Portal Supply and Venous Drainage of the Caudate Lobe in the Healthy Human Liver: Virtual Three-Dimensional Computed Tomography Volume Study.

OBJECTIVE: The venous vascular anatomy of the caudate lobe is exceptional. The purpose of this study was to assess portal inflow and venous outflow volumes of the caudate lobe. METHODS: Extrahepatic (provided by the first-order branches) versus intrahepatic (provided by the second- to third-order branches) portal inflow, as well as direct (via Spieghel veins) versus indirect (via hepatic veins) venous drainage patterns were analyzed in virtual 3-D liver maps in 140 potential live liver donors. RESULTS: The caudate lobe has a greater intrahepatic than extrahepatic portal inflow volume (mean 55 ± 26 vs. 45 ± 26%: p = 0.0763), and a greater extrahepatic than intrahepatic venous drainage (mean 54-61 vs. 39-46%). Intrahepatic drainage based on mean estimated values showed the following distribution: middle > inferior (accessory) > right > left hepatic vein. CONCLUSIONS: Sacrifice of extrahepatic caudate portal branches can be compensated by the intrahepatic portal supply. The dominant outflow via Spieghel veins and the negligible role of left hepatic vein in caudate venous drainage may suggest reconstruction of caudate outflow via Spieghel veins in instances of extended left hemiliver live donation not inclusive of the middle hepatic vein. The anatomical data and the real implication for living donors must be further verified by clinical studies.

Splenorenal Arterial Bypass: Description of Technique and Case Example in an Instance of Renal Revascularization during Adrenalectomy for Adrenocortical Carcinoma.

We present a patient with a 16 cm adrenocortical carcinoma that underwent a left adrenalectomy en bloc with resection of the involved segment of the left renal artery. A splenectomy and splenorenal bypass was performed to revascularize the left kidney. To our knowledge, this is the first instance in the literature of a splenorenal arterial bypass being reported for renal revascularization during an extirpative oncologic procedure. A 64-year-old male patient, with history significant for adrenocortical carcinoma, status post prior right adrenalectomy with partial right nephrectomy, presented for an elective left adrenalectomy. Preoperative work-up revealed an 11.4 × 13.2 × 16 cm left adrenal mass, most consistent with an adrenocortical carcinoma. At the time of surgery, the mass was found to be intimately adherent to the aorta at the takeoff of the left renal artery. Moreover, the left renal artery appeared to be coursing directly through the mass. The involved segment of the left renal artery was resected en bloc with the tumor. Because of concerns for a small and likely poorly functioning right renal remnant, a decision was made to attempt to salvage the left kidney. This was accomplished by performing a splenectomy and constructing a splenorenal bypass. Serial Duplex Doppler renal ultrasound studies were obtained over the first three postoperative days and demonstrated improved arterial waveforms. Serum creatinine reached a peak level of 3.76 mg/dL on postoperative day 3, and then began to slowly trend down to 3.37 mg/dL on the day of discharge (postoperative day7).

Elevated human chorionic gonadotropin levels in patients with chronic kidney disease: Case series and review of literature.

Women are often subjected to serum human chorionic gonadotropin (HCG) testing prior to diagnostic and therapeutic interventions. A positive result leads to further testing to rule out pregnancy and avoid possible fetal teratogenicity. The impact of chronic kidney disease (CKD) on HCG testing has not been studied. We report a series of 5 women out of 62 with CKD, who had a positive HCG test on routine pre-transplant screening at a single transplant center. We analyzed their case records retrospectively. Despite aggressive investigation, their elevated HCG levels remained unexplained. The positive test contributed to delays in transplantation and increased overall cost of treatment.

Transhilar passage in right graft live donor liver transplantation: intrahilar anatomy and its impact on operative strategy.

The passage through the hilar plate during right graft live donor liver transplantation (LDLT) can have dangerous consequences for both donors and recipients. The purpose of our study was to delineate hilar transection and biliary reconstruction strategies in right graft LDLT, with special consideration of central and peripheral hilar anatomical variants. A total of 71 consecutive donors underwent preoperative three-dimensional (3D) CT reconstructions and virtual 3D hepatectomies. A three-modal hilar passage strategy was applied, and its impact on operative strategy analyzed. In 68.4% of cases, type I and II anatomical configurations allowed for an en block hilar transection with simple anastomotic reconstructions. In 23.6% of cases, donors had "difficult" type II and types III/IV hilar bile duct anatomy that required stepwise hilar transections and complex graft biliary reconstructions. Morbidity rates for our early (A) and recent (B) experience periods were 67% and 39%, respectively. (1) Our two-level classification and 3D imaging technique allowed for donor-individualized transhilar passage. (2) A stepwise transhilar passage was favored in types III and IV inside the right-sided hilar corridor. (3) Reconstruction techniques showed no ameliorating effect on early/late biliary morbidity rates.

