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A 53-year-old man with alcoholic liver cirrhosis underwent orthotopic liver transplantation (OLT) using a marginal graft. Persistent cholestasis post-OLT was successfully treated using a molecular adsorbent recirculating system (MARS). Afterwards, the patient developed refractory ascites, which was controlled by a transjugular intrahepatic portosystemic shunt (TIPS). TIPS reduction and eventually occlusion was necessary due to the development of encephalopathy. Despite TIPS occlusion, the ascites did not relapse probably because of the onset of other adaptive mechanisms. MARS and TIPS used sequentially were capable of rescuing a liver graft, thereby avoiding the morbidity and mortality associated with early retransplantation and sparing a liver graft from the donor pool.

Objective: Gastrointestinal discomfort is one of the main adverse events in patients treated with mycophenolic acid (MPA). The aim of this prospective study was to evaluate the effect of conversion from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS) in liver transplant patients with gastrointestinal side effects., Materials and Methods: A single center, open-label, single arm, prospective study was undertaken in previous MMF-treated liver transplant patients who stopped MMF due to gastrointestinal side effects. Patients were rechallenged with the same dose of MMF which previously provoked the discomfort. Subsequently, patients with gastrointestinal complaints were switched from MMF (mean dose, 1325 mg [interquartile range (IQR), 750-2000 mg]) to equimolar doses of EC-MPS (mean dose, 858 mg [IQR, 525-1170 mg])., Results: Twelve patients received a rechallenge and 10 patients experienced complaints again. These patients (4 males, all Caucasian) of ages 14 to 68 years (mean, 54.5 years) were included in the study. There was a decrease in Visual Analogue Scale (VAS) of upper and lower gastrointestinal discomfort/pain between baseline to month 3 from mean 3.9 to 1.75 and from mean 7.6 to 0.2. The number of stools decreased from a mean of 2.25 (IQR, 1.4-2.9) to 0.5 (IQR, 0.3-0.625)/d and mean maximal stool frequency from 3 (IQR, 2-3.5) to 0.9 (IQR, 0.5-1.25)/d. No patients developed rejection. There was no graft loss. No significant changes occurred in hematological or biochemical parameters., Conclusions: Our results suggested that converting patients with gastrointestinal complaints from MMF to equimolar doses of EC-MMF reduced gastrointestinal-related symptom burden and frequency of stools.

Objective: Hypothermic machine perfusion (HMP) is superior to simple cold storage for kidney preservation. We previous observed in a porcine liver transplantation model increased tumor necrosis factor-alpha (TNF-alpha) production eventually leading to poor recipient survival after HMP using standard kidney perfusion solution (KPS-1) compared with simple cold storage. We compared two solutions for HMP preservation of the liver: enriched KPS-1 (EKPS-1) and Aqix RS-I., Methods: Pig livers were obtained after cold flushing with histidine-tryptophan-ketoglutarate solution. Subsequently, the livers were subjected to dual-vessel perfusion with two preservation solutions: EKPS-1 (n = 6) and Aqix RS-I (n = 3). After HMP preservation and transplantation, graft and recipient survival, hepatocellular damage (aspartate aminotransferase concentration), TNF-alpha production, and endothelial cell damage (hyaluronic acid clearance) were recorded., Results: No primary graft nonfunction was observed. Recipient survival at postoperative day 3 was similar in both groups (33%). Aspartate aminotransferase concentration measured in serum samples after reperfusion was similar in both groups. After reperfusion, TNF-alpha concentration was higher and hyaluronic acid clearance was lower in the EKPS-1 group vs the Aqix RS-I group at 60, 120, and 180 minutes (all P < .05)., Conclusion: Hypothermic machine perfusion provided adequate longer term graft survival. After reperfusion, TNF-alpha production seems to be reduced, and endothelial cell dysfunction remains pronounced with Aqix RS-1 solution compared with EKPS-1 solution.

