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Interest in anonymous nondirected living organ donation is increasing in the United States and a small number of transplantation centers are accumulating an experience regarding nondirected donation in living donor liver transplantation. Herein, we review current transplant policy, discuss emerging data, draw parallels from nondirected kidney donation, and examine relevant considerations in nondirected living liver donation. We aim to provide a consensus guidance to ensure safe evaluation and selection of nondirected living liver donors and a schema for just allocation of nondirected grafts.
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Transplante de Rim , Transplante de Fígado , Obtenção de Tecidos e Órgãos , Humanos , Rim , Doadores Vivos , Estados UnidosRESUMO
INTRODUCTION: In July 2017, a policy to increase the use of segmental grafts (SGs) was implemented at our institution. The aim was to compare changes in waitlist activity after implementation of this policy. METHODS: A single-center, retrospective study. Pediatric patients on the liver waiting list between January 2015 and December 2019 were screened. Patients were classified as receiving a liver transplant (LT) before (Period 1) or after (Period 2) policy changes. Primary end points were transplant rates and time to transplant. RESULTS: Sixty five first LT performed on 65 patients were included. Twenty nine LT were performed during Period 1 and 36 during Period 2. More than half (55%) of LT in Period 2 were SG, compared to 10.3% in Period 1 (P < 0.001). Forty nine and 56 pediatric candidates on the waiting list accounted for 38.78 and 24.48 person-years during Period 1 and Period 2, respectively. Transplant rates per 100 person-years on the waiting list increased from 85.09 during Period 1 to 187.87 in Period 2 (Rate ratio: 2.20; P < 0.001). Median time to receive a LT decreased from 229 d in Period 1 to 75 d during Period 2 (P = 0.013). One-year patient survival rates were 96.6% in Period 1 and 95.7% in Period 2. One-year graft survival rates were 89.7% and 88% in Period 1 and Period 2, respectively. CONCLUSIONS: A policy to increase the use of SG was associated with significantly higher transplant rates and lower waiting times. Implementation of this policy can be done successfully with no observed negative impact on patient and graft survival.
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Transplante de Fígado , Humanos , Criança , Estudos Retrospectivos , Fígado , Taxa de Sobrevida , Listas de EsperaRESUMO
The practice of LDLT currently delivers limited impact in western transplant centers. The American Society of Transplantation organized a virtual consensus conference in October 2021 to identify barriers and gaps to LDLT growth, and to provide evidence-based recommendations to foster safe expansion of LDLT in the United States. This article reports the findings and recommendations regarding innovations and advances in approaches to donor-recipient matching challenges, the technical aspects of the donor and recipient operations, and surgical training. Among these themes, the barriers deemed most influential/detrimental to LDLT expansion in the United States included: (1) prohibitive issues related to donor age, graft size, insufficient donor remnant, and ABO incompatibility; (2) lack of acknowledgment and awareness of the excellent outcomes and benefits of LDLT; (3) ambiguous messaging regarding LDLT to patients and hospital leadership; and (4) a limited number of proficient LDLT surgeons across the United States. Donor-recipient mismatching may be circumvented by way of liver paired exchange. The creation of a national registry to generate granular data on donor-recipient matching will guide the practice of liver paired exchange. The surgical challenges to LDLT are addressed herein and focuses on the development of robust training pathways resulting in proficiency in donor and recipient surgery. Utilizing strong mentorship/collaboration programs with novel training practices under the auspices of established training and certification bodies will add to the breadth and depth of training.
