Single incision simultaneous liver kidney transplantation: Feasibility and outcomes.

BACKGROUND: Traditionally, simultaneous liver kidney transplantation (SLK) has been performed using a subcostal incision for the liver allograft and a lower abdominal incision for kidney transplantation (dual incision, DI). At our institution, we performed SLK using a single subcostal incision (SI). The aim of this study was to report the outcomes of single versus dual incisions for SLK. METHODS: A retrospective cohort study of consecutive SLK procedures performed at our center from January 2015 to April 2021 was performed. The demographic characteristics, complications, intraoperative findings, and complications after SI and DI were statistically compared. RESULTS: A total 37 SLK were performed (19 DI and 18 SI). The age and indications for transplantation were comparable between the two groups. Patient in SI group had significantly higher MELD score (27.0 ± 1.5 vs. 31.7 ± 1.5, p = .038). The cold ischemic time of kidney transplantation (599 ± 26 min vs. 447 ± 27 min, p < .001) and the total surgical time (508 ± 21 min vs. 423 ± 22 min, p = .008) were significantly shorter in the SI group. The incidence of complications and post-transplant kidney function was comparable between the groups. A slightly higher incidence of surgical site complications was noted in the DI group without any statistically significance (p = .178). CONCLUSIONS: Single-subcostal incision SLK is technically feasible and has comparable outcomes to dual-incision SLK. SI was associated with shorter cold ischemic time for kidney transplant, as well as shorter overall operative time.

Liver transplantation for post-COVID-19 cholangiopathy: A case series.

BACKGROUND: Post-COVID-19 cholangiopathy is an emerging cholestatic liver disease observed in patients recovering from severe COVID-19 infection. Its prognosis is poor, necessitating liver transplantation in some cases. This study aimed to investigate the outcomes of liver transplantation for post-COVID-19 cholangiopathy. METHODS: Seven patients who underwent liver transplantation for post-COVID-19 cholangiopathy at three institutions between 2020 and 2022 were included in this retrospective multi-center case series. RESULTS: At the time of initial COVID-19 infection, all patients developed acute respiratory distress syndrome, and six patients (86%) required ICU admission. Median time intervals from the initial COVID-19 diagnosis to the diagnosis of post-COVID-19 cholangiopathy and liver transplantation were 4 and 12 months, respectively. Four patients underwent living donor liver transplantation, and three patients underwent deceased donor liver transplantation. The median MELD score was 22 (range, 10-38). No significant intraoperative complications were observed. The median ICU and hospital stays were 2.5 and 12.5 days, respectively. One patient died due to respiratory failure 5 months after liver transplantation. Currently, the patient and graft survival rate is 86% at a median follow-up of 11 months. CONCLUSIONS: Liver transplantation is a viable option for patients with post-COVID-19 cholangiopathy with acceptable outcome. Timely identification of this disease and appropriate management, including evaluation for liver transplantation, are essential.

Nutritional Status of Patients with Cancer: A Prospective Cohort Study of 1,588 Hospitalized Patients.

BACKGROUND: We aimed to assess the nutritional status of cancer patients according to site or treatment type. METHODS: We prospectively evaluated the nutritional status of 1,588 patients based on cancer site and treatment type using the Patient-Generated Subjective Global Assessment tool. We also investigated length of stay (LOS), complication rates after surgery and quality of life (QoL). RESULTS: The patients with esophageal, pancreaticobiliary, and lung cancer had higher malnutrition rates than those with stomach, liver, and colon cancer (52.9%, 47.6%, and 42.8% vs. 29.1%, 24.7%, and 15.9%, respectively; P < 0.05). Patients undergoing chemoradiotherapy (CRT) or supportive care had higher malnutrition rates than those undergoing surgery (35.2% or 68.6% vs. 12.3%; P < 0.05). Among patients undergoing surgery, malnourished patients had longer LOS and tended to have more complications than well-nourished patients (P < 0.05 and P = 0.146, respectively). Malnourished patients had also poorer QoL than well-nourished patients (P < 0.05). CONCLUSION: Malnutrition complicated more in patients with esophageal, pancreaticobiliary, or lung cancer than in those with stomach, liver, or colon cancer. Patients undergoing CRT or supportive care are more likely to be malnourished than those undergoing surgery. Malnutrition may increase LOS and impair QoL.

