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Surgical treatments of advanced tumors have expanded in the last two decades as a result of ad-vances in surgical techniques, advanced interventional radiology methods, improved intensive care unit settings and increased overall life expectancy. Advanced liver tumors represent a broad category from various malignancies such as liver metastasis or native liver tumors. Not uncom-monly these tumors are not amenable to curative treatment and require down-staging, or local control at the initial diagnosis. Herein we discuss the portal vein embolization (PVE), transarterial radioembolization (TARE) with Yttrium-90 (Y-90), and surgical options namely, two-staged hepatectomy (TSH), and associating liver partition and portal vein ligation for staged hepatecto-my (ALPPS) as bridging strategies for definitive surgical treatment.

Donor BMI above 30 is generally considered contraindication for donor hepatectomy. We compared the donor outcomes based on BMI threshold and weight loss.All potential donors were identified and data were collected retrospectively. Steatosis was assessed based on liver-spleen Hounsfield unit difference and absolute liver intensity values. We compared BMI≥30 (n = 53) and BMI 30 (n = 64) donor outcomes. Donors with weight loss (WL) prior to surgery were also analyzed separately. Complications were graded by Clavien-Dindo classification.All donors underwent open right donor hepatectomy. There was no difference between BMI≥30 and 30 groups except female predominance in BMI≥30 group (P = .006). Both groups had similar rates of complication rates in all categories, similar remnant volume, operative time, length of stay and similar postoperative liver function recovery (all P .05). On the other hand, donors with WL were more commonly male, had smaller graft size, and higher biliary complications rates compared to no-WL donors (all P .05). Multivariate binary logistics regression analysis revealed no association between BMI or WL and outcomes.We demonstrate that donors with BMI≥30 have similar outcomes compared to BMI 30 donors with our defined selection criterion, therefore BMI≥30 is not an absolute contraindication to donate right liver, provided that there is no significant steatosis and remnant liver is satisfactory. For potential overweight donors, WL down to BMI 30 is a reasonable target. Higher biliary complication rates after WL should be investigated further.

The most important factor in the transmission of the COVID-19 is asymptomatic carriers. We’ve tested all oncology patients , that receive anti-cancer therapy, for COVID-19. We aimed to determine the rate of asymptomatic carriers, and analyze the clinical and ra- diological findings of infected patients. Oncology patients who have indications of receiving anti-cancer treatment in the hospital were tested for COVID-19, two day prior to their treatment even if they were asymptomatic by collecting nasopharyngeal and oropharyngeal swab specimens for RT-PCR for viral RNA detection. Positive patients, underwent inspiratory phase of chest computed tomography examination. Infected patients were given the recommended treatment for COVID-19. PCR test was positive in 28 of 312 patients that we tested, and the positivity rate was 8.9%. Three patients (10.7%) had symptoms, 25 patients (89.3%) had no symptoms. Covid-19 testing before anti-cancer treatment may be recommended in order to continue their treatment without any problems and to prevent the risk of transmission due to the high rate of asymptomatics in infected patients. Keywords: COVID-19, Pandemic, Chemotherapy, Oncology

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

We implemented a multicenter interview with the donors to investigate Quality of Life (QoL) up to 20 years following donation.Data were collected retrospectively. Complications were graded by Dindo-Clavien classification.Median follow-up was 16.1 years. Out of 485 donors, 272 responded (56.1%). The majority (90%) reported they are in excellent/good overall health and positive or no impact of donation on professional life. Length of stay (LOS) was associated with impact on professional life and return to baseline functionality (both p = 0.046). Major complication was not associated with current physical condition or return to baseline normalcy (p = 0.06). Seventy-five (27.5%) reported unsure or no to donate again. None of the parameters were associated with donation again response. Faster return to baseline functionality, and more positive impact on professional life were reported in the last decade, likely secondary to less complication rates (all p0.001).This the longest follow up reports after living liver donation among German and Turkish populations. Although subject to recall bias, LOS was associated with negative impact on professional life and return to baseline functionality. Regret feelings were higher than literature. These long-term effects should be incorporated into donor discussions.

Objective: The post-operative serum level of N-terminal pro-brain natriuretic peptide (NT-proBNP) has been found to be associated with post-operative cardiovascular complications and mortality in high-risk surgeries. The usefulness of the post-operative NT-proBNP level as a predictor of mortality after liver transplantation (LT) is unknown. Methods: The records of patients at a single, tertiary university hospital who had undergone adult living donor liver transplantation (LDLT) with data of post-operative NT-proBNP level values were retrospectively analyzed for in-hospital mortality. The highest post-operative NT-proBNP level from the first 3 days after surgery was included in the study. Receiver operating characteristic curve analysis was performed to assess the best cut-off value of post-operative NT-proBNP, and Cox regression analysis was performed to investigate the effect of NT-proBNP on mortality. Results: A total of 114 LT recipients with a mean Model for End-Stage Liver Disease score of 15.8 were included in the study. In-hospital mortality occurred in 11 (9.6%) of the patients. A history of diabetes mellitus and the post-operative NT-proBNP level were found to be associated with mortality (p=0.011 for diabetes mellitus and p

The timing of removing abdominal drains, central venous catheters (CVC), and urinary catheters (UC) on post liver transplantation (LT) outcomes is not well elucidated.To provide international expert panel recommendations and guidelines on time of drain and catheter removal as a part of an ERAS protocol to reduce the length of hospital stay and enhance recovery.Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Papers considered were those reporting one or more outcomes of interest related to drainage and line removal in the setting of LT. POSPERO Protocol ID: CRD42021238349 RESULTS: On analyzing five relevant studies pertaining to drains in patients undergoing LT (four retrospectives and one prospective), the length of hospital and/or ICU stay was similar or shorter, and postoperative morbidity and mortality were lower in those without drains. No studies pertaining specifically to the time of removal of drains, CVC's, or UC's in LT were found. Studies in patients undergoing major abdominal surgery or hepatectomies recommend early removal of CVC and UC to reduce catheter-associated infections.Based more on expert recommendation, we propose that abdominal drains, if placed during LT, should be removed by postoperative day 5 after LT, based on quantity and fluid characteristics (Quality of Evidence; Low to Moderate | Grade of Recommendation; Strong). Larger studies are needed to more reliably determine indications for early drain and line removal in an ERAS protocol setting.

