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Park H, Han ES, Park SJ, Hong SY, Suh S, Lee S, Lee JM, Hong SK, Choi Y, Lee KW, Suh KS, Yi NJ, Han JK. Anatomical classification and clinical outcomes of biliary strictures in living donor liver transplantation using right liver grafts. Liver Transpl 2023; 29:307-317. [PMID: 37160060 DOI: 10.1002/lt.26580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 08/28/2022] [Accepted: 09/06/2022] [Indexed: 01/12/2023]
Abstract
This study aimed to classify the anatomical types of biliary strictures, including intrahepatic biliary stricture (IHBS), after living donor liver transplantations (LDLTs) using right liver grafts and evaluate their prognosis. Among 692 adult patients who underwent right liver LDLT, 198 recipients with biliary strictures (28.6%) were retrospectively reviewed. Based on data obtained during the first cholangiography, the patients' biliary strictures were classified into the following three types according to the levels and number of branches involved: Types 1 (anastomosis), 2 (second-order branch [a, one; b, two or more; c, extended to the third-order branch]), and 3 (whole graft [a, multifocal strictures; b, diffuse necrosis]). IHBS was defined as a nonanastomotic stricture. Among the 198 recipients with biliary strictures, the IHBS incidence rates were 38.4% ( n = 76). The most common type of IHBS was 2c ( n = 43, 56.6%), whereas Type 3 ( n = 10, 13.2%) was uncommon. The intervention frequency per year significantly differed among the types (Type 1, 2.3; Type 2a, 2.3; Type 2b, 2.8; Type 2c, 4.3; and Type 3, 7.2; p < 0.001). The intervention-free period for more than 1 year, which was as follows, also differed among the types: Type 1, 84.4%; Type 2a, 87.5%; Type 2b, 86.7%; Type 2c, 72.1%; and Type 3, 50.0% ( p = 0.048). The graft survival rates of Type 3 (80.0%) were significantly lower than those of the other types ( p = 0.001). IHBSs are relatively common in right liver LDLTs. Although Type 3 IHBSs are rare, they require more intensive care and are associated with poorer graft survival rates than anastomosis strictures and Type 2 IHBS.
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Affiliation(s)
- Hansang Park
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Eui Soo Han
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Sae-Jin Park
- Department of Radiology , Seoul National University College of Medicine , Seoul , South Korea
| | - Su Young Hong
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Sanggyun Suh
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Sola Lee
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Jeong-Moo Lee
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Suk Kyun Hong
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - YoungRok Choi
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Kwang-Woong Lee
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Kyung-Suk Suh
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Nam-Joon Yi
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Joon Koo Han
- Department of Radiology , Seoul National University College of Medicine , Seoul , South Korea
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2
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Frasco PE, Mathur AK, Chang YH, Alvord JM, Poterack KA, Khurmi N, Bauer I, Aqel B. Days alive and out of hospital after liver transplant: comparing a patient-centered outcome between recipients of grafts from donation after circulatory and brain deaths. Am J Transplant 2023; 23:55-63. [PMID: 36695622 DOI: 10.1016/j.ajt.2022.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
We retrospectively compared outcomes between recipients of donation after circulatory death (DCD) and donation after brain death (DBD) liver allografts using days alive and out of hospital (DAOH), a composite outcome of mortality, morbidity, and burden of care from patient perspective. The initial length of stay and duration of any subsequent readmission for the first year after liver transplantation were recorded. Donor category and perioperative and intraoperative characteristics pertinent to liver transplantation were included. The primary outcome was DAOH365. Secondary outcomes included early allograft dysfunction and hepatic arterial and biliary complications. Although the incidence of both early allograft dysfunction (P < .001) and ischemic cholangiopathy (P < .001) was significantly greater in the recipients of DCD, there were no significant differences in the length of stay and DAOH365. The median DAOH365 was 355 days for recipients of DBD allografts and 353 days for recipients of DCD allografts (P = .34). Increased transfusion burden, longer cold ischemic time, and non-White recipients were associated with decreased DAOH. There were no significant differences in graft failure (P = .67), retransplantation (P = .67), or 1-year mortality (P = .96) between the 2 groups. DAOH is a practical and attainable measure of outcome after liver transplantation. This metric should be considered for quality measurement and reporting in liver transplantation.
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Affiliation(s)
- Peter E Frasco
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA.
| | - Amit K Mathur
- Department of Transplantation Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jeremy M Alvord
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Karl A Poterack
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Isabel Bauer
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Bashar Aqel
- Department of Transplant Hepatology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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3
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Croome KP, Mathur AK, Aqel B, Yang L, Taner T, Heimbach JK, Rosen CB, Paz-Fumagalli R, Taner CB. Classification of Distinct Patterns of Ischemic Cholangiopathy Following DCD Liver Transplantation: Distinct Clinical Courses and Long-term Outcomes From a Multicenter Cohort. Transplantation 2022; 106:1206-1214. [PMID: 34468429 DOI: 10.1097/tp.0000000000003928] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As the number of donation after circulatory death (DCD) liver transplants (LTs) performed in the United States continues to increase annually, there has been interest by policy makers to develop a more robust exception point safety net for patients who develop ischemic cholangiopathy (IC) following DCD LT. As such, there is a need for better understanding of the clinical course and long-term outcomes in patients who develop IC, as well as determining if IC can be classified into distinct categories with distinctly different clinical outcomes. METHODS All DCD LT performed at Mayo Clinic Florida, Mayo Clinic Arizona, and Mayo Clinic Rochester from January 1999 to March 2020 were included (N = 770). Outcomes were compared between 4 distinct radiologic patterns of IC: diffuse necrosis, multifocal progressive, confluence dominant, and minor form. RESULTS In total, 88 (11.4%) patients developed IC, of which 42 (5.5%) were listed for retransplantation of liver (ReLT). Patients with diffuse necrosis and multifocal progressive patterns suffered from frequent hospital admissions for cholangitis in the first year following DCD LT (median 3 and 2), were largely stent dependent (100% and 85.7%), and almost universally required ReLT. Patients with confluence dominant disease were managed with multiple stents and frequently recovered, ultimately becoming stent free without need for ReLT. Patients with the minor form IC did well with limited need for stent placement or repeat procedures and did not require ReLT. Graft survival was different between the 4 distinct IC patterns (P < 0.001). CONCLUSIONS The present analysis provides a detailed analysis on the natural history and clinical course of IC. Patients developing IC can be classified into 4 distinct patterns with distinct clinical courses.
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Affiliation(s)
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Bashar Aqel
- Division of Gastroenterology and hepatology, Mayo Clinic Arizona, Phoenix, AZ
| | - Liu Yang
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Timucin Taner
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | | | | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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4
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Fasullo M, Shah T, Zhou H, Siddiqui MS. Post-Transplant Biliary Strictures: An Updated Review. Semin Liver Dis 2022; 42:225-232. [PMID: 35263796 DOI: 10.1055/s-0042-1744144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease with excellent long-term survival; however, LT recipients are at risk of significant complications. Among these complications are biliary complications with an incidence ranging from 5 to 32% and associated with significant post-LT morbidity and mortality. Prompt recognition and management are critical as these complications have been associated with mortality rates up to 19% and retransplantation rates up to 13%. An important limitation of published studies is that a large proportion does not discriminate between anastomotic strictures and nonanastomotic strictures. This review aims to summarize our current understanding of risk factors and natural history, diagnostic testing, and treatment options for post-LT biliary strictures.
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Affiliation(s)
- Matthew Fasullo
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Tilak Shah
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Huiping Zhou
- Department of Microbiology and Immunology, VCU and McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Mohammad S Siddiqui
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia
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Sanada Y, Sakuma Y, Onishi Y, Okada N, Hirata Y, Horiuchi T, Omameuda T, Lefor AK, Sata N. Hepatolithiasis After Living Donor Liver Transplantation in Pediatric Patients: Mechanism, Diagnosis, Treatment, and Prognosis. Transpl Int 2022; 35:10220. [PMID: 35237098 PMCID: PMC8883429 DOI: 10.3389/ti.2022.10220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/12/2022] [Indexed: 11/25/2022]
Abstract
There is little information about the outcomes of pediatric patients with hepatolithiasis after living donor liver transplantation (LDLT). We retrospectively reviewed hepatolithiasis after pediatric LDLT. Between May 2001 and December 2020, 310 pediatric patients underwent LDLT with hepaticojejunostomy. Treatment for 57 patients (18%) with post-transplant biliary strictures included interventions through double-balloon enteroscopy (DBE) in 100 times, percutaneous transhepatic biliary drainage (PTBD) in 43, surgical re-anastomosis in 4, and repeat liver transplantation in 3. The median age and interval at treatment were 12.3 years old and 2.4 years after LDLT, respectively. At the time of treatments, 23 patients (7%) had developed hepatolithiasis of whom 12 (52%) were diagnosed by computed tomography before treatment. Treatment for hepatolithiasis included intervention through DBE performed 34 times and PTBD 6, including lithotripsy by catheter 23 times, removal of plastic stent in 8, natural exclusion after balloon dilatation in 7, and impossibility of removal in 2. The incidence of recurrent hepatolithiasis was 30%. The 15-years graft survival rates in patients with and without hepatolithiasis were 91% and 89%, respectively (p = 0.860). Although hepatolithiasis after pediatric LDLT can be treated using interventions through DBE or PTBD and its long-term prognosis is good, the recurrence rate is somewhat high.
