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Objective: The aim of this study is to determine whether post-transarterial chemoembolization imaging (computed tomography or magnetic resonance imaging) could accurately predict the tumors' necrosis on pathologic specimens., Background: Transarterial chemoembolization with drug-eluting beads has been proven to be an effective way to bridge patients with hepatocellular carcinomas to liver transplantation., Materials and Methods: From September 2012 to June 2017, 59 patients with a total of 78 hepatocellular carcinomas, who received transarterial chemoembolization with drug-eluting beads before liver transplantation in Kaohsiung Chang Gung Memorial Hospital, were included in the study. All patients and hepatocellular carcinomas have pre-transarterial chemoembolization and post-transarterial chemoembolization images (computed tomography or magnetic resonance imaging) and pathological findings for correlation. Tumor response was evaluated according to modified Response Evaluation Criteria in Solid Tumors. The ranges of necrotic percentage are 100%, 91-99%, 51-90%, and <50%., Results: The accuracy rate between the imaging and pathology correlation was 40% for computed tomography and 42% for magnetic resonance imaging. The recurrent rate of the complete respond group is 11.5%, the partial respond group is 16.0%, and the stationary group is 28.6%., Conclusion: Computed tomography and magnetic resonance imaging sensitivity is not satisfactory for microscopic evaluation of residual tumors after transarterial chemoembolization with drug-eluting beads. However, survival is good after liver transplantation no matter what the microscopic findings were., (Copyright © 2018. Published by Elsevier Inc.)

Background: The acoustic radiation force impulse elastography (ARFI) is a new technology of elastography integrated into B-mode ultrasonography. It has been a reliable method to evaluate liver fibrosis of chronic liver disease in recent years, but less applied in the posttransplantation liver. The aim of the study was to evaluate liver fibrosis by the ARFI with correlation of pathological stages in living donor liver transplantation (LDLT)., Materials and Methods: From August 2010 to August 2012, there were 57 LDLT patients with liver biopsy (LB) due to posttransplantation dysfunction; all patients also received posttransplantation ARFI liver stiffness measurement (LSM) after transplantation for liver fibrosis staging. The ARFI elastography was performed using a Siemens Acuson S2000 ultrasound system with 4V1 transducers (Acusion, Siemens Medical Systems Co. Ltd. Erlangen, Germany). The ARFI LSM value was presented by shear wave velocity (SWV, m/s). The fibrosis staging as F0 to F4 was in accordance with the Metavir scoring system., Results: A total of 57 patients had both posttransplantation LB and effective ARFI fibrosis staging for correlation. The ARFI LSM value increased with severity of liver fibrosis and had significant linear correlation with the results of histological fibrosis staging. The ARFI LSM sensitivities (Se), specificities (Sp), and cutoff values based on receiver-operator characteristic curve were F0: 0.75 m/s (Se: 93.8%, Sp: 4%), F1: 1.06 m/s (Se: 95.5%, Sp: 25.7%), F2: 1.81 m/s (Se: 50%, Sp: 83.6%) and F3: 2.33 m/s (Se: 100%, Sp: 92.9%). Predictive value of ARFI LSM reported a significant difference between early fibrosis stage (F0-F1) and advanced fibrosis stage (F ≧ 2) (P < .05)., Conclusion: In this study, ARFI demonstrated a strong linear correlation and severity of liver fibrosis with LB pathologic staging. ARFI can be an alternative and compensatory method for frequent LB in the posttransplantation liver., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to evaluate portal vein stenosis (PVS) in pediatric liver transplantation (PLT) using Doppler ultrasound (DUS) before and after interventional management for hemodynamic changes., Materials and Methods: From 2000 to 2010, we encountered 11 PVS cases among 180 PLT that were evaluated using DUS and computed tomography (CT) angiography (CTA); all underwent portal stenting. DUS was used to monitor portal hemodynamics. For the diagnosis of PVS, we investigated multiple parameters including stenotic size (SS), stenotic ratio (SR) (SR [%]=PRE-SS/PRE [PRE=stenotic size]), portal flow velocity ratio (VR) (VR=VS/PRE [PRE=velocity at prestenotic site; VS=peak velocity at stenotic site]), spleen size, and platelet count., Results: The incidence of PVS was 5.6% (11/180). The PV was 2.5 mm using DUS and 2.7 mm using CTA. The average SR was 65% fitting the criterion. Low prestenotic portal flow<12 cm/sec and high peak velocity in the stenotic segment (up to 147 cm/sec) were observed in 6 cases. The VR value was high at 7.5:1 and there was splenomegaly with thrombocytopenia. After portal vein stenting, hyperperfusion occurred might after reopening the stenosis: the flow increased to an average of 34 cm/sec and then flow decreased slowly to a stable level 2 weeks later. The size of the spleen decreased from 17 to 12 cm and the thrombocytopenia also improved with platelet counts increasing from 67×10(3) to 178×10(3)/μl at 2 months follow-up. The changes in portal flow, portal vein size, spleen size, and platelet count were significant (P<.05)., Conclusion: PVS is diagnosed using DUS by increased intrahepatic PV dilatation, peak flow at the stenotic site, discrepant VR. Early portal stenting showed a better prognosis. DUS is essential and effective for hemodynamic monitoring and management of PVS., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aim: To evaluate the postoperative portal vein stenosis (PVS) and the diagnostic efficiency of Doppler ultrasound (DUS) in adult living donor liver transplantation (ALDLT)., Materials and Method: From January 2007 to December 2008, 103 ALDLTs were performed and postoperatively followed by routine DUS. The morphologic narrowing at the anastomotic site (AS) of the PVS was analyzed. We calculated the PV stenotic ratio (SR) using the following formula: SR (%)=PRE-AS/PRE (PRE=pre-stenotic caliber). An SR>50% was defined as the critical point for PVS. We also calculated the velocity ratio (VR) between the AS and PRE, and set the significant VR as >3:1. Statistical analyses were carried out to determine clinical significance., Results: Using the definition of morphologic PVS by DUS, there were total 20 cases (19.4%) in this series with SR>50%, which included 17 cases with VR>3:1. Eight cases of severe PVS had a stenotic AS>5 mm and subsequently underwent interventional management. Doppler criteria of SR and VR values were elevated up to 75.8% and 7.5:1, respectively, in these treated cases. Two cases of severe PVS subsequently developed PV thrombosis. Intervention by balloon dilation and/or stenting was performed successfully in this PVS case., Conclusion: DUS is the most convenient and efficient imaging modality to detect and follow postoperative PVS in ALDLT. The Doppler criteria of SR and VR are both sensitive but less specific. Cases of AS<5 mm require interventional management for good long-term graft survival., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

