Outcomes of long storage times for cryopreserved vascular grafts in outflow reconstruction in living donor liver transplantation.

The outflow reconstruction of the right anterior sector in a right liver graft (RLG) with cryopreserved vascular grafts (CVGs) is crucial for preventing graft congestion in living donor liver transplantation (LDLT). The impact of the duration of cryopreservation has not been evaluated so far. From 2006 to 2009, 250 LDLT were performed: 47 of these patients (group 1) received CVGs stored for ≦1 year, and 33 patients (group 2) received CVGs stored for >1 year. Single or multiple segment 8 hepatic veins were reconstructed. The number of anastomoses did not affect vascular graft patency (P = 0.21). The length of the cryopreservation time did not affect the histological findings for CVGs. The preoperative and postoperative liver graft volumes were 783.8 ± 129.7 and 1102 ± 194.7 cc, respectively, for group 1 and 753.7 ± 158.5 and 1097.2 ± 178.7 cc, respectively, for group 2. The regeneration indices for liver grafts in the whole patient group, group 1, and group 2 were 48.9%, 47.4%, and 51.05%, respectively. In conclusion, the storage duration has no impact on the patency of CVGs in outflow reconstruction or on the regeneration of RLGs in LDLT. CVGs stored for >1 year can be safely used for the outflow reconstruction of RLGs in LDLT.

Early and long-term results of routine microsurgical biliary reconstruction in living donor liver transplantation.

We describe our early and long-term experience with routine biliary reconstruction via a microsurgical technique in living donor liver transplantation (LDLT). One hundred seventy-seven grafts (including 3 dual grafts) were primarily transplanted into 174 recipients. The minimum follow-up was 44 months. Biliary reconstructions were based on biliary anatomical variations in graft and recipient ducts. The recipient demographics, graft characteristics, types of biliary reconstruction, biliary complications (BCs), and outcomes were evaluated. There were 130 right lobe grafts and 47 left lobe grafts. There were single ducts in 71.8%, 2 ducts in 26.0%, and 3 ducts in 2.3% of the grafts. The complications were not significantly related to the size and number of ducts, the discrepancy between recipient and donor ducts, the recipient age, the ischemia time, or the type of graft. The overall BC rate was 9.6%. The majority of the complications occurred within the first year, and only 1 patient developed a stricture at 20 months. No new complications were noted after 2 years. When the learning-curve phase of the first 15 cases was excluded, the overall BC rate was 6.79%, and the rate of complications requiring interventions was 2.5%. In conclusion, the routine use of microsurgical biliary reconstruction decreases the number of early and long-term anastomotic BCs in LDLT.

All-in-one sleeve patch graft venoplasty for multiple hepatic vein reconstruction in living donor liver transplantation.

OBJECTIVES: This paper presents an innovative technique to address complex multiple hepatic vein (HV) reconstruction in right lobe graft living donor liver transplantation (RL-LDLT). METHODS: A patient with hepatitis C virus-related cirrhosis underwent RL-LDLT. The graft had seven HVs, including: the right HV (17 mm); one segment VII HV (11 mm); two segment VI HVs (6 mm and 16 mm), and three segment V HVs. The graft weighed 663 g (53% of standard liver volume; ratio of graft weight to recipient body weight: 0.96). Each HV had significant drainage territory requiring reconstruction. A cryopreserved iliac vein graft was used to create a sleeve patch to incorporate the HV openings. The holes were anastomosed to their corresponding HV tributaries using continuous 6-0 polydioxanone (PDS) sutures. Two of the three segment V HVs were combined using a smaller iliac vein patch, which was anastomosed in an end-to-side fashion to a previously harvested recipient umbilical vein interposition graft. The other end of the umbilical vein graft was anastomosed to the larger iliac vein sleeve patch. RESULTS: Overall, six HV openings were incorporated in one sleeve patch to allow a single wide anastomosis with the recipient inferior vena cava. Doppler ultrasound after reconstruction showed adequate flow patterns in all the HVs. CONCLUSIONS: All-in-one sleeve patch graft venoplasty simplifies the reconstruction of multiple HVs and reduces warm ischaemia time in RL-LDLT with excellent outcomes.

