every month during and after therapy.Each episodes of decompensation was recorded.Results: Between April 2015 and June 2016, 41 patientswith decompensated HCV-related LC with median baseline CTP score of 9 (range 7 to 13), CTP B/C (23/18), median MELD score of 14 (range 8 to 35), median liver stiffness median 40.7 kpa (range 17 to 75).Twenty (20), 12 and 9 patients were having MELD of <15, 15-20 and >20 respectively.Thirty five patient (87.5%) had genotype 3, four (9.7%) had genotype 1 and one (1.4%) each had genotype 2 and 4 infections.37 patients were treatment naïve while 4 patients were treatment experienced (PEG-IFN-RBV failures).Between April 2015 and January 2016, SOF was used with ribavirin (RBV) for 24 weeks (n = 13).After January 2016, SOF-daclatasvir for 24 weeks (n = 16), SOF-DCV-RBV for 12/24 weeks (n = 7), SOF-ledipasvir for 12/24 weeks (n = 5).Thirty nine patients (95.1%) completed while 2 patients discontinued treatment due to worsening liver function.All patient achieved ETR response.21 patient achieved SVR12 and SVR12 is awaited for rest of the patient, 70% (29/41) patient showed improvement of liver functions with improvement in MELD score by ≥2 points and CTP score≥2 points at treatment completion or at 3 month after completion of therapy.Four patient required hospitalisation for worsening ascites during therapy or follow up.Conclusions: In decompensated cirrhosis sofosbuvir and daclatasvir/ ledipasvir are safe and effective.

Background. In chronic liver diseases of different etiologies, including viral hepatitis, genotoxic effects of oxidative stress have been shown, both in clinical and in experimental conditions, suggesting that this mechanism may contribute to the evolution of the disease. Aim. To evaluate DNA damage in the peripheral blood of untreated non-diabetic patients with chronic hepatitis C and control subjects, and its correlation with demographic, anthropometric, biochemical, and histological parameters in the patient sample. Patients and methods. This study comprised 100 subjects of both genders, 60 of whom were treatment-naive patients with positive serology for genotype 1 hepatitis C. The remaining 40 were blood donors with negative serology for hepatitis who were used as control subjects, and matched by gender, age, weight, and BMI. DNA damage was determined using the comet assay in the total peripheral blood. Results. The DNA damage evaluated by the comet assay revealed higher values in the group of patients with hepatitis compared with that in the control group. The relationships of the comet assay with the studied variables were assessed using multivariate analysis; significant correlations were only identified with insulin (r = 0.343, p = 0.008) and Homeostasis Model Assessment Insulin Resistance (HOMA-IR) (r = 0.331, p = 0.011). Conclusion. Patients with genotype 1 chronic hepatitis C have higher rates of DNA damage, as determined by comet assay and this alteration is correlated with the HOMA index of insulin resistance.

POSTERSor African-Americans.Maximum decreases in hemoglobin (Hb), neutrophils, platelets, and weight were assessed by virologic response status (SVR, relapse, breakthrough, and nonresponder) and by race/ethnicity.Results: Of 1778 HCV genotype 1, 4, 5, or 6 patients analyzed, the majority were male, non-Hispanic Caucasians, with baseline HCV RNA >800,000, and ALT ≤3×ULN.Mean baseline BMI was 27.5 kg/m 2 .Adjusted* Mean Maximum Decreases from Baseline Viral Response and Race/Ethnic Groups Neutrophils in 10 9 /L, Mean (SE) Platelets in 10 9 /L, Mean (SE) Hb in g/dL, Mean (SE)