The color Doppler ultrasound has been used to evaluate hepatic vein (HV) outflow insufficiency based on flow velocity and waveforms. In our experience, some cases with flat waveforms are clinically asymptomatic. The parameters of HV flow velocity and waveforms are not always correlated with clinical problems. So, we proposed that total HV flow volume (HVFV) may be a more reliable index. From August 2001 to July 2003, 31 cases among 48 adult-to-adult living related transplants of a right liver graft had one HV anastomosis. HV velocity, waveforms, and HVFV were compared both before and after transplantation. We set the minimal HVFV ratio at 80% based on the original HVFV before graft retrieval. There was no significant difference in HVFV before liver graft retrieval between the 2 groups, but there was a significant change after transplantation. There were no cases of HV insufficiency among group A patients (>80%), whose HVFV ranged from 397 to 1181 mL/min with ratios from 75% to 180% (mean 115%). In group B, there were 4 complicated cases with prolonged severe ascites (<80%) with HVFV ratios from 56% to 76% (mean 66%). Fisher exact test showed a great significance (P < .001). Thus the preliminary criteria of 80% minimal HVFV ratio allows detection of HV insufficiency for further interventional management.

Hepatic outflow insufficiency remains one of the major complications causing postoperative graft failure especially among partial liver graft transplantations (PLT) including living donor liver transplantation (LDLT), reduced size liver transplantation (RLT), and split liver transplantation (SLT). These procedures are different from the whole liver graft transplantations (OLT), which include multiple vascular anastomoses. Color Doppler ultrasound (CDUS) was used to evaluate the hepatic venous outflow from grafts before and after radiological interventional management and to document treatment effects. From June 1994 to March 2003, our 136 cases of PLTs included 131 LDLTs, two RLTs, and three SLTs. Seven cases (six children and one adult) showed postoperative hepatic vein outflow obstruction and persistent massive ascites, as detected by color Doppler ultrasound (CDUS) and confirmed by interventional angiography. The CDUS showed a monophasic flat waveform with a relatively low hepatic vein average peak velocity (Va) in all cases (mean 11 cm/s). Successful interventional procedures included balloon dilatation in three cases and metallic stent replacement in four cases. CDUS was used with guidance during the procedure to confirm restoration of normal hepatic vein flow with a multiphasic waveform and an objective increase of average flow velocity (high to average 66 cm/s). Ascites disappeared dramatically after the procedure. In conclusion CDUS is the prime modality to diagnose and document a treatment response.

Introduction: Transarterial embolization (TAE) is the treatment of choice for advanced HCC to control or even induce tumor shrinkage. The aim of this study was to evaluate the effect of pretransplantation TAE for treatment of advanced HCC., Material and Methods: From 1996 to 2002, we studied 12 cirrhotic patients with HCC, including six who met and six who exceeded the Milan criteria. All patients had sufficient hepatic function to undergo TAE. Liver transplantations were performed subsequently and they were followed prospectively for a median of 22 months (range = 12 to 53 months)., Results: The explanted livers from the 12 patients who had undergone TAE were noted to have extensive tumor necrosis. The pathological specimens at LT showed downstaging of the HCC, which allowed those six patients to meet the Milan criteria. The overall 1- and 2-year survival rates were 92% and 73%, respectively. The overall 1- and 2-year disease-free survival rates were 92% and 73%, respectively. One death unrelated to liver disease at 2 years after LT was noted in the downgraded group. One patient of the initially eligible group developed lung metastasis at 6 months and died at 12 months after LT., Conclusion: TAE is effective to downstage advanced HCC and reduce the dropout rate on the LT waiting list. Pre-LT TAE may be considered as a better therapeutic strategy for patients with advanced HCC.