The predictive value of risk indices for cardiac complications in living donor liver transplantation.

BACKGROUND AND AIMS: The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) risk tool and Revised Cardiac Risk Index (RCRI) are recommended tools for cardiovascular assessment before non-cardiac surgery to predict early postoperative cardiac morbidity and mortality. Their predictive value for postoperative cardiovascular morbidity and mortality after liver transplantation is unknown. We aimed to evaluate the validity of these two risk tools to predict early (30-day) cardiovascular complications and in-hospital all-cause mortality. METHODS: Patients who underwent living donor liver transplantation were retrospectively analyzed. Consecutive 278 adult patients were included and their NSQIP and RCRI scores were calculated. RESULTS: Cardiovascular morbidity occurred in 5 (1.8 %) patients. In-hospital all-cause mortality occurred in 18 (6.4 %) patients. None-of the patients died from cardiac complications. Causes of cardiac morbidity were as follows; acute coronary syndrome in 1 patient, intraoperative cardiac arrest with successful resuscitation in 1 patient, heart failure in 3 patients. Neither the NSQIP nor the RCRI score were associated with cardiovascular morbidity. Only RCRI medium-high score, DM and Nonalcoholic steatohepatitis as transplant indications were associated with in-hospital all-cause mortality (p = 0.001). CONCLUSIONS:  The NSQIP risk calculator and RCRI scores failed to accurately predict the risk of perioperative cardiac complications (Tab. 3, Ref. 30). Text in PDF www.elis.sk.

Management of patients with recurrent hepatocellular carcinoma following living donor liver transplantation: a single center experience.

OBJECTIVE: Tumor recurrence is the most important predictive factor for the survival of patients following liver transplantation for hepatocellular carcinoma (HCC). The management of recurrent HCC remains controversial. In this study, we presented the clinical outcomes of patients with recurrent HCC following living donor liver transplantation. MATERIAL AND METHODS: Of the 109 patients who underwent liver transplantation due to hepatocellular carcinoma, sixteen (14.7%) developed tumor recurrence and were included in the study. We analyzed the management of patients with recurrent tumors and their outcomes. RESULTS: The mean age of patients included in the study was 55.2 ± 7.82 (28-65) years, and 13 patients (81%) were male. The mean follow up and time to recurrence were 25.8 ± 19.2 (5-78) months and 11 ± 9.4 (4-26) months, respectively. Four patients developed recurrence in the liver graft and 12 (75%) developed recurrence in extrahepatic organs. Of these patients, seven had surgical treatment, seven received chemotherapy, and two did not receive any treatment. All four surviving patients received surgical treatment. CONCLUSION: Recurrence of HCC following liver transplantation generally occurs in the first two years and in extrahepatic organs. The most effective treatment for patients with single and isolated recurrent tumors is surgery. However, the long term survival differed according to the type of recurrence, depending on which organs recurrence occurred in and whether recurrence was in single or multiple locations. Therefore, the treatment strategy should be individualized for longer survival. KEYWORDS: The management of HCC, Recurrent HCC, Living donor liver transplantation.

Which incision is better for living-donor right hepatectomy? Midline, J-shaped, or Mercedes.

Incision-related morbidity for donors is a major concern in living-donor right hepatectomy (LDRH). Open approaches use midline, J-shaped, and Mercedes incisions for LDRH. We retrospectively studied 95 consecutive donors who underwent LDRH between January 2009 and November 2010. They underwent midline (n = 32), J-shaped (n = 28), or Mercedes (n = 35) incisions. We studied resection times, perioperative bleeding, postoperative hospital stay, and postoperative pain assessed by the visual analog scale (VAS) and by analgesic requirements as well as laboratory data and complications. Postoperative analgesic requirements and postoperative VAS scores were significantly lower in the midline group (P < .05) upon univariate but not multivariate analyses. The postoperative complications as well as other parameters were similar between the groups. In conclusion, compared with a J-type shaped or not for Mercedes incision, a donor hepatectomy can be satisfactorily performed via a midline incision by experienced surgeons without increased risk.