Comparison of major hepatectomy performed under intermittent Pringle maneuver versus continuous Pringle maneuver coupled with in situ hypothermic perfusion.

BACKGROUND: The Pringle maneuver (hepatic inflow occlusion), applied intermittently or continuously, carries the risk of inducing ischemic and reperfusion injury. The risk of damage is higher in the latter procedure. Studies have shown that continuous Pringle maneuver coupled with in situ hypothermic perfusion (CPM-HP) circumvents such adversity. However, reports comparing this technique with the intermittent Pringle maneuver (IPM) are lacking. We therefore report our experience with the use of CPM-HP and compare its outcome with that of IPM. METHODS: We evaluated the outcome of similar sets of patients who had major hepatic resections performed under IPM and CPM-HP. Variables including short-term survival rate (>90 days), complications, operative time, transection time, intraoperative blood loss, postoperative liver functions, and postoperative hospital stay were used to compare the two groups. RESULTS: Eighteen major hepatectomies were performed with CPM-HP and 16 with IPM. CPM-HP was safely performed in patients with chronic liver disease. Lowering the liver's temperature extends the clamping period to 140 min. Perioperative outcomes including operative time (383.9 ± 89.4 vs. 351.9 ± 70.3 min, p = 0.252), blood loss (225.6 ± 48.4 vs. 351.9 ± 70.3 ml, p = 0.057), postoperative hospital stay, morbidity rate, and the rate of liver functions following resections were comparable for the CPM-HP and IPM groups. There was no mortality. Parenchymal transection time was significantly longer in the CPM-HP group (104.1 ± 20.2 vs. 85.0 ± 15.4 min, p = 0.004) CONCLUSION: Our findings did not show there to be a significant advantage of CPM-HP over IPM.

Resection of large hepatocellular carcinoma using the combination of liver hanging maneuver and anterior approach.

BACKGROUND: Resection of a large hepatocellular carcinoma (HCC) is difficult and is associated with a poor outcome. Herein we describe our experience with the use of a liver hanging maneuver (LHM) in conjunction with the anterior approach (AA) in patients with large HCC (>10 cm) and compare the perioperative outcome with the conventional method (CM) for hepatic resection. METHODS: Patients who underwent major hepatic resections for large HCC (>10 cm) were categorized as group 1 (n = 14), treated with LHM and AA, versus group 2 (n = 11), treated with CM. Variables including patient age, tumor size, operative time and transection time, blood loss, blood transfusion requirements, and postoperative ICU and hospital stay were used to compare the two groups. RESULTS: There were 14 and 11 patients in groups 1 and 2, respectively. The variables in group 1 and 2 of median tumor size, median operative time, median transection time, median ICU stay, and median hospital stay were comparable. In contrast, the intraoperative blood loss and the blood transfusion requirements were significantly higher in group 2. Patients under LHM and AA and CM had a median blood loss of 375 ml (237.5-850) and 1,000 ml (500-1,200), requirement of blood transfusion of 3 (21.42%) and 8 (72.7%), respectively. Postoperative complications were comparable in the two groups. There were no deaths in the series. CONCLUSIONS: The liver hanging maneuver in conjunction with AA is a safe and highly feasible procedure, particularly in patients with sizable (>10 cm) tumors and tumors found to be adherent to the diaphragm and retroperitoneum. The use of the procedure eventuated in lower blood loss as well as fewer blood transfusion requirements when compared to the conventional method.

Cryopreserved arterial grafts as a conduit in outflow reconstruction in living donor liver transplantation.

BACKGROUND: Few reports have addressed the use of cryopreserved arterial grafts (CAG) for anterior section drainage in right lobe living donor liver transplantation (RL LDLT), and the impact of atherosclerosis on patency rate (PR) is not well studied. Also, those reports have limited case numbers. The aim of the present study is to report the largest experience with CAG in outflow reconstruction in RL LDLT and the impact of atherosclerosis on its patency. METHODS: During 2010 and 2011, 62 of 243 patients who underwent LDLT received outflow reconstruction with CAG for RL grafts. Atherosclerosis in CAG was classified into early, intermediate and advanced lesions according to the classification adopted by the American Heart Association: group 1 with grafts having no atherosclerosis or early lesions; and group 2 with grafts having intermediate and advanced lesions. Patency rates of CAG correlated with atherosclerotic change of CAG were retrospectively analyzed. RESULTS: The study group comprised 65 CAGs with 1, 3 and 6 months PR of 86.2%, 84.6% and 75.2% respectively. Histopathological examination was successful in 53 CAGs. The 1, 3 and 6 months PR of group with no/early atherosclerosis were 86%, 83.7% and 76.7%, respectively, while for groups with intermediate/advanced lesions they were 90%. However, there was no significant difference between the two groups (P = 0.384). CONCLUSIONS: Cryopreserved arterial grafts can be used for outflow reconstruction in RL LDLT with a good patency rate. Atherosclerosis appears to have minimal effect on CAG patency, yet further studies with larger cohorts are needed to support our results.

