151
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Yi PS, Zhang M, Xu MQ. Management of the middle hepatic vein in right lobe living donor liver transplantation: A meta-analysis. ACTA ACUST UNITED AC 2015. [PMID: 26223934 DOI: 10.1007/s11596-015-1477-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Living donor liver transplantation (LDLT) is a curative treatment for end stage liver disease. It is advantageous due to the shortage of deceased donors. However, in LDLT, whether the middle hepatic vein (MHV) should be preserved in donors remains controversial. We conducted searches in Pubmed, Embase, Cochrane Library, Web of Science, Ovid, and Google Scholar using the key words "living donor liver transplantation" and "middle hepatic vein". Due to ethical issues, there were no randomized control trails focusing on MHV in LDLT. The majority of reports were retrospective studies. We examined the reference lists to identify related investigations. Google Scholar was then used to obtain full texts. Nine observational studies were analyzed. There were no significant differences in liver function (WMD, -5.51; P=0.12) and complications (RR, 0.98; P=0.89) in donors with or without MHV. However, the liver function in recipients was greatly improved after LDLT with MHV (WMD, -78.32; P=0.01). No definite conclusion was obtained in terms of the liver regeneration indices between LDLT with or without MHV. It was conclude that grafts with MHV in LDLT favor recipient outcomes and do not harm the living donor if a careful preoperative evaluation is performed.
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Affiliation(s)
- Peng-Sheng Yi
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Ming Zhang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Ming-Qing Xu
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
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152
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Simoes P, Kesar V, Ahmad J. Spectrum of biliary complications following live donor liver transplantation. World J Hepatol 2015; 7:1856-1865. [PMID: 26207167 PMCID: PMC4506943 DOI: 10.4254/wjh.v7.i14.1856] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/22/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.
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153
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Diniz MF, Siqueira SL, Baumfeld TS, Pereira LFC, Moreira FG, Ribeiro GM, de Souza IKF. Analysis of liver fragment subjected to autologous transplant at rat's retroperitoneum. J Surg Res 2015; 199:407-11. [PMID: 26169032 DOI: 10.1016/j.jss.2015.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 05/22/2015] [Accepted: 06/11/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND To investigate the regeneration process of autologous implants of liver on the retroperitoneum. METHODS Thirty male Fisher rats were used divided in to group 1 (G1): studied 60 d after surgery; group 2 (G2): studied 90 d after surgery; group 3 (G3): studied 180 d after surgery; and group C (GC): animals without surgery. Hepatic fragment was processed for histologic and biochemical analysis. RESULTS There was inflammatory infiltrate, diffuse hydropic degeneration, necrosis, and moderate fibrosis that reduced in direct relation to the postsurgical time. The concentration of albumin was different between GC and G1 and between G1 and G3 (P = 0.0007). The Catalase (CAT) was related to the time of surgery with GC being different when compared with G1, G2, and G3 (P < 0.0001). The oxidative stress measured through the thiobarbituric acid reactive substances lipid peroxidation was different between the GC and the G2 groups (P = 0.0381). CONCLUSIONS The analysis made showed hepatic regeneration in the fragment subjected to autologous transplant at the retroperitoneum.
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Affiliation(s)
- Mirla Fiuza Diniz
- School of Medicine, Federal University of Ouro Preto (UFOP), Ouro Preto, Brazil
| | - Sávio Lana Siqueira
- School of Medicine, Federal University of Ouro Preto (UFOP), Ouro Preto, Brazil.
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154
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Complications after endoscopic sphincterotomy in liver transplant recipients: A retrospective single-centre study. Arab J Gastroenterol 2015; 16:46-9. [PMID: 26166543 DOI: 10.1016/j.ajg.2015.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 01/11/2015] [Accepted: 04/07/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND STUDY AIMS Biliary tract complications after liver transplantation are usually treated by endoscopic retrograde cholangiopancreatography. When biliary tract intervention is indicated, endoscopic sphincterotomy is often required. However, data regarding complication rates after endoscopic sphincterotomy in liver transplant recipients are limited. This study therefore investigated complication rates during the first 15 days after endoscopic sphincterotomy in liver transplant recipients. PATIENTS AND METHODS This study retrospectively reviewed 157 consecutive liver transplant recipients who underwent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy between January 1998 and August 2013 at the University Hospital of Münster, Germany. Complications that occurred within the first 15 days after the procedure were recorded, and complication rates were compared between patients who underwent conventional and precut endoscopic sphincterotomy. RESULTS A total of 24 complications (15.2%) were recorded, including 9 cases (5.7%) of pancreatitis, 6 cases (3.8%) of bleeding, and 1 case (0.6%) of perforation. There were no procedure-related deaths. There were no significant differences in complication rates between the two sphincterotomy techniques. The rate of post-procedural pancreatitis decreased over time. CONCLUSION Endoscopic sphincterotomy is a safe procedure in liver transplant recipients. The procedure-related complication rate is reasonable and most complications can be managed conservatively.
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155
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Weeder PD, van Rijn R, Porte RJ. Machine perfusion in liver transplantation as a tool to prevent non-anastomotic biliary strictures: Rationale, current evidence and future directions. J Hepatol 2015; 63:265-75. [PMID: 25770660 DOI: 10.1016/j.jhep.2015.03.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/25/2015] [Accepted: 03/02/2015] [Indexed: 02/08/2023]
Abstract
The high incidence of non-anastomotic biliary strictures (NAS) after transplantation of livers from extended criteria donors is currently a major barrier to widespread use of these organs. This review provides an update on the most recent advances in the understanding of the etiology of NAS. These new insights give reason to believe that machine perfusion can reduce the incidence of NAS after transplantation by providing more protective effects on the biliary tree during preservation of the donor liver. An overview is presented regarding the different endpoints that have been used for assessment of biliary injury and function before and after transplantation, emphasizing on methods used during machine perfusion. The wide spectrum of different approaches to machine perfusion is discussed, including the many different combinations of techniques, temperatures and perfusates at varying time points. In addition, the current understanding of the effect of machine perfusion in relation to biliary injury is reviewed. Finally, we explore directions for future research such as the application of (pharmacological) strategies during machine perfusion to further improve preservation. We stress the great potential of machine perfusion to possibly expand the donor pool by reducing the incidence of NAS in extended criteria organs.
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Affiliation(s)
- Pepijn D Weeder
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rianne van Rijn
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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156
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O'Neill S, Roebuck A, Khoo E, Wigmore SJ, Harrison EM. A meta-analysis and meta-regression of outcomes including biliary complications in donation after cardiac death liver transplantation. Transpl Int 2015; 27:1159-74. [PMID: 25052036 DOI: 10.1111/tri.12403] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/05/2014] [Accepted: 07/12/2014] [Indexed: 12/11/2022]
Abstract
Donation after cardiac death (DCD) liver transplantation is increasingly common but concerns exist over the development of biliary complications and ischemic cholangiopathy (IC). This study aimed to compare outcomes between DCD and donation after brain death (DBD) liver grafts. Studies reporting on post-transplantation outcomes after Maastricht category III DCD liver transplantation were screened for inclusion. Odds ratios (OR) with 95% confidence intervals were produced using random-effects models for the incidence of biliary complications, IC, graft and recipient survival. Meta-regression was undertaken to identify between-study predictors of effect size for biliary complications and IC. PROSPERO Record: CRD42012002113. Twenty-five studies with 62 184 liver transplant recipients (DCD = 2478 and DBD = 59 706) were included. In comparison with DBD, there was a significant increase in biliary complications [OR = 2.4 (1.9, 3.1); P < 0.00001] and IC [OR = 10.5 (5.7, 19.5); P < 0.00001] following DCD liver transplantation. In comparison with DBD, at 1 year [OR = 0.7 (0.5, 0.8); P = 0.0002] and 3 years [OR = 0.6 (0.5, 0.8); P = 0.001], there was a significant decrease in graft survival following DCD liver transplantation. At 1 year, there was also a nonsignificant decrease [OR = 0.8 (0.6, 1.0); P = 0.08] and by 3 years a significant decrease [OR = 0.7 (0.5, 1.0); P = 0.04] found in recipient survival following DCD liver transplantation. Eleven factors were entered into meta-regression models, but none explained the variability in effect size between studies. DCD liver transplantation is associated with an increase in biliary complications, IC, graft loss and mortality. Significant unexplained differences in effect size exist between centers.
