Intra-operative management of low portal vein flow in pediatric living donor liver transplantation.

For pediatric living donor liver transplantation, portal vein complications cause significant morbidity and graft failure. Routine intra-operative Doppler ultrasound is performed after graft reperfusion to evaluate the flow of portal vein. This retrospective study reviewed 65 children who had undergone living donor liver transplantation. Seven patients were detected with suboptimal portal vein flow velocity following vascular reconstruction and abdominal closure. They underwent immediate on-table interventions to improve the portal vein flow. Both surgical and endovascular modalities were employed, namely, graft re-positioning, collateral shunt ligation, thrombectomy, revision of anastomosis, inferior mesenteric vein cannulation, and endovascular stenting. The ultrasonographic follow-up assessment for all seven patients demonstrated patent portal vein and satisfactory flow. We reviewed our experience on the different modalities and proposed an approach for our future intra-operative management to improve portal vein flow at the time of liver transplantation.

Living donor hepatectomy in a pregnant woman.

Liver transplantation with a live donor is an effective way to expand the donor pool. Restrictive selection of living donors may assure donor safety but limit the utility of this resource. A 12-month-old recipient with biliary atresia was rapidly deteriorating with hepatic encephalopathy, massive ascites and coagulopathy. Her mother, the only possible living donor, expressed a strong desire to donate part of liver to her baby, although she was found to be pregnant. The donor hepatectomy was then undertaken at 18 weeks of gestation. A left lateral segmentectomy was performed. Her postoperative course was uneventful and she was discharged 7 days after the operation. She gave birth to a healthy term baby without any complications 5 months later. Both recipient and her younger brother are well 12 months after the operation. Despite the limited experience reported herein, pregnancy may no longer be considered an absolute contraindication for live liver donation.

A Prognostic Model Using Inflammation- and Nutrition-Based Scores in Patients With Metastatic Gastric Adenocarcinoma Treated With Chemotherapy.

The outcomes of patients with metastatic gastric cancer (mGC) are poor. Recent studies have identified the prognostic impact of inflammatory response and nutritional status on survival for patients with gastric cancer. This study aims to create a prognostic model using inflammatory- and nutrition-based scores to predict survival in patients with mGC treated with chemotherapy.After institutional review board approval, patients who had mGC and were treated with chemotherapy from 2007 to 2012 at Kaohsiung Chang Gung Memorial Hospital were retrospectively reviewed. Significantly predictive factors were identified by multivariate Cox regression analyses. Based on these variables, a prognostic model using inflammatory- and nutrition-based scores was constructed to predict survival. Kaplan-Meier curves were plotted to estimate overall survival. The c-statistic values with 95% confidence interval (CI) were also calculated to access their predicting performances.Our study consisted of 256 patients with a median age of 60 years and a median follow-up visit of 18.5 months. Multivariate analyses showed that neutrophil to lymphocyte ratio (NLR), modified Glasgow prognostic score (mGPS), and Patient-Generated Subjective Global Assessment (PG-SGA) were independently related to survival. After computing these scores, patients were classified into favorable-, intermediate-, and poor-risk groups. The median overall survival were 27.6 versus 13.2 versus 8.2 months in favorable, intermediate, and poor-risk groups, respectively. The 2-year survival rate was 52% versus 16% versus 3% in favorable-, intermediate-, and poor-risk groups, respectively. (P < 0.001). The c-statistic value of our model at 2 years is 0.8 (95% CI, 0.75-0.86).NLR, mGPS, and PG-SGA were independently related to survival. Our prognostic model using inflammatory- and nutrition-based scores could provide prognostic information to patients and physicians.

Dextrose in the banked blood products does not seem to affect the blood glucose levels in patients undergoing liver transplantation.