Background Previously published data have shown that age alone is not a contraindication for living donor liver transplantation (LDLT). However, careful evaluation is needed to identify the patients who are unlikely to benefit from LDLT. We hypothesized that the Charlson Comorbidity Index (CCI) could be used as one of the criteria for risk stratification in elderly patients undergoing LDLT. Patients and Methods There were 951 patients who underwent LDLT between October 2004 and February 2018. All recipients who were older than 60 years of age at the time of transplantation were identified. The comorbidity score was retrospectively assessed for each elderly patient according to the Charlson Comorbidity Index. Univariate and multivariate Cox regression analyses were performed to identify independent predictive factors for survival in elderly patients after LDLT. Results There were 96 patients (10.1%) in the age of > 60 years. All patients received the right lobe of their donor. Out of these patients, 18 (18.7%) died in the median time of 4 months. The remaining 78 patients (81.2%) are alive, with a median survival of 33 months. The CCI of these patients was significantly lower compared to the other 18 patients (2 versus 4). None of the patients with a CCI above 4 survived longer than 12 months. The results of the multivariate Cox regression analyses have shown that pulmonary disease, renal disease, and CCI are independent negative predictive factors for survival. Conclusion The results of our study show clearly that the CCI has a significant influence on survival after LDLT in elderly patients and can be used as one of the selection criteria for LDLT in elderly patients.

Knowledge of living donor liver transplantation (LDLT) for autoimmune liver diseases (AILDs) is scarce. This study analyzed survival in LDLT recipients registered in the European Liver Transplant Registry with autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis (PSC) and the non-autoimmune disorder alcohol-related cirrhosis. In total, 29 902 individuals enrolled between 1998 and 2017 were analyzed, including 1003 with LDLT. Survival from >90 days after LDLT for AILDs in adults was 85.5%, 74.2%, and 58.0% after 5, 10, and 15 years. Adjusted for recipient age, sex, and liver transplantation era, adult PSC patients receiving LDLT showed increased mortality compared to donation after brain death (DBD) (hazard ratio [HR] = 1.95, 95% confidence interval [CI] = 1.36-2.80, p < .001). Pediatric PSC patients showed also increased mortality >90 days after LDLT compared to DBD (HR = 3.00, 95% CI 1.04-8.70, p = .043). Multivariate analysis identified several risk factors for death in adult PSC patients receiving LDLT including a male donor (HR = 2.49, p = .025). Adult PSC patients with LDLT versus DBD conferred increased mortality from disease recurrence (subdistribution hazard ratio [subHR] = 5.36, p = .001) and biliary complications (subHR = 4.40, p = .006) in multivariate analysis. While long-term outcome following LDLT for AILD is generally favorable, PSC patients with LDLT compared to DBD might be at increased risk of death., Astellas Pharma; Novartis; Institut Georges Lopez; Sandoz, The Organ Sharing Organizations: the French ABM (Sami Djabbour), the Dutch NTS (Maaike de Wolf), the Eurotransplant Foundation (Marieke Van Meel), the Spanish RETH (Gloria de la Rosa), the UK-Ireland NHSBT (Michael Daynes), and the Scanditransplant (Ilse Duus Weinreich) are acknowledged for the data cross-check and sharing with the ELTR. The European Liver Transplant Registry is supported by a grant from Astellas Pharma, Novartis, Institut Georges Lopez, and Sandoz and receives logistical support from the Paul Brousse Hospital (AP-HP).

Despite advances in prevention techniques, screening, and new technologies in both diagnosis and treatment, the incidence and mortality of hepatocellular carcinoma (HCC) continue to rise. To obtain the best treatment result for HCC, early diagnosis is the key. In this study, we investigated the accuracy of noninvasive fibrosis markers, which have been typically used to predict liver fibrosis in recent years, in the prediction of HCC development in patients with chronic hepatitis B and chronic hepatitis B + D-induced cirrhosis.Between 2004 and 2018, 1216 patients with chronic liver disease were retrospectively reviewed, and 331 patients (27%) with hepatitis B and hepatitis B+D virus-related cirrhosis were enrolled in our study. Patients were divided into 2 groups based on HCC diagnosis (HCC and non-HCC group). Eleven noninvasive fibrosis markers were evaluated in the groups. These markers included 3 alpha-fetoprotein (AFP)-based models (PAPAS index, Fibro-alpha, and BRC score) and 8 non-AFP based models (Lok index, FIB-4, Fibro-O index, APRI, King's score, Forns index, Bonacini score, and HUI model) for each Child-Pugh score in the prediction of HCC.AFP-based models were higher in HCC group patients, and statistically significant outcomes were detected with these methods in each Child-Pugh score group for HCC prediction (P .05). Non-AFP based-methods showed different and inconsistent results in each Child-Pugh score group.These easily applied fibrosis markers, particularly AFP-based models, may provide an effective, simple, and low-cost way to predict HCC development in patients with hepatitis B and hepatitis B + D cirrhosis.

Background The purpose of this study was to determine the utility of some imaging findings in predicting microvascular invasion (MVI) and hepatocellular carcinoma (HCC) recurrence risk after liver transplantation. Method This retrospective study included 123 patients with histopathologically proven HCC at explant. All HCCs were classified as MVI positive (group I) or negative (group II) based on histopathological findings. In each group, multifocality, largest tumor size, bulging (tumor causing liver capsule expansion), beak sign (the acute angle between the tumor and liver parenchyma), and diffusion restriction on diffusion weighted images (DWI) were evaluated. These findings were compared between the groups by Student’s t test. The relation between the parameters and MVI was analyzed by using the Spearman’s correlation test. Results Of the total patients, 30.1% had MVI (group I) and 69.9% (group II) did not have MVI. Presence of beak sign (P ≤ .005), bulging sign (P = .002), and diffusion restriction (P = .045) were significantly more frequent in group I than group II. The beak sign, bulging sign, and diffusion restriction were correlated with presence of MVI. Largest tumor size and multifocality were higher in group I than group II, but the differences were not statistically significant. Conclusion Radiologists and transplant surgeons should be aware of some clue imaging findings, especially beak and bulging signs because these findings may predict the presence of MVI in HCC. These patients might benefit from histologic confirmation of the tumor characteristics through biopsy and subsequent bridging treatment options before liver transplantation to reduce the risk of recurrence.

