Epidemiology and outcomes of surgical site infections among pediatric liver transplant recipients.

INTRODUCTION: Surgical site infections (SSI) are a significant cause of morbidity in liver transplant recipients, and the current data in the pediatric population are limited. The goal of this study was to identify the incidence, classification, risk factors, and outcomes of SSIs among children undergoing liver transplantation (LT). METHODS: A single-center, retrospective descriptive analysis was performed of patients age ≤18 years undergoing LT between September 2007 and April 2017. SSI identified within the first 30 days were analyzed. Primary endpoints included incidence, classification, risk factors, and outcomes associated with SSIs. RESULTS: We included 86 patients, eight patients (9.3%) developed SSIs. Among segmental grafts (SG) recipients, 7/61 (11.4%) developed SSI. Among whole grafts recipients, 1/25 (4%) developed SSI. SSIs were associated with the presence of biliary complications (35% vs. 3%, p < .01; odds ratios 24, 95% CI: 3.41-487.37, p<.01). There were no differences in long term graft or patient survival associated with SSI. Patients who developed SSI were more likely to undergo reoperation (50% vs. 16.7%, p = .045) and had an increased total number of hospital days in the first 60 days post-transplant (30.5 vs. 12.5 days, p = .001). CONCLUSIONS: SSIs after pediatric LT was less frequent than what has been previously reported in literature. SSIs were associated with the presence of biliary complications without an increase in mortality. SG had an increased rate of biliary complications without an association to SSIs but, considering its positive impact on organ shortage barriers, should not be a deterrent to the utilization of SGs.

Protocolized management of pediatric complicated appendicitis leads to improved outcomes.

PURPOSE: We aimed to evaluate a complicated appendicitis clinical practice guideline at our institution. METHODS: Records were compared before and after protocol implementation. We standardized an ED consult pathway, antibiotic use and need for early appendectomy (EA) versus interval appendectomy (IA). We evaluated demographics, clinical characteristics, and outcomes. Subgroup analysis was performed to compare patients with small abscess treated with IA pre-protocol versus similar patients treated by EA post-protocol. RESULTS: In total 246 patients were reviewed (Pre-protocol = 152, Post-protocol = 94). Pre-protocol early appendectomy rate was 51% versus 82% on post-protocol patients. There were no differences in demographics. Post-protocol the use of preoperative imaging significantly decreased (Pre 92% vs. 56%, p = 0.0001), as well as the use of discharge antibiotics (Pre 93% vs. Post 27%, p = 0.0001) with no change in abscess rate. Overall, post-protocol patients had fewer total CT scans performed (Pre 40% vs. Post 28%, p = 0.03) and decreased total length of stay (Pre 7.7 vs. Post 6.5 days, p = 0.049). On subgroup analysis, post-protocol EA with no or small abscess had lower median number of admissions, decreased total LOS (Pre IA 9 days vs. Post EA 5 days, p = 0.00001) and fewer complications (Pre IA 42% vs. EA 22%, p = 0.022). CONCLUSION: The establishment of a standardized pediatric complicated appendicitis protocol may lead to improved outcomes and resource utilization. Patients presenting with no or small abscess may be the least likely to benefit from interval appendectomy. LEVEL OF EVIDENCE: Level III.

Open Gastrostomy Tube Placement is Associated With Higher Complications in Infants: A National Surgical Quality Improvement Program Database Analysis.

BACKGROUND: The purpose of this study was to compare outcomes between open versus laparoscopic gastrostomies in children aged ≤1 y. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Pediatric database was reviewed between 2012 and 2017. Chi-square analysis was performed on children aged ≤1 y to compare complication rates between open and laparoscopic procedures. RESULTS: A total of 7940 patients were aged ≤1 y. Of which, 20% underwent open gastrostomy (OGT), and 80% received laparoscopic gastrostomy (LGT). There were no differences in sex or race. However, OGT patients were younger (119 d versus 134 d; P = 0.0001), smaller at birth (1.84 kg versus 1.85 kg; P = 0.03), and were smaller at operation (4.6 kg versus 5 kg; P = 0.0001). Also, patients were more likely to be inpatient at the time of surgery and had more congenital malformations. Complications (OGT 6% versus LGT 4%; P = 0.001) and mortality were significantly higher in the open group (OGT 2.3% versus LGT 0.6%; P = 0.001). However, matched control analysis demonstrated OGT patients have more complications. CONCLUSIONS: OGT patients are smaller and with more significant comorbidities in this data set. In fact, even after matched control analysis, these patients experience more complications.