Section 9. Technical details of microsurgical biliary reconstruction in living donor liver transplantation.

Small size and multiple ducts, particularly in right lobe liver grafts, are major factors that contribute to biliary complications in living donor liver transplantation. To improve the outcome of biliary reconstruction, further investigation and refinement of reconstruction techniques and management strategies are necessary. From March 2006 to June 2012, routine MBR was performed in 584 grafts in 581 consecutive LDLT (including 3 dual graft transplants). All biliary reconstructions were performed using microsurgical technique by a single microsurgeon. The classification of biliary reconstruction was based according to the number of ducts in the graft, the manner in which these ducts were reconstructed (with or without ductoplasty), and the conduit used (recipient duct or jejunum) to reconstruct the biliary tree. In duct-to-duct reconstruction, posterior wall first technique by using interrupted suture and continuous running and interrupted tie technique (combined method) for the anterior wall were performed. Recipient reduction ductoplasty was done, if necessary. In duct-to-jejunum reconstruction, enterotomy was performed first under microscope; then, the serosal and mucosal layers were sutured together using 8-0 prolene to facilitate the anastomosis. Posterior wall first by using interrupted suture technique and combined method for the anterior wall were also performed. Overall, there were 397 right and 184 left lobe grafts. Single duct opening was noted in 440 (75.34%), two duct openings in 135(23.12%), and three duct openings in 9 (1.54%) grafts. Duct-to-duct anastomosis was performed in 473 (81%) and duct-to-jejunum Roux limb in 111 (19%) biliary reconstructions. Size discrepancy in the graft and recipient ducts was noted in 394 (83.3%) reconstructions. The overall biliary complication was 7.9%. These included 19 (3.3%) bile leaks and 27 (4.6%) biliary strictures. The routine use of MBR capably surmounts the difficulties brought about by the anatomic variations and the size discrepancies between the graft and recipient hepatic ducts with excellent outcome.

How to improve the outcome in patients with AJCC stage I hepatocellular carcinoma.

AIM: Survival of patients with stage I hepatocellular carcinoma (HCC) is higher than in patients with more advanced disease, however many of them will ultimately die of tumor recurrence and liver failure. Our objective focuses on identifying the pathological and clinical factors that could affect disease-free (DFS) and overall survival (OS). In addition we reviewed the treatment offered for recurrence and its impact on OS. PATIENTS AND METHODS: Between January 1992 and December 2002, a total of 473 patients who underwent hepatectomy for HCC at the Kaohsiung Chang Gung Memorial Hospital were enrolled in this study. Relevant clinicopathological and perioperative variables were subjected to univariate and multivariate analysis. RESULTS: A total of 224 patients with a mean follow-up period of 4.6 years were analyzed. The 1-, 3-, 5-, and 10-year DFS rates were 82.5%, 57.6%, 46.9% and 32.0% respectively. The 1-, 3-, 5-, and 10-year OS rates were 91.5%, 83.0%, 70.1% and 56.3% respectively. The multivariate analysis identified age >50 years, Indocyanine Green (ICG) clearance test and cirrhosis as independent factors that negatively impact DFS and age ≥ 50 years, resection type, presence of complications and tumor recurrence as factors affecting OS. In patients with recurrence (n=130), the factors that negatively impact OS were blood transfusion, age ≥ 50, blood loss and presence of surgical complications. CONCLUSION: Meticulous surgical technique is the key to improving the outcome of patients with stage I HCC. The presence of complications was the only modifiable clinicopathological factor that affected the OS in our study.