Purpose Nonalcoholic steatohepatitis (NASH) is an increasing cause of liver transplantation (LT) worldwide, especially in Europe and North America. In this study, we aimed to investigate the changing pattern of etiologic causes of LT in our center for the past 15 years. Materials and methods A cohort of 967 consecutive adult patients with history of LT between 2004 and 2018 in our center was reviewed regarding etiologies for LT. All patients who had a transplant during this time frame were divided into 3 time periods as follows: 2004 to 2009, 2010 to 2013, and 2014 to 2018. All explanted liver samples were sent to pathology for establishment of a definitive etiologic cause. Results Chronic hepatitis B virus (HBV) infection was the leading cause of LT in the overall cohort (37%), followed by hepatitis C virus (HCV) infection (11%), and alcoholic liver disease (9.5%). NASH accounted for 7.5% of the cases. While HBV decreased from 44% in 2004 to 2009 to 36% in 2014 to 2018, NASH increased from 1.1% to 9.4% in overall transplants during the same period, accounting for one-third of the etiologies for LT following HBV and HCV. Conclusions There might be a global changing figure regarding etiology for LT in Turkey, especially NASH, which is the fastest growing cause of LT. However, this topic needs to be evaluated in large cohort series from collaborative multicenter studies from Turkey.

Purpose Data on recurrence of hepatitis D virus (HDV) and its long-term impact on liver transplant (LT) are limited. In this study, we investigated the incidence of hepatitis B virus (HBV) and the long-term effect of postoperative HDV recurrence HDV coinfection in our liver transplant patients. Patients and Methods Between 2004 and 2018, all patients with LT because of HBV (n = 361; 37.3%) were reviewed, and those with HBV and HDV coinfection (n = 104; 30% of all HBV patients) were enrolled in our study. All patients received post-transplant combination therapy with nucleos(t)ide analogue and antihepatitis B immunoglobulins. Breakthrough infection was defined as reemergence of HBV DNA or hepatitis B surface antigen during postoperative treatment. In case of recurrence, another oral nucleos(t)ide analogue was added and antihepatitis B immunoglobulins were stopped. Results During the study period, the frequency of HDV (+) was decreased (41% to 14%). Median follow-up time was 82 months (range, 1-274 months). Post LT survival and HBV recurrence were 97% (n = 15) and 13.4%, respectively. Only 15 patients (14%) developed breakthrough infection. There was no predictive factor for recurrent HDV infection, including demographics data and concomitant hepatocellular carcinoma (P = .73). Mortality was similar between patients with and without recurrence (2.2% vs 7.1%, P = .35) Conclusions Patients who received transplants for hepatitis B and D virus cirrhosis had favorable prognosis and good long-term results despite recurrent infection. Close follow-up of patients and effective postoperative viral suppression with appropriate medications seems to be favorable for both prevention and management of recurrence and provides comparable outcome with patients without recurrence.

Objectives Although endoscopic management is considered as the first-line treatment for biliary strictures, it may be challenging in living donor liver transplant recipients due to the complex nature of duct-to-duct reconstruction. In this study we present the use of a pigtail drainage catheter as a biliary stent to treat biliary strictures after a living donor liver transplant. Methods Twenty-seven patients with biliary strictures were treated with our novel technique. In this technique, a pigtail catheter was trimmed into 3 parts (proximal, middle, and distal portions). A suture string was passed through the distal hole of the middle portion, which was then reversed and used as a stent while the proximal portion was used as a pusher. Following balloon dilation of the stenotic segment, the distal, reversed middle, and proximal portions were loaded over the guidewire. After proper placement of the stent, the retractor suture string, pusher, and guidewire were removed. The stent was removed during the third or fourth month of placement through endoscopic retrograde cholangiopancreatography (ERCP) in all patients. Results No significant complications developed during the procedure or follow-up period. Ten patients required re-stenting by ERCP during the same session. The mean follow-up period was 2 years. Cholestase enzymes and bilirubin levels were within normal limits in all patients during follow-up. Conclusion Stents derived from drainage catheter facilitate treatment of biliary strictures in patients not eligible for the retrograde approach. This stent is cheap, easy to implement, can be easily removed by ERCP, and re-stenting can be applicable in retrograde if needed.

Introduction: Liver transplantation offers the most reasonable expectation for curative treatment for hepatocellular carcinoma. Living-donor liver transplantation represents a treatment option, even in patients with extended Milan criteria. This study aimed to evaluate the outcomes of hepatocellular carcinoma patients, particularly those extended Milan criteria. Materials and Patients: All HCC patients who received liver transplant for HCC were included in this retrospective study. Clinical characteristics including perioperative data and survival data (graft and patient) were extracted from records. Univariate and multivariate analyses was performed to identify significant prognostic factors for survival, postoperative complications and recurrence. Results: Two-hundred and two patients were included. The median age was 54.8 years (IQR 53-61). Fifty-one patients (25.3%) underwent deceased donors liver transplantation and 151 patients (74.7%) underwent living donor liver transplantation. Perioperative mortality rate was 5.9% (12 patients). Recurrent disease occurred in 43 patients (21.2%). The overall 1-year and 5-year survival rates were 90.7% and 75.6%, respectively. Significant differences between patients beyond Milan criteria compared to those within Milan criteria were not found. Alpha-fetoprotein level >300 ng/mL, vascular invasion, and bilobar tumor lesions were independent negative prognostic factors for survival. Conclusion: Liver transplantation is the preferred treatment for hepatocellular carcinoma and it has demonstrated an excellent potential to cure even in patients with beyond Milan criteria. This study shows that the Milan criteria alone are not sufficient to predict survival after transplantation. The independent parameters for survival prediction are Alpha-Fetoprotein-value and status of vascular invasion.

