Hepatic Hilar and Sectorial Vascular and Biliary Anatomy in Right Graft Adult Live Liver Donor Transplantation

Abstract Introduction The aim of this study was to analyze vascular and biliary variants at the hilar and sectorial level in right graft adult living donor liver transplantation. Methods From January 2003 to June 2007, 139 consecutive live liver donors underwent three-dimensional computed tomography (3-D CT) reconstructions and virtual 3-D liver partitioning. We evaluated the portal (PV), arterial (HA), and biliary (BD) anatomy. Results The hilar and sectorial biliary/vascular anatomy was predominantly normal (70%–85% and 67%–78%, respectively). BD and HA showed an equal incidence (30%) of hilar anomalies. BD and PV had a nearly identical incidence of sectorial abnormalities (64.7% and 66.2…

Orthotopic Liver Transplantation: T-Tube or Not T-Tube? Systematic Review and Meta-Analysis of Results

Background The purpose of this study was to compare outcomes after duct-to-duct anastomoses with or without biliary T-tube in orthotopic liver transplantation. Methods We pooled the outcomes of 1027 patients undergoing choledocho-choledochostomy with or without T-tube in 9 of 46 screened trials by means of fixed or random effects models. Results The "without T-tube" and "with T-tube" groups had equivalent outcomes for: anastomotic bile leaks or fistulas, choledocho-jejunostomy revisions, dilatation and stenting, hepatic artery thromboses, retransplantation, and mortality due to biliary complications. The "without T-tube" group had better outcomes when considering "fewer episodes of cholangi…

Intrahepatic biliary anatomy derived from right graft adult live donor liver transplantation

Abstract Objective The successful management of the bile duct in right graft adult live donor liver transplantation requires knowledge of both its central (hilar) and distal (sectorial) anatomy. The purpose of this study was to provide a systematic classification of its branching patterns to enhance clinical decision-making. Patients and Methods We analyzed three-dimensional computed tomography (3-D CT) imaging reconstructions of 139 potential live liver donors evaluated at our institution between January 2003 and June 2007. Results Fifty-four (n = 54 or 38.8%) donor candidates had a normal (classic) hilar and sectorial right bile duct anatomy (type I). Seventy-eight (n = 78 or 56.1%) cases…

Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. “Neural networks” as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial …

A New Systematic Classification of Peripheral Anatomy of the Right Hepatic Duct: Experience From Adult Live Liver Donor Transplantation

Abstract Objective The peripheral intrahepatic biliary anatomy, especially at the sectorial level on the right side, has not been adequately described. The purpose of our study was to systematically describe this complex anatomy in clinically applicable fashion. Patients and Methods We analyzed three-dimensional computed tomography (CT) imaging reconstructions of 139 potential living liver donors evaluated at our institution between January 2003 and June 2007. Results Eighty-nine (64%) donors had a normal right bile duct sectorial anatomy. In the other 50/139 (36%) cases, we observed abnormal sectorial branching patterns, with 45/50 abnormalities as trifurcations, whereas the remaining ones…

Living Donor Liver Transplantation for Hepatocellular Carcinoma in Patients Exceeding the UCSF Criteria

Abstract Background Living donor liver transplantation (LDLT) represents an alternative to expand the organ pool for adult patients with hepatocellular carcinoma (HCC) and end-stage liver disease. The purpose of this study was to demonstrate our institutional experience using criteria exceeding those of the University of California San Francisco (UCSF). Patients and Methods Between September 1998 and December 2006, 22 LDLTs were performed for HCC among patients exceeding the UCSF criteria. Results There were 17 men and 5 women of median age 55 years. Multifocal tumors were present in 19 of 22 patients. Tumor grading was: grade I (n = 8), grade II (n = 10), and grade III (n = 4). Microvascul…

Anatomical Classification of the Peripheral Right Hepatic Duct: Early Identification of a Preventable Source of Morbidity and Mortality in Adult Live Donor Liver Transplantation

Abstract Introduction The purpose of this study was to determine the impact of our classification on right graft adult live donor liver transplantation (ALDLT) outcomes. Methods Three-dimensional computed tomography (CT) reconstructions were used to classify the hilar and sectorial biliary anatomy of 71 consecutive live liver donors. Four possible clinical types were defined, based on the normal (N) or abnormal (A) features of the corresponding hilar/sectorial ducts: type I, N/N; type II, N/A; type III, A/N; and type IV, A/A. We subsequently performed an analysis of the operative outcomes based on the donor anatomy. Results Type I was encountered in 47.9% of cases, type II in 29.6%, type II…

“Anatomical” versus “Territorial” Belonging of the Middle Hepatic Vein: Virtual Imaging and Clinical Repercussions