Vascular complications in hepatic transplantation: single-center experience in 14 years.

PURPOSE: To evaluate the spectrum of liver transplantation-related vascular complications that occurred in a single center over the past 14 years. MATERIALS AND METHODS: Vascular complications and their clinical outcomes were reviewed among 744 liver transplant recipients. All patients underwent Doppler ultrasound with findings correlated with conventional or computed tomography angiography (CTA) in 111 patients. RESULTS: Among 70 recipients with vascular complications (%0.9), 14/26 patients with hepatic artery thrombosis underwent thrombectomy and arterial reanastomosis; six were retransplanted and six died. Among hepatic artery stenoses, three of nine were treated with balloon angioplasty and six underwent reanastomosis. Among 20 portal vein thromboses, 16 underwent thrombectomy, two patients retransplantation and two died. Seven patients with portal vein stenosis were followed. Two of six hepatic vein stenosis were restored with balloon angioplasty and three patients with metallic stent placement; the one other died. One patient with hepatic vein thrombosis died while the other patient was retransplanted. CONCLUSION: Transplantation related hepatic vascular complications diagnosed and managed in timely fashion showed a low mortality rate in our series.

International collaboration of Turkey in liver transplantation research: a bibliometric analysis.

OBJECTIVES: Scientific publications are valuable markers of scientific activity for countries. We performed a bibliometric study to evaluate the number of publications written by Turkish authors. The aim of this study is to evaluate Turkey's contribution in terms of number of publications included in Science Citation Index Expanded (SCI-E) in the scientific field of liver transplantation compared with other countries. To our knowledge, this is the first bibliometric study in liver transplantation research of Turkey. MATERIALS AND METHODS: ISI Web of Knowledge-Science was used for the analysis. All scientific works published included in SCI-E in English from 1980 to August 10, 2011, were analyzed. A retrospective search was performed using key words "liver transplantation," "hepatic transplantation," "liver transplant," and "hepatic transplant." We further analyzed these results by the "analyze" function of the software in terms of number of papers for each country, type of documentation, number of publications per year, journal, institute, and author. The number of citations to published works was calculated by using the citation function of the same software. We also used the same function of the software to analyze publications from Turkey in the last three decades between 1980 and 1989, 1990 and 1999, and 2000 and 2009 for statistical evaluation. Collected data from the comparison periods were statistically analyzed using the chi-square test. RESULTS: In all, 48,418 publications related to liver transplantation were included in SCI-E in English between 1980 and August 2011. Overall, 675 of those publications were from Turkey (2.05%). There was no publication from Turkey between 1980 and 1989; 37 between 1990 and 1999; and 511 between 2000 and 2009. The rank of Turkey among other countries according to the number of publications was 25th between 1990 and 1999 and improved to 14th between 2000 and 2009. The number of scientific publications in the field of liver transplantation from Turkey among other countries increased during the last three decades. CONCLUSIONS: Turkey showed a significant positive trend in publications in the scientific field of liver transplantation in the last 30 years, and the rank of Turkey among other countries improved in recent decades. Currently, Turkey is one of the top 17 countries in terms of number of scientific publications listed in SCI-E. This can be considered as another indicator for Turkey's progress in the field of liver transplantation.

Cryopreserved aortic quilt plasty for one-step reconstruction of multiple hepatic venous drainage in right lobe living donor liver transplantation.

Hepatic venous outflow should be maintained for the success of living right lobe liver transplantation. In cases when the right hepatic vein is not the dominant venous drainage, the anterior branch of the middle hepatic vein and the accessory hepatic veins should be adequately drained to preserve graft function. One-step reconstruction of the hepatic veins became a preferred technique to create separate outflow for each of the graft's veins. In this report, we have described a quilt plasty technique for 1-step reconstruction of living donor hepatic veins using cadaveric cryopreserved aorta and iliac vein grafts.