Rationale and Objectives To evaluate the results of 18F-FDG PET/MRI in relation to the histopathologic subtypes and histologic grades of mass-forming primary intrahepatic neoplasms. Materials and Methods We retrospectively evaluated 18F-FDG positron emission tomography/magnetic resonance imaging (PET/MRI) results for 39 patients with histopathologically confirmed primary hepatic neoplasms, 15 with mass-forming intrahepatic cholangiocarcinoma (ICC) and 24 with hepatocellular carcinoma (HCC). The apparent diffusion coefficient (ADC) and standardized uptake value (SUV) were analyzed in relation to the histopathologic diagnosis and histologic grade, including calculating the sensitivity and specificity of the imaging findings. Results The median SUV of ICC (6.0 [interquartile range, 5–10]) was significantly higher than that of HCC (4.0 [2.62–6.50]) (p = 0.002). An area under the curve (AUC) of 0.79 (95% confidence interval 0.649–0.932) had a sensitivity of 86.7% and a specificity of 67% at the best cut-off SUV of 4.41 to differentiate between ICC and HCC. ADC values did not differ significantly between HCCs and ICCs (p = 0.283). Both SUV and ADC values differed significantly between low-grade (well- and moderately differentiated) and high-grade (poorly differentiated) HCCs. Combining ADC and SUV further improved differentiation of low- from high-grade HCCs to a significant level (0.929). The SUV did not differ significantly between ICC histologic grades (p = 0.280), while the ADC differed significantly only between well and poorly differentiated ICCs (p = 0.004). Conclusion Assessing primary hepatic neoplasms with 18F-Fluorodeoxyglucose PET/MRI may help to predict tumor grade and differentiate between types of intrahepatic neoplasms.

Introduction Combined hepatocellular-cholangiocarcinoma is rare and comprises features of hepatocellular carcinoma and cholangiocarcinoma. The treatment of choice has not yet been defined. The aim of the study is to analyze outcomes of patients with combined hepatocellular-cholangiocarcinoma, who underwent liver transplantation. Material and methods All patients with combined hepatocellular-cholangiocarcinoma, who underwent liver transplantation, from January 2001 to August 2018 were identified. Pre-, intra and postoperative data were retrospectively assessed. A Univariate analysis was performed to identify prognostic factors. Results A total number of 19 patients were included to this study. Perioperative death was seen in two patients (10.5%). Recurrent disease was reported in 11 patients (64.7%) within the median time of 4 months. One- and three years survival rates were 57.1% (CI 0.301-1) and 38.1% (CI 0.137-1). Factors associated mortality were tumor size >3cm, presence of lymphatic invasion and prolonged ICU-stay. Patients with mixed HCC-CC lesions have significantly better survival compared to patients with separate lesions of HCC and CCC in one liver (p=0.025). Conclusion Although overall survival rates are clearly decreased compared to HCC patients, liver transplantation should be taken under consideration for selected patients with early stage and real mixed HCC-CC, who are likely to benefit from liver transplantation.

Despite the national immunization program, hepatitis B virus remains the leading cause of hepatocellular carcinoma (HCC) in Turkey, followed by hepatitis C virus (HCV), alcohol-related liver disease, cryptogenic liver failure, and NASH. There are variations in the country, not only in terms of etiology of HCC but also distribution of the disease stage. Liver transplantation is widely utilized in Turkey with good outcomes based on single-center reports. More research addressing socioeconomic and cultural differences that may pose a barrier to health care is needed as well as research on tumor characteristics and multicenter treatment outcomes in order to better characterize the features of HCC in a national scale. Lastly, the lack of HCC screening programs in addition to the lack of a national HCC registry magnifies the burden of HCC in Turkey.

Background/aims: an increased post-operative mortality risk has been reported among patients who undergo living donor liver transplantation (LDLT) with higher model for end-stage liver disease (MELD) scores. In this study, we investigated the effect of MELD score reduction on post-operative outcomes in patients with a high MELD (>= 20) score by pre-transplant management. Materials and methods: we retrospectively analyzed 386 LDLT cases, and patients were divided into low-MELD (= 20, n=93) groups according to their MELD score at the time of index hospitalization. Patients in the high-MELD group were managed specifically according to a treatment algorithm in an effort to decrease the MELD score. Patients in the high-MELD group were further divided into 2 subgroups: (1) responders (n=34) to pre-transplant treatment with subsequent reduction of the MELD score by a minimum of I point vs. (2) non-responders (n=59), whose MELD score remained unchanged or further increased on the day of LDLT. Responders vs. non-responders were compared according to etiology, demographics, and survival., NA

Investigating the association between maximum standardized uptake value (SUVForty-four patients [8 women and 36 men, median age of 62 (21-76)] with single HCCs (≥2 cm) who underwent preoperative 18F-FDG PET/MRI were retrospectively evaluated. The peritumoral and intratumoral ADC values were evaluated on diffusion-weighted images using Image J an open software and the intratumoral SUVUnivariate analysis showed that the histologic grade, tumor size, maximum peritumoral ADC (PT18F-FDG PET/MRI is a useful noninvasive imaging tool for predicting the MVI of HCC.

Hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and combined hepatocellular and cholangiocarcinoma are the most common cancers of the liver. In this study, our first aim is to evaluate the relationship between prognosis and clinicopathological parameters. The second aim involves investigating the need for immunohistochemical staining and patterns of tumours to differentiate between them. Sixty-one cases were included in this study. For IHC, we used Hep par-1, CK7, CK19, CD56 and p53 staining, and the patterns of tumours were evaluated in haematoyxylin-eosin sections. No significant differences were found in Kaplan-Meier life analysis between the tumour types and OS and DFS values, but these values were greater in HCC than in ICC. There were no relationships between clinicopathologic parameters and OS and DFS. Although the multifocality, stage and grade of tumour were higher in HCC than in ICC, the perineural invasion and lymph node metastasis were more common in ICC than in HCC. The diagnosis was changed in 4 cases, from HCC to ICC in one case and to combined type in 3 cases after IHC. Pathologist should be alert to mixed patterns in terms of diagnosis and IHC, because it helps differential diagnosis in these cases.