Background Venous drainage patterns are of vital importance in live donor liver transplantation. The purpose of this study was to delineate “anatomical-topographical” and “territorial-physiologic” patterns of the middle hepatic vein (MHV) in a 3-D liver model as determined by the Pringle line and its drainage volume of the right and left hemilivers. Methods One hundred thirty-seven consecutive live donor candidates were evaluated by 3-D CT reconstructions and virtual hepatectomies. Based on right (R) and left (L), anatomical (A) and territorial (T) belonging patterns of the MHV, each individual was assigned to one of four possible types: type I:AR–TR; type II:AL–TL; type III:AR–TL; type IV:…

Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes

Abstract Background The objective of this study was to examine the outcomes of comparisons between laparoscopic and open mesh repairs in the setting of recurrent inguinal hernia. Methods The electronic databases MEDLINE, Embase, Pubmed, and the Cochrane Library were used to search for articles from 1990 to 2008. The present meta-analysis pooled the effects of outcomes of a total of 1,542 patients enrolled into 5 randomized controlled trials and 7 comparative studies, using classic and modern meta-analytic methods. Results Significantly fewer cases of hematoma/seroma formation were observed in the laparoscopic group in comparison with the Lichtenstein group (odds ratio, .38; .15–.96; P = .04…

Corticosteroid-free immunosuppression in liver transplantation: a meta-analysis and meta-regression of outcomes.

To examine the impact of steroid withdrawal from the immunosuppression protocols in liver transplantation. The electronic databases Medline, Embase, Pubmed and the Cochrane Library were searched. Meta-analysis pooled the effects of outcomes of a total of 2590 patients enrolled into 21 randomized controlled trials (RCTs), using classic and modern meta-analytic methods. Meta-analysis of RCTs addressing patients transplanted for any indication showed no differences between corticosteroid-free immunosuppression and steroid-based protocols in most of the analyzed outcomes. More importantly, steroid-free cohorts appeared to benefit in terms of de novo diabetes mellitus development [R.R = 1.86 (1.…

Liver transplantation with grafts from septuagenarians.

Abstract Background The purpose of this study was to evaluate our experience with orthotopic liver transplantation (OLT) using grafts from septuagenarians. Patients and Methods Seventeen adult patients underwent transplantation with grafts from donors 70 years of age or older during an 8-year period. Results The median donor age was 73 years (range, 70–83). Eleven (64.7%) donors had experienced at least 1 hypotensive period and received vasoactive drugs. Median cold and warm ischemia times were 7.25 hours and 35 minutes, respectively. Two recipients underwent retransplantation because of dysfunction or primary nonfunction. Morbidity rate was 47% and hospital mortality rate was 23.5%. After …

Liver transplantation for hepatocellular carcinoma with intrahepatic lymphatic invasion: case reports.

Multiple studies addressing liver transplantation (OLT) for hepatocellular carcinoma (HCC) have identified various prognostic determinants of tumor recurrence and decreased patient survival. However, little information is available on the impact of intrahepatic lymphatic invasion on tumor recurrence and survival after OLT for HCC. Intrahepatic lymphatic invasion was observed in 1.4% (n = 2) of liver explants with HCC in our series. Both recipients are alive without tumor recurrence at 16 and 39 months post-OLT, respectively. Intrahepatic lymphatic invasion may not be an absolute adverse prognostic factor in cases of HCC with no hilar lymph node involvement at the time of OLT.

Liver Transplantation for Hepatocellular Carcinoma After Yttrium Therapy: A Case Report

Yttrium-90 microspheres constitute one of the most recent treatment options for hepatocellular carcinoma (HCC) in the setting of cirrhosis. As such, their spectrum of indication is not yet fully established. Herein, we have reported the case of a patient with HCC beyond the listing criteria for liver transplantation (OLT) who was treated preoperatively with selective transarterial chemoembolization and yttrium-90 microspheres. He was subsequently transplanted with a liver from an 81-year-old donor allocated through Eurotransplant as a "rescue offer." The posttransplant course was uneventful. Pathologic examination revealed a multifocal, well-differentiated pT2 tumor with no vascular invasio…

Liver "Compliance": A previously unrecognized preoperative predictor of small-for-size syndrome in adult living donor liver transplantation

The purpose of this study was to investigate the effect of liver compliance on computed tomography (CT) volumetry and to determine its association with postoperative small-for-size syndrome (SFSS).Unenhanced, arterial, and venous phase CT images of 83 consecutive living liver donors who underwent graft hepatectomy for adult-to-adult living donor liver transplantation (ALDLT) were prospectively subjected to three-dimensional (3-D) CT liver volume calculations and virtual 3-D liver partitioning. Graft volume estimates based on 3-D volumetry, which subtracted intrahepatic vascular volume from the "smallest" (native) unenhanced and the "largest" (venous) CT phases, were subsequently compared wi…

