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Yl MK, Patil NS, Mohapatra N, Sindwani G, Dhingra U, Yadav A, Kale P, Pamecha V. Temporary Portocaval Shunt Provides Superior Intraoperative Hemodynamics and Reduces Blood Loss and Duration of Surgery in Live Donor Liver Transplantation: A Randomized Control Trial. Ann Surg 2024; 279:932-944. [PMID: 38214167 DOI: 10.1097/sla.0000000000006200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To compare intraoperative hemodynamic parameters, blood loss, renal function, and duration of surgery with and without temporary portocaval shunt (TPCS) in live donor liver transplantation (LT) recipients. Secondary objectives were postoperative early graft dysfunction, morbidity, mortality, total intensive care unit, and hospital stay. BACKGROUND Blood loss during recipient hepatectomy for LT remains a major concern. Routine use of TPCS during LT is not yet elucidated. METHODS This study is a single-center, open-label, randomized control trial. The sample size was calculated based on intraoperative blood loss. After exclusion, a total of 60 patients, 30 in each arm (TPCS vs no TPCS) were recruited in the trial. RESULTS The baseline recipient and donor characteristics were comparable between the groups. The median intraoperative blood loss ( P = 0.004) and blood product transfusions ( P < 0.05) were significantly less in the TPCS group. The TPCS group had significantly improved intraoperative hemodynamics in the anhepatic phase as compared with the no TPCS group ( P < 0.0001), requiring significantly less vasopressor support. This led to significantly better renal function as evidenced by higher intraoperative urine output in the TPCS group ( P = 0.002). Because of technical simplicity, the TPCS group had significantly fewer inferior vena cava injuries (3.3 vs 26.7%, P = 0.026) and substantially shorter hepatectomy time and total duration of surgery (529.4 ± 35.54 vs 606.83 ± 48.13 min, P < 0.0001). The time taken for normalization of lactate in the immediate postoperative period was significantly shorter in the TPCS group (median, 6 vs 13 h; P = 0.04). Although postoperative endotoxemia, major morbidity, 90-day mortality, total intensive care unit, and hospital stay were comparable between both groups, tolerance to enteral feed was earlier in the TPCS group. CONCLUSIONS In live donor LT, TPCS is a simple and effective technique that provides superior intraoperative hemodynamics and reduces blood loss and duration of surgery.
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Affiliation(s)
| | | | | | | | | | | | - Pratibha Kale
- Microbiology, Institute of Liver and Biliary Sciences, DL, India
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2
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Raja K, Panackel C. Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice. J Clin Exp Hepatol 2024; 14:101306. [PMID: 38274509 PMCID: PMC10806298 DOI: 10.1016/j.jceh.2023.101306] [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] [Received: 01/10/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.
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Affiliation(s)
- Kaiser Raja
- Department of Gastroenterology and Hepatology, King's College Hospital London, Dubai, United Arab Emirates
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3
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Shaker TM, Eason JD, Davidson BR, Barth RN, Pirenne J, Imventarza O, Spiro M, Raptis DA, Fung J. Which cava anastomotic techniques are optimal regarding immediate and short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14681. [PMID: 35567584 PMCID: PMC10078200 DOI: 10.1111/ctr.14681] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has long been debated whether cava anastomosis should be performed with the piggyback technique or cava replacement, with or without veno-venous bypass (VVB), with or without temporary portocaval shunt (PCS) in the setting of liver transplantation. OBJECTIVES To identify whether different cava anastomotic techniques and other maneuvers benefit the recipient regarding short-term outcomes and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021240979). RESULTS Of 3205 records screened, 307 publications underwent full-text assessment for eligibility and 47 were included in qualitative synthesis. Four studies were randomized control trials. Eighteen studies were comparative. The remaining 25 were single-center retrospective noncomparative studies. CONCLUSION Based on existing data and expert opinion, the panel cannot recommend one cava reconstruction technique over another, rather the surgical approach should be based on surgeon preference and center dependent, with special consideration toward patient circumstances (Quality of evidence: Low | Grade of Recommendation: Strong). The panel recommends against routine use of vevo-venous bypass (Quality of evidence: Very Low | Grade of Recommendation: Strong) and against the routine use of temporary porto-caval shunt (Quality of evidence: Very Low | Grade of Recommendation: Strong).
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Affiliation(s)
- Tamer M Shaker
- Division of Transplant, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - James D Eason
- James D. Eason Transplant Institute, University of Tennessee, Memphis, Tennessee, USA
| | - Brian R Davidson
- UCL Division of Surgery & Interventional Science, University College London, Royal Free Campus, Rowland Hill Street, London, United Kingdom of Great Britain and Northern Ireland
| | - Rolf N Barth
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Jacques Pirenne
- Department of Microbiology, Immunology, and Transplantation, Lab of Abdominal Transplantation, Transplantation Research Group, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplantation Surgery and Coordination, University Hospitals of Leuven, Leuven, Belgium
| | - Oscar Imventarza
- Liver Transplant Unit, Hospital Argerich, Hospital Garrahan, Stalyc Representative, Buenos Aires, Argentina
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - John Fung
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
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4
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[Kidney failure after liver transplantation]. Nephrol Ther 2022; 18:89-103. [PMID: 35151596 DOI: 10.1016/j.nephro.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/11/2021] [Accepted: 11/06/2021] [Indexed: 02/06/2023]
Abstract
One third of cirrhotic patients present impaired kidney function. It has multifactorial causes and has a harmful effect on patients' morbi-mortality before and after liver transplant. Kidney function does not improve in all patients after liver transplantation and liver-transplant recipients are at high risk of developing chronic kidney disease. Causes for renal dysfunction can be divided in three groups: preoperative, peroperative and postoperative factors. To date, there is no consensus for the modality of evaluation the risk for chronic kidney disease after liver transplantation, and for its prevention. In the present review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease to determine a risk stratification for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this setting, and highlight the indications of combined liver-kidney transplantation.
