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.

Surgical experience of adult primary hepatic sarcomas

BACKGROUND

Primary hepatic sarcoma (PHS) is a rare primary liver malignancy. The histological types of PHS are diverse, and the clinical outcomes and management mainly depend on the histopathology. This study aims to evaluate the results of surgical intervention.

METHODS

Between January 2003 and June 2009, 13 adult patients with pathologically proven PHS were identified by record review. The patients' demographic profile, tumor characteristics, treatment modalities, and outcomes were reviewed and analyzed. The end of follow-up was December 2014.

RESULTS

Nine (69%) underwent curative liver resection and two underwent liver transplantation; the others received non-operative treatments. The pathologic findings were six (46%) angiosarcomas, four (30.7%) undifferentiated sarcomas, one (7.6%) leiomyosarcoma, one (7.6%) malignant mesenchymoma, and one (7.6%) hepatic epithelioid hemangioendothelioma. The median follow-up was 31.4 (2.8 ~ 142.5) months. The 1-, 2-, and 5-year survival of surgical patients were 72.7%, 63.6%, and 36.4%, respectively. Importantly, the 1-, 2-, and 5-year survival rates of non-angiosarcoma patients were superior to those of angiosarcoma (85.7% vs. 33.3%, 71.4% vs. 16.7%, and 57.1% vs. 0%, respectively, P = 0.023).

CONCLUSIONS

Surgical intervention provides the possibility of long-term survival from PHS. Angiosarcoma is associated with a more dismal outcome than non-angiosarcoma.

Section 14. Combination of entecavir plus low-dose on-demand hepatitis B immunoglobulin is effective with very low hepatitis B recurrence after liver transplantation

BACKGROUND AND AIMS

Antiviral prophylaxis with hepatitis B immunoglobulin (HBIg) plus lamivudine reduces the risk of hepatitis B virus (HBV) recurrence after HBV-related liver transplant (LT). However, HBIg is expensive, and lamivudine therapy is limited by drug resistance. This study assessed a pilot study of entecavir plus low-dose, on-demand HBIg in preventing HBV recurrence after LT.

METHODS

Between 2006 and May 2011, approximately 145 patients undergoing HBV-related LT and receiving entecavir plus low-dose, on-demand HBIg were enrolled and followed for a median of 36 months. A historical control group of 171 patients undergoing HBV-related LT between 1998 and 2010 and receiving lamivudine plus HBIg were followed for a median of 77 months. The primary end point was the proportion of patients with recurrent HBsAg-positivity.

RESULTS

In the entecavir cohort, 2 (1.37%) of 145 patients experienced HBV recurrence, none of which had evidence of viral resistance. In the lamivudine cohort, 11 (6.4%) of 171 cases of HBV recurrence were observed, 5 of which were associated with lamivudine resistance. The cumulative probabilities of HBV recurrence were significantly different between both cohorts (P=0.055). HBsAg recurrence was associated with lower overall survival (P<0.001), even in patients with undetectable HBV DNA. Using pooled data from both cohorts, predictors of HBV recurrence were nucleoside selection, pre-LT hepatocellular carcinoma, post-LT low anti-HBs, male sex, and HBsAg-positivity in the explant liver tissue.

CONCLUSIONS

Entecavir plus low-dose, on-demand HBIg resulted in a low rate of HBV recurrence without evidence of resistance development and provided an effective and cost-saving strategy for patients having HBV-related LT.

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.

Interventional radiology in living donor liver transplant

The shortage of deceased donor liver grafts led to the use of living donor liver transplant (LDLT). Patients who undergo LDLT have a higher risk of complications than those who undergo deceased donor liver transplantation (LT). Interventional radiology has acquired a key role in every LT program by treating the majority of vascular and non-vascular post-transplant complications, improving graft and patient survival and avoiding, in the majority of cases, surgical revision and/or re-transplant. The aim of this paper is to review indications, diagnostic modalities, technical considerations, achievements and potential complications of interventional radiology procedures after LDLT.

Section 18. Professional framework for liver transplantation for overseas patients: traveling for living donor liver transplantation

BACKGROUND

Liver transplantation (LT) in overseas patients is a sensitive issue because of the possibility of organ trafficking and transplant tourism. In the Istanbul Summit, there was a call to develop standardized professional frameworks to prevent these practices.