Background/Aim: Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) has deeply affected life all over the World. The World Health Organization named this disease as COVID-19. The most important factor in the transmission of the disease is asymptomatic carriers. We’ve tested all oncology patients, that receive anti-cancer therapy, for COVİD-19 to prevent asymptomatic oncology patients from spreading infection and to make the decision to postpone chemotherapy in infected patients. Then, we analyzed the clinical and radiological findings of infected patients.Materials and Methods: Oncology patients who have indications of receiving anti-cancer treatment in the hospital were tested for COVID-19, two day prior to their treatment even if they were asymptomatic by collecting nasopharyngeal and oropharyngeal swab specimens for RT-PCR for viral RNA detection. Positive patients, underwent inspiratory phase of chest computed tomography (CT) examination. Infected patients were given the recommended treatment for COVID-19. Anti-cancer treatment of all patients that had positive PCR results was delayed for 14 days.Results: PCR test was positive in 28 of 312 patients that we tested, and the positivity rate was 8.9%. Three patients (10.7%) had symptoms; 2 of whom had dyspnea and cough, and 1 had headache, and 25 patients (89.3%) had no symptoms.Conclusion: In oncology patients, who are receiving anti-cancer treatment, we have to recognize the asymptomatic COVID-19 infection. We recommend testing for COVID-19 in oncology patients receiving chemotherapy, periodically or before each anti-cancer treatment, in order to continue their treatment without any problems and to prevent the risk of transmission.

To evaluate the diagnostic accuracy of intravoxel incoherent motion (IVIM) and diffusion-weighted imaging (DWI) parameters in the differential diagnosis of portal vein thrombus (PVT). Thirty-five patients with PVT were enrolled in this retrospective study. Precontrast axial in-phase and out-of-phase T1-weighted (W) turbo field echo (TFE), axial and coronal T2-W single-shot turbo spin echo, IVIM with b values between 0 and 1300 s/mm2 and conventional DWI with b factors of 50, 400, and 800 s/mm2 with single-shot echo-planar imaging, and postcontrast dynamic T1-W volumetric interpolated breath-hold examination images obtained with 1.5 T MR unit were evaluated. For quantitative analysis of conventional DWI, an ADC map was reconstructed from conventional DWI using all b values. For quantitative evaluation of IVIM, the SI was calculated from each b value. A specific software program was applied to calculate D (true diffusion coefficient), D* (pseudodiffusion coefficient associated with blood flow), and f (perfusion fraction). The differentiation between benign and malignant PVT was based on the criteria outlined in the study by Catalano et al. (Radiology 254:154–162, 2010). The ADC values of the malignant PVT were significantly lower than those of benign PVTs (p = 0.005). Malignant PVTs had a tendency to show higher f values in comparison with benign PVTs without statistical significance (p = 0.750). The best discriminative parameter was ADC values, which demonstrated a sensitivity of 80.0% and a specificity of 72.7% with cut-off value of 1.00 × 10−3 mm2/s. ADC values might be more superior tool than IVIM parameters in differentiation between malignant and benign PVT.

Background and aims The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) risk tool and Revised Cardiac Risk Index (RCRI) are recommended tools for cardiovascular assessment before non-cardiac surgery to predict early postoperative cardiac morbidity and mortality. Their predictive value for postoperative cardiovascular morbidity and mortality after liver transplantation is unknown. We aimed to evaluate the validity of these two risk tools to predict early (30-day) cardiovascular complications and in-hospital all-cause mortality. Methods Patients who underwent living donor liver transplantation were retrospectively analyzed. Consecutive 278 adult patients were included and their NSQIP and RCRI scores were calculated. Results Cardiovascular morbidity occurred in 5 (1.8 %) patients. In-hospital all-cause mortality occurred in 18 (6.4 %) patients. None-of the patients died from cardiac complications. Causes of cardiac morbidity were as follows; acute coronary syndrome in 1 patient, intraoperative cardiac arrest with successful resuscitation in 1 patient, heart failure in 3 patients. Neither the NSQIP nor the RCRI score were associated with cardiovascular morbidity. Only RCRI medium-high score, DM and Nonalcoholic steatohepatitis as transplant indications were associated with in-hospital all-cause mortality (p = 0.001). Conclusions The NSQIP risk calculator and RCRI scores failed to accurately predict the risk of perioperative cardiac complications (Tab. 3, Ref. 30). Text in PDF www.elis.sk.

Lecture Last 20 years there was a great change and improvement in liver transplantation. The greatest improvement was Living Donor Liver Transplantation. Lots of things changed from the beginning, venous outflow with Seg 5-8 drainage, MHV usage in selected cases. Inflow modulation, dual lobe transplants,small for size grafts. Arterial anastomosis techniques with microscope. Transplant oncology, for HCC, colorectal metastasis and cholangiocarcinoma,was the new challenging area. This lecture will enlighten the journey of LDLT in the last 20 years.

BACKGROUNDS We evaluate whether it is safe to accept donors with Gilbert's syndrome (GS) for a living donor liver transplantation (LDLT) or not. This study is the first controlled study to be conducted. METHODS Between January 2004 and May 2014, 600 LDLTs which used right lobe liver grafts were performed in our center. Forty-five of the 600 donors had a GS diagnosis. For a control group, 99 donors without GS who had completed 1 year or more of follow-up were selected retrospectively and consecutively. The clinical results of the donors and recipients were then analyzed. RESULTS A total of 45 donors with GS and 99 donors without GS were included. There were no significant differences in patient demographics, actual graft weight, remnant ratio, portal and ductal variations, pre-peri-post-operative liver enzymes. The donors with GS had significantly higher bilirubin levels compared with the control group at first reading, at maximal peak, and post-operative 1-7 days, 1st and 6th months (P

