Using IV-Tubing "Bridge" from Splenic Artery to Superior Mesentery Artery to Create a Single Arterial Cannulation for Normothermic Machine Perfusion When Donor Liver Has Replaced Right Hepatic Artery.

BACKGROUND The presence of anatomical variations of the hepatic artery poses a challenge for normothermic machine perfusion (NMP). Here, we describe our experience of creating a single arterial cannulation for NMP in 3 donor livers with replaced right hepatic artery. CASE REPORT Three donor livers with replaced right hepatic artery were perfused using NMP (OrganOx® metra®) for liver transplantation. To maintain hepatic artery integrity and establish an intact arterial vascular inflow for NMP, a single vasculature was created to allow single arterial cannulation for NMP. A piece of intravenous-line tubing was used as a bridge from the splenic artery to the superior mesenteric artery during the back-table preparation. After 1 h of NMP, the lactate of 2 livers decreased from >10.0 to about 1.0 mmol/L, and the lactate of 1 liver decreased from >4.0 to <0.4 mmol/L. Three livers made >100 mL of bile after 4 h of NMP and were successfully implanted after >10 h of NMP. The recipients spent 2, 3, and 4 days in the Intensive Care Unit and were discharged home at 6, 7, and 9 days, respectively. None of the patients experienced early allograft dysfunction or any early technical complication or non-anastomotic biliary stricture. CONCLUSIONS Creating an intravenous-line tubing bridge from the splenic artery to the superior mesenteric artery prior to NMP of liver grafts associated with replaced right hepatic artery could reduce the cold ischemia time associated with vessel reconstruction and reduce bleeding risk during NMP. This is feasible, safe, and effective.

Resection of tumor from the supragastric lesser sac with peritonectomy.

This 48 yr old lady underwent laparotomy for primary appendiceal carcinoma metastatic within the peritoneal cavity including the lesser omentum (LO) and supragastric lesser sac (Fig. 1). The left triangular ligament was divided allowing retraction of the left lobe of the liver. The stomachwasmanually pulled to stretch out the LO and facilitate resection. The left gastric, common hepatic and left hepatic arteries and the vagal nerves of Latarjet running along the lesser curve of the stomachwere avoided. Tumorwasmobilized frombetween the left liver and anterior caudate lobe and from behind the pont hepatique. Care was taken to avoid damage to a branch of the left hepatic artery running in the roof of the lesser sac. The stomach was elevated and the caudate lobe carefully retracted to expose the posterior surface of the supragastric lesser sac formed by a single layer of peritoneum. This was stripped off and then detached from the caudate lobe. Tumor was then stripped or wiped off the anterior surface of the caudate lobe. Residual visible tumor was ablated. At the end of the procedure there was no visible disease. The patientwas then treatedwith hyperthermic intraperitoneal chemotherapy with mitomycin for 90min. The postoperative course was uncomplicated apart from short-term ileus and urinary retention.

Acalculous candidal cholecystitis after pediatric renal transplant.

AAC caused by Candida is an uncommon entity usually seen in the critically ill. Here, we present the case of an 18-month-old renal transplant patient who developed candidal AAC during the post-operative period. Previous articles have addressed acalculous cholecystitis secondary to a variety of causes, or addressed a wide variety of Candida infections in the biliary tract, but this is the first discussion of cholecystitis caused by Candida without confounding factors such as biliary calculi or multiple pathogens. After the discussion of our patient's case, we also reviewed the English-language literature regarding candidal AAC and discussed diagnosis, treatment, and mortality.

Opportunities and challenges of expanded criteria organs in liver and kidney transplantation as a response to organ shortage.

