Probability, management, and long-term outcomes of biliary complications after hepatic artery thrombosis in liver transplant recipients.

BACKGROUND: Hepatic artery thrombosis after liver transplantation is a devastating complication associated with ischemic cholangiopathy that can occur even after successful revascularization. This study explores long-term outcomes after hepatic artery thrombosis in adult liver transplantation recipients, focusing on the probability, risk factors, and resolution of ischemic cholangiopathy. METHODS: A retrospective chart review of 1,783 consecutive adult liver transplantations performed between 1995 and 2014 identified 44 cases of hepatic artery thrombosis (2.6%); 10 patients underwent immediate retransplantation, and 34 patients received nontransplant treatments, involving revascularization (n = 19) or expectant nonrevascularization management (n = 15). RESULTS: The 1-year graft survival after nontransplant treatment was favorable (82%); however, 16 of the 34 patients who received a nontransplant treatment developed ischemic cholangiopathy and required long-term biliary intervention. A Cox regression model showed that increased serum transaminase and bilirubin levels at the time of hepatic artery thrombosis diagnosis, but not nonrevascularization treatment versus revascularization, were risk factors for the development of ischemic cholangiopathy. Ischemic cholangiopathy in revascularized grafts was less extensive with a greater likelihood of resolution within 5-years than that in nonrevascularized grafts (100% vs 17%). Most liver abscesses without signs of liver failure also were reversible. Salvage retransplantation after a nontransplant treatment was performed in 8 patients with a 1-year survival rate equivalent to immediate retransplantation (88% vs 80%). CONCLUSION: Selective nontransplant treatments for hepatic artery thrombosis resulted in favorable graft survival. Biliary intervention can resolve liver abscess and ischemic cholangiopathy that developed in revascularized grafts in the long-term; salvage retransplantation should be considered for ischemic cholangiopathy in nonrevascularized grafts because of a poor chance of resolution.

Surgical telepresence: the usability of a robotic communication platform.

INTRODUCTION: The benefits of telepresence in trauma and acute surgical care exist, yet its use in a live, operating room (OR) setting with real surgical cases remains limited. METHODS: We tested the use of a robotic telepresence system in the OR of a busy, level 1 trauma center. After each case, both the local and remote physicians completed questionnaires regarding the use of the system using a five point Likert scale. For trauma cases, physicians were asked to grade injury severity according to the American Association for the Surgery of Trauma (AAST) Scaling System. RESULTS: We collected prospective, observational data on 50 emergent and elective cases. 64% of cases were emergency surgery on trauma patients, almost evenly distributed between penetrating (49%) and blunt injuries (51%). 40% of non-trauma cases were hernia-related. A varied distribution of injuries was observed to the abdomen, chest, extremities, small bowel, kidneys, spleen, and colon. Physicians gave the system high ratings for its audio and visual capabilities, but identified internet connectivity and crowding in the operating room as potential challenges. The loccal clinician classified injuries according to the AAST injury grading system in 63% (n=22) of trauma cases, compared to 54% (n=19) of cases by the remote physicians. The remote physician cited obstruction of view as the main reason for the discrepancy. 94% of remote physicians and 74% of local physicians felt comfortable communicating via the telepresence system. For 90% of cases, both the remote and local physicians strongly agreed that a telepresence system for consultations in the OR is more effective than a telephone conversation. CONCLUSIONS: A telepresence system was tested on a variety of surgical cases and demonstrated that it can be an appropriate solution for use in the operating room. Future research should determine its impact on processes of care and surgical outcomes.

Heterotopic uterus transplantation in a swine model.

BACKGROUND: The aim of our study was to examine the feasibility of allogeneic uterine transplantation in a large animal model. METHODS: We performed heterotopic uterine transplants in genetically defined mini-pigs. Immunosuppression was tacrolimus administered intravenously for the first 12 days posttransplantation followed by oral cyclosporine maintenance immunosuppression. The graft was transplanted heterotopically in the lower abdominal cavity of the recipient. The vaginal vault was exteriorized as a stoma in the lower right abdominal wall. The uterine grafts were followed with endoscopies and biopsies. RESULTS: Ten transplants were performed. Follow-up was until July 2008. At the end of the follow-up period, 5 animals were alive and healthy, 0.5 to 12 months posttransplantation. There were 5 deaths due to pneumonia (n=1), intussusception of the graft (n=1), cardiorespiratory arrest during anesthesia (n=1), and complications of the stoma (n=2). Acute rejections of the graft presented during the 2nd and 3rd month posttransplantation were treated successfully with increase of the maintenance immunosuppression and steroids. Other complications included prolapse and infections of the graft stoma. Pathological changes seen in the endometrial biopsies included acute rejection and acute endometritis. CONCLUSION: These findings demonstrate that successful uterus transplantation in a large animal model (miniature swine) is feasible using this heterotopic model, and it can be useful for the study of these transplants.

Right trisectionectomy of the liver for intrahepatic cholangiocarcinoma with bile duct invasion in a Jehovah's Witness.

Intrahepatic cholangiocarcinoma (ICC) is well known to have a very poor prognosis. Aggressive surgical strategies in the treatment of ICC, including major hepatectomy, have been reported to afford patients the best chance for significant survival. Recent advancements in surgical techniques concerning live donor liver transplantation have dramatically improved the results of major hepatectomy. However, surgical treatment of biliary malignancy is complex and is known to increase the likelihood of blood transfusion. We describe a Jehovah's Witness patient with ICC and concomitant bile duct invasion who had a successful right trisectionectomy with bile duct resection, lymph node dissection, and Rouxen-Y hepatico-jejunostomy without blood transfusion. A multidisciplinary preparation was crucial in obtaining this positive outcome. Importantly, bloodless liver transection techniques with inflow clamping, meticulous dissection, and hemostasis should be utilized for major hepatectomy in a Jehovah's Witness. The success of this case may alert clinicians to consider a hepatectomy as a possible option in the treatment of ICC in a Jehovah's Witness.