The natural history of hepatitis C virus (HCV) infection following liver transplantation and predictors of disease severity remain controversial. The aims of the study were to assess in a homogeneous population of 81 cyclosporinebased HCV-infected liver transplant recipients mostly infected with genotype 1b and undergoing strict protocol annual biopsies: 1) the histological progression of posttransplantation HCV disease and, in particular, the incidence of HCV-related graft cirrhosis within the first 5 years after surgery; and 2) the relationship between progression to cirrhosis and i) rejection episodes and ii) first-year liver biopsy findings. We studied 81 consecutive HCV-RNApositive patients (96% genotype 1b) undergoing liver transplantation between 1991 and 1996 with a minimum histological follow-up of 1 year. All patients received cyclosporinebased immunosuppression and underwent protocol yearly liver biopsies for the first 5 years. The mean histological follow-up was 32 months (range, 12-60 months). Biopsies were scored according to the histological activity index (HAI), with separate evaluation of grade (activity) and stage (fibrosis). Histological hepatitis, present in 97% of patients in the most recent biopsy, was moderate or severe in 64%. Twelve patients developed HCV-related cirrhosis at a median time of 24 months (range, 12-48 months), with an actuarial rate of HCV-cirrhosis of 3.7%, 8.5%, 16%, 28%, and 28% at 1, 2, 3, 4, and 5 years, respectively. Rejection was significantly more common among patients with cirrhosis versus those without (83% vs. 48%; P ‫؍‬ .02), with an association between the incidence of cirrhosis and the number of rejection episodes: 5%, 15%, and 50% in patients without rejection, one and two episodes, respectively (P ‫؍‬ .001). The degree of activity and fibrosis score in the first-year biopsy were higher in patients who developed cirrhosis than in those who did not (P ‫؍‬ .008 and .18, respectively). Cirrhosis related to chronic infection with the hepatitis C virus (HCV) has emerged as one of the leading indications for orthotopic liver transplantation (OLT) worldwide, accounting for 50% of transplantation in Spain.

The aim of this study is to analyze the incidence, risk factors, management, and follow-up of patients with portal vein thrombosis (PVT) undergoing primary orthotopic liver transplantation (OLT). Four hundred fifteen OLTs were performed in 391 patients. In 62 patients, partial (group 1; n ‫؍‬ 48) or complete (group 2; n ‫؍‬ 14) PVT was found at the time of surgery. Portal flow was reestablished by venous thrombectomy. In this study, we compare 62 primary OLTs performed in patients with PVT at the time of OLT with a group of 329 primary OLTs performed in patients without PVT (group 3) and analyze the incidence of PVT, use of diagnostic methods, surgical management, and outcome. We found no significant differences among the 3 groups for length of surgery, cold and warm ischemic times, and postoperative stay in the intensive care unit. With the piggyback technique, groups 1 and 2 had greater blood losses and required more blood transfusions than group 3. The early reoperation rate was greater in group 2. The incidence of rethrombosis was 4.8% (group 1, 2%; group 2, 14.3%). Reexploration and thrombectomy (2 patients) and retransplantation (1 patient) had a 100% mortality rate. In particular, the mortality rate of patients with complete PVT with extension into the splanchnic veins is high (33%). Three-month and 4-year patient survival rates were statistically similar in the 3 groups. The presence of PVT at the time of OLT is not a contraindication for OLT. However, if PVT extends into the splanchnic veins, the outcome is guarded. (Liver Transpl 2001;7:125-131.)

Orthotopic liver transplantation (OLT) selection for patients with hepatocellular carcinoma (HCC) is a matter of debate. The Milan criteria (MC) have been largely adopted by the international community. The main aim of this study was to evaluate the survival rates and recurrence probabilities of a new proposal for criteria (up to 3 tumors, each no larger than 5 cm, and a cumulative tumor burden Յ 10 cm). Patients with cirrhosis and HCC included on the waiting list (WL) from 1991 to 2006 were retrospectively analyzed. Outcomes in patients who had tumors within and beyond the MC were compared. The survival analysis was done (1) with the intention-to-treat principle and (2) among transplanted patients. A total of 281 patients were included in WL. Twenty-four cases did not undergo OLT (a dropout rate of 8.5%); all but 1 case had tumors within the MC. Of the 257 transplanted patients, 26 had tumors beyond the MC in the pre-OLT evaluation. Based on the intention-to-treat analysis, the 5-year survival was 56% versus 66% in patients who had tumors within and beyond the MC, respectively (P ϭ 0.487). Among transplanted patients, the 5-year survival was 62% versus 69%, respectively (P ϭ 0.734). Through multivariate analysis, microvascular invasion was an independent prognostic factor of poor survival (P ϭ 0.004). The recurrence probabilities at 1 and 5 years were 7% versus 12% and 14% versus 28% in patients with tumors within and beyond the MC, respectively (P ϭ 0.063). The multivariate analysis demonstrated that both poorly differentiated tumors (P Ͻ 0.001) and microvascular invasion (P Ͻ 0.001) increased the risk of recurrence. The expansion to up to 3 nodules, each up to 5 cm, and a cumulative tumor burden Յ 10 cm did not result in a reduction of survival in comparison with patients who had tumors within the MC.