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Transplante de Fígado , Humanos , Incompatibilidade de Grupos Sanguíneos , Transplante de Fígado/métodos , Doadores VivosRESUMO
INTRODUCTION: Surgical site infections (SSI) are a significant cause of morbidity in liver transplant recipients, and the current data in the pediatric population are limited. The goal of this study was to identify the incidence, classification, risk factors, and outcomes of SSIs among children undergoing liver transplantation (LT). METHODS: A single-center, retrospective descriptive analysis was performed of patients age ≤18 years undergoing LT between September 2007 and April 2017. SSI identified within the first 30 days were analyzed. Primary endpoints included incidence, classification, risk factors, and outcomes associated with SSIs. RESULTS: We included 86 patients, eight patients (9.3%) developed SSIs. Among segmental grafts (SG) recipients, 7/61 (11.4%) developed SSI. Among whole grafts recipients, 1/25 (4%) developed SSI. SSIs were associated with the presence of biliary complications (35% vs. 3%, p < .01; odds ratios 24, 95% CI: 3.41-487.37, p<.01). There were no differences in long term graft or patient survival associated with SSI. Patients who developed SSI were more likely to undergo reoperation (50% vs. 16.7%, p = .045) and had an increased total number of hospital days in the first 60 days post-transplant (30.5 vs. 12.5 days, p = .001). CONCLUSIONS: SSIs after pediatric LT was less frequent than what has been previously reported in literature. SSIs were associated with the presence of biliary complications without an increase in mortality. SG had an increased rate of biliary complications without an association to SSIs but, considering its positive impact on organ shortage barriers, should not be a deterrent to the utilization of SGs.
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Sistema Biliar , Transplante de Fígado , Humanos , Criança , Adolescente , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Transplante de Fígado/efeitos adversos , Estudos Retrospectivos , Incidência , Fatores de Risco , TransplantadosRESUMO
PURPOSE OF REVIEW: Living donor liver transplantation (LT) has been increasingly recognized as an effective treatment modality with excellent patient survival. Indications for LT have evolved not only for cholestatic liver disease, but also metabolic liver diseases. Living donor selection, particularly for pediatric inherited disease, is essential to prevent morbidity, both in the donor and recipient. RECENT FINDINGS: Based on 30âyears of experience in pediatric living donor LT in Japan, we could identify marginal parental living donors who have potential risks following LT, including heterozygous mothers with ornithine transcarbamylase deficiency, heterozygous protein C deficiency, heterozygous hypercholesterolemia, heterozygous protoporphyria, asymptomatic parental donors with paucity of intrahepatic bile duct, and human leukocyte antigen-homozygous parental donors. SUMMARY: Although these situations seem rare due to infrequency of the condition, careful living donor evaluation is required to optimize the outcomes for pediatric recipients. In the setting of an appropriate selection of a living donor, we should avoid any additional hazards, given that the procedure itself has risks for a healthy individual.
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Hepatopatias , Transplante de Fígado , Doença da Deficiência de Ornitina Carbomoiltransferase , Criança , Humanos , Doadores Vivos , Transplante de Fígado/métodos , PaisRESUMO
Organ shortage is a barrier to liver transplantation (LT). Split LT (SLT) increases organ utilization, saving 2 recipients. A simulation of Organ Procurement and Transplantation Network/United Network for Organ Sharing data (2007-2017) was performed to identify whole-organ LT grafts (WLT) that met the criteria for being splittable to 2 recipients. Waitlist consequences presented. Deceased donor (DD) livers transplanted as whole organs were evaluated for suitability to split. Of these DD organs, we identified the adolescent and adult recipients of WLT who were suitable for SLT. Pediatric candidates suitable to share the SLT were ascertained from DD match-run lists, and 1342 splittable DD organs were identified; 438 WLT recipients met the criteria for accepting a SLT. Review of the 438 DD match-run lists identified 420 children next on the list suitable for SLT. Three hundred thirty-three children (79%) underwent LT, but had longer wait-times compared to 591 actual pediatric SLT recipients (median 147 days vs 44 days, P < 0.001). Thirty-three of 420 children died on waitlist after a mean 206 days (standard deviation 317). Sharing organs suitable for splitting increases the number of LT, saving more lives. With careful patient selection, SLT will not be a disadvantage to the adult recipients. With a children-first allocation scheme, SLT will naturally increase the number of allografts because adult organs are too large for small children.
