Right Ex-situ split grafts for adult liver transplantation - A Multicenter Benchmarking Analysis.

OBJECTIVE: To analyse outcomes after adult right ex-situ split graft liver transplantations (RSLT) and compare with available outcome benchmarks from whole liver transplantation (WLT). SUMMARY BACKGROUND DATA: Ex-situ SLT may be a valuable strategy to tackle the increasing graft shortage. Recently established outcome benchmarks in WLT offer a novel reference to perform a comprehensive analysis of results after ex-situ RSLT. METHODS: This retrospective multicenter cohort study analyzes all consecutive adult SLT performed using right ex-situ split grafts from 01.01.2014 to 01.06.2022. Study endpoints included 1 year graft and recipient survival, overall morbidity expressed by the comprehensive complication index (CCI©) and specific post-LT complications. Results were compared to the published benchmark outcomes in low-risk adult WLT scenarii. RESULTS: In 224 adult right ex-situ SLT, 1y recipient and graft survival rates were 96% and 91.5%, within the WLT benchmarks. The 1y overall morbidity was also within the WLT benchmark (41.8 CCI points vs. <42.1). Detailed analysis, revealed cut surface bile leaks (17%, 65.8% Grade IIIa) as a specific complication without a negative impact on graft survival. There was a higher rate of early hepatic artery thrombosis (HAT) after SLT, above the WLT benchmark (4.9% vs. ≤4.1%), with a significant impact on early graft but not patient survival. CONCLUSION: In this multicentric study of right ex-situ split graft LT, we report 1-year overall morbidity and mortality rates within the published benchmarks for low-risk WLT. Cut surface bile leaks and early HAT are specific complications of SLT and should be acknowledged when expanding the use of ex-situ SLT.

European validation of the classification for the anticipated difficulty of liver transplantation.

BACKGROUND: Appropriate risk stratification for the difficulty of liver transplantation (LT) is essential to guide the selection and acceptance of grafts and avoid morbidity and mortality. METHODS: Based on 987 LTs collected from 5 centers, perioperative outcomes were analyzed across the 3 difficulty levels. Each LT was retrospectively scored from 0 to 10. Scores of 0-2, 3-5 and 6-10 were then translated into respective difficulty levels: low, moderate and high. Complications were reported according to the comprehensive complication index (CCI). RESULTS: The difficulty level of LT in 524 (53%), 323 (32%), and 140 (14%) patients was classified as low, moderate and high, respectively. The values of major intraoperative outcomes, such as cold ischemia time (p = 0.04) and operative time (p < 0.0001) increased gradually with statistically significant values among difficulty levels. There was a corresponding increase in CCI (p = 0.04), severe complication rates (p = 0.05) and length of ICU (p = 0.01) and hospital (p = 0.004) stays across the different difficulty levels. CONCLUSION: The LT difficulty classification has been validated.

Patients' perceptions of the definition of a textbook outcome following liver transplantation.

BACKGROUND: A textbook outcome (TO) describes the results of a successful liver transplantation (LT) in which all aspects of the LT and posttransplant courses were uneventful. We compared patient perceived experience of a TO with clinically defined TO. METHODS: This was a single-institution cohort study with retrospective chart review including patients who underwent LT from 2019 to 2021. Patients were asked to complete the survey at a scheduled posttransplant visit. The survey was designed to assess their viewpoints on the definition of a TO. A clinically defined TO was defined as no mortality, no severe complications, no need for reintervention, no prolonged hospital and intensive care unit stays, and no readmission. RESULTS: Of the 182 patients who were contacted, 132 (72.5%) completed the survey. Overall, 98 patients (74%) considered that they had experienced a TO. The clinically defined TO rate was 22.0%. Multivariate analysis showed that patients who did not experience severe complications were more likely to consider that they had a TO (P = 0.01; odds ratio: 3.2; 95% confidence interval: 1.3-7.9). CONCLUSIONS: From patients' perspectives, survival and avoidance of complications were the major characteristics of a TO.

