Optimal Timing of Cholecystectomy for Acute Cholecystitis: A Retrospective Cohort Study

Background

Laparoscopic cholecystectomy performed less than 72 hours from hospital admission for acute cholecystitis has shown to decrease hospital cost without an increase in length of stay (LOS). Very few studies have examined clinical and cost outcomes of performing cholecystectomy less than 24 hours from hospital admission. The aim of this study was to examine the cost and LOS of laparoscopic cholecystectomy performed on an early (less than 24 hours from admission) and late (more than 24 hours from hospital admission) basis.

Methods

We performed a retrospective observational study of 569 patients at Baystate Medical Center, Springfield, USA, who underwent urgent laparoscopic cholecystectomy for acute cholecystitis between January 1, 2018 and February 28, 2020. We evaluated preoperative/postoperative LOS, operative duration, hospital cost, and patient complications.

Results

468 patients underwent urgent laparoscopic cholecystectomy for acute cholecystitis during our study period. Early cholecystectomy (less than 24 hours from admission) had an overall decreased LOS (43.6 hours versus 102.9 hours, p-value < 0.01) and decreased hospital cost ($23,736.70 versus $30,176.40, p-value < 0.01) compared to late cholecystectomy (more than 24 hours from admission). There was also a significantly higher rate of bile leak in patients who underwent surgery more than 24 hours from hospital admission compared to those who had surgery less than 24 hours from admission (5.9% versus 0.4%, p-value < 0.01). Additionally, those procedures performed greater than 24 hours from hospital admission were significantly more likely to be converted to an open procedure (6.9% versus 2.2%, p-value = 0.02). 

Conclusion

Urgent laparoscopic cholecystectomy performed within 24 hours of hospital admission for acute cholecystitis decreased hospital cost, LOS, and operative complications in our institution's patient population. Our data suggests that performing laparoscopic cholecystectomy within 24 hours of hospital admission would be beneficial from a patient and hospital standpoint.

Long term results on the severity of acute appendicitis during COVID-19 pandemic

Background

Acute appendicitis cases increased in severity following COVID-19–related restrictions in March, 2020. We investigated if similar changes occurred during Wave 2.

Methods

Acute appendicitis patients during Wave 1 were grouped 8 weeks before (Group A) and after (Group B) stay-at-home restrictions were initiated on March 15, 2020. Cases in Wave 2 were grouped 8 weeks before (Group C) and after (Group D) November 6, 2020. Groups were compared to equivalent time frames in 2018/2019.

Results

Group A versus B revealed 42.6% decrease (confidence interval: − 59.4 to − 25.7) in uncomplicated appendicitis and 21.1% increase (confidence interval: 4.8–37.3) in perforated appendicitis. Similar patterns were noted comparing Group C versus D without statistical significance. The changes seen in Wave 1 were significantly different than in 2018/2019. This trend continued in Wave 2.

Conclusion

Similar to Wave 1, acute appendicitis cases increased in severity during wave 2 of COVID-19, but with less prominence.

Increasing incidence of complicated appendicitis during COVID-19 pandemic

Background

The novel coronavirus (COVID-19) strain has resulted in restrictions potentially impacting patients presenting with acute appendicitis and their disease burden.

Methods

All acute appendicitis admissions (281 patients) between 1/1/2018-4/30/2020 were reviewed. Two groups were created: 6 weeks before (Group A) and 6 weeks after (Group B) the date elective surgeries were postponed in Massachusetts for COVID-19. Acute appendicitis incidence and disease characteristics were compared between the groups. Similar time periods from 2018 to 2019 were also compared.

Results

Fifty-four appendicitis patients were categorized in Group A and thirty-seven in Group B. Those who underwent surgery were compared and revealed a 45.5% decrease (CI: 64.2,-26.7) in uncomplicated appendicitis, a 21.1% increase (CI:3.9,38.3) in perforated appendicitis and a 29% increase (CI:11.5,46.5) in gangrenous appendicitis. Significant differences in the incidence of uncomplicated and complicated appendicitis were also noted when comparing 2020 to previous years.

Conclusions

The significant increase in complicated appendicitis and simultaneous significant decrease in uncomplicated appendicitis during the COVID-19 pandemic indicate that patients are not seeking appropriate, timely surgical care.

Letter to the Editor: Assessing the Long-Term Potential of Relaxing Regulations: Should We Go Back to Business as Usual?

The response to the COVID-19 pandemic resulted in reallocation of health care resources and removal of barriers to deliver expedited care to those in need. This might be a unique moment in history to reconsider the regulations within our health care system that significantly increase its cost.

Perioperative Considerations During Emergency General Surgery in the Era of COVID-19: A U.S. Experience

The novel coronavirus SARS-CoV-2 (COVID-19) strain has caused a pandemic that affects everyday clinical practice. Care of patients with acute surgical problems is adjusted to minimize exposing health care providers to this highly contagious virus. Our goal is to describe a specific and reproducible perioperative protocol aiming to keep health care providers safe and, simultaneously, not compromise standard of care for surgical patients.

The Use of Autologous Peritoneum for Complete Caval Replacement Following Resection of Major Intra-abdominal Malignancies

OBJECTIVE

Assessment of a simple layer peritoneal tube used as an autogenous inferior vena cava replacement.

BACKGROUND

Extensive en-bloc multivisceral resection including major vessels is effective in selected abdominal malignancies, but the need for vascular reconstruction represents a surgical challenge. We describe the use of autologous peritoneum for caval replacement.

METHODS

Autogenous parietal peritoneum without fascial backing was harvested and tubularized to replace the inferior vena cava (IVC) in four patients with complex abdominal tumors. Surgical morbidity was evaluated using the Clavien-Dindo classification, and graft patency was systematically evaluated with ultrasound.

RESULTS

All four patients had multiorgan resections for malignancies involving the retro-hepatic IVC, and they all required the replacement of infrarenal and suprarenal IVC segments. Additionally, all four required a right nephrectomy, two had a combined major hepatectomy, and one patient needed a veno-venous bypass. All had an R0 resection. A clinical follow-up took place between 5 and 11 months after surgery for each patient. Four-month graft patency was confirmed by ultra-sound and TDM with no sign of disease recurrence.

