Using extracorporeal membrane oxygenation in donations after cardiac death or brain death: A single-center experience and long-term outcome.

Aims: The use of extended criteria donors is a routine practice that sometimes involves extracorporeal membrane oxygenation (ECMO) in donations after cardiac death or brain death. Methods: We performed a retrospective study in a single center from January 2006 to December 2019. The study included 90 deceased donor liver transplants. The patients were divided into three groups: the donation after brain death (DBD) group (n = 58, 64.4%), the DBD with ECMO group (n = 11, 12.2%) and the donation after cardiac death (DCD) with ECMO group (n = 21, 23.3%). Results: There were no significant differences between the DBD with ECMO group and the DBD group. When comparing the DCD with ECMO group and the DBD group, there were statistically significant differences for total warm ischemia time (p < 0.001), total cold ischemia time (p = 0.023), and split liver transplantation (p < 0.001), and there was significantly poor recovery in regard to total bilirubin level (p = 0.027) for the DCD with ECMO group by repeated measures ANOVA. The 5-year survival rates of the DBD, DBD with ECMO, and DCD with ECMO groups were 78.1%, 90.9%, and 75.6%, respectively. The survival rate was not significantly different when comparing the DBD group to either the DBD with ECMO group (p = 0.435) or the DCD with ECMO group (p = 0.310). Conclusions: Using ECMO in donations after cardiac death or brain death is a good technology, and it contributed to 35.6% of the liver graft pool.

The role of Roux-en-Y hepaticojejunostomy for the management of biliary complications after living donor liver transplantation.

INTRODUCTION: Post living donor liver transplantation (LDLT) biliary complications can be troublesome over the post-operative course of patients, especially those with recurrent cholangitis or choledocholithiasis. Thus, in this study, we aimed to evaluate the risks and benefits of Roux-en-Y hepaticojejunostomy (RYHJ) performed after LDLT as a last option to deal with post-LDLT biliary complications. METHODS: Retrospectively, of the 594 adult LDLTs performed in a single medical center in Changhua, Taiwan from July 2005 to September 2021, 22 patients underwent post-LDLT RYHJ. Indications for RYHJ included choledocholithiasis formation with bile duct stricture, previous intervention failure, and other factors. Restenosis was defined if further intervention was needed to treat biliary complications after RYHJ was performed. Thereafter, patients were categorized into success group (n = 15) and restenosis group (n = 4). RESULTS: The overall success rate of RYHJ in the management of post-LDLT biliary complications was 78.9% (15/19). Mean follow-up time was 33.4 months. As per our findings, four patients experienced recurrence after RYHJ (21.2%), and mean recurrence time was 12.5 months. Three cases were recorded as hospital mortality (13.6%). Outcome and risk analysis presented no significant differences between the two groups. A higher risk of recurrence tended to be related to patients with ABO incompatible (ABOi). CONCLUSION: RYHJ served well as either a rescue but definite procedure for recurrent biliary complications or a safe and effective solution to biliary complications after LDLT. A higher risk of recurrence tended to be related to patients with ABOi; however, further research would be needed.

Length of Alcohol Abstinence Predicts Posttransplant Delirium in Living Donor Liver Transplant Recipients with Alcoholic Cirrhosis.

OBJECTIVES: History of alcohol abuse is a predictive factor for posttransplant delirium. We aimed to investigate whether preoperative abstinence was associated with posttransplant delirium in liver transplant recipients with alcohol-related cirrhosis. MATERIALS AND METHODS: From January 2014 to December 2019, 84 patients with alcohol-related cirrhosis who received living donor liver transplant were retrospectively reviewed and divided into a delirium group (n = 46, 54.8%) and a nondelirium group (n = 38, 45.2%) using the Richmond Agitation- Sedation Scale and the Confusion Assessment Method for the Intensive Care Unit. RESULTS: In the delirium group versus the nondelirium group, patients were more likely to have preoperative hepatic encephalopathy (58.7% vs 31.6%; P = .013), more likely to have higher Model for End-Stage Liver Disease scores (27.05 ± 10.56 vs 18.85 ± 7.96; P < .001), less likely to have preoperative alcohol abstinence (43.5% vs 68.4%%; P = .022), had longer duration of mechanical ventilation (7.57 ± 7.82 vs 2.50 ± 5.96 days; P = .001), and had longer stays in the intensive care unit (14.85 ± 15.01 vs 8.84 ± 7.84 days; P = .021) and in the hospital (37.89 ± 18.85 vs 27.15 ± 10.43 days; P = .002). Multivariate analysis revealed that preoperative alcohol abstinence (odds ratio 4.953; 95% CI, 1.519-16.152; P = .008) was a significant predictor and that more patients had abstinence durations <3 months (60.9% vs 34.2%; P = .048) in the delirium group. CONCLUSIONS: A high incidence of posttransplant delirium in liver transplant recipients with alcohol- related cirrhosis was associated with preoperative abstinence. Abstinence >6 months before living donor liver transplant is suggested to reduce the risk of posttransplant delirium.