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5
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Abstract
One-third of patients with cirrhosis present kidney failure (AKI and CKD). It has multifactorial causes and a harmful effect on morbidity and mortality before and after liver transplantation. Kidney function does not improve in all patients after liver transplantation, and liver transplant recipients are at a high risk of developing chronic kidney disease. The causes of renal dysfunction can be divided into three groups: pre-operative, perioperative and post-operative factors. To date, there is no consensus on the modality to evaluate the risk of chronic kidney disease after liver transplantation, or for its prevention. In this narrative review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease in order to establish a risk categorization for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this context, and highlight the indications of combined liver–kidney transplantation.
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Rodríguez-Laiz GP, Melgar-Requena P, Alcázar-López CF, Franco-Campello M, Villodre-Tudela C, Pascual-Bartolomé S, Bellot-García P, Rodríguez-Soler M, Miralles-Maciá CF, Más-Serrano P, Navarro-Martínez JA, Martínez-Adsuar FJ, Gómez-Salinas L, Jaime-Sánchez FA, Perdiguero-Gil M, Díaz-Cuevas M, Palazón-Azorín JM, Such-Ronda J, Lluís-Casajuana F, Ramia-Ángel JM. Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol. World J Surg 2021; 45:1262-1271. [PMID: 33620540 PMCID: PMC8026463 DOI: 10.1007/s00268-021-05963-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 01/14/2023]
Abstract
Introduction Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results.
Patients and methods Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.
Results A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years. Conclusion Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care
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Affiliation(s)
- Gonzalo P Rodríguez-Laiz
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain.
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain.
| | - Paola Melgar-Requena
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Cándido F Alcázar-López
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Mariano Franco-Campello
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
| | - Celia Villodre-Tudela
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Sonia Pascual-Bartolomé
- Hepatology and Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Pablo Bellot-García
- Hepatology and Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - María Rodríguez-Soler
- Hepatology and Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Cayetano F Miralles-Maciá
- Hepatology and Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Patricio Más-Serrano
- Pharmacy and Pharmacokinetics, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - José A Navarro-Martínez
- Anesthesiology and Surgical Critical Care, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Luis Gómez-Salinas
- Anesthesiology and Surgical Critical Care, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | | | - Miguel Perdiguero-Gil
- Nephrology and Renal Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - María Díaz-Cuevas
- Nephrology and Renal Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | | | - José Such-Ronda
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - José M Ramia-Ángel
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
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7
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The technical aspects of ex vivo hepatectomy with autotransplantation: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:2177-2200. [PMID: 33591451 DOI: 10.1007/s00423-021-02093-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/15/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE Ex vivo hepatectomy is the incorporation of liver transplant techniques in the non-transplant setting, providing opportunity for locally advanced tumors found conventionally unresectable. Because the procedure is rare and reports in the literature are limited, we sought to perform a systematic review and meta-analysis investigating technical variations of ex vivo hepatectomies. METHODS In the literature, there is a split in those performing the procedure between venovenous bypass (VVB) and temporary portacaval shunts (PCS). Of the 253 articles identified on the topic of ex vivo resection, 37 had sufficient data to be included in our review. RESULTS The majority of these procedures were performed for hepatic alveolar echinococcosis (69%) followed by primary and secondary hepatic malignancies. In 18 series, VVB was used, and in 18, a temporary PCS was performed. Comparing these two groups, intraoperative variables and morbidity were not statistically different, with a cumulative trend in favor of PCS. Ninety-day mortality was significantly lower in the PCS group compared to the VVB group (p=0.03). CONCLUSION In order to better elucidate these differences between technical approaches, a registry and consensus statement are needed.
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8
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Addeo P, Julliard O, Terrone A, Schaaf C, Faitot F, Bachellier P. Temporary portal decompression during liver transplantation: a video review of the different techniques. Langenbecks Arch Surg 2020; 406:227-231. [PMID: 32965584 DOI: 10.1007/s00423-020-01991-z] [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: 05/08/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Temporary portal decompression (TPD) during liver transplantation (LT) remains a divisive technical issue in the liver transplant community. In this video-based article, we show the technical details of the different techniques used for TPD during LT. METHODS An early portal section, before liver mobilization, should be preferred in order to achieve hepatectomy of a totally devascularized liver. Portal decompression can be achieved through direct right portocaval shunts and indirect portosystemic shunts (i.e., mesentericosaphenous and portosaphenous shunts). RESULTS The preference for direct portocaval or indirect portosystemic shunts is tailored on patients and anatomical characteristics. Each of these three techniques presents specific indications, limitations, and advantages. CONCLUSION TPD during LT can be achieved through different techniques that aim to facilitate the recipient hepatectomy, reduce the blood loss, and maintain hemodynamic stability.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France.