CONCLUSIONS

Autologous peritoneum without fascial backing is a good and safe option for circumferential replacement of IVC after extensive en-bloc tumor resection with IVC involvement.

Surgical Treatment of Colorectal Cancer with Peritoneal and Liver Metastases Using Combined Liver and Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Report from a Single-Centre Experience

BACKGROUND

Chemotherapeutic advances have enabled successful cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) expansion in treating metastatic colorectal cancer.

OBJECTIVES

The aims of this study were to evaluate the safety of combining liver surgery (LS) with HIPEC and CRS (which remains controversial) and its impact on overall survival (OS) rates.

METHODS

From 2007 to 2015, a total of 77 patients underwent CRS/HIPEC for peritoneal carcinomatosis (PC) of colorectal cancer. Twenty-five of these patients underwent concomitant LS for suspicion of liver metastases (LM; group 2), and were compared with patients who underwent CRS/HIPEC only (group 1). Demographic and clinical data were reviewed retrospectively.

RESULTS

Among the group 2 patients, two underwent major hepatectomies, six underwent multiple wedge resections, 16 underwent single wedge resections (one with radiofrequency ablation), and one underwent radiofrequency ablation alone. For groups 1 and 2, median peritoneal cancer index was 6 and 10 (range 0-26; p = 0.08), complication rates were 15.4 and 32.0 % (Dindo-Clavien ≥3; p = 0.15), and median follow-up was 34.2 and 25.5 months (range 0-75 and 3-97), respectively. One group 2 patient died of septic shock after 66 days. Pathology confirmed LM in 21 patients in group 2 (four with benign hepatic lesions were excluded from long-term outcome analysis). Two-year OS rates were 89.5 and 70.2 % (p = 0.04), and 2-year recurrence-free survival rates were 38.3 and 13.4 % (p = 0.01) in groups 1 and 2, respectively.

CONCLUSIONS

Simultaneous surgery for colorectal LM and PC is both feasible and safe, with low postoperative morbidity. Further longer-term studies would help determine its impact on patient survival.

Weight loss in a patient with polycystic kidney disease: when liver cysts are no longer innocent bystanders

OBJECTIVE AND IMPORTANCE

Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent inherited kidney disorder, and liver involvement represents one of its major extra-renal manifestations. Although asymptomatic in most patients, polycystic liver disease (PLD) can lead to organ compression, severe disability and even become life-threatening, thereby warranting early recognition and appropriate management.

CLINICAL PRESENTATION

We report the case of a 56-year-old woman with ADPKD and severe weight loss secondary to a giant hepatic cyst compressing the pylorus. Partial hepatectomy was required after failure of cyst aspiration and sclerotherapy, and patient's condition improved rapidly.

DISCUSSION AND CONCLUSIONS

We discuss the presentation and classification of compressing liver cysts, and the available therapeutic alternatives for this potentially severe complication of ADPKD.

Presentation and Clinical Outcomes of Choledochal Cysts in Children and Adults: A Multi-institutional Analysis

IMPORTANCE

Choledochal cysts (CCs) are rare, with risk of infection and cancer.

OBJECTIVE

To characterize the natural history, management, and long-term implications of CC disease.

DESIGN, SETTING, AND PARTICIPANTS

A total of 394 patients who underwent resection of a CC between January 1, 1972, and April 11, 2014, were identified from an international multi-institutional database. Patients were followed up through September 27, 2014. Clinicopathologic characteristics, operative details, and outcome data were analyzed from May 1, 2014, to October 14, 2014.

INTERVENTION

Resection of CC.

MAIN OUTCOMES AND MEASURES

Management, morbidity, and overall survival.

RESULTS

Among 394 patients, there were 135 children (34.3%) and 318 women (80.7%). Adults were more likely to present with abdominal pain (71.8% vs 40.7%; P < .001) and children were more likely to have jaundice (31.9% vs 11.6%; P < .001). Preoperative interventions were more commonly performed in adults (64.5% vs 31.1%; P < .001), including endoscopic retrograde pancreatography (55.6% vs 27.4%; P < .001), percutaneous transhepatic cholangiography (17.4% vs 5.9%; P < .001), and endobiliary stenting (18.1% vs 4.4%; P < .001)). Type I CCs were more often seen in children vs adults (79.7% vs 64.9%; P = .003); type IV CCs predominated in the adult population (23.9% vs 12.0%; P = .006). Extrahepatic bile duct resection with hepaticoenterostomy was the most frequently performed procedure in both age groups (80.3%). Perioperative morbidity was higher in adults (35.1% vs 16.3%; P < .001). On pathologic examination, 10 patients (2.5%) had cholangiocarcinoma. After a median follow-up of 28 months, 5-year overall survival was 95.5%. On follow-up, 13 patients (3.3%), presented with biliary cancer.

CONCLUSIONS AND RELEVANCE

Presentation of CC varied between children and adults, and resection was associated with a degree of morbidity. Although concomitant cancer was uncommon, it occurred in 3.0% of the patients. Long-term surveillance is indicated given the possibility of future development of biliary cancer after CC resection.

Impact of Intraoperative Pancreatoscopy with Intraductal Biopsies on Surgical Management of Intraductal Papillary Mucinous Neoplasm of the Pancreas

BACKGROUND

Because of its known malignant potential, precise histologic diagnosis of intraductal papillary mucinous neoplasm of the pancreas (IPMN) during intraoperative pancreatoscopy (IOP) is essential for complete surgical resection. The impact of IOP on perioperative IPMN patient management was reviewed over 20 years of practice at Cliniques universitaires Saint-Luc, Brussels, Belgium.

STUDY DESIGN

Among 86 IPMN patients treated by pancreatectomy between 1991 and 2013, 21 patients had a dilated main pancreatic duct enabling IOP and were retrospectively reviewed. The IOP was performed using an ultrathin flexible endoscope and biopsy forceps, and specimens of all suspicious lesions underwent frozen section examination.

RESULTS

Complete IOP with intraductal biopsies was easily and safely performed in 21 patients, revealing 8 occult IPMN lesions. In 5 cases (23.8%), initially planned surgical resection was modified secondary to IOP: 3 for carcinoma in situ and 2 for invasive carcinoma. The postoperative morbidity rate at 3 months was 25.0% (5 of 20); 1 patient died from septic shock postoperatively and was excluded. Median follow-up was 93 months (range 13 to 248 months). Nineteen of 21 patients were still alive and free of disease at last follow-up (90.5%); there was 1 patient with invasive carcinoma at initial pathology (pT3 N1) who died of pulmonary recurrence 21 months after surgery.

