Aborted donor hepatectomy in living donor liver transplantation: lessons learned.

BACKGROUND: Aborted donor hepatectomy (ADH) during any stage of living donor hepatectomy (LDH) is a rare event. We describe our experience and discuss the lessons from these events. METHODS: From September 2005 to January 2019, 77 of 2 031 (3.79%) LDH were aborted at various stages of surgical procedure due to donor or recipient related reasons. Demographic and clinical data of aborted donor candidates and the clinical course of their potential recipients were analysed. RESULTS: LDH of 77 donor candidates was aborted due to donor (n = 53) or recipient (n = 24) related reasons. The most common donor related reason was the quality of liver parenchyma (n = 31). The most common recipient related reason was haemodynamic instability (n = 11). Twenty-three recipients underwent either living donor liver transplantation (LDLT) (n = 21) or deceased donor liver transplantation (DDLT) (n = 2) at a median of 6 days following ADH. In one aborted due to a donor reason and two aborted for recipient reasons, LDLT was performed using the same donor candidates. Thirty-six recipients had no liver transplantation (LT) and died a median of 17.5 days following ADH. CONCLUSIONS: We believe that ADH will decrease with experience and meticulous preoperative clinical and radiological evaluations. Abandoning the donor hepatectomy is always a valid option at any stage of the surgery when the unexpected is encountered.

Early Hepatic Artery Thrombosis After Pediatric Living Donor Liver Transplantation.

AIM: Hepatic artery thrombosis is one of the major complications affecting patient and graft survival after liver transplantation. In this study, we analyzed the factors affecting the development of early hepatic artery thrombosis (eHAT) and its outcomes in pediatric liver transplantation. METHODS: A total of 175 pediatric patients underwent living donor liver transplantation between January 2013 and November 2018. Factors affecting eHAT and its outcomes were examined. RESULTS: Nine patients (5.1%) developed eHAT. In multivariate analysis, intraoperative hepatic artery revision and Roux-en-Y hepaticojejunostomy biliary reconstruction type were statistically significant (all, P < .05). Thrombectomy and reanastomosis was performed in 5 patients. Two of them were successful. In total, 3 retransplantations were performed and all of those patients are still alive. CONCLUSION: The factors affecting eHAT are still a matter of debate. Intraoperative hepatic artery anastomosis revision and Roux-en-Y hepaticojejunostomy reconstruction were independent risk factors for development of eHAT. In the present study, the confidence interval of the variables is high, therefore exact determination of the risk factors may not be possible. Early detection and thrombectomy and reanastomosis may be the first treatment of choice to rescue the patient and graft. When it fails, retransplantation must be an alternative. The results of the present study state that at least once a day the vascular anastomosis must be examined by Doppler ultrasonography in the post-transplant first week. It must be repeated when liver enzymes increase. The patients under high risk for eHAT may be followed up closer.

Factors affecting the accuracy of 18F-FDG PET/CT in evaluating axillary metastases in invasive breast cancer.

BACKGROUND AND AIM: There are conflicting results of studies on accuracy of positron emission tomography (PET)/computed tomography (CT) for axillary staging. The aim of this study is to determine the factors affecting the efficacy of 18F-fluorodeoxyglucose (18F-FDG) PET/CT in detecting axillary metastases in invasive breast cancer. MATERIALS AND METHODS: Data of 232 patients with invasive breast cancer who underwent 18F-FDG PET/CT examination before surgery between January 2013 and September 2017 were reviewed retrospectively. Histopathological examination of axillary lymph nodes (ALNs) was used as a reference to assess the efficacy of 18F-FDG PET/CT in detecting axillary metastases. RESULTS: While 134 (57.8%) patients had axillary metastases as detected in 18F-FDG PET/CT scans, histopathologically axillary metastases were detected in 164 (70.7%) patients. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of 18F-FDG PET/CT in detection of axillary metastasis were 72.56%, 77.94%, 88.8%, 54%, and 74.1%, respectively. The false-negative and false-positive rates were 27.4% and 22%, respectively. In univariate analysis, patients' age, estrogen receptor positivity, higher ALN SUVmax, greater tumor size, and lymph node size determined by 18F-FDG PET/CT were all significantly associated with accuracy of 18F-FDG PET/CT for axillary metastasis. In multivariate analysis, tumor size determined by 18F-FDG PET/CT and ALN SUVmax were independent variables associated with axillary metastasis. The accuracy of 18F-FDG PET/CT for axillary metastasis was higher in patients with a larger tumor (≥19.5 mm) and a higher ALN SUVmax (≥3.2). CONCLUSION: 18F-FDG PET/CT should not be routinely used for axillary staging, especially in patients with small tumors. It cannot eliminiate the necessity of sentinel lymph node biopsy. When it is used, both visual information and optimal cut-off value of axillary node SUVmax should be taken into consideration.