| | - Olivier Julliard
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France
| | - Alfonso Terrone
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France
| | - Caroline Schaaf
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France
| | - François Faitot
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France
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9
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Protective Role of the Portocaval Shunt in Liver Transplantation. Transplant Proc 2020; 52:1455-1458. [PMID: 32217010 DOI: 10.1016/j.transproceed.2020.01.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Advances in medical management and surgical technique have resulted in stepwise improvements in early post-transplant survival rates. Modifications in the surgical technique, such as the realization of the portocaval shunt (PCS), could influence survival rates. The aim of this study was to evaluate the mortality rate for 12 months after liver transplantation, analyzing the causes and risk factors related to its development and assessing the impact that PCS could have on them. METHODS A total of 231 recipients were included in the retrospective, longitudinal, and nonrandomized study. RESULTS The overall survival of the transplant was 85.2% (197 patients). The most frequent cause of death was infection (38.2%), followed by the multiorgan failure of multiple etiology (23.5%). Most of the risk factors related to mortality correspond to variables of the postoperative period. The results of the multivariate analysis identified the main risk factors for death: the presence of surgical complications and the need for renal replacement therapy. In contrast, the performance of PCS exerted a protective effect, reducing the probability of death by 70%. CONCLUSIONS Despite the good results obtained in several studies, there is still debate regarding the benefit of its realization. In our study, PCS was a factor associated with a reduction in mortality, with a markedly lower probability of adverse events. However, we agree with other authors on the need for larger and randomized studies to adequately determine the validity of such results.
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Pietersen LC, Sarton E, Alwayn I, Lam HD, Putter H, van Hoek B, Braat AE. Impact of Temporary Portocaval Shunting and Initial Arterial Reperfusion in Orthotopic Liver Transplantation. Liver Transpl 2019; 25:1690-1699. [PMID: 31276282 DOI: 10.1002/lt.25592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 06/06/2019] [Indexed: 01/13/2023]
Abstract
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center-based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End-Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1-year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
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Affiliation(s)
- Lars Cornelis Pietersen
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise Sarton
- Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ian Alwayn
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hwai-Ding Lam
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andries Erik Braat
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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11
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Passive mesenterico-saphenous shunt: An alternative to portocaval anastomosis for tailored portal decompression during liver transplantation. Surgery 2019; 165:970-977. [DOI: 10.1016/j.surg.2018.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/30/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023]
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12
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Biancofiore G, Blasi A, De Boer MT, Franchini M, Hartmann M, Lisman T, Liumbruno GM, Porte RJ, Saner F, Senzolo M, Werner MJ. Perioperative hemostatic management in the cirrhotic patient: a position paper on behalf of the Liver Intensive Care Group of Europe (LICAGE). Minerva Anestesiol 2019; 85:782-798. [PMID: 30945514 DOI: 10.23736/s0375-9393.19.13468-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recent data demonstrated that amongst patients undergoing elective surgery the prevalence of cirrhosis is 0.8% equating to approximately 25 million cirrhotic patients undergoing surgery each year worldwide. Overall, the presence of cirrhosis is independently associated with 47% increased risk of postoperative complications and over two and a half-increased risk of in-hospital mortality in patients undergoing elective surgery. In particular, perioperative patients with chronic liver disease have long been assumed to have a major bleeding risk on the basis of abnormal results for standard tests of hemostasis. However, recent evidence outlined significant changes to traditional knowledge and beliefs and, nowadays, with more sophisticated laboratory tests, it has been shown that patients with chronic liver disease may be in hemostatic balance as a result of concomitant changes in both pro- and antihemostatic pathways. The aim of this paper endorsed by the Liver Intensive Care Group of Europe was to provide an up-to-date overview of coagulation management in perioperative patients with chronic liver disease focusing on patient blood management, monitoring of hemostasis, and current role of hemostatic agents.
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Affiliation(s)
- Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy -
| | - Annabel Blasi
- Department of Anesthesia, Hospital Clinic, Barcelona, Spain
| | - Marieke T De Boer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Massimo Franchini
- Department of Hematology and Transfusion Medicine, Hospital of Mantua, Mantua, Italy
| | - Matthias Hartmann
- Department of Anesthesiology and Critical Care, University of Duisburg-Essen, Duisburg, Germany
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Fuat Saner
- Department of General-, Visceral- and Transplant Surgery, University Duisburg-Essen, Duisburg, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Maureen J Werner
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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13
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Pardo F, Pons JA, Castells L, Colmenero J, Gómez MÁ, Lladó L, Pérez B, Prieto M, Briceño J. VI consensus document by the Spanish Liver Transplantation Society. Cir Esp 2019; 96:326-341. [PMID: 29776591 DOI: 10.1016/j.ciresp.2017.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 11/19/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022]
Abstract
The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.
