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Quintini C, Del Prete L, Diago Uso T, Liu Q. Will This Liver Work? The "Ibis Redibis" of Machine Preservation Viability Assessment. Liver Transpl 2022; 28:751-753. [PMID: 35092160 DOI: 10.1002/lt.26411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Cristiano Quintini
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Luca Del Prete
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Qiang Liu
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Gadani S, Partovi S, Levitin A, Zerona N, Sengupta S, D’Amico G, Diago Uso T, Menon KVN, Quintini C. Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective. Cardiovasc Diagn Ther 2022; 12:135-146. [PMID: 35282661 PMCID: PMC8898691 DOI: 10.21037/cdt-21-98] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 10/25/2021] [Indexed: 09/01/2023]
Abstract
OBJECTIVE This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided. BACKGROUND Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation. METHODS Computerized literature search as well as discussion with experts in the field. CONCLUSIONS Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.
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Affiliation(s)
- Sameer Gadani
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sasan Partovi
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Abraham Levitin
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Zerona
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shreya Sengupta
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giuseppe D’Amico
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa Diago Uso
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - K. V. Narayanan Menon
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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3
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Quintini C, Del Prete L, Simioni A, Del Angel L, Diago Uso T, D'Amico G, Hashimoto K, Aucejo F, Fujiki M, Eghtesad B, Sasaki K, Kwon CHD, Cywinski J, Bennett A, Bilancini M, Miller C, Liu Q. Transplantation of declined livers after normothermic perfusion. Surgery 2022; 171:747-756. [PMID: 35065791 DOI: 10.1016/j.surg.2021.10.056] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/29/2021] [Accepted: 10/27/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND The persistent shortage of liver allografts contributes to significant waitlist mortality despite efforts to increase organ donation. Normothermic machine perfusion holds the potential to enhance graft preservation, extend viability, and allow liver function evaluation in organs previously discarded because considered too high-risk for transplant. METHODS Discarded livers from other transplant centers were transplanted after assessment and reconditioning with our institutionally developed normothermic machine perfusion device. We report here our preliminary data. RESULTS Twenty-one human livers declined for transplantation were enrolled for assessment with normothermic machine perfusion. Six livers (28.5%) were ultimately discarded after normothermic machine perfusion because of insufficient lactate clearance (>4.1 mmol/L after 4 hours), limited bile production (<0.5 mI/h), or moderate macrosteatosis, whereas 15 (71.5%) were considered suitable for transplantation. Normothermic machine perfusion duration was from 3 hours, 49 minutes to 10 hours, 29 minutes without technical problems or adverse events. No intraoperative or major early postoperative complications occurred in all transplanted recipients. No primary nonfunction occurred after transplantation. Seven livers had early allograft dysfunction with fast recovery, and 1 patient developed ischemic cholangiopathy after 4 months treated with biliary stents. All other patients had good liver function with a follow-up time of 8 weeks to 14 months. CONCLUSION In total, 71.5% of discarded livers subjected to ex vivo normothermic machine perfusion were successfully transplanted after organ perfusion and assessment using an institutionally built device. This study challenges the current viability criteria reported in the literature and calls for a standardization of viability markers collection, an essential condition for the advancement of the field.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Masato Fujiki
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | | | | | | | - Ana Bennett
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | | | - Qiang Liu
- Transplantation Center, Cleveland Clinic, Cleveland, OH
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Sharma V, Kleb C, Sheth C, Verma BR, Jain V, Sharma R, Parikh P, Cywinski J, Menon KVN, Esfeh JM, Eghtesad B, Quintini C, Uso TD, Tong MZY, Nair R, Bhargava A, Fares M. Cardiac considerations in liver transplantation. Cleve Clin J Med 2022; 89:46-55. [PMID: 34983801 DOI: 10.3949/ccjm.89a.21006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Cardiovascular events have a major impact on overall outcomes after liver transplantation. Today's transplant patients are older than those in the past and therefore are more likely to have coexisting cardiac comorbidities. In addition, pathophysiologic effects of advanced liver disease on the circulatory system pose challenges in perioperative management. This review discusses important preoperative, intraoperative, and postoperative cardiac considerations in patients undergoing liver transplant.
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Affiliation(s)
- Vikram Sharma
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH; Department of Cardiovascular Medicine, University of Iowa, Iowa City
| | - Cerise Kleb
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Chirag Sheth
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Beni Rai Verma
- Department of Hospital Medicine, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Ruchi Sharma
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH
| | - Parth Parikh
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic; Clinical Instructor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Jacek Cywinski
- Department of General Anaesthesia, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - K V Narayanan Menon
- Medical Director of Liver Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | | | - Bijan Eghtesad
- Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Teresa Diago Uso
- Digestive Disease and Surgery Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Michael Z Y Tong
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Ravi Nair
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic; Professor Emeritus, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Ajay Bhargava
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Maan Fares
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Nair A, Sasaki K, Diago Uso T, D'Amico G, Eghtesad B, Aucejo F, Kwon CHD, Fujiki M, Miller C, Hashimoto K, Quintini C. The Prognostic Utility of Intraoperative Allograft Vascular Inflow Measurements in Donation After Circulatory Death Liver Transplantation. Liver Transpl 2022; 28:65-74. [PMID: 34133830 DOI: 10.1002/lt.26212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/23/2021] [Accepted: 05/27/2021] [Indexed: 01/13/2023]
Abstract
Donation after circulatory death (DCD) liver transplantation improves deceased donor liver use and decreases waitlist burden, albeit at an increased risk of biliary complications and inferior graft survival. Employing liver vascular inflow measurements intraoperatively permits allograft prognostication. However, its use in DCD liver transplantation is hitherto largely unknown and further explored here. DCD liver transplantation patient records at a single center from 2005 to 2018 were retrospectively scrutinized. Intraoperative flow data and relevant donor parameters were analyzed against endpoints of biliary events and graft survival. A total of 138 cases were chosen. The incidence of cumulative biliary complications was 38%, the majority of which were anastomotic strictures and managed successfully by endoscopic means. The ischemic cholangiopathy rate was 6%. At median thresholds of a portal vein (PV) flow rate of <92 mL/minute/100 g and buffer capacity (BC) of >0.04, both variables were independently associated with risk of biliary events (P = 0.01 and 0.04, respectively). Graft survival was 90% at 12 months and 75% at 5 years. Cox regression analysis revealed a PV flow rate of <50 mL/minute/100 g as predictive of poorer graft survival (P = 0.01). Furthermore, 126 of these DCD livers were analyzed against a propensity-matched group of 378 contemporaneous donation after brain death liver allografts (1:3), revealing significantly higher rates (P < 0.001) of both early allograft dysfunction (70% versus 30%) and biliary complications (37% versus 20%) in the former group. Although flow data were comparable between both sets, PV flow and BC were predictive of biliary events only in the DCD cohort. Intraoperative inflow measurements therefore provide valuable prognostication on biliary/graft outcomes in DCD liver transplantation, can help inform graft surveillance, and its routine use is recommended.