Kidney transplant ureteroneocystostomy techniques and complications: review of the literature.

Despite a variety of urinary tract reconstructive techniques, urinary complications are the most frequent technical adverse event following renal transplantation. These complications can be associated with substantial morbidity and generate excess cost. In this review we comprehensively discuss 4 techniques of ureteroneocystostomy, compare complications, and evaluate the strengths and weaknesses of each technique focusing on 4 specific urologic complications: urine leak, ureteric obstruction, hematuria, and symptomatic vesicoureteral reflux.

Donor/recipient algorithm for management of the middle hepatic vein in right graft live donor liver transplantation.

BACKGROUND: The aim of this study was to delineate an algorithm for donor and recipient criteria and middle hepatic vein (MHV) management in right-graft live-donor liver transplantation (LDLT) on the basis of computerized 3-dimensional computed tomographic image analysis. METHODS: Data on 94 consecutive right-graft LDLTs were prospectively collected. Graft and remnant data for the first 23 cases were retrospectively evaluated by means of 3-dimensional computed tomographic reconstructions, and on the basis of that preliminary series, a graft selection algorithm using 3 parameters-hepatic vein dominance classification, graft and remnant graft volume/body weight ratios, and congestion volumes-was created. It was subsequently applied to the next 71 right-graft LDLTs. RESULTS: Fifty-nine right grafts contained the MHV. Four of the 12 grafts with no MHVs required MHV reconstructions. In 18 cases, small liver grafts were used. The postoperative function of liver grafts and remnants with versus without MHVs was not statistically different. CONCLUSIONS: The proposed algorithm favored the inclusion of the MHV with the right grafts. It also allowed for the procurement of grafts that were potentially small for size without compromising donor or recipient safety.

Major liver resections for primary liver malignancies in the elderly.

PURPOSE: The aim of our prospective study was to assess the results of major hepatic resections for primary liver tumours in patients 75 years of age or older. METHODS: From 10/1999 to 04/2006, 23 patients with non-cirrhotic livers > or = 75 years presented to our department to undergo curative resection for primary liver malignancies. Data were collected prospectively. Patients were assigned to two groups. Group A included those with resectable tumours, while Group B was made up of those with unresectable lesions. RESULTS: Fourteen patients had intrahepatic cholangiocarcinoma while 9 had hepatocellular carcinoma. Comorbidities were present in every case. Morbidity and hospital mortality rates for group A patients were 25% and 8%, respectively. The corresponding rates for group B patients were 9% and 9%. The 1-, 2-, and 3-year cumulative group A survival was 71%, 51% and 26% for cholangiocarcinoma and 80%, 60% and 60% for hepatocellular carcinoma, respectively. The corresponding group B survival was 45%, 18% and 0%. CONCLUSION: Advanced age does not seem to negatively affect the outcome of liver resections for malignancies. Hepatic resections in patients 75 years of age or older may be carried out with relative safety as long as patients are appropriately selected.

Territorial belonging of the middle hepatic vein in living liver donor candidates evaluated by three-dimensional computed tomographic reconstruction and virtual liver resection.

BACKGROUND: Postoperative venous congestion can lead to graft and remnant liver failure in living donor liver transplantation. This study was designed to delineate 'territorial belonging' of the middle hepatic vein (MHV) and to identify hepatic venous anatomy at high risk of outflow congestion. METHODS: MHV belonging patterns for right (RHL) and left (LHL) hemilivers were evaluated by three-dimensional computed tomographic reconstruction and virtual hepatectomy in 138 consecutive living liver donor candidates. RESULTS: The right hepatic vein (RHV) was dominant in 84.1 per cent and an accessory inferior hepatic vein (IHV) was present in 47.1 per cent of livers. Three MHV belonging types were identified for the RHL. Strong and complex MHV types A and C were associated with large RHL venous congestion. The MHV belonged to the LHL in 65.9 per cent, draining 37 per cent of this hemiliver. In virtual liver resections, left MHV type D was a risk category for small left liver remnants. CONCLUSION: MHV territorial belonging types A and C were identified as high risk for RHL venous congestion. Their presence should prompt consideration of either inclusion of the MHV with the right graft or reconstruction of its tributaries, and preservation of IHV territory.

