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The graft-to-recipient weight ratio (GRWR) is an important selection criterion for living donor liver transplantation (LDLT). The generally accepted threshold is known to be 0.8%. We believe that this threshold can be reduced under certain conditions. The aim of this study was to evaluate the results of these patients with GRWR < 0.8%. Between 2004 and 2015, 649 patients underwent right lobe LDLT for end-stage liver disease in adult patients. All recipients who had GRWR < 0.8% were identified. The data of these patients were retrospectively analyzed and compared to patients with GRWR ≥ 0.8%. There were 43 patients with GRWR < 0.8%. Out of these patients, 7 (16%) had GRWR of 0.6%. The median Model for End-Stage Liver Disease (MELD) score was 15, and the median donor age was 30 years. Anterior segment drainage was ensured. Portal inflow modulation was performed by splenic artery ligation according to the portal flow. Postoperative complications were seen in 6 (14%) patients. Of all 43 patients, 3 (7%) died perioperatively within 1 month, and 1 (2%) patient underwent retransplantation due to graft failure. The mean hospital stay was 18 days. The 1-year survival rate was 93%. None of the patients had a laboratory MELD score above 20. The comparison of the results with the patients who had GRWR ≥ 0.8% has shown no significant difference, except MELD score, body mass index (BMI), and rate of anterior segment drainage. The GRWR can be decreased even to 0.6% if the MELD score is below 20, donor age is below 45 years, and there are no signs for any hepatosteatosis of the donor graft. In these patients, it is essential that the anterior segment drainage is secured and the portal inflow modulation is performed according to the portal flow. Liver Transplantation 22 1643-1648 2016 AASLD.

Background The aim of this study was to determine the long-term efficacy of nucleos(t)ide analog (NA) and low-dose hepatitis B immunoglobulin (HBIG) combination treatment for preventing post-transplant hepatitis B virus (HBV) recurrence. Methods A total of 296 patients with HBV-associated liver disease who underwent liver transplantation (LT) were enrolled. A combination of a daily NA and low-dose HBIG was used after LT. Results The median follow-up period was 46 months. HBV recurrence occurred in eight patients. The cumulative probability of HBV recurrence at 1, 3, 5, and 7 years was 1%, 3%, 3%, and 4%, respectively. Seven were on lamivudine (LMV) or adefovir dipivoxil (ADV), or LMV and ADV and HBIG combination treatment and one entecavir (ETV) and HBIG. With Cox regression analysis, HBV recurrence was determined to be associated with the presence of hepatocellular cancer (HCC) prior to LT (HR: 12.3, P=.02). Overall, 44 patients died. Survival was significantly better in the ETV or tenofovir disoproxil fumarate (TDF) and HBIG group than the other group (P

Amac : Bu calismanin amaci hepatoselluler karsinom (HSK) tanisi ile karaciger nakli yapilmis hastalarin sonuclarini degerlendirmektir. Hastalar ve yontemler : 2004 ve 2015 yillari arasinda toplam 841 hastaya karaciger nakli yapildi. Bu hastalarin 192’sine (%20) kadavra vericiden, 649’una (%80) ise canli vericiden karaciger nakli yapildi. Hepatoselluler karsinom tanisi konulmus tum hastalar (n=220) tespit edildi. Bu hastalarin klinik ozellikleri, ameliyat oncesi, sirasi ve sonrasi verileri, greft ve hasta sagkalim sureleri retrospektif olarak incelendi. Sonuclar istatistiksel olarak analiz edildi. Bulgular : Hepatoselluler karsinom tanisiyla karaciger nakli yapilan toplam 220 hastanin ortalama yasi 58 yil (IQR 53-61) olarak saptandi. Bu hastalarin 54’une (%24) kadavra vericiden, 166’sina (%76) canli vericiden karaciger nakli yapildi. Ortalama MELD skoru 12 (IQR 9-17) idi. Median serum AFP degeri 27 ng/mL (IQR 7-109) idi. Milan kriterleri 139 hastada (%64) saglandi. Milan kriterleri disi hasta sayisi 81 (%36) idi. Patoloji raporunda uc hastada (%1) kolanjioselluler karsinom (KSK), yedi hastada (%4) mix HSK + KSK ve 210 hastada (%95) pur HSK goruldu. Ameliyat sirasi olum 14 hastada (%6) goruldu. Kirk uc hastada (%19) nuks hastalik goruldu. Toplam bir yillik sagkalim orani %89, bes yillik sagkalim orani %76 idi. Sonuc : Calismamizin bulgularina dayanarak, hastalar dusuk AFP degerleri ile vaskuler invazyon olmaksizin iyi secilir ise karaciger nakli karaciger sirozu ile beraber olan HSK tedavisinde hastalik kuru icin mukemmel bir potansiyel olusturdugu ve onerilen tedavi secenegi oldugu soylenebilir.

OBJECTIVES Early hepatic artery thrombosis is rare but devastating in living-donor liver transplant recipients. In this study, our aim was to evaluate the results of all patients with early hepatic artery thrombosis at our center. MATERIALS AND METHODS Between October 2004 and November 2015, 841 patients underwent liver transplant for end-stage liver disease at our center. All recipients with early hepatic artery thrombosis were identified and retrospectively analyzed. Early hepatic artery thrombosis was defined in our study as its occurrence within the first postoperative week. RESULTS Early hepatic artery thrombosis was seen in 12 patients (1.8%). Seven of these 12 patients developed hepatic artery thrombosis on postoperative day 1 after intraoperative dissection of the hepatic artery with necessity of repeated reconstruction. However, the primary liver function of these patients was excellent, with nearly normal serum liver panel results. The other 5 patients were diagnosed after sudden significant increases of liver values followed by graft dysfunction within the first postoperative week. All patients were listed as high urgent and underwent retransplant. Two patients died perioperatively due to primary nonfunction, and 2 other patients died due to liver cirrhosis based on recurrent autoimmune hepatitis 29 and 106 months after retransplant. The remaining patients were alive with good liver function after a median time of 18 months (interquartile range, 13-45 mo). CONCLUSIONS Early hepatic artery thrombosis is not always associated with graft dysfunction. Retransplant is still necessary due to ischemic cholangiopathy in the long-term follow-up. However, an elective retransplant, which could mean better outcomes, should be preferred instead of an emergency retransplant.