Screening Laboratory Testing in Asymptomatic Minor Pediatric Blunt Trauma Leads to Unnecessary Needle Sticks.

OBJECTIVE: Screening blood work after minor injuries is common in pediatric trauma. The risk of missed injuries versus diagnostic necessity in an asymptomatic patient remains an ongoing debate. We evaluated the clinical utility of screening blood work in carefully selected asymptomatic children after minor trauma. METHODS: Patients seen at a level 1 pediatric center with "minor trauma" for blunt trauma between 2010 and 2015 were retrospectively reviewed. Exclusion criteria were age <4 of >18 years, a Glasgow Coma Scale score of <15, penetrating trauma, nonaccidental trauma, hemodynamic instability, abdominal findings (pain, distension, bruising, tenderness), hematuria, pelvic/femur fracture, multiple fractures, and operative intervention. Data abstraction included demographics, blood work, interventions, and disposition. RESULT: A total of 1308 patients were treated during the study period. Four hundred thirty-three (33%) met inclusion criteria. Mean ± SD age was 12.7 ± 4 years (range, 4-18 years), and 59% were male. Seventy-eight percent were discharged home from the emergency department. All patients had blood work. Twenty-eight percent had at least one abnormal laboratory value. The most common abnormal blood work was leukocytosis (16%). Thirty percent had an intervention, and none prompted by abnormal blood work. One patient had an intra-abdominal finding (psoas hematoma). CONCLUSION: When appropriately selected, screening laboratory testing in asymptomatic minor pediatric blunt trauma patients leads to unnecessary needle sticks without significant advantage.

Standardized text messages improve 30-day patient follow-up for ACS pediatric NSQIP cases.

PURPOSE: Thirty-day follow-up is a critical and challenging component of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). We hypothesized the simplicity and immediacy of text messaging would increase response rates while reducing workload. METHODS: For 6 months, text messages were the primary form of contact for first and second follow-up attempts. If no response, a phone call was made. Results of this protocol were compared to the previous 6 months when phone calls were the primary method. RESULTS: The text message (TM) group had 298 cases and phone call (PC) group had 354. The first contact was successful in 63.8% of the TM group compared to 47.5% of the PC group. The second contact was successful in 15.4% (TM) and 16.9% (PC). In the third attempt, 3.0% answered the call in the TM group versus 9.3% in the PC group. Some families remained unreachable: 17.8% in TM group and 26.3% in PC group (p = 0.01). When totaled, time spent to obtain caregivers' responses was over five times higher in the PC group (910 min) than the TM group (173 min) (p = 0.005). CONCLUSION: Patient follow-up using text messaging has improved our follow-up rate while decreasing workload.

A new method to measure intestinal secretion using fluorescein isothiocyanate-inulin in small bowel of rats.

BACKGROUND: Small intestine ischemia can be seen in various conditions such as intestinal transplantation. To further understand the pathologic disruption in ischemia-reperfusion injury, we have developed a method to measure fluid changes in the intestinal lumen of rats. METHODS: Two 10-cm rat intestine segments were procured, connected to the terminal apertures of a perfusion device, and continuously infused with 3 mL of HEPES solution (control solution) containing 50 µM of fluorescein isothiocyanate (FITC)-inulin. The perfusion device consists of concentric chambers that contain the perfused bowel segments, which are maintained at 37°C via H2O bath. The individual chamber has four apertures as follows: two fill and/or drain the surrounding HEPES solution on the blood side of the tissue. The others provide flow of HEPES solution containing FITC-inulin through the lumens. The experimental intestine was infused with the same solution with 100 µM of Forskolin. A pump continuously circulated solutions at 6 mL/min. Samples were collected at 15-min intervals until 150 min and were measured by the nanoflourospectrometer. RESULTS: A mean of 6-µM decrease in the FITC-inulin concentration in the Forskolin-treated experimental intestine was observed in comparison with that in the control intestine. The FITC-inulin count dilution in the experimental intestine is a result of an increase of fluid secretion produced by the effect of Forskolin, with P values <0.0001. CONCLUSIONS: We demonstrate that it is possible to measure luminal fluid changes over time using our new modified perfusion system along with FITC-inulin to allow real-time determinations of fluid and/or electrolyte movement along the small intestine.