Auxiliary Liver Transplantation for Cirrhosis: From APOLT to RAPID: A Scoping Review.

OBJECTIVE: To survey the available literature regarding the use of auxiliary liver transplantation (ALT) in the setting of cirrhosis. SUMMARY OF BACKGROUND: ALT is a type of liver transplantation (LT) procedure in which part of the cirrhotic liver is resected and part of the liver graft is transplanted. The cirrhotic liver left in situ acts as an auxiliary liver until the graft has reached sufficient volume. Recently, a 2-stage concept named RAPID (Resection and Partial Liver segment 2/3 transplantation with Delayed total hepatectomy) was developed, which combines hypertrophy of the small graft followed by delayed removal of the native liver. METHODS: A scoping review of the literature on ALT for cirrhosis was performed, focusing on the historical background of RAPID and the status of RAPID for this indication. The new comprehensive nomenclature for hepatectomy ("New World" terminology) was used in this review. RESULTS: A total of 72 cirrhotic patients underwent ALT [heterotopic (n = 34), orthotopic (Auxiliary partial orthotopic liver transplantation, n = 34 including 5 followed by resection of the native liver at the second stage) and RAPID (n = 4)]. Among the 9 2-stage LTs (APOLT, n = 5; RAPID, n = 4), portal blood flow modulation was performed in 6 patients by deportalization of the native liver (n = 4), portosystemic shunt creation (n = 1), splenic artery ligation (n = 3) or splenectomy (n = 1). The delay between the first and second stages ranged from 18 to 90 days. This procedure led to an increase in the graft-to-recipient weight ratio between 33% and 156%. Eight patients were alive at the last follow-up. CONCLUSIONS: Two-stage LT and, more recently, the RAPID procedure are viable options for increasing the number of transplantations for cirrhotic patients by using small grafts.

Novel Composite Endpoint for Assessing Outcomes in Liver Transplantation: Arterial and Biliary Complication-Free Survival.

Transplant and patient survival are the validated endpoints to assess the success of liver transplantation (LT). This study evaluates arterial and biliary complication-free survival (ABCFS) as a new metric. ABC, considered as an event, was an arterial or biliary complication of Dindo-Clavien grade ≥III complication dated at the interventional, endoscopic, or surgical treatment required to correct it. ABCFS was defined as the time from the date of LT to the dates of first ABC, death, relisting, or last follow-up (transplant survival is time from LT to repeat LT or death). Following primary whole LT (n = 532), 106 ABCs occurred and 99 (93%) occurred during the first year after LT. An ABC occurring during the first year after LT (overall rate 19%) was an independent factor associated with transplant survival (hazard ratio [HR], 3.17; P < 0.001) and patient survival (HR, 2.7; P = 0.002) in univariate and multivariate analyses. This result was confirmed after extension of the cohort to split-liver graft, donation after circulatory death, or re-LT (n = 658). Data from 2 external cohorts of primary whole LTs (n = 249 and 229, respectively) confirmed that the first-year ABC was an independent prognostic factor for transplant survival but not for patient survival. ABCFS was correlated with transplant and patient survival (ρ = 0.85 [95% CI, 0.78-0.90] and 0.81 [95% CI, 0.71-0.88], respectively). Preoperative factors known to influence 5-year transplant survival influenced ABCFS after 1 year of follow-up. The 1-year ABCFS was indicative of 5-year transplant survival. ABCFS is a reproducible metric to evaluate the results of LT after 1 year of follow-up and could serve as a new endpoint in clinical trials.

Enhanced Recovery in Liver Transplantation: A Feasibility Study.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT. METHODS: We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery. RESULTS: Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0-10.5) days versus 18.0 (14.3-24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm. CONCLUSION: Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.

Clinical efficacy of anti-migration features in fully covered metallic stents for anastomotic biliary strictures after liver transplantation: comparison of conventional and anti-migration stents.