Nonalcoholic steatohepatitis (NASH)-related cirrhosis has become one of the most common indications for liver transplantation (LT), particularly in candidates older than 65 years. Typically, NASH candidates have concurrent obesity, metabolic, and cardiovascular risks, which directly impact patient evaluation and selection, waitlist morbidity and mortality, and eventually posttransplant outcomes. The purpose of these guidelines is to highlight specific features commonly observed in NASH candidates and strategies to optimize pretransplant evaluation and waitlist survival. More specifically, the working group addressed the following clinically relevant questions providing recommendations based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system supported by rigorous systematic reviews and consensus: (1) Is the outcome after LT similar to that of other etiologies of liver disease? (2) Is the natural history of NASH-related cirrhosis different from other etiologies of end-stage liver disease? (3) How should cardiovascular risk be assessed in the candidate for LT? Should the assessment differ from that done in other etiologies? (4) How should comorbidities (hypertension, diabetes, dyslipidemia, obesity, renal dysfunction, etc.) be treated in the candidate for LT? Should treatment and monitoring of these comorbidities differ from that applied in other etiologies? (5) What are the therapeutic strategies recommended to improve the cardiovascular and nutritional status of a NASH patient in the waiting list for LT? (6) Is there any circumstance where obesity should contraindicate LT? (7) What is the optimal time for bariatric surgery: before, during, or after LT? (8) How relevant is donor steatosis for LT in NASH patients?

C-reactive protein (CRP) is a blood marker for inflammation and is an independent prognostic factor for many human cancers. Combined with albumin levels, it forms the basis of the Glasgow Index for cancer prognosis. We reviewed the literature on CRP and HCC and also evaluated blood CRP levels and combination CRP plus albumin levels in a large HCC cohort. In order to understand the prognostic significance of CRP, we retrospectively examined a large HCC cohort and examined the relationship of CRP levels to tumor parameters. We report, that CRP alone and CRP plus albumin combined as well, significantly correlated with parameters of HCC aggressiveness, such as maximum tumor dimension (MTD), portal vein thrombosis (PVT) and blood alpha-fetoprotein (AFP) levels, both as individual parameters and all parameters together (Aggressiveness Index). This extends current thinking, to suggest a possible explanation for the usefulness of blood CRP levels in HCC prognostication.

ALTINTAS, Engin/0000-0003-0796-1456; Sonsuz, Prof.Dr.Abdullah/0000-0002-8336-5472; ALTINTAS, ENGIN/0000-0003-0796-1456; kuran, sedef/0000-0001-7019-8911; uskudar, oguz/0000-0003-2789-1467; EKIN, NAZIM/0000-0001-5302-8953; Akkiz, Hikmet/0000-0001-9745-8875; Tokmak, Salih/0000-0002-2727-5632; Carr, Brian/0000-0002-6111-5077 WOS: 000436297600001 PubMed: 30009156 Macroscopic portal vein invasion (PVT) by hepatocellular carcinoma (HCC) in the liver is one of the most important negative prognostic factors for HCC patients. The characteristics of a large cohort of such patients were examined. We found that the percent of patients with PVT significantly increased with increasing maximum tumor diameter (MTD), from 13.7% with tumors of MTD 10cm. There were similar numbers of HCC patients with very large tumors with and without PVT. Thus, MTD alone was insufficient to explain the presence of PVT, as were high AFP levels, since less than 50% of high AFP patients had PVT. However, the percent of patients with PVT was also found to significantly increase with increasing blood alpha-fetoprotein (AFP) levels and tumormultifocality. A logistic regressionmodel that included these 3 factors together showed an odds ratio of 17.9 for the combination of MTD >5.0cm plus tumor multifocality plus elevated AFP, compared to low levels of these 3 parameters. The presence or absence of macroscopic PVT may therefore represent different HCC aggressiveness phenotypes, as judged by a significant increase in tumor multifocality and AFP levels in the PVT positive patients. Factors in addition to MTD and AFP must also contribute to PVT development. NIHUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USA [CA 82723] This work is supported in part by NIH Grant CA 82723 (Brian I. Carr)Y

Primary hyperoxaluria is a rare hereditary metabolic disorder resulting in accumulation of calcium oxalate in visceral organs, including the heart. We report a 19-year-old male with non- compaction cardiomyopathy combined with patent ductus arteriosus awaiting combined liver-kidney transplantation for primary hyperoxaluria. After surgical closure of the patent ductus arteriosus, the patient underwent a successful renal and subsequent liver transplantation. The presence of hypertrophic cardiomyopathy in hyperoxaluria patients has been reported before, but this is the first report of non-compaction myocardium with patent ductus arteriosus in a patient with primary hyperoxaluria. At the third month after combined liver and renal transplantation, improvement in cardiac functions were observed. Primary hyperoxaluria is a clinical entity to be taken into consideration in differential diagnosis of hypertrophied myocardium with high myocardial echocardiographic intensity. In cases of hyperoxaluria, additional congenital abnormalities may complicate the clinical picture.

Living donor liver transplantation (LDLT) is an accepted option for end-stage liver disease, particularly in countries in which there are organ shortages. However, little is known about LDLT for obese patients. We sought to determine the effects of obesity on pretransplant living donor selection for obese recipients and their outcomes. On the basis of body mass index (BMI) values, 148 patients were classified as normal weight (N), 148 were classified as overweight (OW), and 74 were classified as obese (O). O recipients had significantly greater BMI values (32.1 ± 1.6 versus 23.2 ± 1.9 kg/m(2), P < 0.001) and received larger actual grafts (918.9 ± 173 versus 839.4 ± 162 g, P = 0.002) than recipients with normal BMI values. Donors who donated to O recipients had a greater mean BMI (26.3 ± 3.8 kg/m(2)) than those who donated to N recipients (24.4 ± 3.2 kg/m(2), P = 0.001). Although O recipients were more likely to face some challenges in finding a suitable living donor, there were no differences in graft survival [hazard ratio (HR) = 0.955, 95% confidence interval (CI) = 0.474-1.924, P = 0.90] or recipient survival (HR = 0.90, 95% CI = 0.56-1.5, P = 0.67) between the 3 groups according to an adjusted Cox proportional hazards model. There were no significant differences in posttransplant complication rates between the 3 recipient groups or in the morbidity rates for the donors who donated to O recipients versus the donors who donated to OW and N recipients (P = 0.26). Therefore, we recommend that obese patients undergo pretransplant evaluations. If they are adequately evaluated and selected, they should be considered for LDLT.

The timing and selection of patients for liver transplantation in acute liver failure are great challenges. This study aimed to investigate the effect of Glasgow coma scale (GCS) and APACHE-II scores on liver transplantation outcomes in patients with acute liver failure.A total of 25 patients with acute liver failure were retrospectively analyzed according to age, etiology, time to transplantation, coma scores, complications and mortality.Eighteen patients received transplants from live donors and 7 had cadaveric whole liver transplants. The mean duration of follow-up after liver transplantation was 39.86+/-40.23 months. Seven patients died within the perioperative period and the 1-, 3-, 5-year survival rates of the patients were 72%, 72% and 60%, respectively. The parameters evaluated for the perioperative deaths versus alive were as follows: the mean age of the patients was 33.71 vs 28 years, MELD score was 40 vs 32.66, GCS was 5.57 vs 10.16, APACHE-II score was 23 vs 18.11, serum sodium level was 138.57 vs 138.44 mmol/L, mean waiting time before the operation was 12 vs 5.16 days. Low GCS, high APACHE-II score and longer waiting time before the operation (P0.01) were found as statistically significant factors for perioperative mortality.Lower GCS and higher APACHE-II scores are related to poor outcomes in patients with acute liver failure after liver transplantation.

