Utility of Polyethylene Terephthalate (Dacron) Vascular Grafts for Venous Outflow Reconstruction in Living-Donor Liver Transplantations.

BACKGROUND: Venous outflow reconstruction of modified right-lobe liver grafts has been shown to prevent the occurrence of graft congestion and subsequent complications, including graft loss. In the present study, we aimed to investigate the safety and efficacy of Dacron grafts for venous reconstruction in living donor liver transplantation (LDLT). METHODS: Between January 2016 and January 2018, Dacron grafts were used in 148 liver transplants. Of these, 104 patients who had a follow-up computerized tomography (CT) scan were enrolled into the study. A total of 179 outflow hepatic veins including V5, V8, partial middle hepatic vein, and accessory inferior right hepatic veins (IRHV) were reconstructed using synthetic Dacron grafts. Graft patency was evaluated with both intraoperative Doppler ultrasonography following reconstruction, and a follow-up CT was performed on the postoperative day 7 (±1). Retrospective data collection included demographics, parameters for small-for-size (laboratory tests [bilirubin, International Normalized Ratio] and ascites) syndrome, postoperative morbidity, and mortality. RESULTS: Follow-up CT revealed graft patency in 155 out of 179 (86.6%) vascular grafts. Postoperative seventh-day patency rates for each reconstructed vein were as follows: V5, 87.5% (70/80); V8, 87.7% (50/57); partial middle hepatic vein, 100% (11/11); and IRHV, 77.4% (24/31). No major graft-related complications (early graft dysfunction, graft infection) or graft-related mortality were observed. None of the recipients developed small-for-size syndrome based on laboratory tests and clinical findings. CONCLUSIONS: Dacron vascular grafts appear as an advantageous and useful alternative for venous outflow reconstruction in LDLT.

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.

The prevention of bone fractures after liver transplantation: experience with alendronate treatment.

OBJECTIVE: The aim of this study was to prevent fractures in the first postoperative year. METHODS AND PATIENTS: We studied 59 patients (48 men, 11 women) aged 42.6+/-11.4 years, who underwent liver transplantation. All patients received oral alendronate 70 mg weekly and calcium 1 g and calcitriol 0.5 mug daily. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the lumbar spine and proximal femur at baseline as well as at 6 and 12 months after transplantation for comparison with an historical control group (n=31). Spinal radiographs were obtained to assess vertebral fractures at the same time. Additionally, serum osteocalcin, serum parathyroid hormone (PTH), urinary deoxypyridinoline (DPD), and biochemical parameters were determined every 3 months. RESULTS: At baseline, femoral total BMD of men was significantly greater than that of women (P<.05, .85+/-.1 vs .74+/-.1). A significant increase in BMD was observed at 12 months (P<.05), no patient developed a bone fracture. Comparison analysis of genders showed that there was a significant difference in favor of men (P<.05). The lumbar BMD, neck T-, and Z-scores were significantly higher among patients treated with alendronate than historical controls (P<.05). After 3 months, serum PTH was increased and serum osteocalcin and urinary DPD were reduced. No severe side effects from alendronate treatment were observed during the study. CONCLUSION: A direct sign of the success of our study was no fracture observed during the first postoperative year. Alendronate should be considered for patients with low bone mass after liver transplantation.

Hepatocellular carcinoma in children and effect of living-donor liver transplantation on outcome.

Hepatocellular carcinoma (HCC) is primarily observed in the older children and in most cases it develops in association with liver cirrhosis. Liver transplantation offers a good chance for long-term cure. To evaluate the outcome of children with HCC and the impact of living-donor orthotopic liver transplantation (OLT) on survival a retrospective review of radiographic, laboratory, pathologic, and therapeutic data in 13 children (six female and seven male) with chronic liver disease accompanied with HCC were studied. The patients were divided into two groups according to therapeutic modality: transplanted and non-transplanted patients. Kaplan-Meier survival curves in various therapeutic groups were plotted. The mean age of patients was 6.4 +/- 4.8 yr. Pediatric end-stage liver disease score was adapted to model for end-stage liver disease score for HCC and ranged between 1-44 and 18-44, respectively. The underlying liver diseases were tyrosinemia type 1 (n = 6), chronic hepatitis B infection (n = 6), glycogen storage disease type 1 (n = 1). Alfa-feto protein levels were elevated in all patients except one. Median number of tumor nodules was three (1-10), median maximal diameter of tumor nodules was 3.4 cm (0.5-8). Eleven patients were eligible for OLT whereas two patients were not eligible. Seven of the 11 patients considered for transplantation underwent living-donor OLT. Remaining four patients died while waiting on cadaveric transplant list. Overall 1 and 4-yr survival rates for all patients were 53.3 and 26.6%, respectively, and were found significantly higher in transplanted children than non-transplanted children (72%, 72% vs. 33% and 16.6%). No patient had tumor recurrence at median of 36-month follow-up after OLT. OLT is a life-saving procedure for children with chronic liver disease accompanying with HCC. Living-donor OLT avoids the risk of tumor progression and transplant ineligibility in these children.

Outcome of pediatric liver transplant recipients in Turkey: single center experience.