Livers exposed to prolonged warm ischemia (WI), such as those from non-heart-beating donors (NHBDs), are at higher risk of primary graft nonfunction (PNF). In a pig model of liver transplantation (LTx) from NHBDs, hepatocellular vacuolation, focal hepatocyte dropout, congestion, and sinusoidal dilatation appeared on biopsies taken after exposure to WI. In functioning grafts, vacuolation and sinusoidal dilatation were reversible after LTx, in contrast to PNF grafts. We studied whether the extent of these morphological signs and particularly vacuolation, present on pre-LTx biopsies, was associated with WI length and able to predict PNF, hepatocellular damage, and survival. Pre-LTx biopsies from pig livers exposed to incremental periods of WI were reviewed retrospectively. The extent of vacuolation was quantified blindly by a pathologist's semiquantitative score, validated by stereological point counting and digital image analysis, and then used to predict PNF and hepatocellular damage. On biopsies taken after WI, stereological point counting and digital analysis scoring contributed significantly in predicting PNF (P = 0.027 and P = 0.043, respectively) versus the pathologist's semiquantitative score (P = 0.058). Stereological point counting and digital image analysis predicted the extent of hepatocellular damage (P < 0.0001 and P = 0.001) versus the pathologist's semiquantitative score (P = 0.085). In conclusion, the extent of parenchymal vacuolation present on WI liver grafts reflects the severity of hepatocellular damage and predicts pig liver graft viability before LTx. Further studies are now warranted to evaluate whether these anoxic changes that are associated with liver graft viability in pigs also apply to human NHBD liver biopsies.

Background and Aim: Congenital portosystemic veno-venous malformations are rare abnomalities that often remain undiagnosed. Typically they are classified by their anatomical characteristics according to Morgan (extrahepatic, Abernethy malformations type Ia,b and II) and Park (intrahepatic, types 1-4). However, their clinical presentation is less dependent on the anatomical type., Method: We reviewed the clinical characteristics of six cases drawn from our files (from 1970 to 2006)., Results: One patient, a 25-year-old male, had extrahepatic shunting whereby the liver receives only arterial blood because the portal vein (PV) connects with the inferior caval vein (ICV) (Abernethy Ib); he presented with episodes of jaundice and pruritus. Three patients had extrahepatic shunting with patent intrahepatic portal veins, but with shunting of splenomesenterial blood towards the ICV (Abernethy II); these included a 66-year-old male with hepatic encephalopathy, a 17-year-old female with (porto?-)pulmonary hypertension without portal hypertension, and a 33-year-old female with epidsodes of acute pain secondary to spontaneous bleeding within a primary liver tumor. Two patients had intrahepatic shunting; these included an 8-year-old boy who was diagnosed incidentally during work-up for abnormal liver enzymes with a communication between right PV and ICV (Park type 1), and a 59-year-old male with multiple PV-ICV-shunts in several liver segments (Park, type 4) who presented with hepatic encephalopathy., Conclusion: Patients often present with signs of hepatic shunting (encephalopathy, pulmonary hypertension, hepatopulmonary syndrome, and/or hypoglycemia) with relative sparing of the synthetic liver function in the absence of portal hypertension. Some shunts present with space-occupying lesions (focal nodular hyperplasia, hepatocellular carcinoma, nodular regenerative hyperplasia, etc.) or biliary atresia. Finally, some cases are detected incidentally.

Background: Intrahepatic bile duct strictures are a serious complication after non-heart-beating (NHB) liver transplantation. Bile salt toxicity has been identified as an important factor in the pathogenesis of bile duct injury and cholangiopathies. The role of bile salt toxicity in the development of biliary strictures after NHB liver transplantation is unclear., Methods: In a porcine model of NHB liver transplantation, we studied the effect of different periods of warm ischemia in the donor on bile composition and subsequent bile duct injury after transplantation. After induction of cardiac arrest in the donor, liver procurement was delayed for 0 min (group A), 15 min (group B), or more or equal to 30 min (group C). Livers were subsequently transplanted after 4 hr of cold preservation. In the recipients, bile flow was measured, and bile samples were collected daily to determine the bile salt-to-phospholipid ratio. Severity of bile duct injury was semiquantified by using a histologic grading scale., Results: Posttransplantation survival was directly related to the duration of warm ischemia in the donor. The bile salt-to-phospholipid ratio in bile produced early after transplantation was significantly higher in group C, compared with group A and B. Histopathologic condition showed the highest degree of bile duct injury in group C., Conclusion: Prolonged warm ischemia in NHB donors is associated with the formation of toxic bile after transplantation, with a high biliary bile salt-to-phospholipid ratio. These data suggest that bile salt toxicity contributes to the pathogenesis of bile duct injury after NHB liver transplantation.

