Hepaticojejunostomy in Orthotopic Liver Transplant: A Retrospective Case Control Study.

The reported biliary morbidity rate for deceased donor full-size orthotopic liver transplantation is up to 30%. The technique used may be influenced by multiple factors, and in some situations, biliary reconstruction must be carried out through Roux-en-Y hepaticojejunostomy. The aim of our study was to determine the results of the orthotopic liver transplantation according to the technique used in the biliary reconstruction. A retrospective study was performed with the first 1000 orthotopic liver transplants (951 patients) carried out consecutively (1996-2013) with follow-up until 2017. A matched case-control study was designed in 1:3 ratio (47/136) to compare the reconstruction by hepaticojejunostomy vs the end-to-end coledoco-coledocostomy. Hepaticojejunostomy was associated with patients with cholestatic (44.7% vs 3.7%) and ischemic disease (14.9% vs 0%; P < .001) and previous transplant (29.8% vs 1.5%; P = .003). The mean biliary duct reconstruction, surgery, and cold ischemia times were also higher. Vascular complications were significantly more frequent in the hepaticojejunostomy group (36.1% vs 10.4%; P < .001), mainly because of differences in early arterial complications. Nevertheless, there were no differences in the total biliary complication (21.2% vs 16.9%; P = .5). The biliary leakage rate and the biliary stricture rate were also similar. Hepaticojejunostomy in orthotopic liver transplantation presented longer biliary reconstruction, surgery, and cold ischemia times when compared with end-to-end coledoco-coledocostomy. In addition, it was followed by a higher incidence of arterial complications but had similar biliary complication rate and graft survival. Differences could be explained by the fact that hepaticojejunostomy was used more often in cholestatic or ischemic diseases and in retransplant procedures.

Octogenarian Donors in Liver Transplantation.

INTRODUCTION: Due to the disparity between the number of patients on the list for liver transplantation and the availability of organs, the use of older donors has become necessary. The aim of this study was to investigate the outcomes of liver transplantation using octogenarian donors. METHODS: From December 2003 to February 2016, 777 liver transplantations were performed at our institution, 33 of them (4.2%) with donors 80 years old and above. Our policy for the acceptance of these donors is based on preoperative liver function tests, donor hemodynamic stability, and intraoperative normal gross aspect. Octogenarian grafts were deliberately not assigned to retransplantations or to recipients with multiple previous surgical procedures or extensive portal thrombosis. RESULTS: Mean donor age was 82.7 ± 2.1 years, with a range between 80 and 88. Only 12.1% suffered hemodynamic instability during the intensive care unit stay. Three donors (9.1%) had a history of diabetes mellitus. The mean Model for End-Stage Liver Disease score among recipients was 14.7 ± 5.6. Mean cold ischemia time was 302 ± 61 minutes. After a median follow-up of 18.5 months (range 7.5 to 47.5), no graft developed primary nonfunction. We observed hepatic artery thrombosis in 1 patient (3%) and biliary complications in 4 patients (12.5%). There was 1 case of ischemic-type biliary lesion, although it was related to hepatic artery thrombosis. Patient survival at 1 and 3 years was 90.3%, whereas graft survival was 92.6% and 86.4%, respectively. CONCLUSIONS: Excellent mid-term results can be obtained after liver transplantation with octogenarian donors with strict donor selection and adequate graft allocation.

Intraoperative Portal Flow of Less Than 1 Liter per Minute After Orthotopic Liver Transplantation Is Not Associated Per Se With an Increased Rate of Early Graft Dysfunction.

OBJECTIVE: The aim of this study was to determine whether a portal flow of <1,000 mL/min in orthotopic liver transplantation (OLT) is associated with a higher incidence of early graft dysfunction (EGD) and graft loss. METHODS: A retrospective study was performed of 540 OLTs carried out consecutively from December 2004 to December 2013. Patients were divided into 2 groups: group A, portal flow <1,000 mL/min; and group B, portal flow >1,000 mL/min. We studied the incidence of EGD and graft survival. A subanalysis was performed to define the minimum acceptable portal flow/100 g of liver weight to reduce the development EGD and graft loss. RESULTS: Group A included 29 patients and group B, 511 patients. Group A had significantly lower-weight donors and recipients, female recipients with cholestatic disease, lower MELD scores, and lower hepatic artery flow. EGD occurred in 7 patients in group A (24.1%) versus 101 patients in group B (19.8%; P = .43). No significant differences were found in 1- and 5-year graft survival. A portal flow of <80 mL/min/100 g of liver weight was related to a significantly higher risk of developing EGD (odds ratio, 4.35; 95% confidence interval [CI], 1.46-12.91; P = .008) and graft loss (hazard ratio, 4.05; 95% CI, 1.32-12.42; P = .014). CONCLUSIONS: Intraoperative portal flow of <1,000 mL/min in OLT was not related per se with a higher incidence of EGD or graft loss. Significantly higher risk of developing EGD and graft loss was associated with a portal flow of <80 mL/min/100 g of liver weight.

Risk factors for biliary complications after orthotopic liver transplantation with T-tube: a single-center cohort of 743 transplants.