Donor/recipient algorithm for management of the middle hepatic vein in right graft live donor liver transplantation

Abstract Background The aim of this study was to delineate an algorithm for donor and recipient criteria and middle hepatic vein (MHV) management in right-graft live-donor liver transplantation (LDLT) on the basis of computerized 3-dimensional computed tomographic image analysis. Methods Data on 94 consecutive right-graft LDLTs were prospectively collected. Graft and remnant data for the first 23 cases were retrospectively evaluated by means of 3-dimensional computed tomographic reconstructions, and on the basis of that preliminary series, a graft selection algorithm using 3 parameters—hepatic vein dominance classification, graft and remnant graft volume/body weight ratios, and congestion v…

Superficial esophageal cancer: endoscopic resection or radical surgery?

Dissection of lymph node metastases in esophageal cancer.

There has been much recent debate regarding the best surgical procedure to treat esophageal cancer, in particular with regard to the optimum extent of lymphadenectomy to improve survival while minimizing morbidity. No results obtained by prospective, randomized studies on the comparison of radical esophagectomy and extended lymphadenectomy with limited or less invasive resections following neoadjuvant therapy with regard to perioperative morbidity and prognosis are available to date. Until now, there has been no evidence suggesting the usefulness of sentinel lymph node navigation in esophageal cancers, regardless of the cell type. Furthermore, the question as to the benefits and risks of tw…

Detection of lymph node metastases in esophageal cancer.

Lymph node status is the most important single prognostic factor in esophageal cancer. The detection of involved lymph nodes is therefore the key to cure. This article will provide a meta-analysis and metaregression analysis on the diagnostic performances of current lymph node-detection devices; discuss the recent status of the sentinel lymph node concept in esophageal cancer by the two sentinel node-mapping procedures (the radio-guided and the blue dye techniques) and the developing computed tomography (CT) lymphography; discuss the detection of micrometastases; and the potential clinical application of molecular-based patients' profiles. Combined use of endoscopic ultrasonography fine-nee…

Risk of lymph node metastasis in submucosal esophageal cancer: a review of surgically resected patients

Endoscopic local procedures are increasingly applied in patients with superficial esophageal cancer as an alternative to radical oncologic resection. The objective of this article is to determine the risk of nodal metastases in submucosal (sm) esophageal cancer, comparing the two predominating histologic tumor types, squamous cell cancer (SCC) and adenocarcinoma (ADC).A query of PubMed, MEDLINE, Embase and Cochrane Library (1980-2009) using predetermined search terms revealed 675 abstracts, of which 485 full-text articles were reviewed. A total of 105 articles met the selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion.…

Five-Year Survival After Monotherapy for Hepatocellular Carcinoma in the Setting of Cirrhosis

The purpose of this study was to evaluate the long-term results with monotherapy for hepatocellular carcinoma (HCC) in the setting of cirrhosis. We reviewed data of 14 patients who survived for at least 5 years after performance of liver resection (n = 1), transarterial chemoembolization (TACE, n = 3), or liver transplantation (OLT, n = 19). Eight patients were within the Milan criteria, whereas the remaining 6 were beyond the criteria. Tumor stages according to the UICC were I (n = 8), II (n = 5), and IIIA (n = 1). Vascular invasion was not detected in any patient. The HCCs recurred in 2 patients, at 81 and 48 months' posttransplant. Sites of recurrence were the intrathoracic lymph nodes i…

Transanal Endoscopic Microsurgery for T1 and T2 Rectal Cancers: A Meta–Analysis and Meta-Regression Analysis of Outcomes

The objective of this study is to assess transanal endoscopic microsurgery (TEM) as a surgical strategy for stage I rectal cancer. The literature lacks level I and level II evidence of the oncologic competence of TEM. Three randomized controlled, one prospective, and seven retrospective comparative studies were evaluated. End-points included perioperative outcomes, margin involvement, disease-free and overall survival, and recurrence. The number of patients with major (odds ratio (OR) = 0.24,95% confidence interval (CI) 0.07–0.91) and overall postoperative complications (OR = 0.16, 95% CI 0.06-0.38) were significantly lower in TEM. The disease-free survival was higher in standard resection…

Prediction model of lymph node metastasis in superficial esophageal adenocarcinoma and squamous cell cancer including D2-40 immunostaining