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Doença Hepática Terminal/mortalidade , Rejeição de Enxerto/mortalidade , Transplante de Fígado/mortalidade , Transplante de Fígado/estatística & dados numéricos , Seleção de Pacientes , Alocação de Recursos/normas , Doadores de Tecidos/provisão & distribuição , Listas de Espera/mortalidade , Adulto , Criança , Doença Hepática Terminal/cirurgia , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto , Humanos , Transplante de Fígado/efeitos adversos , Masculino , Prognóstico , Alocação de Recursos/estatística & dados numéricos , Fatores de Risco , Fatores de Tempo , Obtenção de Tecidos e Órgãos/estatística & dados numéricosRESUMO
OBJECTIVE: The aim of the study was to investigate the impact of prioritizing infants, children, adolescents, and the sickest adults (Status 1) for deceased donor livers. We compared outcomes under two "SharePeds" allocation schema, which prioritize children and Status 1 adults for national sharing and enhanced access to pediatric donors or all donors younger than 35 years, to outcomes under the allocation plan approved by the Organ Procurement and Transplant Network in December 2017 (Organ Procurement and Transplantation Network [OPTN] 12-2017). METHODS: The 2017 Liver Simulated Allocation Model and Scientific Registry of Transplant Recipients data on all US liver transplant candidates and liver offers 7/2013 to 6/2016 were used to predict waitlist deaths, transplants, and post-transplant deaths under the OPTN 12-2017 and SharePeds schema. RESULTS: Prioritizing national sharing of pediatric donor livers with children (SharePeds 1) would decrease waitlist deaths for infants (<2 years, Pâ=â0.0003) and children (2-11 years, Pâ=â0.001), with no significant change for adults (Pâ=â0.13). Prioritizing national sharing of all younger than 35-year-old deceased donor livers with children and Status 1A adults (SharePeds 2) would decrease waitlist deaths for infants, children, and all Status 1A/B patients (Pâ<â0.0001 for each). SharePeds 1 and 2 would increase the number of liver transplants done in infants, children, and adolescents compared to the OPTN-2017 schema (Pâ<â0.00005 for all age groups). Both SharePeds schema would increase the percentage of pediatric livers transplanted into pediatric recipients. CONCLUSIONS: Waitlist deaths could be significantly decreased, and liver transplants increased, for children and the sickest adults, by prioritizing children for pediatric livers and with broader national sharing of deceased donor livers.
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Transplante de Fígado , Modelos Teóricos , Obtenção de Tecidos e Órgãos , Listas de Espera , Adolescente , Criança , Pré-Escolar , Humanos , Estados UnidosRESUMO
Development of macrovesicular steatosis post-LT in patients with PFIC-1 is increasingly being observed, with the etiology not fully understood. We highlight successful and effective EBD for reversal of allograft steatosis in 2 patients with PFIC-1 disease and discuss our experience with internal biliary diversion in this patient population.
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Colestase Intra-Hepática/cirurgia , Drenagem/métodos , Fígado Gorduroso/terapia , Transplante de Fígado , Complicações Pós-Operatórias/terapia , Aloenxertos , Fígado Gorduroso/etiologia , Feminino , Humanos , Lactente , Masculino , Transplante HomólogoRESUMO
BACKGROUND: Delirium is increasingly recognized as a common and important postoperative complication that significantly hinders surgical recovery. However, there is a paucity of data examining the incidence and impact of delirium after liver transplantation. METHODS: Retrospective case series in a tertiary care center examining all (n = 144) adult patients who underwent liver transplantation during a 6-y period. RESULTS: Delirium occurred in 25% of the patients with an average duration of 4.56 d. Patients who developed delirium were older (P = 0.007), had higher preoperative model for end-stage liver disease score (P = 0.019) and longer pretransplant hospital length of stay (LOS; P = 0.003). Patients with delirium were also more likely to have alcohol ingestion as an etiology of the liver failure (P = 0.033). Delirious patients had a trend toward increased ventilator days (P = 0.235) and significantly longer postoperative hospital (P = 0.001) and intensive care unit LOS (P = 0.001). Delirium was also associated with an increased frequency of hospital acquired infections including urinary tract infections (P = 0.005) and pneumonias (P = 0.001). CONCLUSIONS: Delirium is a common occurrence among liver transplant patients associated with increased complications and LOSs. Further prospective studies are needed to determine the specific risk factors in this complex population and to determine if delirium has an impact on long-term outcomes.