Pregnancy After Liver Transplantation: Risks and Outcomes.

OBJECTIVE: The aim of this study was to evaluate the outcomes of liver transplant recipients who became pregnant after transplantation. METHODS: The clinical data of all patients who underwent liver transplantation between January 2007 and December 2016 in our liver transplantation institute were reviewed. The following data were analyzed: indications for transplantation, recipient age at the beginning of pregnancy, the interval between transplantation and pregnancy, maternal and fetal complications, type of delivery, the health condition of neonates, and modifications in immunosuppressive therapy. RESULTS: During the study period, 1890 patients underwent liver transplantation. There were 185 women (9.8%) in childbearing age (15-45 years old), and 18 (9.7%) of them became pregnant during the study period. There were a total of 26 pregnancies. The mean age of patients at the time of operation was 25.3 ± 5.2 years, and the mean interval between operation and conception was 32.7 ± 15.3 months. Seventeen pregnancies (65.4%) ended in a live birth in the study. Six pregnancies (23%) resulted with no maternal or fetal complications. The most frequent maternal complication during pregnancy was pregnancy-induced hypertension (n = 3; 16.6%). CONCLUSIONS: Despite advances in immunosuppressive therapy and increasing experience in the management of these patients, pregnancies in liver transplant recipients are still more risky than in the general population for both the mother and the fetus. Thus, the issues related to fertility should be comprehensively discussed with the patients and their partners, preferably before transplantation, and pregnancies in liver transplant recipients should be followed up more carefully by a multidisciplinary team.

Outcomes of Kidney Transplantations From the Same Deceased Donor to Two Different Recipients: A Single-Center Experience.

BACKGROUND: Kidney transplantation is the best treatment method for end-stage renal disease. Technically, left kidney transplantation is easier than right kidney, and the complication rates in the right are higher than the left kidney. We performed 28 kidney transplantations from 14 deceased donors between November 2010 and May 2016. Our aim was to share our outcomes and experiences about these 28 patients. METHODS: We performed 182 kidney transplantations between November 2010 and May 2016. Fifty-four kidney transplantations were performed from deceased donors. Thirty-two of these were performed from 16 of the same donors. These 32 recipients' data were collected and retrospectively analyzed. We excluded the transplantations from two same-donors to their four recipients in this study. The remaining 28 recipients were included in the study. RESULTS: The left and right kidney recipients' numbers were equal (14:14). The left kidney:right kidney rate was 11:3 in the first kidney transplantation recipient group; in the second kidney transplantation recipient group, the rate was 3:11. The difference was statistically significant (P = .002). We found no statistical differences for sex, mean age, and body mass index of recipients, total ischemic time of grafts, hospitalization times, creatinine levels at discharge time, and current ratio of postoperative complications of recipients (P > .05). CONCLUSIONS: There were no differences in the left or the right kidneys or in the first and the second kidney transplantations during the long follow-up period.

Laparoscopic right colectomy with transvaginal extraction in a patient with prior pancreaticoduodenectomy.