Purpose In living donor liver transplantation, poor compatibility of the recipient hepatic artery remains a technical challenge. Here, we analyzed our 14 years of experience with extra-anatomic hepatic artery reconstruction. Methods Between July 2004 and December 2018, there were 1063 liver transplantations at our center. All patients with an extra-anatomic hepatic artery reconstruction were identified. The gastroduodenal artery and the transposed splenic artery were the primary options for extra-anatomic arterial reconstruction. Patient characteristics, operative data, and post-transplant outcome were reviewed retrospectively. Results There were 22 patients with extra-anatomic hepatic artery reconstruction, 6 with gastroduodenal artery, and 16 with splenic artery. There were 2 major complications: 1 patient underwent early reoperation due to bleeding from the splenic artery trunk and another had an iatrogenic injury to the transposed splenic artery during conversion hepaticojejunostomy. Both were treated successfully with surgery. One patient died perioperatively due to sepsis. The 1- and 3-year graft survival rates of these 16 patients were 93.7% and 87.5%. Conclusion If the hepatic arteries are not suitable for anastomosis, then we consider the gastroduodenal artery and the splenic artery to be the conduits of choice for extra-anatomic arterial reconstruction. The transposed splenic artery is very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.

Background Chronic hepatitis C virus (HCV) infection is a global health problem, and the need for liver transplants is ever-growing. For optimal surgical success, risk factors must be identified and HCV viral load must be reduced to a minimum to avoid complications. In this study, we aimed to investigate the role of HCV viral load on the post-transplant biliary complications. Method Between 2004 and 2018, the cases of 114 liver transplant recipients with HCV infection were retrospectively reviewed. Data collection included demographic variables, preoperative and postoperative amount of serum HCV RNA copies, preoperative diagnosis of hepatocellular carcinoma (HCC), and postoperative biliary complications in the early and late period. After missing values were excluded, the remaining 97 patients were divided into 2 groups according to preoperative HCV RNA status (Group A: HCV RNA [+] and Group B: HCV RNA [-]). Results Demographic parameters were similar among both groups. There were 67 patients in Group A and 30 patients in Group B. The overall rate of biliary complications was higher in Group A without statistical significance (20% [n = 14] vs 13% [n = 4], respectively, P = .573). Biliary stricture occurrence in the late period was also higher in Group A. In HCC (+) patients (n = 26), biliary complications were significantly higher compared to HCC (-) patients (34% vs 12%, P = .018). However, in patients with biliary complications, the rate of multiple duct anastomoses was higher with no statistical significance (45% vs 26%, respectively, P = .14). Conclusion The biliary complications on patient survival has been previously established, and this is mostly evident in those patients with viral etiology and hepatocellular carcinoma. As was also suggested in our study, hepatocellular carcinoma and positive viral status should be considered as predisposing factors for postoperative biliary complications after liver transplantation. However, the rate of multiple duct anastomoses should also be taken into consideration. New standards of antiviral medications and bridge therapy for HCC may improve transplant outcomes.

Background In living-donor liver transplantation, donor hepatic steatosis is crucial for both the donor and the recipient. Body mass index (BMI) and the unenhanced computed tomography liver attenuation index (CT LAI) are noninvasive methods to predict hepatic steatosis in living-donor liver candidates. Aim To analyze the diagnostic accuracy of CT LAI in conjunction with different BMI values for macrovesicular steatosis in living-donor liver candidates. Methods A total of 264 potential liver donors were included. The diagnostic accuracy of 2 CT LAI cut-offs and 3 BMI cut-off values for the assessment of hepatic steatosis ≥15% and ≤5% was determined. Results Using CT LAI, the area under the receiver operating characteristic curve was 0.97 (95% CI = 0.89–0.99) for hepatic steatosis ≥15% in donors with BMI Conclusions In donors with BMI 6, liver biopsy might be avoided. Biopsy may be reserved solely for donors with CT LAI value >0 and BMI ≥30 kg/m2 as the diagnostic accuracy of computed tomography for predicting hepatic steatosis decreases with increasing BMI.

Background Preoperative cardiac troponin-I (cTnI) elevation has been shown to be a predictor of mortality after liver transplantation. Myocardial injury after non-cardiac surgery (MINS) has been defined as elevation of serum cardiac troponin levels in the perioperative period that does not fulfill the criteria for myocardial infarction. MINS has been shown to be a prognostic factor for in-hospital and long-term mortality, but there is limited data in patients undergoing living-donor liver transplantation (LDLT). In this study, we aimed to evaluate the relationship between MINS and postoperative mortality. Material and methods Patients who had undergone adult LDLT at Florence Nightingale Hospital Liver Transplantation Unit between December 2012 and December 2015 were retrospectively analyzed for 30-day in-hospital and 1-year mortality. Myocardial injury was defined as cTnI level above 0.04 ng/mL. Patients (N = 214) were divided into 2 groups according to postoperative cTnI levels. The following were the exclusion criteria: 1. patients under 18 years old, 2. patients undergoing deceased-donor liver transplantation or dual liver-kidney transplantation, 3. cTnI elevation due to other causes (sepsis, renal failure, pulmonary embolism, myocardial infarction), and 4. patients without postoperative troponin levels. Results MINS occurred in 123 (57.4%) patients after LDLT. There was no difference between the groups according to age, sex, creatinine levels, presence of ischemic heart disease, hypertension, diabetes mellitus, and tobacco use. The presence of MINS did not predict 30-day and 1-year mortality in the study population. Conclusion Myocardial injury detected by serum cTnI elevation was frequent after LDLT; however, it was not associated with 30-day in-hospital and 1-year mortality.

Background Liver transplantation (LT) is an important treatment for acute liver failure and end-stage liver disease. Due to the limited supply of livers, there are still thousands of candidates waiting for transplantation in Turkey. We aimed to analyze LT waiting list access by demographics and etiology, particularly the diagnosis of hepatocellular carcinoma (HCC), which has been prioritized for LT in recent years. Materials and Methods Between 2011 and 2018, all patients listed for LT in our center were retrospectively reviewed. Demographic features, etiology of liver disease, waiting time, Model for End-Stage Liver Disease (MELD) score, and survival data were recorded. Differences between the LT group and deceased patients on the waiting list were evaluated. Results During this period, 266 patients were included in the LT waiting list. Only 119 patients (44.7%) underwent LT (men, 94; women, 25; mean age, 53 years), whereas 103 (38%) died (men, 60; women, 43; mean age, 53 years) in the waiting period. Seventeen patients were status 1A or 1B and of these, 7 patients died from fulminant hepatic failure. MELD score was significantly higher in deceased group (28 ± 7 vs 25 ± 6; P = .014). The frequency of HCC was significantly higher in LT group (29% vs 11%; P = .002). Overall survival of the patients in the waiting list with and without liver transplantation were 63% and 41%, respectively. Conclusions HCC is one of the leading etiologies that is considered for cadaveric LT from the waiting list in our center. These patients had slightly lower MELD scores compared to deceased patients with shorter waiting times. We recommend early referral and close monitoring of the patients who are LT candidates.