Split liver transplantation is considered the most effective method for increasing the human liver graft pool. Two techniques are currently in use for splitting liver grafts. In the classic "ex situ" technique the division of the hilar structures as well as of the liver parenchyma is performed on the back table, after harvesting. Since the first case reported by Pichlmayr et al. (1) in 1988, this method has been performed in several centers (2-4). Although increasing experience has been achieved during these years, the results obtained with the ex situ technique are inferior when compared with other procedures such as whole, reduced, and living donor graft transplantation (5). Two major problems can be identified in the ex situ technique: the difficulty to properly recognize the hilar structures during bench dissection, particularly the arterial and biliary elements, which may lead to bile duct devascularization and biliary complications in the recipient, and the extended cold ischemia time expended during the back table work, which includes the usual whole graft preparation, dissection and division of hilar structures after a cholangiogram, and the complete separation of liver parenchyma. Recently, Rogiers et al. (6) described the "in situ" technique in which hilar and parenchymal division are completed before graft perfusion, without vascular supply interruption, as in the living donor operation. This method provided excellent results with significant lower graft dysfunction and biliary complication rates (7, 8). The clear advantages of the in situ technique are: appropriate observation of hilar anatomy, allowing preservation of the bile duct and/or hepatic duct irrigation, reduction of cold ischemia time, and less bleeding from the cut surfaces of both grafts. Nevertheless, the major problem for the routine utilization of the in situ procedure is the significant extension of operation time, which can be harmful to the multiorgan donor, leading to a low rate of acceptance by other organ transplant teams. We devised a combined technique for splitting liver grafts that is carried out with minimal in situ dissection, followed by multiorgan perfusion and completion of hilar and parenchymal separation on the back table. The aim of this approach is to properly recognize the anatomic structures with minimal increase of donor operation time and an easier back table division of the graft, associating the advantages of both methods currently used. After standard preparation for multiorgan perfusion, the hepatic hilum is approached. The left hepatic artery and the left branch of the portal vein are carefully identified. However, these vessels are not completely dissected at this moment. Next, a small portion of liver parenchyma is sectioned starting from the hepatic edge toward the hilum, down to the hepatic duct. A cholangiogram is performed through the cystic duct for biliary anatomy evaluation and choosing the best site for sectioning. The left hepatic duct is severed, and the stump is closed at the common hepatic duct level. Next, multiorgan perfusion and harvesting are carried out as usual. Back table preparation is performed in the same way as for whole grafts. Hilar dissection, previously initiated in situ, is now completed. The left hepatic artery is sectioned at the point determined during the in situ dissection, and the portal vein left branch is severed at the portal bifurcation level. These maneuvers are quite facilitated by previous in situ dissection. Parenchymal cleavage is continued toward the left hepatic vein, which is identified and sectioned, completing the graft division. Hemostatic sutures are placed on the cut surfaces of both grafts followed by fibrin glue spray. Two stable donors, weighing 75 and 65 kg each, were operated on by the above-described technique on November 96 and April 97, respectively, resulting in four grafts implanted in two adults weighing 64 and 75 kg and two children weighing 16.5 and 7.9 kg. Because in one donor no anatomic variation was observed, biliary and vascular divisions were performed at the common duct, hepatic artery, and portal vein respective bifurcations. In the other case, the right hepatic artery originated from the superior mesenteric artery, and sections were performed only at the biliary and portal vein bifurcation levels. Donor operation extra time required for partial in situ dissection was of 65 and 45 min for each case. Segments II+III were transplanted in both children after "piggy-back" hepatectomy. Implantation was carried out starting by an end-to-side anastomosis between the left hepatic vein and inferior vena cava, followed by portal vein anastomosis without interposition grafts. Due to the left hepatic artery small diameter, in one case the arterial anastomosis was performed by microsurgical technique. Roux en Y hepatojejunal anastomosis was performed on both children. Segments I+IV-VIII were transplanted in the adult recipients by standard orthotopic technique, followed by duct to duct biliary anastomosis. Cold ischemia times were 270 and 240 min for left grafts and 540 and 510 min for right grafts. All allografts had good postoperative function with aspartate aminotransferase and alanine aminotransferase postoperative peak levels ranging from 252 to 1474 IU and 200 to 1303 IU, respectively. One child died on the seventh postoperative day, due to cerebral edema and ischemia, but with no graft dysfunction. The other three patients had uneventful outcomes and are now 19 months (two patients) and 24 months (one patient) after transplantation, with good graft function. Organ scarcity is the main obstacle to fulfill the worldwide increasing liver transplantation demand. Because other graft sources, such as xenotransplantation, are not yet available, surgeons have to innovate to face the increasing mortality and morbidity on the liver transplant waiting lists. Although split liver transplantation is considered the most rational policy for expanding the human liver donor pool, technical and logistic difficulties, observed in the early experience with the classic ex situ technique, have discouraged its wide utilization. Despite improvement in patient and graft survival rates, reported in a recent series, a significant incidence of biliary complications, ranging from 16 to 25%, is still observed with the ex situ technique (4, 9, 10). This is due to the difficulty in identifying and correctly dividing the biliary tract and hepatic arterial branches during bench dissection, which may cause bile duct devascularization leading to anastomotic leakage and/or stenosis in the recipient. Another unfavorable feature of the ex situ method is the longer cold ischemia time and frequent warming up of the graft imposed by extensive back table work. This can be responsible for the higher graft dysfunction rate observed with this technique, mainly on right grafts (7, 8). Recently, Rogiers et al. (6) introduced the in situ technique. This procedure is carried out as in the living liver donor, allowing proper anatomic observation and division of the hilar structures. Complete dissection of the left hepatic artery and of the left portal vein is performed in situ, keeping the right hilar elements untouched. The left hepatic duct is sectioned during the parenchymal division without entering the periductal tissue, to preserve its irrigation. After completing the parenchymal separation and left hepatic vein isolation and section, the left graft is removed and flushed on the back table, ready for implantation. During the in situ procedure the right liver blood supply is maintained uninterrupted until multiorgan harvesting is performed. Therefore, cold ischemia time is considerably decreased for both grafts. The experience with the in situ splitting, recently reported by Rogiers et al. (7) and Goss et al. (8), demonstrated better results with 6-month patient and graft survival rates of 92% and 86%, respectively. On both series primary nonfunction was reduced and no vascular nor biliary complications were observed. Despite these results, the in situ technique has some limitations that preclude its wider use. It has to be performed preferably by surgeons experienced with living donor operation. Even when carried out by trained teams, removal of the left graft requires from 1 to 4.5 additional hours to the regular harvesting procedure (7, 8). This may cause donor instability and refusal by other organ transplant teams. The objective of the combined procedure proposed herein is to keep the anatomic precision of the in situ method without a significant increase in donor operation time. For this purpose, the left hepatic artery and the left branch of the portal vein are not fully dissected and just the small portion of liver tissue necessary to identify and section the left bile duct is divided in situ. After preliminary in situ dissection, division of the graft on the back table is quite facilitated and cold ischemia time is decreased. Although good graft function and acceptable donor operation and cold ischemia times were accomplished in these two cases, no definitive conclusion can be drawn from this preliminary experience. A large series will be necessary to confirm the theoretical advantages of the proposed technical modifications. Eduardo Carone1 Paulo Chapchap Vincenzo Pugliese Gilda Porta Irene Miura Edison R. Parise Mário Kondo Department of Surgery; Division of Liver Transplantation; Hospital Sírio Libanês; São Paulo, Brasil