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Delírio/etiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Transplante de Fígado , Complicações Pós-Operatórias , Adulto , Idoso , Delírio/diagnóstico , Delírio/epidemiologia , Delírio/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Prevalência , Estudos RetrospectivosRESUMO
BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). In fact, death from cardiovascular disease is the number one cause of graft loss in kidney transplant (KTx) patients. Compared to patients on dialysis, CKD patients with KTx have increased quality and length of life. It is not known, however, whether outcomes of coronary artery bypass graft (CABG) surgery differ between CKD patients with KTx or on dialysis. METHODS: This was a retrospective cohort study comparing CKD patients with KTx or on dialysis undergoing CABG surgery included in the Nationwide Inpatient Sample from 2002 to 2011. Logistic and linear regression models were used to estimate the adjusted associations of KTx on all-cause in-hospital mortality, length of stay, cost of hospitalization, and rate of complications in CABG surgery. RESULTS: CKD patients with KTx had decreased all-cause in-hospital mortality (2.68% vs 5.86%, odds ratio (OR)=0.56, 95% confidence interval (CI)=0.32 to 0.99, P=.046), length of stay (ß=-2.96, 95% CI=-3.67 to -2.46, P<.001), and total hospital charges (difference=-$38 884, 95% CI=-$48 173 to -29 596, P<.001). They also had decreased rate of a number of perioperative complications. CONCLUSIONS: CKD patient with KTx have better perioperative outcomes in CABG surgery compared to patients on dialysis.
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Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Transplante de Rim , Diálise Renal , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/economia , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/mortalidade , Bases de Dados Factuais , Feminino , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Insuficiência Renal Crônica/economia , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
Organ shortage remains a major barrier to transplantation. While many efforts have focused on educating the general population regarding donation, few studies have examined knowledge regarding donation and donor registration rates among waitlisted candidates. We aimed to determine waitlisted patients' willingness to donate, elucidate attitudes surrounding organ allocation, and identify barriers to donation. A cross-sectional survey was distributed to assess demographics, knowledge regarding organ donation, and attitudes regarding the allocation process. Responses from 225 of 579 (39%) waitlisted patients were collected. Seventy-one respondents (32%) were registered donors, while 64 patients (28%) noted no interest in participating in donation. A total of 19% of respondents felt their medical treatment would change by being a donor, while 86 patients (38%) felt their condition precluded them from donation. Forty patients (18%) felt they should be prioritized on the waitlist if they agreed to donate. A minority of patients (28%) reported discussion of organ donation with their physician. Waitlisted candidates constitute a population of willing, although often unregistered, organ donors. Moreover, many endorse misconceptions regarding the allocation process and their donation eligibility. In a population for which transplantation is not always possible, education is needed regarding organ donation among waitlisted patients, as this may enhance donation rates.
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Conhecimentos, Atitudes e Prática em Saúde , Doadores de Tecidos/psicologia , Obtenção de Tecidos e Órgãos , Listas de Espera , Adulto , Idoso , Estudos Transversais , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Educação de Pacientes como Assunto , Sistema de Registros/estatística & dados numéricos , Doadores de Tecidos/estatística & dados numéricos , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos/organização & administração , Obtenção de Tecidos e Órgãos/estatística & dados numéricosRESUMO
BACKGROUND: Small intestine ischemia can be seen in various conditions such as intestinal transplantation. To further understand the pathologic disruption in ischemia-reperfusion injury, we have developed a method to measure fluid changes in the intestinal lumen of rats. METHODS: Two 10-cm rat intestine segments were procured, connected to the terminal apertures of a perfusion device, and continuously infused with 3 mL of HEPES solution (control solution) containing 50 µM of fluorescein isothiocyanate (FITC)-inulin. The perfusion device consists of concentric chambers that contain the perfused bowel segments, which are maintained at 37°C via H2O bath. The individual chamber has four apertures as follows: two fill and/or drain the surrounding HEPES solution on the blood side of the tissue. The others provide flow of HEPES solution containing FITC-inulin through the lumens. The experimental intestine was infused with the same solution with 100 µM of Forskolin. A pump continuously circulated solutions at 6 mL/min. Samples were collected at 15-min intervals until 150 min and were measured by the nanoflourospectrometer. RESULTS: A mean of 6-µM decrease in the FITC-inulin concentration in the Forskolin-treated experimental intestine was observed in comparison with that in the control intestine. The FITC-inulin count dilution in the experimental intestine is a result of an increase of fluid secretion produced by the effect of Forskolin, with P values <0.0001. CONCLUSIONS: We demonstrate that it is possible to measure luminal fluid changes over time using our new modified perfusion system along with FITC-inulin to allow real-time determinations of fluid and/or electrolyte movement along the small intestine.