Background Venous outflow reconstruction of modified right-lobe liver grafts has been shown to prevent the occurrence of graft congestion and subsequent complications, including graft loss. In the present study, we aimed to investigate the safety and efficacy of Dacron grafts for venous reconstruction in living donor liver transplantation (LDLT). Methods Between January 2016 and January 2018, Dacron grafts were used in 148 liver transplants. Of these, 104 patients who had a follow-up computerized tomography (CT) scan were enrolled into the study. A total of 179 outflow hepatic veins including V5, V8, partial middle hepatic vein, and accessory inferior right hepatic veins (IRHV) were reconstructed using synthetic Dacron grafts. Graft patency was evaluated with both intraoperative Doppler ultrasonography following reconstruction, and a follow-up CT was performed on the postoperative day 7 (±1). Retrospective data collection included demographics, parameters for small-for-size (laboratory tests [bilirubin, International Normalized Ratio] and ascites) syndrome, postoperative morbidity, and mortality. Results Follow-up CT revealed graft patency in 155 out of 179 (86.6%) vascular grafts. Postoperative seventh-day patency rates for each reconstructed vein were as follows: V5, 87.5% (70/80); V8, 87.7% (50/57); partial middle hepatic vein, 100% (11/11); and IRHV, 77.4% (24/31). No major graft-related complications (early graft dysfunction, graft infection) or graft-related mortality were observed. None of the recipients developed small-for-size syndrome based on laboratory tests and clinical findings. Conclusions Dacron vascular grafts appear as an advantageous and useful alternative for venous outflow reconstruction in LDLT.

Purpose Estimation of graft volume is critical in living donor liver transplantation (LDLT). In this study, we aimed to evaluate the accuracy of software-aided automated computer tomography (CT) volumetry in the preoperative assessment of graft size for LDLT and to compare this method with manual volumetry. Materials and Methods Forty-one donors (27 men; 14 women) with a mean age in years ± standard deviation (28.4 ± 6.6) underwent contrast-enhanced CT prior to graft removal for LDLT. A liver transplant surgeon determined the weights of liver grafts using automated 3-dimensional volumetry software, and an abdominal radiologist specializing in liver imaging independently and blindly used the commercial interactive volumetry-assisted software on a viewing workstation to determine the liver volume on CT images. Both results were then compared to the weights of actual grafts obtained during surgery. Intraclass correlation coefficients were used to assess the consistency of numerical measurements and Pearson correlation coefficients were calculated to detect a linear relationship between numerical variables. To compare correlation coefficients, z scores were used. Results Regarding the right and left lobe graft volume estimation by the surgeon, there was a positive correlation between the results and actual graft weight ( r = 0.834; P = .001; and r = 0.587; P = .001, respectively). Likewise, graft volume estimation by the radiologist for the right and left lobe was also positively correlated with the actual graft weight ( r = 0.819; P = .001 and r = 0.626, P = .001, respectively). There was no significant difference between correlation coefficients ( P = .836). Conclusion Volumetric measurement of donor graft using 3-dimensional software provides comparable results to manual CT calculation of liver volume.

Purpose The variation of multiple bile ducts in a living donor graft is not infrequent; however, the literature on the impact of the number of bile ducts on postoperative biliary complications is scarce. We investigated whether the number of biliary duct anastomoses affects the rate of postoperative biliary complications in patients undergoing living donor liver transplantation (LDLT). Materials and Methods Between January 2016 and January 2018, all patients who underwent LDLT were reviewed. The patients were divided into 2 groups according to the number bile duct anastomoses (single duct [group A, n = 78] or multiple ducts [group B, n = 94]). Data collection included demographic features, Child Pugh Score (CPS), graft-recipient weight ratio (GRWR), surgical data including technique of biliary anastomosis (duct-to-duct, duct-to-sheath, double duct-to-duct, and hepaticojejunostomy), and postoperative morbidity and mortality. Results The duct-to-duct anastomosis was the mostly commonly performed technique in group A, whereas double duct-to-duct and duct-to-sheath were significantly higher in group B. Operating time was quite high in group B compared to group A (438 ± 72 minutes vs 420 ± 61 minutes, respectively; P = .05). Regarding biliary complications (n = 40, 23.2%), the rates of biliary leakage (n = 17, 9.9%) and strictures (n = 25, 14.5%) were similar in both groups (P = .164 and .773, respectively). CPS was positively correlated (for Child B and C, odds ratio [OR]: 10.669 and 17.866, respectively), whereas GRWR was negatively correlated (OR: 9.530) with biliary stricture. Increased risk for bile leakage was observed in younger donors (OR: .929). Although overall mortality rate was 9.8% (n = 17), only 5 of the patients (29%) died of biliary complications. Conclusion The number of biliary ducts and anastomoses did not affect the rate of complications. However, CPS, GRWR, and young donor age were found to be predisposing factors for postoperative biliary complications. Mortality was mostly based on the causes other than biliary complications.