In right lobe (RL) living donor liver transplantation (LDLT), portal vein (PV) variations are of immense clinical significance. In this study, we describe in detail our PV reconstruction techniques in RL grafts with variant PV anatomy and evaluate the impact of accompanying biliary variations on the recipient outcomes. In a total of 386 RL LDLTs performed between July 2004 and July 2012, the clinical data on 52 (13%) transplants using RL grafts with variant PV anatomy were retrospectively analyzed. Portal vein anatomy was classified as type 2 in 20 patients, type 3 in 24 patients, and type 4 in eight patients. The PV reconstruction techniques utilized included back-wall plasty (n = 21), back-wall plasty with saphenous vein graft interposition (n = 6), saphenous vein graft interposition (n = 5), cryopreserved iliac vein Y-graft interposition (n = 6), and quiltplasty (n = 3). There was no donor mortality. In a median follow-up of 29 months, none of the recipients had vascular complications. Anomalous PV anatomy was associated with a high (54%) incidence of biliary variations; however, these variations did not result in increased biliary complication rate. Overall, the 1- and 3-year patient survival rates of recipients were 91% and 81%, respectively. Vascular and biliary variations in RL grafts render LDLT technically more challenging. By employing appropriate reconstruction techniques, it is possible to successfully use RL grafts with PV variations without endangering recipient and donor safety.

Incision-related morbidity for donors is a major concern in living-donor right hepatectomy (LDRH). Open approaches use midline, J-shaped, and Mercedes incisions for LDRH. We retrospectively studied 95 consecutive donors who underwent LDRH between January 2009 and November 2010. They underwent midline (n = 32), J-shaped (n = 28), or Mercedes (n = 35) incisions. We studied resection times, perioperative bleeding, postoperative hospital stay, and postoperative pain assessed by the visual analog scale (VAS) and by analgesic requirements as well as laboratory data and complications. Postoperative analgesic requirements and postoperative VAS scores were significantly lower in the midline group (P < .05) upon univariate but not multivariate analyses. The postoperative complications as well as other parameters were similar between the groups. In conclusion, compared with a J-type shaped or not for Mercedes incision, a donor hepatectomy can be satisfactorily performed via a midline incision by experienced surgeons without increased risk.

FH is an autosomal dominant genetic disorder characterized by increased TC and LDL level, which leads to xanthomas, atherosclerosis, and cardiac complications even in childhood. The treatment options are diet, medical treatment, lipid apheresis, and LT. The aim of our study was to analyze our data of patients with FH. Between 2004 and 2015, there were 51 patients who underwent pediatric LT at our center. All patients with FH were identified, and the data were retrospectively analyzed. There were eight patients with homozygous FH in the median age of 10 years (IQR 6-12) who underwent LT. The median pre-operative TC and LDL levels were 611 mg/dL (IQR: 460-844) and 574 mg/dL (IQR: 398-728) and decreased to normal levels 1 week after LT (TC: 193 mg/dL and LDL: 141 mg/dL). Two patients died two and 18 months after LT due to sudden cardiac arrest. Both patients were diagnosed with cardiovascular disease pre-operatively. The LT is the only curative treatment for this disease. To achieve an excellent outcome, it should be performed before the development of cardiovascular disease, because the regression of severe cardiovascular disease after transplantation is limited.

In living donor liver transplantation (LDLT), an adequate hepatic venous outflow constitutes one of the basic principles of a technically successful procedure. The issue of whether the anterior sector (AS) of the right lobe (RL) graft should or should not be routinely drained has been controversial. The aim of this 10-year, single-center, retrospective cohort study was to review the evolution of our hepatic venous outflow reconstruction technique in RL grafts and evaluate the impact of routine AS drainage strategy on the outcome. The study group consisted of 582 primary RL LDLT performed between July 2004 and December 2014. The cases were divided into 3 consecutive periods with different AS venous outflow reconstruction techniques, which included middle hepatic vein (MHV) drainage in Era 1 (n=119), a more selective AS drainage with cryopreserved homologous grafts in Era 2 (n=391), and routine segment 5 and/or 8 oriented AS drainage with synthetic grafts in Era 3 (n=72). Intraoperative portal flow measurement with routine splenic artery ligation (SAL) technique (in RL grafts with a portal flow of ≥ 250 mL/min/100 g liver tissue) was added later in Era 3. These 3 groups were compared in terms of recipient and donor demographics, surgical characteristics and short-term outcome. The rate of AS venous drainage varied from 58.8% in Era 1 and 35.0% in Era 2 to 73.6% in Era 3 (P

Background In liver transplantation or resection for hepatocellular carcinoma (HCC), patient selection depends on morphological features. In patients with HCC, we performed a clinicopathological analysis of risk factors that affected survival after liver transplantation. Methods In 389 liver transplantations performed from 2004 to 2010, 102 were for HCC patients. Data were collected retrospectively from the Organ Transplantation Center Database. Variables were as follows: age, gender, preoperative alpha-fetoprotein (AFP) levels, Child-Pugh and MELD scores, prognostic staging criteria (Milan and UCSF), etiology, number of tumors, the largest tumor size, total tumor size, multifocality, intrahepatic portal vein tumor thrombosis, bilobarity, and histological differentiation. Results One hundred and two patients were evaluated. The 5-year overall survival rate was 56.5%. According to the UCSF criteria, 63% of the patients were within and 37% were beyond UCSF ( P =0.03). Ten patients were excluded (one with fibrolamellary HCC and 9 because of early postoperative death without HCC recurrence), and 92 patients were assessed. The mean age of the patients was 56.5±6.9 years. Sixty-two patients underwent living donor liver transplantations. The mean follow-up time was 29.4±22.6 months. Fifteen patients (16.3%) died in the follow-up period due to HCC recurrence. Univariate analysis showed that AFP level, intrahepatic portal vein tumor thrombosis, histologic differentiation and UCSF criteria were significant factors related to survival and tumor recurrence. The 5-year estimated overall survival rate was 62.2% in all patients. According to the UCSF criteria, and the 5-year overall survival rate was 66.7% within and 52.7% beyond the criteria ( P =0.04). Multivariate analysis showed that AFP level and poor differentiation were independent factors. Conclusions For proper patient selection in liver transplantation for HCC, prognostic criteria related to tumor biology (especially AFP level and histological differentiation) should be considered. Poor differentiation and higher AFP levels are indicators of poor prognosis after liver transplantation.