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Affiliation(s)
- Stephen O'Neill
- MRC Centre for Inflammation Research, Tissue Injury and Repair Group, University of Edinburgh, Edinburgh, UK
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157
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Macías-Gómez C, Dumonceau JM. Endoscopic management of biliary complications after liver transplantation: An evidence-based review. World J Gastrointest Endosc 2015; 7:606-616. [PMID: 26078829 PMCID: PMC4461935 DOI: 10.4253/wjge.v7.i6.606] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/21/2015] [Accepted: 03/18/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary tract diseases are the most common complications following liver transplantation (LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior (except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.
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158
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Yankol Y, Mecit N, Kanmaz T, Cimsit B, Cakaloglu Y, Acarli K, Kalayoglu M. Lessons Learned From Review of a Single Center Experience With 500 Consecutive Liver Transplants in a Region With Insufficient Deceased-Donor Support. EXP CLIN TRANSPLANT 2015; 14:191-200. [PMID: 26030810 DOI: 10.6002/ect.2014.0170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We present here the outcomes of our first 500 liver transplants and discuss the lessons learned during this time. MATERIALS AND METHODS We retrospectively analyzed the first 500 consecutive transplants within the listing criteria of the United Network for Organ Sharing, with recipients and donors with minimum 1-year follow-up. Patient survival and donor complications were analyzed for 31 liver transplant recipients with hepatocellular carcinoma beyond the Milan criteria who had transplant performed during the same time. RESULTS Between August 2006 and March 2013, there were 519 liver transplants performed in 500 patients (365 adult, 135 pediatric). There were 394 living-donor and 125 deceased-donor liver transplants. In addition, 31 adult liver transplants were performed in patients with hepatocellular carcinoma beyond Milan criteria (22 living-donor and 9 deceased-donor transplants). The main cause of chronic liver failure was biliary atresia in pediatric patients (30.4%) and chronic hepatitis B infection in adults (35.6%). The complication rate for primary nonfunction was 3.8%, overall biliary complications 24.0% (significantly higher after adult living-donor liver transplant, 30.3%), hepatic artery thrombosis 1.6%, portal vein thrombosis 3.0%, retransplant 3.8%, acute cellular rejection 29.6%, and bacterial infection 39.4%. Overall 1-, 3-, and 5-year patient survival rates in the first 500 consecutive transplants performed on recipients within United Network for Organ Sharing listing criteria were 87.8%, 85.0%, and 78.6%; for hepatocellular carcinoma patients beyond the Milan criteria, survival rates were 71.9%, 52.5%, and 38.2%. CONCLUSIONS In regions without a sufficient number of deceased donors, living-donor liver transplant, with its associated problems, is the only alternative to deceased-donor liver transplant. Liver transplant requires teamwork, with all players working well together for a successful outcome. The important keys to success in liver transplant include decision-making, timing, surgical skills, experience, and close follow-up.
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Affiliation(s)
- Yucel Yankol
- From the Organ Transplantation Center, Memorial Sisli Hospital, Istanbul, Turkey
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159
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Karimian N, Matton APM, Westerkamp AC, Burlage LC, Op den Dries S, Leuvenink HGD, Lisman T, Uygun K, Markmann JF, Porte RJ. Ex Situ Normothermic Machine Perfusion of Donor Livers. J Vis Exp 2015:e52688. [PMID: 26067131 DOI: 10.3791/52688] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In contrast to conventional static cold preservation (0-4 °C), ex situ machine perfusion may provide better preservation of donor livers. Continuous perfusion of organs provides the opportunity to improve organ quality and allows ex situ viability assessment of donor livers prior to transplantation. This video article provides a step by step protocol for ex situ normothermic machine perfusion (37 °C) of human donor livers using a device that provides a pressure and temperature controlled pulsatile perfusion of the hepatic artery and continuous perfusion of the portal vein. The perfusion fluid is oxygenated by two hollow fiber membrane oxygenators and the temperature can be regulated between 10 °C and 37 °C. During perfusion, the metabolic activity of the liver as well as the degree of injury can be assessed by biochemical analysis of samples taken from the perfusion fluid. Machine perfusion is a very promising tool to increase the number of livers that are suitable for transplantation.
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Affiliation(s)
- Negin Karimian
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Alix P M Matton
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Andrie C Westerkamp
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Laura C Burlage
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Sanna Op den Dries
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Henri G D Leuvenink
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Ton Lisman
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Korkut Uygun
- Center of Engineering in Medicine/Surgical Services, Massachusetts General Hospital, Harvard Medical School, and Shriners Burns Hospital
| | - James F Markmann
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Robert J Porte
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen;
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160
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Girotra M, Soota K, Klair JS, Dang SM, Aduli F. Endoscopic management of post-liver transplant biliary complications. World J Gastrointest Endosc 2015; 7:446-459. [PMID: 25992185 PMCID: PMC4436914 DOI: 10.4253/wjge.v7.i5.446] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/15/2014] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.
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161
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Donation After Cardiac Death Liver Transplantation in Primary Sclerosing Cholangitis. Transplantation 2015; 99:973-8. [DOI: 10.1097/tp.0000000000000447] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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162
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Bruinsma BG, Avruch JH, Weeder PD, Sridharan GV, Uygun BE, Karimian NG, Porte RJ, Markmann JF, Yeh H, Uygun K. Functional human liver preservation and recovery by means of subnormothermic machine perfusion. J Vis Exp 2015:52777. [PMID: 25938299 PMCID: PMC4420550 DOI: 10.3791/52777] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
There is currently a severe shortage of liver grafts available for transplantation. Novel organ preservation techniques are needed to expand the pool of donor livers. Machine perfusion of donor liver grafts is an alternative to traditional cold storage of livers and holds much promise as a modality to expand the donor organ pool. We have recently described the potential benefit of subnormothermic machine perfusion of human livers. Machine perfused livers showed improving function and restoration of tissue ATP levels. Additionally, machine perfusion of liver grafts at subnormothermic temperatures allows for objective assessment of the functionality and suitability of a liver for transplantation. In these ways a great many livers that were previously discarded due to their suboptimal quality can be rescued via the restorative effects of machine perfusion and utilized for transplantation. Here we describe this technique of subnormothermic machine perfusion in detail. Human liver grafts allocated for research are perfused via the hepatic artery and portal vein with an acellular oxygenated perfusate at 21 °C.