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6
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Meier RPH, Kelly Y, Yamaguchi S, Braun HJ, Lunow-Luke T, Adelmann D, Niemann C, Maluf DG, Dietch ZC, Stock PG, Kang SM, Feng S, Posselt AM, Gardner JM, Syed SM, Hirose R, Freise CE, Ascher NL, Roberts JP, Roll GR. Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation. Front Surg 2022; 8:808733. [PMID: 35071316 PMCID: PMC8766343 DOI: 10.3389/fsurg.2021.808733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally. Methods: Based on 1-year DCD-LT graft survival predictors in multivariate logistic regression models, we designed, validated, and compared a simple index using the University of California, San Francisco (UCSF) cohort (n = 136) and a universal-comprehensive (UC)-DCD score using the United Network for Organ Sharing (UNOS) cohort (n = 5,792) to previously published DCD scoring systems. Results: The total warm ischemia time (WIT)-index included donor WIT (dWIT) and hepatectomy time (dHep). The UC-DCD score included dWIT, dHep, recipient on mechanical ventilation, transjugular-intrahepatic-portosystemic-shunt, cause of liver disease, model for end-stage liver disease, body mass index, donor/recipient age, and cold ischemia time. In the UNOS cohort, the UC-score outperformed all previously published scores in predicting DCD-LT graft survival (AUC: 0.635 vs. ≤0.562). In the UCSF cohort, the total WIT index successfully stratified survival and biliary complications, whereas other scores did not. Conclusion: DCD risk scores generated in large cohorts provide general guidance for safe recipient/donor selection, but they must be tailored based on non-/partially-modifiable local circumstances to expand DCD utilization.
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Affiliation(s)
- Raphael P. H. Meier
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Surgery, University of Maryland, Baltimore, MD, United States
| | - Yvonne Kelly
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Seiji Yamaguchi
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Hillary J. Braun
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Tyler Lunow-Luke
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Dieter Adelmann
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | - Claus Niemann
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel G. Maluf
- Department of Surgery, University of Maryland, Baltimore, MD, United States
| | - Zachary C. Dietch
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Peter G. Stock
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Sang-Mo Kang
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Andrew M. Posselt
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - James M. Gardner
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Shareef M. Syed
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Chris E. Freise
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Nancy L. Ascher
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Garrett R. Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
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7
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Skogsberg Dahlgren U, Herlenius G, Gustafsson B, Mölne J, Rydberg L, Socratous A, Bennet W. Excellent outcome following emergency deceased donor ABO-incompatible liver transplantation using rituximab and antigen specific immunoadsorption. Scand J Gastroenterol 2022; 57:50-59. [PMID: 34541993 DOI: 10.1080/00365521.2021.1976269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The acceptance of ABO-incompatible (ABOi) liver grafts will expand the donor pool for a patient in urgent need for a liver transplantation (LT). Here we report our results with emergency ABOi DD (deceased donor) LT using rituximab and antigen specific immunoadsorption. PATIENTS AND METHODS 2009 to 2019 we performed 20 ABOi DD LTs (adults n = 17, children n = 3) for patients in urgent need for a LT. Immunosuppression consisted of rituximab (n = 20) and basiliximab (n = 15) or anti-thymocyte globuline (n = 4), intravenous immunoglobulin (IVIG; n = 6), tacrolimus, prednisolone and mycophenolate mofetil. Fifteen patients were treated with IA (n = 14) or both IA and plasmapheresis (PP; n = 1) pre-transplant and 18 patients were treated with IA (n = 15) or both IA and PP (n = 3) post-transplant. The median pre-transplant MELD- score was 40 (range 18-40). Patient and graft survival and complications were compared to a 1:4 case matched control group of ABO-identical or compatible (ABOid/c) DDLT. RESULTS The 1-, 3- and 5-year patient and graft survival rates were 85, 85 and 78% for the ABOi recipients and not significantly different compared to ABOid/c controls. Only one ABOi patient developed antibody-mediated rejection. CONCLUSION Patient and graft survival after emergency ABOi DDLT using rituximab and immunoadorption was equal to ABOid/DDLT. ABOi DD LT was a successful approach to expand the donor pool for patients in urgent need for a liver graft.
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Affiliation(s)
| | - Gustaf Herlenius
- Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
| | - Bengt Gustafsson
- Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
| | - Johan Mölne
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Biomedicine, Laboratory Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
| | - Lennart Rydberg
- Department of Clinical Chemistry and Transfusion Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Socratous
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - William Bennet
- Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
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8
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Radiologic Classification of Distinct Patterns of Non-Anastomotic Strictures; can we Predict the Course of the Disease? Transplantation 2021; 106:1107-1108. [PMID: 34456265 DOI: 10.1097/tp.0000000000003929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Rodrigues T, Boike JR. Biliary Strictures: Etiologies and Medical Management. Semin Intervent Radiol 2021; 38:255-262. [PMID: 34393335 DOI: 10.1055/s-0041-1731086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Biliary strictures have several etiologies that can broadly be classified into benign and malignant causes. The clinical presentation is variable with strictures identified incidentally on imaging or during the evaluation of routine laboratory abnormalities. Symptoms and cholangitis lead to imaging that can diagnose biliary strictures. The diagnosis and medical management of biliary strictures will be discussed in this article.
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Affiliation(s)
- Terrance Rodrigues
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Justin R Boike
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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10
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Croome KP, Taner CB. Expanding Role of Donation After Circulatory Death Donors in Liver Transplantation. Clin Liver Dis 2021; 25:73-88. [PMID: 33978584 DOI: 10.1016/j.cld.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Better understanding of how to utilize donation after circulatory death (DCD) liver grafts has resulted in improved national outcomes and expansion in the number of DCD liver transplants (LTs). This improvement has been driven by better donor and recipient matching, careful evaluation of hemodynamics during withdrawal of life support, and refinement of the procurement operation. Changes to liver allocation likely will result in increased utilization of DCD liver grafts. Ischemic cholangiopathy remains the Achilles heel of DCD LTs and, although rates have fallen with improved protocols, a certain rate likely is unavoidable. This review discusses contemporary issues with DCD LTs.
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Affiliation(s)
- Kristopher P Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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11
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Natsuda K, Murokawa T, Lee KW, Yoon KC, Hong SK, Lee JM, Cho JH, Yi NJ, Suh KS. No diffuse intrahepatic biliary stricture after ABO-incompatible adult living donor liver transplantation using tailored rituximab-based desensitization protocol. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:30. [PMID: 33553323 PMCID: PMC7859775 DOI: 10.21037/atm-20-4703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Rituximab (RTx) desensitization protocol offered good outcome in ABO-incompatible (ABOi) living donor liver transplantation (LDLT). However, diffuse intrahepatic biliary stricture (DIHBS) is still inevitable hurdle. We selectively added postoperative high dose intravenous immunoglobulin (IVIG) and/or simultaneous splenectomy if ABO isoagglutinin titer just before liver transplantation after plasma exchange (PE) was higher than 1/16. Herein, we reported the excellent outcome of ABOi LDLT without DIHBS using tailored desensitization protocol and compared it with that of ABO-compatible (ABOc) LDLT. Methods Sixty-five cases (14.8%) of ABOi LDLTs were performed among 438 primary adult LDLTs in our center between March 2012 and June 2017. We performed 1-to-2 propensity score matching (PSM) to extract 60 cases of ABOi LDLTs and 120 cases of ABOc LDLTs. Results There were no significant differences in clinical characteristics between ABOi and ABOc recipients. There were no significant differences in complications and rejection. There was no DIHBS in both groups. The 1-, 3-, and 5-year overall survival rates were 98.3%, 86.7%, and 82.9% in ABOi group and 96.7%, 86.7%, and 85.4% in ABOc group, respectively (P=0.88). Most common cause of deaths of both groups was hepatocellular recurrence. The 1-, 3-, and 5-year biliary complication (anastomosis leakage or stricture) free survival rates were 81.4%, 69.5%, and 67.5% in ABOi group and 83.0%, 81.3%, and 80.0% in ABOc group, with no significant differences (P=0.11). Conclusions RTx-based tailored (optional IVIG + splenectomy) desensitization protocol for ABOi LDLT was feasible and acceptable.