The aim of this study is to contribute our experience to the knowledge of the anatomic variations of the hepatic arterial supply. The surgical anatomy of the extrahepatic arterial vascularization was investigated prospectively in 1,081 donor cadaveric livers, transplanted at La Fe University Hospital from January 1991 to August 2004. The vascular anatomy of the hepatic grafts was classified according to Michels description (Am J Surg 1966;112:337-347) plus 2 variations. Anatomical variants of the classical pattern were detected in 30% of the livers (n ϭ 320). The most common variant was a replaced left artery arising from the left gastric artery (9.7%) followed by a replaced right hepatic artery arising from the superior mesenteric artery (7.8%). In conclusion, the information about the different hepatic arterial patterns can help in reducing the risks of iatrogenic complications, which in turn may result in better outcomes not only following surgical interventions but also in the context of radiological treatments. Knowledge of hepatic arterial vascularization has a significant relevance for the daily practice of a wide range of practitioners including not only surgeons specialized in the hepato-biliary-pancreatic area, but also general surgeons and radiologists, mainly those who are dedicated to interventional radiologic treatments.In the last few years, substantial improvements have been achieved in the surgical and/or radiological treatment of benign and malignant liver, pancreatic, and biliary diseases. With laparoscopic surgery the need has arisen for exact descriptions of the hepatic vascularization to avoid iatrogenic vascular lesions.In the setting of liver transplantation, the most effective approach to reduce the dropout rate on the waiting lists is to expand the number of available livers. Several strategies including living donors and split livers have been developed for this purpose. These are extremely complex techniques in which the exact knowledge of the arterial anatomy is a required step to plan the best resection as well as to minimize the risks of morbidity.The patterns of hepatic arterial supply are not constant. The usual anatomy of the hepatic arterial vascularization is a common hepatic artery arising from the celiac axis, accounting for 25 to 75% of the cases. 1 In the variant patterns, the hepatic lobes receive arterial flow through branches coming from the superior mesenteric artery, left gastric artery, or, rarely, from other arterial trunks. 2 Since Michels 3 published his first report, several studies have reported not only common and rare hepatic artery variants, but also different classifications. These studies are based on angiographic data and autopsy dissections, and mainly derive from surgery and transplantation literature. [4][5][6][7][8][9][10][11][12][13][14] The large sample size of transplanted livers is one of the major interests of this study. Indeed, harvested livers offer an excellent opportunity to describe, in situ, the anatomic variants of the arteries since all e...

Hepatocellular carcinoma (HCC) is still considered a controversial indication for liver transplantation (LT), mainly because of long waiting times and underlying viral cirrhosis. The goal was to evaluate the outcome of LT in 104 patients with HCC and cirrhosis, mainly hepatitis C virus (HCV)-related, in a center with a short waiting time (median, 105 days). Four groups were formed according to the HCC and HCV status: HCV positive with HCC (group 1, n ‫؍‬ 81), HCV negative with HCC (group 2, n ‫؍‬ 23), HCV positive without HCC (group 3, n ‫؍‬ 200), and HCV negative without HCC (group 4, n ‫؍‬ 207). Predictive factors of tumor recurrence were demographics, tumor related (size or number of nodules, capsule, bilobar involvement, vascular or lymphatic invasion, clinical and pathologic TNM staging, pre-LT percutaneous ultrasound-guided ethanol injection or transarterial chemoembolization, ␣-fetoprotein levels), donor and surgery related, and year of transplantation. The same variables and "tumor recurrence (yes/no)" were applied to evaluate the effect on survival. The median follow up was 29 months (range, 0 to 104 months). Patient survival was 70% at 1 year and 59% at 5 years for group 1, 87% at 1 year and 77% at 5 years for group 2, 81% at 1 year and 64% at 5 years for group 3, and 88% at 1 year and 77% at 5 years for group 4 (P ‫؍‬ .013). Survival was significantly lower in patients with HCC than in those without (74% and 63% versus 85% and 70%, at 1 and 5 years, respectively; P ‫؍‬ .05). The causes of death in those with and without HCC were tumor recurrence (24%) and recurrent HCV (8%) versus sepsis (34%) and recurrent HCV (14%). HCC recurrence occurred in 12 patients (11.5%) at a median of 14 months (range, 3 to 60 months) with a probability increasing from 8% at 1 year to 16% at 5 years. In patients with HCC, tumor recurrence was associated with vascular invasion (P ‫؍‬ .0004) by multivariate analysis; variables predictive of survival were donor old H epatocellular carcinoma (HCC) is the most frequent primary liver cancer worldwide, responsible for more than 1 million deaths yearly. 1 Without specific interventions, the mean survival time in patients with HCC in advanced stages is approximately 1 to 2 months, and that of patients with HCC in early stages only reaches 9 to 10 months. 2 Data from our country are slightly more optimistic, with survival rates of 3 and 15 months, respectively. 3 In a large recent prospective study based on cirrhotic patients with HCC, the median survival time was 17 months, ranging from 1 to 60 months, with a cumulative survival rate at 1, 3, and 5 years of 54%, 40%, and 28%, respectively. 4 Surgical resection is the only procedure capable of achieving a complete cure of this disease, and in that sense, it is likely that liver transplantation (LT) might be the best available oncologic option. 5 During the early years of transplantation activity, transplantation was only used in patients with large tumors. Unfortunately, results were highly disappointing because of the high rates of ...