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Affiliation(s)
- Bote G Bruinsma
- Center for Engineering in Medicine, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - James H Avruch
- Transplant Center, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Pepijn D Weeder
- Center for Engineering in Medicine, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Gautham V Sridharan
- Center for Engineering in Medicine, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Basak E Uygun
- Center for Engineering in Medicine, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Negin G Karimian
- Center for Engineering in Medicine, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen
| | - James F Markmann
- Transplant Center, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Heidi Yeh
- Transplant Center, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School;
| | - Korkut Uygun
- Center for Engineering in Medicine, Dept. of Surgery, Massachusetts General Hospital, Harvard Medical School;
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163
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Zhou CG, Wei BJ, Gao K, Dai DK, Zhai RY. Successful treatment of complex cholangiolithiasis following orthotopic liver transplantation with interventional radiology. World J Gastroenterol 2015; 21:2000-2004. [PMID: 25684970 PMCID: PMC4323481 DOI: 10.3748/wjg.v21.i6.2000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/28/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
Bile duct stones are a serious and the third most common complication of the biliary system that can occur following liver transplantation. The incidence rate of bile duct stones after liver transplantation is 1.8%-18%. The management of biliary stones is usually performed with endoscopic techniques; however, the technique may prove to be challenging in the treatment of the intrahepatic bile duct stones. We herein report a case of a 40-year-old man with rare, complex bile duct stones that were successfully eliminated with percutaneous interventional techniques. The complex bile duct stones were defined as a large number of bile stones filling the intra- and extrahepatic bile tracts, resulting in a cast formation within the biliary tree. Common complications such as hemobilia and acute pancreatitis were not present during the perioperative period. The follow-up period was 20 mo long. During the postoperative period, the patient maintained normal temperature, and normal total bilirubin and direct bilirubin levels. The patient is now living a high quality life. This case report highlights the safety and efficacy of the percutaneous interventional approach in the removal of complex bile duct stones following liver transplantation.
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164
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Dai J, Wu XF, Yang C, Li HJ, Chen YL, Liu GZ, Song YZ, Wu HH, Ding JL, Li N. Study of relationship between the blood supply of the extrahepatic bile duct and duct supply branches from gastroduodenal artery on imaging and anatomy. Chin Med J (Engl) 2015; 128:322-6. [PMID: 25635427 PMCID: PMC4837862 DOI: 10.4103/0366-6999.150097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Liver transplantation has become the treatment of choice for patients with end-stage acute or chronic hepatic disease. Bile duct complications are common events after liver transplantation. The aim of this study was to evaluate the blood supply of the human bile duct and identify the underlying mechanisms of bile duct complications after liver transplantation. Methods: The duct supply branches from gastroduodenal artery and blood supply of extrahepatic bile duct system were re-evaluated through selective hepatic angiography from 600 patients. In addition, 33 cadavers were injected with latex casting material into the common hepatic artery, then the extrahepatic bile duct and the branches from the common hepatic artery were carefully dissected to visualize the gastroduodenal artery and its branching to the extrahepatic bile duct. Results: The bile duct artery arose from the branch of the gastroduodenal artery in 8.1% (49/600). Of these 49 individuals, the bile duct artery was supplied by the gastroduodenal artery (61.22%, 30/49), the proper hepatic artery (14.29%, 7/49), or both the gastroduodenal artery and the proper hepatic artery (24.49%, 12/49). In our study of 33 cadavers, the percentage that the bile duct artery arose from the gastroduodenal artery was 27.27%. The blood supply to the bile extrahepatic bile ducts was divided into different segments and formed longitudinal and arterial network anastomosed on the walls of the duct. Conclusions: There is a close relationship between the duct supply branches from gastroduodenal artery and the blood supplying patterns of the extrahepatic bile duct system. In liver transplant surgery, the initial part of the gastroduodenal artery is preferred to be preserved in the donor liver. It is of great significance to improve the success rate of operation and reduce complications.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ning Li
- Department of Radiology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
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165
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Predictors of endoscopic treatment outcome in the management of biliary complications after orthotopic liver transplantation. Eur J Gastroenterol Hepatol 2015; 27:150-4. [PMID: 25486026 DOI: 10.1097/meg.0000000000000251] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS The most common complications after liver transplantation nowadays affect the biliary tract.We carried out a retrospective study to identify predictors of endoscopic treatment outcome in the management of post-transplantation biliary complications. METHODS Data from all patients with post-transplantation biliary complications subjected to endoscopic treatment at the University of Udine between 2000 and 2012 were extracted. To identify predictors of endoscopic treatment outcome, a logistic regression analysis was carried out. Cox modeling was used to identify factors associated with mortality. RESULTS We identified 142 patients who developed biliary complications: 83 of these patients had a successful endoscopic therapy, whereas 45 had a failure. Fourteen patients, who developed nonanastomotic biliary stricture, were excluded from the analysis. Patients with biliary complications who had pretransplant Model for End-Stage Liver Disease score more than 10 [odds ratio (OR) 3.88; 95% confidence interval (CI) 1.16-12.95; P = 0.03] and stent retention time more than 12 months (OR 6.45; 95% CI 2.14-19.42; P < 0.01) were less likely to respond to endoscopic therapy. In contrast, both dilatation and stenting procedures (OR 0.10; 95% CI 0.03-0.30; P < 0.01) and 10 Fr diameter stent placement (OR 0.21; 95% CI 0.07-0.70; P = 0.01) predicted favorable endoscopic treatment outcome. Time to the occurrence of biliary complications of more than 3 months [hazard ratio (HR) 0.24; 95% CI 0.10-0.56] and placement of five or more stents (HR 0.31; 95% CI 0.12-0.79) were found to be protective against mortality, whereas hepatic artery thrombosis was a significant risk factor for mortality (HR 13.88; 95% CI 4.08-47.25). CONCLUSION We found endoscopic treatment to be less effective in patients with pretransplant Model for End-Stage Liver Disease score more than 10 and stent retention time more than 12, whereas dilatation and stenting procedure and 10 Fr diameter stent placement predicted a favorable outcome.
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Li J, Liu B, Yan LN, Lau WY. The roles and potential therapeutic implications of CXCL4 and its variant CXCL4L1 in the pathogenesis of chronic liver allograft dysfunction. Cytokine Growth Factor Rev 2015; 26:67-74. [DOI: 10.1016/j.cytogfr.2014.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 11/05/2014] [Indexed: 12/20/2022]
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National assessment of early biliary complications after liver transplantation: economic implications. Transplantation 2015; 98:1226-35. [PMID: 25119126 DOI: 10.1097/tp.0000000000000197] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite improvement in surgical technique and medical management of liver transplant recipients, biliary complications remain a frequent cause of posttransplant morbidity and graft loss. Biliary complications require potentially expensive interventions including radiologic procedures and surgical revisions. METHODS A national data set linking transplant registry and Medicare claims data for 12,803 liver transplant recipients was developed to capture information on complications, treatments, and associated direct medical costs up to 3 years after transplantation. RESULTS Biliary complications were more common in recipients of donation after cardiac death compared to donation after brain death allografts (23% vs. 19% P<0.001). Among donation after brain death recipients, biliary complications were associated with $54,699 (95% confidence interval [CI], $49,102 to $60,295) of incremental spending in the first year after transplantation and $7,327 in years 2 and 3 (95% CI, $4,419-$10,236). Biliary complications in donation after cardiac death recipients independently increased spending by $94,093 (95% CI, $64,643-$124,542) in the first year and $12,012 (95% CI, $-1,991 to $26,016) in years 2 and 3. CONCLUSION This national study of biliary complications demonstrates the significant economic impact of this common perioperative complication and suggests a potential target for quality of care improvements.