BACKGROUND AND AIMS: Anastomotic biliary strictures (ABSs) are one of the most frequent adverse events that occur after orthotopic liver transplantation (OLT). Multiple plastic stents (MPS) have been validated for this indication. More recently, fully covered self-expandable metallic stents (FCSEMSs) have been used with positive outcomes, but also have a higher rate of migration, which may limit success. Our primary objective was to compare stent migration rates observed with standard FCSEMSs (Std-FCSEMSs) and so-called anti-migration FCSEMSs (Am-FCSEMSs), which are newly designed with reversed proximal side flaps. Secondary objectives were to compare rates of stricture resolution and procedure-related morbidity. METHODS: We conducted a retrospective analysis of a subset of patients (FCSEMSs for post-OLT ABS) from 2 prospectively maintained databases of (1) OLT patients, and (2) ERCP and stent placement. Between January 2009 and January 2016, consecutive patients presenting with ABS after OLT referred to Cochin Hospital (Paris, France) for ERCP and receiving a FCSEMS were included. Exclusion criteria were any other cause of biliary stricture (ie, malignant stricture, ischemic origin), and biliary fistulae. RESULTS: One hundred twenty-five FCSEMSs (57 Am-FCSEMSs, 52 type 1 Std-FCSEMSs, and 16 type 2 Std-FCSEMSs) were used in 75 patients for ABS after OLT, with a planned stent placement period of 6 months in all patients. Patient characteristics and rates of previous endoscopic treatment or timing of ABS occurrence after OLT were not different between the groups. The rate of FCSEMS complete migration was 16% (20/125), consisting of 1.7% (1/57) for Am-FCSEMSs and 28% (19/68) for type 1 and 2 Std-FCSEMSs (P < .0001). All attempted stent removals (100% of patients) were successful. First follow-up ERCP after each FCSEMS highlighted a stricture resolution rate of 78.4% (98/125), including 93% (53/57) for Am-FCSEMSs and 66.2% (45/68) for type 1 and 2 Std-FCSEMSs (P < .001). After a median follow-up of 28 months after stent removal (range, 12-66 months), stricture recurrence was observed in 12.3% (range, 11%-17%) of patients treated with Am-FCSEMSs against 55.9% (range, 54%-56%) of those receiving Std-FCSEMSs (P < .0001). CONCLUSIONS: In patients with ABS after OLT, the use of Am-FCSEMSs significantly decreased the risk of stent migration, improved stricture resolution at the time of stent removal, and reduced the rate of stricture recurrence during follow-up. Endoscopic removal success and procedure-related morbidity were similar for both standard and anti-migration stents.

Clinical impact of laparoscopic hepatectomy: technical and oncological viewpoints.

The objective of this study was to assess the clinical impact of laparoscopic hepatectomy from technical and oncological viewpoints through the consecutive 5-year experience of an expert team. The subjects consisted of 491 consecutive hepatectomies performed over the course of 5 years. A total of 190 hepatectomies (38.6 %) were performed laparoscopically, and the remaining 301 (61.4 %) were open hepatectomies. Chronological trends of operative procedures and their indications were evaluated, and patients with hepatocellular carcinoma (HCC) were analyzed from an oncological viewpoint. The proportion of laparoscopic hepatectomies performed increased significantly during the study period (from 17.6 to 49.5 %). According to chronological trends, right hepatectomy was standardized using consecutive steps after minor hepatectomy, left lateral sectionectomy, and left hepatectomy were standardized. The proportion of laparoscopic hepatectomies performed for HCC increased from 21.4 to 71.0 %. No significant difference was observed in the proportion of major hepatectomies performed for HCC between the open and laparoscopy groups (50.6 vs. 48.6 %, p = 0.8053), whereas that of anatomical segmentectomy for HCC was significantly lower in the laparoscopy group (28.7 vs. 11.1 %, p = 0.0064). All laparoscopic anatomical segmentectomies were of segments 5 and 6, and there was no segmentectomy of posterosuperior lesions. The present study shows the consecutive technical developmental processes for minor hepatectomy, left lateral sectionectomy, left hepatectomy, and right hepatectomy without compromising oncological principles. Laparoscopic anatomical segmentectomy for posterosuperior lesions may be the most technically demanding procedure, requiring individualized standardization.