AIM: Hyperglycemia commonly seen in liver transplantation (LT) has often been attributed to the dextrose in the storage solution of blood transfusion products. The purpose of the study is to compare the changes of the blood glucose levels in transfused and non-transfused patients during LT. METHODS: A retrospective study on 60 biliary pediatric patients and 16 adult patients undergoing LT was carried out. Transfused pediatric patients were included in Group I (GI), those not transfused in Group II (GII). Twelve adult patients were not given transfusion and assigned to Group III (GIII); whereas, four adult patients who received massive transfusion were assigned to Group IV (GIV). The blood glucose levels, volume of blood transfused, and the volume of crystalloid infused were recorded, compared and analyzed. RESULTS: Results showed that the changes in blood glucose levels during LT for both non-transfused and minimally transfused pediatric groups and non-transfused and massively-transfused adult groups were almost the same. CONCLUSION: We conclude that blood transfusion does not cause significant changes in the blood glucose levels in this study.

Effect of autologous blood donation on the central venous pressure, blood loss and blood transfusion during living donor left hepatectomy.

AIM: Autologous blood donation (ABD) is mainly used to reduce the use of banked blood. In fact, ABD can be regarded as acute blood loss. Would ABD 2-3 d before operation affect the CVP level and subsequently result in less blood loss during liver resection was to be determined. METHODS: Eighty-four patients undergoing living donor left hepatectomy were retrospectively divided as group I (GI) and group II (GII) according to have donated 250-300 mL blood 2-3 d before living donor hepatectomy or not. The changes of the intraoperative CVP, surgical blood loss, blood products used and the changes of perioperative hemoglobin (Hb) between groups were analyzed and compared by using Mann-Whitney U test. RESULTS: The results show that the intraoperative CVP changes between GI (n = 35) and GII (n = 49) up to graft procurement were the same, subsequently the blood loss, but ABD resulted in significantly lower perioperative Hb levels in GI. CONCLUSION: Since none of the patients required any blood products perioperatively, all the predonated bloods were discarded after the patients were discharged from the hospital. It indicates that ABD in current series had no any beneficial effects, in term of cost, lowering the CVP, blood loss and reduce the use of banked blood products, but resulted in significant lower Hb in perioperative period.

Characterization of liver enzymes on living related liver transplantation patients with acute rejection.

BACKGROUND/AIMS: To determine the biochemical data that reliably predict allograft injury from acute rejection (AR) in patients with living related liver transplantation (LRLT), liver function test and histopathological characteristics of AR were compared and analyzed retrospectively. METHODOLOGY: From Aug. 1994 to Nov. 2000, 101 cases received orthotopic liver transplantation (OLT), which included 53 patients with LRLT in our series. Completed liver functions including aspartate transferase (AST), alanine transferase (ALT), bilirubin total/direct (Bil.T/D), alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) were collected with peak level when AR was diagnosed by liver biopsy. The best data of the same patients when disease free, were compared and analyzed with non-parametric Wilcoxon signed ranks test and Mann-Whitney test. All of the ARs were reversed with steroid pulse therapy, and two cases converted to FK506. No steroid-resistant rejection or chronic rejection was found in our series. RESULTS: In the patients with LRLT, 17 episodes in 13 patients with AR were found. The incidence of histological analysis proved AR was 12.9% (13/101) in OLT and 24.5% (13/53) in LRLT respectively. Among the liver function tests, AST (p<0.0001), ALT (p<0.0001), Bil.T (p=0.001), Bil.D (p=0.001), GGT (p<0.0001), and INR (p=0.034) were the significant predictors respectively in the patients with AR episode. Once liver enzymes had elevated, the AST/ALT ratio <1.0 showed a more significant difference in AR than in those of the no rejection group (p<0.0001). ALP showed significant difference in our series. The severity of histological change was not correlated to the degree of liver enzymes elevation. CONCLUSIONS: Complete liver function tests especially AST, ALT, Bil.T/D, GGT and the ratio of AST/ALT are very sensitive tests in a group of patients receiving LRLT with AR. The severity of AR is based on the histopathologic change but is not related to the degree of liver enzymes elevation itself. Meanwhile, the outcome of acute rejection in living related liver transplantation is quite good.