Budd-Chiari syndrome is a rare but life-threatening disorder characterized by obstruction of the hepatic venous outflow. Treatment depends on the underlying cause, the location, and extent of the obstruction, and the functional capacity of the liver. A stepwise therapeutic approach is commonly accepted. When all other therapy options are unsuccessful, or in case of end-stage liver disease, transplant should be considered. We present case reports of 3 patients with Budd-Chiari syndrome who underwent living-donor liver transplant. Characteristic features of Budd-Chiari syndrome, diagnostic and therapeutic interventions, complications, and overall outcomes are discussed. We believe that when a deceased donor graft is unavailable, a living-donor liver transplant can be a safe option for patients with end-stage liver disease associated with Budd-Chiari syndrome.

Objectives Donor safety is one of the most important aspects of living-donor liver transplant. The preoperative evaluation of candidates for such transplants essentially starts with serologic and biochemical analyses. However, some potential liver donors with normal liver function test results may have isolated mild hyperbilirubinemia (serum indirect bilirubin level > 20.5 μmol/L [1.2 mg/dL]). Gilbert syndrome is an autosomal recessive condition that is a common cause of nonhemolytic unconjugated hyperbilirubinemia, and its prevalence is 3% to 10% in the healthy US population. Mild hyperbilirubinemia episodes are expected in people with Gilbert syndrome when they are exposed to physical stress, such as operative intervention or low energy intake. The liver morphologic findings of these individuals are normal; however, there is a debate on the use of people with Gilbert syndrome as living-liver donors. The purpose of this study was to assess the results of right-lobe living-donor hepatectomy of liver donors with Gilbert syndrome. Materials and methods Between 2004 and 2010, two hundred twenty-five living-donor liver transplants using right-lobe grafts were performed in our hospital. Donors with Gilbert syndrome were defined as those whose serum bilirubin level was greater than 20.5 μmol/L (1.2 mg/dL). Six of 225 right-lobe living-donor liver transplants were performed using donors with Gilbert syndrome. Results The median follow-up after transplant was 34 months (range, 18 to 51 mo). One week after the operation, the median bilirubin level for right-lobe liver donors was 34.5 μmol/L (2.02 mg/dL) (range, 17.1 to 51.3 μmol/L [1 to 3 mg/dL]), and the median prothrombin time (international normalized ratio) was 1.36 (range, 1.1 to 1.7). The median bilirubin level of the donors after 6 months was 29 μmol/L (1.7 mg/dL) (range, 20.5 to 41 μmol/L [1.2 to 2.4 mg/dL]). Conclusions Living-donor liver transplant from Gilbert syndrome donors can be safely performed.

BackgroundBiliary complications that developed after right lobe liver transplantation from living donors were studied in a single centre.MethodsFrom 2004 to 2010, 200 consecutive living donor right lobe liver transplantations were performed. The database was evaluated retrospectively. Biliary complications were diagnosed according to clinical, biochemical and radiological tests. The number of biliary ducts in the transplanted graft, the surgical techniques used for anastomosis, biliary strictures and bile leakage rates were analysed.ResultsOf a total of 200 grafts, 117 invloved a single bile duct, 77 had two bile ducts and in six grafts there were three bile ducts. In 166 transplants, the anastomosis was performed as a single duct to duct, in 21 transplants double duct to ducts, in one transplant, three duct to ducts and in 12 transplants as a Roux-en-Y reconstruction. In all, 40 bile leakages (20%) and 17 biliary strictures (8.5%) were observed in 49 patients resulting in a total of 57 biliary complications (28.5%). Seventeen patients were re-operated (12 as a result of bile leakages and five owing to biliary strictures).ConclusionIdentification of more than one biliary orifice in the graft resulted in an increase in the complication rates. In grafts containing multiple orifices, performing multiple duct-to-duct (DD) or Roux-en-Y anastomoses led to a lower number of complications.

Objectives Scientific publications are valuable markers of scientific activity for countries. We performed a bibliometric study to evaluate the number of publications written by Turkish authors. The aim of this study is to evaluate Turkey's contribution in terms of number of publications included in Science Citation Index Expanded (SCI-E) in the scientific field of liver transplantation compared with other countries. To our knowledge, this is the first bibliometric study in liver transplantation research of Turkey. Materials and methods ISI Web of Knowledge-Science was used for the analysis. All scientific works published included in SCI-E in English from 1980 to August 10, 2011, were analyzed. A retrospective search was performed using key words “liver transplantation,” “hepatic transplantation,” “liver transplant,” and “hepatic transplant.” We further analyzed these results by the “analyze” function of the software in terms of number of papers for each country, type of documentation, number of publications per year, journal, institute, and author. The number of citations to published works was calculated by using the citation function of the same software. We also used the same function of the software to analyze publications from Turkey in the last three decades between 1980 and 1989, 1990 and 1999, and 2000 and 2009 for statistical evaluation. Collected data from the comparison periods were statistically analyzed using the chi-square test. Results In all, 48,418 publications related to liver transplantation were included in SCI-E in English between 1980 and August 2011. Overall, 675 of those publications were from Turkey (2.05%). There was no publication from Turkey between 1980 and 1989; 37 between 1990 and 1999; and 511 between 2000 and 2009. The rank of Turkey among other countries according to the number of publications was 25th between 1990 and 1999 and improved to 14th between 2000 and 2009. The number of scientific publications in the field of liver transplantation from Turkey among other countries increased during the last three decades. Conclusions Turkey showed a significant positive trend in publications in the scientific field of liver transplantation in the last 30 years, and the rank of Turkey among other countries improved in recent decades. Currently, Turkey is one of the top 17 countries in terms of number of scientific publications listed in SCI-E. This can be considered as another indicator for Turkey's progress in the field of liver transplantation.

Summary We examined the outcomes of patients who received living donor liver transplantation (LDLT) for HCC comparing the impact of up-to-seven criteria and Asan Criteria (AC) with Milan Criteria (MC). Between July 2004 and July 2009, of 175 consecutive LDLT, there were 45 consecutive patients with HCC. Forty patients who completed 12 months follow-up were enrolled. In search for the highest number of expansion, we selected AC as the extended criteria. Patients were divided into having tumors within MC, beyond MC within AC and Beyond Criteria (BC) groups. With a median follow-up of 46 months, overall 1, 3, and 5 years survival was )90%, )81%, and )70%, respectively. In patients within AC, estimated mean survival was 49.8 vs. 40.5 months for BC group (P = 0.2). Disease-free survival was significantly higher in patients within AC comparing with BC group; 48.0 vs. 38.6 months (P = 0.04). Preoperative AFP level >400 and poor tumor differentiation were factors adversely effecting recipient survival. On multivariate analysis, the presence of poor tumor differentiation (P = 0.018 RR: 2.48) was the only independent predictor of survival. Extension of tumor size and number to AC is feasible, without significantly compromising outcomes; however, the presence of poor tumor differentiation was associated with worse outcomes after LDLT.

