The role of graft to recipient weight ratio on enhanced recovery of the recipient after living donor liver transplantation - A systematic review of the literature and expert panel recommendations.

BACKGROUND: There continues to be debate about the lower limit of graft-to-recipient weight ratio (GRWR) for living donor liver transplant (LDLT). OBJECTIVES: To identify the lower limit of GRWR compatible with enhanced recovery after living donor liver transplant and to provide international expert panel recommendations. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies assessing how GRWR affects recipient outcomes such as small for size syndrome, other complications, patient and graft survival, and length of stay were included. PROTOCOL REGISTRATION: CRD42021260794. RESULTS: Twenty articles were included in the qualitative synthesis, and all were retrospective observational studies. There was heterogeneity in the definition of study cohorts and key outcome measures such as small-for-size syndrome. Most studies lacked risk adjustment given limited single-center sample size. GRWR of ≥ .8% is associated with enhanced recovery. Recipients of grafts with GRWR < .8%, however, were found to have similar outcomes as those with ≥ .8% when appropriate consideration is made for portal flow modulation and recipient illness severity. CONCLUSIONS: GRWR ≥ .8% is often compatible with enhanced recovery, but grafts < .8% can be used in selected LDLT recipients with optimal donor-recipient selection, surgical technique, and perioperative management (Quality of Evidence; Low | Grade of Recommendation; Strong).

Current state of kidney utilization in multiorgan transplants.

PURPOSE OF REVIEW: In the United States, the leading indication for kidney transplant is primary kidney dysfunction arising from chronic hypertension and diabetes. However, an increasing indication for kidney transplantation is secondary kidney dysfunction in the setting of another severe organ dysfunction, including pancreas, liver, heart, and lung disease. In these settings, multiorgan transplantation is now commonly performed. With the increasing number of multiorgan kidney transplants, an assessment of guidelines and trends for in multiorgan kidney is necessary. RECENT FINDINGS: Although the utilization of kidney transplants in combined liver-kidney transplant was sharply rising, following the introduction of the 'safety net' policy, combined liver-kidney transplant numbers now remain stable. There is an increasing trend in the utilization of kidney transplantation in heart and lung transplantation. However, as these surgeries were historically uncommon, guidelines for patients who require simultaneous heart or lung transplants are limited and are often institution specific. SUMMARY: Strict guidelines need to be established to assess candidacy for kidney transplantation in multiorgan failure patients, particularly for combined heart-kidney and lung-kidney patients.

Arterial reinforcement following pancreatoduodenectomy: The solution to prevent delayed hemorrhage caused by postoperative pancreatic fistula.

PURPOSE: Delayed hemorrhage (DH) is a rare and yet well-known fatal complication associated with postoperative pancreatic fistula (POPF) in pancreatoduodenectomy (PD). The study aimed to investigate whether arterial reinforcement (AR) using polyglycolic acid sheets (PAS) followed by fibrin sealant (FS) to the hepatic artery could prevent DH in the setting of POPF after PD. METHODS: A total of 345 patients underwent PD for periampullary tumors from March 2011 to March 2022. From March 2011 to March 2018, 225 patients underwent PD, and AR was not performed (non-AR group). From April 2018 to March 2022, 120 patients underwent PD, and AR was performed (AR group). AR was achieved by wrapping the proper hepatic artery all the way down to the celiac artery with PAS followed by coating with FS. Demographic profile and various outcomes including DH of these two groups were compared and analyzed retrospectively. RESULTS: In non-AR group, 48 (21.3%) and 12 (5.3%) patients had grade B and C POPF, respectively. In AR group, 26 (21.7%) and four (3.3%) patients had grade B and C POPF, respectively. The incidence of POPF was not statistically significant (p = .702) between the groups. Among the patients with grade B or C POPF, DH occurred in 14 (23.3%) patients in non-AR group and only one patient in AR group (p = .016). Of the 15 patients with DH, four (26.7%) patients died. CONCLUSION: AR using PAS and FS is effective in preventing DH in the setting of POPF.

Biliary Internal Stents and Biliary Complications in Adult Liver Transplantation.

BACKGROUND: Biliary complications in liver transplantation (LT) can cause significant morbidity or even lead to a potential graft loss and patient mortality. Oftentimes biliary internal stents (ISs) are used at the time of LT to lower the risk for or prevent these biliary complications; however, their efficacy and outcomes remain controversial. METHODS: A retrospective cohort study was conducted on all of the adult patients who underwent a deceased-donor LT (DDLT) with an end-to-end choledococholedocostomy. An IS was placed across the biliary anastomosis, passing through the ampulla. We compared the demographic profiles and various outcomes between the 2 groups (no-IS group vs IS group) and examined risk factors associated with anastomotic biliary complications. RESULTS: The study comprised 350 patients in the no-IS group and 132 patients in the IS group. Anastomotic biliary fistula (ABF) occurred in 5 (1.4%) and 1 (0.8%) patients in the no-IS group and the IS group, respectively (P = .55). Anastomotic biliary stricture (ABS) occurred in 53 (15.1%) and 18 (13.6%) patients, respectively (P = .68). No significant difference was found in the overall biliary complications between the 2 groups (P = .33). In multivariate logistic regression analysis, acute rejection was the only risk factor for ABS (P = .02). One biliary complication-induced mortality occurred in the no-IS group in which the patient died of an ABF-induced hepatic artery pseudoaneurysm rupture. CONCLUSION: The use of biliary ISs in DDLT did not reduce the overall risk for biliary complications, but more research is needed to draw definite conclusions.