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Affiliation(s)
- Fernando Pardo
- Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Clínica Universitaria de Navarra, Pamplona, España
| | - José Antonio Pons
- Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Hospital Virgen de la Arrixaca, Murcia, España
| | - Lluís Castells
- Unidad de Trasplante Hepático, Hospital Vall d'Hebron, Barcelona, España
| | - Jordi Colmenero
- Unidad de Trasplante Hepático, Hospital Clínic, Barcelona, España
| | - Miguel Ángel Gómez
- Unidad de Trasplante Hepático, Hospital Virgen del Rocío, Sevilla, España
| | - Laura Lladó
- Unidad de Trasplante Hepático, Hospital de Bellvitge, Barcelona, España
| | - Baltasar Pérez
- Unidad de Trasplante Hepático, Hospital Universitario de Valladolid, Valladolid, España
| | - Martín Prieto
- Unidad de Trasplante Hepático, Hospital Universitario La Fe, Valencia, España
| | - Javier Briceño
- Comité Científico de la Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Hospital Universitario Reina Sofía, Córdoba, España.
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14
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Pratschke S, Bender A, Boesch F, Andrassy J, van Rosmalen M, Samuel U, Rogiers X, Meiser B, Küchenhoff H, Driesslein D, Werner J, Guba M, Angele MK. Association between donor age and risk of graft failure after liver transplantation: an analysis of the Eurotransplant database. Transpl Int 2018; 32:270-279. [PMID: 30260509 DOI: 10.1111/tri.13357] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/05/2018] [Accepted: 09/20/2018] [Indexed: 12/16/2022]
Abstract
Grafts from elderly donors are increasingly used for liver transplantation. As of yet there is no published systematic data to guide the use of specific age cutoffs the effect of elderly donors on patient outcomes must be clarified. This study analyzed the Eurotransplant database (01/01/2000-31/07/2014; N = 26 294) out of whom 8341 liver transplantations were filtered to identify for this analysis. 2162 of the grafts came from donors >60 including 203 from octogenarians ≥80 years. Primary outcome was the risk of graft failure according to donor age using a confounder adjusted Cox-Regression model with frailty terms (or random effects). The proportion of elderly grafts increased during the study period [i.e., octogenarians 0.1% (n = 1) in 2000 to 3.4% (n = 45) in 2013]. Kaplan-Meier and Cox-analyses revealed a reduced survival and a higher risk for graft failure with increasing donor age. Although the age effect was allowed to vary non-linearly, a linear association hazard ratio (HR = 1.1 for a 10 year increase in donor age) was evident. The linearity of the association suggests that there is no particular age at which the effect increases more rapidly, providing no evidence for a cutoff age. In clinical practice, the combination of high donor age with HU-transplantations, hepatitis C, high MELD-scores and long cold ischemic time should be avoided.
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Affiliation(s)
- Sebastian Pratschke
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Andreas Bender
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - Florian Boesch
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | | | - Undine Samuel
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Xavier Rogiers
- Transplantatiecentrum, Universitair Ziekenhuis Gent, Gent, Belgium
| | - Bruno Meiser
- Transplant Center, Hospital of the LMU Munich, Munich, Germany
| | - Helmut Küchenhoff
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - David Driesslein
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Markus Guba
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Martin K Angele
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
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15
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Nacif LS, Zanini LY, Sartori VF, Kim V, Rocha-Santos V, Andraus W, Carneiro D'Albuquerque L. Intraoperative Surgical Portosystemic Shunt in Liver Transplantation: Systematic Review and Meta-Analysis. Ann Transplant 2018; 23:721-732. [PMID: 30323164 PMCID: PMC6248172 DOI: 10.12659/aot.911435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Expanded clinical and surgical techniques in liver transplantation can markedly improve patient and graft survival. The main purpose of this study was to evaluate the efficacy of intraoperative portocaval shunts in liver transplantation. Material/Methods Searches were conducted in Cochrane, MEDLINE, and EMBASE databases, and updated in January 2018. The following specific outcomes of interest were defined and evaluated separated using 2 different reviews and meta-analyses for 1) hemi-portocaval shunt (HPCS) and 2) temporary portocaval shunt (TPCS). Comparative studies were analyzed separately for both surgical portocaval shunt modalities. Results Only 1 well-designed randomized controlled trial was found. Most studies were retrospective or prospective. Initially, we found 1479 articles. Of those selected, 853 were from PubMed/MEDLINE, 32 were from Cochrane and 594 were from EMBASE. Our meta-analysis included a total of 3232 patients for all the included studies. Results found that 41 patients with HPCS experienced increased 1-year patient survival (OR 16.33; P=0.02) and increased 1-year graft survival (OR 17.67; P=0.01). The TPCS analysis with 1633 patients found patients had significantly shorter intensive care unit length of stay (days) (P=0.006) and hospital length of stay (P=0.02) and had decreased primary nonfunction (PNF) (OR 0.30, P=0.02) and mortality rates (OR 0.52, P=0.01). Conclusions Intraoperative surgical portosystemic shunt in relation to liver transplantation with TPCS was able to prevent PNF, decrease hospital length of stay and unit care length of stay. Furthermore, in analyzing data for patients with HPCS, we observed increases in the 1-year graft and patient survival rates. More prospective randomized trials are needed to arrive at a more precise conclusion.