International audience; The current methods for characterization of frequency-dependent material properties of human liver are very limited. In fact, there is almost no data available in the literature showing the variation in dynamic elastic modulus of healthy or diseased human liver as a function of excitation frequency. We show that frequency-dependent dynamic material properties of a whole human liver can be easily and efficiently characterized by an impact hammer. The procedure only involves a light impact force applied to the tested liver by a hand-held hammer. The results of our experiments conducted with 15 human livers harvested from the patients having some form of liver disease show that the proposed approach can successfully differentiate the level of fibrosis in human liver. We found that the storage moduli of the livers having no fibrosis (F0) and that of the cirrhotic livers (F4) varied from 10 to 20 kPa and 20 to 50 kPa for the frequency range of 0 to 80 Hz, respectively.

Objective The purpose of this study was to investigate the ability of magnetic resonance cholangiography (MRC) in the depiction of biliary anatomy of living liver donors by using intraoperative cholangiography (IOC) as a gold standard. Materials and Methods Between 2004 and 2006, 86 potential adult-to-adult living donor liver transplantation donors had preoperative MRC at our institution. Of these, 24 potential donors were excluded due to various clinical factors. A total of 62 of these individuals were selected for liver donation and included in the study. MRC was performed on a 1.5-T scanner with breath-hold, rapid acquisition with relaxation enhancement (RARE) sequence with half-Fourier acquisition (HASTE; Siemens) and free-breathing, three-dimensional turbo spin-echo sequence with respiratory triggering. Thin- and thick-slab imaging techniques were employed with half-Fourier RARE MRC. IOC was performed in all 63 cases. The images of IOC and MRC were classified according to a modified Huang classification, independently. The results of the MRC were then compared with the IOC results. Results IOC was used as the reference standard; a total of 43 (69.3%) liver donors were considered to have normal biliary anatomy, whereas 19 (30.7%) were considered to have variants of biliary anatomy. Compared with IOC, MRC correctly revealed biliary anatomy in 59 of 62 (95.1%) donors. The sensitivity, specificity, positive predictive value and negative predictive value of MRC in distinguishing normal and any type of variant biliary anatomy were 84.2%, 100%, 100%, and 93.4%, respectively. Conclusion MRC is an effective imaging technique for the preoperative evaluation of the biliary anatomy in living liver donors. However, MRC and IOC should be considered complementary to one another in order to avoid complications.

Echinococcus alveolaris is a parasite from tenia family which causes tumor-like lesions in the livers of infected people. If it is not diagnosed in the early stage of the disease, it frequently causes multiple cysts in the liver. The clinical importance of the disease is rapid progression, infiltration into different tissues like a malignant tumor and capacity of creating metastatic masses. The disease could be treated either by surgical resection or liver transplantation. The resection of the cystic disease is the preferred treatment method. In cases where resection is not possible, liver transplantation is the choice of treatment. Here we present three cases which were admitted to the hospital with unresectable hepatic alveolar echinococcosis and treated by liver transplantation successfully. Patients for whom surgical resection is not possible, we recommend liver transplantation as the treatment method.

Introduction. Previous published studies have shown that age is not a contraindication for deceased donor liver transplantation. The data about elderly recipient after living donor liver transplantation (LDLT) is unsatisfactory. The aim of this study was to evaluate the outcome of the LDLT with recipients aged 70 years or older. Patients and Methods. Between 2005 and 2013, 469 patients underwent LDLTs. The clinical characteristics, preoperative, intraoperative, and postoperative data, graft, and patients’ survival of these patients were retrospectively analyzed. All recipients who were 70 years or older at the time of liver transplantation were indentified. The results were compared to the results of the patients younger than 70 years. Results. There were 12 patients (2%) 70 years or older. All patients received the right lobe of their donor in a standard technique. One patient died postoperatively because of pulmonary infection, and one patient died 6 months after the operation because of graft failure after cardiac infarction. The comorbidity score of these two patients were significantly higher compared to the other ten patients without any complications (8.5 vs. 4.6, P=0.01). The 1-year and 3-year patient and graft survival was 84%. There were no significant differences in complications, hospital stay, perioperative mortality, or median survival compared to the younger group. Conclusion. Although the number of the patients is small, our study emphasizes that LDLT of patients 70 years or older can be performed safely in patients without major comorbidities. Elderly patients with increased risk for postoperative complications should be excluded from LDLT.

Anti-HBs immunoglobulins (HBIG) and lamivudine are main options to prevent hepatitis B virus (HBV) reinfection after liver transplantation. Although they are very effective, development of mutant viruses and high cost of treatment are main limitations for their application. Additionally there is an uncertainity for the duration of that prophylaxis regimen and its mostly applied indefinitely. Recently, post-transplant HBV vaccination is reported to be a cheaper alternative prophylaksis strategy, that enables discontinuation of HBIG. To investigate the efficacy of HBV vaccination in patients transplanted for HBV cirrhosis, we administered double course of double dose recombinant HBV vaccine (Genhavac B; containing HBV pre-S1, pre-S2, and S gene products). Vaccination has been started 1 month after HBIg discontinuation, and lamivudine (100 mg/day) was given throughout the study. The first cycle consisted of 0, 1- and 6-month schedule, and, in nonresponders, second cycle 0, 1-, 2-month schedule. Fourteen patients included into the study. Only one patient seroconverted (an anti-HBs titre of 37 IU/L) after the first cycle. No other patient responded to second cycle. HBV vaccination in the post-transplantation setting does not seems like an effective strategy in the prophylaxis of HBV recurrence.

Anatomical variations in the venous system of liver are not a rarity. A prospective helical computerized tomography (CT) study was undertaken to determine the prevalence of surgically significant hepatic venous anatomic variations among 100 consecutive living liver donors. The studies evaluated the ramification pattern of hepatic veins, the presence of accessory hepatic veins, and of segment 5 or 8 veins (or both) draining into middle hepatic vein. These data obtained by CT influenced surgical planning. Sixty-four donors donated their right lobes and 24 donors, left lateral segments. Only one donor candidate was refused due to combined hepatic and portal venous variations accompanied by multiple bile ducts. Eleven donors were also refused due to reasons other than anatomical variations. Seventeen segment 5 and 17 segment 8 veins draining into middle hepatic vein were anastomosed to inferior vena cava in 23 (36%) of the right lobe liver transplantations. The middle hepatic vein was harvested in only one of the donors. Among the 100 cases, 47 had accessory right inferior hepatic veins, 13 of which were multiple. Twenty-two of the right lobe grafts required surgical anastomoses of these accessory hepatic veins (34%). An isolated hepatic vein anomaly or the presence of accessory hepatic veins are not contraindications to be a living liver donor candidate. However, preoperative knowledge of vascular variations alters surgical management. Helical CT is a valuable tool to delineate the hepatic venous anatomy for surgical planning in living liver donors.