Multislice computed tomography angiography in pediatric liver transplantation.

BACKGROUND: Preoperative delineation of any vascular anomalies offers planning for possible alteration of surgical procedures, especially in pediatric recipients undergoing living-related liver transplantation. PURPOSE: We assess the efficacy of three-dimensional (3D) multislice computed tomography (CT) angiography in the hope of replacing conventional angiography as the pretransplant evaluation of the hepatic vascular system for potential recipients of liver transplantation. METHODS: 3D CT angiography was performed in 38 children with biliary atresia. Conventional angiography was also performed in the first 15 patients. Twelve patients underwent living-related liver transplantation. The findings on 3D CT angiography were compared with conventional angiography and operative findings. RESULTS: 3D CT angiography was successfully performed in 37 pediatric patients. All findings of 3D CT angiography on hepatic artery, portal vein, and inferior vena cava paralleled those of catheter angiography and operative findings. Four patients were unsuitable to receive living grafts because of pathologic insults of the hepatic artery (one patient) and the portal vein (three patients). Three patients were advised to undergo a venous graft for portal anastomoses. Eight patients demonstrated portosystemic shunts that may require closure. CONCLUSION: 3D CT angiography proves to be a better tool in the demonstration of the vascular system and identification of pathologic insults in pediatric patients. It is superior to conventional angiography because it is less invasive, more convenient, and more efficient in providing thorough preoperative information that would have a major impact on patient selection and surgical planning.

Impacts of pretransplant infections on clinical outcomes of patients with acute-on-chronic liver failure who received living-donor liver transplantation.

BACKGROUND: Liver transplantation is the only therapeutic modality for patients with acute-on chronic liver failure (ACLF). These patients are at high risk for bacterial infections while awaiting transplantation. The aim of this study was to elucidate whether an adequately treated bacterial infection influences the outcomes after transplantation in this patient population. METHODOLOGY/PRINCIPAL FINDINGS: 54 recipients (median age, 49.5 years [range, 22-60]) of adult-to-adult living donor liver transplant (LDLT) for ACLF were categorized as those with pretransplant infection (Group 1, n=34) or without pretransplant infection (Group 2, n=20) for retrospective analyses. With the exception of a higher male-female ratio (P=0.046) and longer length of pretransplant hospital stay (P=0.026) in Group 1, similar demographic, laboratory and clinical features were found in both groups. Patients in Group 1 (totally 42 pretransplant infection episodes) were adequately treated with effective antibiotic(s) before receiving LDLT. All included patients were followed up until one year after transplantation or death. Sixty-one posttransplant infection episodes were found in an overall of 44 ACLF patients (27 in Group 1 vs. 15 in Group 2; P=0.352). Frequently encountered posttransplant infections were intraabdominal infection, pneumonia, bloodstream infection and urinary tract infection. Two patients died in each group (P=0.622). No significant difference was found in the length of posttransplant ICU stay, and in one-year survival, graft rejection, and posttransplant infection rate between both groups. The longer overall hospital stay (mean day, 89.0 vs. 65.5, P=0.024) found in Group 1 resulted from a longer pretransplant hospital stay receiving treatment for pretransplant infection(s) and/or awaiting transplantation. CONCLUSIONS: These data suggested that an adequately treated pretransplant infection do not pose a significant risk for clinical outcomes including posttransplant fatality in recipients in adult-to-adult LDLT for ACLF.

Deceased-donor liver transplantation: 10 years' experience at Change Gung Memorial Hospital-Kaohsiung Medical Center.