To Button or Not to Button? Primary Gastrostomy Tubes Offer No Significant Advantage Over Buttons.

Purpose: Outcomes between primary gastrostomy tubes and buttons (G-tube and G-button) have not been established in pediatric patients. We hypothesized that primary G-tube have decreased complications when compared to G-button. Methods: A retrospective review of surgically placed gastrostomy devices from 2010 to 2017 was performed. Data collected included demographics, outcomes and 90-day complications. We divided the patients into primary G-tube and primary G-button. Results: Of 265 patients, 142 (53.6%) were male. Median age and weight at the time of surgery were 7 months (interquartile range [IQR], 2-44 months) and 6.70 kg (IQR, 3.98-14.15 kg), respectively. Among the groups, G-tube had 80 patients (30.2%) while G-button 185 patients (69.8%). There were 153 patients with at least one overall complication within 90 days postoperative. There was no significant difference in overall complications between groups (G-tube 63.8% vs. G-button 55.7%, p=0.192). More importantly, there were no significant differences in major complications among the groups, G-tube vs. G-button (5% vs. 4%; p=0.455). Conclusion: Primary G-tube offers no significant advantage in overall, minor or major complications when compared to primary G-button.

To operate or not to operate? Assessing NSQIP surgical outcomes in trisomy 18 patients.

BACKGROUND: Trisomy 18 is associated with a wide range of potentially fatal congenital conditions. Historically, clinical attitudes on treatment have been ambiguous, with palliative care as the standard of care. The aim of our study was to provide a descriptive analysis of surgical outcomes in patients with trisomy 18. STUDY DESIGN: We identified patients with trisomy 18 aged 0-18 years using the NSQIP-Pediatric database from 2012 to 2017 and analyzed demographics, surgery types, and perioperative characteristics of patients with trisomy 18 patients undergoing surgical intervention. Additionally, a case-match analysis was performed to assess surgical outcome differences. RESULTS: A total of 310 patients with trisomy 18 were identified. Thirty-one percent were >5 years of age and 73% were female. The most common surgical types were general surgery procedures (57.4%), followed by orthopedics (18.1%) and ENT (10.3%). Operations performed increased from 8% (2012) to 26% (2017), and only 23% of patients had previous cardiac surgery. Majority of patients had no prior history of malignancy (95%) and 5% had a tracheostomy placed. Discharge to home was achieved in 74% of patients, with a median total hospital length of stay of 5 days (IQR 17). Furthermore, 90% survived over 30 days from the operation. Thirty-two patients had readmissions and the most common reasons were dehydration, gastrostomy infection or malfunction. Surgical site infections occurred in <3% of patients. No differences in complications, length of stay, reoperations, and readmissions were identified by case-match analysis. CONCLUSION: In this data set, patients with trisomy 18 undergoing noncardiac surgical procedures experience excellent surgical outcomes with minimal morbidity and low mortality. Most patients more than a year of age will experience similar outcomes to patients without trisomy 18. TYPE OF STUDY: Treatment study (retrospective comparative study) LEVEL OF EVIDENCE: Level III.

Human Small Intestine Transplantation: Segmental Susceptibility to Ischemia Using Different Preservation Solutions and Conditions.