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Affiliation(s)
- Amit Nair
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Kazunari Sasaki
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Giuseppe D'Amico
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Federico Aucejo
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Choon Hyuck David Kwon
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Masato Fujiki
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Kleb C, Jain V, Sheth C, Wolski K, Kapadia S, Grimm R, Desai M, Krishnaswamy A, Kassis N, Sheng C, Zheng H, Cywinski J, Menon KVN, Eghtesad B, Diago Uso T, Quintini C, Schoenhagen P, Harb SC, Sharma V, Fares M. Comparison of Coronary Artery Calcium Scoring with Dobutamine Stress Echo for Detection of Coronary Artery Disease Before Liver Transplantation. Ann Transplant 2021; 26:e934163. [PMID: 34934037 PMCID: PMC8711211 DOI: 10.12659/aot.934163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Dobutamine stress echocardiography (DSE) is commonly used for cardiovascular assessment before orthotopic liver transplantation (OLT). The coronary artery calcium score (CACS) is a useful screening tool for coronary artery disease (CAD). We aimed to compare the sensitivity and specificity of DSE and CACS for CAD in OLT candidates. Material/Methods A total of 265 of the 1589 patients who underwent OLT at our center between 2008 and 2019 had preoperative coronary angiography (CAG). Of these, 173 had DSE and 133 had a CT scan suitable for CACS calculation within 1 year of OLT. Patients with a nondiagnostic DSE were excluded (n=100). Two reviewers evaluated CACS on CT scans. The sensitivity/specificity of DSE and CACS for detection of angiographically significant CAD were calculated for patients with both tests (n=36). A separate analysis compared the sensitivity/specificity of a diagnostic DSE (n=73) and CACS (n=133) against CAG for all patients with either test. Results Sensitivity and specificity were 57.1% and 89.7%, respectively, for DSE, compared with 71.4% and 62.1% for CACS at ≥100 Agatston score. For the analysis of all patients with either test, the sensitivity/specificity of DSE for detection of CAD and CACS were 30.8% and 85.0% and 80.0% and 62.8%, respectively. On ROC analysis, CACS was a satisfactory predictor of obstructive CAD (AUC, 0.76±0.06, 95% CI, 0.66–0.87; P<0.001). Conclusions CACS may be an important tool for cardiovascular assessment in patients undergoing OLT. DSE was nondiagnostic in a large percentage of OLT candidates, limiting its use in this population.
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Affiliation(s)
- Cerise Kleb
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Chirag Sheth
- Department of Internal Medicine, Sutter Tracy Community Hospital, Tracy, CA, USA
| | - Kathy Wolski
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Richard Grimm
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Milind Desai
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Kassis
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Calvin Sheng
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Huili Zheng
- Department of Statistics, National University Heart Centre Singapore, Singapore, Singapore
| | - Jacek Cywinski
- Department of Anesthesia, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - K V Narayanan Menon
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bijan Eghtesad
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa Diago Uso
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Paul Schoenhagen
- Department of Diagnostic Radiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Vikram Sharma
- Department of Cardiology, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Maan Fares
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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7
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Liu Q, Del Prete L, Hassan A, Pezzati D, Bilancini M, D'Amico G, Diago Uso T, Hashimoto K, Aucejo F, Fujiki M, Sasaki K, Kwon CHD, Eghtesad B, Miller C, Quintini C. Two pumps or one pump? A comparison of human liver normothermic machine perfusion devices for transplantation. Artif Organs 2021; 46:859-866. [PMID: 34904245 DOI: 10.1111/aor.14150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/06/2021] [Accepted: 12/10/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Normothermic machine perfusion provides continuous perfusion to ex situ hepatic grafts through the portal vein and the hepatic artery. Because the portal vein has high flow with low pressure and the hepatic artery has low flow with high pressure, different types of perfusion machines have been employed to match the two vessels' infusion hemodynamics. METHODS We compared transplanted human livers perfused through a 2-pump (n = 9) versus a 1-pump perfusion system (n = 6) where a C-clamp is used as a tubing constrictor to regulate hemodynamics. RESULTS There was no significant difference between groups in portal vein or hepatic artery flow rate. The 1-pump group had more hemoglobin in the perfusate. However, there was no significant difference in plasma hemoglobin between the 2-pump and 1-pump groups at each time point or in the change in levels, proving no hemolysis occurred due to C-clamp tube constriction. After transplantation, the 2-pump group had two cases of early allograft dysfunction (EAD), whereas the 1-pump group had no EAD. There was no graft failure or patient death in either group during follow-up ranging from 20-52 months. CONCLUSIONS Our data show that the 1-pump design provided the same hemodynamic output as the 2-pump design, with no additional hemolytic risk, but with the benefits of lower costs, easier transport and faster and simpler setting.
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Affiliation(s)
- Qiang Liu
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Luca Del Prete
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ahmed Hassan
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniele Pezzati
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mary Bilancini
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Federico Aucejo
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Masato Fujiki
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kazunari Sasaki
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Bijan Eghtesad
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic, Cleveland, Ohio, USA
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Sasaki K, Aucejo FN, Nair A, Fujiki M, Diago Uso T, Quintini C, Miller CM, Hashimoto K, Kwon CHD. Seamless Introduction of a Purely Laparoscopic Full-Lobe Living Donor Hepatectomy Program in a North American Center. Liver Transpl 2021; 27:1203-1206. [PMID: 33629504 DOI: 10.1002/lt.26030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/07/2020] [Accepted: 02/07/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Kazunari Sasaki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Federico N Aucejo
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Amit Nair
- Department of Transplant and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, NY
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Charles M Miller
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Choon Hyuck David Kwon
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Sasaki K, Nair A, Firl DJ, McVey JC, Moro A, Diago Uso T, Fujiki M, Aucejo FN, Quintini C, Kwon CHD, Eghtesad B, Miller CM, Hashimoto K. Conditional probability of graft survival in liver transplantation using donation after circulatory death grafts - a retrospective study. Transpl Int 2021; 34:1433-1443. [PMID: 33599045 DOI: 10.1111/tri.13846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 01/11/2023]
Abstract
The use of livers from donation after circulatory death (DCD) is historically characterized by increased rates of biliary complications and inferior short-term graft survival (GS) compared to donation after brain death (DBD) allografts. This study aimed to evaluate the dynamic prognostic impact of DCD livers to reveal whether they remain an adverse factor even after patients survive a certain period following liver transplant (LT). This study used 74 961 LT patients including 4065 DCD LT in the scientific registry of transplant recipients from 2002-2017. The actual, 1 and 3-year conditional hazard ratio (HR) of 1-year GS in DCD LT were calculated using a conditional version of Cox regression model. The actual 1-, 3-, and 5-year GS of DCD LT recipients were 83.3%, 73.3%, and 66.3%, which were significantly worse than those of DBD (all P < 0.01). Actual, 1-, and 3-year conditional HR of 1-year GS in DCD compared to DBD livers were 1.87, 1.49, and 1.39, respectively. Graft loss analyses showed that those lost to biliary related complications were significantly higher in the DCD group even 3 years after LT. National registry data demonstrate the protracted higher risks inherent to DCD liver grafts in comparison to their DBD counterparts, despite survival through the early period after LT. These findings underscore the importance of judicious DCD graft selection at individual center level to minimize the risk of long-term biliary complications.
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Affiliation(s)
- Kazunari Sasaki
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Amit Nair
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel J Firl
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - John C McVey
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Amika Moro
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Teresa Diago Uso
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Federico N Aucejo
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Choon-Hyuck D Kwon
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Charles M Miller
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
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10
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D'Amico G, Matsushima H, Del Prete L, Diago Uso T, Armanyous SR, Hashimoto K, Eghtesad B, Fujiki M, Aucejo F, Sasaki K, Kwon CHD, Simioni A, Miller C, Quintini C. Long term outcomes and complications of reno-portal anastomosis in liver transplantation: results from a propensity score-based outcome analysis. Transpl Int 2021; 34:1938-1947. [PMID: 34008257 DOI: 10.1111/tri.13920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/29/2021] [Accepted: 05/11/2021] [Indexed: 12/23/2022]
Abstract
Diffuse splanchnic vein thrombosis (DSVT) remains a serious challenge in liver transplantation (LT). Reno-portal anastomosis (RPA) has previously been reported as a valid option for management of patients with DSVT during LT. The aim of this study was to evaluate post-transplant renal function and surgical outcomes of patients with DSVT who underwent RPA during LT. Between January 2005 and December 2017, 1270 patients underwent LT at our institution, including 16 with DSVT managed with RPA (RPA group). We compared renal function and surgical outcomes in these patients to outcomes in 48 propensity score (PS)-matched patients without thrombosis (control group), using a 1:3 matching model. The two groups had similar rates of postoperative portal vein thrombosis (PVT), renal dysfunction as measured by estimated glomerular filtration rate (eGFR), and overall postoperative complications (Clavien grade III), although the RPA group had a higher incidence of postoperative upper gastrointestinal (GI) bleeding (31.3% vs 4.2%; P = 0.009) that had no clinical consequence. There were no significant differences in five-year graft and patient survival rates between the groups (P = 0.133 and P = 0.166, respectively). RPA is an established technique in the management of patients with DSVT during LT, with comparable outcomes to patients without thrombosis. Our report is the first to demonstrate similar surgical outcomes, including long-term renal function, in LT recipients with or without RPA.