In 1989, there were 19,000 patients on the UNOS (United Network of Organ Sharing) wait list for organs compared to 110,000 today. Without an equivalent increase in donors, the patients awaiting these organs for transplant face increasing severity of illness and risk of dying without receiving a transplant. This disparity in supply and demand has led to acceptance of organs with lower than expected success rates compared to previous standard donors variously defined as extended criteria donors in order to increase transplantation. The reluctance to wider use of these types of organs is based on the less than expected transplant center graft and patient survival results associated with their use, as well as the increased resources required to care for the patients who receive these organs. The benefits need to be compared to the survival of not receiving a transplant and remaining on the waiting list rather than on outcomes of receiving a standard donor. A lack of a systematic risk outcomes adjustment is one of the most important factors preventing more extensive utilization as transplant centers are held to patient and graft survival statistics as a performance measure by multiple regulatory organizations and insurers. Newer classification systems of such donors may allow a more systematic approach to analyzing the specific risks to individualized patients. Due to changes in donor policies across the country, there has been an increase in Extended Criteria Donors (ECD) organs procured by organ procurement organizations (OPO) but their uneven acceptance by the transplant centers has contributed to an increase in discards and organs not being used. This is one of the reasons that wider sharing of organs is currently receiving much attention. Transplanting ECD organs presents unique challenges and innovative approaches to achieve satisfactory results. Improved logistics and information technology combined strategies for improving donor quality with may prevent discards while insuring maximal benefit. Transplant centers, organ procurement organizations, third party payers and government agencies all must be involved in maximizing the potential for ECD organs.

The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome.

HYPOTHESIS: We hypothesized that the model for end-stage liver disease (MELD) score may be a better and less subjective method than the Child-Turcotte-Pugh score for stratifying patients with cirrhosis before abdominal surgery. DESIGN: Retrospective medical record review. SETTING: Tertiary care institution. PATIENTS: Fifty-three adult patients with histologically proven cirrhosis undergoing abdominal surgery at Saint Louis University Hospital, St Louis, Mo, between 1991 and 2001. Those undergoing hepatic surgery (such as resection or transplantation) or closed abdominal surgery (such as hernia repair) were excluded. MAIN OUTCOME MEASURE: A poor outcome after surgery was defined as death or liver transplantation within 90 days of the operative procedure or a hospital stay of longer than 21 days. Demographic, clinical, and laboratory features predictive of poor outcome were assessed by multivariate analysis. RESULTS: A total of 13 patients (25%) had poor outcomes including 9 deaths (17%). Model for end-stage liver disease score and plasma hemoglobin levels lower than 10 g/dL were found to be independent predictors of poor outcomes. A MELD score of 14 or greater was a better clinical predictor of poor outcome than Child-Turcotte-Pugh class C. CONCLUSIONS: A MELD score of 14 or greater should be considered as a replacement for Child-Turcotte-Pugh class C as a predictor of being very high risk for abdominal surgery. Patients with cirrhosis with hemoglobin levels lower than 10 g/dL should receive corrective blood transfusions before abdominal surgery.

Cholangiocarcinoma metastatic to the neck: first report of a case.

We describe a unique case of a cholangiocarcinoma that metastasized to a cervical lymph node--to our knowledge the only such case ever reported. The diagnosis was based on fine-needle aspiration cytology and confirmed by excision biopsy. This case illustrates the importance of keeping all possible options in mind when diagnosing head and neck masses.

The role of positive flow cytometry crossmatch in late renal allograft loss.

Many studies relating flow cytometery crossmatch (FCXM) results to kidney transplant outcomes have examined risk in the first 3 to 12 months. We used Organ Procurement and Transplant Network registry data for 66,594 kidney transplants from 1995 to 2007 to investigate associations of T-cell positive (T+) and T-cell negative/B-cell positive (T(-)B+) FCXM with graft failure risk early (years 0-1) and late (years >1-5) after transplant. Compared with transplants with T-cell negative/B-cell negative (T(-)B(-)) FCXM, living-donor transplants performed after T+ FCXM had significantly higher adjusted, relative risks of both early (adjusted hazards ratio [aHR] 1.71, p < 0.0001) and late (aHR 1.36, p = 0.017) graft loss. T(-)B+ FCXM was associated with approximately 40% higher relative risk of graft loss in the late period only. Patterns were similar for deceased-donor transplants. The risks of positive FCXM persist beyond the peritransplant period for years after transplant. Damage by memory effector cells may explain the long-term risks associated with positive FCXM.

Splenectomy for thrombocytopenia in patients with hepatitis C cirrhosis.