Using the Cystic Duct for Biliary Reconstruction in Dual-Graft Living Donor Liver Transplantation: A Case Report.

In Taiwan, living donor liver transplant (LDLT) has accounted for the majority of liver transplantation due to organ shortage. Dual-graft LDLT is a feasible way to resolve the insufficient graft size and remnant liver in donors. We presented a heavy-weight patient underwent dual-graft LDLT, and cystic duct was used to resolve the inadequate bile duct length and limited appropriate position in dual-graft LDLT. We harvested a right lobe graft (segment 5, 6, 7, and 8 without middle hepatic vein) and a left lobe graft (segment 1, 2, 3, and 4 without middle hepatic vein) stepwise, and placed the grafts orthotopically. For proper tension and length of biliary reconstruction, we anastomosed the right intrahepatic duct of the right lobe graft to cystic duct of the recipient. Before the biliary reconstruction, the metal probe was inserted in the lumen of cystic duct in recipient to ensure the patency and destroy the Heister valve of cystic duct, then the internal biliary stent (5 Fr pediatric feeding tube) was placed in the donor's right intrahepatic duct to recipient's cystic duct and common bile duct, which allows the endoscopic removal of the internal stent. The patient has survived more than 16 months with normal liver function.

Living donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria: outcome of expanded criteria in tumor size.

BACKGROUND: The Milan criteria are the universal standard of liver transplantation for hepatocellular carcinoma (HCC). Numerous expanded criteria have shown outcomes as good as the Milan criteria. In Taiwan, living donor liver transplant (LDLT) accounts for the majority of transplantations due to organ shortages. METHODS: We retrospectively enrolled 155 patients who underwent LDLT for HCC from July 2005 to June 2017 and were followed up for at least 2 years. Patients beyond the Milan criteria (n = 78) were grouped as recurrent or nonrecurrent, and we established new expanded criteria based on these data. RESULTS: Patients beyond the Milan criteria with recurrence (n = 31) had a significantly larger maximal tumor diameter (4.13 ± 1.96 cm versus 6.10 ± 3.41 cm, p = 0.006) and total tumor diameter (7.19 ± 4.13 cm versus 10.21 ± 5.01 cm, p = 0.005). Therefore, we established expanded criteria involving maximal tumor diameter ≤ 6 cm and total tumor diameter < 10 cm. The 5-year survival rate of patients who met these criteria (n = 134) was 77.3%, and the 5-year recurrence rate was 20.5%; both showed no significant differences from those of the Milan criteria. Under the expanded criteria, the pool of eligible recipients was 35% larger than that of the Milan criteria. CONCLUSION: Currently, patients with HCC who undergo LDLT can achieve good outcomes even when they are beyond the Milan criteria. Under the new expanded criteria, patients can achieve outcomes as good as those with the Milan criteria and more patients can benefit.

Postoperative incision scars and cosmetic satisfaction of living liver donors.