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Affiliation(s)
| | | | - Luca Del Prete
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Federico Aucejo
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Kazunari Sasaki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Andrea Simioni
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
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11
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Tong MZ, Quintini C, D'Amico G, Laczynski D, Diago Uso T, Al Khalloufi K, Del Prete L, Partovi S, Martin C, Miller C. Severe Outflow Obstruction After Liver Transplantation: Rescue Stapled Cavo-Cavostomy via the Right Atrial Approach and Hypothermic Circulatory Arrest. Liver Transpl 2021; 27:763-766. [PMID: 33232553 DOI: 10.1002/lt.25954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/23/2020] [Accepted: 11/17/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Michael Z Tong
- Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Giuseppe D'Amico
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - David Laczynski
- Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Teresa Diago Uso
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | | | - Luca Del Prete
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Sasan Partovi
- Diagnostic Radiology, Cleveland Clinic Foundation, Cleveland, OH
| | - Charles Martin
- Diagnostic Radiology, Cleveland Clinic Foundation, Cleveland, OH
| | - Charles Miller
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
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12
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D'Amico G, Uso TD, Del Prete L, Hashimoto K, Aucejo FN, Fujiki M, Eghtesad B, Sasaki K, David Kwon CH, Miller CM, Quintini C. Neuroendocrine liver metastases: The role of liver transplantation. Transplant Rev (Orlando) 2021; 35:100595. [PMID: 33548685 DOI: 10.1016/j.trre.2021.100595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Neuroendocrine tumor (NET) metastasis localized to the liver is an accepted indication for liver transplantation as such tumors have a low biological aggressiveness in terms of malignancy and are slow growing. RECENT FINDINGS The long-term results are comparable with and in some cases even better than those of transplantations performed for primary liver cancer. However, compared with nonmalignant conditions, neuroendocrine liver metastasis (NELM) may result in an inferior outcome of transplantation. In the face of the scarcity of donated organs and recent improved results of non-surgical treatment for NELM, controversy over patient selection and timing for liver transplantation continues. SUMMARY In this review, we provide an overview of the diagnostic work-up and selection criteria of patients with NELM being considered for liver transplantation. Thereafter, we provide a critical analysis of the reported outcomes of OLT.
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Affiliation(s)
- Giuseppe D'Amico
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Teresa Diago Uso
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Del Prete
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Federico N Aucejo
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kazunari Sasaki
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Choon H David Kwon
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charles M Miller
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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13
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D’Amico G, Uso TD. Liver Transplantation for Neuroendocrine Metastases. Curr Transpl Rep 2020. [DOI: 10.1007/s40472-020-00309-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Li X, D'Amico G, Quintini C, Uso TD, Gadani S, Romero-Marrero C, Martin C, Partovi S. Intravascular ultrasound in the diagnosis and treatment of central venous diseases. VASA 2020; 50:2-10. [PMID: 33138741 DOI: 10.1024/0301-1526/a000914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Intravascular ultrasound (IVUS) has been used extensively in coronary applications. Its use in venous applications has increased as endovascular therapy has increasingly become the mainstay therapy for central venous diseases. IVUS has been used for both diagnostic and therapeutic purposes in managing venous stenotic disease, venous occlusive disease, and IVC filter placement and removal. IVUS has been proven to be effective in providing detailed measurement of the venous anatomy, which aid in determining the appropriate size and the approach for venous stent placement. In IVC filter placement, IVUS can provide detailed measurement and guide IVC filter placement in emergent and critical care settings. It also has certain utility in filter removal. At any rate, to date there are only a few studies examining its impact on patient outcomes. Prospective randomized controlled trials are warranted in the future.
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Affiliation(s)
- Xin Li
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Giuseppe D'Amico
- Department of Transplant Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Department of Transplant Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Teresa Diago Uso
- Department of Transplant Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sameer Gadani
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Carlos Romero-Marrero
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Martin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
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15
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Quintini C, Diago Uso T, Liu Q. Ischemia-Free Liver Transplantation: Will the Diamond With a Flaw Replace the Pebble Without? Liver Transpl 2020; 26:1391-1392. [PMID: 32935907 DOI: 10.1002/lt.25892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - Qiang Liu
- Transplantation Center, Cleveland Clinic, Cleveland, OH
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16
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Matsushima H, Fujiki M, Sasaki K, Cywinski JB, D’Amico G, Uso TD, Aucejo F, David Kwon CH, Eghtesad B, Miller C, Quintini C, Hashimoto K. Can pretransplant TIPS be harmful in liver transplantation? A propensity score matching analysis. Surgery 2020; 168:33-39. [DOI: 10.1016/j.surg.2020.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/10/2020] [Accepted: 02/18/2020] [Indexed: 12/31/2022]
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17
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Matsushima H, Acevedo-Moreno LA, Sasaki K, Fujiki M, Kwon CHD, Uso TD, D'Amico G, Aucejo F, Eghtesad B, Miller C, Quintini C, Hashimoto K. Does graft hemodynamics affect the risk of hepatocellular carcinoma recurrence after liver transplantation? Clin Transplant 2020; 34:e14004. [PMID: 32515016 DOI: 10.1111/ctr.14004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/15/2020] [Accepted: 05/29/2020] [Indexed: 12/11/2022]
Abstract
Although experimental studies have reported that hepatic ischemia-reperfusion injury promotes tumor growth and metastases, the impact of graft hemodynamics on the recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) is unclear. To investigate the association between graft hemodynamics and HCC recurrence after LT, we conducted a retrospective analysis of 279 patients who underwent LT for HCC. Graft hemodynamics including portal vein flow (PVF), hepatic artery flow (HAF), and total hepatic flow (THF) was analyzed as a predictor of HCC recurrence, using competing risk regression analyses. The cutoff values of PVF, HAF, and THF were set at the lower quartile of distribution. A cumulative recurrence curve demonstrated that low THF (<1511 mL/min, P = .005) was significantly associated with increased recurrence, whereas neither low PVF (<1230 mL/min, P = .150) nor low HAF (<164 mL/min, P = .110) was significant. On multivariate analysis, outside Milan criteria (sub-hazard ratio [SHR] = 3.742; P < .001), microvascular invasion (SHR = 3.698; P < .001), and low THF (SHR = 2.359; P = .010) were independently associated with increased HCC recurrence. In conclusion, our findings suggest that graft hemodynamics may play an important role in HCC recurrence after LT.