CONCLUSIONS

Intraoperative pancreatoscopy of the main pancreatic duct combined with intraductal biopsies plays a significant role in the surgical management of IPMN patients and should be used in all patients presenting a sufficiently dilated main pancreatic duct.

Minimally invasive resection of choledochal cyst: a feasible and safe surgical option

BACKGROUND

The use of minimally invasive surgery (MIS) for choledochal cyst (CC) has not been well documented. We sought to define the overall utilization and outcomes associated with the use of the open versus MIS approach for CC. We examined the factors associated with receipt of MIS for CC, as well as characterized perioperative and long-term outcomes following open versus MIS for CC.

METHODS

Between 1972 and 2014, a total of 368 patients who underwent resection for CC were identified from an international, multicenter database. A 2:1 propensity score matching was used to create comparable cohorts of patients to assess the effect of MIS on short-term outcomes.

RESULTS

Three hundred thirty-two patients had an open procedure, whereas 36 patients underwent an MIS approach. Children were more likely to be treated with a MIS approach (children, 24.0 % vs. adults, 2.1 %; P<0.001). Conversely, patients who had any medical comorbidity were less likely to undergo MIS surgery (open, 26.2 % vs. MIS, 2.8 %; P=0.002). In the propensity-matched cohort, MIS resection was associated with decreased length of stay (open, 7 days vs. MIS, 5 days), lower estimated blood loss (open, 50 mL vs. MIS, 17.5 mL), and longer operative time (open, 237 min vs. MIS, 301 min) compared with open surgery (all P<0.05). The overall and degree of complication did not differ between the open (grades I-II, n=13; grades III-IV, n=15) versus MIS (grades I-II, n=5; grades III-IV, n=5) cohorts (P=0.85). Five-year overall survival was 98.6 % (open, 98.0 % vs. MIS, 100.0 %; P=0.45); no patient who underwent MIS developed a subsequent cholangiocarcinoma.

CONCLUSIONS

MIS resection of CC was demonstrated to be a feasible and safe approach with acceptable short-term outcomes in the pediatric population. MIS for benign CC disease was associated with similar perioperative morbidity but a shorter length of stay and a lower blood loss when compared with open resection.

Successful emergency resection of a massive intra-abdominal hemophilic pseudotumor

An intra-abdominal pseudotumor is a rare complication of hemophilia. Surgical treatment is associated with high morbidity and mortality rates and reported cases are scarce. We present a 66-year-old Caucasian male suffering from severe hemophilia type A treated for 10 years with Factor VIII. Major complications from the disease were chronic hepatitis B and C, cerebral hemorrhage and disabling arthropathy. Twenty-three years ago, retro-peritoneal bleeding led to the development of a large intra-abdominal pseudotumor, which was followed-up clinically due to the high surgical risk and the lack of clinical indication. The patient presented to the emergency department with severe sepsis and umbilical discharge that had appeared over the past two days. Abdominal computed tomography images were highly suggestive of a bowel fistula. The patient was taken to the operating room under continuous infusion of factor VIII. Surgical exploration revealed a large infected pseudotumor with severe intra-abdominal adhesions and a left colonic fistula. The pseudotumor was partially resected en bloc with the left colon leaving the posterior wall intact. The postoperative period was complicated by septic shock and a small bowel fistula that required reoperation. He was discharged on the 73^rd hospital day and is well 8 mo after surgery. No bleeding complications were encountered and we consider surgery safe under factor VIII replacement therapy.

Does the site of platelet sequestration predict the response to splenectomy in adult patients with immune thrombocytopenic purpura?

Splenectomy is the only potentially curative treatment for chronic immune thrombocytopenic purpura (ITP) in adults. However, one-third of the patients relapse without predictive factors identified. We evaluate the predictive value of the site of platelet sequestration on the response to splenectomy in patients with ITP. Eighty-two consecutive patients with ITP treated by splenectomy between 1992 and 2013 were retrospectively reviewed. Platelet sequestration site was studied by (111)Indium-oxinate-labeled platelets in 93% of patients. Response to splenectomy was defined at last follow-up as: complete response (CR) for platelet count (PC) ≥100 × 10(9)/L, response (R) for PC≥30 × 10(9)/L and <100 × 10(9)/L with absence of bleeding, no response (NR) for PC<30 × 10(3)/L or significant bleeding. Laparoscopic splenectomy was performed in 81 patients (conversion rate of 16%), and open approach in one patient. Median follow-up was 57 months (range, 1-235). Platelet sequestration study was performed in 93% of patients: 50 patients (61%) exhibited splenic sequestration, 9 (11%) hepatic sequestration and 14 patients (17%) mixed sequestration. CR was obtained in 72% of patients, R in 25% and NR in 4% (two with splenic sequestration, one with hepatic sequestration). Preoperative PC, age at diagnosis, hepatic sequestration and male gender were significant for predicting CR in univariate analysis, but only age (HR = 1.025 by one-year increase, 95% CI [1.004-1.047], p = 0.020) and pre-operative PC (HR = 0.112 for > 100 versus <=100, 95% CI [0.025-0.493], p = 0.004) were significant predictors of recurrence-free survival in multivariate analysis. Response to splenectomy was independent of the site of platelet sequestration in patients with ITP. Pre-operative platelet sequestration study in these patients cannot be recommended.

Outcomes of patients with portal vein thrombosis undergoing live donor liver transplantation

BACKGROUND

Live donor liver transplantation (LDLT) for patients with portal vein thrombosis (PVT) creates several technical challenges due to severe pre-operative condition and extensive collaterals. Although deceased donor liver transplantation in patients with PVT is now routinely performed at most centers, the impact of PVT on LDLT outcomes is still controversial.

OBJECTIVE

To determine the outcome of patients with PVT who underwent LDLT.

METHODS

We reviewed the outcome of adult patients with PVT who underwent LDLT in the USA from 1998 to 2009.