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Affiliation(s)
- Koji Natsuda
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takahiro Murokawa
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Kyung Chul Yoon
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Surgery, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jae-Hyung Cho
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
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12
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Kohli DR, Pannala R, Crowell MD, Fukami N, Faigel DO, Aqel BA, Harrison ME. Interobserver Agreement for Classifying Post-liver Transplant Biliary Strictures in Donation After Circulatory Death Donors. Dig Dis Sci 2021; 66:231-237. [PMID: 32124198 DOI: 10.1007/s10620-020-06169-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/20/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Biliary strictures are a common complication of donation after circulatory death (DCD) liver transplantation (LT) and require multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures. Three classification systems, based on cholangiograms, have been proposed for categorizing post-LT biliary strictures. We examined the interobserver agreement for each of the three classifications. METHODS DCD LT recipients from 2012 through March 2017 undergoing ERCP for biliary strictures were included in the study. Initial cholangiograms delineating the entire biliary tree prior to endoscopic intervention were selected. One representative cholangiogram was selected from each ERCP. Five interventional endoscopists independently viewed each anonymized cholangiogram and classified the post-LT stricture according to each of the three classification systems. The Ling classification proposes four types of post-LT strictures based on their location. The Lee classification proposes four classes based on location and number of intrahepatic strictures. The binary system classifies strictures into anastomotic or non-anastomotic types. The Krippendorff's alpha reliability estimate was used to grade the strength of agreement as "poor," "fair," "moderate," "good," or "excellent" for values between 0-0.20, 0.21-0.4, 0.41-0.6, 0.61-0.08, and 0.81-1, respectively. RESULTS One hundred DCD LT recipients (age 57.07 ± 8.8 years; 71 males) were initially evaluated. Of these, 49 patients who underwent 206 ERCP procedures for biliary strictures were included in the analysis. One hundred thirty-nine cholangiograms were selected and subsequently classified by five endoscopists. Interobserver agreement for post-LT biliary strictures was 0.354 for Ling classification (fair agreement), 0.405 for Lee classification (fair agreement), and 0.421 for the binary classification (moderate agreement). The binary classification provided the least amount of detail regarding the location and number of biliary strictures. DISCUSSION The currently available classification systems for assessing post-LT biliary strictures have sub-optimal interobserver agreement. A better-designed classification system is needed for categorizing post-LT biliary strictures.
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Affiliation(s)
- Divyanshoo R Kohli
- Division of Gastroenterology and Hepatology, Kansas City VA, 4801 E Linwood Blvd, Kansas City, MO, 64128, USA. .,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.
| | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Michael D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Douglas O Faigel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Bashar A Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - M Edwyn Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
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13
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Park JK, Yang JI, Lee JK, Park JK, Lee KH, Lee KT, Joh JW, Kwon CHD, Kim JM. Long-term Outcome of Endoscopic Retrograde Biliary Drainage of Biliary Stricture Following Living Donor Liver Transplantation. Gut Liver 2020; 14:125-134. [PMID: 30970446 PMCID: PMC6974332 DOI: 10.5009/gnl18387] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/12/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Biliary strictures remain one of the most challenging aspects after living donor liver transplantation (LDLT). The aim of this study was to assess long-term outcome of endoscopic treatment of biliary strictures occurring after LDLT and to identify risk factors of recurrent biliary strictures following endoscopic retrograde biliary drainage (ERBD) in LDLT. Methods A total of 1,106 patients underwent LDLT from May 1995 to May 2014. We compared the risk factors between patients with and without recurrent biliary strictures. Results Biliary strictures developed in 24.0% of patients. Technical success rate of ERBD for biliary stricture after LDLT was 66.2% (145/219). Among 145 patients managed by endoscopic drainage, stricture resolution occurred in 69 with median duration of stent indwelling of 13.6 months (range, 0.5 to 67.3 months), and stricture recurrence was seen in 20 (21.3%) out of 94. The median recurrence-free duration after final endoscopic success was 13.1 months (range, 0.5 to 67.3 months). Older donor age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03 to 1.17; p=0.004) and non-B, non-C liver cirrhosis (HR, 5.10; 95% CI, 1.10 to 25.00; p=0.043) were associated with higher recurrence of biliary stricture. Conclusions Long-term stricture resolution rate after ERBD insertion for biliary stricture occurring after LDLT was 73.4%. Clinicians should pay careful attention during following-up to decide when to remove ERBD in patients who have factors associated with recurrent biliary strictures.
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Affiliation(s)
- Jae Keun Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Il Yang
- Division of Gastroenterology, Department of Internal Medicine, Good Gangan Hospital, Busan, Korea
| | - Jong Kyun Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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14
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Croome KP. Donation after Circulatory Death: Potential Mechanisms of Injury and Preventative Strategies. Semin Liver Dis 2020; 40:256-263. [PMID: 32557479 DOI: 10.1055/s-0040-1709487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Donation after circulatory death (DCD) donors represent a potential means to help address the disparity between the number of patients awaiting liver transplantation (LT) and the availability of donor livers. While initial enthusiasm for DCD LT was high in the early 2000s, early reports of high rates of biliary complications and inferior graft survival resulted in reluctance among many transplant centers to use DCD liver grafts. As with all innovations in transplant practice, there is undoubtedly a learning curve associated with the optimal utilization of liver grafts from DCD donors. More contemporary data has demonstrated that results with DCD LT are improving and the number of DCD LT performed annually has been steadily increasing. In this concise review, potential mechanisms of injury for DCD livers are discussed along with strategies that have been employed in clinical practice to improve DCD LT outcomes.
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15
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Abstract
Purpose of Review The transplant community continues to look for ways to help address the discordance between donor liver graft availability and patients on the liver transplant waiting list. Donation after circulatory death (DCD) donor livers represents one potential means to help address this discordance. The present review describes the changing landscape of DCD liver transplantation (LT). Recent Findings The number of DCD LTs performed annually within the USA has continued to grow on an annual basis. Importantly, national data has demonstrated that outcomes with DCD LT have been improving. This improvement has been driven by better understanding of how to successfully utilize these organs through better donor and recipient matching and careful evaluation of both hemodynamics during withdrawal of life support and the refinement of the procurement operation. Summary Despite these improvements in outcome, ischemic cholangiopathy (IC) continues to be the Achilles heel of DCD LT. Emerging technologies such as various forms of machine perfusion may allow for reduction of complications and better prognostication of the risk associated with DCD liver grafts.
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Affiliation(s)
- Kristopher P Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
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16
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Kohli DR, Harrison ME, Mujahed T, Fukami N, Faigel DO, Pannala R, Moss A, Aqel BA. Outcomes of endoscopic therapy in donation after cardiac death liver transplant biliary strictures. HPB (Oxford) 2020; 22:979-986. [PMID: 31676256 DOI: 10.1016/j.hpb.2019.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/22/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Biliary strictures after donation-after-cardiac-death (DCD) liver transplantation (LT) require multiple endoscopic retrograde cholangiopancreatographies (ERCP). The outcomes of endoscopic dilation and maximal stenting are not well-characterized in this high-risk population. METHODS DCD LT recipients who underwent LT and ERCP from 2012-2018 were selected. Anastomotic and non-anastomotic strictures were treated with balloon dilation and maximal stenting. A successful stent-free trial was defined as absence of biochemical, clinical or imaging evidence of strictures on follow-up exceeding 6 months. Adverse events were defined as unplanned admission or inpatient evaluation within 7 days of ERCP. RESULTS Forty-nine DCD LT recipients underwent ERCP and 34 patients were diagnosed with strictures (20 anastomotic). Stent-free trial was successful in 27 patients. Adverse events occurred after 20 ERCPs. Patients with anastomotic strictures required fewer stents (1.43 ± 1.37 vs 2.63 ± 1.66; P < 0.001), shorter procedure and fluoroscopy times (34.15 ± 20.9 vs 59.6 ± 30.7 minutes, P < 0.001; 5.99 ± 7.4 vs 14.73 ± 10.74 minutes, P < 0.001), fewer relapses (10% vs 57%, P = 0.003), shorter intervals between initial ERCP and stent-free success (136.9 ± 118.3 vs 399.56 ± 234.7; P = 0.003), and between LT and stent-free success (227.8 ± 171.9 vs 464.1 ± 224.6 days; P = 0.005) compared to non-anastomotic strictures. CONCLUSION Endoscopic dilation and maximal stenting resolves biliary strictures in DCD LT recipients with sustained success and relatively few adverse events.
