Non-standard hepatic venous reconstruction in the setting of absent inferior vena cava in partial graft pediatric liver transplantation-A matched retrospective cohort study.

Recipient cava may be unavailable for outflow reconstruction in some children undergoing liver transplantation (PLT) due to caval agenesis, tumor, or fibrotic caval occlusion. Non-standard hepatic venous reconstruction (NHVR) with a direct veno-caval anastomosis or neo-cava reconstruction is necessary in such cases. Retrospective review of all PLT needing NHVR performed in our unit from January 2010 to September 2019 was performed. Outcomes of this group were compared to a 2:1 matched control group who underwent transplantation with standard piggyback technique. Fifteen children (4.9%) of 304 PLT recipients underwent NHVR. Caval agenesis in biliary atresia (n = 5, 33%) and hepatoblastoma infiltrating the cava (n = 4, 27%) were the commonest indications. Ten children had neo-cava reconstruction, while 5 had direct anastomosis to the supra-hepatic caval cuff or right atrium. One child had developed neo-cava thrombosis without graft venous outflow obstruction in the post-operative period. There was no significant difference in major morbidity, need for re-operation (20% vs 16.7%; P = 1.00), hospital stay (24 days, vs 21 days; P = .32), graft & patient survival among the study and control groups. Absent or inadequate recipient cava during PLT with a partial liver graft can be safely managed with technical modifications. Results equivalent to standard piggyback implantation can be achieved.

Eversion Bile Duct Anastomosis: A Safe Alternative for Bile Duct Size Discrepancy in Deceased Donor Liver Transplantation.

Bile duct size discrepancy in liver transplantation may increase the risk of biliary complications (BCs). The aim of this study was to evaluate the safety and outcomes of the eversion bile duct anastomosis technique in deceased donor liver transplantation (DDLT) with duct-to-duct anastomosis. A total of 210 patients who received a DDLT with duct-to-duct anastomosis from 2012 to 2017 were divided into 2 groups: those who had eversion bile duct anastomosis (n = 70) and those who had standard bile duct anastomosis (n = 140). BC rates were compared between the 2 groups. There was no difference in the cumulative incidence of biliary strictures (P = 0.20) and leaks (P = 0.17) between the 2 groups. The BC rate in the eversion group was 14.3% and 11.4% in the standard anastomosis group. All the BCs in the eversion group were managed with endoscopic stenting. A severe size mismatch (≥3:1 ratio) was associated with a significantly higher incidence of biliary strictures (44.4%) compared with a 2:1 ratio (8.2%; P = 0.002). In conclusion, the use of the eversion technique is a safe alternative for bile duct discrepancy in DDLT. However, severe bile duct size mismatch may be a risk factor for biliary strictures with such a technique.

Fighting Mortality in the Waiting List: Liver Transplantation in North America, Europe, and Asia.

Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.

Combined Urinary Reconstruction During en Bloc Kidney Transplantation From a Pediatric Donor to an Adult Recipient: A Case Report.

Urinary reconstruction during en bloc kidney transplantation is challenging, with different techniques described. Here, we report a case of combined urinary reconstruction using modified Lich ureteroneocystostomy and ureteroureterostomy.

Segments 4, 7, and 8 liver resection: A case report.

Right superior resection (segments 7 and 8) is an uncommon resection for liver malignancies, with most of the literature limited to case reports and small series. Resection of segments 4, 7, and 8 has been reported in only a few cases. When the right hepatic vein is resected, venous reconstruction or identification of one or more right inferior hepatic veins is considered mandatory, to maintain segmentary function of segments 5 and 6. We present a case of liver resection of segments 4, 7, and 8 including the right and middle hepatic veins for symptomatic benign liver disease with no right hepatic vein reconstruction, nor a prominent right inferior hepatic vein(s). After the resection, there was no change in liver function tests, and the patient made an unremarkable recovery. Three months after the operation, partial atrophy of segments 5 and 6 with hypertrophy of the left lateral section was observed, while two and one half years after resection, the patient is asymptomatic. When right hepatic vein reconstruction would add unnecessary operative time, and there is low likelihood of the need for repeated resection, particularly when the hepatic vein is difficult to dissect, this approach can be safe and useful, while providing an adequate postoperative liver mass in the short-term to recover uneventfully from major liver resection.

Liver Recovery and Transplantation From Deceased Donors in the Metropolitan Area of the Valley of Mexico.

BACKGROUND: Evaluation of donation and transplantation activity allows for strategic planning. Liver donation and transplantation activity in the Metropolitan Area of the Valley of Mexico (MAVM) has never been published. The aim of this study was to analyze deceased liver donation and transplantation, liver use, and observed-to-expected (O:E) ratio in the MAVM. METHODS: Information from 2014 to 2018 was obtained from the National Center of Transplantation and adjusted per million persons. O:E ratio was analyzed and compared between regions. RESULTS: From all Mexican states, Mexico City (CDMX) had the highest liver donation and transplantation per million persons rates in the country. In contrast, when the MAVM was considered, the region was sixth in liver donation and first in transplantation, although the latter was not statistically different to Nuevo Leon (5.4 vs 4.3; P = .52). Liver use in Mexico State within the MAVM (37.8%) was not different from that of CDMX (15th in the nation, 35.2%, P = .78), while deceased donor liver use in the rest of the state was statistically higher (52.4%, P = .01; third in the nation). O:E ratio was higher in Mexico states outside the MAVM (CDMX 10.1, 2.1 vs 29.4, 26.5; P = .009). CONCLUSIONS: Analysis of deceased donation and transplantation of Mexican states without considering the metropolitan areas is insufficient. To consider CDMX as a region without acknowledging the MAVM leads to an inappropriately small denominator during efficiency analysis.

Iatrogenic bile duct injury with loss of confluence.

AIM: To describe our experience concerning the surgical treatment of Strasberg E-4 (Bismuth IV) bile duct injuries. METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo (median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study. RESULTS: Patients were divided in three groups: G1 (n = 21): Construction of neoconfluence + Roux-en-Y hepatojejunostomy. G2 (n = 26): Roux-en-Y portoenterostomy. G3 (n = 6): Double (right and left) Roux-en-Y hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation. CONCLUSION: Loss of confluence represents a surgical challenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis (neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.