RESULTS

68 (2.9%) of 2402 patients who underwent LDLT had PVT. Comparing patients with and without PVT who underwent LDLT, those with PVT were older (53 vs 50 yrs), more likely to be male, had longer length of stay (25 vs 18 days) and higher retransplantation rate (19% vs 10.7%). The allograft and patient survival was lower in patients with PVT. In Cox regression analysis, PVT was associated with worse allograft survival (HR=1.7, 95% CI: 1.1-2.5, p<0.001) and patient survival (HR=1.6, 95% CI: 1.2-2.4, p<0.001) than patients without PVT.

CONCLUSIONS

Patients with PVT who underwent LDLT had a worse prognosis than those without PVT.

Living Donor Liver Transplantation for Hepatocellular Carcinoma: It Is All about Donors?

BACKGROUND

Live-donor liver transplantation (LDLT) is a valuable option for patients with hepatocellular carcinoma (HCC) as compared with deceased-donor liver transplantation (DDLT); the tumor could be eradicated early.

METHODS

Herein, we reviewed the outcome of adult patients with HCC who underwent LDLT from 1990 to 2009 in the USA, as reported to United Network for Organ Sharing.

RESULTS

Compared to DDLT (n=5858), patients who underwent LDLT for HCC (n=170) were more likely to be female (43.8% vs 23.8%), younger (mean age 48.6 vs 54.9 years) and have more tumors outside Milan criteria (30.7% vs 13.6%). However, the recipients of LDLT for HCC had a significantly shorter mean wait time before transplantation (173 vs 219 days; p=0.04). The overall allograft and patient survival were not different, though more patients in LDLT group were outside Milan criteria. Since implementation of the MELD exception for HCC, DDLT for HCC has increased form 337 (2.3%) cases in 2002 to 1142 (18.7%) in 2009 (p<0.001). However, LDLT for HCC has remained stable from 16 (5.7%) in 2002 to 14 (9.2%) in 2009 (p=0.1). Regions 1, 5 and 9 had the highest rate of LDLT for HCC compared to other regions.

CONCLUSIONS

LDLT can achieve the same long-term outcomes compared to DDLT in patients with HCC. The current MELD prioritization for HCC reduces the necessity of LDLT for HCC except in areas with severe organ shortage.

Improving Outcomes of Liver Transplantation for Polycystic Disease in MELD Era

BACKGROUND

Liver transplantation (LT) for polycystic liver disease (PLD) has evolved to be an option for treating these patients. Patients with PLD suffer from incapacitating symptoms because of very large liver volumes but liver function is preserved until a late stage.

OBJECTIVE/METHODS

Herein, we reviewed the outcome of adult patients with PLD who underwent LT in the US comparing pre-MELD (1990-2001) to MELD era (2002-2009).

RESULTS

During this period, only 309 patients underwent LT for PLD. The number of LT for PLD is very low comparing the two eras. The percentage of patients who had combined liver and kidney transplantation (CLKT) for this disease has not changed during MELD era (42.8% vs 38.6%). The waiting time for LT (337 vs 272 days) and CLKT (289 vs 220) has increased in MELD era (p<0.001). In MELD era, 53.4% of LT and 31.2% of CLKT were done as MELD exceptional cases. The allograft and patent survival have significantly improved in MELD era.

CONCLUSION

Patients with PLD had marked improvement of their outcomes after LT in MELD era.

Liver transplantation from hepatitis B surface antigen-positive donors

One possibility to increase the organ pool is to use grafts from hepatitis B virus (HBV) surface antigen (HBsAg)-positive donors, but few data are currently available in this setting. Herein, we reviewed the outcome of 92 liver transplantations using allografts from HBsAg-positive donors in the United States (1990-2009). They had experienced HBV-related (n = 68) or HBV-unrelated disease (n = 24). There was no difference between patients who received HBsAg-positive versus HBsAg-negative allografts based on age, Model for End-stage Liver Disease (MELD) score, length of stay, wait time, and donor risk index. HBsAg-positive allografts were more likely to be imported and used in MELD exceptional cases. Allograft and patient survival were comparable between the two groups. HBsAg-positive allografts deserve consideration when no other organ is available in a suitable waiting time in the present era of highly effective antiviral therapy.

Centre volume and resource consumption in liver transplantation

BACKGROUND

Using SRTR/UNOS data, it has previously been shown that increased liver transplant centre volume improves graft and patient survival. In the current era of health care reform and pay for performance, the effects of centre volume on quality, utilization and cost are unknown.

METHODS

Using the UHC database (2009-2010), 63 liver transplant centres were identified that were organized into tertiles based on annual centre case volume and stratified by severity of illness (SOI). Utilization endpoints included hospital and intensive care unit (ICU) length of stay (LOS), cost and in-hospital mortality.

RESULTS

In all, 5130 transplants were identified. Mortality was improved at high volume centres (HVC) vs. low volume centres (LVC), 2.9 vs. 3.4%, respectively. HVC had a lower median LOS than LVC (9 vs. 10 days, P < 0.0001), shorter median ICU stay than LVC and medium volume centres (MVC) (2 vs. 3 and 3 days, respectively, P < 0.0001) and lower direct costs than LVC and MVC ($90,946 vs. $98,055 and $101,014, respectively, P < 0.0001); this effect persisted when adjusted for severity of illness.

CONCLUSIONS

This UHC-based cohort shows that increased centre volume results in improved long-term post-liver transplant outcomes and more efficient use of hospital resources thereby lowering the cost. A better understanding of these mechanisms can lead to informed decisions and optimization of the pay for performance model in liver transplantation.

Is left lobe adult-to-adult living donor liver transplantation ready for widespread use? The US experience (1998-2010)

OBJECTIVES

Living donor liver transplantation (LDLT) is an accepted treatment for patients with end-stage liver disease. To minimize risk to the donor, left lobe (LL) LDLT may be an ideal option in adult LDLT.

METHODS

This study assessed the outcomes of LL-LDLT compared with right lobe (RL) LDLT in adults (1998-2010) as reported to the United Network for Organ Sharing (UNOS) Organ Procurement and Transplantation Network (OPTN).