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Affiliation(s)
- Lucas Souto Nacif
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Leonardo Yuri Zanini
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vinicius Farina Sartori
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vera Kim
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Vinicius Rocha-Santos
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Wellington Andraus
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
| | - Luiz Carneiro D'Albuquerque
- Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
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17
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Pardo F, Pons JA, Castells L, Colmenero J, Gómez MÁ, Lladó L, Pérez B, Prieto M, Briceño J. VI consensus document by the Spanish Liver Transplantation Society. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:406-421. [PMID: 29866511 DOI: 10.1016/j.gastrohep.2018.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 02/19/2018] [Accepted: 05/14/2018] [Indexed: 12/13/2022]
Abstract
The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.
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Affiliation(s)
- Fernando Pardo
- Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Clínica Universitaria de Navarra, Pamplona, España
| | - José Antonio Pons
- Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Hospital Virgen de la Arrixaca, Murcia, España
| | - Lluís Castells
- Unidad de Trasplante Hepático, Hospital Vall d'Hebron, Barcelona, España
| | - Jordi Colmenero
- Unidad de Trasplante Hepático, Hospital Clínic, Barcelona, España
| | - Miguel Ángel Gómez
- Unidad de Trasplante Hepático, Hospital Virgen del Rocío, Sevilla, España
| | - Laura Lladó
- Unidad de Trasplante Hepático, Hospital de Bellvitge, Barcelona, España
| | - Baltasar Pérez
- Unidad de Trasplante Hepático, Hospital Universitario de Valladolid, Valladolid, España
| | - Martín Prieto
- Unidad de Trasplante Hepático, Hospital Universitario La Fe, Valencia, España
| | - Javier Briceño
- Comité Científico de la Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Hospital Universitario Reina Sofía, Córdoba, España.
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18
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Temporary Intraoperative Porto-Caval Shunts in Piggy-Back Liver Transplantation Reduce Intraoperative Blood Loss and Improve Postoperative Transaminases and Renal Function: A Meta-Analysis. World J Surg 2017; 40:2988-2998. [PMID: 27464915 DOI: 10.1007/s00268-016-3656-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The value of temporary intraoperative porto-caval shunts (TPCS) in cava-sparing liver transplantation is discussed controversially. Aim of this meta-analysis was to analyze the impact of temporary intraoperative porto-caval shunts on liver injury, primary non-function, time of surgery, transfusion of blood products and length of hospital stay in cava-sparing liver transplantation. METHODS A systematic search of MEDLINE/PubMed, EMBASE and PsycINFO retrieved a total of 909 articles, of which six articles were included. The combined effect size and 95 % confidence interval were calculated for each outcome by applying the inverse variance weighting method. Tests for heterogeneity (I 2) were also utilized. RESULTS Usage of a TPCS was associated with significantly decreased AST values, significantly fewer transfusions of packed red blood cells and improved postoperative renal function. There were no statistically significant differences in primary graft non-function, length of hospital stay or duration of surgery. CONCLUSION This meta-analysis found that temporary intraoperative porto-caval shunts in cava-sparing liver transplantation reduce blood loss as well as hepatic injury and enhance postoperative renal function without prolonging operative time. Randomized controlled trials investigating the use of temporary intraoperative porto-caval shunts are needed to confirm these findings.
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19
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Temporary Intra-Operative Portocaval Shunts, Post-Operative Infections, and Mid-Term Survival after Cava-Sparing Liver Transplantation. Surg Infect (Larchmt) 2017; 18:803-809. [DOI: 10.1089/sur.2017.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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20
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Lauterio A, De Carlis R, Di Sandro S, Ferla F, Buscemi V, De Carlis L. Liver transplantation in the treatment of severe iatrogenic liver injuries. World J Hepatol 2017; 9:1022-1029. [PMID: 28932348 PMCID: PMC5583534 DOI: 10.4254/wjh.v9.i24.1022] [Citation(s) in RCA: 8] [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: 02/28/2017] [Revised: 05/19/2017] [Accepted: 07/17/2017] [Indexed: 02/06/2023] Open
Abstract
The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreato-biliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.
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Affiliation(s)
- Andrea Lauterio
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Riccardo De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Surgical Sciences, University of Pavia, 27100 Pavia, Italy
| | - Stefano Di Sandro
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Experimental Medicine, University of Pavia, 27100 Pavia, Italy
| | - Fabio Ferla
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Vincenzo Buscemi
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Surgical Sciences, University of Pavia, 27100 Pavia, Italy
| | - Luciano De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- School of Medicine, University of Milan-Bicocca, 20162 Milan, Italy
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21
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Rayar M, Levi Sandri GB, Cusumano C, Locher C, Houssel-Debry P, Camus C, Lombard N, Desfourneaux V, Lakehal M, Meunier B, Sulpice L, Boudjema K. Benefits of temporary portocaval shunt during orthotopic liver transplantation with vena cava preservation: A propensity score analysis. Liver Transpl 2017; 23:174-183. [PMID: 27706895 DOI: 10.1002/lt.24650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/20/2016] [Accepted: 09/26/2016] [Indexed: 02/07/2023]
Abstract
During orthotopic liver transplantation (OLT), clamping of the portal vein induces splanchnic venous congestion and accumulation of noxious compounds. These adverse effects could increase ischemia/reperfusion injury and subsequently the risk of graft dysfunction, especially for grafts harvested from extended criteria donors (ECDs). Temporary portocaval shunt (TPCS) could prevent these complications. Between 2002 and 2013, all OLTs performed in our center were retrospectively analyzed and a propensity score matching analysis was used to compare the effect of TPCS in 686 patients (343 in each group). Patients in the TPCS group required fewer intraoperative transfusions (median number of packed red blood cells-5 versus 6; P = 0.02; median number of fresh frozen plasma-5 versus 6; P = 0.02); had improvement of postoperative biological parameters (prothrombin time, Factor V, international normalized ratio, alkaline phosphatase, and gamma-glutamyltransferase levels); and showed significant reduction of biliary complications (4.7% versus 10.2%; P = 0.006). Survival analysis revealed that TPCS improved 3-month graft survival (94.2% versus 88.6%; P = 0.01) as well as longterm survival of elderly (ie, age > 70 years) donor grafts (P = 0.02). In conclusion, the use of TPCS should be recommended especially when considering an ECD graft. Liver Transplantation 23 174-183 2017 AASLD.