The serum values of the total biliary acids were dosed through the enzymatic-colorimetric method in 15 dyspeptic persons with no hepatic disease (control-group) and in 52 patients with chronic hepatic disease of alcoholic etiology, subdivided according to the Child-Pugh functional classification (Child A = 17; Child B = 18, and C = 17) or according to the clinic exam in one compensated group (n = 22) and in one decompensated group (n = 30). The serum dosages of the biliary acids, particularly the posprandial ones, presented high discriminative power in the detection of chronic hepatopathy, separating the control-group from any of the other groups of alcoholic patients with chronic hepatopathy. The dosages also presented significant correlation with the biochemical tests more directly related to the hepatocellular function, as albumin, total bilirubin and the activity of prothrombin, besides the Child-Pugh numeric score classification. Nevertheless, when the cirrhotic patients were separated in accordance with the clinical presentation, the serum dosage of the biliary acids presented inferior discriminative capacity in relation to the conventional exams as the Child-Pugh numeric classification and the time of prothrombin. Therefore, demonstrating to have limited value in the functional evaluation and in the evolutional following-up of the alcoholic chronic hepatopathy.

AFP is an oncofetal protein found in increased levels in hepatocellular carcinoma, liver metastasis and other benign liver diseases. PURPOSE--To know the behaviour of this protein in each of these clinical situations would undoubtedly help us to discriminate between hepatocellular carcinoma and benign diseases. PATIENTS--A hundred forty nine patients were divided into 4 groups: 1. acute hepatitis (AH) n = 24, 2. chronic liver disease, viral or alcoholic (CLD) n = 81, 3. hepatic metastasis (HM) n = 29, 4. hepatocellular carcinoma (HCC) n = 15. AFP assays were done by ELISA (Abbott Diagnostica, ref. value: 15ng/mL). RESULTS--The results observed were as follows: AFP < 15ng/mL: AH 75%, CLD 86.4%, HM 79.3%, HCC 6.6%, AFP > 15 e < 100ng/mL: AH 25%, CLD 8.6%, HM 20.6%, HCC 20%, AFP > 100ng/mL: AH zero, CLD 4.9%, HM zero, HCC 49%. It is clear that depending on the cut off level, there is a decrease of sensibility which is paralleled by an increase in specificity. CONCLUSIONS--AFP levels are increased in benign liver diseases (AH, CLD) and HM, how ever levels above 100ng/mL occur much more frequently in HCC. In our sample, 93.3% of the HCC showed high levels of AFP, probably because most of the patients had advanced clinical stages of the disease.