ABSTRACT: Cosmetic appearance is a major concern for living donors. However, little is known about the impact of a surgical scar on body image changes in living liver donors. The aim of this study was to identify potential factors that cause displeasing upper midline incision scar, and to evaluate the overall satisfaction regarding body image and scarring after living donor hepatectomy.Donors who underwent right lobe hepatectomy were recruited. Exclusion criteria included reoperation, refusal to participate, and lost follow-up. All donors were invited to complete the Vancouver Scar Scale (VSS) and the body image questionnaire. According to the VSS results of upper midline incision scar, donors were divided into 2 groups: good scarring group (VSS ≤4) and bad scarring group (VSS >4). we compared the clinical outcomes, including the demographics, preoperation, intraoperation, and postoperation variables. The study also analyzed the results of the body image questionnaire.The proportion of male donors was 48.9%. The bad scarring group consisted of 63% of the donors. On multivariate analysis, being a male donor was found to be an independent predictor of a cosmetically displeasing upper midline incision scar with statistical significance. The results of body image questionnaires, there were significant differences in cosmetic score and confidence score among the 2 groups.The upper midline incision and male donors have higher rates of scarring in comparison with the transverse incision and female donors. Donors who reported having a higher satisfaction with their scar appearance usually had more self-confidence. However, the body image won't be affected. Medical staff should encourage donors to take active participation in wound care and continuously observe the impact of surgical scars on psychological changes in living liver donors.

Association between surgical volumes and hospital mortality in patients: a living donor liver transplantation single center experience.

BACKGROUND: Many factors cause hospital mortality (HM) after liver transplantation (LT). METHODS: We performed a retrospective research in a single center from October 2005 to June 2019. The study included 463 living donor LT patients. They were divided into a no-HM group (n = 433, 93.52%) and an HM group (n = 30, 6.48%). We used logistic regression analysis to determine how clinical features and surgical volume affected HM. We regrouped patients based on periods of surgical volume and analyzed the clinical features. RESULTS: Multivariate analysis revealed that donor age (OR = 1.050, 95% CI 1.011-1.091, p = 0.012), blood loss (OR = 1.000, 95% CI 1.000-1.000, p = 0.004), and annual surgical volumes being < 30 LTs (OR = 2.540, 95% CI 1.011-6.381, p = 0.047) were significant risk factors. A comparison of years based on surgical volume found that when the annual surgical volumes were at least 30 the recipient age (p = 0.023), donor age (p = 0.026), and ABO-incompatible operations (p < 0.001) were significantly higher and blood loss (p < 0.001), operative time (p < 0.001), intensive care unit days (p < 0.001), length of stay (p = 0.011), rate of re-operation (p < 0.001), and HM (p = 0.030) were significantly lower compared to when the annual surgical volumes were less than 30. CONCLUSIONS: Donor age, blood loss and an annual surgical volume < 30 LTs were significant pre- and peri-operative risk factors. Hospital mortality and annual surgical volume were associated with statistically significant differences; surgical volume may impact quality of care and transplant outcomes.

Clinical Outcome of Residual Liver Volume and Hepatic Steatosis After Right-Lobe Living-Donor Hepatectomy.

BACKGROUND We examine how residual liver volume (RLV) and hepatic steatosis (HS) of living liver donors affect the regeneration process and clinical outcomes. MATERIAL AND METHODS We longitudinally studied 58 donors who underwent right-lobe hepatectomy during the period February 2014 to February 2015 at a single medical institution. The patients were classified based on RLV (30-35%, 35-40%, 40-50%) subgroups and HS (<10%, 10-30%, 30-50%) subgroups. Clinical parameters such as clinical outcome, liver volumetric recovery (LVR,%) rate and remnant left-liver (RLL,%) growth rate were collected for analysis. RESULTS The clinical features of postoperative peak total bilirubin (p=.024) were significant in the 3 RLV subgroups. Body mass index (p=.017), preoperative alanine transaminase (p<.001), and pleural effusion (p=.038) were significant in the 3 HS subgroups. The LVR rate and RLL growth rate equations showed significant variation in regeneration among the 3 RLV subgroups. The LVR rate and RLL growth rate equations did not show significant variation in regeneration among the 3 HS subgroups. CONCLUSIONS Hyperbilirubinemia was a risk factor in the small-RLV group, and a large amount of pleural effusion was a risk factor in the steatosis 30-50% group. Hepatic steatosis subgroups did not show significantly different degrees of regeneration. The safety of living donors was a major concern while we compiled the extended living-donor criteria presented in this paper.

Treating Intimal Injury to the Graft Hepatic Artery by Intraoperative Fluorescence Vascular Stenting.