Improving graft survival by understanding the mechanism of segment 4 complications after split liver transplantation.

BACKGROUND: This study was designed to assess the actual mechanism of segment 4 (S4)-related complications after split liver transplantation (SLT) and their impact on graft and overall survival with reference to those of left lateral sectionectomy for pediatric living donor liver transplantation (LLSLD). METHODS: Clinical data from 53 SLT recipients and 62 LLSLD patients were assessed to determine the mechanism of S4-related complications. The postoperative parameters of SLT and their impact on graft and overall survival were also evaluated. RESULTS: Although two biliary leakages were noted (3.2%), no necrosis of S4 developed after LLSLD. S4-related complications were seen in 15 (28.3%) patients after SLT. Radiological volumetry of S4 and the ischemic area after SLT showed no significant difference between those with and without S4-related complications. There were no significant differences between the patients with and without S4-related complications regarding both overall and graft survival rates. Significant better overall and graft survival rates were observed in patients treated during the later period. CONCLUSIONS: S4-related complications after SLT are totally independent of the S4 volume, and biliary leakage is inherently an actual mechanism. Adequate intervention with early identification leads to better graft and overall survival, which validates SLT as a treatment option.

Laparoscopic versus open major hepatectomy for hepatocellular carcinoma: a matched pair analysis.

BACKGROUND: Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) is currently perceived a complex and challenging laparoscopic procedure and is limited to a few expert teams. This study analyzed the short- and long-term outcomes of LMH for HCC compared with open hepatectomy. METHODS: From January 2006 to May 2014, 38 patients underwent LMH for HCC (10 left and 28 right hepatectomy). They were matched and compared to 38 patients (10 left and 28 right hepatectomy) who underwent a conventional open approach. Short-term operative and postoperative outcomes as well as long-term outcomes, including disease-free survival and overall survival rates, were evaluated. RESULTS: Patients were well matched for several preoperative factors. Overall complication rates were significantly higher for the open group. No significant difference was seen in 3-year overall survival between the open and laparoscopic groups (69.2 vs. 73.4 %; p = 0.951). A trend toward better 3-year disease-free survival after laparoscopy was observed (29.7 vs. 50.3 %; p = 0.219), even though the difference did not reach statistical significance. The same trend was seen in subgroup analyses of right and left hepatectomy. CONCLUSIONS: This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes. LMH offers many advantages commonly attributed to laparoscopy and is well suited for HCC with cirrhosis when performed by experienced surgeons.

In Situ Hypothermic Perfusion of the Liver for Complex Hepatic Resection: Surgical Refinements.

INTRODUCTION: While total vascular exclusion (TVE) with veno-venous bypass and hypothermia may be undertaken to increase liver tolerance for complex liver resection, these procedures are still associated with elevated rates of postoperative complications and mortality. In particular, one of the main issues of this strategy is the management of bleeding after declamping, which is enhanced by both hypothermic state and acidosis. To overcome this high risk of morbidity, several technical refinements might be undertaken and here described (with video). METHODS: All patients, requiring TVE >60 min and liver cooling during hepatectomy, were retrospectively included in this study. Technical key points as (a) patient selection, (b) anesthetic management, (c) two-surgeon's technique, (d) preparation for clamping, (e) veno-venous bypass, (f) cooling of the liver, and (g) parenchymal transection, rewarming, and declamping are described and detailed. RESULTS: From 2011 to 2013, we included 8 cases of liver resection with TVE, veno-venous bypass, and hypothermia for malignant disease. Due to the technical refinements, median observed overall blood loss of 550 ml (300-900) including 200 ml (50-300) at declamping and transfusion of packed red blood cell (PRBC) units was required in 5 patients with a mean of 1.25 PRBC/patient. CONCLUSION: The association of TVE, veno-venous bypass, and liver cooling can reduce the time of transection, and blue dye injection and liver rewarming before declamping can reduce blood loss and coagulopathy. Altogether, limited blood loss can be achieved for these complex procedures and may allow to decreasing morbidity.

