Adult living donor liver transplantation from donors with Gilbert's syndrome: Is it safe?

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 < .001 for all readings). Post-operative complication ratio was 40% in GS, 34.3% in non-GS group. In GS and non-GS group, hospitalization period was 10.2 and 9.2 days, respectively. The 1-year donor survival rate was 100% for both groups and 1-year recipient survival was similar who have donors with GS and non-GS (93.3%; 92.9%, P = .93). CONCLUSIONS: The use of right lobe grafts from donors with GS appears to be safe for donor health.

Major complications of adult right lobe living liver donors.

BACKGROUND: The right lobe of the liver is generally preferred for living donor liver transplantation in adult patients with end-stage liver disease. It is important to know the preoperative factors relating to the major postoperative complications. We therefore evaluated the possible risk factors for predicting postoperative complications in right lobe liver donors. METHODS: Data from 378 donors who had undergone right lobe hepatectomy at our center were evaluated retrospectively. The factors we evaluated included donor age, gender, body mass index (BMI), remnant liver volume, operation time, history of previous abdominal surgery, inclusion of the middle hepatic vein and variations in the portal and bile systems. RESULTS: Of the 378 donors, 219 were male and 159 female. None of the donors died, but 124 (32.8%) donors experienced complications including major complications (Clavien scores III and IV) in 27 (7.1%). Univariate analysis showed that complications were significantly associated with male gender and higher BMI (P<0.05), but not with donor age, remnant liver volume, operation time, graft with middle hepatic vein, variations in the portal and bile systems and previous abdominal surgery (P<0.05). Multivariate logistic regression analysis showed that major complications were significantly associated with male gender (P=0.005) and higher BMI (P=0.029). Moreover, the Chi-square test showed that there were significant relationships between major complications and male gender (P=0.010, X2=6.614, df=1) and BMI >25 kg/m2 (P=0.031, X2=8.562, df=1). Of the 96 male donors with BMI >25 kg/m2, 14 (14.6%) with major complications had significantly smaller mean remnant liver volume than those (82, 85.4%) without major complications (32.50%+/-4.45% vs 34.63%+/-3.11%, P=0.029). CONCLUSION: Male donors with BMI >25 kg/m2 and a remnant liver volume ≤32.50% had a significantly increased risk for major complications.

Living Donor Liver Transplantation in Patients 70 Years or Older.

INTRODUCTION: Previous published studies have shown that age is not a contraindication for deceased donor liver transplantation. The data about elderly recipient after living donor liver transplantation (LDLT) is unsatisfactory. The aim of this study was to evaluate the outcome of the LDLT with recipients aged 70 years or older. PATIENTS AND METHODS: Between 2005 and 2013, 469 patients underwent LDLTs. The clinical characteristics, preoperative, intraoperative, and postoperative data, graft, and patients' survival of these patients were retrospectively analyzed. All recipients who were 70 years or older at the time of liver transplantation were indentified. The results were compared to the results of the patients younger than 70 years. RESULTS: There were 12 patients (2%) 70 years or older. All patients received the right lobe of their donor in a standard technique. One patient died postoperatively because of pulmonary infection, and one patient died 6 months after the operation because of graft failure after cardiac infarction. The comorbidity score of these two patients were significantly higher compared to the other ten patients without any complications (8.5 vs. 4.6, P = 0.01). The 1-year and 3-year patient and graft survival was 84%. There were no significant differences in complications, hospital stay, perioperative mortality, or median survival compared to the younger group. CONCLUSION: Although the number of the patients is small, our study emphasizes that LDLT of patients 70 years or older can be performed safely in patients without major comorbidities. Elderly patients with increased risk for postoperative complications should be excluded from LDLT.

Living Donor Liver Transplantation Outcomes for Hepatocellular Carcinoma Beyond Milan or UCSF Criteria.