Dual left lobe living donor liver transplantation using donors unacceptable for right lobe donation: a case report.

Living donor liver transplantation (LDLT) has become a viable alternative for end-stage liver disease. The shortage of brain-dead donors has led to development of advanced surgical approaches. Dual lobe LDLT has been performed successfully in the recent years. The major indication for this complex procedure has been insufficient graft size from a single donor or insufficient remnant in the donor. We performed a dual left lobe LDLT using 2 donors who were unacceptable for right lobe donation.

Splenic abscess after splenic artery ligation in living donor liver transplantation: a case report.

Although recent developments in living donor liver transplantation (LDLT) yield promising results, a size mismatch between the weights of the graft and the recipient remains a significant problem. Recipients of LDLT may have hyperdynamic splanchnic circulations resulting in graft hyperperfusion and increased portal vein flow leading to small-for-size syndrome. Splenic artery ligation is one of the least invasive measures to prevent occurrence of this syndrome. Despite its potentially devastating consequences, splenic infarction following splenic artery ligation has received little attention to date. Herein we have reported a patient who developed a splenic abscess due to a splenic infarction following splenic artery ligation during LDLT.

Living donor liver transplantation from hepatitis B core antibody positive donors.

UNLABELLED: Liver allografts from donors previously exposed to hepatitis B virus (HBV) carry the risk of transmission of HBV infection to immunosuppressed recipients. However, exclusion of donor candidates with the serologic evidence of resolved hepatitis B-HBV surface antigen (HbsAg) negative and HBV core antibody (anti-HBc) positive-is not feasible in countries endemic for HBV. AIM: Our aim was to assess the safety of living donor liver transplantation from anti-HBc positive donors. MATERIALS AND METHODS: In our institution, 152 transplants were performed between June 1999 and April 2004. Fifty-six (37%) of the living donors were anti-HBc positive. Twenty of these liver grafts were transplanted to HbsAg-negative recipients. We excluded four HBsAg negative recipients who died because of early complications after transplantation. Lamivudine (100 mg/day) was given for prophylaxis of de novo HBV infection. RESULTS: The mean follow-up time for 16 HBsAg-negative recipients was 21.7 (7-48) months. None of them experienced de novo HBV infection. CONCLUSION: The use of liver allografts from anti-HBc-positive living donors is reasonably safe in HBsAg-negative recipients under lamivudine prophylaxis.

A very rare venous anomaly in a living liver donor: left hepatic venous connection to the right atrium.

In humans, three main hepatic veins drain the liver into the inferior vena cava below the diaphragm. This report represents the first living donor liver that had a rare anatomic variation of the left hepatic vein draining directly to the right atrium, which was detected preoperatively by routine investigations of the living donor transplantation. This type of anomaly may present potentially fatal challenges to a donor operation if not detected preoperatively, especially when the left lobe is the choice for explantation.

Acute hepatic vein thrombosis after liver transplantation in a child with biliary atresia and absent inferior vena cava.

Stenosis of the hepatic venous outflow anastomosis is rare after liver transplantation. Hepatic venous outflow obstruction affects 5.1% to 7% of transplanted patients. Clinical findings among children include massive ascites and abdominal pain and laboratory findings demonstrate altered liver function tests and coagulopathy. In this article, we report a case of hepatic venous thrombosis occurring 22 days after living-related liver transplantation. The patient was treated with hepatic venoplasty and stent implantation.

Variations of hepatic veins: helical computerized tomography experience in 100 consecutive living liver donors with emphasis on right lobe.