Ribavirin in a fixed doses of 1.0 g/day was administered to 15 cirrhotic patients with portal hypertension and HCV-RNA detected in the blood by PCR during a six months period, in a non-controlled study. Two patients presented complications due to hepatic insufficiency and their data were not available at the end of the study. In four patients the hemoglobin levels fell below 20% of the initial value and in one the ribavirin dose had to be reduced. No other significant adverse reaction to the drug was observed. Almost all patients experienced a decrease in the aminotransferases levels during the study, specially in the first three months of treatment when the AST and ALT levels were significantly reduced when compared with the initial values. At the end of six months, four patients presented a complete response with normal aminotransferases levels, but only in one patient the HCV-RNA was not detected in the blood. In this patient the drug interruption was followed by elevation in aminotransferases levels and HCV-RNA detection in the blood 45 days later. Such results suggest that although well tolerated and inducing a transient decrease in AST and ALT, ribavirin alone administration is not able to erradicate virus C infection in patients with hepatic cirrhosis and portal hypertension.

UNLABELLED:Patients with alcoholic chronic liver disease when treated with colchicine during a 12 month-period improved significantly the plasmatic levels of albumin and prothrombin when compared with a similar group of patients who took placebo. No differences in the mortality rate and in number of patients admitted at the hospital could be detected among those groups during this period.PURPOSE:To evaluate the clinical outcome and the plasmatic levels of albumin, pre-albumin, prothrombin and transferrin in patients presenting alcoholic chronic liver disease taking colchicine or placebo, during a 12-month period.METHODS:In a double-blind, randomized, controlled trial, 41 patients with alcoholic chronic liver disease were assigned to either placebo (20 patients) or a colchicine (21 patients) treatment group, assessing their clinical course (mortality rate and hospital admission) and plasmatic protein levels during a 12-month period. Albumin, pre-albumin and transferrin plasmatic levels were assessed through a immunodiffusion radial method and prothrombin time and activity was assessed by a one stage Quick modified method.RESULTS:At the end of the trial, only 7.3% of the patients were lost during follow-up. No statistical differences could be found in mortality and number of patients admitted at the hospital among placebo and colchicine groups. Comparatively to the placebo group, a significant increase in the mean of percentage variation was found in patients of the colchicine group for serum albumin levels (17.9% colchicine x 3.6% placebo, p < 0.05) and for prothrombin activity (19.2% colchicine x 2.1% placebo, p < 0.05). A similar pattern of response was found in pre-albumin serum levels, but such differences were not statistically different. No differences were found in serum transferrin levels among both groups.CONCLUSION:These results suggest that colchicine intake has a positive effect on plasmatic protein levels in patients with alcoholic chronic liver disease.

In Brazil, hepatocellular carcinoma (HCC) is not a common tumour. Virus B hepatitis and cirrhosis play an important role in the development of HCC. The authors described 14 cases of HCC registered in our service during the last 33 months. PURPOSE--Evaluate clinical and laboratory aspects of the hepatocarcinoma treated in our service. MATERIAL--Fourteen patients evaluated between 1990 and 1993 were described. Ten were men the median age was 53 years. RESULTS--The main symptoms were: abdominal pain, weight loss and jaundice. Among the fourteen patients, 42% percent were positive for HBsAg, 0.7% for anti HCV and 57% were cirrhotic. Eighty percent had an advanced disease and serum alphafeto-protein was elevated in 92%. The patients underwent different kinds of treatment. Systemic chemotherapy was started in 5 patients, however without any response. Surgery was done in three patients, one underwent partial resection of the tumour and in the others a total resection was carried out. CONCLUSION--The hepatocarcinoma is rare in our service, eighty percent had advanced disease and 42% were positive for HBsAg.