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Singla S, Piraka C. Endoscopic retrograde cholangiopancreatography. Clin Liver Dis (Hoboken) 2015; 4:133-137. [PMID: 30992940 PMCID: PMC6448759 DOI: 10.1002/cld.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sumit Singla
- Division of GastroenterologyHenry Ford Health SystemDetroitMI
| | - Cyrus Piraka
- Section of Advanced Therapeutic Endoscopy, Division of GastroenterologyHenry Ford Health SystemDetroitMI
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Halldorson JB, Bakthavatsalam R, Montenovo M, Dick A, Rayhill S, Perkins J, Reyes J. Differential rates of ischemic cholangiopathy and graft survival associated with induction therapy in DCD liver transplantation. Am J Transplant 2015; 15:251-8. [PMID: 25534449 DOI: 10.1111/ajt.12962] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 07/09/2014] [Accepted: 08/04/2014] [Indexed: 01/25/2023]
Abstract
Transplantation utilizing donation after circulatory death (DCD) donors is associated with ischemic cholangiopathy (IC) and graft loss. The University of Washington (UW) DCD experience totals 89 DCD liver transplants performed between 2003 and 2011. Overall outcome after DCD liver transplantation at UW demonstrates Kaplan-Meier estimated 5-year patient and graft survival rates of 81.6% and 75.6%, respectively, with the great majority of patient and graft losses occurring in the first-year posttransplant from IC. Our program has almost exclusively utilized either anti-thymocyte globulin (ATG) or basiliximab induction (86/89) for DCD liver transplantations. Analysis of the differential effect of induction agent on graft survival demonstrated graft survival of 96.9% at 1 year for ATG versus 75.9% for basiliximab (p = 0.013). The improved survival did not appear to be from a lower rate of rejection (21.9% vs. 22.2%) but rather a differential rate of IC, 35.2% for basiliximab versus 12.5% for ATG (p = 0.011). Multivariable analysis demonstrated induction agent to be independently associated with graft survival and IC free graft survival when analyzed against variables including donor age, fWIT, donor cold ischemia time and transplant era.
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Affiliation(s)
- J B Halldorson
- Division of Transplantation, University of California, San Diego, CA
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172
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Axelrod DA, Dzebisashvili N, Lentine KL, Xiao H, Schnitzler M, Tuttle-Newhall JE, Segev DL. Variation in biliary complication rates following liver transplantation: implications for cost and outcome. Am J Transplant 2015; 15:170-9. [PMID: 25534447 DOI: 10.1111/ajt.12970] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/09/2014] [Accepted: 07/19/2014] [Indexed: 01/25/2023]
Abstract
Although biliary complications (BCs) have a significant impact on the outcome of liver transplantation (LT), variation in BC rates among transplant centers has not been previously analyzed. BC rate, LT outcome and spending were assessed using linked Scientific Registry of Transplant Recipients and Medicare claims (n = 16,286 LTs). Transplant centers were assigned to BC quartiles based upon risk-adjusted observed to expected (O:E) ratio of BC separately for donation after brain death (DBD) and donation after cardiac death (DCD) donors. The median incidence of BC was 300% greater in the highest versus lowest DBD quartiles (19.0% vs. 5.9%) and varied 250% between DCD quartiles (20.3%-8.4%). Donor and recipient characteristics suggest that high BC centers actually used lower donor risk index organs, fewer split livers and fewer imports (p < 0.001 for all). Transplant at a center in the highest O:E quartile was associated with increased posttransplant mortality (adjusted hazard ratio [aHR] 2.53, p = 0.007) in DCD transplant and increased graft loss (aHR 1.21, p = 0.02) in DBD transplant. Medicare spending was $22,895 (p < 0.0001) higher at centers in highest versus lowest BC quartile. In summary, BC rates vary widely among transplant centers and higher rates are a marker for an increased risk of death, graft failure and health-care spending.
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Affiliation(s)
- D A Axelrod
- Section of Transplant Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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EXP CLIN TRANSPLANTExp Clin Transplant 2014; 12. [DOI: 10.6002/ect.2014.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liu Y, Wang J, Yang P, Lu H, Lu L, Wang J, Li H, Duan Y, Wang J, Li Y. Delayed rearterialization unlikely leads to nonanastomotic stricture but causes temporary injury on bile duct after liver transplantation. Transpl Int 2014; 28:341-51. [PMID: 25406364 PMCID: PMC4383644 DOI: 10.1111/tri.12490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 10/17/2014] [Accepted: 11/16/2014] [Indexed: 01/16/2023]
Abstract
Nonanastomotic strictures (NAS) are common biliary complications after liver transplantation (LT). Delayed rearterialization induces biliary injury in several hours. However, whether this injury can be prolonged remains unknown. The correlation of this injury with NAS occurrence remains obscure. Different delayed rearterialization times were compared using a porcine LT model. Morphological and functional changes in bile canaliculus were evaluated by transmission electron microscopy and real-time PCR. Immunohistochemistry and TUNEL were performed to validate intrahepatic bile duct injury. Three months after LT was performed, biliary duct stricture was determined by cholangiography; the tissue of common bile duct was detected by real-time PCR. Bile canaliculi were impaired in early postoperative stage and then exacerbated as delayed rearterialization time was prolonged. Nevertheless, damaged bile canaliculi could fully recover in subsequent months. TNF-α and TGF-β expressions and apoptosis cell ratio increased in the intrahepatic bile duct only during early postoperative period in a time-dependent manner. No abnormality was observed by cholangiography and common bile duct examination after 3 months. Delayed rearterialization caused temporary injury to bile canaliculi and intrahepatic bile duct in a time-dependent manner. Injury could be fully treated in succeeding months. Solo delayed rearterialization cannot induce NAS after LT.
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Affiliation(s)
- Yang Liu
- Department of General Surgery, Second Affiliated Hospital, Xi'an Jiaotong University School of Medicine, Xi'an, China
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Knaak JM, Spetzler VN, Goldaracena N, Boehnert MU, Bazerbachi F, Louis KS, Adeyi OA, Minkovich L, Yip PM, Keshavjee S, Levy GA, Grant DR, Selzner N, Selzner M. Subnormothermic ex vivo liver perfusion reduces endothelial cell and bile duct injury after donation after cardiac death pig liver transplantation. Liver Transpl 2014; 20:1296-305. [PMID: 25179693 DOI: 10.1002/lt.23986] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 07/18/2014] [Accepted: 08/11/2014] [Indexed: 12/18/2022]
Abstract
An ischemic-type biliary stricture (ITBS) is a common feature after liver transplantation using donation after cardiac death (DCD) grafts. We compared sequential subnormothermic ex vivo liver perfusion (SNEVLP; 33°C) with cold storage (CS) for the prevention of ITBS in DCD liver grafts in pig liver transplantation (n = 5 for each group). Liver grafts were stored for 10 hours at 4°C (CS) or preserved with combined 7-hour CS and 3-hour SNEVLP. Parameters of hepatocyte [aspartate aminotransferase (AST), international normalized ratio (INR), factor V, and caspase 3 immunohistochemistry], endothelial cell (EC; CD31 immunohistochemistry and hyaluronic acid), and biliary injury and function [alkaline phosphatase (ALP), total bilirubin, and bile lactate dehydrogenase (LDH)] were determined. Long-term survival (7 days) after transplantation was similar between the SNEVLP and CS groups (60% versus 40%, P = 0.13). No difference was observed between SNEVLP- and CS-treated animals with respect to the peak of serum INR, factor V, or AST levels within 24 hours. CD31 staining 8 hours after transplantation demonstrated intact EC lining in SNEVLP-treated livers (7.3 × 10(-4) ± 2.6 × 10(-4) cells/μm(2)) but not in CS-treated livers (3.7 × 10(-4) ± 1.3 × 10(-4) cells/μm(2) , P = 0.03). Posttransplant SNEVLP animals had decreased serum ALP and serum bilirubin levels in comparison with CS animals. In addition, LDH in bile fluid was lower in SNEVLP pigs versus CS pigs (14 ± 10 versus 60 ± 18 μmol/L, P = 0.02). Bile duct histology revealed severe bile duct necrosis in 3 of 5 animals in the CS group but none in the SNEVLP group (P = 0.03). Sequential SNEVLP preservation of DCD grafts reduces bile duct and EC injury after liver transplantation.