Due to the sharp increase in liver transplant candidates and the subsequent shortage of suitable donor livers, an extension of the current donor criteria is necessary. Simple cold storage, the current standard in organ preservation has proven to be insufficient to preserve extended criteria donor livers. Therefore a renewed interest grew toward alternative methods for liver preservation, such as hypothermic machine perfusion and normothermic machine perfusion. These "new" preservation methods were primarily assessed in rat models, and only a few clinically relevant large animal models have been described so far. This review will elaborate on these alternative preservation methods.

Arginine is an important substrate in health and disease. It is a commonly held view that arginase-1 release from injured erythrocytes and hepatocytes leads to arginine breakdown; however, the true relationship between plasma arginase-1 concentration and activity has remained unaddressed. In the present study, blood was sampled from patients undergoing liver resection, a known cause of hepatocyte injury and arginase-1 release, to determine arginase-1, arginine and ornithine plasma levels. Arginase activity was assessed in vitro by measuring changes in arginine and ornithine plasma levels during incubation of plasma and whole-blood samples at 37 degrees C. Arginase-1 plasma levels increased 8-10-fold during liver resection, whereas arginine and ornithine levels remained unchanged. In accordance with these in vivo findings, arginine and ornithine levels remained unchanged in plasma incubated at 37 degrees C irrespective of the arginase-1 concentration. In contrast, arginine plasma levels in whole blood decreased significantly during incubation, with ornithine increasing stoichiometrically. These changes were irrespective of arginase-1 plasma levels and were explained by arginase activity present in intact erythrocytes. Next, plasma samples with 1000-fold normal arginase-1 concentrations were obtained from patients undergoing cadaveric liver transplantation. A significant decrease in arginine plasma levels occurred in vivo and in vitro. In contrast with commonly held views, moderately increased arginase-1 plasma levels do not affect plasma arginine. Very high plasma arginase-1 levels are required to induce potential clinically relevant effects.

Background: It is controversial whether pediatric liver transplantation (OLT) should only be performed in a high-volume pediatric or in mixed adult/pediatric centers. We reviewed pediatric OLT results in an originally adult OLT center., Methods/results: Our adult OLT program was initiated in 1989, currently transplanting approximately 55 livers/year. A pediatric OLT program was launched in 1999. Pre- and posttransplant follow-up is multidisciplinary. In the study period, 26 OLT were performed in 25 patients (6% of all OLT; n = 430). The mean age was 8 years (range: 1 month to 18 years). Mean weight was 22 kg (4 to 80 kg). The indications were: acute liver failure in one (4%); chronic liver failure in 25 (96%)-10 metabolic, six biliary atresia, five polycystic/liver fibrosis, four other, and one retransplant. Nine (35%) received partial graft; 5 (19%) multivisceral grafts (liver-kidney, liver-bowel) and 12 (46%), conventional OLT. In all small-weight children, microsurgery was used. Immunosuppression included calcineurin inhibitors (cyclosporine/tacrolimus), azathioprine/mycophenolate mofetil, low-dose steroid, and anti-interleukin-2 receptor in 14. Early hepatic artery thrombosis (HAT), portal vein thrombosis, and primary nonfunction were not encountered. One retransplantation (4%) was done at 4 years posttransplantation for late HAT. Three biliary complications (11%) were encountered at 2 weeks, 4 months, and 2 years. Percentage of early acute and chronic rejections were 7.7% and 0%. Three deaths occurred due to mycotic aneurysm at 2 weeks; Cytomegalovirus at 4 months; pulmonary infection at 2 years. Twenty-two of 25 patients (88%) are well at last follow-up (up to 8 years)., Conclusion: Despite representing a small percentage of overall OLT activity pediatric OLT were performed with excellent results in a center with sufficient OLT volume and ad hoc surgical, pediatric, and intensive care team expertise.