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Fluoresceína-5-Isotiocianato/análogos & derivados , Corantes Fluorescentes , Secreções Intestinais/fisiologia , Intestino Delgado/fisiopatologia , Inulina/análogos & derivados , Traumatismo por Reperfusão/fisiopatologia , Animais , Masculino , Perfusão , Distribuição Aleatória , Ratos , Ratos Sprague-Dawley , Espectrometria de FluorescênciaRESUMO
We examined written informed consent forms for living liver donor evaluations to determine whether they incorporated elements required by the Centers for Medicare and Medicaid Services (CMS) and suggested by the Organ Procurement and Transplantation Network (OPTN). We contacted each of the 41 US centers that performed at least 1 living donor liver transplant in 2011; 37 centers reported active living donor evaluation programs. Twenty-six centers shared their consent form for living donor evaluation (response rate = 70%). Each document was double-coded for consent element content. We found that 57% of the centers included the 9 mandated CMS elements. Although the OPTN guidelines are non-binding, 78% of the centers used consent forms that addressed at least two-thirds of the elements recommended by OPTN. Only 17% of the centers provided written offers of an alibi to donors who withdrew from the evaluation. On the basis of our findings, we offer suggestions that may be relevant to ongoing revisions to the OPTN living liver donor consent policy and may help centers to improve the clarity of their written consent forms.
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Consentimento Livre e Esclarecido/normas , Transplante de Fígado/legislação & jurisprudência , Transplante de Fígado/métodos , Doadores Vivos , Centers for Medicare and Medicaid Services, U.S. , Guias como Assunto , Humanos , Internet , Transplante de Fígado/normas , Medicaid , Medicare , Obtenção de Tecidos e Órgãos/legislação & jurisprudência , Obtenção de Tecidos e Órgãos/normas , Estados UnidosRESUMO
In cases of uncontrollable hepatic hemorrhage or acute hepatic failure after trauma, liver transplantation can be a lifesaving procedure. Traumatic tricuspid valve injuries are rare, and symptoms can range from indolent to acute right heart failure. When concomitant, traumatic liver transplant and tricuspid injuries have significant physiologic interplay and management implications. We present a 14-year-old male injured in an all-terrain vehicle accident, who sustained a devastating disruption of the common bile duct and celiac artery injury, leading to acute hepatic failure, necessitating a two-stage liver transplantation. He was subsequently found to have a severe traumatic tricuspid injury, which required tricuspid valve replacement. At 4 years post-injury, he is without major complications. This is the first case presentation of the cooccurrence of these complex pathologies. Importantly, we demonstrate the complex decision-making surrounding traumatic liver transplantation and timing of subsequent tricuspid valve repair, weighing the complex interplay of these 2 pathologies.
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Transplante de Fígado , Valva Tricúspide , Ferimentos não Penetrantes , Humanos , Masculino , Adolescente , Ferimentos não Penetrantes/cirurgia , Ferimentos não Penetrantes/complicações , Valva Tricúspide/lesões , Valva Tricúspide/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Acidentes de Trânsito , Falência Hepática Aguda/cirurgia , Falência Hepática Aguda/etiologia , Traumatismos Cardíacos/cirurgia , Traumatismos Cardíacos/etiologiaRESUMO
Background: In the United States, no published guidelines promote exposure to technical variants (ie, living donor or split liver) during transplant fellowship. Simulation with hands-on liver models may improve training in transplantation. This pilot study addressed 3 overall goals (material and model creation tools, recruitment rates and assessment of workload, and protocol adherence). Methods: A patient-specific hands-on liver model was constructed from clinical imaging, and it needed to be resilient and realistic. Multiple types of materials were tested between January 2020 and August 2022. Participants were recruited stepwise. A left lateral segmentectomy simulation was conducted between August 2022 and December 2022 to assess protocol adherence. Results: Digital anatomy 3-dimensional printing was considered the best option for the hands-on liver model. The recruitment rate was 100% and 47% for junior attendings and surgical residents, respectively. Ten participants were included and completed all the required surveys. Seven (70%) and 6 (60%) participants "agreed" that the overall quality of the model and the material were acceptable for surgical simulation. Five participants (50%) "agreed" that the training improved their surgical skills. Nine participants (90%) "strongly agreed" that similar sessions should be included in surgical training programs. Conclusions: Three-dimensional hands-on liver models have the advantage of tactile feedback and were rated favorably as a potential training tool. Study enrollment for further studies is possible with the support of leadership. Rigorous multicenter designs should be developed to measure the actual impact of 3-dimensional hands-on liver models on surgical training.
