network for Organ Sharing, respectively. The transplant records were retrospectively analyzed. RESULTS: All were within Milan criteria at time of transplantation. A novel approach to downstaging tumors initially beyond the Milan criteria was evaluated using transarterial embolization or percutaneous ethanol injection. Our initial results were encouraging as recipients whose tumors had been downstaged had not had recurrence to date. Seven (20%) patients underwent hepatectomy for HCC before undergoing transplant. The overall mean posttransplant follow-up in this series was 40.3 months (range, 23-75). The overall posttransplant complication rate requiring intervention was 11%. There was only one malignancy recurrence for an overall recurrence rate of 3%. Vascular invasion and small- for-size transplants did not seem to influence tumor recurrence. The nonestimated recipient 1-year, 3-year, and 5-year survivals were 98%, 96%, and 90%, respectively. CONCLUSION: This review emphasizes the need for early disease recognition and prompt intervention when Milan criteria are met to improve survival from HCC after LDLT.

Macro-regenerative nodules in biliary atresia: CT/MRI findings and their pathological relations.

AIM: To describe the radiological findings of a macro-regenerative nodule (MRN) in the liver of pre-transplantation biliary atresia (BA) patients and to correlate it with histological findings. METHODS: Between August 1990 and November 2007, 144 BA patients underwent liver transplantation (LT) at our institution. The pre-transplantation computer tomograghy (CT) and magnetic resonance imaging (MRI) findings were reviewed and correlated with the post-transplantation pathological findings. RESULTS: Nine tumor lesions in 7 patients were diagnosed in explanted livers. The post-transplantation pathological findings showed that all the lesions were MRNs without malignant features. No small nodule was detected by either MRI or CT. Of the 8 detectable lesions, 6 (75%) were in the central part of the liver, 5 (63%) were larger than 5 cm, 5 (63%) had intra-tumor tubular structures, 3 (38%) showed enhancing fibrous septa, 3 (38%) had arterial enhancement in CT, one (13%) showed enhancement in MRI, and one (13%) had internal calcifications. CONCLUSION: Although varied in radiological appearance, MRN can be differentiated from hepatocellular carcinoma (HCC) in most of BA patients awaiting LT. The presence of an arterial-enhancing nodule does not imply that LT is withheld solely on the basis of presumed malignancy by imaging studies. Liver biopsy may be required in aid of diagnostic imaging to exclude malignancy.

Spleen volume and platelet count changes among donors after living donor liver transplantation.

BACKGROUND/AIMS: The long-term changes in and the relation of spleen volume and platelet counts after liver graft harvest in living donors is still unknown. The purpose of this study is to compare spleen volume and platelet count changes among living donors of different types of liver graft harvest (group RL, right lobectomy; group LH, left hepatectomy). METHODOLOGY: Between June 1994 and December 2004, 205 healthy individuals donated part of their liver to 204 liver transplant recipients which included 1 re-transplantation and 1 dual-graft transplantation. The pre-liver donation and 6 months post-liver donation spleen volumes were measured. The platelet counts were determined on the pre-donation day, post-donation day, the end of the 2nd week post-donation, the 6th month post-donation, and at 1 year after donation. RESULTS: There was no difference in the spleen volume in the different groups at pre-donation. There was a significant increase in the spleen volumes in both groups at 6 months post-donation. The postoperative spleen volumes were significantly larger in group RL than in group LH. The average spleen ratio (S(6m)/(S0)) and spleen change rate (deltaS) were also significantly larger in group RL. The platelet counts were all decreased in the first 3 days post-donation in both groups. From the 2nd week to the 6th month post-donation, the platelet counts gradually decreased and were near preoperative values by 6 months. Significantly, there was lower platelet counts noted starting on the 2nd postoperative day until 6 months post-donation in group RL. There was no significant difference between the levels of platelet counts in both groups at 1-year post-donation. CONCLUSIONS: a significant increase in spleen volumes was noted in most donors 6 months after partial liver donation. The spleen volume change may be proportional to the size of the hepatectomy. Post-donation, the platelet counts decrease. The spleen volume change is one factor affecting platelet count change.

Living donor liver transplantation in children with congenital heart disease.

BACKGROUND: The occurrence of congenital heart disease (CHD) with congenital biliary disease is uncommon. Our aim is to present our experience in living donor liver transplantation (LDLT) as treatment for end-stage liver disease (ESLD) in children with CHD. METHODS: A review of transplant records from June 1994 to December 2004 was performed. Twenty-three LDLT (13 males, 10 females) recipients were diagnosed to have both CHD and ESLD. RESULTS: CHD diagnoses were made preoperatively using transthoracic two-dimensional color flow Doppler echocardiography. The mean age was 22.3 months. There were 20 (87%) biliary atresia, two (9%) neonatal hepatitis, and one (4%) glycogen storage disease patients. Isolated CHD associated with ESLD included atrial septal defect (11, 48%), pulmonary stenosis (including 2 Alagille syndrome; 4, 17%), patent foramen ovale (4, 17%), ventricular septal defect (1, 4%), and mitral valve prolapse (1, 4%). Complex CHD included atrial septal defect + patent ductus arteriosus + patent foramen ovale (1, 4%), and atrial septal defect + pulmonary stenosis (1, 4%). The median Child's and Pediatric End-stage Liver Disease scores were 9, and 17, respectively. In all, 70% presented with varying degrees of pulmonary congestion pretransplant. There were no perioperative cardiac complications. Posttransplant, the patent foramen ovale in four recipients and atrial septal defect in four recipients closed spontaneously; and two recipients with pulmonary stenosis had their stenoses resolved spontaneously. The overall rejection rate was 17%. There was no mortality. The overall recipient and graft survivals at 1 and 5 years were both 100%. CONCLUSION: LDLT is a safe procedure in a select group of ESLD patients with CHD.