BACKGROUND AND AIMS: Among all transplanted abdominal organs, the small intestine is one of the most ischemia sensitive. Appropriate graft selection, procurement, and preservation are crucial for optimum graft and patient survival. We evaluated ischemic damage in human small intestine grafts under different hypothermic preservation conditions (cold static and continuous perfusion) and solutions: histidine-tryptophan-ketoglutarate (HTK) and University of Wisconsin (UW). METHODS: Fourteen small intestinal grafts were procured from deceased donors. HTK and UW were used for the vascular perfusion at the cross clamp, and UW, HTK, or Ringer Lactate were used for the luminal flush at the back table. Therefore, part of the same harvested intestine was stored in cold static storage and in continuous perfusion preservation (with intestinal perfusion unit) simultaneously. Histological samples were collected from the jejunum and ileum at different time points and different preservation conditions. The samples were collected before the initiation of cold storage (T0), after 8 hours of cold static (ST8), or after 8 hours of continuous perfusion preservation (PT8) (n = 161 samples). Blinded histological evaluation was conducted and ischemic damage was determined using the Park/Chiu scale. RESULTS: The ileum had less ischemic damage than the jejunum, regardless of using static or continuous perfusion preservation. There was no significantly ischemic damage difference between intestinal grafts flushed and perfused with UW or HTK. CONCLUSION: The jejunum is more susceptible to ischemic injury than the ileum. UW and HTK are equivalent to preserve intestinal graft. This suggests that selective transplantation of ileum could reduce ischemia-related postoperative complications.

Multicenter retrospective comparison of spontaneous intestinal perforation outcomes between primary peritoneal drain and primary laparotomy.

PURPOSE: The purpose of our study was to compare outcomes of infants with spontaneous intestinal perforation (SIP) treated with primary peritoneal drain versus primary laparotomy. METHODS: We performed a multi-institution retrospective review of infants with diagnosis of SIP from 2012 to 2016. Clinical characteristics and outcomes were compared between infants treated with primary peritoneal drain vs infants treated with laparotomy. RESULTS: We identified 171 patients treated for SIP (drain n = 110 vs. laparotomy n = 61). There were no differences in maternal or prenatal characteristics. There were no clinically significant differences in vital signs, white blood cell or platelet measures, up to 48 h after intervention. Patients who were treated primarily with a drain were more premature (24.9 vs. 27.2 weeks, p < 0.001) and had lower median birth weight (710 g vs. 896 g, p < 0.001). No significant differences were found in complications, time to full feeds, length of stay (LOS) or mortality between the groups. Primary laparotomy group had more procedures (median number 1 vs. 2, p = 0.002). There were 32 (29%) primary drain failures whereby a laparotomy was ultimately needed. CONCLUSIONS: SIP treated with primary drain is successful in the majority of patients with no significant differences in outcomes when compared to laparotomy with stoma. THE LEVEL OF EVIDENCE: III.

Laparoscopic Division of Median Sacral Artery and Dissection of Types III and IV Sacrococcygeal Teratomas to Decrease Intraoperative Hemorrhagic Complications: Case Series and Review of the Literature.

INTRODUCTION: Sacrococcygeal teratoma (SCT) is the most common teratoma presenting at birth. Life-threatening bleeding is a major complication during tumor excision in children. In this study we demonstrate our technique for laparoscopic division of median sacral artery (MSA) during dissection of SCT in 2 pediatric patients as a safe technique to minimize risk of hemorrhage. METHODS: Two female infants diagnosed with types III and IV SCTs underwent preoperative evaluation in the postnatal period. The first patient was an 18-month-old girl who presented with metastatic type IV teratoma, resected after neoadjuvant therapy, and the second patient was a 6-day-old girl with prenatal diagnosis of cystic type III teratoma. Using laparoscopy in both patients, the presacral space was reached by opening the peritoneal reflection with blunt dissection and the MSA was identified. Then it was carefully isolated and divided with 3 or 5 mm sealing device. The pelvic components of the tumors were partially dissected using laparoscopy. The first patient's tumor resection was completed using a posterior sagittal approach and the second patient required a standard Chevron incision. Along with the description of our technique, a review of the current literature for the management of SCT and MSA was performed. RESULTS: Both patients underwent successful laparoscopic division of the MSA and resection of the SCTs without complications. CONCLUSION: Laparoscopic MSA division before SCT excision offers a safe approach that can reduce the risk of hemorrhage during surgery.