Liver transplantation (LT) is the most effective treatment for hepatocellular carcinoma (HCC) that arises from cirrhosis. The Milan and the University of California, San Francisco (UCSF) selection criteria have resulted in major improvements in patient survival. We assessed our outcomes for patients with HCC that were beyond the Milan and UCSF criteria after living donor liver transplantation. We reviewed the data for 109 patients with cirrhosis and HCC who underwent living donor right lobe liver transplantation (living donor liver transplantation; LDLT) during the period from July 2004 to July 2012. Sixteen (14.7 %) patients had HCC recurrences during a mean follow-up of 35.4 ± 26.2 months (range 4-100 months). The mean time to recurrence was 11 ± 9.4 months (range 4-26 months). Survival rates were not significantly different between patients with HCC that met and were beyond the Milan and UCSF criteria (p = 0.761 and p = 0.861, respectively). The Milan and UCSF criteria were not independent risk factors for HCC recurrence or patient survival. Only poorly differentiated tumors were associated with a lower survival rate (OR = 8.656, 95 % confidence interval (CI) 2.01-37.16; p = 0.004). Survival rates for patients with HCC that were beyond conventional selection criteria should encourage reconsidering the acceptable thresholds of these criteria so that more HCC patients may undergo LT without affecting outcomes.

Living donor liver transplantation for obese patients: challenges and outcomes.

Living donor liver transplantation (LDLT) is an accepted option for end-stage liver disease, particularly in countries in which there are organ shortages. However, little is known about LDLT for obese patients. We sought to determine the effects of obesity on pretransplant living donor selection for obese recipients and their outcomes. On the basis of body mass index (BMI) values, 148 patients were classified as normal weight (N), 148 were classified as overweight (OW), and 74 were classified as obese (O). O recipients had significantly greater BMI values (32.1 ± 1.6 versus 23.2 ± 1.9 kg/m(2), P < 0.001) and received larger actual grafts (918.9 ± 173 versus 839.4 ± 162 g, P = 0.002) than recipients with normal BMI values. Donors who donated to O recipients had a greater mean BMI (26.3 ± 3.8 kg/m(2)) than those who donated to N recipients (24.4 ± 3.2 kg/m(2), P = 0.001). Although O recipients were more likely to face some challenges in finding a suitable living donor, there were no differences in graft survival [hazard ratio (HR) = 0.955, 95% confidence interval (CI) = 0.474-1.924, P = 0.90] or recipient survival (HR = 0.90, 95% CI = 0.56-1.5, P = 0.67) between the 3 groups according to an adjusted Cox proportional hazards model. There were no significant differences in posttransplant complication rates between the 3 recipient groups or in the morbidity rates for the donors who donated to O recipients versus the donors who donated to OW and N recipients (P = 0.26). Therefore, we recommend that obese patients undergo pretransplant evaluations. If they are adequately evaluated and selected, they should be considered for LDLT.

Glasgow coma scale and APACHE-II scores affect the liver transplantation outcomes in patients with acute liver failure.

BACKGROUND: The timing and selection of patients for liver transplantation in acute liver failure are great challenges. This study aimed to investigate the effect of Glasgow coma scale (GCS) and APACHE-II scores on liver transplantation outcomes in patients with acute liver failure. METHOD: A total of 25 patients with acute liver failure were retrospectively analyzed according to age, etiology, time to transplantation, coma scores, complications and mortality. RESULTS: Eighteen patients received transplants from live donors and 7 had cadaveric whole liver transplants. The mean duration of follow-up after liver transplantation was 39.86+/-40.23 months. Seven patients died within the perioperative period and the 1-, 3-, 5-year survival rates of the patients were 72%, 72% and 60%, respectively. The parameters evaluated for the perioperative deaths versus alive were as follows: the mean age of the patients was 33.71 vs 28 years, MELD score was 40 vs 32.66, GCS was 5.57 vs 10.16, APACHE-II score was 23 vs 18.11, serum sodium level was 138.57 vs 138.44 mmol/L, mean waiting time before the operation was 12 vs 5.16 days. Low GCS, high APACHE-II score and longer waiting time before the operation (P<0.01) were found as statistically significant factors for perioperative mortality. CONCLUSION: Lower GCS and higher APACHE-II scores are related to poor outcomes in patients with acute liver failure after liver transplantation.