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Affiliation(s)
- Hajime Matsushima
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lou-Anne Acevedo-Moreno
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Choon Hyuck David Kwon
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Teresa Diago Uso
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Giuseppe D'Amico
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Federico Aucejo
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Miller
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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18
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Liu Q, Hassan A, Pezzati D, Soliman B, Lomaglio L, Grady P, Del Angel Diaz L, Simioni A, Maikhor S, Etterling J, D'Amico G, Iuppa G, Diago Uso T, Hashimoto K, Aucejo F, Fujiki M, Eghtesad B, Sasaki K, Kwon CHD, Cywinski J, Irefin S, Bennett A, Baldwin W, Miller C, Quintini C. Ex Situ Liver Machine Perfusion: The Impact of Fresh Frozen Plasma. Liver Transpl 2020; 26:215-226. [PMID: 31642164 DOI: 10.1002/lt.25668] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/07/2019] [Indexed: 12/14/2022]
Abstract
The primary aim of this single-center, phase 1 exploratory study was to investigate the safety, feasibility, and impact on intrahepatic hemodynamics of a fresh frozen plasma (FFP)-based perfusate in ex situ liver normothermic machine perfusion (NMP) preservation. Using an institutionally developed perfusion device, 21 livers (13 donations after brain death and 8 donations after circulatory death) were perfused for 3 hours 21 minutes to 7 hours 52 minutes and successfully transplanted. Outcomes were compared in a 1:4 ratio to historical control patients matched according to donor and recipient characteristics and preservation time. Perfused livers presented a very low resistance state with high flow during ex situ perfusion (arterial and portal flows 340 ± 150 and 890 ± 70 mL/minute/kg liver, respectively). This hemodynamic state was maintained even after reperfusion as demonstrated by higher arterial flow observed in the NMP group compared with control patients (220 ± 120 versus 160 ± 80 mL/minute/kg liver, P = 0.03). The early allograft dysfunction (EAD) rate, peak alanine aminotransferase (ALT), and peak aspartate aminotransferase (AST) levels within 7 days after transplantation were lower in the NMP group compared with the control patients (EAD 19% versus 46%, P = 0.02; peak ALT 363 ± 318 versus 1021 ± 999 U/L, P = 0.001; peak AST 1357 ± 1492 versus 2615 ± 2541 U/L, P = 0.001 of the NMP and control groups, respectively). No patient developed ischemic type biliary stricture. One patient died, and all other patients are alive and well at a follow-up of 12-35 months. No device-related adverse events were recorded. In conclusion, with this study, we showed that ex situ NMP of human livers can be performed safely and effectively using a noncommercial device and an FFP-based preservation solution. Future studies should further investigate the impact of an FFP-based perfusion solution on liver hemodynamics during ex situ normothermic machine preservation.
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Affiliation(s)
- Qiang Liu
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmed Hassan
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Daniele Pezzati
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Basem Soliman
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Laura Lomaglio
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Patrick Grady
- Perfusion Services, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Laurent Del Angel Diaz
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Andrea Simioni
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Shana Maikhor
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - John Etterling
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Giuseppe D'Amico
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Giuseppe Iuppa
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Federico Aucejo
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Masato Fujiki
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Kazunari Sasaki
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Choon Hyuck David Kwon
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Jacek Cywinski
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Samuel Irefin
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Ana Bennett
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - William Baldwin
- Inflammation and Immunity Department, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
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19
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Matsushima H, Fujiki M, Sasaki K, Rotroff DM, Sands M, Bayona Molano MDP, Aucejo F, Diago Uso T, Eghtesad B, Miller C, Quintini C, Hashimoto K. Predictive Value of Hepatic Venous Pressure Gradient for Graft Hemodynamics in Living Donor Liver Transplantation. Liver Transpl 2019; 25:1034-1042. [PMID: 30980599 DOI: 10.1002/lt.25471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 03/08/2019] [Indexed: 02/07/2023]
Abstract
The hepatic venous pressure gradient (HVPG) measurement is known to correlate with the severity of portal hypertension in patients with liver cirrhosis. This retrospective study investigated the clinical value of preoperative measurement of HVPG in patients who underwent adult-to-adult living donor liver transplantation (LDLT) and its predictive value for hepatic hemodynamics after graft reperfusion. For this study, 75 patients who underwent adult-to-adult LDLT were divided into 2 groups (HVPG <16 mm Hg or HVPG ≥16 mm Hg) to investigate the correlation between preoperative HVPG and characteristics and surgical outcomes of the patients, including portal vein flow (PVF) and hepatic artery flow (HAF) after graft reperfusion. In total, 35 (46.7%) patients had an HVPG ≥16 mm Hg. These patients had significantly higher international normalized ratio values, serum creatinine levels, and Model for End-Stage Liver Disease scores compared with the 40 patients with HVPG <16 mm Hg. They also had higher rates of variceal bleeding, encephalopathy, and intractable ascites as well as lower serum albumin levels and platelet counts compared with those patients with HVPG <16 mm Hg. Portal inflow modulation (PIM) was frequently performed in the patients with HVPG ≥16 mm Hg compared with those with HVPG <16 mm Hg. No significant differences in surgical outcomes after LDLT were found between these 2 groups except for postoperative ascites. Preoperative HVPG showed a positive correlation with PVF and a negative correlation with HAF after graft reperfusion (false discovery rate [FDR] P = 0.08 and FDR P = 0.08, respectively). In linear regression analyses, preoperative HVPG was independently associated with PVF after graft reperfusion. In conclusion, our findings indicate that preoperative HVPG is associated with hepatic hemodynamics after graft implantation in LDLT. HVPG as a routine preoperative evaluation may be helpful for surgical planning of PIM.
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Affiliation(s)
- Hajime Matsushima
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Kazunari Sasaki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel M Rotroff
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Mark Sands
- Department of Radiology, Cleveland Clinic, Cleveland, OH
| | | | - Federico Aucejo
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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20
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Sasaki K, Firl DJ, McVey JC, Schold JD, Iuppa G, Diago Uso T, Fujiki M, Aucejo FN, Quintini C, Eghetsad B, Miller CM, Hashimoto K. Elevated Risk of Split-Liver grafts in adult liver Transplantation: Statistical Artifact or Nature of the Beast? Liver Transpl 2019; 25:741-751. [PMID: 30615254 DOI: 10.1002/lt.25409] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023]
Abstract
A recent study using US national registry data reported, using Cox proportional hazards (PH) models, that split-liver transplantation (SLT) has improved over time and is no more hazardous than whole-liver transplantation (WLT). However, the study methods violated the PH assumption, which is the fundamental assumption of Cox modeling. As a result, the reported hazard ratios (HRs) are biased and unreliable. This study aimed to investigate whether the risk of graft survival (GS) in SLT has really improved over time, ensuring attention to the PH assumption. This study included 80,998 adult deceased donor liver transplantation (LT) (1998-2015) from the Scientific Registry Transplant Recipient. The study period was divided into 3 time periods: era 1 (January 1998 to February 2002), era 2 (March 2002 to December 2008), and era 3 (January 2009 to December 2015). The PH assumption was tested using Schoenfeld's test, and where the HR of SLT violated the assumption, changes in risk for SLT over time from transplant were assessed. SLT was performed in 1098 (1.4%) patients, whereas WLT was used in 79,900 patients. In the Cox PH analysis, the P values of Schoenfeld's global tests were <0.05 in all eras, which is consistent with deviation from proportionality. Assessing HRs of SLT with a time-varying effect, multiple Cox models were conducted for post-LT intervals. The HR curves plotted according to time from transplant were higher in the early period and then decreased at approximately 1 year and continued to decrease in all eras. For 1-year GS, the HRs of SLT were 1.92 in era 1, 1.52 in era 2, and 1.47 in era 3 (all P < 0.05). In conclusion, the risk of SLT has a time-varying effect and is highest in the early post-LT period. The risk of SLT is underestimated if it is evaluated by overall GS. SLT was still hazardous if the PH assumption was considered, although it became safer over time.