Pure laparoscopic left lateral sectionectomy in living donors: from innovation to development in France.

OBJECTIVE: In this study, we report the results obtained from 70 living donors in France. BACKGROUND: Left lateral sectionectomy for pediatric live donor liver transplantation is a well-standardized surgical procedure. Our team introduced the laparoscopic approach to live donation in 2002, and the reproducibility and safety of this method was discussed in 2006. METHODS: Between March 2001 and October 2012, a total of 70 donors underwent a liver procurement. Sixty-seven donors (95.7%) underwent a left lateral sectionectomy, and 3 underwent a left hepatectomy without middle hepatic vein procurement. All data were prospectively recorded in a database. RESULTS: Of the 70 donors, 66 (94%) liver grafts were procured by laparoscopy, whereas 4 (6%) patients required conversion into an open technique. Seventeen donors experienced complications, leading to an overall complication rate of 24.2%. Eleven donors (16%) had grade 1 complications, according to the Clavien system. Five donors (7.1%) presented grade 2 complications, and 1 donor (1.4%) had a grade 3 complication. No death occurred. Overall, patient and graft survival rates for pediatric recipients were 95% and 92% at 1 year, 95% and 88% at 3 years, and 95% and 84% at 5 years, respectively. CONCLUSIONS: The laparoscopic retrieval of the left lateral section for live donor liver transplantation is safe and reproducible and has transitioned from an innovative surgery to a development phase in France.

Early and resectable HCC: Definition and validation of a subgroup of patients who could avoid liver transplantation.

BACKGROUND: Liver transplantation (LT) remains the best curative option for early hepatocellular carcinoma (HCC) but is limited by the ongoing graft shortage. The present study aimed at defining the population in which primary liver resection (LR) could represent the best alternative to LT. METHODS: An exploration set of 357 HCC patients (LR n = 221 and LT n = 136) operated between 2000-2012 was used in order to identify factors associated with survival following LR and define a good prognosis (GP) group for which LR may challenge the results of upfront LT. These factors were validated in an external validation set of 565 HCC patients operated at another center (LR n = 287 LR and LT n = 278). RESULTS: In the exploration set, factors associated with survival on multivariate analysis were a solitary lesion, a diameter <50 mm, a well-moderately differentiated lesion, the absence of microvascular invasion, and preoperative AST level <2N. Thirty-nine patients (18%) displayed all these criteria and constituted the GP patients. Overall survivals at 1, 3, and 5 years did not significantly differ between GP resected patients, and the in Milan transplanted patients (93, 80.4, and 80.4% vs. 86.9, 82, and 78.8%, P = 0.79). In the validation cohort, patients with GP factors of survival still displayed better overall survivals than those without (P = 0.036) but also displayed better survivals than in Milan HCC transplanted patients (P = 0.005). CONCLUSION: In a group of early HCC patients gathering all factors of GP, primary LR achieves at least similar survival as upfront LT and should be the approach of choice.

Preliminary report of major surgery in liver transplant recipients receiving m-TOR inhibitors without therapeutic discontinuation.