Anatomical variations in the venous system of liver are not a rarity. A prospective helical computerized tomography (CT) study was undertaken to determine the prevalence of surgically significant hepatic venous anatomic variations among 100 consecutive living liver donors. The studies evaluated the ramification pattern of hepatic veins, the presence of accessory hepatic veins, and of segment 5 or 8 veins (or both) draining into middle hepatic vein. These data obtained by CT influenced surgical planning. Sixty-four donors donated their right lobes and 24 donors, left lateral segments. Only one donor candidate was refused due to combined hepatic and portal venous variations accompanied by multiple bile ducts. Eleven donors were also refused due to reasons other than anatomical variations. Seventeen segment 5 and 17 segment 8 veins draining into middle hepatic vein were anastomosed to inferior vena cava in 23 (36%) of the right lobe liver transplantations. The middle hepatic vein was harvested in only one of the donors. Among the 100 cases, 47 had accessory right inferior hepatic veins, 13 of which were multiple. Twenty-two of the right lobe grafts required surgical anastomoses of these accessory hepatic veins (34%). An isolated hepatic vein anomaly or the presence of accessory hepatic veins are not contraindications to be a living liver donor candidate. However, preoperative knowledge of vascular variations alters surgical management. Helical CT is a valuable tool to delineate the hepatic venous anatomy for surgical planning in living liver donors.

Bioembolisation for unresectable hepatocellular carcinoma: preliminary results of a translational research study.

Lack of effective treatment for surgically unresectable hepatocellular carcinoma has made this disease dismal. Although, systemic and/or locoregional chemotherapy and chemo-embolization are among the established treatment options, the results of these modalities are still far from being satisfactory. Systemic interferon administration is also used for the treatment of this disease however it has high toxicity rates. We conducted a pharmacology guided phase I/II study with the aim to explore the effect of hypoxy and interferon alpha-2a in vitro using the HepG2 Hepatoma cell line. We then translated the in-vitro results to the clinical setting and designed a treatment protocol. This schema consisted of lipiodol embolisation via a hepatic artery port in between two sets of seven loco-regional injections of IFNalpha-2a, 3 MU every other day. The in-vitro study revealed the best sequence of hypoxy and IFN as IFN-Hypoxy-IFN. Based on this finding, ten patients with HCC were treated with loco-regional IFN and lipiodolisation. Seven of them achieved partial response and the mean duration of response was 10 months. There was no Grade 4 toxicity. In conclusion, our preliminary clinical results suggest that the combined use of IFN and lipiodolisation in the optimal sequence may provide a new therapeutic option for patients with HCC.

Anesthetic management and complications in living donor hepatectomy.

A total of 112 living donor hepatectomies (LDHs) performed from October 1999 to April 2003 at Ege University Hospital Organ Transplantation Center were reviewed and perioperative anesthetic courses and complications were determined. There was no perioperative mortality. Mean duration of operations was 333 +/- 77 minutes (range, 160 to 540 minutes) for right lobectomies and 277 +/- 88 minutes (range, 150 to 500 minutes) for left lateral segment plus left lobe operations. The remnant liver volume ratios of the patients was 0.58 +/- 0.16 (range, 0.30 to 0.91) after harvesting. Crystalloids, colloid infusions, and transfusions aimed to keep hematocrit >25%, central venous pressure (CVP) <5 mm Hg and to maintain a urine output >1 mL/kg(-1) while nitroglycerin was infused (0.5 to 2.0 microg/kg(-1)h(-1)) when needed to allow fluid infusions freely without increasing the CVP values. No transfusion was needed for 91 patients (81%) and 21 right lobectomy patients needed transfusion of blood products. Initial mean hematocrit of 38.9 +/- 4.9% (range, 27% to 50%) for all patients was found 31.5% +/- 5% (21% to 44%) at the end of the operation. Albumin blood levels averaged 4.27 +/- 0.49 g/dL(-1) at the beginning and 3.28 +/- 0.45 g/dL(-1) after hepatic resection. Perioperative complications were one air embolism, postoperative systemic inflammatory response syndrome in one patient, transient but severe hemoglobinuria due to a predonated autologous blood transfusion in another, prolonged recovery for neuromuscular blocker overdose in one patient, and postoperative atelectasis in three patients, two of whom had pneumonia later while two other patients had pleural effusions. One required a drainage. Living donor hepatectomies were performed with acceptable complications in anesthetic management during this study. The operation provides us with an optimal liver segment without resulting in mortality.