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Affiliation(s)
- Kazunari Sasaki
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Daniel J Firl
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - John C McVey
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Giuseppe Iuppa
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Masato Fujiki
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Federico N Aucejo
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghetsad
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Charles M Miller
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Digestive Disease Institute, Department of General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH
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21
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Quintini C, Lomaglio L, Pezzati D, Diago Uso T, Liu Q. Combined Hypothermic and Normothermic Perfusion for the Optimization of Injured Liver Grafts. Liver Transpl 2018; 24:1647-1648. [PMID: 30371975 DOI: 10.1002/lt.25370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023]
Affiliation(s)
| | - Laura Lomaglio
- Liver Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | - Daniele Pezzati
- Centro Trapianti di Fegato, Universita' di Pisa, Pisa, Italy
| | | | - Qiang Liu
- Liver Transplant Program, Cleveland Clinic, Cleveland, Ohio
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22
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D'Amico G, Hassan A, Diago Uso T, Hashmimoto K, Aucejo FN, Fujiki M, Eghtesad B, Sasaki K, Lindenmeyer CC, Miller CM, Quintini C. Renoportal anastomosis in liver transplantation and its impact on patient outcomes: a systematic literature review. Transpl Int 2018; 32:117-127. [DOI: 10.1111/tri.13368] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/28/2018] [Accepted: 10/19/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Giuseppe D'Amico
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Ahmed Hassan
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Teresa Diago Uso
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Koji Hashmimoto
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Federico N. Aucejo
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Masato Fujiki
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Bijan Eghtesad
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Kazunari Sasaki
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Christina C. Lindenmeyer
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Charles M. Miller
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Cristiano Quintini
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
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Liu Q, Buccini L, Pezzati D, Hassan A, Diago Uso T, Miller C, Quintini C. Reply. Liver Transpl 2018; 24:710. [PMID: 29389070 DOI: 10.1002/lt.25028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/03/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Qiang Liu
- Transplantation Center Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Laura Buccini
- Transplantation Center Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Daniele Pezzati
- Transplantation Center Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Ahmed Hassan
- Transplantation Center Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Transplantation Center Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Transplantation Center Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Transplantation Center Department of General Surgery, Cleveland Clinic, Cleveland, OH
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Liu Q, Nassar A, Buccini L, Grady P, Soliman B, Hassan A, Pezzati D, Iuppa G, Diago Uso T, Miller C, Quintini C. Ex situ 86-hour liver perfusion: Pushing the boundary of organ preservation. Liver Transpl 2018; 24:557-561. [PMID: 29316185 DOI: 10.1002/lt.25007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/15/2017] [Accepted: 12/16/2017] [Indexed: 12/07/2022]
Affiliation(s)
- Qiang Liu
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Ahmed Nassar
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Laura Buccini
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Patrick Grady
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Basem Soliman
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Ahmed Hassan
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Daniele Pezzati
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Giuseppe Iuppa
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
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Liu Q, Nassar A, Buccini L, Iuppa G, Soliman B, Pezzati D, Hassan A, Blum M, Baldwin W, Bennett A, Chavin K, Okamoto T, Uso TD, Fung J, Abu-Elmagd K, Miller C, Quintini C. Lipid metabolism and functional assessment of discarded human livers with steatosis undergoing 24 hours of normothermic machine perfusion. Liver Transpl 2018; 24:233-245. [PMID: 29125712 DOI: 10.1002/lt.24972] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/18/2017] [Accepted: 11/05/2017] [Indexed: 02/07/2023]
Abstract
Normothermic machine perfusion (NMP) is an emerging technology to preserve liver allografts more effectively than cold storage (CS). However, little is known about the effect of NMP on steatosis and the markers indicative of hepatic quality during NMP. To address these points, we perfused 10 discarded human livers with oxygenated NMP for 24 hours after 4-6 hours of CS. All livers had a variable degree of steatosis at baseline. The perfusate consisted of packed red blood cells and fresh frozen plasma. Perfusate analysis showed an increase in triglyceride levels from the 1st hour (median, 127 mg/dL; interquartile range [IQR], 95-149 mg/dL) to 24th hour of perfusion (median, 203 mg/dL; IQR, 171-304 mg/dL; P = 0.004), but tissue steatosis did not decrease. Five livers produced a significant amount of bile (≥5 mL/hour) consistently throughout 24 hours of NMP. Lactate in the perfusate cleared to <3 mmol/L in most livers within 4-8 hours of NMP, which was independent of bile production rate. This is the first study to characterize the lipid profile and functional assessment of discarded human livers at 24 hours of NMP. Liver Transplantation 24 233-245 2018 AASLD.
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Affiliation(s)
- Qiang Liu
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Ahmed Nassar
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Laura Buccini
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Basem Soliman
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Ahmed Hassan
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Matthew Blum
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Ana Bennett
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Kenneth Chavin
- University Hospital, Case Western Reserve University, Cleveland, OH
| | | | | | - John Fung
- Transplantation Center, Cleveland Clinic, Cleveland, OH
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Quintini C, Diago Uso T, Fujiki M, Eghtesad B, Iuppa G, Aucejo F, Miller C, Hashimoto K. Liver "lobe neutrality" in the era of donor safety. Could "safe" be safer? Transpl Int 2018; 31:588-589. [PMID: 29360227 DOI: 10.1111/tri.13117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/30/2017] [Indexed: 01/02/2023]
Affiliation(s)
| | | | - Masato Fujiki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Federico Aucejo
- Department of Transplant Surgery, Digestive Disease Institute, Cleveland, OH, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
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Pezzati D, Hassan A, Buccini L, Liu Q, Diago Uso T, Quintini C. Liver transplantation with geriatric liver allograft in the US: a matter of epidemiology or outcome requirements? Transpl Int 2017; 30:1190-1191. [PMID: 28777472 DOI: 10.1111/tri.13013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Daniele Pezzati
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Hassan
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Laura Buccini
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Qiang Liu
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Teresa Diago Uso
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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Power C, Joyce D, Anzlovar N, Uso TD, Walsh MR, Morris-Stiff G. Bacteriological Profiles of Surgical Site Infections after Pancreatoduodenectomy: Do We Need to Change the Prophylactic Antibiotic Regimen? J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shiba H, Hashimoto K, Kelly D, Fujiki M, Quintini C, Aucejo F, Uso TD, Yerian L, Yanaga K, Matsushima M, Eghtesad B, Fung J, Miller C. Risk stratification of allograft failure secondary to hepatitis C recurrence after liver transplantation. Hepatol Res 2016; 46:1099-1106. [PMID: 26833562 DOI: 10.1111/hepr.12661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 01/06/2016] [Accepted: 01/22/2016] [Indexed: 12/24/2022]
Abstract
AIM Hepatitis C virus (HCV) recurrence after liver transplantation decreases survival rates. Improved understanding of the multiple factors influencing HCV recurrence could aid decision-making for donor-recipient pairing and maximize transplant outcomes. The aim of this study was to create a model based on pretransplant variables to stratify patients at risk of HCV-related allograft failure. METHODS This retrospective study enrolled 154 liver transplant recipients with HCV at Cleveland Clinic. RESULTS Among the study population, 54 recipients (35.1%) experienced HCV recurrence, histologically defined as moderate to severe hepatitis and/or bridging fibrosis to cirrhosis. The multivariate analysis found donor age (≥60 years, P < 0.002), donor body mass index (≥30 kg/m2 , P < 0.05), African American recipient (P < 0.01) and genotype 1 (P < 0.02) as risk factors for HCV-related allograft failure. When these four factors were scored as a combined index (no factor [n = 15], one factor [n = 76], two factors [n = 43] and three or more factors [n = 20]), the HCV recurrence-free survival showed good stratification according to the scores: 93.3% with no factor, 79.3% with one factor, 52.0% with two factors and 24.4% with three or more factors at 3 years after transplant (P < 0.0001). Moreover, this risk index also identified the patient group at high risk of HCV recurrence after acute rejection. CONCLUSION While the introduction of direct-acting antiviral agents has been changing the paradigm of HCV treatment, the natural history of recipients with HCV as shown in this study would help estimate the risk of HCV-related allograft failure in those who do not tolerate such new treatment.