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Affiliation(s)
- Divyanshoo R Kohli
- Division of Gastroenterology and Hepatology, Mayo Clinic, AZ, United States; Division of Gastroenterology and Hepatology, Kansas City VA Medical Center, MO, United States.
| | - M E Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, AZ, United States
| | - Tala Mujahed
- Mayo Clinic School of Medicine, Mayo Clinic, AZ, United States
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic, AZ, United States
| | - Douglas O Faigel
- Division of Gastroenterology and Hepatology, Mayo Clinic, AZ, United States
| | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic, AZ, United States
| | - Adyr Moss
- Department of Surgery, Mayo Clinic, AZ, United States
| | - Bashar A Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic, AZ, United States
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17
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Kim JD, Kwak SG, Choi DL. Safety and Efficacy of Living Donor Hepatectomy Without Systemic Heparinization: Short- and Long-Term Outcomes. Transplant Proc 2020; 52:1778-1783. [PMID: 32571699 DOI: 10.1016/j.transproceed.2020.01.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 11/26/2022]
Abstract
There is no consensus regarding the use of systemic heparin, and long-term outcomes of living donor hepatectomy (LDH) without systemic heparinization have not yet been determined. This study was performed to determine whether systemic heparinization can be omitted during LDH, with a focus on donor safety and long-term outcomes. We retrospectively analyzed the outcomes of 175 cases of LDH performed in our institution between January 2011 and December 2014: group I (n = 79) received systemic heparinization, whereas group II (n = 96) did not, but liver graft was flushed with a heparinized perfusate. Postoperative bleeding requiring blood transfusion or intervention was more frequent in group I than in group II (P = .028). The decreases in donor hemoglobin and hematocrit levels, and platelet count during the early postoperative period, were greater in group I than in group II. In multivariate analysis, systemic heparin was the only independent risk factor for blood transfusion (odds ratio [OR] = 5.114; 95% confidence interval [CI]: 1.201-21.775; P = .027) and significant postoperative bleeding (OR = 7.731; 95% CI: 1.345-44.429; P = .022) after LDH. Most postoperative complications including graft vascular thrombosis were similar between the 2 groups, as was the survival rate, and neither graft loss due to vascular thrombosis nor non-anastomotic biliary stricture was evident. In conclusion, omission of systemic heparinization during LDH is a feasible and safe option without adverse effects.
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Affiliation(s)
- Joo Dong Kim
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea.
| | - Sang-Gyu Kwak
- Department of Medical Statistics, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dong Lak Choi
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea
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18
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Liver Transplantation Using Uncontrolled Donors After Circulatory Death: A 10-year Single-center Experience. Transplantation 2020; 103:2497-2505. [PMID: 31765364 DOI: 10.1097/tp.0000000000002780] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND One method for increasing the donor pool for orthotopic liver transplantations (OLTs) is to use uncontrolled donation after circulation death (uDCDs). METHODS From January 2006 to December 2016, we performed 75 OLTs using uDCD livers. The control group comprised a sample of 265 OLTs using livers of donations after brain death (DBDs). A comparative study was performed. RESULTS Of 256 potential uDCD donors cannulated, 75 (29.3%) livers were accepted for OLT. The amount of hemoderivatives transfused was significantly higher in the uDCD group. The rate of primary nonfunction was also significantly higher (P = 0.031) in uDCD recipients (8%) than DBD recipients (1.5%). The overall rate of biliary complications was significantly higher (P = 0.001) in uDCD recipients (23 cases, 30.6%) than DBD recipients (28 cases, 10.6%). In the uDCD group, 1-, 3-, and 5-year patient survival rates were 82.7%, 73%, and 71.5%, respectively; in the DBD group, they were 89%, 83.7%, and 78.8%, respectively (P = 0.180). In the uDCD group, 1-, 3-, and 5-year graft survival rates were 73.3%, 65.1%, and 63.6%, respectively; in the DBD group, they were 87.1%, 81.9%, and 76.5%, respectively (P = 0.013). Multivariate analysis showed that independent risk factors for patient and graft survival were intraoperative transfusion of >6 units of packed red blood cell concentrates and recipients who were older than 60 years. CONCLUSIONS Although graft survival is significantly lower using uDCD livers, 5-year patient survival in recipients of DBD and uDCD livers is similar. After careful selection, the livers of uDCD can be selectively used for OLT.
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19
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Richards JA, Sherif AE, Butler AJ, Hunt F, Allison M, Oniscu GC, Watson CJE. Model for early allograft function is predictive of early graft loss in donation after circulatory death liver transplantation. Clin Transplant 2020; 34:e13982. [PMID: 32441409 DOI: 10.1111/ctr.13982] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 12/17/2022]
Abstract
Donation after circulatory death (DCD) liver transplantation is associated with higher rates of graft loss. In this paper, we explored whether the Model for Early Allograft Function (MEAF) predicted outcome in DCD liver transplantation. We performed a retrospective analysis of prospectively collected data from all adult DCD (Maastricht 3) livers transplanted in Cambridge and Edinburgh between 1 January 2011 and 30 June 2017, excluding those undergoing any form of machine perfusion. 187 DCD liver transplants were performed during the study period. DCD liver transplants with a lower MEAF score had a significantly better survival compared to those with a high MEAF score (Mantel-Cox P < .0001); this was largely due to early graft loss. Beyond 28 days post-transplant, there were no significant long-term graft or patient survival differences irrespective of the grade of MEAF (Mantel-Cox P = .64 and P = .43, respectively). The MEAF score correlated with the length of ICU (P = .0011) and hospital stay (P = .0007), but did not predict the requirement for retransplantation for ischemic cholangiopathy (P = .37) or readmission (P = .74). In this study, a high MEAF score predicted early graft loss, but not the subsequent need for re-transplantation or late graft failure as a result of intrahepatic ischemic bile duct pathology.
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Affiliation(s)
- James A Richards
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ahmed E Sherif
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew J Butler
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Fiona Hunt
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael Allison
- The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.,Department of Medicine, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Christopher J E Watson
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
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20
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Jia J, Nie Y, Li J, Xie H, Zhou L, Yu J, Zheng SS. A Systematic Review and Meta-Analysis of Machine Perfusion vs. Static Cold Storage of Liver Allografts on Liver Transplantation Outcomes: The Future Direction of Graft Preservation. Front Med (Lausanne) 2020; 7:135. [PMID: 32528963 PMCID: PMC7247831 DOI: 10.3389/fmed.2020.00135] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/30/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Machine perfusion (MP) and static cold storage (CS) are two prevalent methods for liver allograft preservation. However, the preferred method remains controversial. Aim: To conduct a meta-analysis on the impact of MP preservation on liver transplant outcome. Methods: PubMed, EMBASE, and Cochrane Library databases were systematically searched to identify relevant trials comparing the efficacy of MP vs. CS. Odds ratios (OR) and fixed-effects models were calculated to compare the pooled data. Results: Ten prospective cohort studies and two randomized controlled trials (RCTs) were included (MP livers vs. CS livers = 315:489). Machine perfusion demonstrated superior outcomes in posttransplantation aspartate aminotransferase levels compared to CS (P < 0.05). The overall incidence of early allograft dysfunction (EAD) was significantly reduced with MP preservation than CS [OR = 0.46; 95% confidence interval (CI) = 0.31–0.67; P < 0.0001]. The incidence of total biliary complications (OR = 0.53; 95% CI = 0.34–0.83; P = 0.006) and that of ischemic cholangiopathy (OR = 0.39; 95% CI = 0.18–0.85; P = 0.02) were significantly lower in recipients with MP preservation compared with CS preservation. Hypothermic machine perfusion (HMP) but not normothermic machine perfusion (NMP) was found to significantly protect grafts from total biliary complications and ischemic cholangiopathy (P < 0.05). However, no significant differences could be detected utilizing either HMP or NMP in primary nonfunction, hepatic artery thrombosis, postreperfusion syndrome, 1-year patient survival, or 1-year graft survival (P > 0.05). Conclusions: Machine perfusion is superior to CS on improving short-term outcomes for human liver transplantation, with a less clear effect in the longer term. Hypothermic machine perfusion but not NMP conducted significantly protective effects on EAD and biliary complications. Further RCTs are warranted to confirm MP's superiority and applications.