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Affiliation(s)
- Michel Rayar
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Giovanni B Levi Sandri
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Caterina Cusumano
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Clara Locher
- Service de Pharmacologie Clinique et Épidémiologique, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Pauline Houssel-Debry
- Service des Maladies du Foie, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Christophe Camus
- Réanimation Médicale, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France
| | - Nicolas Lombard
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Veronique Desfourneaux
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Mohamed Lakehal
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Bernard Meunier
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Laurent Sulpice
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Karim Boudjema
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire Rennes, Rennes, France.,INSERM, CIC 1414, Rennes, France.,Faculté de Médecine, Université Rennes 1, Rennes, France
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22
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Urahashi T, Ihara Y, Sanada Y, Okada N, Yamada N, Hirata Y, Katano T, Mizuta K. Recanalized umbilico-caval anastomosis as a temporary portosystemic shunt in pediatric living donor liver transplantation: the crossed fingers method. Clin Transplant 2016; 30:1425-1432. [DOI: 10.1111/ctr.12835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Taizen Urahashi
- Department of Transplant Surgery; Jichi Medical University; Tochigi Japan
| | - Yoshiyuki Ihara
- Department of Transplant Surgery; Jichi Medical University; Tochigi Japan
| | - Yukihiro Sanada
- Department of Transplant Surgery; Jichi Medical University; Tochigi Japan
| | - Noriki Okada
- Department of Transplant Surgery; Jichi Medical University; Tochigi Japan
| | - Naoya Yamada
- Department of Transplant Surgery; Jichi Medical University; Tochigi Japan
| | - Yuta Hirata
- Department of Transplant Surgery; Jichi Medical University; Tochigi Japan
| | - Takumi Katano
- Department of Transplant Surgery; Jichi Medical University; Tochigi Japan
| | - Koichi Mizuta
- Department of Transplant Surgery; Jichi Medical University; Tochigi Japan
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23
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Rayar M, Levi Sandri GB, Cusumano C, Houssel-Debry P, Camus C, Desfourneaux V, Lakehal M, Meunier B, Sulpice L, Boudjema K. Risk analysis of ischemic-type biliary lesions after liver transplant using octogenarian donors. Liver Transpl 2016; 22:1301-2. [PMID: 27197713 DOI: 10.1002/lt.24482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 05/09/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Michel Rayar
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France.,INSERM CIC 1414, Rennes, France.,Université Rennes, Faculté de Médecine, Rennes, France
| | | | - Caterina Cusumano
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France
| | | | - Christophe Camus
- CHU Rennes, Réanimation médicale, Rennes, France.,INSERM CIC 1414, Rennes, France
| | | | - Mohamed Lakehal
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France
| | - Bernard Meunier
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France.,Université Rennes, Faculté de Médecine, Rennes, France
| | - Laurent Sulpice
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France.,INSERM CIC 1414, Rennes, France.,Université Rennes, Faculté de Médecine, Rennes, France
| | - Karim Boudjema
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France.,INSERM CIC 1414, Rennes, France.,Université Rennes, Faculté de Médecine, Rennes, France
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24
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Ghinolfi D, De Simone P, Pezzati D, Cirillo G, Filipponi F. Reply. Liver Transpl 2016; 22:1303. [PMID: 27197627 DOI: 10.1002/lt.24481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/09/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Daniele Pezzati
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giulia Cirillo
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Franco Filipponi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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25
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Results of the TOP Study: Prospectively Randomized Multicenter Trial of an Ex Vivo Tacrolimus Rinse Before Transplantation in EDC Livers. Transplant Direct 2016; 2:e76. [PMID: 27500266 PMCID: PMC4946517 DOI: 10.1097/txd.0000000000000588] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 12/29/2022] Open
Abstract
Background Organ shortage results in the transplantation of extended donor criteria (EDC) livers which is associated with increased ischemia-reperfusion injury (IRI). Experimental studies indicate that an organ rinse with the calcineurin inhibitor tacrolimus before implantation protects against IRI. The tacrolimus organ perfusion study was initiated to examine the effects of ex vivo tacrolimus perfusion on IRI in transplantation of EDC livers. Methods A prospective randomized multicenter trial comparing ex vivo perfusion of marginal liver grafts (≥2 EDC according to Eurotransplant manual) with tacrolimus (20 ng/mL) or histidine-tryptophane-ketoglutarate solution (control) was carried out at 5 German liver transplant centers (Munich Ludwig-Maximilians University, Berlin, Heidelberg, Mainz, Regensburg) between October 2011 and July 2013. Primary endpoint was the maximum alanine transaminase (ALT) level within 48 hours after transplantation. Secondary endpoints were aspartate transaminase (AST), prothrombine ratio, and graft-patient survival within an observation period of 1 week. After an interim analysis, the study was terminated by the scientific committee after the treatment of 24 patients (tacrolimus n = 11, Control n = 13). Results Tacrolimus rinse did not reduce postoperative ALT peaks compared with control (P = 0.207; tacrolimus: median, 812; range, 362-3403 vs control: median, 652; range, 147-2034). Moreover, ALT (P = 0.100), prothrombine ratio (P = 0.553), and bilirubin (P = 0.815) did not differ between the groups. AST was higher in patients treated with tacrolimus (P = 0.011). Survival was comparable in both groups (P > 0.05). Conclusions Contrary to experimental findings, tacrolimus rinse failed to improve the primary endpoint of the study (ALT). Because 1 secondary endpoint (AST) was even higher in the intervention group, the study was terminated prematurely. Thus, tacrolimus rinse cannot be recommended in transplantation of EDC livers.