BACKGROUND: The purpose of this study was to summarize the outcomes we achieved using deceased-donor liver transplantation (DDLT) in the past 10 years at Chang Gung Memorial Hospital-Kaohsiung Medical Center (CGMH-KMC). METHODS: Between March 1993 and March 2003, 53 DDLTs were performed at CGMH-KMC. Patients were divided into 2 stages: stage 1 (n = 22) from March 1993 to February 1998, and stage 2 (n = 31) from March 1998 to March 2003. Indications for transplantation, patient demographics, surgical procedures, and long-term outcomes were reviewed. RESULTS: Indications for transplantation were biliary atresia (16), post-hepatitis B/C viral cirrhosis with or without hepatocellular carcinoma (21), Wilson's disease (8), primary biliary cirrhosis (3), and miscellaneous (5). Two retransplants were carried out for secondary biliary cirrhosis using primary live-donor liver transplantation (LDLT). Ten patients received grafts from 6 split-liver transplantations. Over-all Kaplan-Meier 1-, 3-, and 5-year survival rates were 88.46%, 83.86%, and 79.87%, respectively. A significant improvement in patient survival was observed in stage 2. The Kaplan-Meier 1- and 5-year patient survival rates in stage 2 were 96.67% and 92.95%, respectively. Fifteen patients developed vascular complications. Nine patients died in this series for an overall mortality rate of 17%. CONCLUSIONS: Deceased-donor liver transplantation is well established as the treatment of choice for acute and chronic liver failure in Taiwan. Satisfactory outcomes have been attained in those transplanted to date.

Prevention of de novo hepatitis B virus infection in living donor liver transplantation using hepatitis B core antibody positive donors.

Exclusion of liver grafts from hepatitis B core antibody (anti-HBc) positive donors to prevent de novo hepatitis B virus (HBV) infection after liver transplantation is not feasible in areas highly endemic for HBV virus like Taiwan, where approximately 80% of adults are anti-HBc(+). The efficacy of lamivudine monotherapy to prevent de novo HBV infection after living donor liver transplantation (LDLT) using grafts from anti-HBc(+) donors remains to be elucidated. From June 1994 to August 2000, LDLT was performed in 42 recipients. Twenty-four of the 42 donors were anti-HBc(+) (57%). Pre-transplant HBV vaccination was given to all recipients irrespective of anti-HBc status at monthly intervals for 3 months. Until December 1997, eight recipients received liver grafts from anti-HBc(+) donors without prophylaxis. Since January 1998, prophylaxis with lamivudine monotherapy was given to 16 recipients receiving liver grafts from anti-HBc(+) donors. De novo HBV infection occurred in three of the eight recipients (37.5%) who did not receive prophylaxis, while none of the 16 recipients given lamivudine developed de novo HBV infection after a mean follow-up of 25 months. Two of the three recipients with de novo HBV infection were anti-HBs(-) and one recipient was anti-HBs(+). Lamivudine was well tolerated, and no side effects were noted. These results suggest that lamivudine monotherapy for recipients receiving anti-HBc(+) liver grafts is a simple, relatively inexpensive and effective prophylactic regimen for prevention of de novo HBV infection. The additive protection provided by vaccine-induced or natural immunity is uncertain.

Ionized calcium changes during living-donor liver transplantation in patients with and without administration of blood-bank products.

Exogenous citrate load from blood transfusion during orthotopic liver transplantation is thought to be the main cause of ionized hypocalcemia, which may result in hemodynamic instability. This implies that if no blood is transfused, chelation of free ionized calcium (Ca(++)) by citrate is avoided and supplemental calcium need not be given. For this study, we divided 39 pediatric living-donor liver transplant patients into two groups according to the blood component replacement given: group I received packed red blood cells and fresh frozen plasma with and without 5% albumin, and group II received 5% albumin alone. The intra-operative serial ionized calcium level was recorded, and the amount of calcium chloride replacement to maintain acceptable blood Ca(++) levels was compared between the groups. The mean serum ionized calcium level changes of both groups could be maintained within lower-to-normal limits intra-operatively. The amount of supplemental calcium chloride required to correct the hypo-ionized calcium was not significantly different between the groups. We can conclude that if an exogenous citrate load is eliminated by the avoidance of blood transfusion and 5% albumin infusion is used, instead, to replace the blood and ascites loss during OLT, the risk of ionic hypocalcemia still persists. Serum Ca(++) monitoring and adequate replacement are, therefore, still required in this setting.