Hepatocellular carcinoma in liver transplant era: a clinicopathologic analysis.

Hepatocellular carcinoma (HCC) is one of the most common tumors in the world, and the prognosis is usually poor. Today, liver transplantation (LT) is a radical but frequently curative treatment modality for HCC. In selected patients, it cures HCC and the underlying cirrhosis at the same time. The present clinicopathological study examined the importance of tumor characteristics for their effects on recurrence and survival rates after LT for HCC. Forty-two native hepatectomy specimens among 250 consecutive orthotopic liver transplantations contained HCC. Patients were predominantly men (30 men, 12 women), ranging in age from 1 to 61 years (median 51). While 20 patients received cadaveric organs, 22 were transplanted from living donors. In 14 patients (33%) HCC presented as a solitary nodule, 5 (12%) as two nodules; 2 (5%) as three nodules; and 21 patients (50%) as more than three nodules. The maximal diameter of the largest tumor not larger than 3 cm in 28 patients (66%), exceeding this size in 14 patients (34%). There was a significant correlation between nodule number and tumor size (r = 0.36, P = 0.05). While 23 patients had no sign of vascular involvement, 17 tumors showed microscopic invasion and two large vessel involvement. There was a positive correlation between vascular invasion and nodule number (r = 0.41, P = 0.05). The histopathological grade of differentiation of the tumors was assessed as "well" in seven patients (14%), moderate in 28 (72%), and poor in 7 (14%). The differentiation was significantly poorer when vascular invasion was observed (r = 0.43, P =.01). According to the TNM classification, 11 patients (26%) were stage I, 6 (14%) stage II, 13 (31%) stage III, and 12 (29%) stage IV. After a median follow-up of 10 months (1-50 months), the overall mortality was 18% (n = 8). Patient survival at 6 month, 1, and 4 years was 88%, 80%, and 60%, respectively. The outcome was significantly poorer for TNM stage IV versus stage I,II, and III tumors to (P =.02). Tumor recurred in three patients at 4,6, and 50 months after liver transplantation. The sites of recurrence were bone, lung, and adrenal glands. In conclusion, liver transplantation represents a safe and feasible treatment for hepatocellular carcinoma with excellent outcomes compared with other treatment modalities. Liver transplantation offers excellent survival rates and chance for cure in stages I, II, and III hepatocellular carcinoma in cirrhotic patients.

Roux-en-Y bleeding after living donor liver transplantation: a novel technique for surgical treatment.

Upper gastrointestinal bleeding (GIB) is one of the most common gastroenterologic complications following liver transplantation. The aim of this study is to define the prevalence of GIB due to Roux- en Y (R-Y) enteral anastomoses after living donor liver transplantation (LDLT) and recommend an anastomotic technique for easy surgical intervention. Ninety-five patients underwent 96 LDLT from June 1999 through January 2003. R-Y biliary reconstruction was employed in 43 patients. Anastomoses were end-to-side (ES) in the first 25 patients and side-to-side (SS) type in the last 18 patients. GIB occurred in 13 patients (30%). The R-Y anastomotic line was shown to be the bleeding site in 10 patients. Anastomoses were in ES fashion in 7 of 10 patients (70%). In other words 28% of ES and 17% of SS anastomoses displayed a bleeding episode after LDLT. Four patients required surgical intervention (Three ES, one SS), namely an operative rate of 9%. The type of the jejunojejunostomy, the UNOS or Child-Pugh scores, the presence of preexisting portal hypertension, the duration of portal vein clamping, the GRWR of patients, revealed no statistical significant difference between bleeding and non- bleeding patients. Although statistical analyses did not reveal any significant difference (P =.47), GIB was higher among patients with an ES type of anastomoses. As a result we recommend a jejunojejunostomy in SS fashion on the antimesenteric borders of the jejunal segments with a 3-4 cm blind intestinal segment. The surgical procedure for R-Y bleeding may then be performed without disrupting the jejunojejunostomy.