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Affiliation(s)
- Junjun Jia
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Yu Nie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Jianhui Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Haiyang Xie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Lin Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Jun Yu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Shu-Sen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
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21
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Jiménez-Romero C, Manrique A, García-Conde M, Nutu A, Calvo J, Caso Ó, Marcacuzco A, García-Sesma Á, Álvaro E, Villar R, Aguado JM, Conde M, Justo I. Biliary Complications After Liver Transplantation From Uncontrolled Donors After Circulatory Death: Incidence, Management, and Outcome. Liver Transpl 2020; 26:80-91. [PMID: 31562677 DOI: 10.1002/lt.25646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/16/2019] [Indexed: 12/26/2022]
Abstract
The utilization of livers from donation after uncontrolled circulatory death (uDCD) increases the availability of liver grafts, but it is associated with a higher incidence of biliary complications (BCs) and lower graft survival than those organs donated after brain death. From January 2006 to December 2016, we performed 75 orthotopic liver transplantations (OLTs) using uDCD livers. To investigate the relationship of BCs with the use of uDCD OLT, we compared patients who developed BCs (23 patients) with those who did not (non-BC group, 43 patients) after excluding cases of hepatic artery thrombosis (a known cause of BC) and primary nonfunction. The groups had similar uDCD donor maintenance, donor and recipient characteristics, and perioperative morbidity/mortality rates, but we observed a higher rate of hepatocellular carcinoma and hepatitis C virus in the non-BC group. Percutaneous transhepatic biliary dilation, endoscopic retrograde cholangiopancreatography dilation, Roux-en-Y hepaticojejunostomy (HJ), a T-tube, and retransplantation were used for BC management. In the BC group, 1-, 3-, and 5-year patient survival rates were 91.3%, 69.6%, and 65.2%, respectively, versus 77.8%, 72.9%, and 72.9%, respectively, in the non-BC group (P = 0.89). However, 1-, 3-, and 5-year graft survival rates were 78.3%, 60.9%, and 56.5%, respectively, in the BC group versus 77.8%, 72.9%, and 72.9%, respectively, in the non-BC group (P = 0.38). Multivariate analysis did not indicate independent risk factors for BC development. In conclusion, patient and graft survival rates were generally lower in patients who developed BCs but not significantly so. These complications were managed in the majority of patients through radiological dilation, endoscopic dilation, or Roux-en-Y HJ. Retransplantation is necessary in rare cases after the failure of biliary dilation or surgical procedures.
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Affiliation(s)
- Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - María García-Conde
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Anisa Nutu
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Jorge Calvo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Óscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Álvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Edurne Álvaro
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Roberto Villar
- Department of Radiology, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - María Conde
- Service of General and Digestive Surgery, Lucus Augusti Hospital, Lugo, Spain
| | - Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
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22
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Biliary Complications Following Pediatric Living Donor Liver Transplantation: Risk Factors, Treatments, and Prognosis. Transplantation 2019; 103:1863-1870. [DOI: 10.1097/tp.0000000000002572] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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23
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Sanada Y, Katano T, Hirata Y, Yamada N, Okada N, Onishi Y, Yasuda Y, Mizuta K. Long‐term outcome of percutaneous transhepatic biliary drainage for biliary strictures following pediatric liver transplantation. Clin Transplant 2019; 33:e13570. [DOI: 10.1111/ctr.13570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 03/21/2019] [Accepted: 04/11/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Takumi Katano
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Yuta Hirata
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Naoya Yamada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Noriki Okada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Yasuharu Onishi
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | | | - Koichi Mizuta
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
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24
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Yi NJ, Kim J, Choi Y, Kim H, Lee KB, Jang JJ, Lee JY, Lee JM, Han JK, Lee KW, Suh KS. Alteration of MRP2 expression and the graft outcome after liver transplantation. Ann Surg Treat Res 2018; 95:249-257. [PMID: 30402443 PMCID: PMC6204325 DOI: 10.4174/astr.2018.95.5.249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/25/2018] [Accepted: 06/01/2018] [Indexed: 01/18/2023] Open
Abstract
Purpose Multidrug resistance-associated protein (MRP) 2 is a glutathione conjugate in the canalicular membrane of hepatocytes. Early graft damage after liver transplantation (LT) can result in alteration of MRP2 expression. The purpose of this study was to evaluate the relationship between the pattern of MRP2 alteration and graft outcome. Methods Forty-one paraffin-embedded liver graft tissues obtained by protocol biopsy within 2 months after LT; these were stained using monoclonal antibodies of MRP2. We selected 15 live donor biopsy samples as a control, that showed homogenous canalicular staining for MRP2. The pattern of canalicular MRP2 staining of graft was classified into 3 types: homogenous (type C0), focal (type C1), and no (type C2,) staining of the canaliculi. Results In total, 17.1% graft tissues were type C0, 36.6% were type C1, and 46.3% were type C2. The median operation time was longer in patients with type C2 (562.6 minutes) than in patients with type C0 (393.8 minutes) (P = 0.038). The rates of posttransplant complications were higher in patients with type C2 (100%) than in patients with type C0 (42.9%) and C1 (73.3%) (P < 0.001). Conclusion MRP2 expression pattern was altered in 82.9% after LT. The pattern of MRP2 alteration was associated with longer operation time and higher rates of post-LT complications.
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Affiliation(s)
- Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Joohyun Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Transplant Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Heyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Bun Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Ja-June Jang
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Young Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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25
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Probability, management, and long-term outcomes of biliary complications after hepatic artery thrombosis in liver transplant recipients. Surgery 2017; 162:1101-1111. [DOI: 10.1016/j.surg.2017.07.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 06/22/2017] [Accepted: 07/05/2017] [Indexed: 12/13/2022]
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26
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Ghinolfi D, De Simone P, Lai Q, Pezzati D, Coletti L, Balzano E, Arenga G, Carrai P, Grande G, Pollina L, Campani D, Biancofiore G, Filipponi F. Risk analysis of ischemic-type biliary lesions after liver transplant using octogenarian donors. Liver Transpl 2016; 22:588-98. [PMID: 26784011 DOI: 10.1002/lt.24401] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/23/2015] [Accepted: 12/31/2015] [Indexed: 12/22/2022]
Abstract
The use of octogenarian donors to increase the donor pool in liver transplantation (LT) is controversial because advanced donor age is associated with a higher risk of ischemic-type biliary lesions (ITBL). The aim of this study was to investigate retrospectively the role of a number of different pre-LT risk factors for ITBL in a selected population of recipients of octogenarian donor grafts. Between January 2003 and December 2013, 123 patients underwent transplantation at our institution with deceased donor grafts from donors of age ≥80 years. Patients were divided into 2 groups based on the presence of ITBL in the posttransplant course. Exclusion criteria were retransplantations, presence of vascular complications, and no availability of procurement liver biopsy. A total of 88 primary LTs were included, 73 (83.0%) with no posttransplant ITBLs and 15 (17.0%) with ITBLs. The median follow-up after LT was 2.1 years (range, 0.7-5.4 years). At multivariate analysis, donor hemodynamic instability (hazard ratio [HR], 7.6; P = 0.005), donor diabetes mellitus (HR, 9.5; P = 0.009), and donor age-Model for End-Stage Liver Disease (HR, 1.0; P = 0.04) were risk factors for ITBL. Transplantation of liver grafts from donors of age ≥80 years is associated with a higher risk for ITBL. However, favorable results can be achieved with accurate donor selection. Donor hemodynamic instability, a donor history of diabetes mellitus, and allocation to higher Model for End-Stage Liver Disease score recipient all increase the risk of ITBL and are associated with worse graft survival when octogenarian donors are used. Liver Transplantation 22 588-598 2016 AASLD.
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Affiliation(s)
- Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Quirino Lai
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Daniele Pezzati
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Laura Coletti
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Emanuele Balzano
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giuseppe Arenga
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paola Carrai
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Gennaro Grande
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Luca Pollina
- Department of Pathology, University of Pisa Medical School Hospital, Pisa, Italy
| | - Daniela Campani
- Department of Pathology, University of Pisa Medical School Hospital, Pisa, Italy
| | - Gianni Biancofiore
- Post-transplant Intensive Care Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - Franco Filipponi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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27
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Park SH, Kim KW, Kim B, Lee SJ, Lee JS, Kim HJ, Song GW, Lee SG, Jeong WK. Imaging of biliary complications in recipients of right-lobe living donor liver transplantation. Acta Radiol 2016; 57:401-12. [PMID: 25972371 DOI: 10.1177/0284185115584814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 04/09/2015] [Indexed: 11/15/2022]
Abstract
Right-lobe living donor liver transplantation (RL-LDLT) is a common method devised in order to fulfill the demands of donor organ shortage in adult patients with end-stage liver diseases. However, biliary complications remain as the "Achilles' heel" of RL-LDLT, with wide variety of incidence among transplantation centers. Patients with biliary complications after RL-LDLT may have similar clinical presentations to those with other causes of graft dysfunction. Therefore, radiological evaluation plays a key role for differential diagnosis of such complications. In this article, we discuss the various methods of biliary reconstruction and imaging findings of common and uncommon biliary complications in recipients of RL-LDLT.
