ObjectiveThis study analyzed the incidence and timing of biliary tract complications after orthotopIc liver transplantation (OL Tx) in 1792 consecutive patients. These results were then compared with those of previously reported series. Finally, recommendations were made on appropriate management strategies. Summary Background DataTechnical complications after OL Tx have a significant Impact on patient and graft survival. One of the principle technical advances has been the standardization of techniques for biliary reconstruction. Nonetheless. biliary complications stili occur. A 1983 report from the University of Pittsburgh reported biliary complications in 19% of all transplants, and an update in 1987 reported biliary complications In 13.2% of transplants. MethodsThe medical records of all patients who underwent liver transplantation and were hospitalized between January 1,1988 and July 31.1991 were revieWed. The case matenal conSisted of the medical records of 217 patients treated for 245 biliary complICations. Results Primary biliary continuity was established by either choledochocholedochostomy over a T·tube(C-C, n = 129) or a Roux-en-Y choledochoJeJunostomy With an internal stent (C-RY, n = 85). The overall Incidence for biliary complication in this large senes was 11.5%. Strictures (n = 93) and bile leak (n = 58) were the most common complications (69.6%). Most biliary complications (n = 143, 66%) occurred Within the first 3 months after surgery. In general, leaks occurred early, and strictures developed later. Bile leaks were equally frequent In both C-C and CoRY (27.1 % and 25.9%, respectively): strictures were more common after a CoRY type of reconstruction (36.4% and 52.9%, respectively). Twenty-one patients died, an InCidence of 9.6%. Fifteen of the 21 biliary-related deaths were among patients treated for rejectIOn before the recognition of biliary tract pathologiC findings. 40

Given the shortage of cadaveric organs, we began a study utilizing NHBD for OLTx and KTx. There were 24 NHBD between January 1989 and September 1993. These donors were divided into 2 groups: uncontrolled NHBD (G1) (n = 14) were patients whose organs were recovered following a period of CPR; and controlled NHBD (G2) (n = 10) were patients whose organs were procured after sustaining cardiopulmonary arrest (CA) following extubation in an operating room setting. Eight kidneys and 5 livers were discarded because of macroscopic or biopsy findings. In G1, 22/27 (81.5%) kidneys were transplanted; 14/22 (64%) developed ATN; 20/22 (95%) recipients were off dialysis at the time of discharge. With a mean follow-up of 32.7 +/- 21.1 months, sixteen (73%) kidneys are still functioning, with a mean serum creatinine of 1.7 +/- 0.6 mg/dl. The one-year actuarial patient and graft survivals are 95% and 86%. In G2, 17/20 (85%) kidneys were transplanted; 13/17 (76%) kidneys experienced ATN. All patients were off dialysis by the time of discharge. With a mean follow-up of 17.6 +/- 15.4 months, twelve (70%) kidneys are still functioning, with a mean serum creatinine of 2.5 +/- 2.1 mg/dl. The one-year actuarial patient and graft survivals are 94% and 82%, respectively. In G1, 6/10 (60%) livers were transplanted; 3/6 (50%) livers functioned, the other 3 patients required ReOLTx in the first week postoperatively because of PNF (n = 2) and inadequate portal flow (n = 1). Two functioning livers were lost due to HAT (n = 1) and CMV hepatitis (n = 1). In G2, 6/7 (85.7%) livers were transplanted. All the livers (100%) functioned. 2 patients required ReOLTx for HAT at 0.9 and 1.0 months. Both patients eventually died. One patient with a functioning liver died 2 months post OLTx. The remaining 3 patients are alive and well at 27 months of follow-up. This study shows that the procurement of kidneys from both uncontrolled and controlled NHBD leads to acceptable graft function despite a high incidence of ATN. The function of liver allografts is adequate in the controlled NHBD but suboptimal in the uncontrolled NHBD, with a high rate of PNF.

