Os achados de imagem para avaliação da tríade portal são confiáveis para realização do transplante hepático com doador vivo? / Are the imaging findings used to assess the portal triad reliable to perform living-donor liver transplant?

RACIONAL: Um aspecto crucial do transplante hepático inter-vivos é o risco imposto ao doador, devido ser procedimento realizado em pessoa saudável, com possibilidade de alta morbidade pós-operatória. OBJETIVO: Correlacionar os achados de imagem do pré e intra-operatório dos doadores adultos vivos de fígado. MÉTODOS: No período de 2003 a 2008 foram revisados os prontuários de 66 doadores. Foram 42 homens (64%) e 24 mulheres (36%), com média de idade de 30 anos (± 8 anos). A anatomia pré-operatória foi analisada através de colangiografia por ressonância nuclear magnética para estudo dos ductos biliares e angiografia por tomografia computadorizada para artéria hepática e veia porta. Critérios de normalidade foram estabelecidos de acordo com estudos prévios da literatura. RESULTADOS: Variações anatômicas dos ductos biliares foram encontradas em 59,1% dos doadores; da artéria hepática em 31,8% e da veia porta em 30,3% dos casos no pré-operatório. A colangiografia por ressonância nuclear magnética apresentou achados concordantes em 44 (66,6%) doadores e discordantes em 22 (33,3%). Com relação à artéria hepática em todos os doadores os achados do exame de imagem foram concordantes com os do intra-operatório. Para a veia porta a tomografia computadorizada apresentou achados concordantes em 59 (89,4%) doadores e discordantes em sete (10,6%). CONCLUSÕES: As variações anatômicas dos ductos biliares são frequentes, com a colangiografia por ressonância nuclear magnética apresentando acurácia moderada (70%) na reprodução dos achados cirúrgicos; a tomografia computadorizada reproduziu os achados do intra-operatório da artéria hepática em 100% dos doadores, e reproduziu os achados intra-operatórios em 89,4% dos casos em relação à veia porta, apresentando acurácia elevada (89%).

BACKGROUND: A crucial aspect of living-donor liver transplant is the risk imposed to the donor due to a procedure performed in a healthy individual that can lead to a high postoperative morbidity rate AIM: To correlate the pre- and intraoperative hepatic imaging findings of living adult donors. METHODS: From 2003 to 2008 the medical charts of 66 donors were revised; in that, 42 were males (64%) and 24 females (36%), mean age of 30±8 years. The preoperative anatomy was analyzed by magnetic resonance cholangiography to study the bile ducts and by computed tomography angiography to evaluate the hepatic artery and portal vein. Normalcy criteria were established according to previously published studies. RESULTS: Anatomic variations of the bile ducts were found in 59.1% of donors, of the artery hepatic in 31.8% and of the portal vein in 30.3% of the cases during the preoperative period. The magnetic resonance cholangiography findings were in agreement in 44 (66.6%) of donors and in disagreement in 22 (33.3%). With regards to hepatic artery, in all donors the findings of the imaging examination were in agreement with those of the intraoperative period. As to the portal vein, the computed tomography findings were in agreement in 59 (89.4%) donors and in disagreement in seven (10.6%). CONCLUSIONS: The bile duct anatomic variations are frequent, and the magnetic resonance cholangiography showed moderate accuracy (70%) in reproducing the surgical findings; the computed tomography reproduced the intraoperative findings of the hepatic artery in 100% of donors, and of the portal vein in 89.4% of the cases, thus demonstrating high accuracy (89%).

Are the imaging findings used to assess the portal triad reliable to perform living-donor liver transplant?

BACKGROUND: A crucial aspect of living-donor liver transplant is the risk imposed to the donor due to a procedure performed in a healthy individual that can lead to a high postoperative morbidity rate AIM: To correlate the pre- and intraoperative hepatic imaging findings of living adult donors. METHODS: From 2003 to 2008 the medical charts of 66 donors were revised; in that, 42 were males (64%) and 24 females (36%), mean age of 30 ± 8 years. The preoperative anatomy was analyzed by magnetic resonance cholangiography to study the bile ducts and by computed tomography angiography to evaluate the hepatic artery and portal vein. Normalcy criteria were established according to previously published studies. RESULTS: Anatomic variations of the bile ducts were found in 59.1% of donors, of the artery hepatic in 31.8% and of the portal vein in 30.3% of the cases during the preoperative period. The magnetic resonance cholangiography findings were in agreement in 44 (66.6%) of donors and in disagreement in 22 (33.3%). With regards to hepatic artery, in all donors the findings of the imaging examination were in agreement with those of the intraoperative period. As to the portal vein, the computed tomography findings were in agreement in 59 (89.4%) donors and in disagreement in seven (10.6%). CONCLUSIONS: The bile duct anatomic variations are frequent, and the magnetic resonance cholangiography showed moderate accuracy (70%) in reproducing the surgical findings; the computed tomography reproduced the intraoperative findings of the hepatic artery in 100% of donors, and of the portal vein in 89.4% of the cases, thus demonstrating high accuracy (89%).

