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.

Epidemiology and management of trauma patients in a Greek multispecialty hospital in the absence of a dedicated trauma center.

PURPOSE: In the absence of dedicated trauma centers, surgical emergency departments in hospitals assigned as trauma centers accept a huge load of trauma patients. In this audit, we aim to document and assess the epidemiologic data of trauma patients and their injuries in order to give a picture of the impact of trauma in the workload of a surgical department in the Greek healthcare system. METHODS: During a period of 2 years, we managed 6,041 trauma patients in the accident and emergency (A&E) department based on the Advanced Trauma Life Support (ATLS) protocols. We retrospectively reviewed the emergency department registry and the admissions. RESULTS: 47.56 % of the patients seen in the A&E department were trauma patients. The mean age of the trauma patients was 44.52 years (range 15-106 years). The majority were men (60.4 %). The leading cause of trauma was motor and vehicle accidents, followed by slip and fall accidents, physical assault, fall from height, and vehicle pedestrian accidents. The majority of the patients were discharged from the hospital. Only 29 (4.6 %) out of 624 patients who were admitted to the general surgery department underwent an operation, while the rest were admitted for observation. On the other hand, patients were admitted to other departments only when surgical treatment was necessary. CONCLUSIONS: In the absence of level one trauma centers, in multispecialty urban hospitals, the coordination of trauma burdens the general surgery team. This has financial and administrative implications. The collection of important epidemiologic data from these hospitals is mandatory in order to develop national prevention measures against injuries.

[Laparoscopic versus endoscopic primary management of choledocholithiasis. A retrospective case-control study]. / Primär laparoskopische, einzeitige versus endoskopische Therapie der Choledocholithiasis. Eine retrospektive Fall-Kontroll-Studie.

BACKGROUND: The aim was to present the long-term results of one-stage laparoscopic procedure for the management of common bile duct (CBD) lithiasis in comparison with the primary endoscopic approach via ERCP. PATIENTS AND METHODS: A retrospective case-control study was performed to determine the outcome of patients treated for CBD lithiasis (04/1997 - 11/2011). Data of patients with choledocholithiasis undergoing the two treatment modalities - laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE + LC, group A, n = 101) versus endoscopic retrograde cholangiopancreatography/sphincterotomy and laparoscopic cholecystectomy (ERCP/S + LC, group B, n = 116) were matched according to their clinical characteristics. Patients of group A underwent either laparoscopic choledochotomy or transcystic exploration. The policy was to convert to open choledochotomy only after the sequential application of the two treatment modalities (laparoscopic/endoscopic procedure) had failed. RESULTS: No significant difference in morbidity was found between the groups (group A 8% versus group B 11.2%). Conversion to another procedure was mandatory in 12 out of 101 and 17 out of 116 patients of groups A and B, respectively. The mean follow-up period was 7.8 years (range 1-12 years). Effective laparoscopic treatment of CBD stones (cholecystectomy and CBD clearance) was possible in 89 of the 101 patients in group A (88.1%) compared with 99 of the 116 patients in group B (85.4%) after the endoscopic approach. CONCLUSIONS: This study showes that both - primary endoscopy and one-stage laparoscopic management of CBD lithiasis - are highly effective and safe with comparable results.

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.

Severe monobacterial necrotizing soft tissue infection by group A Streptococcus: A surgical emergency.

Eight percent of necrotizing soft tissue infections (NSTI) are attributable to group A Streptococci (GAS), and among these, 50% develop streptococcal toxic shock syndrome. The reported mortality associated with NSTI reaches 32%. We present cases of two healthy individuals with minor GAS skin infection which developed to a rapidly progressed NSTI and sepsis despite of the antibiotic treatment, aiming to discuss the lessons learned from the course and management of these patients.

Impact of minimally invasive surgery in the spectrum of current achalasia treatment options.

Minimally invasive Heller myotomy has evolved the "gold standard" procedure for achalasia in the spectrum of current treatment options. The laparoscopic technique has proved superior to the thoracoscopic approach due to improved visualization of the esophagogastric junction. Operative controversies most recently include the length of the myotomy, especially of its fun-dic part, with respect to the balance between postoperative persistent dysphagia and development of gastroesophageal reflux, as well as the type of the added antireflux procedure. Peri-operative mortality should approach 0%, and favorable long-term results can be achieved in > 90%.

Arterial en bloc resection for pancreatic carcinoma.