BACKGROUND: Many patients with hepatitis C cirrhosis and low Model for End-Stage Liver Disease scores are too early for transplant but too thrombocytopenic to treat with interferon. GOAL: To report a case series of splenectomy to raise platelet counts so that pegylated interferon and ribavirin can be given in patients with hepatitis C cirrhosis. METHODS: Retrospective chart and computer record review. RESULTS: Seven patients with hepatitis C cirrhosis (mean age=45.4+/-11.1 y, 4 men) had elective splenectomy for thrombocytopenia before pegylated interferon-alpha 2b therapy. All had thrombocytopenia contraindicating antiviral therapy. Five were Child's-Pugh Class A; 2 were B. All 7 had increases in platelet count (mean 32,400 to 222,140 /mL, P<0.01) at 221+/-151 days postsurgery. Median hospital stay and blood loss were 9 days (4 to 25) and 750 mL (100 to 2500 mL). Median platelet packs, units of packed red blood cells and fresh frozen plasma given were 1 (0 to 7), 0 (0 to 14) and 0 (0 to 2), respectively. There were no deaths or portal vein thrombosis. One patient who was status-post liver transplantation had significant morbidity. Five completed pegylated interferon-alpha 2b and ribavirin therapy; 1 is on therapy and 1 awaits initiation. Of the 5 who completed therapy, there were 2 with sustained virologic response, 1 nonresponse, 1 breakthrough, and 1 relapse. CONCLUSIONS: Splenectomy in patients with hepatitis C cirrhosis can be done safely to allow application of antiviral treatment and potentially avoid transplantation. It may be considered in patients with Child's-Pugh A cirrhosis, no prior abdominal surgeries and with non-1 HCV viral genotype.

Disease- and cell-specific expression of GP73 in human liver disease.

OBJECTIVES: GP73, a Golgi membrane protein, is expressed at high levels in hepatocytes of patients with decompensated cirrhosis. Its expression in other forms of liver disease has not been investigated. Therefore, we studied GP73 expression in patients with noncirrhotic liver disease. METHODS: GP73 expression was detected immunohistochemically and by immunofluorescence microscopy in patients with acute hepatitis of various etiologies, autoimmune hepatitis, chronic HCV infection, and alcoholic liver disease. In order to quantitate hepatocyte GP73 expression, an immunohistochemical scoring system was developed, and validated by a direct comparison with GP73 protein levels as determined by Western blotting. RESULTS: GP73 immunostaining and Western blotting data were highly correlated, demonstrating the suitability of the immunohistochemical scoring system to quantitate hepatocyte GP73 expression. Hepatocyte GP73 expression was increased in patients with acute and autoimmune hepatitis. Treatment of autoimmune hepatitis was associated with a normalization of GP73 expression, indicating that the initial upregulation was reversible. Increased levels of GP73 expression were also noted in chronic HCV infection and alcoholic liver disease. Under these conditions, GP73 levels were correlated with disease stage but not grade. GP73 immunoreactivity was occasionally detected in alpha-SMA-positive, sinusoidal lining cells, suggesting activated stellate cells as a potential source of GP73. CONCLUSIONS: Hepatocyte GP73 levels are upregulated in acute hepatitis and during the progression of liver disease to cirrhosis. This expression pattern suggests the presence of two regulatory mechanisms, the first triggered during acute hepatocellular injury, the second during the progression of chronic liver disease.

Biliary-venous fistula complicating transjugular intrahepatic portosystemic shunt presenting with recurrent bacteremia, jaundice, anemia and fever.

A 50-year-old White man with noncirrhotic portal hypertension presented with bleeding from gastric varices. Bleeding was initially managed with band ligation and subsequent transjugular intrahepatic portosystemic shunt (TIPS). Over the next few months, the patient had recurrent episodes of anemia, jaundice, fever and polymicrobial bacteremia. Computed tomography (CT) of the abdomen and chest, upper and lower endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and echocardiography failed to explain the bacteremia and anemia. Follow-up CT scan and Doppler sonography 9 months after placement showed TIPS was occluded. Repeat ERCP showed a bile leak with free run-off of contrast from the left hepatic duct into a vascular structure. The patient's status was upgraded for liver transplantation with Regional Review Board agreement and subsequently received a liver transplant. Gross examination of the native liver demonstrated a fistula between the left bile duct and the middle hepatic vein. Pathologic evaluation confirmed focal necrosis of the left hepatic duct communicating with an occluded TIPS and nodular regenerative hyperplasia consistent with noncirrhotic portal hypertension. Infection is rarely reported in a totally occluded TIPS. Biliary fistulas in patent TIPS have been treated by endoluminal stent graft and endoscopic sphincterotomy with biliary stent placement. Liver transplantation may be the preferred treatment if TIPS becomes infected following its complete occlusion.