INTRODUCTION: Previous complicated abdominal surgeries such as pancreaticoduodenectomy with large abdominal incisions may keep the surgeons away from major laparoscopic procedures. To the best of our knowledge, there is no published study that shows the feasibility of major laparoscopic surgery in a patient with previous pancreaticoduodenectomy. CASE REPORT: A 68-year-old female (BMI 27 kg/m2, ASA II), was admitted for anemia. Her medical history included an open pancreaticoduodenectomy four years ago for chronic pancreatitis. She had an abdominal Mercedes incision. Computed tomography and colonoscopy showed a 5-cm cecal mass with a histological diagnosis of adenocarcinoma. We performed a totally laparoscopic right hemicolectomy and intracorporeal ileotransverse anastomosis. The specimen was extracted through the vagina. The operating time was 500 minutes and the blood loss was 400 ml. The patient was uneventfully discharged on postoperative day four. CONCLUSIONS: Laparoscopic colon surgery can be feasible and safe despite previous extensive abdominal surgeries such as pancreaticoduodenectomy. Moreover, laparoscopic surgery in these cases can also be completed with intracorporeal anastomosis and specimen extraction through a natural orifice.

Partial cholecystectomy: a technique that makes hilar dissection easier in recipient hepatectomy.

BACKGROUND: Intraoperative blood loss and red blood cell transfusion requirements have a negative impact on outcome after orthotopic liver transplantation. In this study we compared blood transfusion requirements, bile duct injury, and dissection of hepatic artery rates in the patients with or without partial cholecystectomy during recipient hepatectomy. METHODS: From December 2008 to August 2011, 100 recipient hepatectomies were performed by the same surgeon. Patients were divided into 2 groups. The first group included patients with partial cholecystectomy, and the other group patients without partial cholecystectomy. Each group consisted of 50 patients. RESULTS: In recipient hepatectomy group without partial cholecystectomy, intraoperative blood transfusions were in the range of 3-11 units (mean, 6.3 units). In this group there were 4 hepatic artery dissections and 2 bile duct injuries. In the group with partial cholecystectomy, intraoperative blood transfusions were in the range of 0-7 units (mean, 3.1 units). In this group there was 1 hepatic artery dissection. There were no operative mortalities in either group. CONCLUSIONS: We recommend partial cholecystectomy during recipient hepatectomy of cirrhotic patients, particularly with hydropic gallbladders, because bleeding from the points of adherent gallbladder during mobilization of the liver is diminished and fewer artery dissections and bile duct injuries develop, because the procedure facilitates dissection of the hilar structures.

Acinetobacter infection in a liver transplantation intensive care unit.

OBJECTIVE: Despite the advances in surgical technique and postoperative care, infectious complications are associated with high mortality rates. Acinetobacter species are emerging as a leading worldwide nosocomial pathogen in intensive care unit (ICU) patients. This study was designed to evaluate the results of the patients who developed Acinetobacter infection in the ICU after liver transplantation. METHODS: We retrospectively analyzed 220 patients who had undergone liver transplantation between August 2011 and August 2012. Among the 55 positive culture results with clinical signs of infection, Acinetobacter was the single infectious agent for 10 of them, who were included in the study. RESULTS: The mean age of the patients was 43.1 ± 11.79 years with a male dominance (70%, n = 7). Eighty percent of the patients underwent living donor liver transplantations (n = 8). Mean Model for End-stage Liver Disease score was 28.5 ± 14.99. Graft dysfunction was present in 50% (n = 5), all of whom had a history of preoperative hospitalization (100%, n = 10). Forty percent (n = 4) of patients had a history of diabetes mellitus and 60% were subject to extended mechanical ventilation. Mean platelet count was 20.32 ± 8.1 × 10(9)/mL. The majority of the patients had multiple culture-positive sites (90%, n = 9). Positive culture results for Acinetobacter species included bloodstream (n = 8), drain fluid (n = 5), sputum (n = 3), paracenthesis material (n = 3), and catheter (n = 1). The mean period of postoperative positive culture results was 12.7 ± 9.5 days. Mortality was 90% (n = 9). CONCLUSION: Acinetobacter infections in the ICU after liver transplantation were asociated with a high mortality presenting with thrombocytopenia.