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Affiliation(s)
- So Hyun Park
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyoung Won Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bohyun Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - So Jung Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Seok Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyoung Jung Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gi-Won Song
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Gyu Lee
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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28
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Sharzehi K. Biliary strictures in the liver transplant patient. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016. [DOI: 10.1016/j.tgie.2016.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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29
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First Comparison of Hypothermic Oxygenated PErfusion Versus Static Cold Storage of Human Donation After Cardiac Death Liver Transplants: An International-matched Case Analysis. Ann Surg 2016; 262:764-70; discussion 770-1. [PMID: 26583664 DOI: 10.1097/sla.0000000000001473] [Citation(s) in RCA: 264] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Exposure of donor liver grafts to prolonged periods of warm ischemia before procurement causes injuries including intrahepatic cholangiopathy, which may lead to graft loss. Due to unavoidable prolonged ischemic time before procurement in donation after cardiac death (DCD) donation in 1 participating center, each liver graft of this center was pretreated with the new machine perfusion "Hypothermic Oxygenated PErfusion" (HOPE) in an attempt to improve graft quality before implantation. METHODS HOPE-treated DCD livers (n = 25) were matched and compared with normally preserved (static cold preservation) DCD liver grafts (n = 50) from 2 well-established European programs. Criteria for matching included duration of warm ischemia and key confounders summarized in the balance of risk score. In a second step, perfused and unperfused DCD livers were compared with liver grafts from standard brain dead donors (n = 50), also matched to the balance of risk score, serving as baseline controls. RESULTS HOPE treatment of DCD livers significantly decreased graft injury compared with matched cold-stored DCD livers regarding peak alanine-aminotransferase (1239 vs 2065 U/L, P = 0.02), intrahepatic cholangiopathy (0% vs 22%, P = 0.015), biliary complications (20% vs 46%, P = 0.042), and 1-year graft survival (90% vs 69%, P = 0.035). No graft failure due to intrahepatic cholangiopathy or nonfunction occurred in HOPE-treated livers, whereas 18% of unperfused DCD livers needed retransplantation. In addition, HOPE-perfused DCD livers achieved similar results as control donation after brain death livers in all investigated endpoints. CONCLUSIONS HOPE seems to offer important benefits in preserving higher-risk DCD liver grafts.
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30
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Lee ES, Han JK, Baek JH, Suh SW, Joo I, Yi NJ, Lee KW, Suh KS. Long-Term Efficacy of Percutaneous Internal Plastic Stent Placement for Non-anastomotic Biliary Stenosis After Liver Transplantation. Cardiovasc Intervent Radiol 2016; 39:909-15. [PMID: 26817760 DOI: 10.1007/s00270-016-1297-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/10/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE We aimed to evaluate the long-term efficacy of percutaneous management of non-anastomotic biliary stenosis after liver transplantation, using plastic internal biliary stents. MATERIALS AND METHODS This study included 35 cases (28 men, 7 women; mean age: 52.09 ± 8.13 years, range 34-68) in 33 patients who needed repeated interventional procedures because of biliary strictures. After classification of the biliary strictures, we inserted percutaneous biliary plastic stents through the T-tube or percutaneous transhepatic biliary drainage tracts. Stents were exchanged according to percutaneous methods at regular 2- to 6-month intervals. The stents were removed if the condition improved, as observed on cholangiogram as well as based on clinical findings. The median patient follow-up period after initial diagnosis and treatment was 6.04 years (range 0.29-9.95 years). We assessed treatment success rate and patient and graft survival times. RESULTS During the follow-up period, 14 patients (14/33, 42.42 %) were successfully treated and were tube-free. The median tube-free time, time without a stent, was 4.13 years (range 1.00-9.01). In contrast, internal plastic stents remained in 9 patients (9/33, 27.27 %) until the last follow-up. These patients had acceptable hepatic function. Among the remaining 10 patients, 3 (3/33, 9.09 %) were lost to regular follow-up and the other 7 (7/33, 21.21 %) patients died. The overall graft loss rate was 20.0 % (7/35). The median time from initial treatment to graft loss was 1.84 years (range 0.42-4.25). CONCLUSIONS Percutaneous plastic stents placement is technically feasible and clinically useful in patients with multiple biliary stenoses following liver transplantation.
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Affiliation(s)
- Eun Sun Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea.,Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea. .,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea. .,Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea.
| | - Ji-Hyun Baek
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea
| | - Suk-Won Suh
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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31
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Firl DJ, Hashimoto K, O'Rourke C, Diago-Uso T, Fujiki M, Aucejo FN, Quintini C, Kelly DM, Miller CM, Fung JJ, Eghtesad B. Impact of donor age in liver transplantation from donation after circulatory death donors: A decade of experience at Cleveland Clinic. Liver Transpl 2015; 21:1494-503. [PMID: 26334196 DOI: 10.1002/lt.24316] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/23/2015] [Accepted: 08/12/2015] [Indexed: 12/12/2022]
Abstract
The use of liver grafts from donation after circulatory death (DCD) donors remains controversial, particularly with donors of advanced age. This retrospective study investigated the impact of donor age in DCD liver transplantation. We examined 92 recipients who received DCD grafts and 92 matched recipients who received donation after brain death (DBD) grafts at Cleveland Clinic from January 2005 to June 2014. DCD grafts met stringent criteria to minimize risk factors in both donors and recipients. The 1-, 3-, and 5-year graft survival in DCD recipients was significantly inferior to that in DBD recipients (82%, 71%, 66% versus 92%, 87%, 85%, respectively; P = 0.03). Six DCD recipients (7%), but no DBD recipients, experienced ischemic-type biliary stricture (P = 0.01). However, the incidence of biliary stricture was not associated with donor age (P = 0.57). Interestingly, recipients receiving DCD grafts from donors who were <45 years of age (n = 55) showed similar graft survival rates compared to those receiving DCD grafts from donors who were ≥45 years of age (n = 37; 80%, 69%, 66% versus 83%, 72%, 66%, respectively; P = 0.67). Cox proportional hazards modeling in all study populations (n = 184) revealed advanced donor age (P = 0.05) and the use of a DCD graft (P = 0.03) as unfavorable factors for graft survival. Logistic regression analysis showed that the risk of DBD graft failure increased with increasing age, but the risk of DCD graft failure did not increase with increasing age (P = 0.13). In conclusion, these data suggest that stringent donor and recipient selection may ameliorate the negative impact of donor age in DCD liver transplantation. DCD grafts should not be discarded because of donor age, per se, and could help expand the donor pool for liver transplantation.
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Affiliation(s)
- Daniel J Firl
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Koji Hashimoto
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Colin O'Rourke
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Masato Fujiki
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Federico N Aucejo
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Cristiano Quintini
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Dympna M Kelly
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Charles M Miller
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - John J Fung
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Bijan Eghtesad
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
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32
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Capela T, Tavares I, Pereira P, Vigia E, Perdigoto R, Barroso E, Marcelino P. Is there a relationship between intraoperative hemodynamic instability and calcineurin inhibitor-related toxicity, early after liver transplantation? A single-center observational study. Transplant Proc 2015; 46:1789-93. [PMID: 25131038 DOI: 10.1016/j.transproceed.2014.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This study evaluated the relationship between intraoperative hemodynamic instability (IOHI) and the development of calcineurin inhibitor (CNI) toxicity in the early postoperative period after liver transplantation (LT). Eighty-two patients were enrolled during a 1-year period and a 3-month follow-up. IOHI, requiring continuous infusion of vasopressors, was observed in 31 patients (38%, group 1; control group 2, n = 51). Acute kidney injury (AKI) developed in 28 patients (52% in group 1 vs 24% in group 2, P = .02), and CNI-related neurotoxicity (CNI-NT) in 26 (48% in group 1 vs 22% in group 2, P = .03). Group 1 patients received mainly deceased donor grafts (87% vs 57% in group 2, P < .001). An independent association between IOHI and CNI-NT (P = .029) and AKI (P = .016) was observed. The receiver-operator characteristic curve revealed an area under the curve of 0.63 for IHI (sensitivity 56%; specificity 75%) and 0.65 for AKI (sensitivity 56%; specificity 70.2%). In conclusion, patients undergoing LT with IOHI may be more prone to developing CNI-NT and AKI in the early postoperative period.
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Affiliation(s)
- T Capela
- Liver Transplantation Unit, Hospital Curry Cabral, Lisbon, Portugal
| | - I Tavares
- Liver Transplantation Unit, Hospital Curry Cabral, Lisbon, Portugal
| | - P Pereira
- CEDOC, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - E Vigia
- CEDOC, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - R Perdigoto
- CEDOC, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - E Barroso
- CEDOC, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - P Marcelino
- Liver Transplantation Unit, Hospital Curry Cabral, Lisbon, Portugal.