Living donor right liver lobe transplantation with or without inclusion of the middle hepatic vein: analysis of complications.

BACKGROUND: For living-related liver transplantation, harvesting a right hepatic graft that includes the middle hepatic vein (MHV) has been recommended to improve venous drainage of the graft. However, it may result in congestion of the donor's remaining segment IV, increasing the potential risk to the donor. This study aimed to compare safety levels for liver donors during procedures with or without removal of the MHV. METHODS: A total of 68 living donor liver transplantations were performed from March 2001 to May 2007. In 39 procedures, the MHV was not included in the graft (group A), and in 29 the MHV was included in the graft (group B). The analyzed data included surgical time, use of blood derivatives, length of hospital stay, laboratory analyses, weight of the graft, and clinical complications. RESULTS: No differences were observed regarding the need for blood derivatives or laboratory parameters. The frequency of postoperative complications was similar in the two groups, with 10 cases (25.6%) in group A and 7 cases (24.1%) in group B (P=0.887). No deaths were seen. The rate of observed complications was 25% among living donors, most of them being managed without surgical intervention. CONCLUSIONS: The inclusion of the MHV does not add morbidity in living donors in selected cases.

The presence of bilobar tumor should be considered as a new limit for transplantation beyond the Milan criteria? / A presença de tumor bilobar deve ser considerado novo limite para exclusão de transplante em pacientes que excedem os critérios de Milão?

BACKGROUND: An imprecise estimate of the tumor's aggressiveness of the hepatocellular carcinoma especially in transplanted patients beyond the Milan criteria has a poor outcome, although a more reliable criteria including microscopic vascular invasion is difficult to be established before transplantation. AIM: To examine a cohort of patients with hepatocellular carcinoma undergoing liver transplantation to evaluate the preoperative predicting factors for microscopic vascular invasion. METHODS: A series of 46 consecutive cirrhotic patients with hepatocellular carcinoma undergoing transplantation based on Milan criteria or similar criteria in a single center were enrolled between 1993 and 2007. The survival was calculated using Kaplan-Meyer's method and a multivariate Cox regression was performed to evaluate survival and factors related to microscopic vascular invasion. RESULTS: Multifocal tumors were present in 39 percent. Microvascular invasion, tumor relapses and hepatocellular carcinoma beyond the Milan criteria were identified in 33 percent, 13 percent and 33 percent, respectively. Overall 1-, 3-, and 5-year actuarial patient survival rates were 64 percent, 59 percent and 45 percent respectively. Patients who exceeded the Milan criteria had a higher incidence of microscopic vascular invasion and bilobar tumor compared to those who met the Milan criteria (53 percent vs. 23 percent and 80 percent vs. 19 percent; p<0.05, respectively). After multivariate analysis, the variable identified as independent risk factor for microscopic vascular invasion was the presence of bilobar tumor (hazard ratio, 3.67; 95 percent confidence interval, 1.01 to 13.34; p<0.05). CONCLUSIONS: The presence of a bilobar tumor is more frequent in hepatocellular carcinoma beyond the Milan criteria and it is an independent predictive factor of a high risk of microscopic vascular invasion. The presence of bilobar tumor in hepatocellular carcinoma beyond the Milan ...

RACIONAL: A recidiva tumoral após o transplante de fígado para o carcinoma hepatocelular tem grande impacto desfavorável na mortalidade e a presença de invasão microvascular desempenha papel importante na recidiva tumoral. OBJETIVO: Avaliar a sobrevida, o risco de recidiva tumoral pós-transplante e os fatores relacionados à invasão microvascular de uma série de transplantados por carcinoma hepatocelular. MÉTODOS: No período entre 1993 e 2007 foi estudada uma série consecutiva de 46 cirróticos com carcinoma hepatocelular submetidos à transplante de fígado baseado nos critérios de Milão a partir de 1996 ou critérios semelhantes no período anterior a esta data. Inicialmente todas as variáveis foram analisadas descritivamente, e as quantitativas através da observação dos valores mínimos e máximos, e do cálculo de médias e desvios-padrão e medianas. Para as variáveis qualitativas calcularam-se frequências absolutas e relativas. Realizou-se a regressão logística com ajuste pelo modelo de Cox para avaliar a sobrevida e os fatores relacionados à recidiva tumoral e invasão microvascular. RESULTADOS: A sobrevida da amostra foi de 64 por cento, 59 por cento e 45 por cento para 1, 3 e 5 anos, respectivamente. Em 13 por cento dos casos, a recidiva tumoral foi verificada. A análise multivariada identificou a chance de um paciente com nódulo bilobar sofrer invasão microvascular é 3,67 vezes maior em relação a um paciente com nódulo unilobar e a presença de um tumor unilobar representar um significativo efeito protetor em relação à invasão microvascular (p = 0,048). CONCLUSÕES: A identificação de um tumor bilobar no estadiamento tumoral é fator preditivo independente de maior risco de invasão microvascular e é necessário ainda confirmar se a presença de tumor bilobar deve ser adicionada aos critérios de Milão para melhor indicação de transplante de fígado em pacientes cirróticos com carcinoma hepatocelular.