OBJECTIVES

Our objectives are three-fold, to critically evaluate our professional framework, to study the demographic profiles, and to identify the outcome and impact of LT in overseas patients.

METHODS

Recipient and donor case records, e-mail communications, and medico-legal records were collected and analyzed for management strategy, demographic profile, donor and recipient characteristics, and outcome.

RESULTS

Only 5% of our total LT operations were for overseas patients. Forty-two (79%) were pediatric cases for which 39 (93%) were due to biliary atresia (P<0.001). Sixty-eight percent were from the Philippines. Thirty-seven (70%) of the donors were first-degree relative. The average hospital days of a pediatric living donor liver transplant (LDLT) recipient was 65.48±28.7, and average cost was 44,602 USD. An adult LDLT recipient stayed for 52.09±11.3 days and spent around 75, 013 USD. A donor of pediatric LDLT stayed in the hospital for 17.42±5 days and spent round 8,176 USD. A donor for adult LDLT was admitted for 15.5±4 days and spent an average 9,612 USD. The total cost for recipient and donor were 56,615 USD (range, 28,976-82,056) for pediatric LDLT and 84,483 USD (range, 64,851-108,467) for adult LDLT. Actuarial survival rates were 91% at 1 year, 88% at 3 years, and 86% at 5 years and 10 years.

CONCLUSION

Travelling for LDLT may be a wise and cost-effective step for patients with end-stage liver disease seeking alternative ways from their country. Our professional framework is effective to prevent practice of organ trafficking and transplant tourism. It may be useful to develop international guidelines for the practice of LT in overseas patients.

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.

Impacts of pretransplant infections on clinical outcomes of patients with acute-on-chronic liver failure who received living-donor liver transplantation

Background

Liver transplantation is the only therapeutic modality for patients with acute-on chronic liver failure (ACLF). These patients are at high risk for bacterial infections while awaiting transplantation. The aim of this study was to elucidate whether an adequately treated bacterial infection influences the outcomes after transplantation in this patient population.

Methodology/Principal Findings

54 recipients (median age, 49.5 years [range, 22–60]) of adult-to-adult living donor liver transplant (LDLT) for ACLF were categorized as those with pretransplant infection (Group 1, n = 34) or without pretransplant infection (Group 2, n = 20) for retrospective analyses. With the exception of a higher male-female ratio (P = 0.046) and longer length of pretransplant hospital stay (P = 0.026) in Group 1, similar demographic, laboratory and clinical features were found in both groups. Patients in Group 1 (totally 42 pretransplant infection episodes) were adequately treated with effective antibiotic(s) before receiving LDLT. All included patients were followed up until one year after transplantation or death. Sixty-one posttransplant infection episodes were found in an overall of 44 ACLF patients (27 in Group 1 vs. 15 in Group 2; P = 0.352). Frequently encountered posttransplant infections were intraabdominal infection, pneumonia, bloodstream infection and urinary tract infection. Two patients died in each group (P = 0.622). No significant difference was found in the length of posttransplant ICU stay, and in one-year survival, graft rejection, and posttransplant infection rate between both groups. The longer overall hospital stay (mean day, 89.0 vs. 65.5, P = 0.024) found in Group 1 resulted from a longer pretransplant hospital stay receiving treatment for pretransplant infection(s) and/or awaiting transplantation.

Conclusions

These data suggested that an adequately treated pretransplant infection do not pose a significant risk for clinical outcomes including posttransplant fatality in recipients in adult-to-adult LDLT for ACLF.

High Flow-Mediated Vasodilatation Predicts Pulmonary Edema in Liver Transplant Patients

BACKGROUND

Early pulmonary edema is common after orthotopic liver transplantation. Associated pathogenic mechanisms might involve increased activity of cardiac-inhibitory systems due to increased vasodilator production, mainly nitric oxide (NO). NO is primarily responsible for flow-mediated vasodilatation (FMD). We investigated the incidence of pulmonary edema in liver transplant patients and its correlation with FMD.

METHODS

We prospectively evaluated traditional risk factors, Doppler echocardiographic findings, derived hemodynamic data, and brachial artery nitroglycerin-induced vasodilatation (NTD) and FMD within 1 week prior to liver transplantation in 54 consecutive liver transplant patients with cirrhosis. Post-transplantation chest roentgenography was performed daily. In-hospital outcomes, transfusion volume of blood components, and hemodynamic data during surgery and at the intensive care unit were analyzed.