Risk prediction of post-hepatectomy liver failure in patients with perihilar cholangiocarcinoma.

BACKGROUND AND AIM: In most patients with perihilar cholangiocarcinoma (PHCC), major hepatectomy and extrahepatic bile duct resection are needed for surgical radicality, and a high risk of hepatic insufficiency exists. This study aims to develop a prediction model for post-hepatectomy liver failure (PHLF) in patients with PHCC. METHODS: A total of 143 patients who underwent major liver resection and extrahepatic bile duct resection for PHCC between October 2001 and December 2013 were included. Clinically relevant PHLF was defined as liver failure corresponding to grade B or C of the International Study Group of Liver Surgery criteria. Multivariate logistic regression was used to develop the PHLF risk model. Model performance was evaluated internally using the area under the curve analysis (discrimination) after 1000 bootstrap resampling and the Hosmer-Lemeshow goodness-of-fit test (calibration). RESULTS: Post-hepatectomy liver failure occurred in 43.4% of patients (n = 62). In multivariate analysis, PHLF was significantly associated with future liver remnant ratio (odds ratio [OR] per 10% = 0.68, 95% confidence interval [CI] 0.51-0.88), intraoperative blood loss (OR per 1 L = 1.82, 95% CI 1.11-3.17), and preoperative prothrombin time > 1.20 (OR = 3.22, 95% CI 1.15-9.97). The PHLF risk score model showed good discrimination (area under the curve = 0.708, 95% CI 0.623-0.793) and calibration (P = 0.227). CONCLUSIONS: The risk model proposed in this study accurately predicted PHLF in patients with PHCC. This offers surgeons a practical guide to quantitative risk assessment of hepatic insufficiency and aids decision-making in surgical treatment and perioperative management.

Ligation and cut as a method for bile duct division in living donor right hepatectomy.

The importance of bile duct division cannot be overemphasized in living donor surgery. Ligation and cut (LC) as a method for bile duct division in living donor right hepatectomy (LDRH) has never been reported. The purpose of this study was to introduce the LC method of bile duct division in LDRH. All LDRH donors were identified through a prospectively maintained database at the authors' institution between September 2009 and March 2013, and the 2 methods, LC and cut and oversewing (CO), were compared both in terms of donor and recipient outcomes of right lobe living donor liver transplantation. In the LC method, after complete parenchymal transection, the right hepatic duct was dissected in the Glisson's sheath and ligated just at the right side of the confluence, and then the right side of the ligature was cut. The LC and CO methods were performed in 109 and 134 donors, respectively. Bile duct division time (P < 0.001) and operative time (P < 0.001) were significantly shorter in the LC group than in the CO group. With a median follow-up of 60.2 months, biliary complication rate was lower in the LC group than in the CO group (0% versus 5.2%; P = 0.01), but with no significant difference between the recipient groups. All donors made a complete recovery. In conclusion, the bile ducts of living donors can be dissected safely from the Glisson's sheath, and the LC method facilitates bile duct division and has a lower incidence of biliary complication in LDRH without compromising the recipient outcomes. Liver Transplantation 23 448-456 2017 AASLD.

Feasibility and Midterm Results of Endovascular Treatment of Hepatic Artery Occlusion within 24 Hours after Living-Donor Liver Transplantation.