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Affiliation(s)
- Jan M Knaak
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada
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176
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Parra DA, Fecteau A, Connolly BL. Placement of an internal-external biliary drain through a bilio-enteric fistula in a neonate to re-establish antegrade bile flow after liver transplantation. Pediatr Transplant 2014; 18:E236-9. [PMID: 25135526 DOI: 10.1111/petr.12336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2014] [Indexed: 10/24/2022]
Abstract
Three-month-old baby girl with history of post-liver transplant hepatic artery dissection treated with ligation after take down of the biliary anastomosis and placement of a surgical external common bile duct drain. There was persistent malfunction of this drain. A bilio-enteric fistula was noted during the later placement of an image guided percutaneous external drain. Subsequently, an internal-external biliary drain was successfully placed through this fistula. An excellent clinical and functional result was achieved.
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Affiliation(s)
- Dimitri A Parra
- Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
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177
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Toniutto P, Bitetto D, Falleti E, Vadalà S, Cmet S, Cussigh A, Bulajic M, Zilli M, Fabris C. Biliary strictures after liver transplantation: role of interleukin 28B genotypes in cyclosporine treated. Int J Surg 2014; 12:1082-7. [PMID: 25219480 DOI: 10.1016/j.ijsu.2014.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/03/2014] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The role of Interleukin 28B (IL-28B) genetic polymorphisms in influencing the occurrence of biliary complications after liver transplantation has never been evaluated. This study aimed to investigate whether IL-28B rs12979860C/T polymorphisms associate with the occurrence of biliary complications after liver transplantation and if these complications may influence survival. METHODS One hundred seventy one recipients (133 males) who underwent liver transplantation were recruited. To confirm the mechanical etiology of cholestasis, endoscopic cholangio pancreatography, percutaneous and/or trans-Kehr cholangiography or cholangio magnetic resonance were performed. Two main clinical pictures were identified: biliary strictures and biliary leakage. Immunosuppressive therapy was based on cyclosporine (N = 54) or tacrolimus (N = 117), in association with steroids during the first month after operation. IL-28B rs12979860C/T genotypes were detected by means of polymerase chain reaction. RESULTS Forty patients (23.4%) presented anastomotic strictures, 7 (4.1%) non-anastomotic strictures, 10 (5.8%) leakage, 8 (4.7%) leakage plus anastomotic strictures. IL-28B rs12979860C/C genotype in association with cyclosporin was found to be an independent predictor of anastomotic strictures occurrence (p = 0.008). A significant difference in 5 years survival was observed between patients with viral etiology of liver disease experiencing either anastomotic or non-anastomotic strictures (16/23) and the remaining patients (104/112, p = 0.001). CONCLUSIONS In recipients carrying rs12979860 IL-28B C/C genotype the use of cyclosporine seems to contribute to enhance the probability of developing biliary complications which in hepatitis B and C positives appear to reduce patient survival. If confirmed in larger studies the use of cyclosporine in these patients could be revised.
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Affiliation(s)
- Pierluigi Toniutto
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplantation Section, Internal Medicine, University of Udine, Udine, Italy.
| | - Davide Bitetto
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplantation Section, Internal Medicine, University of Udine, Udine, Italy
| | - Edmondo Falleti
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplantation Section, Internal Medicine, University of Udine, Udine, Italy
| | - Salvatore Vadalà
- Department of Surgery, Gastroenterology Unit, Azienda Ospedaliero-Universitaria, Udine, Italy
| | - Sara Cmet
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplantation Section, Internal Medicine, University of Udine, Udine, Italy
| | - Annarosa Cussigh
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplantation Section, Internal Medicine, University of Udine, Udine, Italy
| | - Milutin Bulajic
- Department of Surgery, Gastroenterology Unit, Azienda Ospedaliero-Universitaria, Udine, Italy
| | - Maurizio Zilli
- Department of Surgery, Gastroenterology Unit, Azienda Ospedaliero-Universitaria, Udine, Italy
| | - Carlo Fabris
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplantation Section, Internal Medicine, University of Udine, Udine, Italy
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Cervera C, van Delden C, Gavaldà J, Welte T, Akova M, Carratalà J. Multidrug-resistant bacteria in solid organ transplant recipients. Clin Microbiol Infect 2014; 20 Suppl 7:49-73. [DOI: 10.1111/1469-0691.12687] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 05/16/2014] [Accepted: 05/18/2014] [Indexed: 12/23/2022]
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Endoscopic ultrasound: valuable tool for diagnosis of biliary complications in liver transplant recipients? Surg Endosc 2014; 29:1433-8. [PMID: 25159653 DOI: 10.1007/s00464-014-3820-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 08/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary complications after liver transplantation (LT) are still common and are an important cause of mortality and morbidity. Until now, endoscopic retrograde cholangiopancreatography (ERCP) has been considered the gold standard for diagnosing such complications. The aim of this study was to evaluate the diagnostic yield and therapeutic impact of endoscopic ultrasound (EUS) in the management of biliary complications after LT. METHODS Thirty-seven liver transplant patients who presented with clinical, biochemical, sonographic, and/or histological evidence of biliary complications, and who first received EUS followed by ERCP, were enrolled into this prospective observational study. Subsequently, we evaluated the value of EUS in detecting and classifying biliary complications after LT. RESULTS Thirty-seven biliary complications were detected in 32 patients. Endoscopic ultrasound showed an overall sensitivity and accuracy of 94.6 % each. In cases of biliary cast and ischemic cholangiopathy, EUS was found to be diagnostically superior to ERCP and has had, in these cases, a significant impact on clinical decision-making. However, EUS was less reliable when diagnosing anastomotic strictures. CONCLUSION EUS can complement ERCP to improve diagnosis of biliary complications after LT and help guide treatment strategies to address these complications.