Perioperative Antibiotics Are Independent Predictors for Major Complications in Pediatric Patients Undergoing Gastrostomy Placement.

Introduction: Although rare, major complications after gastrostomy tube placement are a significant source of morbidity in children. The purpose of this study was to identify predictors of major complications in pediatric patients undergoing gastrostomy placement. Materials and Methods: Retrospective review of surgically placed gastrostomy tubes from 2010 to 2017 was performed. Data collected included demographics, outcomes, and major complications. We divided the patients into no complications (Group 1) and major complications (Group 2). Excluded were minor complications and percutaneous endoscopic gastrostomy procedures. Results: Of 123 patients, 51.5% were males and 52% infants. Group 1 had 112 patients (91%), whereas Group 2 had 11 patients (9%). Of Group 2 patients, 3 required prolonged nil per os/total parenteral nutrition and 8 surgical reinterventions. Laparoscopy in 110 patients (89%), open surgery in 10 patients (8%), and 3 conversions to open. There were no significant differences in demographics or preoperative characteristics (albumin and comorbidities). We identified surgical approach (open: 6.3% versus 27.3%, P = .014), operative time (58 versus 85 minutes, P = .04), and use of preoperative antibiotics (63% versus 92%, P = .004) as predictors of outcomes. However, on multivariate analysis lack of preoperative antibiotics (adjusted odds ratio [aOR], 14.82 [confidence interval: 2.60-84.34], P = .002), and open procedure (aOR, 6.14 [1.01-37.24], P = .049) were independent predictors of major complications. Conclusion: Most patients with major complications after gastrostomy tube placement require surgical reintervention. Lack of preoperative antibiotics and open procedures are independent predictive factors for major complication in patients undergoing gastrostomy tube placement.

Sterile necrotizing and non-necrotizing granulomas in a heart transplant patient with history of PTLD: A unique finding.

INTRODUCTION: Posttransplant lymphoproliferative disease (PTLD) is a known complication in patients with solid organ transplant. It can present as localized or disseminated tumor. The cornerstone of management consists of reduced immunosuppression (RI). In select cases, localized disease can potentially be curative with surgical excision. PRESENTATION OF CASE: Here we present a case of a 19-year-old female with orthotopic heart transplant with two episodes of recurrent PTLD. After the second episode she was found to have asymptomatic splenic lesions which were refractory to RI and chemotherapy. She subsequently underwent splenectomy that showed sterile necrotizing and non-necrotizing granulomas with no evidence of PTLD. DISCUSSION: Based on our literature search this is the first ever reported case of sterile granulomas in a patient with recurrent PTLD which could potentially be diagnosed with minimally invasive biopsy rather than diagnostic splenectomy. CONCLUSION: This report is an attempt to create awareness regarding potential for presence of sterile granulomas in patients with recurrent PTLD and discuss the use of percutaneous biopsy before splenectomy.

Abscess and symptoms duration upon presentation should guide decision algorithms for early versus interval appendectomy in children.

BACKGROUND: To compare outcomes for complicated appendicitis treated with early versus interval appendectomy and to identify which patients would likely benefit from early appendectomy. METHODS: A retrospective review of complicated appendicitis was performed from 2010 to 2015. Patients were divided into early (EA) versus interval appendectomy (IA) groups. We compared demographics, complications and outcomes. Pearson's Chi square analysis and Student's T test analysis were performed. RESULTS: We identified 316 patients (EA group 53% vs. IA group 47%). Interval appendectomy group had longer symptom duration [IA 3.8 vs. EA 2.3 days (p = 0.0001)], increased leukocytosis [IA 18.7 vs. EA 17.2 (p = 0.008)], more initial abscesses [IA 35% vs. EA 13% (p = 0.0001)], more complications [IA 30% vs. EA 19%, (p = 0.013) and prolonged total length of stay [(LOS), p = 0.009]. Subgroup analysis of all patients revealed 80% of patients presented with ≤3 cm abscess and duration of symptoms (DOS) ≤5 days. Interval appendectomy patients with DOS ≤5 days and or ≤3 cm abscess on admission had no differences in clinical presentation. However, these patients had prolonged total LOS (IA 7.7 vs. EA 6.3 days, p = 0.01) and increased complications (IA 29% vs. EA 19%, p = 0.04). CONCLUSION: The majority of patients with complicated appendicitis in children present with small abscess (≤3 cm) and short symptom duration (≤5 days). This subset of patients might benefit from early appendectomy due to decreased LOS, resource utilization and reduced complications.