RESULTS

Twenty-nine patients (53.7%) developed radiological pulmonary edema within 1 week of transplantation. Diffuse-type interstitial and alveolar pulmonary edema constituted 13 cases (24.1%). Patients with pulmonary edema had higher pretransplantation Child-Turcotte-Pugh scores (p = 0.01), cardiac output (p = 0.03), FMD (p < 0.01), NTD (p = 0.01), and FMD/NTD ratio (p = 0.02). Although the total volume of intravenous fluid transfused was higher in the pulmonary edema group, the net fluid retention during surgery was statistically insignificant. The lengths of intensive care unit stay and hospitalization, as well as mortality rates, were not different in these groups.

CONCLUSIONS

The high incidence of pulmonary edema after living donor liver transplantation was associated with a high FMD and FMD/NTD ratio at pretransplantation. FMD is the only significant predictor associated with pulmonary edema. However, we observed no alteration in mortality rates.

KEY WORDS

Cirrhotic cardiomyopathy; Flow-mediated vasodilatation; Liver transplantation; Pulmonary edema.

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.

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.

Intra-operative management of low portal vein flow in pediatric living donor liver transplantation

For pediatric living donor liver transplantation, portal vein complications cause significant morbidity and graft failure. Routine intra-operative Doppler ultrasound is performed after graft reperfusion to evaluate the flow of portal vein. This retrospective study reviewed 65 children who had undergone living donor liver transplantation. Seven patients were detected with suboptimal portal vein flow velocity following vascular reconstruction and abdominal closure. They underwent immediate on-table interventions to improve the portal vein flow. Both surgical and endovascular modalities were employed, namely, graft re-positioning, collateral shunt ligation, thrombectomy, revision of anastomosis, inferior mesenteric vein cannulation, and endovascular stenting. The ultrasonographic follow-up assessment for all seven patients demonstrated patent portal vein and satisfactory flow. We reviewed our experience on the different modalities and proposed an approach for our future intra-operative management to improve portal vein flow at the time of liver transplantation.

Hemodynamics of portal venous stenosis before and after treatment in pediatric liver transplantation: evaluation with Doppler ultrasound

AIM

The aim of this study was to evaluate portal vein stenosis (PVS) in pediatric liver transplantation (PLT) using Doppler ultrasound (DUS) before and after interventional management for hemodynamic changes.

MATERIALS AND METHODS

From 2000 to 2010, we encountered 11 PVS cases among 180 PLT that were evaluated using DUS and computed tomography (CT) angiography (CTA); all underwent portal stenting. DUS was used to monitor portal hemodynamics. For the diagnosis of PVS, we investigated multiple parameters including stenotic size (SS), stenotic ratio (SR) (SR [%]=PRE-SS/PRE [PRE=stenotic size]), portal flow velocity ratio (VR) (VR=VS/PRE [PRE=velocity at prestenotic site; VS=peak velocity at stenotic site]), spleen size, and platelet count.

RESULTS

The incidence of PVS was 5.6% (11/180). The PV was 2.5 mm using DUS and 2.7 mm using CTA. The average SR was 65% fitting the criterion. Low prestenotic portal flow<12 cm/sec and high peak velocity in the stenotic segment (up to 147 cm/sec) were observed in 6 cases. The VR value was high at 7.5:1 and there was splenomegaly with thrombocytopenia. After portal vein stenting, hyperperfusion occurred might after reopening the stenosis: the flow increased to an average of 34 cm/sec and then flow decreased slowly to a stable level 2 weeks later. The size of the spleen decreased from 17 to 12 cm and the thrombocytopenia also improved with platelet counts increasing from 67×10(3) to 178×10(3)/μl at 2 months follow-up. The changes in portal flow, portal vein size, spleen size, and platelet count were significant (P<.05).

CONCLUSION

PVS is diagnosed using DUS by increased intrahepatic PV dilatation, peak flow at the stenotic site, discrepant VR. Early portal stenting showed a better prognosis. DUS is essential and effective for hemodynamic monitoring and management of PVS.