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Feier FH, Chapchap P, Pugliese R, da Fonseca EA, Carnevale FC, Moreira AM, Zurstrassen C, Santos AC, Miura IK, Baggio V, Porta A, Guimarães T, Cândido H, Benavides M, Godoy A, Leite KMR, Porta G, Kondo M, Seda-Neto J. Diagnosis and management of biliary complications in pediatric living donor liver transplant recipients. Liver Transpl 2014; 20:882-92. [PMID: 24760734 DOI: 10.1002/lt.23896] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/01/2014] [Indexed: 12/17/2022]
Abstract
The incidence of biliary complications (BCs) after living donor liver transplantation (LDLT) can reach 40%. Published data on the pediatric population are limited, and treatment protocols vary. Our aim was to describe the clinical scenario for BCs and treatment approaches after LDLT. Between October 1995 and December 2012, 489 pediatric LDLT procedures were performed. BCs developed in 71 patients (14.5%). Biliary strictures (BSs) developed in 45 (9.2%) patients, and bile leaks (BLs) developed in 33 patients (6.7%). The BL diagnosis was clinical in all cases, and 69.7% of the patients underwent surgery. Nearly half of the BS cases had clinical features or suggestive ultrasound findings. Liver biopsy findings suggested BSs in 51.7%. Percutaneous transhepatic cholangiography was performed in 95.6% of the BS patients. The success rate was 77% [mean number of percutaneous biliary interventions (PBIs) = 3.9 ± 1.98, median drainage time = 8 months]. In conclusion, BL patients can be managed with conservative therapy, even though most of these patients will ultimately be treated with surgery. Diagnosing a BS requires a high degree of clinical suspicion because the available resources for its identification can fail in up to 50% of cases. A higher number of PBIs and the use of a drainage catheter for a longer time may be required to achieve better results with this technique.
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Affiliation(s)
- Flávia H Feier
- Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, Brazil; Hepatology and Liver Transplantation, Sírio Libanês Hospital, São Paulo, Brazil
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Girometti R, Cereser L, Bazzocchi M, Zuiani C. Magnetic resonance cholangiography in the assessment and management of biliary complications after OLT. World J Radiol 2014; 6:424-436. [PMID: 25071883 PMCID: PMC4109094 DOI: 10.4329/wjr.v6.i7.424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/05/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Despite advances in patient and graft management, biliary complications (BC) still represent a challenge both in the early and delayed period after orthotopic liver transplantation (OLT). Because of unspecific clinical presentation, imaging is often mandatory in order to diagnose BC. Among imaging modalities, magnetic resonance cholangiography (MRC) has gained widespread acceptance as a tool to represent the reconstructed biliary tree noninvasively, using both the conventional technique (based on heavily T2-weighted sequences) and contrast-enhanced MRC (based on the acquisition of T1-weighted sequences after the administration of hepatobiliary contrast agents). On this basis, MRC is generally indicated to: (1) avoid unnecessary procedures of direct cholangiography in patients with a negative examination and/or identify alternative complications; and (2) provide a road map for interventional procedures or surgery. As illustrated in the review, MRC is accurate in the diagnosis of different types of biliary complications, including anastomotic strictures, non-anastomotic strictures, leakage and stones.
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Safety and yield of diagnostic ERCP in liver transplant patients with abnormal liver function tests. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2014; 2014:314927. [PMID: 25110455 PMCID: PMC4119651 DOI: 10.1155/2014/314927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 06/19/2014] [Indexed: 12/16/2022]
Abstract
Background. Abnormal liver enzymes postorthotopic liver transplant (OLT) may indicate significant biliary pathology or organ rejection. There is very little known in the literature regarding the current role of diagnostic ERCP in this scenario. Aim. To review the utility of diagnostic ERCP in patients presenting with abnormal liver function tests in the setting of OLT. Methods. A retrospective review of diagnostic ERCPs in patients with OLT from 2002 to 2013 from a prospectively maintained, IRB approved database. Results. Of the 474 ERCPs performed in OLT patients, 210 (44.3%; 95% CI 39.8–48.8) were performed for abnormal liver function tests during the study period. Majority of patients were Caucasian (83.8%), male (62.4%) with median age of 55 years (IQR 48–62 years). Biliary cannulation was successful in 99.6% of cases and findings included stricture in 45 (21.4 %); biliary stones/sludge in 23 (11%); biliary dilation alone in 31 (14.8%); and normal in 91 (43.3%). Three (1.4%) patients developed mild, self-limiting pancreatitis; one patient (0.5%) developed cholangitis and two (1%) had postsphincterotomy bleeding. Multivariate analyses showed significant association between dilated ducts on imaging with a therapeutic outcome. Conclusion. Diagnostic ERCP in OLT patients presenting with liver function test abnormalities is safe and frequently therapeutic.
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Abstract
PURPOSE OF REVIEW The purpose of this study is to provide an overview of bacterial biliary tract infections in liver transplant recipients with a focus on pathogenesis and conservative treatment strategies. RECENT FINDINGS The development of interventional endoscopic and radiologic interventions has improved the outcome of conservative treatments for bile tract strictures and bilomas. However, recent data show an important rise of infections with multidrug-resistant (MDR) pathogens in liver transplant recipients. SUMMARY Both recurrent cholangitis and infected bilomas are bacterial biliary tract infections in liver transplant recipients responsible for significant morbidity and graft loss, which require a multidisciplinary approach. Risk factors for biliary tract strictures and bilomas formation have recently been identified. With the improved outcome of a conservative management including prolonged and/or recurrent antibiotic treatments, the risk of selecting resistant pathogens is increased. There is an urgent need to develop new strategies to reduce the risk of secondary infections by MDR isolates in liver transplant recipients.
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Abstract
PURPOSE OF REVIEW The incidence, pathogenesis and management of the most common biliary complications are summarized, with an emphasis on nonanastomotic biliary strictures (NAS) and potential strategies to prevent NAS after liver transplantation. RECENT FINDINGS NAS have variable presentations in time and localization, suggesting various underlying pathogeneses. Early-onset NAS (presentation within 1 year) have shown to be largely related to ischemia-induced bile duct injury, whereas late-onset NAS [>1 year after orthotopic liver transplantation (OLT)] have more immune-mediated causes. Cytotoxic hydrophobic bile salts and impaired biliary HCO3 secretion may also play a role in the occurrence of NAS. Recently, insufficient biliary epithelial regeneration capacity after transplantation has also been suggested to play a major role in the pathogenesis of NAS. A potential strategy to prevent NAS has been proposed to be preservation by machine perfusion instead of classical static cold storage. Although machine perfusion has been shown to be a better preservation method for the liver parenchyma, efficacy in preventing ischemic injury of the biliary epithelium is largely unknown. SUMMARY The potential advantages of machine perfusion are very promising as it may provide better protection of the vulnerable bile ducts against ischemia-reperfusion injury. Clinical trials will be needed to demonstrate the impact of machine perfusion in reducing the incidence of biliary complications, especially NAS, after OLT.
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185
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Lu D, Xu X, Zheng S. Reply to: "the influence of contemporaneous revascularization on biliary complications after liver transplantation". Surgery 2014; 156:739-40. [PMID: 24947648 DOI: 10.1016/j.surg.2014.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/17/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Di Lu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China.
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Carter T, Bodzin AS, Hirose H, West S, Hasz R, Maley WR, Cavarocchi NC. Outcome of organs procured from donors on extracorporeal membrane oxygenation support: an analysis of kidney and liver allograft data. Clin Transplant 2014; 28:816-20. [PMID: 24805948 DOI: 10.1111/ctr.12384] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation has become rescue therapy for adults with overwhelming cardiac and/or respiratory failure. Not all patients are saved, creating a new cohort of potential organ donors. This study examines the outcomes of liver and kidney allografts procured from donors on extracorporeal membrane oxygenation (ECMO). METHODS A retrospective review was conducted through the local organ procurement organization. Donors on ECMO prior to notification were classified into donation after brain death (DBD) and donation after cardiac death (DCD). We compared short-term outcome data against published standards. RESULTS Between 1995 and 2012, 97 organs were procured from 41 donors supported on ECMO. There were 68 kidneys donated, 51 were transplanted and 17 discarded. Excluding extended criteria donors, 29 DBD and 13 DCD kidneys were transplanted from donors supported on ECMO. Delayed graft function occurred in 34% of DBD kidneys and 38% of DCD kidneys. Kidney allograft survival at one yr was 93%. Twenty-four livers were procured, nine discarded, and 15 transplanted. Ninety-three percent of liver transplant recipients were alive with graft function at one yr. CONCLUSIONS Donation after brain death kidneys procured from donors on ECMO perform similarly to non-ECMO organs with regard to delayed graft function (DGF), one-yr graft survival and function. Livers from ECMO donors have a higher discard rate than non-ECMO donors, but function similarly at six months and one yr.