Aim: To evaluate surgical success, survival rate and relationship of outcome parameters with time at diagnosis and operation of extrahepatic biliary atresia (EHBA) patients in Izmir, Turkey. Methods: Clinical and laboratory data were reviewed from case reports of 27 EHBA patients. Twenty-five patients were operated on using Kasai procedure and two cases received liver transplants without portoenterostomy due to decompansated liver cirrhosis on diagnosis. Post operational success was defined as clearance of jaundice (bilirubine level

A total of 112 living donor hepatectomies (LDHs) performed from October 1999 to April 2003 at Ege University Hospital Organ Transplantation Center were reviewed and perioperative anesthetic courses and complications were determined. There was no perioperative mortality. Mean duration of operations was 333 +/- 77 minutes (range, 160 to 540 minutes) for right lobectomies and 277 +/- 88 minutes (range, 150 to 500 minutes) for left lateral segment plus left lobe operations. The remnant liver volume ratios of the patients was 0.58 +/- 0.16 (range, 0.30 to 0.91) after harvesting. Crystalloids, colloid infusions, and transfusions aimed to keep hematocrit25%, central venous pressure (CVP)5 mm Hg and to maintain a urine output1 mL/kg(-1) while nitroglycerin was infused (0.5 to 2.0 microg/kg(-1)h(-1)) when needed to allow fluid infusions freely without increasing the CVP values. No transfusion was needed for 91 patients (81%) and 21 right lobectomy patients needed transfusion of blood products. Initial mean hematocrit of 38.9 +/- 4.9% (range, 27% to 50%) for all patients was found 31.5% +/- 5% (21% to 44%) at the end of the operation. Albumin blood levels averaged 4.27 +/- 0.49 g/dL(-1) at the beginning and 3.28 +/- 0.45 g/dL(-1) after hepatic resection. Perioperative complications were one air embolism, postoperative systemic inflammatory response syndrome in one patient, transient but severe hemoglobinuria due to a predonated autologous blood transfusion in another, prolonged recovery for neuromuscular blocker overdose in one patient, and postoperative atelectasis in three patients, two of whom had pneumonia later while two other patients had pleural effusions. One required a drainage. Living donor hepatectomies were performed with acceptable complications in anesthetic management during this study. The operation provides us with an optimal liver segment without resulting in mortality.

A 5-yr-old boy who diagnosed acute liver failure and Stage IV hepatic encephalopathy underwent living related liver transplantation and awakened with persistent hand motions visual loss. Serum Tacrolimus, electrolytes, magnesium levels were normal as well as blood pressure. His neurologic and opthamologic examinations were otherwise normal. Visual evoked potential (VEP) was prolonged and brain magnetic resonance immaging (MRI) revealed bilateral parietooccipital white matter signal abnormalities with gliosis. During follow up his visual loss resolved spontoneously as well as the VEP and MRI abnormalities. In this case we aimed to point out hepatic encephalopathy might be a cause of postoperative visual loss and serial VEP analysis is an important diagnostic tool for monitoring visual function of liver graft recipients in the post-operative period.

Keeping patients on mechanical ventilation after orthotopic liver transplantation (OLT) has been a standard anesthetic approach since the first utilization of liver transplantation. Advances in anesthetic management, surgical techniques and patient preparation, in addition to improved postoperative care and the reported advantages of early postoperative tracheal extubation of liver recipients. encouraged us to extubate most recipients at the end of the operation. The aim of the present study is to evaluate the pediatric liver recipients who were extubated immediately at the end of transplantation, in terms of respiratory complications and allograft function during their stay in the ICU. We retrospectively reviewed the records of 40 pediatric recipients who had undergone OLT at the Ege University Organ Transplantation Center between December 1997 and July 2002. Twelve out of 40 patients who had consecutively undergone OLT were extubated immediately at the end of the operation and were included this study. Mean Child Pugh scores of the patients were 9 +/- 2.3 (range 6-12) and the mean PELD score was 23.1 +/- 12.3 (range 7-41). The mean age of the patients was 8.4 +/- 5.2 (range 0.8-16.8 yr). Five of the 12 extubated patients received a cadaveric and seven a living donor liver graft. The mean ICU stay of the patients was 49.1 +/- 24.2 h (6-120 h). No patients required reintubation or mechanical ventilation in the ICU. Respiratory complications diagnosed in the 12 extubated patients were hypercapnia without hypoxemia in three, atelectasis in one and pleural effusion in two. No primary non-function or delayed graft function was detected. The aspartate transaminase (AST), alanine transaminase (ALT) and protrombin time (PT) were normalized within a week. We believe that immediate tracheal extubation in the operating room is a safe procedure for selected cadaveric and living-related liver transplant recipients and will facilitate the patients' recovery and mobilization leading to reduction in complications and a reduced ICU stay.

Tuberculosis (TB) is an unusual infection in transplant recipients. We evaluated (i) the frequency of TB, (ii) the duration to develop the TB infection, and (iii) clinical consequences, in 380 solid-organ recipients from January 1995 to December 2000. A total of 10 (2.63%) patients (eight renal, two liver transplant recipients) were found to have post-transplantation TB. The frequency of TB in this patient population is 8.5-fold higher than the prevalance in the general Turkish population. Tuberculosis developed within 2-33 months after transplantation, with a median of 15 months. In all of these 10 patients, Mycobacterium tuberculosis (MTB) was isolated from the culture. All the patients continued to have low dose immunosuppressive treatment, and also quadriple antituberculosis treatment [isoniazid (INH), rifampin (RIF), pyrazinamide (PRZ) and ethambutol (ETB)] has been given. The two recipients had died of disseminated form of TB. Relapse was detected in one patient 6 months after the completion of the treatment. As post-transplant TB infection develops mostly within the first year after transplantation, clinicians should be more careful for early and fast diagnosis and treatment should be started immediately.

In 50 years after the first liver transplantation, the medical world has witnessed the liver transplantation to become one of the widely recognized and leading branches of surgery. In this period, liver transplantation combined with surgical technique, patient selection, advancements in anesthesia and postoperative care and increased experience has become the most effective treatment option in treatment of several acute and chronic liver diseases. Yet, the worldwide organ restriction and associated high mortality rates in organ transplantation waiting list has compelled referring to living donors in order to expand the donor pool. This paper explains liver transplantation indications from living donors, the surgical technique involved, the complications of the procedure and the medical treatments used.