INTRODUCTION: Mammalian target rapamycin inhibitors (m-TORi) are increasingly used in patients undergoing liver transplantation (LT). Yet, there is rising concern that they also could impair wound healing and favor the development of several surgical complications. This report was designed to evaluate both feasibility and safety of major surgery in liver transplant recipients receiving m-TORi-based immunosuppression without therapeutic discontinuation. METHODS: From 2007 to 2012, six liver transplant recipients underwent nine major abdominal or thoracic surgical procedures without m-TORi discontinuation or specific dosage adjustment. Their characteristics and postoperative outcomes were retrospectively analyzed. RESULTS: Indications for m-TORi were de novo or recurrent malignant disease in five patients and calcineurin inhibitors related neurologic toxicity in one patient. Abdominal procedures, thoracic procedures, and combined thoracic and abdominal procedures were performed in six, two, and one cases respectively. Emergency surgery was performed in one case and elective procedures were performed in eight cases, including five for malignant disease and three for late surgical complications following LT. No patient died postoperatively. One major complication was observed, but no patient required reoperation. No evisceration, incisional surgical site infection, or lymphocele occurred. CONCLUSIONS: Major surgery in liver transplant recipients receiving m-TOR inhibitors appears both feasible and safe without therapeutic discontinuation or specific dosage adjustment.

Is computed tomography volumetric assessment of the liver reliable in patients with cirrhosis?

OBJECTIVES: The estimation of liver volume (LV) has been widely studied in normal liver, the density of which is considered to be equivalent to 1 kg/l. In cirrhosis, volumetric evaluation and its correlation to liver mass remain unclear. The aim of this study was to evaluate the accuracy of computed tomography (CT) scanning to assess LV in patients with cirrhosis. METHODS: Liver volume was evaluated by CT (CTLV) and correlated to the explanted liver weight (LW) in 49 patients. Liver density (LD) and its association with clinical features were analysed. Commonly used formulae for estimating LV were also evaluated. The real density of cirrhotic liver was prospectively measured in explant specimens. RESULTS: Wide variations between CTLV (in ml) and LW (in g) were found (range: 3-748). Cirrhotic livers in patients with hepatitis B virus infection presented significantly increased LD (P = 0.001) with lower CTLV (P = 0.005). Liver volume as measured by CT was also decreased in patients with Model for End-stage Liver Disease scores of >15 (P = 0.023). Formulae estimating LV correlated poorly with CTLV and LW. The density of cirrhotic liver measured prospectively in 15 patients was 1.1 kg/l. CONCLUSIONS: In cirrhotic liver, LV assessed by CT did not correspond to real LW. Liver density changed according to the aetiology and severity of liver disease. Commonly used formulae did not accurately assess LV.

Perceptions of surgical difficulty in liver transplantation: A European survey and development of the Pitié-Salpêtrière classification.

BACKGROUND: Significant variations exist regarding the definition of difficult liver transplantation. The study goals were to investigate how liver transplant surgeons evaluate the surgical difficulty of liver transplantation and to use the identified factors to classify liver transplantation difficulty. METHODS: A Web-based online European survey was presented to liver transplant surgeons. The survey was divided into 3 parts: (1) participant demographics and practices; (2) various situations based on recipient, liver disease, tumor treatment, and technical factors; and (3) 8 real-life clinical vignettes with different levels of complexity. In part 3 of the survey, respondents were asked whether they would perform liver transplantation but were not aware that these patients eventually underwent liver transplantation. RESULTS: A total of 143 invites were sent out, and 97 (67.8%) participants completed the survey. Most participants considered previous spontaneous bacterial peritonitis, previous supra-mesocolic surgery, hypertrophy of segment I, and obesity to be recipient factors for high-difficulty liver transplantation. Most participants considered liver transplantation to be challenging in patients with Budd-Chiari syndrome, Kasai surgery, polycystic liver disease, diffuse portal vein thrombosis, and a history of open hepatectomy. The proportion of participants indicating that liver transplantation was warranted varied across the 8 cases, from 69% to 100%. Our classification of the surgical difficulty of liver transplantation employed these recipient-related, surgical history-related, and liver disease-related variables and 3 difficulty groups were identified: low, intermediate, and high difficulty groups. CONCLUSION: This survey provides an overview of the surgical difficulty of various situations in liver transplantation that could be useful for further benchmark and textbook outcome studies.

