Presentation, diagnosis, and management of early hepatic venous outflow complications in whole cadaveric liver transplant

Machine learning-based predictive model for abdominal diseases using physical examination datasets

Abdominal ultrasound is a key non-invasive imaging method for diagnosing liver, kidney, and gallbladder diseases, despite its clinical significance, not all individuals can undergo abdominal ultrasonography during routine health check-ups due to limitations in equipment, cost, and time. This study aims to use basic physical examination data to predict the risk of diseases of the liver, kidney, and gallbladder that can be diagnosed via abdominal ultrasound. Basic physical examination data contain gender, age, height, weight, BMI, pulse, systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol, triglycerides, fasting blood glucose (FBG), and uric acid-we established seven single-label predictive models and one multi-label predictive model. These models were specifically designed to predict a range of abdominal diseases. The single-label models, utilizing the XGBoost algorithm, targeted diseases such as fatty liver (with an Area Under the Curve (AUC) of 0.9344), liver deposits (AUC: 0.8221), liver cysts (AUC: 0.7928), gallbladder polyps (AUC: 0.7508), kidney stones (AUC: 0.7853), kidney cysts (AUC: 0.8241), and kidney crystals (AUC: 0.7536). Furthermore, a comprehensive multi-label model, capable of predicting multiple conditions simultaneously, was established by FCN and achieved an AUC of 0.6344. We conducted interpretability analysis on these models to enhance their understanding and applicability in clinical settings. The insights gained from this analysis are crucial for the development of targeted disease prevention strategies. This study represents a significant advancement in utilizing physical examination data to predict ultrasound results, offering a novel approach to early diagnosis and prevention of abdominal diseases.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Stapled Anastomosis for Side-to-Side Cavo-Cavostomy in Orthotopic Liver Transplantation

In liver transplantation, a side-to-side anastomosis is one of the commonly performed techniques of the inferior vena cava reconstruction. The authors report a case of an application of an endoscopic vascular linear stapler for a side-to-side caval anastomosis during deceased-donor liver transplantation. The back table procedure was performed in a standard fashion for a side-to-side anastomosis. The linear vascular stapler was introduced during the temporary clamping of the recipient's inferior vena cava and the anastomosis was created without problems. Suturing of the resulting defect completed the anastomosis. The use of the stapler resulted in a shortening of the anastomosis time. The staple line after the reperfusion of the graft was completely sealed. The patient's postoperative course was uncomplicated and post-operative ultrasound and computed tomography confirmed the patency of the anastomosis. This case demonstrates a novel approach to a side-to-side caval reconstruction during liver transplantation that enables a shortening of the implantation time and may improve the quality of anastomoses.

Venous outflow obstruction in pediatric left lateral segment split liver transplantation

BACKGROUND

Venous outflow obstruction (VOO) is a known cause of graft and patient loss after pediatric liver transplantation (LT). We analyzed the incidence, risk factors, diagnosis, management, and outcome of VOO in a large, consecutive series of left lateral segment (LLS) split LT with end-to-side triangular venous anastomosis.

METHODS

We evaluated data collected in our prospective databases relative to all consecutive pediatric liver transplants performed from January 2006 to December 2021. We included in this study children undergoing LLS split liver transplant with end-to-side triangular anastomosis. Diagnosis of VOO was based on clinical suspicion and radiological confirmation.

RESULTS

VOO occurred in 24/279 transplants (8.6%), and it was associated with lower graft weight (p = .04), re-transplantation (p = .008), and presence of two hepatic veins (p < .0001). In presence of two segmental veins' orifices, the type of reconstruction (single anastomosis after venoplasty or double anastomosis) was not significantly related to VOO (p = .87). Multivariable analysis indicated VOO as a risk factor for graft lost (hazard ratio 3.21, 95% confidence interval 1.22-8.46; p = .01). Percutaneous Transluminal Angioplasty (PTA) was effective in 17/22 (77%) transplants. Surgical anastomosis was redone in one case. Overall six grafts (25%) were lost.