BACKGROUND: Surgery for locally advanced pancreatic cancer with arterial involvement of the hepatic artery, coeliac trunk and superior mesenteric artery (SMA) is highly controversial. In a retrospective review, the benefits and harms of arterial en bloc resection (AEBR) for pancreatic adenocarcinoma with arterial involvement were analysed. METHODS: Patients were divided into three groups: 29 patients who had pancreatic resection and AEBR (group 1), 449 who had pancreatic resection with no arterial resection or reconstruction (group 2), and 40 with unresectable tumours who underwent palliative bypass (group 3). RESULTS: Eighteen patients underwent reconstruction of the hepatic artery, eight of the coeliac trunk and three of the SMA. Additional reconstruction of portal vein was required in 15 patients and of adjacent visceral organs in 19. Perioperative morbidity and mortality rates were higher in group 1 than in group 2 (P = 0·031 and P = 0·037 respectively). Additional portal vein resection was an independent predictor of morbidity (P < 0·001). Median overall survival was similar for groups 1 and 2 (14·0 versus 15·8 months; P = 0·152), and lower for group 3 (7·5 months; P = 0·028 versus group 1). CONCLUSION: In selected patients AEBR can result in overall survival comparable to that obtained with standard resection and better than that after palliative bypass. Nevertheless, AEBR is associated with significantly higher morbidity and mortality rates, counterbalancing the overall gain in survival and limiting the overall oncological benefit.

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.

Prediction model of lymph node metastasis in superficial esophageal adenocarcinoma and squamous cell cancer including D2-40 immunostaining.

BACKGROUND: It was the aim of our study to establish a model for prediction of lymph node metastases in superficial esophageal cancer. METHODS: We analyzed the clinical and histopathological data of 50 consecutive patients with pT1-esophageal cancer who underwent oncological resection. Submucosal carcinomas (pT1b) were classified according to sm levels 1-3. D2-40 immunostaining was investigated using the ABC technique. In a first step, we performed univariate analysis (One-way ANOVA: Sigma restricted parameterization; test of SS whole vs. SS predicted) to test the predictive value of the following categorical parameters for lymph node status (positive/negative): sex, histologic tumor type, localization, surgical technique (transhiatal/transthoracic), grading, pT1-subclassification (pT1a, pT1b sm 1-3), pL-, pV-status, and D2-40 labeling. Simple regression was applied for the following continuous predictors: age and tumor size. All significant variables of univariate analysis were included in the multivariate analysis. For this purpose, we used the General Liner Models's analysis (forward stepwise). In a third step, the Kruskal-Wallis test with post hoc comparisons was intended to define the cut-off value of parameters tested. RESULTS: Only the following variables gained statistical significance in univariate analysis: sex, histological tumor type, grading, pT1-subclassification, lymphatic infiltration, microvascular infiltration, D2-40 immunostaining, and tumor size (P < 0.05). Variables reaching significance in multivariate analysis were tumor size (P = 0.017) and pV-status (P = 0.037). In the Kruskal-Wallis test with post hoc comparisons, the cut-off value of tumor size was 2 cm (model P = 0.002) and between the categories (P < 0.05). CONCLUSIONS: Lymph node positivity and lymphatic vessel infiltration did not linearly increase with sm tumor infiltration depth. The risk category of lymph node involvement in superficial esophageal cancer exists according to our prediction model on the basis of tumor size of >2 cm and microvascular infiltration. The hitherto common sm levels 1-3 classification of submucosal cancers appears to display a lesser impact than previously assumed with regard to prediction of potential lymph node metastases and consequently the indication for endoscopic or surgical therapy.

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.

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.

Living donor liver transplantation for hepatocellular carcinoma in patients exceeding the UCSF criteria.

BACKGROUND: Living donor liver transplantation (LDLT) represents an alternative to expand the organ pool for adult patients with hepatocellular carcinoma (HCC) and end-stage liver disease. The purpose of this study was to demonstrate our institutional experience using criteria exceeding those of the University of California San Francisco (UCSF). PATIENTS AND METHODS: Between September 1998 and December 2006, 22 LDLTs were performed for HCC among patients exceeding the UCSF criteria. RESULTS: There were 17 men and 5 women of median age 55 years. Multifocal tumors were present in 19 of 22 patients. Tumor grading was: grade I (n = 8), grade II (n = 10), and grade III (n = 4). Microvascular invasion was observed in 7 liver explants. Five patients died from complications unrelated to HCC recurrence at 2, 6, 9, 10, and 14 months' posttransplant. Seven patients developed tumor recurrences at 3, 3, 5, 7, 9, 10, and 35 months after LDLT, and 4 died at 6, 10, 17, and 75 months' posttransplantation. Currently, 13 patients are alive (3 with tumor recurrence) at a median of 24 months' posttransplant. Rates for 1- and 3-year overall versus recurrence-free survivals were 73% and 62% versus 54% and 34%, respectively. CONCLUSIONS: LDLT for HCC patients exceeding the UCSF criteria is characterized by an acceptable overall but poor recurrence-free survival. Its application requires an honest approach to donor and recipient information.

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.