Anatomical variations of donor portal vein in right lobe living donor liver transplantation: the safe use of variant portal veins.

In right lobe (RL) living donor liver transplantation (LDLT), portal vein (PV) variations are of immense clinical significance. In this study, we describe in detail our PV reconstruction techniques in RL grafts with variant PV anatomy and evaluate the impact of accompanying biliary variations on the recipient outcomes. In a total of 386 RL LDLTs performed between July 2004 and July 2012, the clinical data on 52 (13%) transplants using RL grafts with variant PV anatomy were retrospectively analyzed. Portal vein anatomy was classified as type 2 in 20 patients, type 3 in 24 patients, and type 4 in eight patients. The PV reconstruction techniques utilized included back-wall plasty (n = 21), back-wall plasty with saphenous vein graft interposition (n = 6), saphenous vein graft interposition (n = 5), cryopreserved iliac vein Y-graft interposition (n = 6), and quiltplasty (n = 3). There was no donor mortality. In a median follow-up of 29 months, none of the recipients had vascular complications. Anomalous PV anatomy was associated with a high (54%) incidence of biliary variations; however, these variations did not result in increased biliary complication rate. Overall, the 1- and 3-year patient survival rates of recipients were 91% and 81%, respectively. Vascular and biliary variations in RL grafts render LDLT technically more challenging. By employing appropriate reconstruction techniques, it is possible to successfully use RL grafts with PV variations without endangering recipient and donor safety.

A new technique for the reconstruction of complex portal vein anomalies in right lobe living liver donors.

Living donor liver right lobe transplantation using donors with variation of the right sectorial portal vein is considered a challenging procedure in terms of the donor's safety and the complexity of reconstruction in the recipient. We describe an innovative technique to reconstruct double portal vein orifices via a deceased donor iliac vein graft. The postoperative course of the recipient was uneventful. Doppler ultrasound on the fourth postoperative month revealed equivalent flow in both portal vein branches. Reconstruction of double right portal vein branches using a cryopreserved iliac vein is a valuable technique for utilizing right lobe grafts with challenging portal vein anatomy.

AFP level and histologic differentiation predict the survival of patients with liver transplantation for hepatocellular carcinoma.

BACKGROUND: In liver transplantation or resection for hepatocellular carcinoma (HCC), patient selection depends on morphological features. In patients with HCC, we performed a clinicopathological analysis of risk factors that affected survival after liver transplantation. METHODS: In 389 liver transplantations performed from 2004 to 2010, 102 were for HCC patients. Data were collected retrospectively from the Organ Transplantation Center Database. Variables were as follows: age, gender, preoperative alpha-fetoprotein (AFP) levels, Child-Pugh and MELD scores, prognostic staging criteria (Milan and UCSF), etiology, number of tumors, the largest tumor size, total tumor size, multifocality, intrahepatic portal vein tumor thrombosis, bilobarity, and histological differentiation. RESULTS: One hundred and two patients were evaluated. The 5-year overall survival rate was 56.5%. According to the UCSF criteria, 63% of the patients were within and 37% were beyond UCSF (P=0.03). Ten patients were excluded (one with fibrolamellary HCC and 9 because of early postoperative death without HCC recurrence), and 92 patients were assessed. The mean age of the patients was 56.5+/-6.9 years. Sixty-two patients underwent living donor liver transplantations. The mean follow-up time was 29.4+/-22.6 months. Fifteen patients (16.3%) died in the follow-up period due to HCC recurrence. Univariate analysis showed that AFP level, intrahepatic portal vein tumor thrombosis, histologic differentiation and UCSF criteria were significant factors related to survival and tumor recurrence.The 5-year estimated overall survival rate was 62.2% in all patients. According to the UCSF criteria, and the 5-year overall survival rate was 66.7% within and 52.7% beyond the criteria (P=0.04). Multivariate analysis showed that AFP level and poor differentiation were independent factors. CONCLUSIONS: For proper patient selection in liver transplantation for HCC, prognostic criteria related to tumor biology (especially AFP level and histological differentiation) should be considered. Poor differentiation and higher AFP levels are indicators of poor prognosis after liver transplantation.