CONCLUSION

VOO after LLS split LT with end-to-side triangular anastomosis is an unusual but critical complication leading to graft loss in a quarter of cases. The occurrence of VOO was associated with lower graft weight, re-transplantation, and presence of two hepatic veins. PTA was safe and effective to restore proper venous outflow in most cases.

Histopathology of Budd-Chiari Syndrome

The histopathological changes in Budd-Chiari syndrome (BCS) overlap with those of sinusoidal obstruction syndrome (SOS) and of cardiac or pericardiac disorders resulting in right cardiac failure. These conditions, however, are different on both clinical and pathological grounds and need to be differentiated from BCS. This review is centred on the three main aspects of BCS in diagnostic liver histopathology: (1) general histopathology of BCS; (2) implications for liver biopsy interpretation; and (3) BCS in the liver allograft. The histological features of BCS form a complex spectrum which is shaped differently in each individual case according to the topographical distribution and chronological evolution of the obliterative insult, its upstream effect of the hepatic vascularisation and the consequent parenchymal injury, scarring and remodelling. Sampling variation limits the use of liver biopsy for prognostication in patients with BCS.

Outflow reconstruction of left lateral graft with two widely spaced hepatic veins in pediatric living donor liver transplantation

BACKGROUND

Living donor liver transplantation using the left lateral segment of the liver is the most common type of pediatric liver transplantation. An appropriate surgical approach is crucial for decreasing the risk of vascular complications using these grafts with anatomical variations.

METHODS

Between January 2017 and December 2020, 631 living donor liver transplantations using left lateral segment grafts were performed at Tianjin First Central Hospital. The grafts from 162 (25.7%) donors have 2 hepatic vein openings. A total number of 21 transplantations using left lateral segment grafts with 2 widely spaced hepatic vein openings were performed. In group 1, the unification venoplasty technique with interposition vein graft was used at the back table for the reconstruction of hepatic vein from grafts. In group 2, dual hepatic vein reconstructions were performed, in which venoplasty of recipients' left hepatic vein, middle hepatic vein, and inferior vena cava was performed to create a large orifice for anastomosis with segment Ⅱ hepatic vein from the graft. Segment III hepatic vein from the graft was anastomosed with the recipient's right hepatic vein. The incidence, treatment, and outcomes of hepatic venous outflow obstruction were compared between the 2 groups.

RESULTS

The median follow-up time was 12.8 months. There was no significant difference in the incidence of hepatic venous outflow obstruction between the 2 groups.

CONCLUSION

Dual hepatic vein reconstruction is an alternate surgical option for grafts with 2 widely spaced hepatic veins, and it is associated with ideal graft recovery and vascular condition. However, long-term follow-up is still needed to verify the efficacy and safety of this approach.

Reconstruction of hepatic venous outflow and management of its complications using ex vivo liver resection and autotransplantation: a single-center experience

BACKGROUND

This study was designed to investigate the techniques of hepatic venous outflow reconstruction and the management of its complications using ex vivo liver resection and autotransplantation (ELRA).

METHODS

Being a retrospective case series covering 84 patients who underwent hepatic venous outflow reconstruction during ELRA from January 2016 to October 2020, 11 cases of postoperative hepatic venous outflow obstruction (HVOO), whose surgery details were described and survival rates analyzed.

RESULTS

A total of the 84 alveolar Echinococcosis (AE) series was no intraoperative death. The 30-day mortality was 5.95% (5 /84). The most common postoperative complication was pleural effusion in 21 cases (25%). HVOO occurred in 11 cases, one of them died of liver failure, and the other 10 patients underwent interventional revascularization with good results. There was no significant difference in survival between patients with successful interventional revascularization due to HVOO and patients without HVOO (P > 0.05).

CONCLUSIONS

Individualized and well design reconstruction of hepatic vein can be considered as a key procedure to reduce the complications of HVOO in ELRA. Once HVOO occurs, emergent management must be performed immediately before liver dysfunction. Interventional revascularization showed an effective approach, though the more clinical cases need to be evaluated.