RESULTS

A total of 2844 recipients of LDLT were identified. Of these, 2690 (94.6%) underwent RL-LDLT and 154 (5.4%) underwent LL-LDLT. A recent increase in the number of LL-LDLTs was noted: average numbers of LL-LDLTs per year were 5.2 during 1998-2003 and 19.4 during 2004-2010. Compared with RL-LDLT recipients, LL-LDLT recipients were younger (mean age: 50.5 years vs. 47.0 years), had a lower body mass index (BMI) (mean BMI: 24.5 kg/m(2) vs. 26.8 kg/m(2)), and were more likely to be female (64.6% vs. 41.9%). Donors in LL-LDLT had a higher BMI (mean BMI: 29.4 kg/m(2) vs. 26.5 kg/m(2)) and were less likely to be female (30.9% vs. 48.1%). Recipients of LL-LDLT had a longer mean length of stay (24.9 days vs. 18.2 days) and higher retransplantation rates (20.3% vs. 10.9%). Allograft survival in LL-LDLT was significantly lower than in RL-LDLT and there was a trend towards inferior patient survival. In Cox regression analysis, LL-LDLT was found to be associated with an increased risk for allograft failure [hazard ratio (HR): 2.39)] and inferior patient survival (HR: 1.86).

CONCLUSIONS

The number of LL-LDLTs has increased in recent years.

Rare cause of delayed upper gastrointestinal bleeding after pancreaticoduodenectomy

CONTEXT

Luminal bleeding after pancreaticoduodenectomy can be present in various degrees of acuity in up to 30% of patients.

CASE REPORT

In this report, we describe a rare and uncommon cause of gastrointestinal bleeding after pancreaticoduodenectomy and review of the literature.

CONCLUSIONS

Multiple biliary procedures with common complications increase the difficulty making the correct diagnosis and therefore all possible etiologies of a complication must be evaluated.

Liver Transplantation in Patients with Portal Vein Thrombosis: Comparing Pre-MELD and MELD era

BACKGROUND

Portal vein thrombosis (PVT) used to be a relative contraindication for liver transplantation (LT). This obstacle has been dealt with following the improvement of LT-related techniques.

OBJECTIVE

To compare the outcome of adult patients with PVT who underwent LT before and after adopting MELD.

METHODS

We retrospectively searched our database for deceased donor LT recipients who had PVT, were operated between 1990 and 2009, and were 18 years old or more. The outcome of patients operated in pre-MELD era (1990-2001) was then compared with that of those operated in MELD era (2002-2009).

RESULTS

The incidence of patients undergoing LT with PVT has increased from 1.2% (491/40,730) in pre-MELD era to 6% (2540/42,601) in MELD era (p<0.01). Patients with PVT in MELD era were older (53.6 vs 50.5), had higher calculated MELD (21.3 vs 18.9), shorter length of hospital stay after LT (25 vs 21.7 days), more likely to develop HCC (14.8% vs 0), and more likely to receive DCD allograft (3.9% vs 0.8%). Donor risk indices were comparable in both groups (1.9 vs 1.9). The median waiting time before transplantation decreased during MELD era (71 vs 99 days). Allograft and patients survival was comparable between the two eras. However, allograft and patients survival rates were lower in patients with PVT compared to those without. In Cox regression analysis, PVT was associated with worse allograft (HR=1.3, 95% CI: 1.2-1.4, p<0.001) and patient survival (HR=1.3, 95% CI: 1.2-1.5, p<0.001) compared to non-PVT patients.

CONCLUSIONS

The incidence of patients with PVT has increased in MELD era without improvement in outcomes. Donor and recipients characteristics changed in MELD era. PVT is still associated with poor outcomes compared to patients without PVT.

Outcomes in partial liver transplantation: deceased donor split-liver vs. live donor liver transplantation

BACKGROUND

Organ shortage has resulted in greater emphasis on partial liver transplantation (PLT) as an alternative to whole-organ liver transplantation.

METHODS

This study was conducted to assess outcomes in PLT and to compare outcomes of deceased donor split-liver transplantation (DD-SLT) and live donor liver transplantation (LDLT) in adults transplanted in the USA using data reported to the United Network for Organ Sharing in the era of Model for End-stage Liver Disease (MELD) scores.

RESULTS

Between 2002 and 2009, 2272 PLTs were performed in the USA; these represented 5.3% of all liver transplants carried out in the country and included 557 (24.5%) DD-SLT and 1715 LDLT (75.5%) procedures. The most significant differences between the DD-SLT and LDLT groups related to mean MELD scores, which were lower in LDLT recipients (14.5 vs. 20.9; P < 0.001), mean recipient age, which was lower in the LDLT group (50.7 years vs. 52.8 years; P < 0.001), and mean donor age, which was lower in the DD-SLT group (23.0 years vs. 37.3 years; P < 0.001). Allograft survival was comparable between the two groups (P= 0.438), but patient survival after LDLT was better (P= 0.04). In Cox regression analysis, LDLT was associated with better allograft (hazards ratio [HR]= 0.7, 95% confidence interval [CI] 0.630-0.791; P < 0.0001) and patient (HR = 0.6, 95% CI 0.558-0.644; P < 0.0001) survival than DD-SLT.

CONCLUSIONS

Partial liver transplantation represents a potentially underutilized resource in the USA. Despite the differences in donor and recipient characteristics, LDLT is associated with better allograft and patient survival than DD-SLT. A different allocation system for DD-SLT allografts that takes into consideration cold ischaemia time and recipient MELD score should be considered.

Left renal vein ligation: a technique to mitigate low portal flow from splenic vein siphon during liver transplantation

Low portal vein flows in liver transplant have been associated with poor allograft survival. Identifying and ameliorating causes of inadequate portal flow is paramount. We describe successful reversal of significant splenic vein siphon from a spontaneous splenorenal shunt during liver transplant. The patient is a 43-year-old male with cirrhosis from hepatitis C and Budd-Chiari syndrome, who had a variceal hemorrhage necessitating an emergent splenorenal shunt with 8 mm PTFE graft. Imaging in 2006 revealed thrombosis of the splenorenal shunt and evidence of a new spontaneous splenorenal shunt. The patient developed hepatocellular carcinoma and underwent transplant in 2009. After reperfusion, portal flows were low (150-200 mL/min). A mesenteric varix was ligated without improvement. Due to adhesions, direct collateral ligation was not attempted. In order to redirect the splenic siphon, the left renal vein was stapled at its confluence with the inferior vena cava. Portal flows subsequently increased to 1.28 L/min. Postoperatively, the patient had stable renal and liver function. We conclude that spontaneous splenorenal shunts can cause low portal flows. A diligent search for shunts with understanding of flow patterns is critical; ligation or rerouting of splanchnic flow may be necessary to improve portal flows and allograft outcomes.