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26
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Andrassy J, Wolf S, Hoffmann V, Rentsch M, Stangl M, Thomas M, Pratschke S, Frey L, Gerbes A, Meiser B, Angele M, Werner J, Guba M. Rescue management of early complications after liver transplantation-key for the long-term success. Langenbecks Arch Surg 2016; 401:389-96. [PMID: 26960592 DOI: 10.1007/s00423-016-1398-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 03/01/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Postoperative complications may have not only immediate but also long-term effects on the outcomes. Here, we analyzed the effect of postoperative complications requiring a reoperation (grade 3b) within the first 30 days on patients' and graft survival following liver transplantation. METHODS Graft and patient survival in relation to donor and recipient variables and the need of reoperation for complications of 277 consecutive liver transplants performed from January 2007 to December 2012 were analyzed. RESULTS Two hundred seventy-seven liver transplants were performed in 252 patients. Overall patient and graft survival at 1, 2, and 3 years were significantly reduced in patients requiring a reoperation. The labMELD score was significantly elevated (p = 0.04) and cold ischemia time was prolonged (p = 0.03) in recipients undergoing reoperations. Kaplan-Meier curves indicate that complications impact the outcome primarily within the first 3 months after transplantation. In multivariate analyses, the actual need of reoperation (p < 0.001), the labMELD score (p = 0.05), cold ischemia time (p = 0.02), and the need for hemodialysis pre-transplant (p = 0.05) were the only variables which correlated with the overall survival. CONCLUSION Postoperative complications resulting in reoperations have a significant impact on the outcome primarily in the early phase after liver transplantation. Successful management of postoperative complications is key to every successful liver transplant program.
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Affiliation(s)
- Joachim Andrassy
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany.
| | - Sebastian Wolf
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Verena Hoffmann
- Institute of Medical Information Sciences, Biometry and Epidemiology (IBE), Ludwig Maximilian University, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Manfred Stangl
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Michael Thomas
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Sebastian Pratschke
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Lorenz Frey
- Department of Anesthesiology, Ludwig Maximilian University, Munich, Germany
| | - Alexander Gerbes
- Department of Medicine, MED II, Ludwig Maximilian University, Munich, Germany
| | - Bruno Meiser
- Transplant Center, Ludwig Maximilian University, Munich, Germany
| | - Martin Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Markus Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
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Pezzati D, Ghinolfi D, De Simone P, Balzano E, Filipponi F. Strategies to optimize the use of marginal donors in liver transplantation. World J Hepatol 2015; 7:2636-47. [PMID: 26609341 PMCID: PMC4651908 DOI: 10.4254/wjh.v7.i26.2636] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 10/04/2015] [Accepted: 11/03/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the treatment of choice for end stage liver disease, but availability of liver grafts is still the main limitation to its wider use. Extended criteria donors (ECD) are considered not ideal for several reasons but their use has dramatically grown in the last decades in order to augment the donor liver pool. Due to improvement in surgical and medical strategies, results using grafts from these donors have become acceptable in terms of survival and complications; nevertheless a big debate still exists regarding their selection, discharge criteria and allocation policies. Many studies analyzed the use of these grafts from many points of view producing different or contradictory results so that accepted guidelines do not exist and the use of these grafts is still related to non-standardized policies changing from center to center. The aim of this review is to analyze every step of the donation-transplantation process emphasizing all those strategies, both clinical and experimental, that can optimize results using ECD.