To summarize the evolution of the pediatric liver transplant program in a developing country. Between April 1997, and September 2003, 32 cadaveric (CD) and 35 living donor (LD) liver transplantations were performed on 61 children (median age 3.8 yr, range 0.5-16) at Ege University Organ Transplantation and Research Center. The patient's charts were reviewed retrospectively. The outcome of patient and graft survival was analyzed and the incidence of graft loss, complications and rejections was calculated. Indications for liver transplantation were metabolic liver disease (n = 17), biliary atresia (n = 14), viral hepatitis (n = 4), autoimmune hepatitis (n = 6), cryptogenic cirrhosis (n = 11), fulminant liver failure (n = 5) and others (n = 5). Seven of 61 children with chronic liver disease had hepatocellular carcinoma concomitantly. Median pediatric end-stage liver disease score was 23 (range 1-54). Seven children (11.4%) were UNOS status I, 44 (72%) were UNOS status II and 10 (16.6%) were UNOS status III. The median follow-up of the study population was 3.6 yr (range 0.5-6). Actuarial patient survival rates at 1, 2, 3 and 4 yr were 86, 86, 71.3 and 65% in the CD group vs. 80, 76, 67 and 67% in the LR group, respectively (p = NS). Patients listed as UNOS status 1 had lower survival rates than patients listed as UNOS status 2 and 3 (p < 0.05). The mortality rate was 26.2%. Graft survival rates were 81, 81, 75 and 64% at 1, 2, 3 and 4-yr respectively. Six patients (9%) underwent retransplantation. The main complications were infections (64.7%) and surgical complications (43.2%) (including biliary complication, vascular problems, postoperative bleeding, small for size and large for size). The incidence of acute cellular rejection was 39.3%, whereas chronic rejection was 7.4%. The result of liver transplantation in Turkish children was slightly inferior to those reported for North American and European children. However, an important characteristic of these patients that distinguishes them from Europe and North America is that most were UNOS status IIa and UNOS status I (44%). Despite technical and medical progress, infectious and biliary problems have continued to be an important cause of mortality in these patients.

Successful treatment of liver transplant-associated Kaposi's sarcoma with long-term vincristine.

Kaposi's sarcoma has a higher incidence in organ transplant recipients. We report on a 41-year-old Turkish man with liver transplantation-associated Kaposi's sarcoma that involved the skin and the gut. Immediately after discontinuation of immunosuppressive medication, there was an acute rejection episode. After controlling the acute rejection with steroids, the immunosuppressive treatment was continued together with vincristine, which resulted in disease remission. After 6 months, withdrawal of vincristine lead to relapse of the disease, prompting commencement of vincristine again, which has maintained the patient in remission for more than 3 years without any significant side effects. In conclusion, long-term vincristine may be an effective, safe treatment option for Kaposi's sarcoma.

HBV vaccination in liver transplant recipients: not an effective strategy in the prophylaxis of HBV recurrence.

Anti-HBs immunoglobulins (HBIG) and lamivudine are main options to prevent hepatitis B virus (HBV) reinfection after liver transplantation. Although they are very effective, development of mutant viruses and high cost of treatment are main limitations for their application. Additionally there is an uncertainity for the duration of that prophylaxis regimen and its mostly applied indefinitely. Recently, post-transplant HBV vaccination is reported to be a cheaper alternative prophylaksis strategy, that enables discontinuation of HBIG. To investigate the efficacy of HBV vaccination in patients transplanted for HBV cirrhosis, we administered double course of double dose recombinant HBV vaccine (Genhavac B; containing HBV pre-S1, pre-S2, and S gene products). Vaccination has been started 1 month after HBIg discontinuation, and lamivudine (100 mg/day) was given throughout the study. The first cycle consisted of 0, 1- and 6-month schedule, and, in nonresponders, second cycle 0, 1-, 2-month schedule. Fourteen patients included into the study. Only one patient seroconverted (an anti-HBs titre of 37 IU/L) after the first cycle. No other patient responded to second cycle. HBV vaccination in the post-transplantation setting does not seems like an effective strategy in the prophylaxis of HBV recurrence.

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.

Adefovir treatment in posttransplant hepatitis B virus infection resistant to lamivudine plus hepatitis B virus immunoglobulin.

Failure of prophylaxis for hepatitis B virus (HBV) recurrence in liver transplant patients with HBV immunoglobulin (HBIG) or lamivudine or both can be associated with rapid development of liver failure. Some of these patients develop a devastating clinicopathological state characterized by jaundice and rapidly progressive liver failure or fibrosing cholestatic hepatitis. We present two liver transplant recipients who experienced HBV recurrence while they were under lamivudine and HBIG prophylaxis. One of them had finding of severe HBV infection; the other, fibrosing cholestatic hepatitis. After commencing adefovir dipivoxil both patients showed improvements in clinical status and laboratory data. At month 4 of treatment, HBV DNA values became negative and liver function tests almost normalized. In addition, in one case showed HBs ag/anti-HBs seroconversion. When failure of prophylaxis with lamivudine and HBIG occurs, adefovir dipivoxil should be considered to be a safe and effective choice for recurrent HBV infections in liver transplant patients.

Cytokine gene polymorphism and early graft rejection in liver transplant recipients.

Cytokines, which play important roles in allograft rejection, show variable production among individuals. These variations may be related to genetic polymorphisms within the regulatory regions of the cytokine genes. We investigated the association between the role tumor necrosis factor alpha (TNF-alpha), transforming growth factor-beta (TGF-beta), interferon gamma (IFN-gamma), interleukin (IL)-10 and IL-6 gene polymorphisms and early graft rejection among liver transplant recipients. Forty-three liver transplant recipients enrolled in this study were divided into 2 groups based on events in the first 2 months posttransplantations, namely, those experiencing at least 1 rejection episode (n = 26) or those without any episode (n = 17). The allele or genotype frequencies of cytokine gene polymorphisms showed no difference between liver recipients with or without nonrejection. In conclusion, there was no significant correlation between early graft rejection and cytokine gene polymorphism of TNF-alpha, TGF-beta, IL-10, IL-6, and IFN-gamma in liver transplant recipients.