Liver transplantation for hepatocellular carcinoma after yttrium therapy: a case report.

Yttrium-90 microspheres constitute one of the most recent treatment options for hepatocellular carcinoma (HCC) in the setting of cirrhosis. As such, their spectrum of indication is not yet fully established. Herein, we have reported the case of a patient with HCC beyond the listing criteria for liver transplantation (OLT) who was treated preoperatively with selective transarterial chemoembolization and yttrium-90 microspheres. He was subsequently transplanted with a liver from an 81-year-old donor allocated through Eurotransplant as a "rescue offer." The posttransplant course was uneventful. Pathologic examination revealed a multifocal, well-differentiated pT2 tumor with no vascular invasion. The patient is currently alive and in good condition at 14 months posttransplant, with no evidence of tumor recurrence by a current computed tomography scan. This report provided encouraging information on the potential of yttrium-90 microspheres as a bridging option before OLT for multifocal HCC.

"Preemptive" live donor liver transplantation for fibrolamellar hepatocellular carcinoma: a case report.

Fibrolamellar (FL) hepatocellular carcinoma (HCC) is a distinctive form of primary HCC that occurs principally in children and young adults. Although liver transplantation is not contraindicated for FL-HCC, noncirrhotic patients with large HCC tumors (including FL-HCCs) are not prioritized. Although hepatic resection is considered to be the primary treatment for FL-HCC, living donor liver transplantation is evolving into a potentially better alternative. Herein we have reported successful "preemptive" living donor liver transplantation for presumed recurrence of FL-HCC after an extended right hepatectomy with resection and synthetic graft replacement of the inferior vena cava.

Liver "compliance": a previously unrecognized preoperative predictor of small-for-size syndrome in adult living donor liver transplantation.

BACKGROUND: The purpose of this study was to investigate the effect of liver compliance on computed tomography (CT) volumetry and to determine its association with postoperative small-for-size syndrome (SFSS). PATIENTS AND METHODS: Unenhanced, arterial, and venous phase CT images of 83 consecutive living liver donors who underwent graft hepatectomy for adult-to-adult living donor liver transplantation (ALDLT) were prospectively subjected to three-dimensional (3-D) CT liver volume calculations and virtual 3-D liver partitioning. Graft volume estimates based on 3-D volumetry, which subtracted intrahepatic vascular volume from the "smallest" (native) unenhanced and the "largest" (venous) CT phases, were subsequently compared with the intraoperative graft weights. Calculated (preoperative) graft volume-to-body weight ratios (GVBWR) and intraoperative measured graft weight-to-body weight ratios (GWBWR) were analyzed for postoperative SFSS. RESULTS: Significant differences in minimum versus maximum total liver volumes, graft volumes, and GVBWR calculations were observed among the largest (venous) and the smallest (unenhanced) CT phases. SFSS occurred in 6% (5/83) of recipients, with a mortality rate of 80% (4/5). In four cases with postoperative SFSS (n = 3 lethal, n = 1 reversible), we had transplanted a small-for-size graft (real GWBWR < 0.8). The three SFS grafts with lethal SFSS showed a nonsignificant volume "compliance" with a maximum GVBWR < 0.83. This observation contrasts with the seven recipients with small-for-size grafts and reversible versus no SFSS who showed a "safe" maximum GVBWR of 0.92 to 1.16. CONCLUSION: The recognition and precise assessment of each individual's liver compliance displayed by the minimum and maximum GVBWR values is critical for the accurate prediction of functional liver mass and prevention of SFSS in ALDLT.

Hepatic hilar and sectorial vascular and biliary anatomy in right graft adult live liver donor transplantation.