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BACKGROUND: Children are removed from the liver transplant waitlist because of death or progressive illness. Size mismatch accounts for 30% of organ refusal. This study aimed to demonstrate that 3-dimensional (3D) technology is a feasible and accurate adjunct to organ allocation and living donor selection process. METHODS: This prospective multicenter study included pediatric liver transplant candidates and living donors from January 2020 to February 2023. Patient-specific, 3D-printed liver models were used for anatomic planning, real-time evaluation during organ procurement, and surgical navigation. The primary outcome was to determine model accuracy. The secondary outcome was to determine the impact of outcomes in living donor hepatectomy. Study groups were analyzed using propensity score matching with a retrospective cohort. RESULTS: Twenty-eight recipients were included. The median percentage error was -0.6% for 3D models and had the highest correlation to the actual liver explant (Pearson's R = 0.96, P < 0.001) compared with other volume calculation methods. Patient and graft survival were comparable. From 41 living donors, the median percentage error of the allograft was 12.4%. The donor-matched study group had lower central line utilization (21.4% versus 75%, P = 0.045), shorter length of stay (4 versus 7 d, P = 0.003), and lower mean comprehensive complication index (3 versus 21, P = 0.014). CONCLUSIONS: Three-dimensional volume is highly correlated with actual liver explant volume and may vary across different allografts for living donation. The addition of 3D-printed liver models during the transplant evaluation and organ procurement process is a feasible and safe adjunct to the perioperative decision-making process.
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Transplante de Fígado , Modelos Anatômicos , Criança , Humanos , Fígado , Doadores Vivos , Estudos Prospectivos , Estudos Retrospectivos , Impressão TridimensionalRESUMO
Inflammatory pseudotumors, now more aptly termed inflammatory myofibroblastic tumors (IMTs), are uncommon benign neoplasms, which have been reported in most organs and tissues in the body. Originally described and commonly found in the lung, they are also found in the liver of children and adults. We review the literature and analyze the features of the hepatic IMTs reported in children, along with a case report of a 15-month-old boy who had a persistent IMT in the liver and underwent surgical resection for the same following a trial of conservative management.
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Granuloma de Células Plasmáticas , Inflamação , Neoplasias Hepáticas , Fígado/patologia , Granuloma de Células Plasmáticas/cirurgia , Humanos , Lactente , Inflamação/cirurgia , Fígado/cirurgia , Neoplasias Hepáticas/cirurgia , Masculino , Miofibroblastos , Neoplasias/cirurgiaRESUMO
BACKGROUND: The authors recently published their experience of recanalizing umbilical veins in deceased liver donors, with recanalized umbilical veins as vascular conduits for meso-Rex bypass procedures. They have since found recanalized umbilical veins to be an excellent, easy to harvest vascular conduit that can be used for multiple vascular procedures and repair. Here, they report their experience using this vessel for bypass and vascular reconstruction. METHODS: They have recanalized umbilical veins and used them in a total of 5 Meso-Rex bypasses; 5 pancreaticoduodenectomies; 1 left hepatic trisegmentectomy with right portal vein (PV) resection and reconstruction; 1 right hepatectomy and 1 adrenalectomy, both with partial inferior vena cava (IVC) resection and reconstruction; 1 coronary-Rex bypass shunt for extrahepatic PV thrombosis; and 1 orthotopic liver transplantation with infrahepatic IVC anastomotic dehiscence patched with umbilical vein graft. Umbilical veins were dilated mechanically and used in situ for the meso-Rex bypass surgery; they were ligated in the space of Rex and then dilated ex vivo otherwise to be used as interposition grafts or a vein patch. RESULTS: A total of 15 hepato-pancreato-biliary procedures were done using the recanalized umbilical vein as graft; 2 patients required thrombectomy postoperatively with reexploration, venotomy, thrombectomy with fogarty catheter, and venotomy closure. CONCLUSION: The umbilical vein graft is a fine vascular conduit and can serve many purposes in hepatobiliary surgery.