Review of COVID-19 Outcomes in Surgical Patients.

COVID-19 emerged as a viral pandemic in the year 2019. The practice and scope of surgery and medicine transformed radicially as the virus spread across the world. There is an urgent need to understand the outcomes of COVID-19 infected patients who undergo surgery. We present a comprehensive review of the current literature on the management of surgical patients who develop COVID-19. FINDINGS: Poor outcomes were most frequent in general surgery or oncological surgery patients who were older with chronic comorbidities. In contrast, outcomes among transplant surgery and obstetric patients were not signficantly altered by COVID-19. Surgical societies have released specialty specific guidelines on the managment of patients who require surgical care during the pandemic. CONCLUSION: COVID-19 is associated with adverse outcomes and increased mortality in surgical patients. Data is currently limited, often restricted to single sites and smaller cohorts. As the sequelae of the virus is better understood, the revisions to the guidelines on managment of surgical patients may help improve outcomes.

Intraoperative radiofrequency ablation and distilled water peritoneal lavage for spontaneously ruptured hepatocellular carcinoma.

PURPOSE: Spontaneously ruptured hepatocellular carcinoma (srHCC) is known to be a life-threatening complication with poor prognosis. Although there are various treatment modalities, there is no definite treatment guideline. The purpose of this study was to review the surgical outcome and prognosis of srHCC treated with intraoperative radiofrequency ablation (RFA) and distilled water peritoneal lavage (DWPL). METHODS: From March 2012 to October 2018, 9 patients with srHCC who underwent emergent surgery were reviewed. After hematoma removal, intraoperative RFA and DWPL were applied to all patients. Hepatectomy was performed if necessary. Patients with multiple tumors, distant metastasis, and vascular tumor involvement in radiologic imaging were excluded. RESULTS: Six of 9 patients with diameters less than 7 cm were able to obtain hemostasis using RFA alone (RFA group). However, 3 patients with a tumor size of more than 10 cm underwent liver resection because they could not obtain hemostasis with RFA (hepatectomy only group). The RFA group had shorter operation time (148.3 ± 31.7 minutes vs. 251.7 ± 20.2 minutes, P < 0.05) and less red blood cell transfusion (5.8 ± 2.5 packs vs. 24.0 ± 11.5 packs, P < 0.05) than the hepatectomy only group. There was no peritoneal metastasis at long-term follow-up in the RFA group. Five-year recurrence-free survival rate was 0% in both groups. However, 5-year overall survival rate was better in the RFA group (83.3% vs. 0%, P < 0.05). CONCLUSION: Intraoperative RFA and DWPL are easy to perform and theoretically the best methods for managing relatively small srHCC.

In Situ Left Lateral Sectionectomy in Deceased Donor Liver Transplantation: Could This Be Another Solution for a Large-for-Size Graft? A Case Report.

BACKGROUND: Large-for-size (LFS) graft should be avoided when performing an adult deceased donor liver transplantation (DDLT) as it is associated with abdominal compartment syndrome, severe graft injury, and primary graft nonfunction. When inadvertently facing with LFS graft intraoperatively, the most commonly reported approach has been a surgical reduction of the right lobe despite its technical difficulty in addition to ongoing coagulopathy after graft reperfusion. We report a case where we performed a left lateral sectionectomy instead of a right lobe modification. CASE REPORT: A 44-year-old 58.4 kg female patient was admitted with drug-induced acute hepatic failure and underwent an emergency DDLT. The donor was a 51-year-old 60.0 kg man. At the time of procurement, the liver was noted to be hypertrophic. The estimated graft/recipient weight ratio was 3.49%. After completing the vascular and bile duct anastomosis, the abdomen could not be closed due to its large graft size. Because of the hypertrophic left lateral lobe and ongoing coagulopathy, we decided to perform an in situ left lateral sectionectomy rather than right posterior sectionectomy or right hemihepatectomy. The next day, the liver function failed to improve, and the patient's blood pressure began to decline gradually. Computed tomography showed severe inferior vena cava (IVC) compression by the graft, and the patient underwent transjugular IVC stent placement. Soon after, the patient's blood pressure improved and liver function gradually normalized. The patient was discharged uneventfully on postoperative day 45. CONCLUSION: Under specific conditions, in situ left lateral sectionectomy is a solution for unexpected LFS graft during DDLT.

Pseudolymphoma (reactive lymphoid hyperplasia) of the liver: A clinical challenge.

Reactive lymphoid hyperplasia (RLH), also known as pseudolymphoma or nodular lymphoid lesion of the liver is an extremely rare condition, and only 51 hepatic RLH cases have been described in the literature since the first case was described in 1981. The majority of these cases were asymptomatic and incidentally found through radiological imaging. The precise etiology of hepatic RLH is still unknown, but relative high prevalence of autoimmune disorder in these cases suggests an immune-based liver disorder. Imaging features of hepatic RLH often suggest malignant lesions such as hepatocellular carcinoma and cholangiocarcinoma. In this report, we discuss two cases of hepatic RLH in patients with autoimmune hepatitis. We also present pathologic and magnetic resonance imaging findings, including one case utilizing a hepatocellular contrast agent, Eovist. Definitive diagnosis of hepatic RLH often requires surgical excision.