INTRODUCTION: The aim of this study was to analyze vascular and biliary variants at the hilar and sectorial level in right graft adult living donor liver transplantation. METHODS: From January 2003 to June 2007, 139 consecutive live liver donors underwent three-dimensional computed tomography (3-D CT) reconstructions and virtual 3-D liver partitioning. We evaluated the portal (PV), arterial (HA), and biliary (BD) anatomy. RESULTS: The hilar and sectorial biliary/vascular anatomy was predominantly normal (70%-85% and 67%-78%, respectively). BD and HA showed an equal incidence (30%) of hilar anomalies. BD and PV had a nearly identical incidence of sectorial abnormalities (64.7% and 66.2%, respectively). The most frequent "single" anomaly was seen centrally in HA (21%) and distally in BD (18%). A "double" anomaly involved BD/HA (7.2%) in the hilum, and HA/PV and BD/PV (6.5% each) sectorially. A "triple" anomaly involving all systems was found at the hilum in 1.4% of cases, and at the sectorial level in 9.4% of instances. Simultanous central and distal abnormalities were rare. In this study, 13.7% of all donor candidates showed normal hilar and sectorial anatomy involving all 3 systems. A simultaneous central and distal "triple" abnormality was not encountered. A combination of "triple" hilar anomaly with "triple" sectorial normality was observed in 2 cases (1.4%). A central "triple" normality associated with a distal "triple" abnormality occurred in 7 livers (5%). CONCLUSIONS: Our data showed a variety of "horizontal" (hilar or sectorial) and "vertical" (hilar and sectorial) vascular and biliary branching patterns, providing comprehensive assistance for surgical decision-making prior to right graft hepatectomy.

Intrahepatic biliary anatomy derived from right graft adult live donor liver transplantation.

OBJECTIVE: The successful management of the bile duct in right graft adult live donor liver transplantation requires knowledge of both its central (hilar) and distal (sectorial) anatomy. The purpose of this study was to provide a systematic classification of its branching patterns to enhance clinical decision-making. PATIENTS AND METHODS: We analyzed three-dimensional computed tomography (3-D CT) imaging reconstructions of 139 potential live liver donors evaluated at our institution between January 2003 and June 2007. RESULTS: Fifty-four (n = 54 or 38.8%) donor candidates had a normal (classic) hilar and sectorial right bile duct anatomy (type I). Seventy-eight (n = 78 or 56.1%) cases had either hilar or sectorial branching abnormalities (types II or III). Seven (n = 7 or 5.1%) livers had a mixed type (IV) of a rare and complex central and distal anatomy. CONCLUSIONS: We believe that the classification proposed herein can aid in the better organization and categorization of the variants encountered within the right-sided intrahepatic biliary system.

Anatomical classification of the peripheral right hepatic duct: early identification of a preventable source of morbidity and mortality in adult live donor liver transplantation.

INTRODUCTION: The purpose of this study was to determine the impact of our classification on right graft adult live donor liver transplantation (ALDLT) outcomes. METHODS: Three-dimensional computed tomography (CT) reconstructions were used to classify the hilar and sectorial biliary anatomy of 71 consecutive live liver donors. Four possible clinical types were defined, based on the normal (N) or abnormal (A) features of the corresponding hilar/sectorial ducts: type I, N/N; type II, N/A; type III, A/N; and type IV, A/A. We subsequently performed an analysis of the operative outcomes based on the donor anatomy. RESULTS: Type I was encountered in 47.9% of cases, type II in 29.6%, type III in 19.7%, and type IV in 2.8%. The highest incidence of biliodigestive anastomoses was observed with type III (50%) and type IV (100%) variants. Type I was associated with the highest incidence of single anastomoses (single vs multiple, P = .001) and of single bile duct anastomoses (single vs multiple, P = .004). Type III was associated with more multi-duct reconstructions compared with types I and II (P = .002 and P = .05, respectively). There were no significant differences in early (P = .08) or late (P = .33) biliary complications, or deaths due to a biliary etiology (P = .55) among the 4 types. CONCLUSIONS: Complex biliary anatomy in the right liver graft usually requires biliodigestive anastomoses, which are often associated with complicated procedures. The precise delineation of the intrahepatic biliary anatomy provided by our clinical classification may contribute to better morbidity and mortality rates, especially for grafts at greatest anatomical risk.

A new systematic classification of peripheral anatomy of the right hepatic duct: experience from adult live liver donor transplantation.

OBJECTIVE: The peripheral intrahepatic biliary anatomy, especially at the sectorial level on the right side, has not been adequately described. The purpose of our study was to systematically describe this complex anatomy in clinically applicable fashion. PATIENTS AND METHODS: We analyzed three-dimensional computed tomography (CT) imaging reconstructions of 139 potential living liver donors evaluated at our institution between January 2003 and June 2007. RESULTS: Eighty-nine (64%) donors had a normal right bile duct sectorial anatomy. In the other 50/139 (36%) cases, we observed abnormal sectorial branching patterns, with 45/50 abnormalities as trifurcations, whereas the remaining ones were quadrifurcations. In 22/50 (44%) abnormalities, a linear branching pattern (types B1/C1) and an early segmental origin off the right hepatic duct (types B3/C3) were present, a finding of particular danger when performing a right graft hepatectomy. In 2 cases, we noted a mixed type (B6/C6) of a rare complex anatomy. CONCLUSIONS: Our proposed classification of the right sectorial bile duct system clearly displays the "area at risk" encountered when performing right graft adult live donor liver transplantation and tumor resections involving the right lobe of the liver.