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Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med 2015; 43:1291-325. [PMID: 25978154 DOI: 10.1097/ccm.0000000000000958] [Citation(s) in RCA: 200] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.
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34
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Qin Z, Linghu EQ. New endoscopic classification system for biliary stricture after liver transplantation. J Int Med Res 2014; 42:566-71. [PMID: 24573973 DOI: 10.1177/0300060513507761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
AIM A new classification system for biliary stricture (BS) after liver transplantation (LT) is proposed, aiming to standardize endoscopic treatment for this condition. METHODS Data were retrospectively collected from patients who had undergone endoscopic retrograde cholangiography after LT, and who provided endoscopy images clear enough to reveal the biliary system. Images were classified separately by two endoscopists, who discussed and resolved any disputed findings. From these images, a new classification system is proposed (Ling classification): type A, normal biliary structure; type B, anastomotic stricture and normal intrahepatic biliary structure; type C, narrow and stiff intrahepatic biliary structure or beaded intrahepatic biliary structure or intrahepatic biliary cast without anastomotic stricture; type D, narrow and stiff intrahepatic biliary structure or beaded intrahepatic biliary structure or intrahepatic biliary cast with anastomotic stricture. RESULTS Analysis involved 93 patients: 76 men and 17 women, median age 54 years (range, 12-69 years). Type B was the most commonly observed BS after LT, accounting for 44 cases (47.3%). Type A, the least commonly observed type, accounted for nine (9.7%), type C for 22 (23.7%) and type D for 18 (19.3%) cases. CONCLUSION A new endoscopic classification system for BS after LT is proposed, to help determine the most appropriate treatment for patients with each type of stricture.
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Affiliation(s)
- Zhichu Qin
- Department of Gastroenterology, People's Liberation Army General Hospital, Beijing, China
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35
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Elaffandi AH, Bonney GK, Gunson B, Scalera I, Mergental H, Isaac JR, Bramhall SR, Mirza DF, Perera MTPR, Muiesan P. Increasing the donor pool: consideration of prehospital cardiac arrest in controlled donation after circulatory death for liver transplantation. Liver Transpl 2014; 20:63-71. [PMID: 24142867 DOI: 10.1002/lt.23772] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 10/01/2013] [Indexed: 12/14/2022]
Abstract
Donor warm ischemia has implications for outcomes after liver transplantation (LT) using organs from donation after circulatory death (DCD) donors. Prehospital cardiac arrest (PHCA) before donation may generate a further ischemic insult. The aim of this single-center study of 108 consecutive DCD LT procedures was to compare the outcomes of PHCA and non-PHCA cohorts. A review of a prospectively collected database of all DCD grafts transplanted between January 2007 and October 2011 was undertaken to identify donors who had sustained PHCA. The unit policy was to consider such donors when transaminase levels were ≤4 times the normal range and had an improving trend. Twenty-six of the 108 DCD transplants were from DCD donors with PHCA, and 82 were in the non-PHCA cohort. A comparative analysis of the PHCA and non-PHCA cohorts showed better short-term results (a low incidence of acute kidney injury) for the PHCA group but satisfactory long-term results for both groups with no significant differences in graft or patient survival between them. In conclusion, a careful donor selection policy for including PHCA DCD donors with normalized liver function tests or transaminase levels ≤ 4 times the norm resulted in successful transplantation and could boost the donor pool with no adverse outcomes.
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36
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Lu D, Xu X, Wang J, Ling Q, Xie H, Zhou L, Yan S, Wang W, Zhang M, Shen Y, Zheng S. The influence of a contemporaneous portal and hepatic artery revascularization protocol on biliary complications after liver transplantation. Surgery 2013; 155:190-5. [PMID: 24238120 DOI: 10.1016/j.surg.2013.06.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 06/28/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND We sought to compare the impact of sequential and contemporaneous revascularizations of portal vein and hepatic artery on biliary complications in patients undergoing liver transplantation. METHODS We reviewed 184 patients who underwent liver transplantation in our center, and categorized them into different groups based on the duration of time between the portal venous and hepatic arterial reperfusion: >10 minutes in the sequential portal and hepatic artery revascularization group (SPA; n = 56), and within 1 minute in the contemporaneous portal and hepatic artery revascularization group (CPA; n = 121).The other patients with an interval from 1-10 minutes (n = 7) were excluded. This study then compared the outcomes between the SPA and CPA groups. RESULTS Cold ischemic time (mean ± standard deviation) for the SPA and CPA groups were 561 ± 150 vs 577 ± 187 minutes, respectively (P = .53). The incidence of biliary complications for the SPA and CPA groups were 14/56 and 11/121, respectively (25% vs 9%; P = .005). By the Clavien-Dindo Classification of Surgical Complications, the biliary complications in SPA group tended to be more severe compared with the CPA group (grade I, 0% vs 0%; II, 14% vs 36%; IIIa, 71% vs 64%; IIIb, 7% vs 0%; IV, 7% vs 0%; P = .10). Among biliary complications, the incidence of nonanatomic strictures was greater in the SPA group (9% vs 2%; P = .03), whereas the difference was not significant for anastomotic strictures (P = .054). Except for a lower serum albumin level in the SPA group 1 day after liver transplantation (P < .001), there are no differences in post-transplant liver function or renal function at 1, 7, and 30 days after transplantation. CONCLUSION The CPA protocol can decrease the incidence of biliary complications substantially after liver transplantation and should replace the SPA protocol used by some centers in liver transplantation.
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Affiliation(s)
- Di Lu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianguo Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qi Ling
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haiyang Xie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lin Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yan Shen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Benítez Cantero J, Costán Rodero G, Montero Álvarez J, Ayllón Terán M, Naveas Polo C, Fraga Rivas E, Barrera Baena P, Poyato González A, López Cillero P, Luque Molina A, De la Mata Garcia M. Biliary Complications After Liver Transplantation Using Side-to-Side Choledochocholedochostomy Reconstruction With or Without T-Tube. Transplant Proc 2012; 44:2098-9. [DOI: 10.1016/j.transproceed.2012.07.084] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
INTRODUCTION Focal intrahepatic strictures are becoming more common owing to more prevalent and accurate cross-sectional imaging. However, data relating to their management are lacking. The purpose of the present review was to synthesize the current evidence regarding these lesions and to formulate a strategy for diagnosis and management. METHODS A literature search of relevant terms was performed using Medline. References of papers were subsequently searched to obtain older literature. RESULTS Focal intrahepatic strictures involve segmental hepatic ducts and/or left and right main hepatic ducts during their intrahepatic course. Most patients are asymptomatic while the minority present with vague abdominal pain or recurrent sepsis and only rarely with jaundice. Investigations used to distinguish benign from malignant aetiologies include blood tests (CEA, Ca19.9), imaging studies [ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and fluorodeoxyglucose-positron emission tomography (FDG-PET)], endoscopic modalities [endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic ultrasound (EUS)/cholangioscopy] and tissue sampling (brush cytology/biopsy). CONCLUSIONS A focal intrahepatic stricture requires thorough investigation to exclude malignancy even in patients with a history of biliary surgery, hepatolithiasis or parasitic infection. If during the investigative process a diagnosis or suspicion of malignancy is demonstrated then surgical resection should be performed. If all diagnostic modalities suggest a benign aetiology, then cholangioscopy with targeted biopsies should be performed.
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Affiliation(s)
- David Yeo
- University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.
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Reich DJ, Guy SR. Donation After Cardiac Death in Abdominal Organ Transplantation. ACTA ACUST UNITED AC 2012; 79:365-75. [DOI: 10.1002/msj.21309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Ischemia-Reperfusion Injury and Ischemic-Type Biliary Lesions following Liver Transplantation. J Transplant 2012; 2012:164329. [PMID: 22530107 PMCID: PMC3316988 DOI: 10.1155/2012/164329] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 12/19/2011] [Accepted: 12/23/2011] [Indexed: 12/14/2022] Open
Abstract
Ischemia-reperfusion (I-R) injury after liver transplantation (LT) induces intra- and/or extrahepatic nonanastomotic ischemic-type biliary lesions (ITBLs). Subsequent bile duct stricture is a significant cause of morbidity and even mortality in patients who underwent LT. Although the pathogenesis of ITBLs is multifactorial, there are three main interconnected mechanisms responsible for their formation: cold and warm I-R injury, injury induced by cytotoxic bile salts, and immunological-mediated injury. Cold and warm ischemic insult can induce direct injury to the cholangiocytes and/or damage to the arterioles of the peribiliary vascular plexus, which in turn leads to apoptosis and necrosis of the cholangiocytes. Liver grafts from suboptimal or extended-criteria donors are more susceptible to cold and warm I-R injury and develop more easily ITBLs than normal livers. This paper, focusing on liver I-R injury, reviews the risk factors and mechanisms leading to ITBLs following LT.