Split liver transplantation using extended right grafts: the natural history of segment 4 and its impact on early postoperative outcomes.

Split liver transplantation (SLT) using extended right grafts is associated with complications related to ischemia of hepatic segment 4 (S4), and these complications are associated with poor outcomes. We retrospectively analyzed 36 SLT recipients so that we could assess the association of radiological, biological, and clinical features with S4 ischemia. The overall survival rates were 84.2%, 84.2%, and 77.7% at 1, 3, and 5 years, respectively. The recipients were mostly male (24/36 or 67%) and had a median age of 52 years (range = 13-63 years), a median body mass index of 22.9 kg/m(2) (range = 17.3-29.8 kg/m(2) ), and a median graft-to-recipient weight ratio of 1.3% (range = 0.9%-1.9%). S4-related complications were diagnosed in 22% of the patients (8/36) with a median delay of 22 days (range = 10-30 days). Secondary arterial complications were seen in 3 of these patients and led to significantly decreased graft survival in comparison with the graft survival of patients without complications (50.0% versus 85.6%, P = 0.017). Patients developing S4-related complications had significantly elevated aspartate aminotransferase (AST) levels (>1000 IU/L) on postoperative day (POD) 1 and elevated gamma-glutamyl transpeptidase (GGT) levels (>300 IU/L) on PODs 7 and 10 (P < 0.05). These AST and GGT elevations conferred a significantly high risk of developing these complications (odds ratio = 42, 95% confidence interval = 4-475, P < 0.05). The ischemic volume of S4 was extremely variable (0%-95%) and did not correlate with S4-related complications. In conclusion, our results suggest that S4-related complications are risk factors for worse graft survival, and the development of these complications can be anticipated by the early identification of a specific biological profile and a routine radiological examination.

Vena Cava and Pancreatic head En Bloc Resection for an Invasive Inferior Vena Cava Leiomyosarcoma in a Liver Transplant Patient.

BACKGROUND: De novo neoplasms are one of the major causes of death in patients after the first year of liver transplantation. The occurrence of sarcomas is extremely rare and the survival is often poor. However, early diagnosis and radical surgical treatment, may benefit some select liver transplant patients. METHOD: We describe the case of a liver transplant patient who developed a locally advanced inferior vena cava (IVC) leiomyosarcoma, who underwent radical surgical treatment with resection of the IVC associated with duodenopancreatectomy, right nephrectomy, and IVC reconstruction. We address aspects of the diagnosis and surgical strategy. CONCLUSION: This case report illustrates that IVC and multivisceral resections may be feasible and safe in highly selected liver transplant recipients. Major surgery should not be excluded as treatment option in an immunosuppressed liver transplant patient.

Acute liver failure and HELLP syndrome: A clinical case and literature review.

BACKGROUND: HELLP syndrome is a pregnancy-related liver disease associated with increased maternal and foetal mortality. In rare cases, it can lead to the development of a subcapsular hepatic haematoma as well as its rupture. This rupture is life-threatening if not urgently treated. METHOD: We describe a clinical case of HELLP syndrome involving a ruptured subcapsular liver haematoma and contextualise this with a literature overview. CLINICAL CASE: A 39-year-old woman of 40 weeks' gestation presented to her local Emergency Department with symptoms and serology classically associated with HELLP syndrome. However, she clinically deteriorated and developed a ruptured subcapsular haematoma. She underwent an emergency Caesarean section at her initial hospital. Upon clinical stabilisation, she was transferred to our transplant unit for an urgent liver transplant. CONCLUSION: LT is a life-saving procedure for patients with acute liver failure secondary to HELLP syndrome. These patients should be immediately referred to a high-volume transplant centre.