Ratio of remnant to total liver volume or remnant to body weight: which one is more predictive on donor outcomes?

BACKGROUND: Right lobe donations are known to expose the donors to more surgical risks than left lobe donations. In the present study, the effects of remnant volume on donor outcomes after right lobe living donor hepatectomies were investigated. METHODS: The data on 262 consecutive living liver donors who had undergone a right hepatectomy from January 2004 to June 2011 were retrospectively analysed. The influence of the remnant on the outcomes was investigated according to the two different definitions. These were: (i) the ratio of the remnant liver volume to total liver volume (RLV/TLV) and (ii) the remnant liver volume to donor body weight ratio (RLV/BWR). For RLV/TLV, the effects of having a percentage of 30% or below and for RLV/BWR, the effects of values lower than 0.6 on the results were investigated. RESULTS: Complication and major complication rates were 44.7% and 13.2% for donors with RLV/TLV of ≤30%, and 35.9% and 9.4% for donors with RLV/BWR of < 0.6, respectively. In donors with RLV/TLV of ≤30%, RLV/BWR being below or above 0.6 did not influence the results in terms of liver function tests, complications and hospital stay. The main impact on the outcome was posed by RLV/TLV of ≤30%. CONCLUSION: Remnant volume in a right lobe living donor hepatectomy has adverse effects on donor outcomes when RLV/TLV is ≤30% independent from the rate of RLV/BWR with a cut-off point of 0.6.

Recipient splenic artery utilization for arterial re-anastomosis in living donor liver transplantation: single-center experience.

Thrombosis of recipient hepatic artery is a life threatening complication for liver transplantation. The etiology of hepatic arterial thrombosis is multi-factorial and can be caused by intimal dissection, poor surgical technique and coagulopathies. The patency of hepatic arterial flow is very important for both graft survival and patient survival. Intraoperative diagnosis of inadequate hepatic arterial flow found with Doppler ultrasonography is essential in order to achieve good results after liver transplantation. Urgent re-anastomosis is necessary when the arterial blood flow is insufficient. We performed 317 living donor liver transplantations from July 2004 to July 2011. We used recipient splenic artery for hepatic artery reconstruction in six patients. These six patients were included in this study. Using the recipient splenic artery is a simple, safe and practical alternative for hepatic artery re-anastomosis in living donor liver transplantations.

Biliary complications after right lobe living donor liver transplantation: a single-centre experience.

BACKGROUND: Biliary complications that developed after right lobe liver transplantation from living donors were studied in a single centre. METHODS: From 2004 to 2010, 200 consecutive living donor right lobe liver transplantations were performed. The database was evaluated retrospectively. Biliary complications were diagnosed according to clinical, biochemical and radiological tests. The number of biliary ducts in the transplanted graft, the surgical techniques used for anastomosis, biliary strictures and bile leakage rates were analysed. RESULTS: Of a total of 200 grafts, 117 invloved a single bile duct, 77 had two bile ducts and in six grafts there were three bile ducts. In 166 transplants, the anastomosis was performed as a single duct to duct, in 21 transplants double duct to ducts, in one transplant, three duct to ducts and in 12 transplants as a Roux-en-Y reconstruction. In all, 40 bile leakages (20%) and 17 biliary strictures (8.5%) were observed in 49 patients resulting in a total of 57 biliary complications (28.5%). Seventeen patients were re-operated (12 as a result of bile leakages and five owing to biliary strictures). CONCLUSION: Identification of more than one biliary orifice in the graft resulted in an increase in the complication rates. In grafts containing multiple orifices, performing multiple duct-to-duct (DD) or Roux-en-Y anastomoses led to a lower number of complications.