BACKGROUND: Early hepatic artery (HA) thrombosis and primary graft failure contribute greatly to the mortality of patients after liver transplantation. Herein, we present the treatment of intimal injury of HA by intraoperative fluorescence vascular stenting. METHODS: A sample of 471 patients receiving liver transplantations underwent arterial anastomosis. Six patients (1.3%) were found to have early HA thrombosis. Two patients had thrombi that were impenetrable with a guide wire. Intimal injury on both the graft and the donor sides of the HA was found after thrombectomy. We performed anastomosis between unhealthy graft vessels and healthy recipient vessels. Intraoperative angiography was done immediately because of the guide wire being easier to insert through a fresh thrombus, and a long endovascular stent was inserted to bypass the injured vessels. RESULTS: The proper HA was reconstructed under microscopy. Three days after reconstruction, an angioplasty showed no dissection, stenosis, or pseudoaneurysm of the HA. Unexpectedly, these 2 patients survived well with acceptable graft functionality, one based on a 32-month follow-up and the other based on a 2-month follow-up. CONCLUSION: Anastomosis of the intimally injured graft artery followed by immediate endovascular angioplasty with stenting to bypass the injury zone is an efficacious and tolerable procedure.

Central Pontine Myelinolysis After Living-Donor Liver Transplant: A Report of 2 Cases.

Here, we present 2 patients who developed central pontine myelinolysis after living-donor liver transplant. Both patients had abnormal sodium level before living-donor liver transplant. Patient 1 presented with severe hyponatremia on admission. After administration of 3% saline, her sodium level during the first 24 hours was kept at 100 mEq/L and then increased to 116 mEq/L during the next 24 hours. The level increased 5.8 mEq/L during the 4- to 5-hour transplant procedure. Patient 2 was admitted to the hospital with an unprovoked seizure. The serum sodium concentration was 111 mEq/L, which was treated with 3% saline infusion. Serum sodium concentration escalated to 118 mEq/L over an 8-hour period. Intraoperatively, both patients received large amounts of replacement fluids (0.9% normal saline and albumin), blood transfusion, and sodium bicarbonate during the anhepatic phase, all of which carry high sodium load. Variations in sodium levels changed rapidly in patient 1 during transplant surgery. After they underwent liver transplant, patient 1 had clear mental status and patient 2 demonstrated worsened mental status. On approximately day 14 and day 4 after liver transplant, magnetic resonance imaging showed diffuse abnormalities of the pons, resulting in diagnosis of central pontine myelinolysis. Although both patients survived, 1 remains in a vegetative state and the other continues to present with mild balance and swallowing abnormalities. To reduce the chance of inadvertent overcorrection in patients with hyponatremia, it is therefore important that sodium concentrations should be monitored frequently and fluids and electrolytes titrated carefully.

Portal venous velocity affects liver regeneration after right lobe living donor hepatectomy.

OBJECTIVES: We investigated whether chronological changes in portal flow and clinical factors play a role in the liver regeneration (LR) process after right donor-hepatectomy. MATERIALS AND METHODS: Participants in this prospective study comprised 58 donors who underwent right donor-hepatectomy during the period February 2014 to February 2015 at a single medical institution. LR was estimated using two equations: remnant left liver (RLL) growth (%) and liver volumetric recovery (LVR) (%). Donors were classified into an excellent regeneration (ER) group or a moderate regeneration (MR) group based on how their LR on postoperative day 7 compared to the median value. RESULTS: Multivariate analysis revealed that low residual liver volume (OR = .569, 95% CI: .367- .882) and high portal venous velocity in the immediate postoperative period (OR = 1.220, 95% CI: 1.001-1.488) were significant predictors of LR using the RLL growth equation; high portal venous velocity in the immediate postoperative period (OR = 1.325, 95% CI: 1.081-1.622) was a significant predictor of LR using the LVR equation. Based on the two equations, long-term LR was significantly greater in the ER group than in the MR group (p < .001). CONCLUSION: Portal venous velocity in the immediate postoperative period was an important factor in LR. The critical time for short-term LR is postoperative day 7; it is associated with long-term LR in donor-hepatectomy.

A Cross-Disciplinary Successful Aging Intervention and Evaluation: Comparison of Person-to-Person and Digital-Assisted Approaches.