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Affiliation(s)
| | - Adam S Bodzin
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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187
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Lankisch TO, Voigtländer T, Manns MP, Holzmann A, Dangwal S, Thum T. MicroRNAs in the bile of patients with biliary strictures after liver transplantation. Liver Transpl 2014; 20:673-8. [PMID: 24648209 DOI: 10.1002/lt.23872] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 02/17/2014] [Indexed: 12/14/2022]
Abstract
Biliary complications after liver transplantation remain a major cause of morbidity and reduced graft survival. Ischemic-type biliary lesions (ITBLs) are common and difficult to treat. The pathophysiology of ITBLs remains unclear, and diagnostic markers are still missing. The analysis of microRNA (miRNA) profiles is an evolving field in hepatology. Our aim was to identify specific miRNA patterns in the bile of patients with ITBLs after liver transplantation. Liver transplant patients with biliary complications were included in a cross-sectional study. Patients with ITBLs (n = 37), anastomotic strictures (ASs; n = 39), and bile duct stones (BDSs; n = 12) were compared. Patients with ITBLs were categorized by disease severity. The miRNA concentrations in bile were determined with global miRNA profiling and subsequent miRNA-specific polymerase chain reaction-mediated validation. The concentrations of microRNA 517a (miR-517a), miR-892a, and miR-106a* in bile were increased for patients with ITBLs versus patients with ASs or BDSs (P < 0.05). Categorization by ITBL severity showed higher median concentrations in patients with intrahepatic and extrahepatic strictures (P > 0.05). miR-210, miR-337-5p, miR-577, and miR-329 displayed no statistical differences. In conclusion, miR-517a, miR-892a, and miR-106a* are increased in the bile fluid of patients with ITBLs versus patients with ASs or BDSs. An analysis of miRNA profiles may be useful in the diagnosis and management of patients with ITBLs. Future studies are needed to prove the potential prognostic value of these miRNAs.
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Affiliation(s)
- Tim O Lankisch
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany; Integrated Research and Treatment Center-Transplantation, Hannover Medical School, Hannover, Germany
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188
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Mourad MM, Algarni A, Liossis C, Bramhall SR. Aetiology and risk factors of ischaemic cholangiopathy after liver transplantation. World J Gastroenterol 2014; 20:6159-6169. [PMID: 24876737 PMCID: PMC4033454 DOI: 10.3748/wjg.v20.i20.6159] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/26/2014] [Accepted: 03/19/2014] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is the best treatment for end-stage hepatic failure, with an excellent survival rates over the last decade. Biliary complications after LT pose a major challenge especially with the increasing number of procured organs after circulatory death. Ischaemic cholangiopathy (IC) is a set of disorders characterized by multiple diffuse strictures affecting the graft biliary system in the absence of hepatic artery thrombosis or stenosis. It commonly presents with cholestasis and cholangitis resulting in higher readmission rates, longer length of stay, repeated therapeutic interventions, and eventually re-transplantation with consequent effects on the patient’s quality of life and increased health care costs. The pathogenesis of IC is unclear and exhibits a higher prevalence with prolonged ischaemia time, donation after circulatory death (DCD), rejection, and cytomegalovirus infection. The majority of IC occurs within 12 mo after LT. Prolonged warm ischaemic times predispose to a profound injury with a subsequently higher prevalence of IC. Biliary complications and IC rates are between 16% and 29% in DCD grafts compared to between 3% and 17% in donation after brain death (DBD) grafts. The majority of ischaemic biliary lesions occur within 30 d in DCD compared to 90 d in DBD grafts following transplantation. However, there are many other risk factors for IC that should be considered. The benefits of DCD in expanding the donor pool are hindered by the higher incidence of IC with increased rates of re-transplantation. Careful donor selection and procurement might help to optimize the utilization of DCD grafts.
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189
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Baccarani U, Righi E, Adani GL, Lorenzin D, Pasqualucci A, Bassetti M, Risaliti A. Pros and cons of liver transplantation in human immunodeficiency virus infected recipients. World J Gastroenterol 2014; 20:5353-5362. [PMID: 24833865 PMCID: PMC4017050 DOI: 10.3748/wjg.v20.i18.5353] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/05/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Before the introduction of combined highly active antiretroviral therapy, a positive human immunodeficiency virus (HIV) serological status represented an absolute contraindication for solid organ transplant (SOT). The advent of highly effective combined antiretroviral therapy in 1996 largely contributed to the increased demand for SOT in HIV-positive individuals due to increased patients’ life expectancy associated with the increasing prevalence of end-stage liver disease (ESLD). Nowadays, liver failure represents a frequent cause of mortality in the HIV-infected population mainly due to coinfection with hepatitis viruses sharing the same way of transmission. Thus, liver transplantation (LT) represents a reasonable approach in HIV patients with stable infection and ESLD. Available data presently supports with good evidence the practice of LT in the HIV-positive population. Thus, the issue is no longer “whether it is correct to transplant HIV-infected patients”, but “who are the patients who can be safely transplanted” and “when is the best time to perform LT”. Indeed, the benefits of LT in HIV-infected patients, especially in terms of mid- and long-term patient and graft survivals, are strictly related to the patients’ selection and to the correct timing for transplantation, especially when hepatitis C virus coinfection is present. Aim of this article is to review the pros and cons of LT in the cohort of HIV infected recipients.
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190
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Abstract
PURPOSE OF REVIEW Biliary complications account for relevant morbidity and mortality after liver transplantation. Advances have taken place in understanding their aetiology, in preventive operative techniques, imaging procedures, as well as interventional and endoscopic management. However, progress in living donation, donation after cardiac death as well as paediatric transplant procedures have changed the incidence and causes of biliary complications. This review summarizes recent progress in the field, particularly related to biliary strictures after liver transplantation. RECENT FINDINGS Significant findings in the period of interest for this review focussed on improvements of endoscopic treatment of postliver transplant biliary complications, including novel stenting devices, the routine analysis of bacterial and fungal flora, and the use of steroids to prevent postendoscopic retrograde cholangiopancreaticography pancreatitis. The importance of cytomegalovirus and hepatitis C in the aetiology of biliary complications was highlighted. Under certain circumstances, biliary complications after liver transplantation of organs secondary to donation after cardiac death may be reduced to a level known from liver transplantation after brain death. Further evidence was added to support the risk-adapted use of biliary drainage during liver transplantation. SUMMARY The ongoing research in the aetiology, prevention, and treatment of biliary strictures after liver transplantation highlights the significance of biliary complications for patient and graft outcome.