In renal transplantation, hypothermic machine perfusion optimizes preservation of marginal grafts, assesses their quality prior to transplantation, improves outcome, and may contribute to an increased number of transplantations. Recently, hypothermic machine perfusion has become increasingly popular given the organ shortage and the "obligatory" utilization of marginal organs. Increasing mortality on the liver transplantation waiting list makes it urgent to develop machine perfusion systems for livers, trying to better preserve marginal livers and perhaps to recover currently discarded livers are for clinical transplantation without an increased risk of graft nonfunction. However, data on machine perfusion of livers and perfusion parameters capable of predicting viability are scarce. The aim of this study was to determine the baseline hemodynamic and metabolic profiles and morphology of livers during hypothermic machine perfusion in a porcine model. We used protocol similar to hypothermic machine perfusion of kidneys. Hemodynamic analysis revealed higher vascular resistance in the hepatic artery versus the portal vein. The arterial resistance gradually decreased during perfusion (similar to kidneys), suggesting progressive relaxation of the arterial vasculature, and perhaps better penetration of the microcirculation by the perfusion solution. During hypothermic machine perfusion, transaminases were gradually (but modestly) released, and livers displayed unequivocal signs of aerobic and anaerobic metabolism. After 24 hours, livers appeared morphologically well preserved. In conclusion, this study showed that hypothermic machine perfusion was feasible. During hypothermic machine perfusion, was easily assessed hemodynamic, biochemical, and morphological parameters.

Purpose: Using magnetic resonance imaging, the apparent diffusion coefficient (ADC) is an indicator to assess cerebral ischemia. The aim of this porcine study was to evaluate whether ADC assessed hepatic ischemia during ex vivo hypothermic machine perfusion (HMP) as well as in vivo., Methods: Ex vivo: ADC of normal versus warm ischemic (WI) livers was assessed during HMP and subsequent rewarming to mimic ischemia-reperfusion injury. As the preservation solution, we used either an acellular solution or diluted blood. WI was induced in the left lobe or in the whole liver and compared 2-hour WI and non-WI. In vivo: One liver was scanned with the left lobe vessels occluded for 2-hour WI and subsequently for 3 hour reperfusion to compare with the right lobe without WI. Aspartate aminotransferase (AST) in the perfusate and morphology were used as surrogates of WI., Results: In all WI livers, AST reached high levels and histology showed severe injury. Ex vivo ADC during acellular perfusion showed negligible differences between the livers with versus without WI, namely, 0.75 x 10(-3) or 0.88 x 10(-3) mm(2)/s during HMP. Ex vivo ADC using sanguineous perfusion showed 1.11 x 10(-3) or 0.83 x 10(-3) mm(2)/s during HMP in regions with versus without WI, respectively, a difference that remained stable during the whole experiment. ADC in vivo decreased from the physiological level of 1.07 x 10(-3) mm(2)/s to 0.75 x 10(-3) mm(2)/s in the first 30 minutes of WI, whereas ADC in the non-WI liver remained constant., Conclusion: ADC in vivo decreased during hepatic ischemia, as previously seen in cerebral ischemia. However, the effect of WI on ADC was less clear during ex vivo HMP.