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Fibrolamellar hepatoma (FL-HCC) is an uncommon variant previously reported4-6 ), less than 100 such cases can be found in the literature. 2,3,[7][8][9][10][11][12][13][14][15][16][17] In our series, we have compared the of hepatocellular carcinoma (HCC), distinguished by histopathological features suggesting greater differentiation than survival of patients with FL-HCC with that of patients with conventional HCC who were treated by the same team over conventional HCC. However, the optimal treatment and the prognosis of FL-HCC have been controversial. Follow-up a 27-year period. studies are available from 1 year to 27 years, after 41 patients with FL-HCC were treated with partial hepatectomy (PHx) PATIENTS AND METHODS (28 patients) or liver transplantation (13 patients). In thisCase Material retrospective study, the effect on outcome was determined for the pTNM stage and other prognostic factors routinely Between 1968 and 1995, 477 (range, 9-66; median, 25) (Fig. 1). The median follow-up was 58 tumor-free survival than those with negative nodes (P õ .015).{ 9.3 months. Patient survival was most adversely affected by the presence of vascular invasion (P õ .05). FL-HCC is an indolently grow- Clinicopathological Characteristicsing tumor of the liver, which usually was diagnosed in our patients at a stage too advanced for effective surgical treatmentThe pathology reports and operative findings were used to deterof most conventional HCC. Nevertheless, long-term survival mine: the principal tumor size, number of lesions, lobar distribufrequently was achieved with aggressive surgical treatment. tion, vascular and lymphatic tumor extension, surgical margins, When a subtotal hepatectomy could not be performed, total distant metastases, and the presence or absence of associated cirrhosis. When available, the tumor markers were recorded as well as hepatectomy (THx) with liver transplantation was a valuable the virus markers (hepatitis C virus, hepatitis B virus).

Hepatocellular carcinoma (HCC) is one of the most com-SEE EDITORIAL ON PAGE 507 mon neoplasms worldwide, with an estimated incidence of approximately one million new cases annually. Initially, it was believed that nonresectable hepatic cell malignancy Orthotopic liver transplantation (OLTx) in the presence of would be an ideal indication for orthotopic liver transplantahepatocellular carcinoma (HCC) has been complicated by tion (OLTx). However, as experience accumulated, it soon high recurrence rates. The ability to determine the risk and became obvious that this form of therapy resulted in a higher timing of HCC recurrence on an individual basis would than expected recurrence rate. 1 The current literature is regreatly aid in the candidate selection process resulting in a plete with conflicting recommendations about which tumor more efficient use of donated organs and allow the individualcharacteristics are responsible for HCC recurrence, thereby ization and better evaluation of adjuvant chemotherapy. The yielding disparate suggestions about which groups of patients 214 patients who underwent OLTx in the presence of HCC with HCC should be transplanted. [2][3][4][5][6][7][8] Because each tumor were analyzed. From the 178 patients who survived more characteristic that influences recurrence does not do so than 150 days, 71 (40%) have suffered HCC recurrence. Based equally, and because the timing of recurrence is as crucial, on five risk factors, that is, gender, tumor number, lobar if not more so, than recurrence itself in determining transtumor distribution, tumor size, grade of vascular invasion, plantation candidacy, the ideal solution would be to develop artificial neural network models predicting the likelihood of a multivariate model that could predict both the risk of HCC HCC recurrence within 1, 2, and 3 consecutive years after recurrence for each individual patient and the timing of retransplantation were developed. Based on model predictions, currence. If such a system could be developed, not only could those combinations of risk factors that should/should not lead it aid in the donor liver allocation process by determining to recurrence were generated, allowing stratification of pa-the subgroup(s) of HCC patients for whom OLTx is most tients into the following three groups: 1) patients who should appropriate, but it could also be valuable in determining for not suffer HCC recurrence and who should not need adjuvant which patients cytoreductive adjuvant therapy would be therapy, 2) patients who will suffer recurrence and for whom most beneficial (i.e., given only to patients who are at risk postoperative chemotherapy significantly prolonged survival of recurrence after OLTx). 9-13(but did not prevent recurrence), and 3) patients who mayIn an effort to achieve the above stated goals, we investior may not suffer HCC recurrence and whose recurrence may gated the feasibility of developing a multivariate clinical be prevented by adjuvant chemotherapy. The outcome of model that could predict on an individual p...