Liver transplantation for primary biliary cirrhosis in a hepatitis endemic region: a single-center Asian experience

From March 1984 to November 2008, we performed 539 primary liver transplantations (LTs). Nineteen (19, 3.5%) were transplanted for end-stage liver disease secondary to primary biliary cirrhosis (PBC). There were 17 (89%) female and 2 (11%) male recipients. The overall mean age was 50.3 ± 6.3 yr. The mean model for end-stage liver disease, and Child-Turcotte-Pugh scores were 20.7 ± 2.1, and 11.0 ± 0.5, respectively. There were 2 (11%) United Network for Organ Sharing status 3, 16 (84%) 2B, and 1 (5%) 2A patients. Fourteen patients (14, 73.7%) underwent living donor LT, and five patients (26.3%) received deceased donor LT. The primary immunosuppression consisted of cyclosporine (n = 5) and tacrolimus (n = 14). Liver function returned to normal one month after transplantation. The overall mean follow-up was 5.8 ± 0.8 yr (range, four months to 15.7 yr). The overall one-, three-, and five-yr survival rates were 94.7%, 89.2%, and 89.2%, respectively. Without hepatitis B virus (HBV) prophylaxis, one patient acquired de novo HBV infection after receiving a graft from an anti-HBc(+) donor. Another patient developed recurrent hepatitis C infection and expired 25 months after transplantation. Our results showed that HBV prophylaxis was effective not only against de novo infection, but it also worked on pre-transplant HBV carrier with PBC and helped in virus clearance.

Solitary pulmonary nodule in the liver transplant candidate: importance of diagnosis and treatment

Our objectives were to define the incidence and etiology of solitary pulmonary nodules (SPNs) in patients undergoing living donor liver transplantation (LDLT), describe a diagnostic approach to the management of SPNs in LDLT, and define the impact of SPNs on the overall survival of adult LDLT recipients. Nine patients (9/152, 5.9%) were diagnosed with an SPN on the basis of chest radiography findings during the pretransplant survey. All were male. The mean age was 52 years. All the patients had hepatitis B virus-related cirrhosis with hepatocellular carcinoma. All were asymptomatic for the lung lesion. All underwent contrast-enhanced chest computed tomography (CT) to verify the presence and possible etiology of the SPNs. In 3 cases, CT was used to definitely determine that there was no pulmonary nodule; in 2, CT led to a definite diagnosis of pulmonary tuberculosis. In 4, CT led to a definite identification of an SPN but not to an etiological diagnosis. Two patients underwent outright thoracoscopy and biopsy of their SPNs. Biopsy showed cryptococcosis in both patients. One received a therapeutic trial of an antituberculosis treatment, and repeat CT after 1 month showed a regression in the size of the SPN. A diagnosis of tuberculosis was made. One patient had an inconclusive whole body positron emission tomography scan and subsequently underwent thoracoscopy where biopsy showed tuberculosis. A concomitant malignancy, either primary lung cancer or metastasis from the liver tumor, was not identified. All patients were surviving with their original grafts and were lung infection-free. The overall mean posttransplant follow-up was 54 months (range = 33-96 months).

Hand-assisted laparoscopic splenectomy--preliminary experience in southern Taiwan

BACKGROUND

A hand-assisted laparoscopic procedure allows the surgeon to insert the nondominant hand into the abdomen, and helps to recover the tactile sensation. For a massively enlarged spleen, this technique overcomes difficulty in conventional laparoscopic splenectomy. The advantages of minimally-invasive surgery can still be preserved. We describe our preliminary experience in hand-assisted laparoscopic splenectomy.

METHODS

The data of 5 patients who presented with splenomegaly and underwent hand-assisted laparoscopic splenectomy between April 2000 and January 2004 were reviewed retrospectively for analysis.

RESULTS

The mean age was 45.4 +/- 6.6 years, and the hospital stay was 6.6 +/- 1.0 days. The splenic length and weight averaged 20.6 +/- 5.9 cm and 1084.2 +/- 647.8 g. The operative time and blood loss averaged 218.2 +/- 40.2 minutes and 220 +/- 166.1 ml. There was no conversion to open splenectomy. No mortality or morbidity was noted in our series.