Serum b ile acid determ ination has b een cla im ed as a se n s it iv e liv e r fu n ctio n test in chron ic hepatic d ise a se and sev era l papers ha v e b een pu b lish ed a sse s s in g seru m b ile a c id s (m ore sp ec ific a lly c h o l i l g l y c i n e ) in h e p a t ic s c h i s t o s o m ia s i s , su g g es tin g that th is d eterm ination can b e o f va lu e in the stu dy o f such patien ts5 1. Z w in g erb erg er et a l6 fou n d a d istin ctiv e va lu es fo r h ep a to in testin a l (H I) and h ep atop len ic (H S) p a tien ts, bu t co u ld n o t foun d d ifferen ces betw een co m p en sa ted and d ecom p en sated H S p atien ts w ith a v ery s im ila r v a lu e s fo r b o th g rou p s. A ccord in g to th e se a u th o rs , the in crea sed c h o lilg ly c in e co n cen tra tion in th e serum o f H S patien ts, w o u ld b e related to th e m o d ifica tio n s in th e sinu so ida l e n d o th e liu m and the b yp ass o f the liv er b y the p o rto -ca v a l sh u n tin g . T h e se fin d in g s w o u ld b e in a greem en t w ith experim en ta l stu d ies , w h ere a tem p oral a sso c ia tio n b e tw een the d ev e lo p m en t o f h ep a tic f ib ro sis in m urine hepatic sch isto so m ia sis and in crea sin g c h o lilg ly c in e concen tration in the perip hera l b lo o d is fo u n d 1. S u ch p r o p o s it io n is n o t en tire ly c o n v in c in g , s in c e it is b e lie v e d that s in u so id a l m o rp h o log ica l f ib ro sis is n o rm a lly fou n d in patients w ith the d eco m p en sa ted form o f H S sch isto so m ia s is2 3. F urtherm ore i f the sp illo v e r o f b ile ac id s to the sy stem ic c ircu lation b ecause o f porto-caval shunting resu ltin g fro m portal h y p erten sion , w o u ld increase th e c h o lilg ly c in e le v e ls in th e serum , the overn igh t fastin g can r ec y c le th e b ile ac id s severa l tim es throu gh the l iv e r c ircu la tio n , and the fasten le v e ls o f c h o ly lg ly c in e co u ld b e n orm alized , depend ing o n the h ep atic fu n ctio n . T h is theoretica l h yp o th esis can b e su pp orted b y th e data ob ta ined in hepatic c irrh o sis w h ere severa l p atien ts w ith estab lished h ep atic c irrh o sis presen t norm al serum b ile acids le v e ls . In ou r p r e v io u s ly p u b lish ed w o rk 5 the m ean v a lu e s fo r fastin g serum c h o lilg ly c in e w a s m ore

In the present study we propose a standardization of the method for the induction of fibrosis of the liver in rats by weekly administration of CCl4 by the intragastric route. The present method is a variation of that described by Proctor and Chatamra. The initial CCl4 dose is 0.04 ml (X dose) but the subsequent doses are calibrated using a 5% variation in animal weight as a reference point. For a weight gain of 5% or more, the successive doses are progressively increased by 50 to 150% (1.5X, 2X, 2.5X). When there is no variation in weight or loss in less than 5%, the previous dose is maintained. For a weight loss of more than 5%, the CCl4 dose is decreased by 50%. Consistent fibrosis if obtained as early as during the 8th week. Collagen content increases progressively from the 8th to the 12th week, reaching on average a level eight-fold higher than that observed in the control.

The livers of female CBA mice were examined 9 to 10 weeks after subcutaneous infection with Schistosoma mansoni. Cryostat liver sections and isolated liver cells were examined by indirect immunofluorescence using specific antibodies against basement membrane proteins (laminin, fibronectin and type IV collagen and type III collagen precursor. Liver cells were isolated by collagenase digestion, purification on Percoll density gradients and centrifugal elutriation to yield enriched fractions of hepatocytes, endothelial and Kupffer cells (Fractions I, II, III respectively). Infected animals yielded more than three times the control number of non-parenchymal cells; electron microscopy revealed that the increase in Fraction II was due mainly to eosinophilic leucocytes and in Fraction III due to Kupffer cells and macrophages from the schistosomal granulomata. Studies of cryostat liver sections showed that the schistosomal granulomata contained dense deposits of type III collagen precursor and fibronectin in the distribution of the reticulin fibres but laminin and type IV collagen were conspicuous only in new vessels in the periphery of the granuloma. Isolated liver cells showed fibronectin on their surface. Immunofluoresence studies could not be performed on Kupffer and endothelial cell fractions because of marked non-specific fluorescence. These experiments indicate that centrifugal elutriation is a useful method for isolating the constituent cells of murine schistosomal granulomata.