Introduction: In contrast with kidneys, data on hypothermic machine perfusion (HMP) of livers remain scarce. Optimal liver HMP is poorly defined. Superiority of liver HMP over simple cold storage (SCS), the current standard preservation, must be proven before HMP is applied clinically. In this study, morphology and adenosine triphosphate (ATP) contents of HMP livers at different flows and with versus without O(2) studied in a porcine ex vivo model were compared to SCS., Methods: Pig livers were procured, flushed with HTK and preserved via SCS or HMP at 3 HMP settings: high flow (HF); low flow (LF); low flow + O(2) (300 mm Hg) (LFO). HMP livers were perfused via the hepatic artery (HA) and portal vein (PV) with KPS-1 TM at 4 degrees C to 6 degrees C for 24 hours with HF: PV: 3 to 5 mm Hg, 1 mL/g liver/min for HA and 25 mm Hg; LF: PV: 3 to 5 mm Hg, 0.5 ml/g liver/min with HA: 20 mm Hg. Morphology and ATP levels were measured in preserved liver tissues., Results: Throughout the SCS preservation, livers remained intact. In HMP livers, vacuoles appeared after 4 hours of preservation in the HF group and after 12 hours in the LF livers. LFO livers remained intact with limited vacuoles. Compared to SCS, HMP livers showed dilated sinusoids, particularly in the HF group. ATP remained relatively constant or even increased during HMP, particularly in the LF group, whereas ATP decreased after SCS., Conclusion: Among the various HMP settings, HMP with LFO was superior. ATP levels were the highest in LF. In contrast with all HMP groups, SCS showed the lowest ATP levels, indicating that HMP has the potential to better preserve energy stores.

Unlabelled: Mortality on liver transplantation (OLT) waiting lists has increased dramatically. Until recently, non-heart-beating donors (NHBD) were not considered suitable for OLT, because of a higher risk of primary graft nonfunction (PNF) and biliary strictures. However, recent experimental/clinical evidence has indicated that NHBD-OLT is feasible when the period of warm ischemia is short., Purpose: To characterize the results of NHBD-OLT in Belgium, a survey was sent to all Belgian OLT centers., Results: Between January 2003 and November 2005, 16 livers originating from NHBD were procured and transplanted. The mean donor age was 48.8 years, including 9 males and 7 females with mean time of stop-therapy to cardiac arrest being 18 minutes and from cardiac arrest to liver cold perfusion, 10.5 minutes. Mean recipient age was 52.2 years including 12 males and 4 females. Mean cold ischemia time was 7 hours 15 minutes. No PNF requiring re-OLT was observed. Mean post-OLT peak transaminase was 2209 IU/L, which was higher among imported versus locally procured grafts. Biliary complications occurred in 6 patients requiring re-OLT (n = 2), endoscopic treatment (n = 2), surgical treatment (n = 1), or left untreated (n = 1). These tended to be more frequent after prolonged warm ischemia. Graft and patient survivals were 62.5% and 81.3%, respectively, with a follow-up of 3 to 36 months., Conclusion: This survey showed acceptable graft/patient survivals after NHBD-LT. The NHBD-liver grafts suffered a high rate of ischemic injury and biliary complications and therefore should be used carefully, namely with no additional donor risk factors, lower risk recipients, and short cold/warm ischemia.

More extensive use of non-heart-beating donors (NHBD) could reduce mortality on liver transplantation waiting lists, but this is associated with more primary nonfunction (PNF). We assessed which parameters are involved in the development of PNF in livers from NHBD in a previously validated pig liver transplantation model, in which livers were transplanted after exposure to incremental periods of warm ischemia. The risk of PNF was unacceptably high (>50%) when livers were exposed to >30 minutes' warm ischemia before a short cold ischemic period. This study examined how PNF is affected by Kupffer cell activation (beta-galactosidase), the generation of cytokines tumor necrosis factor alpha and interleukin 6, antioxidant mechanisms (ascorbic acid, alpha-tocopherol, reduced glutathione), circulating redox-active iron, and sinusoidal endothelial cell function (hyaluronic acid clearance). Kupffer cells were more activated in PNF recipients, as suggested by higher beta-galactosidase levels (15 minutes after reperfusion), and secondarily, by higher production of tumor necrosis factor alpha and interleukin 6 (180 minutes after reperfusion). In addition, alpha-tocopherol and reduced glutathione were lower, and ascorbic acid and redox-active iron higher in PNF recipients. Finally, PNF grafts displayed progressively decreasing hyaluronic acid clearance (suggesting sinusoidal endothelial cell dysfunction) and parenchymal edema. Consequently, a reduced-flow phenomenon was documented. In grafts from NHBD that are destined to fail, beta-galactosidase activity (a surrogate of Kupffer cell activation) is higher, proinflammatory cytokines are overproduced, some antioxidant mechanisms fail, and circulating redox-active iron is more rapidly released. A no-flow phenomenon is eventually observed in these failing grafts., ((c) 2007 AASLD.)