PURPOSE: To evaluate the feasibility and midterm results of endovascular treatment of hepatic artery occlusion within 24 hours after living-donor liver transplantation (LDLT). MATERIALS AND METHODS: From January 2012 to June 2014, 189 consecutive patients at a single institution underwent LDLT with right-lobe grafts. Among them, 10 were diagnosed with hepatic artery occlusion within 24 hours after LDLT. All 10 underwent endovascular treatment, including drug-eluting stent placement (n = 2), intraarterial thrombolysis (n = 5), or both (n = 3). Every patient received regular follow-up with multidetector computed tomography (CT). Data on primary technical success, primary and assisted primary patency, and biliary complications were analyzed. RESULTS: Primary technical success was achieved in all 10 cases. Primary patency rates at 1 week, 3 months, and 6 months were all 70% (7 of 10), and the respective assisted primary patency rates were all 80% (8 of 10). Bleeding at the anastomotic site developed in 2 failed cases, prompting repeat liver transplantation. All 8 successfully recanalized cases showed hepatic artery patency on CT throughout follow-up (mean, 643.6 d; range, 236-1,081 d). Six of these cases had anastomotic biliary stricture, 4 of which were successfully treated by multisession biliary intervention. One patient had nonanastomotic biliary stricture and died of hepatic failure despite lifelong external drainage. CONCLUSIONS: Endovascular treatment could be an alternative therapeutic option for patients with hepatic artery occlusion within 24 hours after LDLT. It could help achieve long-term patency of the hepatic artery, but biliary stricture can potentially occur, and bleeding at the anastomotic site is a serious complication.

Survival analysis after liver resection for hepatocellular carcinoma: A consecutive cohort of 1002 patients.

BACKGROUND AND AIM: The improvements in surgical technique and perioperative management in the recent decades may warrant revisit for survival outcomes and prognostic factors after liver resection for hepatocellular carcinoma (HCC). This study aimed to analyze the survival outcomes after liver resection for HCC for a consecutive cohort of 1002 patients. METHODS: This study was performed by analyzing the clinicopathological and follow-up data of 1002 consecutive patients who underwent liver resection for HCC from April 2001 to December 2013. Prognostic factors were investigated by univariate and multivariate analysis, using the Cox's proportional hazards model. RESULTS: The overall incidence of postoperative complications was 16.1% (n = 161), with an in-hospital mortality rate of 0.3% (n = 3). The rates of 1-, 3-, and 5-year overall survival were 91.9%, 78.9%, and 69.5%, while the rates of 1-, 3-, and 5-year recurrence-free survival were 71.7%, 51.7%, and 43.7%, respectively. Multivariate analysis showed that patient age, platelet count, intraoperative estimated blood loss (EBL), tumor number, Edmond-Steiner grade, microvascular invasion, major vessel invasion, and intrahepatic metastasis were independent significant prognostic factors affecting the overall survival. Platelet count, intraoperative EBL, maximal tumor size, major vessel invasion, capsule formation, intrahepatic metastasis, cirrhosis, and the pathological stage were independent prognostic factors for recurrence-free survival. CONCLUSIONS: Survival of patients with HCC after resection should be stratified by various perioperative clinicopathological factors. Platelet count and intraoperative EBL could be considered as one of the powerful predictors of the prognosis and recurrence of HCC in such patients.

Right hepatectomy in living donors with previous abdominal surgery.