Clinicopathological factors impact the survival outcome following the resection of combined hepatocellular carcinoma and cholangiocarcinoma.

Studies have demonstrated poor survival outcomes for patients with resected combined hepatocellular carcinoma-cholangiocarcinoma tumours (CHCC-CC). Our objectives are to report on our institutional experience regarding the clinico-pathological and prognostic features of CHCC-CC and to compare our results with published series. The clinico-pathological features and outcomes of 11 patients with CHCC-CC who had a complete surgical resection for primary liver cancer were reviewed. There were 8 male and 3 female patients. The overall median age was 61 years. Active hepatitis B and hepatitis C infections were present in 6 (54%) and 2 (18%) patients, respectively. Alcoholism was present in one case. Cirrhosis was present in 8 (72%) cases. There were no causative factors identified in 2 patients with non-cirrhotic livers. The median AFP value was 30.56 ng/ml. A single mass located in the right lobe and a single mass located in the left lobe of the liver was noted in 6 (54%) and 4 (36%) patients, respectively. Bilobar involvement was observed in one case. Major and minor resections were performed in 2 (18%) and 9 (81%) cases, respectively. The median tumour size was 3 cm. Tumours measuring >5 cm were identified in only 2 (18%) cases. The majority of the cases were classified as stage I (54%) and stage II (36%). Four patients died 11-50 months after the surgery. Postoperative tumour recurrences were observed in 5 (45.45%) patients within 4 years of surgical resection. The overall 1- and 3-year survival rates in this series were 80% and 69.3%. Our series demonstrated cases of CHCC-CC with more favourable pathological traits and survival outcomes compared with similar studies.

Long term survival in patients with hepatocellular carcinoma directly invading the gastrointestinal tract: case reports and literature review.

Hepatocellular carcinoma (HCC) directly invading the gastrointestinal (GI) organs is rare and is associated with poor survival outcome. We report two patients with good long-term outcome following resection of HCC that invaded the stomach and duodenum, respectively. A literature review was conducted to elucidate the course of patients with this pathology. Two cases (57-year-old and 72-year-old males) with enlarged hepatic tumors directly invading the stomach and duodenum underwent hepatectomies with en-bloc resection of the involved organs. Both patients are still alive at 80 and 68 months following the surgery. Our literature review showed that most of the patients with this pathology have manifested, and died of persistent GI bleeding. Patients who were treated surgically had a statistically significant longer survival than those who were treated with non-surgical palliative treatments (P < 0.001). In addition, patients who were treated with surgery with curative intent tend to have a longer survival times than those who were treated with surgery to palliate the bleeding but the difference was not statistically significant (P < 0.174). Removing the tumor completely could significantly prolong the survival of patients with HCC invading the GI tract.

Magnetic resonance cholangiography in living donor liver transplantation.

OBJECTIVE: Exact knowledge of biliary anatomy is essential in living donor liver transplantation. The purpose of this study was to evaluate the accuracy of pretransplant magnetic resonance cholangiography (MRC) in depicting the biliary anatomy in comparison with intraoperative cholangiography (IOC). MATERIALS AND METHODS: From May 2006 to July 2009, 451 potential living liver donors underwent pretransplant evaluation at the Chang Gung Memorial Hospital-Kaohsiung Medical Center. Two hundred thirty-three donors underwent donor hepatectomy. Of these, only 203 donors with both preoperative MRC and IOC were included in this study. RESULTS: Of the 451 potential donors, 218 (48.3%) were considered unsuitable for liver donation, hence was immediately disqualified after the initial evaluation for various reasons. Six of the 218 unsuitable donors (2.8%) were excluded due to complicated biliary anatomy. The overall accuracy rate of MRC for defining the biliary anatomy was 91.6%, with 84.9% sensitivity, 96% specificity, 88.2% positive predictive value, and 94.7% negative predictive value. There were 14 misidentified cases. The errors in MRC reading was largely attributed to the poor contrast between the biliary ducts and the surrounding tissues and organs. The concurrence between MRC and IOC were commendable (κ=0.9). No significant biliary complications were noted in the mismatch group. CONCLUSION: MRC is essential for all pretransplantation evaluation with 91.6% accuracy rate.