Orthotopic liver transplant using allografts from geriatric population in the United States: is there any age limit?

OBJECTIVES

Observations of minimal pathophysiological changes in the liver with healthy aging represent the rationale for expanding the donor pool with older donors. However, a debate exists for their upper age limit. The aim of this study is to examine the outcomes of orthotopic liver transplants from older patients (>or= 60 years).

MATERIALS AND METHODS

Using the Organ Procurement and Transplant Network/United Network for Organ Sharing (OPTN/UNOS) data, we retrospectively analyzed graft and patient survivals of orthotopic liver transplants done with octogenarian grafts (n=197) and compared them with orthotopic liver transplants done with donors aged between 60 and 79 years (n=4003) and < 60 years (n=21 290) during 2003 to 2007.

RESULTS

One- and 3-year graft and patient survival rates among recipients of hepatic allografts from donors < 60 years of age were significantly superior to recipients of octogenarian grafts (graft: 84% vs 75.5% at 1 year; 74.2% vs 61.2% at 3 years; P < .001; patient: 87.8% vs 81.0% at 1-year; 79.3% vs 69.1% at 3 years; P < .001). However, there was no survival difference between recipients of allografts from donors aged > 80 years and 60-79 years (graft: 75.5% vs 77.4% at 1 year; 61.2% vs 64.2% at 3 years; P = .564; patient: 81.0% vs 83.8% at 1 year; 69.1% vs 71.8% at 3 years; P = .494). It correlates well with hepatitis C virus-seronegativity and relatively lower model for end-stage liver disease score among recipients of octogenarian grafts (P < .001).

CONCLUSIONS

Careful donor evaluation, avoidance of additional donor risk factors, and their pairing with appropriate recipients offer acceptable functional recovery, even with donors > 80 years.

Foregut cystic developmental malformation: new taxonomy and classification--unifying embryopathological concepts

Foregut cystic developmental malformations are rare developmental anomalies. The problems inherent to these malformations are their presentation across specialties that include embryology, anatomy, pathology, thoracic foregut surgery, pediatric surgery and general abdominal surgery. The direct consequence of this variation has resulted in diverse terminology, classification and a failure to identify the correlation. The article aims to summarize and unify the embryological concepts of foregut cystic malformation, to suggest a generic title to the various groups of these interrelated disorders and a uniform use of nomenclature on the basis of unifying concepts of embryopathogeneis.

Nutritional effects of transjugular intrahepatic portosystemic shunt--an often neglected benefit? "A preliminary report"

Transjugular intrahepatic portosystemic shunt (TIPS) is a useful procedure for preventing complications of portal hypertension. Nutritional effects of TIPS have been described in cirrhotics. In this prospective study, the nutritional effects of TIPS in cirrhotics were aimed to be identified. BMI, anthropometric measurements, laboratory parameters and Chronic liverdisease quality of life score were measured at baseline, three and six moths following TIPS placement. Total of 12 patients (6 male, 6 female; mean age 56 years; range 41-80) were enrolled between March 2002 and June 2004. Mean baseline MELD score was 13. Only 6 out of 12 patients were able to complete the study due to several reasons. BMI increased from 21.4 to 25.5. Estimated muscle mass improved from 16.6 to 20.5 (p < 0.05). Mean serum albumin improved from 2.46 to 2.76. CLDQL score improved from 103 to 150 (p < 0.05). This small study suggests potential nutritional benefits of TIPS.

Management of hepatic metastasis from colorectal cancers: an update

Approximately 50%-60% of patients with colorectal cancers will develop liver lesions in their life span. Despite the potential of surgical resection to provide long-term survival in this subset of patients, only 15%-20% are found to be resectable. The introduction of new neoadjuvant chemotherapeutic agents and the expanding criteria of resection have enhanced the overall 5-year survival from 30% to 60% in the past decade. The use of technical innovations such as staged resection; portal vein embolization, and repeat resection have allowed higher resection rates in patients with bilobar disease. Extrahepatic primary and liver-exclusive recurrent disease no longer represent an absolute contraindication to resection. The role of regional therapy using hepatic arterial infusion is being redefined for liver-exclusive unresectable disease. Adjuvant chemotherapy in combination with regional therapies is being looked at from fresh perspectives. Ablative approaches have gained a firm role both as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Overall, the management of hepatic metastasis from colorectal cancers requires a multimodal approach.

Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1

Cirrhosis is associated with global homodynamic changes, but the majority of the complications are usually manifested through the gastrointestinal tract. Therefore, Gastrointestinal Endoscopy has become an important tool in the multidisciplinary approach in the management of these patients. With the ever growing number of cirrhotic patients requiring pre-transplant endoscopic management, it is imperative that the community endoscopists are well aware of the pathologies that can be potentially noted on Gastrointestinal Endoscopy. Their timely management is also considered to have the utmost importance in being able to stabilize the patient until their transfer to a Liver Transplant Center. The aim of this manuscript is to give a comprehensive update and review of various endoscopic findings that a non-transplant endoscopist will encounter in the pre-transplant setting.

Biliary strictures following liver transplantation: past, present and preventive strategies

Biliary complications are still the major source of morbidity for liver transplant recipients. The reported incidence of biliary strictures is 5%-15% after deceased donor liver transplantation and 28%-32% after right-lobe live donor surgery. Presentation is usually within the first year, but the incidence is known to increase with longer follow-up. The anastomotic variant is due to technical factors, whereas the nonanastomotic form is due to immunological and ischemic events, which later may lead to graft loss. Endoscopic management of anastomotic strictures achieves a success rate of 70%-100%; it drops to 50%-75% for nonanastomotic strictures with a higher recurrence rate. Results of endoscopic maneuvers are disappointing for biliary strictures after live donor liver transplantation, and the success rate is 60%-75% for anastomotic strictures and 25%-33% for the nonanastomotic variant. Preventive strategies in the cadaveric donor include the standardization of the type of anastomosis and maintenance of a vascularized ductal stump. In right-lobe live donor livers, donor liver duct harvesting also involves a major risk. The concept of high hilar intrahepatic Glissonian dissection, dissecting the artery and the duct as one unit, use of microsurgical techniques for smaller ducts, use of ductoplasty, and flexibility in the performance of double ductal anastomosis are the critical components of the preventive strategies in the recipient. In the case of live donors, judicious use of intraoperative cholangiograms, minimal dissection of the hilar plate, and perpendicular transection of the duct constitute the underlying principals for obtaining a vascularized duct.