Liver transplantation for hilar cholangiocarcinoma: a German survey.

BACKGROUND: The present study reports a German survey addressing outcomes in nonselected historical series of liver transplantation (OLT) for hilar cholangiocarcinoma (HL). PATIENTS AND METHODS: We sent to all 25 German transplant centers performing OLT a survey that addressed (1) the number of OLTs for HL and the period during which they were performed; (2) the incidence of HL diagnosed prior to OLT/rate of incidental HL (for example, in primary sclerosing cholangitis); (3) tumor stages according to Union Internationale Centre le Cancer; (4) patient survival; and (5) tumor recurrence rate. RESULTS: Eighty percent of centers responded, reporting 47 patients who were transplanted for HL. Tumors were classified as pT2 (25%), pT3 (73%), or pT4 (2%). HL was diagnosed incidentally in 10% of cases. A primary diagnosis of PSC was observed in 16% of patients. Overall median survival was 35.5 months. When in-hospital mortality (n = 12) was excluded, the median survival was 45.4 months, corresponding to 3- and 5-year survival rates of 42% and 31%, versus 31% and 22% when in-hospital mortality was included. HL recurred in 34% of cases. Three- and 5-year survivals for the 15 patients transplanted since 1998 was 57% and 48%, respectively. Median survival ranged from 20 to 42 months based on the time period (P = .014). CONCLUSIONS: The acceptable overall survival, the improved results after careful patient selection since 1998, and the encouraging outcomes from recent studies all suggest that OLT may be a potential treatment for selected cases of HL. Prospective multicenter randomized studies with strict selection criteria and multimodal treatments seem necessary.

Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC). PATIENTS AND METHODS: Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration. RESULTS: Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Those who underwent transplantation in the early period had a preoperative diagnosis of inoperable ICC (n = 4) and ICC in the setting of primary sclerosing cholangitis (n = 2). In the latter period the subjects had a diagnosis of HCC in cirrhosis (n = 3) or recurrent ICC after an extended right hepatectomy (n = 1). Median survival was 25.3 months for the whole series and 32.2 months (range, 18-130 months) when hospital mortality was excluded (n = 3). Four patients are currently alive after 30, 35, 42, and 130 months post-OLT, respectively. Two patients died of tumor recurrence at 18 and 21 months post-OLT, respectively. One-, 3-, and 5-year survival rates were 70%, 50%, and 33%, respectively. CONCLUSIONS: The role of OLT in the setting of ICC may be re-evaluated in the future under strict selection criteria and with prospective multicenter randomized studies. Potential candidates to be included are those with liver cirrhosis and no hilar involvement who meet the Milan criteria for HCC.

Long-term results after liver transplantation with "livers that nobody wants" within Eurotransplant: a center's experience.

BACKGROUND: Orthotopic liver transplantation (OLT) represents the only curative treatment for end-stage liver disease, but its application is limited because of organ shortages. The purpose of this study was to review the long-term outcomes after OLT during a 2-year period of 45 rescue offers organs within Eurotransplant. PATIENTS AND METHODS: Forty-five deceased donor liver allografts had been officially offered to and rejected by other transplantation centers 162 times prior to our acceptance. Data analysis addressed recurrence of primary disease, ischemic-type biliary lesions (ITBL), re-evaluation or relisting for OLT, re-OLT, as well as overall patient and graft survivals. RESULTS: Six patients underwent retransplantation because of primary nonfunction (n = 4), hepatitis C recurrence (n = 1), and secondary biliary cirrhosis following ITBL (n = 1). Five additional patients developed ITBL and received endoscopic treatment. Currently, 34 patients are alive after a median follow-up of 44.5 months. Median graft survival is 43.2 months. Patient versus patient/first graft survival at 1, 3, and 5 years is 82%, 78%, and 74%, versus 76%, 69%, and 65%, respectively. CONCLUSIONS: OLT with rescue organs is a reasonable policy, with acceptable long-term patient/graft survivals, providing a real expansion of the donor pool.