Incidence and Outcomes of Perforated Peptic Ulcers in Children: Analysis of the Kid's Inpatient Database and Report of Two Cases Treated by Laparoscopic Omental Patch Repair.

INTRODUCTION: Peptic ulcer disease (PUD) is a rare condition in children. Perforated peptic ulcer (PPU), a complication of PUD has an estimated mortality between 1.3% and 20%. We evaluate incidence and outcomes of PPU in children using an administrative database, perform a review of the literature, and report our technique for laparoscopic omental patch repair for PPU in two pediatric patients. MATERIALS AND METHODS: Kids' inpatient database (KID's) was analyzed for demographics, incidence, and outcomes. Incidence for each year was calculated based on the reported pediatric population in the United States for 2000, 2003, 2006, 2009, and 2012 by the U.S. Census Bureau. Additionally, we present two PPU cases, accompanied by a comprehensive review of the literature. RESULTS: The annual number of primary discharge diagnosis of PPU in the KID was 178 cases for 2000, 252 for 2003, 255 for 2006, 299 for 2009, and 266 for 2012. An increase trend over time was noted between 2000 and 2009; however, it was not statistically significant (0.05). PPU appears to be more common in Caucasian teenage boys. The mean length of stay was 8.02 days and with a statistically significant increase in healthcare charges ($33,187 versus $78,142, P = .002) when comparing year 2000-2012. DISCUSSION: PPU is a rare cause of abdominal pain in children, but still a PUD complication that requires surgery. PPU should be included in the differential diagnosis in patients presenting with acute abdominal pain of uncertain etiology and pneumoperitoneum. Laparoscopy is both diagnostic and therapeutic. Laparoscopic omental patch repair is a safe and effective treatment for PPUs.

Peritoneal Nodules in a Pediatric Patient with Benign Teratoma. A Case Report and Review of Literature.

BACKGROUND: Mature ovarian teratomas are common in children. These well differentiated tumors are typically confined to the ovary. In rare cases, they can rupture leading to granulomatous peritonitis that mimics carcinomatosis. Ovarian tumors with peritoneal/omental implants suggest malignant pathology with a different prognosis. CASE: A 15-year-old girl presented with 5 months of abdominal pain, and weight loss. Computed tomography (CT) imaging of the abdomen revealed a large mass filling the abdomen. Slightly elevated lactate dehydrogenase (LDH) and carcinoma antigen 125 (CA125). On laparotomy an ovarian tumor with peritoneal and omental implants was identified. Left salpingo-oophorectomy, omentectomy, and peritoneal washing were performed. Pathology revealed a benign cystic teratoma. SUMMARY AND CONCLUSION: Although ovarian teratomas are typically benign, they might mimic carcinomatosis. In patients with unexpected finding of peritoneal implants, histologic diagnosis is recommended before proceeding with a full oncologic ovarian resection.

Use of Fluorescein Isothiocyanate-Inulin as a Marker for Intestinal Ischemic Injury.