CONCLUSION

Hand-assisted laparoscopic splenectomy is a safe and feasible procedure, even in our initial experience. It helps in exploration of the surgical field and handling of a fragile spleen, especially in patients with massively enlarged spleens. Although another incision is necessary, the advantages of laparoscopic surgery are still retained.

Routine microsurgical biliary reconstruction decreases early anastomotic complications in living donor liver transplantation

Biliary reconstruction using a microsurgical technique in living donor liver transplantation was routinely performed on 88 grafts primarily transplanted into 85 patients. All procedures were performed under a microscope by a single microsurgeon. Except for biliary atresia and Alagille syndrome, duct-to-duct reconstruction was performed. Stents were not used. The outcomes with microsurgical biliary reconstruction (MB) were compared with the outcomes of a cohort of 86 grafts in 85 patients that underwent conventional biliary reconstruction (CB). The identification of complications included only up to 12 months of follow-up for each recipient in both groups. The average graft duct sizes were 2.8 mm for MB and 3.4 mm for CB. Most complications occurred in the first 15 cases with MB, and these cases were considered to constitute the learning curve phase. The MB complication rate was 46.7% in the first 15 cases, 20.0% in the next 15 cases, and 5.4% in the last 55 cases. When the learning curve phase was excluded, the overall complication rate over time with MB (8.9%) was significantly lower than that with CB (21.9%). CB increased the risk of biliary complications by 2.5 times (relative risk: 2.5; attributable risk: 128; odds ratio: 2.9). In conclusion, routine MB is a technical innovation that leads to decreased early anastomotic complications in living donor liver transplantation.

Intimal dissection of the hepatic artery following transarterial embolization for hepatocellular carcinoma: an intraoperative problem in adult living donor liver transplantation

The objective of this study was to describe the relationship between intimal dissection (ID) in the recipient hepatic artery (HA) and transarterial embolization (TAE) and highlight the reconstructive methods for the different types of ID encountered in living donor liver transplantation (LDLT). Fifty-four patients with hepatocellular carcinoma underwent LDLT. ID was classified as mild, moderate, or severe, and this classification was based on the extent of intimal injury. Mild, moderate, or severe ID were defined as ID that was less than one-quarter of the circumference of the HA, had reached one-half of the circumference of the HA, or was more than one-half of the circumference of the HA or involved the entire vessel wall, respectively. The reconstructive methods were based on the severity of ID encountered. Forty patients underwent TAE before LDLT, and 23 of these patients (57.5%) had ID. Nine patients had mild ID, 6 had moderate ID, and 8 had severe ID. In the 14 patients who did not undergo TAE, 4 had ID (28.6%; 3 mild and 1 severe). The other 10 patients (71.4%) had normal HA. In mild and moderate ID, the native HA was used after trimming of the HA until a healthy segment was encountered. In severe ID, the HA was reconstructed with alternative vessels. Two HA thromboses occurred postoperatively. TAE increased the risk of developing ID 2-fold. There was no graft loss or mortality in this series due to HA complications. In conclusion, ID of the HA is associated with pretransplant TAE among hepatocellular carcinoma patients undergoing LDLT. Intraoperative recognition of this complication and trimming until good vessel quality is encountered or using alternative vessels are important.

A simple and inexpensive technique of upper abdominal wall retraction in pediatric liver surgery and transplantation

In majority of centers, pediatric liver surgery and transplantation involves a team of four at any given time: the surgeon, the first and second assistants, and the instrument nurse. This creates considerable crowding around both operative field and operating table. Mechanical devices have been occasionally employed to solve this problem, but most table-mounted devices are designed for adult patients. Based on our experience with pediatric living donor liver transplantation, we developed a simple, safe, and inexpensive method of upper abdominal wall retraction to facilitate surgical exposure and avoid over-crowding in the sterile field. The key points of this technique are the use of the Mercedes incision for liver transplantation or right subcostal incision with upper abdominal midline extension for hepatic resection and an adult-designed Kent retractor. A pediatric-designed Kent retractor is expensive, unnecessary, and may even cause complications as rib fractures and nerve paralysis. We used this technique in 142 consecutive pediatric living donor liver transplants and 16 major hepatectomies in children without any complication resulting from the exposure. The presented technique is simple, safe, reliable, and inexpensive. It can be used in pediatric liver surgery, as well as general pediatric upper abdominal operations.