BACKGROUND: Few studies have evaluated the impact of previous abdominal surgery (PAS) on living donor right hepatectomy (LDRH). The aim of this study was to investigate the outcomes of liver transplantation using right lobe grafts of living donors with PAS. METHODS: Data were reviewed from LDRH patients at the authors' institution between March 2008 and November 2014. LDRH patients with PAS were divided into two groups according to upper PAS (group 1) or lower PAS (group 2), and they were compared to those without PAS (group 3) who were matched 1:1 based on age, gender, and body mass index. Perioperative data, complications by the Clavien classification, and the outcomes with more than 14 months follow-up were compared. RESULTS: Twenty-three (4.9%) of a total of 471 LDRH donors had PAS. Eleven donors were assigned to group 1, 12 to group 2, and 23 to group 3. Intraperitoneal adhesions were found in 20 (87.0%) of 23 donors with PAS, of whom 5 (21.7%) had adhesiolysis-related injuries that happened more commonly in group 1 than in group 2 (P=0.025). LDRH was successfully completed under upper midline laparotomy in all donors. No donors received perioperative blood transfusion. The peak postoperative AST, ALT, INR, and total bilirubin levels made no difference between the three groups. Compared with group 3, groups 1 and 2 had a longer operative time (P=0.012) and a higher grade I complication rate (P=0.047). All donors recovered fully to their routine activities. The 23 recipients of grafts from donors with PAS showed good liver function with 1-year graft and patient survivals of 100%. CONCLUSION: A history of PAS is not a contraindication to LDRH in the current era of advanced surgical techniques.

Outcomes for Patients with Recurrent Intrahepatic Cholangiocarcinoma After Surgery.

BACKGROUND: This study aimed to analyze the postoperative outcomes for patients with recurrent intrahepatic cholangiocarcinoma (ICC) and to determine the prognostic factors. In addition, this study investigated the effects of various treatment methods for patients with recurrent ICC. METHODS: This retrospective study analyzed the postoperative outcomes and prognostic factors of recurrent ICC that occurred for 81 of 128 patients who underwent hepatic resection for ICC between April 2001 and April 2013. In addition, the outcomes for a number of treatment methods were assessed for patients with recurrent ICC. RESULTS: After resection, the 128 patients with ICC had survival rates of 73 % at 1 year, 52 % at 3 years, and 43 % at 5 years. Recurrent ICC developed in 81 patients (56 men and 25 women) with a median age of 63 years. The median time from initial resection to recurrence was 9 months (range, 0-124 months), and the median survival time after recurrence was 8 months (range, 0-108 months). After recurrence, the overall survival rates were 47 % at 1 year, 23 % at 3 years, and 15 % at 5 years. Multivariate analysis showed disease-free survival time shorter than 1 year and bile duct invasion to be significant prognostic factors. Among the treatment methods, local management such as surgery, transarterial chemoembolization, and radiofrequency ablation were effective in select cases with localized intrahepatic and extrahepatic recurrence. CONCLUSION: Active local treatment (i.e., surgery, transarterial chemoembolization [TACE], and radiofrequency ablation [RFA]) may improve survival for patients with localized ICC recurrence.

Conversion of twice-daily to once-daily tacrolimus is safe in stable adult living donor liver transplant recipients.

BACKGROUND: Once-daily extended-release tacrolimus (Tac-OD) has been introduced as a useful therapeutic option to increase patient adherence to immunosuppressive therapy. This study aimed to evaluate the safety, efficacy and immunosuppressant adherence of conversion from twice-daily tacrolimus (Tac-BID) to Tac-OD in stable adult living donor liver transplant (LDLT) recipients in a single institution. METHODS: Between February and May 2013, Tac-BID was converted to Tac-OD in recipients followed up for at least 12 months after transplantation and without previous rejection episodes. The switching policy was based on a dose ratio of 1:1 with dose adjustment target trough levels at 3-5 ng/mL. Tacrolimus trough levels, laboratory parameters, metabolic disorders, and adverse events were assessed. RESULTS: A total of 229 patients were enrolled in the study. The median age at conversion was 53 years (range 31-73). The median transplant duration was 35.3 months (range 12.0-95.4). During a median follow-up of 13.5 months after conversion, 9 patients returned to Tac-BID because of adverse events. No acute rejection episodes were observed. Of 214 patients still on Tac-OD at 12 months, 12 (5.6%) received a reduced dose and 95 (44.4%) required an increased dose over baseline. Overall adherence was 82.2% at the end of follow-up. CONCLUSION: The conversion from Tac-BID to Tac-OD with similar target trough levels after conversion is safe and effective for long-term stable LDLT patients.