Unusual presentation of recurrent hepatocellular carcinoma as obstructive jaundice 15 years after liver transplant

Hepatocellular carcinoma recurrence is a known limitation of liver transplant. Recurrence rates have been reported in 10% to 60% of patients within an average of 1 to 2 years following liver transplant. We report a case of recurrent hepatocellular carcinoma 15 years after orthotopic liver transplant, presenting initially as obstructive bile duct compression as detected by cholangiogram. Laparotomy revealed hepatocellular carcinoma invading the common bile duct without any mass in the liver parenchyma. The main focus of the case is the endoscopic retrograde cholangiopancreatography image, which is unique in the setting of liver disease following liver transplant.

Anemia and transfusions in patients undergoing surgery for cancer

Preoperative, operative, and postoperative factors may all contribute to high rates of anemia in patients undergoing surgery for cancer. Allogeneic blood transfusion is associated with both infectious risks and noninfectious risks such as human errors, hemolytic reactions, transfusion-related acute lung injury, transfusion-associated graft-versus-host disease, and transfusion-related immune modulation. Blood transfusion may also be associated with increased risk of cancer recurrence. Blood-conservation measures such as preoperative autologous donation, acute normovolemic hemodilution, perioperative blood salvage, recombinant human erythropoietin (epoetin alfa), electrosurgical dissection, and minimally invasive surgical procedures may reduce the need for allogeneic blood transfusion in elective surgery. This review summarizes published evidence of the consequences of anemia and blood transfusion, the effects of blood storage, the infectious and noninfectious risks of blood transfusion, and the role of blood-conservation strategies for cancer patients who undergo surgery. The optimal blood-management strategy remains to be defined by additional clinical studies. Until that evidence becomes available, the clinical utility of blood conservation should be assessed for each patient individually as a component of preoperative planning in surgical oncology.

Gallbladder Mass with a Carbohydrate Antigen 19-9 Level in the Thousands: Malignant or Benign Pathology? Report of a Case

Tumor markers such as carbohydrate antigen 19-9 (CA 19-9) are commonly measured in the serum of patients with suspected pancreaticobiliary malignancies. Moderate elevations of CA 19-9 may be seen in benign disease, but levels in the thousands are indicative of malignancy. We report the case of a 64-year-old man with an elevated CA 19-9 of 5791 U/ml and radiological findings suggestive of metastatic gallbladder carcinoma. The patient underwent cholecystectomy and excision of a common bile duct stricture, with hepaticojejunostomy and liver biopsy. The final surgical pathology was consistent with xanthogranulomatous cholecystitis (XGC) and the elevated CA 19-9 returned to normal postoperatively. Thus, an elevated CA 19-9 level, even in the thousands, should not preclude patients from an operation if a mass is deemed resectable. Thorough investigation and treatment may result in a curative operation even if unresectable malignant disease is initially suspected.

Living related donor nephrectomy in transfusion refusing donors

Many transplant programs are averse to evaluate potential kidney donors with preferences against accepting human blood products. We examined the donor and graft outcomes between our transfusion-consenting (TC) and transfusion-refusing (TR) live kidney donors to determine whether a functional or survival disadvantage resulted from the disallowance of blood product transfusion during live donor (LD) nephrectomy. From July, 1999 to August, 2005, 82 live donor nephrectomies were performed, eight of who were TR donors (10%). Blood conservation techniques were utilized in TR donors. Demographics, surgical and functional outcomes, admission and discharge hematocrit, and creatinine were compared between TC and TR donors. No donor mortalities occurred. Two TC donors received blood transfusions (2.7%), and each study group experienced a single, <1-year graft loss. Intra-operative blood losses were significantly less in TR donors (298 +/- 412 vs. 121 +/- 91 ml, P < 0.03). No differences were noted between donor demographics, intra-operative events, and graft and patient survival. Successful donor nephrectomy from TR patients has the potential to expand the kidney allograft pool to include the TR donor population. Precautionary blood conservation methods allow the informed and consenting TR individual to donate a kidney with acceptable risk and without compromise to donor or graft outcomes.

Left extended hepatectomy for a metastatic gastrointestinal stromal tumor after a disease-free interval of 17 years: report of a case

Gastrointestinal stromal tumors (GISTs), although rare, are frequently diagnosed with liver metastasis. These metastatic GISTs are poorly responsive to conventional chemotherapy; however, recent studies report improved survival after complete surgical resection of liver metastases. On the other hand, few reports describe the treatment of delayed liver metastasis after resection of a primary GIST. We report the case of a 55-year-old woman found to have liver metastasis from a GIST after a 17-year disease-free interval. The patient underwent a left extended hepatectomy for a complete resection of the metastatic GIST and is alive and well 30 months later. To our knowledge, this is the longest disease-free interval reported in the literature, and emphasizes the importance of considering late metastasis when evaluating patients with a history of GIST. Thus, surgical resection of delayed liver metastasis from a GIST should be considered as primary therapy.

Impact of a transfusion-free program on non-Jehovah's Witness patients undergoing liver transplantation

BACKGROUND

Orthotopic liver transplantation (OLT) is associated with a large amount of blood loss. This article examines the impact of the initiation of a transfusion-free program in January 2000 for Jehovah's Witnesses (JWs) on the overall use of blood products in non-JW patients undergoing OLT.

DESIGN

Retrospective review of OLT from January 1997 through December 2004.

SETTING

University of Southern California University Hospital.