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Affiliation(s)
- Hiroaki Shiba
- Department of General Surgery, Digestive Disease Institute.,Department of Hepatobiliary Surgery
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease Institute.
| | - Dympna Kelly
- Department of General Surgery, Digestive Disease Institute
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease Institute
| | | | | | | | - Lisa Yerian
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Masato Matsushima
- Division of Clinical Research and Development, Jikei University School of Medicine, Tokyo, Japan
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease Institute
| | - John Fung
- Department of General Surgery, Digestive Disease Institute
| | - Charles Miller
- Department of General Surgery, Digestive Disease Institute
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Hashimoto K, Fujiki M, Quintini C, Aucejo FN, Uso TD, Kelly DM, Eghtesad B, Fung JJ, Miller CM. Split liver transplantation in adults. World J Gastroenterol 2016; 22:7500-7506. [PMID: 27672272 PMCID: PMC5011665 DOI: 10.3748/wjg.v22.i33.7500] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/30/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Split liver transplantation (SLT), while widely accepted in pediatrics, remains underutilized in adults. Advancements in surgical techniques and donor-recipient matching, however, have allowed expansion of SLT from utilization of the right trisegment graft to now include use of the hemiliver graft as well. Despite less favorable outcomes in the early experience, better outcomes have been reported by experienced centers and have further validated the feasibility of SLT. Importantly, more than two decades of experience have identified key requirements for successful SLT in adults. When these requirements are met, SLT can achieve outcomes equivalent to those achieved with other types of liver transplantation for adults. However, substantial challenges, such as surgical techniques, logistics, and ethics, persist as ongoing barriers to further expansion of this highly complex procedure. This review outlines the current state of SLT in adults, focusing on donor and recipient selection based on physiology, surgical techniques, surgical outcomes, and ethical issues.
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Nassar A, Liu Q, Farias K, Buccini L, Baldwin W, Bennett A, Mangino M, Irefin S, Cywinski J, Okamoto T, Diago Uso T, Iuppa G, Soliman B, Miller C, Quintini C. Impact of Temperature on Porcine Liver Machine Perfusion From Donors After Cardiac Death. Artif Organs 2016; 40:999-1008. [PMID: 27086771 DOI: 10.1111/aor.12699] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/22/2015] [Accepted: 12/28/2015] [Indexed: 12/11/2022]
Abstract
Normothermic machine perfusion (NMP) has been introduced as a promising technology to preserve and possibly repair marginal liver grafts. The aim of this study was to compare the effect of temperature on the preservation of donation after cardiac death (DCD) liver grafts in an ex vivo perfusion model after NMP (38.5°C) and subnormothermic machine perfusion (SNMP, 21°C) with a control group preserved by cold storage (CS, 4°C). Fifteen porcine livers with 60 min of warm ischemia were preserved for 10 h by NMP, SNMP or CS (n = 5/group). After the preservation phase all livers were reperfused for 24 h in an isolated perfusion system with whole blood at 38.5°C to simulate transplantation. At the end of transplant simulation, the NMP group showed significantly lower hepatocellular enzyme level (AST: 277 ± 69 U/L; ALT: 22 ± 2 U/L; P < 0.03) compared to both SNMP (AST: 3243 ± 1048 U/L; ALT: 127 ± 70 U/L) and CS (AST: 3150 ± 1546 U/L; ALT: 185 ± 97 U/L). There was no significant difference between SNMP and CS. Bile production was significantly higher in the NMP group (219 ± 43 mL; P < 0.01) compared to both SNMP (49 ± 84 mL) and CS (12 ± 16 mL) with no significant difference between the latter two groups. Histologically, the NMP livers showed preserved cellular architecture compared to the SNMP and CS groups. NMP was able to recover DCD livers showing superior hepatocellular integrity, biliary function, and microcirculation compared to SNMP and CS. SNMP showed some significant benefit over CS, yet has not shown any advantage over NMP.
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Affiliation(s)
- Ahmed Nassar
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Qiang Liu
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kevin Farias
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Laura Buccini
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - William Baldwin
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ana Bennett
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Martin Mangino
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Samuel Irefin
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jacek Cywinski
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Toshihiro Okamoto
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa Diago Uso
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giuseppe Iuppa
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Basem Soliman
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cristiano Quintini
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Liu Q, Nassar A, Farias K, Buccini L, Mangino MJ, Baldwin W, Bennett A, O'Rourke C, Iuppa G, Soliman BG, Urcuyo-Llanes D, Okamoto T, Uso TD, Fung J, Abu-Elmagd K, Miller C, Quintini C. Comparing Normothermic Machine Perfusion Preservation With Different Perfusates on Porcine Livers From Donors After Circulatory Death. Am J Transplant 2016; 16:794-807. [PMID: 26663737 DOI: 10.1111/ajt.13546] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/08/2015] [Accepted: 09/25/2015] [Indexed: 01/25/2023]
Abstract
The utilization of normothermic machine perfusion (NMP) may be an effective strategy to resuscitate livers from donation after circulatory death (DCD). There is no consensus regarding the efficacy of different perfusates on graft and bile duct viability. The aim of this study was to compare, in an NMP porcine DCD model, the preservation potential of three different perfusates. Twenty porcine livers with 60 min of warm ischemia were separated into four preservation groups: cold storage (CS), NMP with Steen solution (Steen; XVIVO Perfusion Inc., Denver, CO), Steen plus red blood cells (RBCs), or whole blood (WB). All livers were preserved for 10 h and reperfused to simulate transplantation for 24 h. During preservation, the NMP with Steen group presented the highest hepatocellular injury. At reperfusion, the CS group had the lowest bile production and the worst hepatocellular injury compared with all other groups, followed by NMP with Steen; the Steen plus RBC and WB groups presented the best functional and hepatocellular injury outcomes, with WB livers showing lower aspartate aminotransferase release and a trend toward better results for most parameters. Based on our results, a perfusate that contains an oxygen carrier is most effective in a model of NMP porcine DCD livers compared with Steen solution. Specifically, WB-perfused livers showed a trend toward better outcomes compared with Steen plus RBCs.
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Affiliation(s)
- Q Liu
- Cleveland Clinic, Cleveland, OH
| | | | | | | | - M J Mangino
- Virginia Commonwealth University, Richmond, VA
| | | | | | | | - G Iuppa
- Cleveland Clinic, Cleveland, OH
| | | | | | | | - T D Uso
- Cleveland Clinic, Cleveland, OH
| | - J Fung
- Cleveland Clinic, Cleveland, OH
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Sher LS, Levi DM, Wecsler JS, Lo M, Petrovic LM, Groshen S, Ji L, Uso TD, Tector AJ, Hamilton AS, Marsh JW, Schwartz ME. Liver transplantation for metastatic neuroendocrine tumors: Outcomes and prognostic variables. J Surg Oncol 2015; 112:125-32. [PMID: 26171686 DOI: 10.1002/jso.23973] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/13/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patient selection for liver transplantation for metastatic neuroendocrine tumors remains a topic of debate. There is no established MELD exception, making it difficult to obtain donor organs. METHODS A multicenter database was created assessing outcomes for liver and multivisceral transplantation for metastatic neuroendocrine tumors and identifying prognostic factors for survival. Demographic, transplant, primary tumor site and management, pathology, recurrent disease and survival data were collected and analyzed. Survival probabilities were calculated using the Kaplan-Meier method. RESULTS Analysis included 85 patients who underwent liver transplantation November 1988-January 2012 at 28 centers. One, three, and five-year patient survival rates were 83%, 60%, and 52%, respectively; 40 of 85 patients died, with 20 of 40 deaths due to recurrent disease. In univariate analyses, the following were predictors of poor prognosis: large vessel invasion (P < 0.001), extent of extrahepatic resection at liver transplant (P = 0.007), and tumor differentiation (P = 0.003). In multivariable analysis, predictors of poor overall survival included large vessel invasion (P = 0.001), and extent of extrahepatic resection at liver transplant (P = 0.015). CONCLUSION In the absence of poor prognostic factors, metastatic neuroendocrine tumor is an acceptable indication for liver transplantation. Identification of favorable prognostic factors should allow assignment of a MELD exception similar to hepatocellular carcinoma.