BACKGROUND: Despite recent advances in organ preservation, surgical procedures, and immunosuppression, biliary reconstruction after orthotopic liver transplantation (OLT) remains as a major source of morbidity. The purpose of this study was to identify risk factors for the development of biliary complications (BCs) after end-to-end choledochocholedochostomy (EE-CC) with a T-tube as the standard technique for biliary reconstruction after OLT. METHODS: A total of 833 consecutive liver transplantations that took place from February 1996 to April 2010 were retrospectively reviewed. Patients with concomitant hepatic artery complications were excluded, as were those who underwent urgent retransplantation or died within 1 week after transplantation. Finally, the study group comprised 743 patients. RESULTS: The overall BC rate was 9.8% (73 patients), including stricture in 19 patients (2.6%) and bile leakage in 39 patients (5.2%). After univariate analysis, significant risk factors for BCs were surgery time >5 hours, arterial ischemia time >30 minutes, use of a classic transplant technique, transfusion of red blood cells ≥5 units, anti-cytomegalovirus treatment, and period of transplantation between 1996 and 2002. Stepwise logistic regression study was performed, including those variables with a value of P <.200. Multivariate analysis showed that pretransplant serum creatinine (odds ratio = 1.27; 95% confidence interval [CI], 1.03-1.57; P = .025) and arterial ischemia time >30 minutes (odds ratio = 2.44; 95% CI, 1.45-4.12; P = .001) were the only independent risk factors related to the development of BCs after biliary reconstruction with the T-tube. CONCLUSIONS: The performance of different variables in predicting occurrence of BCs was assessed with the use of receiver operating characteristic analysis. The area under the receiver operating characteristic curve of our model was 0.637 (95% CI, 0.564-0.710), and therefore we must conclude that other variables not included in our model may have influence in the development of BCs after OLT with an EE-CC with a T-tube as the procedure for biliary reconstruction.

Advagraf de novo in liver transplantation: a single-center experience.

UNLABELLED: Advagraf, a prolonged release formulation of tacrolimus, is administered once daily in the morning. The aim of this study was to show the results obtained in our center, analyzing the safety, efficacy, blood trough levels, and drug doses. METHODS: We analyzed 50 consecutive recipients of a first liver transplantation with 6 months follow-up. Efficacy and safety variables were collected as the incidence of acute rejection episodes, patient and graft survivals, kidney function as well as incidences of diabetes mellitus and arterial hypertension de novo. RESULTS: The incidence of biopsy proven acute rejection episodes was 10% (n = 5), none 7 of which were steroid resistant and all resolved favorably. The rate of diabetes mellitus de novo was 22% (n = 11), 7 of whom required insulin. Hypertension developed in 9 patients (18%), all of whom were treated with a single drug. The mean serum creatinine level was 1.08 ± 0.25 mg/dL, with 3 patients (6%) displaying a value ≥ 1.5 mg/dL. Patient and graft survivals were 100%. CONCLUSION: Advagraf is an effective immunosuppressant in liver transplantation with a low incidence of biopsy-confirmed acute rejection episodes. The good results for patient and graft survival with few side effects make it a useful drug for de novo liver transplantation.

Management of hepatocellular carcinoma recurrence after liver transplantation.

UNLABELLED: Management of patients with hepatocellular carcinoma (HCC) recurrence after liver transplantation (OLT) is not well established. We conducted a retrospective analysis of our results in the treatment of HCC recurrence after OLT Patients. The 23 HCC recurrences developed after 182 OLT performed for HCC within Milan criteria, had an average follow-up of 60 months. RESULTS: The median time to recurrence was 23.4 months. Surgical resection of the recurrence was possible in 11 patients, but an R-0 resection was obtained in 8 patients. Four of these 8 patients developed another recurrence, with 3 succumbing due to tumor recurrence and 1 alive at 12 months with recurrence. The other 4 patients without recurrences, include 3 who are alive at 19, 31, and 86 months and 1 who died at 32.6 months due to hepatitis C recurrence. The 3 patients with palliative resections developed recurrences. Twelve patients were rejected for surgery: 8 were treated symptomatically, 2 with systemic chemotherapy, and 2 with everolimus and sorafenib. This last treatment was also prescribed for 2 patients after R-0 surgery who are alive at 19 and 31 months and for 1 patient after R-1 surgery who is alive at 19 months. Of 15 patients who died, 13 succumbed to HCC recurrence. The average survival from transplantation was 61.7 +/- 37.5 and 48 +/- 34.3 months for patients without and with recurrence, respectively (P < .001). The survival from the recurrence was significantly higher among patients with R-0 surgery: 32.3 +/- 21.5 versus 11.9 +/- 6.9 months (P = .006). CONCLUSIONS: HCC recurrence after OLT of patients within Milan criteria was low but had a great impact on survival. Few cases are amenable to R-0 resection, but when possible it was associated with a significantly increased survival, although with an high incidence of a new recurrence. There is a rationale for the use of sorafenib and mammalian target of rapamycin based immunosuppression, which warrants randomized studies.