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Affiliation(s)
- Daniele Pezzati
- Daniele Pezzati, Davide Ghinolfi, Paolo De Simone, Emanuele Balzano, Franco Filipponi, Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, 56124 Pisa, Italy
| | - Davide Ghinolfi
- Daniele Pezzati, Davide Ghinolfi, Paolo De Simone, Emanuele Balzano, Franco Filipponi, Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, 56124 Pisa, Italy
| | - Paolo De Simone
- Daniele Pezzati, Davide Ghinolfi, Paolo De Simone, Emanuele Balzano, Franco Filipponi, Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, 56124 Pisa, Italy
| | - Emanuele Balzano
- Daniele Pezzati, Davide Ghinolfi, Paolo De Simone, Emanuele Balzano, Franco Filipponi, Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, 56124 Pisa, Italy
| | - Franco Filipponi
- Daniele Pezzati, Davide Ghinolfi, Paolo De Simone, Emanuele Balzano, Franco Filipponi, Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, 56124 Pisa, Italy
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Beneficial Impact of Temporary Portocaval Shunt in Living-Donor Liver Transplantation With a Difficult Total Hepatectomy. Transplant Proc 2015; 47:694-9. [DOI: 10.1016/j.transproceed.2014.12.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/31/2014] [Indexed: 12/24/2022]
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29
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Denecke T, Stelter L, Schnapauff D, Steffen I, Sinn B, Schott E, Seidensticker R, Puhl G, Gebauer B, Hänninen EL, Wust P, Neuhaus P, Seehofer D. CT-guided Interstitial Brachytherapy of Hepatocellular Carcinoma before Liver Transplantation: an Equivalent Alternative to Transarterial Chemoembolization? Eur Radiol 2015; 25:2608-16. [DOI: 10.1007/s00330-015-3660-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 01/05/2015] [Accepted: 02/11/2015] [Indexed: 12/12/2022]
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30
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Hwang HP, Yang JD, Bae SI, Hwang SE, Cho BH, Yu HC. Usefulness of artificial jump graft to portal vein thrombosis in deceased donor liver transplantation. Yonsei Med J 2015; 56:586-90. [PMID: 25684014 PMCID: PMC4329377 DOI: 10.3349/ymj.2015.56.2.586] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Severe portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to high associated risks and morbidity. Meanwhile, improvement in operative techniques, resulting in higher success rates has removed PVT from the list of contraindications in deceased donor liver transplantation (DDLT). In this report, we describe a surgical technique for DDLT using polytetrafluoroethylene graft from the inferior mesenteric vein for portal inflow in patient with portomesenteric thrombosis.
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Affiliation(s)
- Hong Pil Hwang
- Department of Surgery, Chonbuk National University Medical School and Hospital, Jeonju, Korea.; Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
| | - Jae Do Yang
- Department of Surgery, Chonbuk National University Medical School and Hospital, Jeonju, Korea.; Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
| | - Sang In Bae
- Department of Surgery, Chonbuk National University Medical School and Hospital, Jeonju, Korea.; Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
| | - Si Eun Hwang
- Department of Surgery, Daejeon Sun Hospital, Daejeon, Korea
| | - Baik Hwan Cho
- Department of Surgery, Chonbuk National University Medical School and Hospital, Jeonju, Korea.; Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea.; Research Institute of Clinical Medicine, Chonbuk National University, Jeonju, Korea
| | - Hee Chul Yu
- Department of Surgery, Chonbuk National University Medical School and Hospital, Jeonju, Korea.; Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea.; Research Institute of Clinical Medicine, Chonbuk National University, Jeonju, Korea.
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31
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Wimmer CD, Angele MK, Schwarz B, Pratschke S, Rentsch M, Khandoga A, Guba M, Jauch KW, Bruns C, Graeb C. Impact of cyclosporine versus tacrolimus on the incidence of de novo malignancy following liver transplantation: a single center experience with 609 patients. Transpl Int 2013; 26:999-1006. [PMID: 23952102 DOI: 10.1111/tri.12165] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/05/2013] [Accepted: 07/21/2013] [Indexed: 12/18/2022]
Abstract
De novo malignancies are a major cause of late death after liver transplantation. Aim of the present study was to determine whether use of cyclosporine versus tacrolimus affects long-term tumor incidence considering potential confounders. De novo malignancies in 609 liver transplant recipients at Munich Transplant Centre between 1985 and 2007 were registered. In 1996, the standard immunosuppressive regimen was changed from cyclosporine to tacrolimus. Different effects of those drugs on long-term tumor incidence were analyzed in multivariate analysis. During 3765 patient years of follow-up (median 4.78 years), 87 de novo malignancies occurred in 71 patients (mean age 47.5 ± 13.3 years, mean time after liver transplantation 5.7 ± 3.7 years). The cumulative incidence of de novo malignancies was 34.7% for all tumor entities after 15 years as compared to 8.9% for a nontransplanted population. The most frequent tumors observed were nonmelanoma skin cancers (44.83%). Moreover, post-transplant lymphoid disease, oropharyngeal cancer (n = 6, 6.9%), upper gastrointestinal tract cancer (n = 4, 4.6%), lung cancer (n = 4, 4.6%), gynecological malignancies (n = 4, 4.6%), and kidney cancer (n = 3, 3.45%) were detected. Multivariate analysis revealed recipient age [hazards ratio (HR) 1.06], male gender (HR 1.73), and tacrolimus-based immunosuppression (HR 2.06) as significant risk factors. Based on those results, a tacrolimus-based immunosuppression should be discussed especially in older male patients. Whether reducing tacrolimus target levels may reduce the risk for de novo malignancies has yet to be determined in prospective trials.
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Affiliation(s)
- Cosmas D Wimmer
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
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32
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Gastaca M. Temporary intraoperative porto-caval shunt: a more complete set of data is needed. Transpl Int 2013; 26:e81-2. [PMID: 23725045 DOI: 10.1111/tri.12128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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