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Affiliation(s)
- Linda S Sher
- Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - David M Levi
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Julie S Wecsler
- Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Mary Lo
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Lydia M Petrovic
- Department of Pathology, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Susan Groshen
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Lingyun Ji
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Teresa Diago Uso
- Department of General Surgery and Transplant Center, Cleveland Clinic, Cleveland, Ohio
| | - A Joseph Tector
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ann S Hamilton
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - J Wallis Marsh
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Myron E Schwartz
- Department of Surgery, Recanati/Miller Transplantation Institute Icahn School of Medicine at Mount Sinai, New York, New York
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Nassar A, Liu Q, Farias K, D'Amico G, Tom C, Grady P, Bennett A, Diago Uso T, Eghtesad B, Kelly D, Fung J, Abu-Elmagd K, Miller C, Quintini C. Ex vivo normothermic machine perfusion is safe, simple, and reliable: results from a large animal model. Surg Innov 2015; 22:61-9. [PMID: 24694840 DOI: 10.1177/1553350614528383] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Normothermic machine perfusion (NMP) is an emerging preservation modality that holds the potential to prevent the injury associated with low temperature and to promote organ repair that follows ischemic cell damage. While several animal studies have showed its superiority over cold storage (CS), minimal studies in the literature have focused on safety, feasibility, and reliability of this technology, which represent key factors in its implementation into clinical practice. The aim of the present study is to report safety and performance data on NMP of DCD porcine livers. MATERIALS AND METHODS After 60 minutes of warm ischemia time, 20 pig livers were preserved using either NMP (n = 15; physiologic perfusion temperature) or CS group (n = 5) for a preservation time of 10 hours. Livers were then tested on a transplant simulation model for 24 hours. Machine safety was assessed by measuring system failure events, the ability to monitor perfusion parameters, sterility, and vessel integrity. The ability of the machine to preserve injured organs was assessed by liver function tests, hemodynamic parameters, and histology. RESULTS No system failures were recorded. Target hemodynamic parameters were easily achieved and vascular complications were not encountered. Liver function parameters as well as histology showed significant differences between the 2 groups, with NMP livers showing preserved liver function and histological architecture, while CS livers presenting postreperfusion parameters consistent with unrecoverable cell injury. CONCLUSION Our study shows that NMP is safe, reliable, and provides superior graft preservation compared to CS in our DCD porcine model.
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Affiliation(s)
| | - Qiang Liu
- Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Cynthia Tom
- Case Western Reserve University, Cleveland, OH, USA
| | | | | | | | | | | | - John Fung
- Cleveland Clinic, Cleveland, OH, USA
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Liu Q, Nassar A, Farias K, Buccini L, Baldwin W, Mangino M, Bennett A, O'Rourke C, Okamoto T, Uso TD, Fung J, Abu-Elmagd K, Miller C, Quintini C. Sanguineous normothermic machine perfusion improves hemodynamics and biliary epithelial regeneration in donation after cardiac death porcine livers. Liver Transpl 2014; 20:987-99. [PMID: 24805852 PMCID: PMC4117809 DOI: 10.1002/lt.23906] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/26/2014] [Indexed: 12/31/2022]
Abstract
The effects of normothermic machine perfusion (NMP) on the postreperfusion hemodynamics and extrahepatic biliary duct histology of donation after cardiac death (DCD) livers after transplantation have not been addressed thoroughly and represent the objective of this study. Ten livers (5 per group) with 60 minutes of warm ischemia were preserved via cold storage (CS) or sanguineous NMP for 10 hours, and then they were reperfused for 24 hours with whole blood in an isolated perfusion system to simulate transplantation. In our experiment, the arterial and portal vein flows were stable in the NMP group during the entire reperfusion simulation, whereas they decreased dramatically in the CS group after 16 hours of reperfusion (P < 0.05); these findings were consistent with severe parenchymal injury. Similarly, significant differences existed between the CS and NMP groups with respect to the release of hepatocellular enzymes, the volume of bile produced, and the levels of enzymes released into bile (P < 0.05). According to histology, CS livers presented with diffuse hepatocyte congestion, necrosis, intraparenchymal hemorrhaging, denudated biliary epithelium, and submucosal bile duct necrosis, whereas NMP livers showed very mild injury to the liver parenchyma and biliary architecture. Most importantly, Ki-67 staining in extrahepatic bile ducts showed biliary epithelial regeneration. In conclusion, our findings advance the knowledge of the postreperfusion events that characterize DCD livers and suggest NMP as a beneficial preservation modality that is able to improve biliary regeneration after a major ischemic event and may prevent the development of ischemic cholangiopathy in the setting of clinical transplantation.
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Waghray A, Nassar A, Hashimoto K, Eghtesad B, Aucejo F, Krishnamurthi V, Uso TD, Srinivas T, Steiger E, Abu-Elmagd K, Quintini C. Combined intestine and kidney transplantation in a patient with encapsulating peritoneal sclerosis: case report. Am J Transplant 2013; 13:3274-7. [PMID: 24266976 DOI: 10.1111/ajt.12505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 09/05/2013] [Accepted: 09/06/2013] [Indexed: 01/25/2023]
Abstract
Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of peritoneal dialysis characterized by fibrosis and calcification of the intestine that, in severe cases, can progress to intestinal failure and total parenteral nutrition dependency. Medical and surgical interventions carry a poor prognosis in these patients. We describe a case of a 36-year-old female with end-stage kidney disease and severe EPS not amenable to surgical intervention who underwent a combined intestinal and kidney transplantation. At 3 years posttransplantation, the patient has normal intestinal and kidney function. This represents, to our knowledge, the first report of severe EPS and end-stage kidney disease treated with a combined transplant.
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Affiliation(s)
- A Waghray
- Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH
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Watson MJ, Kundu N, Coppa C, Djohan R, Hashimoto K, Eghtesad B, Fujiki M, Diago Uso T, Gandhi N, Nassar A, Abu-Elmagd K, Quintini C. Role of tissue expanders in patients with loss of abdominal domain awaiting intestinal transplantation. Transpl Int 2013; 26:1184-90. [PMID: 24118196 DOI: 10.1111/tri.12187] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 06/23/2013] [Accepted: 08/21/2013] [Indexed: 11/27/2022]
Abstract
Abdominal closure is a complex surgical problem in intestinal transplant recipients with loss of abdominal domain, as graft exposure results in profound morbidity. Although intraoperative coverage techniques have been described, this is the first report of preoperative abdominal wall augmentation using tissue expanders in patients awaiting intestinal transplantation. We report on five patients who received a total of twelve tissue expanders as a means to increase abdominal surface area. Each patient had a compromised abdominal wall (multiple prior operations, enterocutaneous fistulae, subcutaneous abscesses, stomas) with loss of domain and was identified as high risk for an open abdomen post-transplant. Cross-sectional imaging and dimensional analysis were performed to quantify the effect of the expanders on total abdominal and intraperitoneal cavity volumes. The overall mean increase in total abdominal volume was 958 cm(3) with a mean expander volume of 896.5 cc. Two expanders were removed in the first patient due to infection, but after protocol modification, there were no further infections. Three patients eventually underwent small bowel transplantation with complete graft coverage. In our preliminary experience, abdominal tissue expander placement is a safe, feasible, and well-tolerated method to increase subcutaneous domain and facilitate graft coverage in patients undergoing intestinal transplantation.
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Affiliation(s)
- Melissa J Watson
- Department of General Surgery, Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
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Affiliation(s)
- Charles Miller
- Cleveland Clinic, Liver Transplant Program, Department of General Surgery Cleveland, OH
| | - Teresa Diago Uso
- Cleveland Clinic, Liver Transplant Program, Department of General Surgery Cleveland, OH
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Miller C, Smith ML, Fujiki M, Uso TD, Quintini C. Preparing for the inevitable: the death of a living liver donor. Liver Transpl 2013; 19:656-60. [PMID: 23463650 DOI: 10.1002/lt.23637] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 02/25/2013] [Indexed: 12/13/2022]
Abstract
Living donor liver transplantation (LDLT) is associated with a low but finite and well-documented risk of donor morbidity and mortality, so organizations and individuals involved in this activity must accept the fact that a donor death is a question of when and not if. Studies in the field of crisis management show that preparing for the inevitable not only is critical in preparing institutions to better respond to catastrophic events but more importantly plays a crucial role in preventing them. This article describes the background of crisis management with specific reference to the death of a living liver donor and proposes a general framework that can be adopted by LDLT programs around the world.