Background It was the aim of our study to establish a model for prediction of lymph node metastases in superficial esophageal cancer. Methods We analyzed the clinical and histopathological data of 50 consecutive patients with pT1-esophageal cancer who underwent oncological resection. Submucosal carcinomas (pT1b) were classified according to sm levels 1–3. D2-40 immunostaining was investigated using the ABC technique. In a first step, we performed univariate analysis (One-way ANOVA: Sigma restricted parameterization; test of SS whole vs. SS predicted) to test the predictive value of the following categorical parameters for lymph node status (positive/negative): sex, histologic tumor type, lo…

Impact of Minimally Invasive Surgery in the Spectrum of Current Achalasia Treatment Options

Minimally invasive Heller myotomy has evolved the “gold standard” procedure for achalasia in the spectrum of current treatment options. The laparoscopic technique has proved superior to the thoracoscopic approach due to improved visualization of the esophagogastric junction. Operative controversies most recently include the length of the myotomy, especially of its fundic part, with respect to the balance between postoperative persistent dysphagia and development of gastroesophageal reflux, as well as the type of the added antireflux procedure. Perioperative mortality should approach 0%, and favorable long-term results can be achieved in > 90%.

Incidence of liver retransplantation and its effect on patient survival.

Purpose. The purpose of this study was to review our institutional experience with re-liver transplantation (OLT) after split and full-size OLT. Patients and methods. We evaluated data corresponding to retransplanted patients over an 8-year period who underwent deceased donor OLT at our institution. Variables analyzed included indications for primary OLT, and re-OLT, the type of graft used during the initial versus re-OLT, the time from initial to re-OLT, and patient survival after re-OLT. Results. Sixty-four of 697 first OLT (9.2%) required re-OLT. Forty-nine cases were among 637 (7.6%) full-size OLT, while 15 were among 60 (25%) split OLT (P <.001). Median time to re-OLT was 8 days (range…

Territorial belonging of the middle hepatic vein in living liver donor candidates evaluated by three-dimensional computed tomographic reconstruction and virtual liver resection.

Abstract Background Postoperative venous congestion can lead to graft and remnant liver failure in living donor liver transplantation. This study was designed to delineate ‘territorial belonging’ of the middle hepatic vein (MHV) and to identify hepatic venous anatomy at high risk of outflow congestion. Methods MHV belonging patterns for right (RHL) and left (LHL) hemilivers were evaluated by three-dimensional computed tomographic reconstruction and virtual hepatectomy in 138 consecutive living liver donor candidates. Results The right hepatic vein (RHV) was dominant in 84·1 per cent and an accessory inferior hepatic vein (IHV) was present in 47·1 per cent of livers. Three MHV belonging type…

Comparison between Minimally Invasive Video-Assisted Thyroidectomy and Conventional Thyroidectomy: Is There Any Evidence-Based Information?

The aim of this study was to test the hypothesis that minimally invasive video-assisted thyroidectomy (MIVAT) affords comparable safety and efficacy as to the open conventional surgery in dealing with patients with small thyroid nodules.Randomized controlled trials comparing the MIVAT with open thyroidectomy were ascertained by methodical search using Medline, Embase, Pubmed, and The Cochrane Library. Primary meta-analysis outcomes were adverse events (laryngeal nerve palsy and hypoparathyroidism), and cosmesis and secondary outcomes were operative time, blood loss, and early and late postoperative pain.Operative time was significantly less with open thyroidectomy than with MIVAT, while MIV…

Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience.

Abstract Background Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC). Patients and Methods Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration. Results Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Tho…

The use of neural networks in identifying risk factors for lymph node metastasis and recommending management of t1b esophageal cancer.

The objective of this study was to establish a prediction model of lymph node status in T1b esophageal carcinoma and define the best squamous and adenocarcinoma predictors. The literature lacks a satisfactory level of evidence of T1b esophageal cancer management. We performed an analysis pooling the effects of outcomes of 2098 patients enrolled into 37 retrospective studies using “neural networks” as data mining techniques. The percentages for lymph node, lymphatic (L1), and vascular (V1) invasion in Sm1 esophageal cancers were 24, 46, and 20 per cent, respectively. The same parameters apply to Sm2 with 34, 63, and 38 per cent as opposed to Sm3 with 51, 69, and 47 per cent. The respective …

Prognostic scoring system predictive of survival after surgical resection of esophageal carcinoma.

BACKGROUND The aim of our study was to develop a prognostic index score for patients undergoing surgical resection for esophageal cancer that accurately determines survival with specific clinicopathological characteristics. METHODS Clinical, histological, and demographical variables of 475 patients were entered in an univariate and multivariate regression model, followed by individual calculation of the Prognostic Indicator Score and model validation via simulation. RESULTS Significant variables included in the scoring system were number of positive lymph nodes, pT, pL, R, obesity, and American Society of Anesthesiologist classification. Survival probability and its associated hazard functi…