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Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/métodos , Prótese Vascular , Procedimentos Cirúrgicos do Sistema Digestório/instrumentação , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Veia Porta/cirurgia , Veias Umbilicais/cirurgia , Adolescente , Adrenalectomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Hepatectomia , Humanos , Fígado/irrigação sanguínea , Fígado/cirurgia , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Pâncreas/irrigação sanguínea , Pâncreas/cirurgia , Pancreaticoduodenectomia , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Venous thromboembolism (VTE) occurs in 0.4% to 15.5% and bleeding occurs in 20% to 35% of patients after liver transplantation (LT). Balancing the risk of bleeding from therapeutic anticoagulation and risk of thrombosis in the postoperative period is challenging. Little evidence exists regarding the best treatment strategy for these patients. We hypothesized that a subset of LT patients who develop postoperative deep vein thromboses (DVTs) could be managed without therapeutic anticoagulation. We implemented a quality improvement (QI) initiative using a standardized Doppler ultrasound-based VTE risk stratification algorithm to guide parsimonious implementation of therapeutic anticoagulation with heparin drip. Methods: In a prospective management QI initiative for DVT management, we compared 87 LT historical patients (control group; January 2016-December 2017) to 182 LT patients (study group; January 2018-March 2021). We analyzed the rates of immediate therapeutic anticoagulation after DVT diagnosis within 14 d of LT, clinically significant bleeding, return to the operating room, readmission, pulmonary embolism, and death within 30 d of LT before and after the QI initiative. Results: Ten patients (11.5%) in the control group and 23 patients (12.6%; P = 0.9) in the study group developed DVTs after LT. Immediate therapeutic anticoagulation was used in 7 of 10 and 5 of 23 patients in the control and study groups, respectively (P = 0.024). The study group had lower odds of receiving immediate therapeutic anticoagulation after VTE (21.7% versus 70%; odds ratio = 0.12; 95% confidence interval, 0.019-0.587; P = 0.013) and a lower rate of postoperative bleeding (8.7% versus 40%; odds ratio = 0.14, 95% confidence interval, 0.02-0.91; P = 0.048). All other outcomes were similar. Conclusions: Implementing a risk-stratified VTE treatment algorithm for immediate post-LT patients appears to be safe and feasible. We observed a decrease in the use of therapeutic anticoagulation and a lower rate of postoperative bleeding without adverse impacts on early outcomes.
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BACKGROUND: Over 16 000 children under the age of 15 died worldwide in 2017 because of liver disease. Pediatric liver transplantation (PLT) is currently the standard of care for these patients. The aim of this study is to describe global PLT activity and identify variations between regions. METHODS: A survey was conducted from May 2018 to August 2019 to determine the current state of PLT. Transplant centers were categorized into quintile categories according to the year they performed their first PLT. Countries were classified according to gross national income per capita. RESULTS: One hundred eight programs from 38 countries were included (68% response rate). 10 619 PLTs were performed within the last 5 y. High-income countries performed 4992 (46.4%) PLT, followed by upper-middle- (4704 [44·3%]) and lower-middle (993 [9·4%])-income countries. The most frequently used type of grafts worldwide are living donor grafts. A higher proportion of lower-middle-income countries (68·7%) performed ≥25 living donor liver transplants over the last 5 y compared to high-income countries (36%; P = 0.019). A greater proportion of programs from high-income countries have performed ≥25 whole liver transplants (52.4% versus 6.2%; P = 0.001) and ≥25 split/reduced liver transplants (53.2% versus 6.2%; P < 0.001) compared to lower-middle-income countries. CONCLUSIONS: This study represents, to our knowledge, the most geographically comprehensive report on PLT activity and a first step toward global collaboration and data sharing for the greater good of children with liver disease; it is imperative that these centers share the lead in PLT.