Inferior Vena Cava Constriction After Liver Transplantation Is a Severe Complication Requiring Individually Adapted Treatment: Report of a Single-Center Experience

Background

Reports on vena cava occlusion after liver transplantation (LT) are rare, but this finding represents a severe complication in the early postoperative period. In the context of the complex presentation of a patient after LT, symptoms are often misinterpreted and can be subtle.

Material/Methods

In our cohort of 138 LTs performed between 2014 and 2017 at our University’s Transplantation Department, 117 transplantations were valid for further analysis after exclusion of pediatric transplantations and transplants with primary non-function grafts. In 101 cases (73%), patients received a deceased-donor full-size organ. Living-donor LT was performed in 8 patients (6.4%) and 8 patients (6.4%) received a split graft. We report on 6 patients who had inferior vena cava (IVC) occlusion and summarize the treatment choices.

Results

In our series, patients with positive findings (age 38–70 years) received an orthotopic full-size deceased-donor graft with end-to-end IVC anastomosis. In the subsequent period, imaging revealing IVC occlusion was done on a follow-up basis (n=2), due to dyspnea (n=1), and for progressive ascites (n=2). In 3 cases, a thrombus was found. We give detailed information on our treatment options from interventional treatment to transcardial thrombus removal and anastomosis augmentation.

Conclusions

IVC constriction and subsequent thrombosis are severe complications after LT that require individually adapted treatment in specialized centers. Since patients often present with subclinical symptoms, vascular diagnosis should be performed early to detect caval anastomosis pathologies. Despite regular ultrasonography, we favor CT and cavography for subsequent quantification. We also review the literature on IVC occlusion after LT.

Liver Transplantation

The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.

Graft Dysfunction and Management in Liver Transplantation

Graft dysfunction of the liver allograft manifests across a spectrum in both timing posttransplantation and clinical presentation. This can range from mild transient abnormalities of liver tests to acute liver failure potentially leading to graft failure. The causes of graft dysfunction can be divided into those resulting in early and late graft dysfunction. Although nonspecific, liver biochemistry abnormalities are still the mainstay investigation used in monitoring for dysfunction. This article provides a summary of the main causes and management strategies for liver graft dysfunction in the early through late posttransplant stages.

Novel use of percutaneous thrombosuction to rescue the early thrombosis of the conduit vein graft after living donor liver transplantation

A 54-year-old woman with liver cirrhosis and hepatocellular carcinoma received a living donor liver transplant. Thrombosis of the segmental hepatic vein occurred on postoperative day 7. We undertook percutaneous catheter thrombosuction under local anesthesia to extract the thrombus successfully without re-exploration. Thrombosuction has been used for thrombosis of the cardiovascular system, limbs, and brain. We first used it in hepatic venous thrombus after liver transplantation. This procedure is simple, less invasive, feasible, safe, repeatable, and effective.

Modified triangular hepatic vein reconstruction for preventing hepatic venous outflow obstruction in pediatric living donor liver transplantation using left lateral segment grafts

HVOO can be a critical complication in pediatric LDLT. The aim of this study was to evaluate a modified triangular technique of hepatic vein reconstruction for preventing HVOO in pediatric LDLT. A total of 298 pediatric LDLTs were performed using a left lateral segment graft by 2 methods for reconstruction of the hepatic vein. In 177 recipients, slit-shaped anastomosis was indicated with partial clamp of the IVC. A total of 121 recipients subjected to the modified triangular anastomosis with total clamp of the IVC. We compared the incidence of hepatic vein anastomotic complications between these 2 methods. Nine of the 177 cases (5.3%) treated with the conventional technique were diagnosed with outflow obstruction. All 9 cases underwent hepatic vein reconstruction with the slit-shaped hepatic vein anastomosis. In contrast, there were no cases of outflow obstruction in the 121 cases treated with the modified triangular anastomosis. The modified triangular technique of hepatic vein reconstruction with total clamping of the IVC was useful for preventing HVOO in pediatric LDLT.