Until 1998, intestinal transplantation (SBT) had not been performed in our region of Flanders, Belgium. Potential SBT activity was not known and selection criteria had not been validated. A multidisciplinary SBT program was launched in 1998. We analyzed requests for SBT and outcomes in these patients whether with or without SBT. Listing for SBT was only considered for patients with irreversible short bowel syndrome who had developed life-threatening complications of total parenteral nutrition, but whose general condition was still thought compatible with surgery and immunosuppression. During the study period 1998 to 2004, one third of the requests for SBT (10/31) were deemed suitable. SBT in this group was lifesaving (100% survival) when performed in time. Mortality in this group without SBT was high (67%). Two thirds of the patients (21/31) did not fulfill the SBT inclusion criteria, either because they were "too moribund" to tolerate transplantation or because they were "too well". This preliminary study emphasized the importance of (1) early referral of potential SBT candidates, (2) adherence to strict criteria for listing patients for SBT, and (3) referral of intestinal donors to procurement organizations.

Context: The shortage of donor organs remains the most important factor of waiting list mortality in organ transplantation worldwide. Donor detection is influenced by the legal system, family refusal, and underreporting caused by erroneous knowledge of donation criteria and lack of familiarity with the procedure., Objective: To identify possible key factors of donor referral patterns within an existing cooperation with donor hospitals and donor units across the Dutch-speaking part of Belgium, an area of approximately 3 million inhabitants. An intervention plan to optimize the cooperation and procedure quality and efficiency was designed., Design: The intervention plan was based on 3 essential principles in donor referral by donor reporters, information on donor criteria, facilitation of the donor procedure, and communication between donor reporters and the transplant center. The interventions were structured to optimize all 3 of these principles. Two successive periods of 4 years were retrospectively compared., Participants: Data were collected retrospectively on donor referral behavior from a total of 37 donor hospitals and donor units over an 8-year period., Main Outcome Measures: The referrals were reviewed for potential donors, effective donors, percentage of effective donors, refusal rate of relatives, number of tissue donors, impact on local and national transplant programs, and national donor numbers., Results: Data showed a significant positive impact on donor referrals and donor referral behavior (+27% potential donors, +30% effective donors, +172.7% tissue donors, -7% family refusals rates, +9.63% national donors). The results stress the importance of reduced workload and optimization of communication and information availability in an existing donor hospital network.

Background: In contrast with kidneys, transplantation of livers originating from non-heart-beating donors remains rare, mainly because warm ischemia causes a higher rate of potentially lethal primary graft nonfunction. Little is known on the tolerance of liver grafts to warm ischemia. No techniques are available to assess the viability of ischemic livers before implantation. Therefore, experimental models are needed to address these questions before non-heart-beating liver transplantation can be more widely applied. This study aims to develop a reproducible large animal model of liver transplantation using non-heart-beating donors and, in this model, to define the tolerance of the liver to warm ischemia., Methods: Pigs weighing 25to 30 kg are used. In donors, cardiac arrest is caused by ventricular fibrillation. After increasing lengths of warm ischemia (0, 15, 30, 45, and 60 min), the liver is flushed in situ with 4 degrees C histidine tryptophan ketoglutarate preservation solution and procured. The liver is transplanted after a 4-hour cold storage period., Results: Control livers (no warm ischemia) and livers exposed to 15 minutes of warm ischemia function normally after transplantation, whereas all livers submitted to 60 minutes of warm ischemia display primary nonfunction and cause recipient death. Graft function and survival are occasionally observed after 30 and 45 minutes of warm ischemia., Conclusions: A reproducible model of non-heart-beating liver transplantation is described. We found that the liver tolerates 15 minutes of warm ischemia. This preclinical model is a valid tool to develop techniques to predict the quality of ischemic livers before implantation and to design interventional strategies to improve the tolerance of the liver to warm ischemia.