Liver transplantation is considered to be the most effective treatment for hepatocellular cancer (HCC) arising in the setting of cirrhosis. However, HCC recurrence remains a concern after liver transplantation. In this study, our goal was to investigate the factors associated with recurrence and survival of the patients after living donor liver transplantation. One hundred and nine patients underwent living donor liver transplantation due to hepatocellular cancer were included in the study. The average age was 55.2±7.82 (26-72) years and 89% of patients were male. Of the 109 patients, 57 (52.3%) met Milan criteria. The mean tumor size was 36.44±22.64 (5-140) mm and 55% of tumor had multifocality. Sixteen (14.7%) patients developed tumor recurrence in a mean follow up of 31.4±26.2 (4-94) months. Tumor size, poor differentiation and hepatitis B recurrence were associated with higher tumor recurrence and lower survival rate. Although tumors outside the Milan criteria were associated with high recurrence, they did not affect survival rate. The survival rate was lower in patients with tumor recurrence. Of the 109 patients, 87 (75.2%) were alive while 27 (24.8%) were deceased. The overall survival rates at first year in patients with recurrence and without recurrence were 54.27±12.89% and 85.54±4.36% respectively. In conclusion, tumor recurrence decreases patients survival rate after living donor liver transplantation performed for HCC. In order to predict both tumor recurrence and patient survival, all other tumor characters should be evaluated with the Milan criteria prior to transplantation., Karaciğer nakli, siroz zemininde gelişen hepatosellüler karsinomlarda en etkili tedavi yöntemi olarak kabul edilmektedir. Ancak nakil sonrası görülen tümör nüksü en kaygı verici sonuçtur. Bu çalışmamızda, canlı vericili karaciğer nakli sonrası karşılaşılan tümör nüksü ve hasta sağkalımına etki eden faktörler araştırıldı. Çalışmamıza hepatosellüler karsinom nedeni ile canlı vericili sağ lob karaciğer nakli olan 109 hasta dahil edildi. Yaş ortalaması 55.2±7.82 (26-72) yıl olan hastaların 57'si (%52.3) Milan kriterleri içinde idi. Ortalama tümör çapı 36.44±22.64 (5-140) mm olan hastalardaki tümörlerin %55'i mültifokal özellik göstermekteydi. Ortalama takip süresi olan 31.4±26.2 (4-94) ay içinde 16 (%14.7) hastada nüks tespit edildi. Tümörün çapı, kötü diferansiye tümör ve hepatit B nüksü olmasının hem tümör nüks riksini arttırdığı hem de sağkalımı düşürdüğü tespit edildi. Tümörün Milan kriterleri dışında olması nüks riskini arttırırken, sağkalım üzerinde etkisi görülmedi. Nüks gelişen hastalarda sağkalım oranı ve süresi daha düşük bulundu. Toplam 109 hastada; 87 hasta yaşarken (%75.2), 27 hastada ise (%24.8) ölüm gözlendi. Nüks gelişen ve gelişmeyen hastalardaki bir yıllık sağ kalım sıra ile %54.27±12.89 ve %85.54±4.36 olarak tespit edildi. Sonuç olarak, hepatosellüler karsinom nedeni ile yapılan karaciğer nakli sonrası gelişen nüks, sağkalım oranını azaltmaktadır. Tümörün hem nüks hem de sağkalıma olan etkisini belirlemek için, nakil öncesi Milan kriterleri ile birlikte tümörün diğer özellikleri de değerlendirilmelidir.

Liver transplantation (LT) is the most effective treatment for hepatocellular carcinoma (HCC) that arises from cirrhosis. The Milan and the University of California, San Francisco (UCSF) selection criteria have resulted in major improvements in patient survival. We assessed our outcomes for patients with HCC that were beyond the Milan and UCSF criteria after living donor liver transplantation. We reviewed the data for 109 patients with cirrhosis and HCC who underwent living donor right lobe liver transplantation (living donor liver transplantation; LDLT) during the period from July 2004 to July 2012. Sixteen (14.7 %) patients had HCC recurrences during a mean follow-up of 35.4 ± 26.2 months (range 4-100 months). The mean time to recurrence was 11 ± 9.4 months (range 4-26 months). Survival rates were not significantly different between patients with HCC that met and were beyond the Milan and UCSF criteria (p = 0.761 and p = 0.861, respectively). The Milan and UCSF criteria were not independent risk factors for HCC recurrence or patient survival. Only poorly differentiated tumors were associated with a lower survival rate (OR = 8.656, 95 % confidence interval (CI) 2.01-37.16; p = 0.004). Survival rates for patients with HCC that were beyond conventional selection criteria should encourage reconsidering the acceptable thresholds of these criteria so that more HCC patients may undergo LT without affecting outcomes.

Background Tuberculosis is an important cause of morbidity and mortality in renal transplant recipients, but there are insufficient data regarding the efficacy and complications of therapy and of INH prophylaxis. Methods This study is a retrospective review of the records of 880 renal transplant recipients in two centers in Turkey. Results Tuberculosis developed in 36 patients (4.1%) at posttransplant 3-111 months, of which 28 were successfully treated. Eight patients (22.2%) died of tuberculosis or complications of anti-tuberculosis therapy. Use of rifampin necessitated a mean of 2-fold increase in the cyclosporine dose, but no allograft rejection occurred due to inadequate cyclosporine levels. Hepatotoxicity developed in eight patients during treatment, two of whom died due to hepatic failure. No risk factor, including age, gender, renal dysfunction, hepatitis C, or past hepatitis B infection, was found to be associated with development of hepatic toxicity. A subgroup of 36 patients with a past history of or radiographic findings suggesting inactive tuberculosis, was considered to be at high risk for developing active disease, of whom 23 were given isoniazid (INH) prophylaxis. None versus 1 of 13 (7.7%) of cases with and without INH prophylaxis, respectively, developed active disease (P>0.05). None of the patients receiving INH had hepatic toxicity or needed modification of cyclosporine dose. Conclusions These data show that tuberculosis has a high prevalence in transplant recipients, that it can effectively be treated using rifampin-containing antituberculosis drugs with a close follow-up of serum cyclosporine levels, and that INH prophylaxis is safe but more experience is needed to define the target population.

Qualitative and quantitative abnormalities of fibrinogen can result in hemostatic disorders (1). Congenital afibrinogenemia is a rare coagulation disorder transmitted as an autosomal recessive trait (2). The incidence of afibrinogenemia is 1–2 cases per million population (3). It is more common in populations with a high rate of consanguinity (3). Symptoms of afibrinogenemia vary from mild hemorrhagic events to severe bleeding episodes, though thrombotic events are very rare. We report an afibrinogenemic patient who presented with hepatic venous thrombosis at 16 years old. Evaluation of all hemostatic parameters and coagulation factors revealed no other pathology except afibrinogenemia. Paradoxically, afibrinogenemia may be a risk factor for vascular thrombotic events like Budd–Chiari Syndrome (BCS).

Living donor liver transplantation (LDLT) is an accepted option for end-stage liver disease, particularly in countries in which there are organ shortages. However, little is known about LDLT for obese patients. We sought to determine the effects of obesity on pretransplant living donor selection for obese recipients and their outcomes. On the basis of body mass index (BMI) values, 148 patients were classified as normal weight (N), 148 were classified as overweight (OW), and 74 were classified as obese (O). O recipients had significantly greater BMI values (32.1 ± 1.6 versus 23.2 ± 1.9 kg/m(2), P0.001) and received larger actual grafts (918.9 ± 173 versus 839.4 ± 162 g, P = 0.002) than recipients with normal BMI values. Donors who donated to O recipients had a greater mean BMI (26.3 ± 3.8 kg/m(2)) than those who donated to N recipients (24.4 ± 3.2 kg/m(2), P = 0.001). Although O recipients were more likely to face some challenges in finding a suitable living donor, there were no differences in graft survival [hazard ratio (HR) = 0.955, 95% confidence interval (CI) = 0.474-1.924, P = 0.90] or recipient survival (HR = 0.90, 95% CI = 0.56-1.5, P = 0.67) between the 3 groups according to an adjusted Cox proportional hazards model. There were no significant differences in posttransplant complication rates between the 3 recipient groups or in the morbidity rates for the donors who donated to O recipients versus the donors who donated to OW and N recipients (P = 0.26). Therefore, we recommend that obese patients undergo pretransplant evaluations. If they are adequately evaluated and selected, they should be considered for LDLT.