PATIENTS

A total of 272 OLTs were performed on non-JW adults. This number includes 216 (79.4%) deceased donor and 56 (20.6%) living donor liver transplantations. Thirty-three OLTs were performed before January 2000 (ie, before the initiation of a transfusion-free program) (group 1), and 239 OLTs were performed after January 2000 (group 2). In group 2, all patients underwent OLT using cell-scavenging techniques and acute normovolemic hemodilution whenever feasible. Demographic, laboratory, and clinical data were collected and matched for severity of disease (model of end-stage liver disease [MELD] score). Transfusion records of packed red blood cells (PRBCs), platelets, and fresh frozen plasma (FFP) were obtained from the University of Southern California blood bank.

RESULTS

In comparing group 2 with group 1, the mean MELD score was statistically significantly higher (P < .001), whereas the mean number of intraoperative PRBC and FFP transfusions was significantly lower (P = .03 and P = .004, respectively). The number of preoperative and postoperative PRBC, FFP, and platelet transfusions between the 2 groups was not statistically different.

CONCLUSION

The development of a transfusion-free surgical program for JW patients has had a positive impact on reducing the overall blood use in non-JW patients undergoing OLT, despite the increase in MELD score.

Extended pancreatectomy with resection of the celiac axis: the modified Appleby operation

BACKGROUND

Celiac axis invasion by central and distal pancreatic cancers has been considered a contraindication to resection. Appleby first described en-bloc celiac axis resection with total gastrectomy for locally advanced gastric cancer. We present our experience with a modification of this procedure in central pancreatic cancers involving the celiac trunk.

METHODS

Three patients with central pancreatic cancers invading the celiac axis are reviewed. All patients underwent extended pancreatectomy with en-bloc resection of the celiac axis.

RESULTS

Margins were grossly clear of tumor in all patients. The mean length of stay was 8.3+/-1.1 days. There was no evidence of clinically significant gastric or hepatic ischemia. All 3 patients remain disease free at 34, 14, and 14 months from surgery, respectively.

COMMENTS

Extended pancreatectomy with celiac axis resection can result in prolonged survival and should be considered in central and distal pancreatic cancers invading the celiac trunk.

Expanding the donor kidney pool: utility of renal allografts procured in a setting of uncontrolled cardiac death

The chronic shortage of deceased kidney donors has led to increased utilization of donation after cardiac death (DCD) kidneys, the majority of which are procured in a controlled setting. The objective of this study is to evaluate transplantation outcomes from uncontrolled DCD (uDCD) donors and evaluate their utility as a source of donor kidneys. From January 1995 to December 2004, 75,865 kidney-alone transplants from donation after brain death (DBD) donors and 2136 transplants from DCD donors were reported to the United Network for Organ Sharing. Among the DCD transplants, 1814 were from controlled and 216 from uncontrolled DCD donors. The log-rank test was used to compare survival curves. The incidence of delayed graft function in controlled DCD (cDCD) was 42% and in uDCD kidneys was 51%, compared to only 24% in kidneys from DBD donors (p < 0.001). The overall graft and patient survival of DCD donors was similar to that of DBD donor kidneys (p = 0.66; p = 0.88). Despite longer donor warm and cold ischemic times, overall graft and patient survival of uDCD donors was comparable to that of cDCD donors (p = 0.65, p = 0.99). Concerted efforts should be focused on procurement of uDCD donors, which can provide another source of quality deceased donor kidneys.

When alcohol abstinence criteria create ethical dilemmas for the liver transplant team

In the setting of transplant medicine, decision making needs to take into account the multiple clinical and psychosocial case variables, rather than turn to arbitrary rules that cannot be scientifically supported

Risk factors for graft survival after liver transplantation from donation after cardiac death donors: an analysis of OPTN/UNOS data

Due to increasing use of allografts from donation after cardiac death (DCD) donors, we evaluated DCD liver transplants and impact of recipient and donor factors on graft survival. Liver transplants from DCD donors reported to UNOS were analyzed against donation after brain death (DBD) donor liver transplants performed between 1996 and 2003. We defined a recipient cumulative relative risk (RCRR) using significant risk factors identified from a Cox regression analysis: age; medical condition at transplantation; regraft status; dialysis received and serum creatinine. Graft survival from DCD donors (71% at 1 year and 60% at 3 years) were significantly inferior to DBD donors (80% at 1 year and 72% at 3 years, p < 0.001). Low-risk recipients (RCRR < or = 1.5) with low-risk DCD livers (DWIT < 30 min and CIT < 10 h, n = 226) achieved graft survival rates (81% and 67% at 1 and 3 years, respectively) not significantly different from recipients with DBD allografts (80% and 72% at 1 and 3 years, respectively, log-rank p = 0.23). Liver allografts from DCD donors may be used to increase the cadaveric donor pool, with favorable graft survival rates achieved when low-risk grafts are transplanted in a low-risk setting. Whether transplantation of these organs in low-risk recipients provides a survival benefit compared to the waiting list is unknown.

A comparison of sirolimus vs. calcineurin inhibitor-based immunosuppressive therapies in liver transplantation

BACKGROUND

Sirolimus is a potent immunosuppressive agent whose role in liver transplantation has not been well-described.

AIM

To evaluate the efficacy and side-effects of sirolimus-based immunosuppression in liver transplant patients.

METHODS

Retrospective analysis of 185 patients who underwent orthotopic liver transplantation. Patients were divided into three groups: group SA, sirolimus alone (n = 28); group SC, sirolimus with calcineurin inhibitors (n =56) and group CNI, calcineurin inhibitors without sirolimus (n = 101).

RESULTS

One-year patient and graft survival rates were 86.5% and 82.1% in group SA, 94.6% and 92.9% in group SC, and 83.2% and 75.2% in group CNI (P = N.S.). The rates of acute cellular rejection at 12 months were comparable among the three groups. At the time of transplantation, serum creatinine levels were significantly higher in group SA, but mean creatinine among the three groups at 1 month was similar. More patients in group SA required dialysis before orthotopic liver transplantation (group SA, 25%; group SC, 9%; group CNI, 5%; P = 0.008), but at 1 year, post-orthotopic liver transplantation dialysis rates were similar.

CONCLUSIONS

Sirolimus given alone or in conjunction with calcineurin inhibitors appears to be an effective primary immunosuppressant regimen for orthotopic liver transplantation patients. Further studies to evaluate the efficacy and side-effect profile of sirolimus in liver transplant patients are warranted.