Complete venous thrombosis of the splanchnic system remains a major challenge in liver transplantation surgery. Some of these patients have been treated successfully by multivisceral transplantation. Cavoportal transposition is another alternative to treat these patients. We reviewed our single-center experience with this technique. Five patients with operatively confirmed complete splanchnic thrombosis were transplanted with the cava portal transposition technique. All survived the procedure; 60% survived long term. This technique is a useful salvage procedure in moribund patients with diffuse portal thrombosis who would otherwise rapidly succumb.

Shortage of liver grafts is the only limiting factor for application of liver transplantation and causes an increasing mortality on the waiting list. Very old donors (>70 to 80 years old) are rarely referred to transplant centers because of the assumption that these livers will not work properly. Alternatively, transplant teams may be reluctant to use these very old livers due to the risk of poor posttransplant outcome. We reviewed our experience with seven liver transplantations using very old donor livers. We found that the results in terms of graft function and patient survival are adequate. Interestingly, the majority of these donors originated from a single referring donor unit (of more than 20 units who belong to our donor network) that systematically refers all brain-dead donors to the transplant center, independent of the age of the potential donor. This implies that many of these donors are left undetected in other units. In conclusion, very old donors should be referred to transplant centers since results of transplantation with these grafts are favorable.

Aims: The use of non-heart-beating (NHB) donor livers is limited by a higher risk for primary nonfunction and the absence of methods to measure this risk. This study was designed to determine whether ex vivo vascular resistance of livers correlates with the length of warm ischemia (WI), and, thus, with viability of NHB livers., Methods: Porcine livers were recovered after 0, 45, or 90 minutes WI. Livers were flushed by gravity and cold stored for 3 hours. Thereafter, livers were perfused at 4 degrees C. Portal vein (PV) and hepatic artery (HA) vascular resistance were calculated during liver flush-out and during 24 hours of machine perfusion., Results: During flush-out, PV and HA vascular resistance were higher among livers with longer WI times; however, only in the PV did the results reach statistical significance. During machine perfusion, PV vascular resistance was low from the start and remained fairly constant. In contrast, HA vascular resistance was higher at the start but gradually diminished to reach a more constant value after 4-6 hours. No correlation was observed between HA or PV vascular resistance and WI during machine perfusion., Conclusions: The vascular resistance during ex vivo machine perfusion of NHB livers does not correlate with the extent of WI damage and, therefore, cannot predict organ viability.

Objective: Liver fatty acid-binding protein (L-FABP) is a small protein (15 kD) involved in the intracellular transport of long-chain fatty acids in the liver. The L-FABP is regarded as a sensitive marker for liver cell damage. In a pig model for liver transplantation (LTx) from non-heart-beating donors (NHBD), we evaluated plasma changes of L-FABP early after reperfusion of grafts exposed to increasing periods of warm ischemia (WI)., Methods: Porcine livers were procured after 0, 15, 30, 45, and 60 minutes' WI. After 4 hours' cold ischemia (CI), LTx was performed. Primary graft nonfunction (PNF) and day 4 survival were recorded. Plasma samples were collected prior to and 15, 60, and 180 minutes after graft reperfusion for determination of L-FABP and aspartate transaminase (AST)., Results: Early after reperfusion, levels of L-FABP correlated well with the duration of WI. The PNF developed in 100% of animals after 60 minutes of WI, 50% after 30, and 45 minutes' WI, and was absent after no WI and 15 minutes of WI. Day 4 survival was 100% in 0 minutes' WI, 83% in 15 minutes' WI, 50% in 30 and 45 minutes' WI, and 0% in 60 minutes of WI., Conclusions: Plasma levels of L-FABP correlated well with WI and concomitant hepatocellular damage in LTx from NHBD. Monitoring of posttransplant L-FABP plasma levels is a valuable new tool to quantify early the extent of parenchymal cell damage of NHBD livers and to predict their viability and function.

Traumatic posterior dislocation of the sternoclavicular joint is an unusual injury. We report a rare, late complication in the form of a thoracic outlet syndrome. Resection of the first rib resulted in prompt and complete resolution of the symptoms and would appear to be the appropriate treatment, avoiding the complications associated with resection of the clavicle.