Hepatorenal syndrome is defined as renal failure caused by acute or chronic liver failure without any laboratory or histological reasons. The exact etiology of this syndrome is unknown. However, vasodilatation in the splanchnic area as a result of cirrhosis and portal hypertension, reflex systemic and splanchnic vasoconstriction are the basic pathophysiological reasons of this syndrome. The decrease of renal perfusion, decrease in glomerular filtration rate, sodium retention and deterioration of excretion of free water are the major renal problems and these remain progressive according to the stage of liver disease. The treatment of this syndrome is correction of the underlying problem. Here, we report a patient who was having hemodialysis due to renal failure as a consequence of liver cirrhosis for three months and returned back to his normal life without a need for dialysis after liver transplantation.

Failure of prophylaxis for hepatitis B virus (HBV) recurrence in liver transplant patients with HBV immunoglobulin (HBIG) or lamivudine or both can be associated with rapid development of liver failure. Some of these patients develop a devastating clinicopathological state characterized by jaundice and rapidly progressive liver failure or fibrosing cholestatic hepatitis. We present two liver transplant recipients who experienced HBV recurrence while they were under lamivudine and HBIG prophylaxis. One of them had finding of severe HBV infection; the other, fibrosing cholestatic hepatitis. After commencing adefovir dipivoxil both patients showed improvements in clinical status and laboratory data. At month 4 of treatment, HBV DNA values became negative and liver function tests almost normalized. In addition, in one case showed HBs ag/anti-HBs seroconversion. When failure of prophylaxis with lamivudine and HBIG occurs, adefovir dipivoxil should be considered to be a safe and effective choice for recurrent HBV infections in liver transplant patients.

Upper gastrointestinal bleeding (GIB) is one of the most common gastroenterologic complications following liver transplantation. The aim of this study is to define the prevalence of GIB due to Roux- en Y (R-Y) enteral anastomoses after living donor liver transplantation (LDLT) and recommend an anastomotic technique for easy surgical intervention. Ninety-five patients underwent 96 LDLT from June 1999 through January 2003. R-Y biliary reconstruction was employed in 43 patients. Anastomoses were end-to-side (ES) in the first 25 patients and side-to-side (SS) type in the last 18 patients. GIB occurred in 13 patients (30%). The R-Y anastomotic line was shown to be the bleeding site in 10 patients. Anastomoses were in ES fashion in 7 of 10 patients (70%). In other words 28% of ES and 17% of SS anastomoses displayed a bleeding episode after LDLT. Four patients required surgical intervention (Three ES, one SS), namely an operative rate of 9%. The type of the jejunojejunostomy, the UNOS or Child-Pugh scores, the presence of preexisting portal hypertension, the duration of portal vein clamping, the GRWR of patients, revealed no statistical significant difference between bleeding and non- bleeding patients. Although statistical analyses did not reveal any significant difference ( P = .47), GIB was higher among patients with an ES type of anastomoses. As a result we recommend a jejunojejunostomy in SS fashion on the antimesenteric borders of the jejunal segments with a 3–4 cm blind intestinal segment. The surgical procedure for R-Y bleeding may then be performed without disrupting the jejunojejunostomy.

Hemophagocytic syndrome (HPS) is a life-threatening hematological disorder in immunocompromised patients. Although the number of patients with HPS following liver transplantation is scarce the outcome is usually fatal. We report a patient who developed HPS following living-related liver transplantation (LRLT) and was treated successfully by a combination of intravenous (IV) immunoglobulin (Ig) and granulocyte colony-stimulating factor (GCSF).

Background: Hepatocellular carcinoma (HCC) is the fifth most common fatal cancer and an important healthcare problem worldwide. There are many studies describing the prognostic and predictive effects of epidermal growth factor receptor 2 (c-erb-B2) and epidermal growth factor receptor 1 (EGFR), transmembrane tyrosine kinases that influence cell growth and proliferation in many tumors. Objectives: The current study aimed to investigate the expression levels of c-erb-B2, EGFR, PTEN, mTOR, PI3K, p27, and ERCC1 in hepatocellular carcinoma (HCC) and their correlation with other clinicopathologic features. Patients and Methods: Fifty HCC cases were stained immunohistochemically with these markers. Correlations between the markers and clinicopathologic characteristics and survival rates were analyzed. Results: No membranous c-erb-B2 staining was seen, whereas cytoplasmic positivity was present in 92% of HCC samples, membranous EGFR was observed in 40%, PI3K was found in all samples, and mTOR was seen in 30%, whereas reduced or absent PTEN expression was observed in 56% of samples and loss of p27 was seen in 92% of the cases. c-erb-B2 and mTOR overexpression, as well as reduced expression of p27, all correlated with multiple tumors (P = 0.041, P < 0.001, and P < 0.001, respectively). P27 loss, and mTOR and EGFR positivity were significantly correlated with AFP (P = 0.047, P = 0.004, and P = 0.008, respectively). Angiolymphatic invasion was more commonly seen in EGFR- and ERCC1-positive cases (P = 0.003 and P = 0.005). EGFR was also correlated with histological grade (P = 0.039). No significant correlations were found among PTEN , PI3K, and the clinicopathological parameters. Disease-free or overall survival rates showed significant differences among therapy modalities, AFP levels, angiolymphatic or lymph node invasions, and ERCC1 and p27 expression levels (P < 0.05). Conclusions: c-erb-B2, EGFR, mTOR, ERCC1 overexpression levels, and loss of p27 may play roles in hepatocarcinogenesis and may be significant predictors of aggressive tumor behavior. These markers were found to be correlated with certain clinicopathologic features, therapy modalities, and survival rates in the current study. These findings may help in planning new, targeted treatment strategies .

Living donor liver right lobe transplantation using donors with variation of the right sectorial portal vein is considered a challenging procedure in terms of the donor\"s safety and the complexity of reconstruction in the recipient. We describe an innovative technique to reconstruct double portal vein orifices via a deceased donor iliac vein graft. The postoperative course of the recipient was uneventful. Doppler ultrasound on the fourth postoperative month revealed equivalent flow in both portal vein branches. Reconstruction of double right portal vein branches using a cryopreserved iliac vein is a valuable technique for utilizing right lobe grafts with challenging portal vein anatomy.