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191
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Axelrod DA, Lentine KL, Xiao H, Dzebisashvilli N, Schnitzler M, Tuttle-Newhall JE, Segev DL. National assessment of early biliary complications following liver transplantation: incidence and outcomes. Liver Transpl 2014; 20:446-56. [PMID: 24478266 DOI: 10.1002/lt.23829] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/19/2013] [Indexed: 02/07/2023]
Abstract
Despite improved overall liver transplant outcomes, biliary complications remain a significant cause of morbidity. A national data set linking transplant registry and Medicare claims data for 17,012 liver transplant recipients was used to identify all recipients with a posttransplant biliary diagnosis code within the first 6 months after transplantation. Patients were further categorized as follows: a diagnosis without a procedure, a diagnosis and an associated radiological or endoscopic procedure, or a diagnosis treated with surgery. Overall, 15.0% had a biliary diagnosis, 11.2% required a procedure, and 2.2% had a surgical revision. Factors independently associated with biliary complications included donation after cardiac death (DCD), donor age, recipient age, split grafts, and long cold ischemia times. Graft loss was significantly more common for patients with biliary diagnoses [adjusted hazard ratio (aHR) = 1.89, confidence interval (CI) = 1.63-2.19], interventions (aHR = 2.08, CI = 1.77-2.44), and surgical procedures (aHR = 1.80, CI = 1.31-2.49). Mortality after transplantation was also markedly increased for patients with biliary diagnoses (aHR = 2.18, CI = 1.97-2.40), procedures (aHR = 2.21, CI = 1.99-2.46), and surgeries (aHR = 1.77, CI = 1.41-2.23). In stratified analyses, the impact of early biliary complications was greater for DCD liver recipients, but they remained highly significant for recipients of allografts from brain-dead donors as well. Reducing biliary complications should improve posttransplant survival and reduce graft loss.
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Affiliation(s)
- David A Axelrod
- Section of Transplant Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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192
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Abstract
OBJECTIVE To provide an approach to the care of liver transplant (LT) patients, a growing patient population with unique needs. METHODS A literature search of PubMed for guidelines and review articles using the keywords "liver transplantation", "long term complications" and "medical management" was conducted, resulting in 77 articles. RESULTS As a result of being on immunosuppression, LT recipients are at increased risk of infections and must be screened regularly for metabolic complications and malignancies. DISCUSSION Although immunosuppression is key to maintaining allograft health after transplantation, it comes with its own set of medical issues to follow. Physicians following LT recipients must be aware of the greater risk for hypertension, diabetes, dyslipidemia, renal failure, metabolic bone disease and malignancies in these patients, all of whom require regular monitoring and screening. Vaccination, quality of life, sexual function and pregnancy must be specifically addressed in transplant patients.
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193
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Liu S, Xing T, Sheng T, Yang S, Huang L, Peng Z, Sun X. The reduction rate of serum C3 following liver transplantation is an effective predictor of non-anastomotic strictures. Hepatol Int 2014. [DOI: 10.1007/s12072-014-9524-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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194
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Desai NS, Khandelwal A, Virmani V, Kwatra NS, Ricci JA, Saboo SS. Imaging in laparoscopic cholecystectomy--what a radiologist needs to know. Eur J Radiol 2014; 83:867-879. [PMID: 24657107 DOI: 10.1016/j.ejrad.2014.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 02/16/2014] [Accepted: 02/18/2014] [Indexed: 12/13/2022]
Abstract
Laparoscopic cholecystectomy is the gold standard treatment option for cholelithiasis. In order to properly assess for the complications related to the procedure, an understanding of the normal biliary anatomy, its variants and the normal postoperative imaging is essential. Radiologist must be aware of benefits and limitations of multiple imaging modalities in characterizing the complications of this procedure as each of these modalities have a critical role in evaluating a symptomatic post-cholecystectomy patient. The purpose of this article is describe the multi-modality imaging of normal biliary anatomy and its variants, as well as to illustrate the imaging features of biliary, vascular, cystic duct, infectious as well as miscellaneous complications of laparoscopic cholecystectomy. We focus on the information that the radiologist needs to know about the radiographic manifestations of potential complications of this procedure.
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Affiliation(s)
- Naman S Desai
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USA.
| | - Ashish Khandelwal
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USA.
| | - Vivek Virmani
- Department of Radiology, Dr. Everett Chalmers Hospital, Priestman St, Fredericton, 700, NB E3B 5N5, Canada.
| | - Neha S Kwatra
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USA.
| | - Joseph A Ricci
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Sachin S Saboo
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USA.
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195
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EPR spectroscopy as a predictive tool for the assessment of marginal donor livers perfused on a normothermic ex vivo perfusion circuit. Med Hypotheses 2014; 82:627-30. [PMID: 24629357 DOI: 10.1016/j.mehy.2014.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 02/24/2014] [Indexed: 12/16/2022]
Abstract
Liver transplantation is a highly successful treatment for end-stage liver disease. While liver transplantation is often the only effective treatment for cirrhosis there is a critical shortage of donor organs, leading to death of many potential recipients on the waiting list. Marginal liver grafts are increasingly being used in an attempt to increase the number of donor livers utilized for transplantation. Marginal donor livers often have complications and worse outcomes for recipients receiving these types of transplant. The ability to predict the outcome with the use of marginal grafts is difficult and often imprecise leading decreased use of potentially suitable grafts. The development and maturation of normothermic ex vivo perfusion as a platform for the assessment of donor organs presents an opportunity to increase the number of usable donor livers available for transplantation. Furthermore, direct measurement of reactive oxygen species (ROS) present in the donor liver on an ex vivo perfusion circuit by electron paramagnetic resonance (EPR) spectroscopy would allow for precise real-time quantification of donor organ injury. The combination normothermic ex vivo liver perfusion with EPR spectroscopy could therefore present a powerful platform to increase the number of donor organs utilized for transplantation.
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196
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Law R, Leal C, Dayyeh BA, Leise MD, Balderramo D, Baron TH, Cardenas A. Role of immunosuppression in post-endoscopic retrograde cholangiopancreatography pancreatitis after liver transplantation: a retrospective analysis. Liver Transpl 2013; 19:1354-60. [PMID: 24115362 DOI: 10.1002/lt.23758] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/27/2013] [Indexed: 12/11/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used for diagnosis and therapeutic interventions in recipients of liver transplantation (LT) who develop biliary complications. Post-endoscopic retrograde cholangiopancreatography acute pancreatitis (PEP) is the most common major adverse event after ERCP; however, the frequency of PEP in LT recipients is not well established. We aimed to determine the rate of PEP in this population and to identify its predictors, especially among immunosuppressive agents. We reviewed all ERCP procedures performed in LT recipients after duct-to-duct biliary anastomoses at 2 high-volume transplant centers. Patients who had undergone sphincterotomy or had a surgically altered pancreaticobiliary anatomy before LT were excluded. Electronic medical records and endoscopy databases were used to obtain clinical, endoscopic, and medication data. A multivariate logistic regression analysis was used to determine predictors of PEP in this cohort. In all, 730 ERCP procedures were performed in 301 patients during the study period with an observed PEP rate of 3% (22/730). A univariate analysis revealed an increased risk of PEP with index ERCP after LT [odds ratio (OR) = 4.04, 95% confidence interval (CI) = 1.40-11.65] and in cases with difficult biliary cannulation (OR = 2.89, 95% CI = 1.10-7.65), whereas prednisone use was found to have a protective effect in both univariate (OR = 0.34, 95% CI = 0.14-0.84) and multivariate analyses (OR = 0.22, 95% CI = 0.09-0.57) after adjustments for difficult biliary cannulation and post-LT index ERCP. This retrospective analysis demonstrates that corticosteroid therapy has a protective role in the development of PEP in LT recipients. Further studies are warranted to confirm our findings.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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197
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Affiliation(s)
- Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, USA
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