Background: Successful aging has been the paradigm of old-age life. The purpose of this study was to implement and evaluate a cross-disciplinary intervention program using two approaches for community-based older adults in Taichung, Taiwan. Methods: The content of the intervention included successful aging concepts and preparation, physical activity, chronic disease and health management, dietary and nutrition information, cognitive training, emotional awareness and coping skills, family relationship and resilience, legal concepts regarding financial protection, and Internet use. The traditional person-to-person (P2P) intervention approach was implemented among participants at urban centers, and the personal-and-digital (P&D) intervention approach was implemented among participants at rural centers; before the P&D group received the intervention, participants were assessed as the control group for comparison. Results: Healthy behavior and nutrition improved for the P2P group, although not significantly. Strategies for adapting to old age and reducing ineffective coping were significantly improved in the P2P group. The ability to search for health information improved in the P&D group, and knowledge of finance-related law increased in the P2P group. Conclusion: A continuous, well-designed and evidence-based intervention program is beneficial for improving the health of older adults, or at least delaying its decline.

Mental health status after living donor hepatectomy.

Donor safety and preservation of donor health after living liver donation are of paramount importance. In addition, the preoperative mental state of a donor is an important factor in determining the psychological impact of donor hepatectomy. Thus, we aimed to explore the mental health status of living liver donors after hepatectomy. We enrolled 60 donors who were scheduled to undergo living donor hepatectomy during the period January 2014 to March 2015 at a single medical center. Mental health status was measured before and 3 months after surgery using 3 self-report questionnaires, namely the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depressive symptoms, the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire to measure quality of life, and the Chinese Health Questionnaire (CHQ) to screen for minor psychiatric disorders. A comparison of the pre- and postdonation CES-D scores revealed a significant reduction in depressive symptoms after surgery (P = .031). There were significant improvements in the physical health domain (P = .031), the psychological health domain (P = .005), the social relationships domain (P = .005), and the environmental health domain (P = .010) of the WHOQOL-BREF. There were no significant changes in CHQ scores after donor hepatectomy (P = .136). All donors reported that they would donate again if required. Approximately one-third (33.3%) of donors experienced more pain than they had anticipated in the immediate postoperative period, and 20.0% of donors had complications after donor hepatectomy. Donor mental health status tended to improve as donors regained physical function during the 1st 3 months of recovery. Long-term monitoring of living donors' mental health is needed to minimize the adverse psychological outcomes of living liver donation.

Predictors of Diarrhea after Hepatectomy and Its Impact on Gastrointestinal Quality of Life in Living Donors.

BACKGROUND: Donor safety and preservation of donor health after living liver donation are of paramount importance. Diarrhea has a significant influence on gastrointestinal quality of life among donors who have undergone living donor hepatectomy. Thus, we aimed to investigate predictors of diarrhea after hepatectomy and its impact on gastrointestinal quality of life in living donors. METHODS: We retrospectively examined the medical records of 204 living liver donors who underwent hepatectomy during the period January 2010 to June 2013 at a single medical center. Diarrhea was defined as the passing of three or more liquid stools per day. The Chinese version of the Gastrointestinal Quality of Life Index (GIQLI) was used to assess the influence of diarrhea on quality of life in donors. RESULTS: During the study period, diarrhea was diagnosed in 62 (30.3%) of the 204 donors and the duration of diarrhea in the majority of them (n = 46, 74%) was <12 months. Risk factors associated with diarrhea included age [risk ratio (RR) = 0.84, 95% confidence interval (CI): 0.79-0.89, risk difference = 16%], and chronic cholecystitis (RR = 0.48, 95% CI: 0.24-0.99, risk difference = 52%). Compared to donors without diarrhea, donors with diarrhea had lower GIQLI scores in the following GIQLI domains: GI symptoms (1.8 vs. 3.6), physical function (2.1 vs. 3.5), emotional function (3.0 vs. 3.6), social function (3.3 vs. 3.7), and treatment reaction (2.6 vs. 3.7). CONCLUSIONS: Our findings show that younger donors and those without chronic cholecystitis are at increased risk for diarrhea after living donor hepatectomy and that diarrhea is associated with lower GIQLI scores after hepatectomy.