Sepsis causes life-threatening organ dysfunction and is the leading cause of morbidity and mortality in critically ill patients worldwide. Mortality rate of sepsis is close to 30% to 50% despite better understanding of the pathophysiology of sepsis, and advances in antimicrobial therapy, resuscitation strategies, and mechanical ventilation. Liver failure is characterized by accumulation of potentially toxic substances in the systemic circulation of the patient. Toxic effects of these molecules can induce cellular injuries leading to multiorgan dysfunction. Hydrophobic unconjugated bilirubin and bile acids, hydrophilic conjugated bilirubin, and ammonium are the main toxins accumulated in liver failure. We carried out cytokine adsorbtion (CytoSorb) procedure with continuous venovenous hemodialysis in 12-hour sessions. The biochemical values of the patients before and after the use of the filter were recorded. The parameters compared were as follows: total bilirubin, direct bilirubin, C-reactive protein, leukocyte, neutrophil, alanine aminotransferase, aspartate aminotransferase, creatinine, colloid oncotic pressure, ammonia, gamma-glutamyl transferase, alkaline phosphatase, procalcitonin, hematocrit, hemoglobin, pH, albumin, international normalized ratio, fibrinogen, lactate dehydrogenase, platelet, temperature, changes in vasoactive medication requirement, temperature. According to these results, cytokine adsorption systems can be considered as an option to lower bilirubin levels in cases of liver failure. Its inability to lower ammonia level is considered a disadvantage compared with other bilirubin-lowering methods. Although further studies are needed to compare different methods, cytokine adsorption systems may be considered in treatment planning as it contributes to the treatment of sepsis and hyperbilirubinemia in liver failure patients with sepsis.

Objective To evaluate the diagnostic accuracy of Intravoxel Incoherent Motion (IVIM) parameters for assessment of tumor response after locoregional treatment (LRT) of hepatocellular carcinoma (HCC). Methods Fifteen patients with HCC who had undergone LRTs (11 transarterial radioembolization, 4 transarterial chemoembolization) were included. In addition to routine upper abdominal magnetic resonance imaging sequences, IVIM with 16 different b values and conventional diffusion weighted imaging with 3 different b factors were obtained immediately before and 8 weeks after LRTs. Magnetic resonance imaging response was evaluated according to modified Response Evaluation Criteria in Solid Tumors (mRECIST) and HCCs were categorized into 2 subgroups, responders and nonresponders. Quantitatively, the number of diffusion-changes were calculated with apparent diffusion coefficient (ADC) and IVIM parameters, including mean D (true diffusion coefficient), pseudo-diffusion coefficient associated with blood flow, and f (perfusion fraction) values. Subsequently, the pre- and post-treatment parameters were compared using the Mann-Whitney U test. Results Considering all HCCs, a significant decrease was observed according to mRECIST criteria (–38.43 ± 16.49). The ADC and D values after LRTs were significantly higher than those of the preceding ones. The f values after LRTs were significantly lower than those of pre-treatment. In the responders group, ADC and D values were significantly increased and f values were significantly decreased after LRTs. No difference of statistical significance was achieved in the nonresponders group. Conclusions ADC values and IVIM parameters appear to reflect the response of LRTs as effectively as those of mRECIST. This promises new horizons in the management of pretransplant patients, especially in renal insufficiency clinical settings, owing to the elimination of contrast media administration.

Purpose The aim of this study is to investigate the effects of risk scores (Pediatric End-stage Liver Disease [PELD], Child-Turcotte-Pugh [CTP], and Pediatric Risk of Mortality [PRISM-III]) of pediatric liver transplant patients on the postoperative period. Method Seven cadaveric and 45 living donors, totaling 52 pediatric liver transplantation (LT) patients, were reviewed retrospectively. PELD and CTP scores were calculated based on data at hospital admission. PRISM-III score was calculated from data during the first 24 hours of intensive care unit (ICU) admission. Hospital length of stay (LOS), ICU LOS, patients who developed acute kidney injury (AKI), requirement for inotropic-vasopressor therapy, hospital mortality, long-term mortality, duration of mechanical ventilation, metabolic disease, and demographic features were documented.For CTP score, class C was defined as high, and A and B as low. Cutoff values of PELD and PRISM-III scores were detected by using receiver operating characteristic curves. According to these cutoff values, patients were divided into 2 groups as high and low for each score. Documented data was analyzed and compared in groups for each score. Results Hospital LOS was significantly longer in the high-PELD (P = .01) and high-CTP (P = .01) groups. ICU LOS was significantly longer in the high-PRISM-III group (P = .01). Requirement for inotropic-vasopressor therapy was significantly higher in the high-PELD (P = .04) and high-CTP (P = .04) groups. Conclusion Hemodynamic instability and long hospital LOS can be expected in pediatric post-LT patients with high PELD or CTP scores; there is also the risk that AKI maybe higher for high-PELD score patients. Unexpectedly, the PRISM-III score did not have any correlation with the severity of physiological condition and mortality.

Background The aim of the present study is to assess acute kidney injury (AKI) incidence according to the pRIFLE and AKIN criteria and to evaluate the risk factors for early developing AKI in postoperative intensive care unit after pediatric liver transplantation (LT). Materials After exclusion of retransplantations, 7 cadaveric and 44 living donors, totaling 51 pediatric LT patients that were performed between 2005 and 2017, were reviewed retrospectively. AKI was defined according to both pediatric RIFLE (Risk for renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal disease) and Acute Kidney Injury Network (AKIN) criteria. Documented data were compared between AKI and non-AKI patients. Results AKI incidences were 17.6% by AKIN and 37.8% by pRIFLE criteria. AKIN-defined AKI group had statistically lower serum albumin level, higher serum sodium level, higher furosemide dose, and higher rate of red blood cell (RBC) transfusion than the non-AKI group (P = .02, P = .02, P = .01 and P = .04, respectively). AKI patients had significantly prolonged mechanical ventilation (P = .01) and hospital LOS (P = .02). The pRIFLE-defined AKI group had significantly lower serum albumin level, higher blood urea nitrogen (BUN) level, and higher ascites drained and also showed higher requirement for RBC and 20% human albumin transfusions than the non-AKI group (P = .02, P = .04, P: =.007, P = .02 and P = .05, respectively). Conclusion We evaluated that hypoalbuminemia, high requirement for RBC and 20% human albumin transfusions, high serum sodium, high furosemide use, and high flow of ascites are risk factors for AKI and high BUN levels can be predictive for AKI in pediatric LT patients. The effect of AKI on outcome variables were prolonged mechanical ventilation and hospital LOS.