Corona mortis: in vivo anatomical knowledge and the risk of injury in totally extraperitoneal inguinal hernia repair.

PURPOSE: Corona mortis (CMOR) is the arterial and/or venous vascular communication(s) between the obturator and external iliac vessels. Totally extraperitoneal (TEP) inguinal hernioplasty can be associated with vascular complications especially during the fixation of the mesh. Theoretically, CMOR is an important nominee. But, the data in literature are insufficient about CMOR injury. Additionally, most of the studies about CMOR have been usually performed on cadavers. We aimed to reveal the preperitoneal vascular anatomy of inguinal area and provide in vivo knowledge about CMOR. The risk of arterial injury was also evaluated. MATERIALS: The data of preperitoneal vascular anatomy of 321 patients who underwent TEP procedure between January 2005 and July 2014 were retrospectively evaluated. RESULTS: Mean age was 46 ± 8.9 years, 53 females vs 268 males. 391 hemipelvises were evaluated. Two types of arterial structure were identified; (1) an aberrant obturator artery forming an anastomosis with branches of ordinary obturator artery; (2) a pubic branch of inferior epigastric artery. The incidence of arterial CMOR was 28.4 % and of any arterial structure was 45.0 %. An arterial CMOR was considered as thick (≥2 mm) or thin (<2 mm). Injury of arterial CMOR during tack stapling on Cooper's ligament was seen in six cases (1.5 %). All of them were thin (<2 mm) in structure. Venous CMOR was visible only under low pressure in work space. CONCLUSION: During TEP hernia repair, CMOR and/or pubic branch of inferior epigastric artery can be damaged. To prevent this complication, tacks should be stapled to Cooper's ligament close to symphysis pubis and dissection should be careful on the posterior surface of superior pubic ramus. Small caliber (<2 mm) arterial CMOR is more prone to be injured during TEP procedure. To explore venous structures properly, pressure in workspace should be kept as low as possible.

Futility Versus Acceptability of the Use of Grafts Taken From End of Line in the National Organ-Sharing Network.

BACKGROUND: The number of suitable donors for organ transplantation is limited in many countries. This limitation can be overcome with the use of organs removed from marginal donors (expanded-criteria donors [ECDs]). We examined the long-term results of 187 patients who underwent marginal cadaveric liver transplantation in our institution. METHODS: The data of patients who underwent cadaveric liver transplantation from January 2007 to April 2014 were retrospectively reviewed. ECDs were evaluated by considering 19 internationally accepted criteria. The clinical data of recipients including age, clinical status, and Model for End-Stage Liver Disease (MELD) score were also assessed. RESULTS: A total of 287 patients underwent cadaveric liver transplantation. A graft from an ECD was used in 181 (63.06%) patients. The mean MELD score was 18.8. In all, 45 patients (24.86%) underwent transplantations for fulminant liver failure and 136 patients (75.14%) underwent transplantations for other chronic conditions. The majority of donors died of cerebrovascular disease and trauma. Only hypotension requiring inotropic drugs and obesity significantly affected survival. The 90-day and 12-month survival rates of the recipients who received a graft from an ECD were 51.93% and 46.2%, respectively. CONCLUSIONS: The use of ECD allografts immediately and significantly expands the existing donor pool. Because of persistent organ scarcity, pressure to use a greater proportion of the existing donor pool will continue to increase.

Evaluation of Potential Donors in Living Donor Liver Transplantation.

INTRODUCTION: Correct donor selection in living donor liver transplantation (LDLT) is essential not only to decrease the risks of complications for the donors but also to increase the survival of both the graft and the recipient. Knowing their most frequent reasons of donor elimination is so important for transplantation centers to gain time. In this study we evaluated the effectiveness of potential donors in LDLT and studied the reasons for nonmaturation of potential liver donors at our transplantation center. PATIENTS AND METHODS: We studied the outcomes of 342 potential living donor candidates for 161 recipient candidates for liver transplantation between January 2013 and June 2014. Donor candidates' gender, age, body mass index (BMI), relationship with recipient, and causes of exclusion were recorded. RESULTS: Among 161 recipients, 96 had a LDLT and 7 had cadaveric liver transplantation. Twelve of the 342 potential donors did not complete their evaluation; 106 of the remaining 330 donor candidates were accepted as suitable for donation (32%) but 10 of these were excluded preoperatively. The main reasons for unsuitability for liver donation were small remnant liver size (43%) and fatty changes of the liver (38.4%). Other reasons were arterial anatomic variations, ABO incompatibility, and Gilbert syndrome. Only 96 of the candidates (29% of the 330 candidates who completed the evaluation) underwent donation. Effective donors were 29% of potential and 90.5% of suitable donors. CONCLUSIONS: In our center, 106 of 330 (32%) donor candidates were suitable for donation and the main reasons for unsuitability for liver donation were small remnant liver size and fatty changes of the liver.