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Liver transplantation using Donation after Cardiac Death donors. J Hepatol 2012; 56:474-85. [PMID: 21782762 DOI: 10.1016/j.jhep.2011.07.004] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 07/01/2011] [Accepted: 07/04/2011] [Indexed: 12/14/2022]
Abstract
The success of solid organ transplantation has brought about burgeoning waiting lists with insufficient donation rates and substantial waiting list mortality. All countries have strived to expand donor numbers beyond the standard Donation after Brain Death (DBD). This has lead to the utilization of Donation after Cardiac Death (DCD) donors, also frequently referred to as Non-Heart Beating Donors (NHBD). Organs from these donors inevitably sustain warm ischaemic damage which varies in its extent and affects early graft function as well as graft survival. As a consequence, 'non-vital' organs such as renal transplants have increased rapidly from DCD donors but more 'vital' organ transplants such as the liver have lagged behind. However, an increasing proportion of liver transplants are now derived from DCD donors. This article covers this expansion, current results, pitfalls, and steps taken to minimize complications and to improve outcome, and future developments that are likely to occur.
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Biliary complications after liver transplantation using grafts from donors after cardiac death: results from a matched control study in a single large volume center. Ann Surg 2012; 254:716-22; discussion 722-3. [PMID: 22042467 DOI: 10.1097/sla.0b013e318235c572] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the incidence and impact of biliary complications in recipients transplanted from donors after cardiac death (DCD) at one single large institution. BACKGROUND Shortage of available cadaveric organs is a significant limiting factor in liver transplantation (LT). The use of DCD offers the potential to increase the organ pool. However, early results with DCD liver grafts were associated with a greater incidence of ischemic cholangiopathy (IC), leading to several programs to abandoning this source of organs. METHODS A retrospective analysis of a prospective database from April 2001 to 2010 focused on 167 consecutive DCD-LT. Each DCD transplant was matched with 2 brain death donors (DBD) grafts (n = 333) according to the period of transplantation. Primary outcome measures were biliary complications including the severity of complications, graft survival and patient survival. Minimum follow-up was 3 months. RESULTS Anastomotic stricture was the most common biliary complication (DCD = 30, 19% vs. DBD = 41, 13%). Most were treated endocoscopically (grade IIIa = 72%), whereas hepatico-jejunostomy (grade IIIb) was performed in 22%. Primary IC occurred in 4 (2.5%) recipients from the DCD group and was absent in the DBD group (P = 0.005). However, none of these patients required retransplantation. Patient and graft survival at 1, 3, and 5 years were similar between DCD and DBD groups (P = 0.106, P = 0.138, P = 0.113, respectively). CONCLUSIONS The encouraging results with DCD-LT are probably due to the selection of DCD grafts and clear definition of warm ischemia.
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Lladó L, Fabregat J, Ramos E, Baliellas C, Torras J, Rafecas A. Complicaciones biliares tras el trasplante hepático. Cir Esp 2012; 90:4-10. [DOI: 10.1016/j.ciresp.2011.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 09/11/2011] [Accepted: 10/03/2011] [Indexed: 12/14/2022]
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Perera MTP, Bramhall SR. Current status and recent advances of liver transplantation from donation after cardiac death. World J Gastrointest Surg 2011; 3:167-76. [PMID: 22180833 PMCID: PMC3240676 DOI: 10.4240/wjgs.v3.i11.167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Revised: 10/21/2011] [Accepted: 10/28/2011] [Indexed: 02/06/2023] Open
Abstract
The last decade saw increased organ donation activity from donors after cardiac death (DCD). This contributed to a significant proportion of transplant activity. Despite certain drawbacks, liver transplantation from DCD donors continues to supplement the donor pool on the backdrop of a severe organ shortage. Understanding the pathophysiology has provided the basis for modulation of DCD organs that has been proven to be effective outside liver transplantation but remains experimental in liver transplantation models. Research continues on how best to further increase the utility of DCD grafts. Most of the work has been carried out exploring the use of organ preservation using machine assisted perfusion. Both ex-situ and in-situ organ perfusion systems are tested in the liver transplantation setting with promising results. Additional techniques involved pharmacological manipulation of the donor, graft and the recipient. Ethical barriers and end-of-life care pathways are obstacles to widespread clinical application of some of the recent advances to practice. It is likely that some of the DCD offers are in fact probably “prematurely” offered without ideal donor management or even prior to brain death being established. The absolute benefits of DCD exist only if this form of donation supplements the existing deceased donor pool; hence, it is worthwhile revisiting organ donation process enabling us to identify counter remedial measures.
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Affiliation(s)
- M Thamara Pr Perera
- M Thamara PR Perera, Simon R Bramhall, The Liver Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
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Biliary Dilatation and Strictures After Composite Liver–Small Bowel Transplantation in Children: Defining a Newly Recognized Complication. Transplantation 2011; 92:461-8. [DOI: 10.1097/tp.0b013e318225278e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
Biliary plastic stenting plays a key role in the endoscopic management of benign biliary diseases. Complications following surgery of the biliary tract and liver transplantation are amenable to endoscopic treatment by plastic stenting. Insertion of an increasing number of plastic stents is currently the method of choice to treat postoperative biliary strictures. Benign biliary strictures secondary to chronic pancreatitis or primary sclerosing cholangitis may benefit from plastic stenting in select cases. There is a role for plastic stent placement in nonoperative candidates with acute cholecystitis and in patients with irretrievable bile duct stones.
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Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcomes from a single center. Ann Surg 2011; 253:817-25. [PMID: 21475025 DOI: 10.1097/sla.0b013e3182104784] [Citation(s) in RCA: 288] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This study evaluates the long-term outcomes, biliary complication rates, and risk factors for biliary complications after liver transplantation from "donation after cardiac death" (DCD) donors. BACKGROUND Recent enthusiasm toward increased use of DCD donors' livers is mitigated by high biliary complication rates. Predictive risk factors for the development of biliary complications after DCD liver transplantation remain incompletely defined. METHODS We performed a retrospective review of 1157 "donation after brain death" (DBD) and 87 DCD liver transplants performed between January 1, 1993, and December 31, 2008. Patient and graft survivals and complication rates within the first year of transplantation were compared between DBD and DCD groups. Cox proportional hazards models were used to assess the influence of potential risk factors. RESULTS Patient survival was significantly lower in the DCD group compared with the DBD group at 1, 5, 10, and 15 years (DCD: 84%, 68%, 54%, and 54% vs DBD: 91%, 81%, 67%, and 58%; P < 0.01). Graft survival was also significantly lower in the DCD group compared with the DBD group at 1, 5, 10, and 15 years (DCD: 69%, 56%, 43%, 43% vs DBD: 86%, 76%, 60%, 51%; P < 0.001). Rates of overall biliary complications (OBC) (DCD: 47% vs DBD: 26%; P < 0.01) and ischemic cholangiopathy (IC) (DCD: 34% vs DBD: 1%; P < 0.01) were significantly higher in the DCD group. Donor age [hazard ratio (HR): 1.04; P < 0.01] and donor age greater than 40 years (HR: 3.13; P < 0.01) were significant risk factors for the development of OBC. Multivariate analysis revealed that cold ischemic time (CIT) greater than 8 hours (HR: 2.46; P = 0.05) and donor age greater than 40 years (HR: 2.90; P < 0.01) significantly increased the risk of IC. CONCLUSIONS Long-term patient and graft survival after DCD liver transplantation remain significantly lower but acceptable when compared with DBD liver transplantations. Donor age and CIT greater than 8 hours are the strongest predictors for the development of IC. Careful selection of younger DCD donors and minimization of CIT may limit the incidence of severe biliary complications and improve the successful utilization of DCD donors' livers.
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Update on Biliary Strictures in Liver Transplants. Transplant Proc 2011; 43:1760-4. [DOI: 10.1016/j.transproceed.2010.12.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 12/20/2010] [Indexed: 12/27/2022]
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Khalaf H, Alawi K, Alsuhaibani H, Hegab B, Kamel Y, Azzam A, Albahili H, Alsofayan M, Al Sebayel M. Surgical management of biliary complications following living donor liver transplantation. Clin Transplant 2011; 25:504-10. [PMID: 21070364 DOI: 10.1111/j.1399-0012.2010.01338.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures. METHODS Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss. RESULTS Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non-surgical procedures, three (11.5%) died from BC-related sepsis, one (3.8%) died from BC-unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow-up period of 4.5 yr (0.1-6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05). CONCLUSIONS In our experience, BCs after LDLT were frequently resistant to non-surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.
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Affiliation(s)
- Hatem Khalaf
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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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] [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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