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Affiliation(s)
- Charles Miller
- Liver Transplant Program, Department of General Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
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Abstract
Living donor liver transplantation (LDLT) is a well-established strategy to decrease the mortality in the waiting list and recent studies have demonstrated its value even in patients with low MELD score. However, LDLT is still under a high level of scrutiny because of its technical complexity and ethical challenges as demonstrated by a decline in the number of procedures performed in the last decade in Western Countries. Many aspects make LDLT different from deceased donor liver transplantation, including timing of transplantation, procedure-related complications as well as immunological factors that may affect graft outcomes. Our review suggests that in selected cases, LDLT offers significant advantages over deceased donor liver transplantation and should be used more liberally.
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Hashimoto K, Eghtesad B, Gunasekaran G, Fujiki M, Uso TD, Quintini C, Aucejo FN, Kelly DM, Winans CG, Vogt DP, Parker BM, Irefin SA, Miller CM, Fung JJ. Use of tissue plasminogen activator in liver transplantation from donation after cardiac death donors. Am J Transplant 2010; 10:2665-72. [PMID: 21114643 DOI: 10.1111/j.1600-6143.2010.03337.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Ischemic-type biliary stricture (ITBS) occurs in up to 50% after liver transplantation (LT) from donation after cardiac death (DCD) donors. Thrombus formation in the peribiliary microcirculation is a postulated mechanism. The aim was to describe our experience of tissue plasminogen activator (TPA) administration in DCD-LT. TPA was injected into the donor hepatic artery on the backtable (n = 22). Two recipients developed ITBS including one graft failure. Although excessive postreperfusion bleeding was seen in 14 recipients, the amount of TPA was comparable between those with and without excessive bleeding (6.4 ± 2.8 vs. 6.6 ± 2.8 mg, p = 0.78). However, donor age (41 ± 12 vs. 29 ± 9 years, p = 0.02), donor BMI (26.3 ± 5.5 vs. 21.7 ± 3.6 kg/m(2) , p = 0.03), previous laparotomy (50% vs. 0%, p = 0.02) and lactate after portal reperfusion (6.3 ± 4.6 vs. 2.8 ± 0.9 mmol/L, p = 0.005) were significantly greater in recipients with excessive bleeding. In conclusion, the use of TPA may lower the risk of ITBS-related graft failure in DCD-LT. Excessive bleeding may be related to poor graft quality and previous laparotomy rather than the amount of TPA. Further studies are needed in larger population.
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Affiliation(s)
- K Hashimoto
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
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Hashimoto K, Miller CM, Quintini C, Aucejo FN, Hirose K, Uso TD, Trenti L, Kelly DM, Winans CG, Vogt DP, Eghtesad B, Fung JJ. Is impaired hepatic arterial buffer response a risk factor for biliary anastomotic stricture in liver transplant recipients? Surgery 2010; 148:582-8. [PMID: 20227098 DOI: 10.1016/j.surg.2010.01.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Accepted: 01/12/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Blood flow to the liver is partly maintained by the hepatic arterial buffer response (HABR), which is an intrinsic autoregulatory mechanism. Temporary clamping of the portal vein (PV) results in augmentation in hepatic artery flow (augHAF). Portal hyperperfusion impairs HAF due to the HABR in liver transplantation (LT). The aim of this study is to examine the effect of the HABR on biliary anastomotic stricture (BAS). METHODS In 234 cadaveric whole LTs, PV flow (PVF), basal HAF, and augHAF were measured intra-operatively after allograft implantation. All recipients with a vascular complication were excluded. Buffer capacity (BC) was calculated as (augHAF - basal HAF)/PVF to quantify the HABR. Recipients were divided into 2 groups based on their BC: low BC (<0.074; n = 117) or high BC (> or =0.074; n = 117). RESULTS Of the 234 recipients, 23 (9.8%) had early BAS (< or =60 days after LT) and 18 (7.7%) had late BAS (>60 days after LT). The incidence of late BAS and bile leakage was similar between the groups; however, the incidence of early BAS in the low BC group was greater than that in the high BC group (15% vs 5.1%; P = .0168). In the multivariate analysis, low BC (P = .0325) and bile leakage (P = .0002) were found to be independent risk factors affecting early BAS. CONCLUSION Recipients with low BC who may have impaired HABR are at greater risk of early BAS after LT. Intraoperative measurements of blood flow help predict the risk of BAS.
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Affiliation(s)
- Koji Hashimoto
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Aucejo F, Kim R, Zein N, Quintini C, Uso TD, Lopez R, Eghtesad B, Fung J, Miller C, Yerian L. Vascular endothelial growth factor receptor 2 expression in non-tumorous cirrhotic liver is higher when hepatoma is beyond Milan criteria. Liver Transpl 2009; 15:169-76. [PMID: 19177438 DOI: 10.1002/lt.21678] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatocellular carcinoma (HCC) is a highly vascular tumor. Angiogenesis in HCC is mediated at least in part by vascular endothelial growth factor (VEGF), which is expressed in HCC and surrounding cirrhotic tissue. VEGF mediates its angiogenic effects through multiple receptors including VEGF receptor 2 (VEGFr2, KDR/FLK-1), The distribution and clinical significance of VEGFr2 expression in HCC and cirrhotic liver in the setting of liver transplantation have not been tissue site specific evaluated. Immunohistochemical staining for VEGFr2 was performed in 78 liver explants from patients with HCC undergoing liver transplantation. VEGFr2 levels in HCC were significantly increased compared to adjacent, nontumorous cirrhotic liver areas (P < 0.05). VEGFr2 levels were significantly higher in the veins and sinusoids of poorly differentiated tumors (P < 0.05). VEGFr2 levels in the tumors were not significantly different between patients within and beyond Milan criteria. However, VEGFr2 levels were significantly higher in the arteries of non-tumorous liver in patients beyond Milan criteria (P < 0.05). No significant association was observed between VEGFr2 levels and the presence of tumor vascular invasion or recurrence post transplantation. These findings suggest that VEGFr2 up-regulation is a feature of poor differentiation and tumor progression. Further investigation is needed to assess the value of angiogenesis modulation in preventing tumor formation and/or progression in cirrhotic patients.
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Affiliation(s)
- Federico Aucejo
- Liver Transplantation, Cleveland Clinic, Cleveland, OH 44195, USA.
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Quintini C, Miller CM, Hashimoto K, Philip D, Uso TD, Aucejo F, Kelly D, Winans C, Eghtesad B, Vogt D, Fung J. Side-to-side cavocavostomy with an endovascular stapler: Rescue technique for severe hepatic vein and/or inferior vena cava outflow obstruction after liver transplantation using the piggyback technique. Liver Transpl 2009; 15:49-53. [PMID: 19109837 DOI: 10.1002/lt.21667] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Venous outflow obstruction is a rare but potentially lethal complication after orthotopic liver transplantation (OLT) with the "piggyback" technique. Therapeutic options include angioplasty with or without stent placement, surgical reconstruction of the venous anastomosis, and retransplantation. Surgical options are technically very challenging and the outcomes discouraging. We describe here two cases of venous outflow obstruction in recipients of piggyback liver grafts, one involving both the vena cava and hepatic veins and the other affecting only hepatic vein outflow. Both patients were treated successfully with side-to-side cavo-cavostomy using an endovascular (endo-GIA) stapler. This novel technique is fast and effective in resolving the outflow obstruction.
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Affiliation(s)
- Cristiano Quintini
- Department of General Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
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