Pulmonary Complications After 1,150 Living Donor Hepatectomies.

AIM: Donor safety is the major concern in living-donor liver transplantation. Studies in literature related to donor hepatectomy (DH) have generally considered intra-abdominal complications. The aim of this study is to specifically evaluate pulmonary complications (PCs) after DH. MATERIALS AND METHODS: We evaluated retrospectively 1150 living donors who underwent to DH between January 2007 and July 2014. Patients with PCs, such as pneumonia, pleural effusion, pneumothorax, and respiratory insufficiency, were considered. A complication was considered only when it was clinically apparent and/or requiring interventions. Any special diagnostic tool was used to expose the clinically silent pathologies. RESULTS: A total of 986 right hepatectomies (RH) and 164 left hepatectomies (LH) (left lobectomy or left lateral segmentectomy) were performed in the study interval. There were 18 (1.6%) donors with PCs (15 males and 3 females). Mean age was 33.8 ± 9.3 years (18-51). Mean hospital stay was 23.8 ± 13.5 days (5-62). Presented PCs were pleural effusion (n = 5, 0.4%), pneumonia (n = 4, 0.3%), combinations (n = 2, 0.2%), pneumothorax (n = 2, 0.2%), and acute respiratory insufficiency (n = 5, 0.4%). Sixteen cases (1.7%) were seen after RH, whereas 2 cases (1.2%) were seen after LH (P = 1.000). CONCLUSION: The most common PCs after living donor hepatectomy were pleural effusion and acute respiratory insufficiency. There was no significant difference between RH and LH. It is possible to overcome those PCs with careful monitoring and timely and appropriate treatment.

Liver Transplantation With Livers From Octogenarians and a Nonagenarian.

INTRODUCTION: A shortage of deceased donors has compelled the use of extended-criteria donor organs in liver transplantation. The purpose of this study was to evaluate the impact of using deceased donors older than 80 years. MATERIALS AND METHODS: We retrospectively evaluated 13 patients who received a liver graft from cadaveric donors older than 80 years between December 2007 and March 2014. We analyzed the donor and their recipient characteristics together with morbidity and mortality of recipients. RESULTS: All 13 donors were older than 80 years (median age, 82.7; range, 80-93). There were 9 male and 4 female recipients with an average age of 50.7 (range, 2-65) years. All of the recipients did not have a living donor for liver transplantation. Recipients' mean model for end-stage liver disease (MELD) score was 14.2 (range, 7-20). Graft with macroscopic steatosis was not accepted. Medium follow-up was 19.5 months. The most frequent cause for liver transplantation (LT) was hepatitis B virus (HBV) cirrhosis (8/13 patients). We had 1 case of primary nonfunction, and 4 patients died in 2 weeks after surgery. Of these patients, 2 of them received a split transplant from an 80-year-old cadaver liver. Overall the survival rate after 1 year was 61.5%. CONCLUSIONS: Deceased elderly donor usage in LT could expand the donor pool. Liver grafts from donors older than 80 years can be used in necessity or emergency situations. However, care should be taken to avoid early mortality and primary nonfunction. Procedures extending cold ischemia time such as split liver transplantation may increase the risk of primary nonfunction.

Clinical Outcomes of Donor Hepatic Artery to Recipient Replaced Right Hepatic Artery Anastomosis in Living-Donor Liver Transplantation.

OBJECTIVE: The aim of this work was to evaluate the clinical outcomes of donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation. METHODS: A retrospective analysis of 12 patients with donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation from January 2012 to July 2014 was performed. Age, sex, clinical diagnosis of the liver disease, ABO mismatch, hepatic artery thrombosis, biliary strictures and leakage, graft loss, and mortality rates were evaluated. RESULTS: Female-to-male ratio was 4:8. Right lobe was transplanted in 11 (91.7%) of the patients. In 1 patient, left lobe was transplanted. In 9 patients, single duct-to-duct biliary anastomosis was performed with cystic duct catheterization. In 2 patients, double duct-to-duct biliary anastomosis was performed. In 1 patient, double biliary duct-to-duct anastomosis was performed after ductoplasty to achieve a single ductal orifice. No hepatic artery thrombosis was observed. Biliary complications were observed in 6 patients (50%: biliary leaks in 2 patients, biliary stricture in 3 patients, and both in 1 patient). ABO mismatch was not observed. No graft loss due to hepatic artery thrombosis was observed. Mortality was observed in 2 patients (16.6%). CONCLUSIONS: Donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation is somewhat related to biliary complications, but not associated with increased rates of hepatic artery thrombosis.