BACKGROUND: Intestinal ischemia is observed in conditions such as mesenteric ischemia, or during traumatic events such as intestinal transplantation. Intestinal ischemia leads to pathophysiologic disruptions that present as increased fluid secretion into the intestinal lumen. We propose a novel method to detect real-time ischemic injury that is used in an in vitro model applicable to intestinal transplantation. STUDY DESIGN: Small intestine segments from rats were procured. The segments were attached to customized perfusion chambers. Both intestines were perfused on the vascular side with a Ringer buffer solution. The experimental buffer solution was bubbled with 100% nitrogen to mimic ischemia. Both lumens were perfused with 3 mL HEPES-Ringer solution containing 50 µM fluorescein isothiocyanate (FITC)-inulin. Intraluminal samples were collected at 15-minute intervals to measure FITC-inulin concentration using a nanofluorospectrophotometer. Intestinal tissue samples were processed and evaluated by a blinded pathologist using the Park/Chiu scoring system for grading intestinal ischemia. RESULTS: Samples collected from the ischemic intestine showed a significant decrease in FITC-inulin fluorescence compared with the control intestine, indicating enhanced fluid secretion. Histopathologic samples from the experimental arm exhibited higher scores of ischemic injury in comparison with the control arm, confirming the FITC-inulin as a correlation to ischemia. CONCLUSIONS: Fluorescein isothiocyanate-inulin can be used as a real-time volume marker to monitor the ischemic state of intestinal tissue. A positive correlation between the degree of fluid shift and presence of ischemic injury. The changes in fluorescence signal provide a potential selective method to measure real-time fluid changes inside an intestinal graft to evaluate viability.

De-novo hepatocellular carcinoma after pediatric living donor liver transplantation.

De-novo malignancies carry an incidence ranging between 3%-26% after transplant and account for the second highest cause of post-transplant mortality behind cardiovascular disease. While the majority of de-novo malignancies after transplant usually consist of skin cancers, there has been an increasing rate of solid tumor cancers over the last 15 years. Although, recurrence of hepatocellular carcinoma (HCC) is well understood among patients transplanted for HCC, there are increasing reports of de-novo HCC in those transplanted for a non-HCC indication. The proposed pathophysiology for these cases has been mainly connected to the presence of advanced graft fibrosis or cirrhosis and always associated with the presence of hepatitis B or C virus. We report the first known case of de-novo HCC in a recipient, 14 years after a pediatric living related donor liver transplantation for end-stage liver disease due to biliary atresia without the presence of hepatitis B or C virus before and after transplant. We present this case report to increase the awareness of this phenomenon and address on the utility for screening and surveillance of hepatocellular carcinoma among these individuals. One recommendation is to use similar guidelines for screening, diagnosis, and treatment for HCC as those used for primary HCC in the pre-transplant patient, focusing on those recipients who have advanced fibrosis in the allograft, regardless of etiology.

Host factors are dominant in the development of post-liver transplant non-alcoholic steatohepatitis.

Non-alcoholic fatty liver disease (NAFLD) is a recognized problem in patients after orthotopic liver transplantation and may lead to recurrent graft injury. As the increased demand for liver allografts fail to match the available supply of donor organs, split liver transplantation (SLT) has emerged as an important technique to increase the supply of liver grafts. SLT allows two transplants to occur from one donor organ, and provides a unique model for observing the pathogenesis of NAFLD with respect to the role of recipient environmental and genetic factors. Here we report on two recipients of a SLT from the same deceased donor where only one developed non-alcoholic steatohepatitis (NASH), suggesting that host factors are critical for the development of NASH.

Extracorporeal Hypothermic Perfusion Device for Intestinal Graft Preservation to Decrease Ischemic Injury During Transportation.

INTRODUCTION: The small intestine is one of the most ischemia-sensitive organs used in transplantation. To better preserve the intestinal graft viability and decrease ischemia-reperfusion injury, a device for extracorporeal perfusion was developed. We present the results for the first series of perfused human intestine with an intestinal perfusion unit (IPU). METHODS: Five human intestines were procured for the protocol. (1) An experimental segment was perfused by the IPU delivering cold preservation solution to the vascular and luminal side continually at 4 ºC for 8 h. (2) Control (jejunum and ileum) segments were preserved in static cold preservation. Tissue samples were obtained for histopathologic grading according to the Park/Chiu scoring system (0 = normal, 8 = transmural infarction). RESULTS: Jejunal experimental segments scored 2.2 with the Park/Chiu system compared to the control segments, which averaged 3.2. Overall scoring for ileum experimental and control segments was equal with 1.6. CONCLUSION: This data presents proof of concept that extracorporeal intestinal perfusion is feasible. The evidence shows that the IPU can preserve the viability of human intestine, and histopathologic evaluation of perfused intestine is favorable. Our early results can eventually lead to expanding the possibilities of intestinal preservation.