General evaluation of hepatectomy and hepatocellular carcinoma cases.

OBJECTIVE: Although the clinical and histopathological findings of hepatocellular carcinoma are well described, there are few national studies. In this study, we aimed to investigate the relationship between these findings in total or partial hepatectomy specimens in our series. MATERIAL AND METHOD: We first collected 190 cases of total or partial hepatectomies performed because of hepatocellular carcinoma, cirrhosis or other disorders from the archives of Pathology. After re-examining the histopathological and clinical features such as age, gender and etiology, the relationship between them and serology results were statistically analyzed using the chi square and Multiple Comparison Tests. RESULTS: Among 190 cases, there were 168 (88.5%) total and 18 (9.5%) partial hepatectomies and 4 (2%) tumorectomy or metastasectomy cases. After gross and microscopic examination, 170 (89.5%) cases had a diagnosis of cirrhosis, 85 (44.7%) hepatocellular carcinoma, 3 parasitic cyst, 7 metastasis, 1 hepatoblastoma, 1 hepatocellular adenoma, 2 cholangiocarcinoma, 2 Budd Chiari Syndrome, 1 focal nodular hyperplasia, 1 cavernous hemangioma, and 2 acute fulminant hepatitis. Among the hepatocellular carcinoma cases, 53 had Hepatitis B virus, 15 Hepatitis C virus , 3 Hepatitis B virus and Hepatitis C virus, and 3 Hepatitis B virus and Hepatitis delta virus etiology, while 6 were alcoholic and 4 were due to other causes. Among cirrhosis patients, 84 (49.4%) had hepatocellular carcinoma. The male to female ratio of hepatocellular carcinoma cases was 74/11. The mean age was 55 and the median age 56.7. CONCLUSION: The results of this study demonstrated that the most common hepatic disorder was cirrhosis due to Hepatitis B virus in the hepatectomy specimens of our series that mostly consisted of total hepatectomies performed for transplantation where 50% had hepatocellular carcinoma.

Negative prognostic factors in colorectal carcinoma: An analysis of 448 patients.

BACKGROUND AND AIMS: Colorectal carcinoma (CRC) is the most frequent malignancy of the gastrointestinal tract. Prognostic researches are carried out for choosing the optimum therapy, evaluating therapy results and comparing multicentre results for better qualification in the therapy of the disease. PATIENTS AND METHODS: In this study, 448 patients, whose surgery and follow-up was performed by the same correspondent surgeon between the years 1995 and 2003, were retrospectively analyzed. RESULTS: Age, presence of comorbidity, weight loss, emergency admission, high serum CEA and CA 19-9 levels, neighboring organ invasion, operation type, major morbidity, tumor size and type, lymph node metastases, venous and perineural invasion, Dukes' classification and local recurrence and distant metastasis during follow-up are found to be significant negative factors affecting prognosis of the CRC patient. CONCLUSION: Therapy results of the CRC are evaluated by survival times regardless of the therapy method selected for each individual. In our study we tried to find out negative prognostic factors by researching possible factors affecting disease free survival time for CRC. Since our understanding of factors that have an impact on prognosis increases, we are hoping to improve survival.

Mechanical bowel obstruction due to colonic hemangioma: report of a case.

Colon hemangiomas are rare benign vascular lesions which are usually seen in teenagers. The frequent presentation is repetitive painless rectal bleeding. Colonic hemangiomas are occasionally found in the rectosigmoid area. A 62-year-old male patient was admitted to the hospital with the complaints of mechanical bowel obstruction. The radiological imaging techniques revealed a transverse colon tumor. Consequently, the patient was operated, and transverse colectomy and end-to-end anastomosis were performed. No postoperative complications occurred. The pathologic examination revealed cavernous hemangioma of the transverse colon. This report describes a very rare case of bowel obstruction due to colonic hemangioma.