Incidence and clinical relevance of bacterial contamination in preservation solution for liver transplantation.

OBJECTIVE: Postoperative infection is considered one of the most important causes of morbidity and mortality after liver transplantation. We prospectively studied the incidence and significance of infections in preservation solutions for liver transplantation. MATERIALS AND METHODS: From March 2007 to March 2008, we cultured the University of Wisconsin preservation solution for 60 consecutive liver transplantations. Fluid samples were obtained at the beginning and at the end of the back table procedure. Our posttransplant infection prophylactic protocol consisted of ampicillin and cefotaxime for 48 hours. RESULTS: Cultures were positive in 59 patients (98.4%). Seventy-five percent of the isolates were superficial saprophytic flora (SSF; Staphylococcus coagulase negative, Streptococcus viridans, and Corynebacterium), nevertheless in 15 cases (25.1%) we isolated high virulence pathogens (Staphylococcus aureus, Klebsiella, Escherichia coli, Enterobacter, and Pseudomonas aeruginosa). There were neither anaerobic nor fungal isolates. Sixteen patients (36%) from the group with SSF developed postoperative fever, including 12 with negative posttransplant cultures, while 4 patients showed positive cultures for various microorganisms distinct from those isolated from the preservation solution. Five patients (30%) with high virulence pathogens in the preservation solution developed posttransplant fever, although no pathogen was isolated. CONCLUSIONS: Positive cultures of preservation fluids were observed in 98% of patients, although most of them (75%) were SSF. Microorganisms isolated from posttransplant cultures did not match the ones obtained from the preservation solution. Our results did not support routine culturing of the preservation solution provided that one administrator an adequate posttransplant antibiotic prophylactic regimen.

Prophylactic therapy with valgancyclovir in high-risk (cytomegalovirus D+/R-) liver transplant recipients: a single-center experience.

A retrospective study was performed in liver transplant patients with high risk to develop cytomegalovirus infection (CMV D+/R-) who were treated with valgancyclovir for 3 months as prophylactic therapy. The aim of this study was to determine the safety and efficacy of prophylactic therapy with valgancyclovir. Weekly CMV antigenemia was routinely assessed during the first 3 months posttransplantation, twice a month to month 6, and monthly until the end of the first year, as well as when clinically indicated. The follow-up period was 1 year. From January 2003 to February 2007, 199 liver transplantations were performed at our institution, including 23 (11%) high-risk patients for CMV infection. Median age was 47 +/- 11.6 years. Nineteen patients (70.4%) were men. Five subjects (21.7%) developed CMV infections. Three patients with positive CMV antigenemia at 3, 4, or 6 months posttransplantation were asymptomatic, while 2 (8.7%) showed gastrointestinal CMV disease at 2 months posttransplantation or CMV hepatitis at 1 month after the end of the prophylactic therapy. Treatment with intravenous gancyclovir followed by oral valgancyclovir was successful in both patients. No opportunistic infections were observed and only 1 patient developed leukopenia as an adverse event related to valgancyclovir.

Donors older than 70 years in liver transplantation.

INTRODUCTION: Expansion of donor criteria has become necessary with the increasing number of liver transplantation candidates, as aged donors who have been considered to yield marginal organs. METHODS: Our database of 477 liver transplants (OLT) included 55 cases performed from donors at least 70 years old vs 422 with younger donors. We analyzed pretransplantation donor and recipient characteristics as well as evolution of the recipients. RESULTS: The old donor group showed significantly lower ALT (23 +/- 17 vs 48.9 +/- 67; P = .0001) and LDH (444 +/- 285 vs 570 +/- 329; P = .01). There was a trend toward fewer hypotensive events in the aged donor group (27.2% vs 40.5%; P = .07). No steatosis (>10%) was accepted in the old donor group. Cold ischemia time was statistically shorter for the aged donors (297 +/- 90 minutes vs 346 +/- 139 minutes; P = .03). With these selected donors, the results were not different for primary nonfunction, arterial and biliary complications, hospitalization, acute reoperation or acute retransplantation, and hospital mortality when donors > or =70 years old were compared to younger donors. Functional cholestasis, neither related to rejection nor to biliary complications, was seen more frequently in old donor recipients (40% vs 22%; P = .03). No differences in 1, and 3 year survivals were observed between recipients of donors over 70 years old and these of younger organs: 93.8% and 90.6% vs 90.7% and 82.8%, respectively. CONCLUSION: When using selected donors > or =70 years old the outcomes were comparable to those obtained with younger donors. Strict selection is necessary to achieve good long-term survival.

Is it worth using mechanical sutures in gastric surgery?

The use of stapler devices in gastrointestinal surgery has to be justified by the results. Since the cost of staplers is very high, their use should be followed by some advantage in the operating time, the morbidity or mortality rate or the postoperative stay. We have found a slight shortening in the operating time, but only statistically significant for Billroth I, and in the postoperative stay only for oesophagojejunostomies mechanically performed. We have not found any advantage with the other techniques and in the other parameters. Consequently, the use of staplers in gastric surgery should be carefully assessed by the surgeon for each patient in particular, and only used in those cases where a real benefit will be presumed.