Utility of laryngoscopy in liver failure

PURPOSE

To determine the utility of laryngoscopy in the evaluation of liver transplant patients.

METHODS

This study is a single center retrospective cohort review of patients with a diagnosis of liver failure who underwent laryngoscopy or stroboscopy exam as part of a pre-transplant evaluation from 1/1/2010 to 12/31/2022. Patients were identified using ICD 9 and 10 codes for liver failure and CPT codes for flexible laryngoscopy and stroboscopy. Only patients who underwent preoperative liver transplant evaluation were included. Demographic data was collected. Cohort analysis between patients who did or did not undergo further diagnostic intervention was undertaken.

RESULTS

1824 patients were identified. 243 of these patients underwent pre-transplant laryngoscopy or stroboscopy. 26 of the 243 (10.7 %) patients had further diagnostic work up for findings during laryngoscopy, stroboscopy, or head and neck examination. There was one patient who was found to have head and neck cancer and was excluded from the transplant list until this was treated.

CONCLUSIONS

Otolaryngologic evaluation of liver transplant patients may be beneficial to identify head and neck pathology.

The immune response of hepatocellular carcinoma after locoregional and systemic therapies: The available combination option for immunotherapy

Hepatocellular carcinoma (HCC) is associated with a highly heterogeneous immune environment that produces an immune response to various locoregional treatments (LRTs), which in turn affects the effectiveness of immunotherapy. Although LRTs still dominate HCC therapies, 50-60% of patients will ultimately be treated with systemic therapies and might receive those treatments for the rest of their life. TACE, SIRT, and thermal ablation can dramatically increase the immunosuppressive state of HCC, a condition that can be addressed by combination with immunotherapy to restore the activity of lymphocytes and the secretion of cellular immune factors. Immune treatment with locoregional and systemic treatments has dramatically changed the management of HCC. In this review, we examine the research on the changes in the immune microenvironment after locoregional or systemic treatment. We also summarize the regulation of various immune cells and immune factors in the tumor microenvironment and discuss the different infiltration degrees of immune cells and factors on the prognosis of HCC to better compare the efficacy between different treatment methods from the perspective of the tumor microenvironment. This information can be used to help develop treatment options for the upcoming new era of HCC treatment in the future.

Imaging and Intervention in the Management of Vascular Complications Following Liver Transplantation

Liver transplantation is the treatment of choice in majority of the patients with end stage liver disease. Vascular complication following liver transplantation is seen in around 7-13% of the patients and is associated with graft dysfunction and high morbidity and mortality. Early diagnosis and prompt treatment are crucial in management of these patients. Advances in interventional radiology have significantly improved the management of vascular complications using minimally invasive percutaneous approach. Endovascular management is preferred in patients with late hepatic artery thrombosis, or stenosis, whereas retransplantation, surgical revision, or endovascular management can be considered in patients with early hepatic artery thrombosis or stenosis. Hepatic artery pseudoaneurysm, arterioportal fistula, and splenic artery steal syndrome are often treated by endovascular means. Endovascular management is also preferred in patients with symptomatic portal vein stenosis, early portal vein thrombosis, and symptomatic late portal vein thrombosis, whereas surgical revision or retransplantation is preferred in patients with perioperative portal vein thrombosis occurring within 3 days of transplantation. Venoplasty with or without stent placement can be considered in patients with hepatic venous outflow tract or inferior vena cava obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) may be required in transplant recipients who develop cirrhosis, often, secondary to disease recurrence, or chronic rejection. Indications for TIPS remain same in the transplant patients; however, major difference is altered vascular anatomy, for which adjunct techniques may be required to create TIPS.

Immediate and Late Complications After Liver Transplantation

Other than rejection, hepatic artery and portal vein thrombosis are the most common complications in the immediate postoperative period with hepatic arterial thrombosis more common and more devastating. Hepatic artery stenosis is more common 1 month after transplantation, whereas portal and hepatic vein stenosis is more often seen as a late complication. Ultrasound is the first-line imaging examination to diagnose vascular complications with contrast-enhanced CT useful if ultrasound findings are equivocal. MR cholangiography is often most helpful in diagnosing bile leaks, biliary strictures, and biliary stones.

Recurrent Portal Vein Thrombosis In Liver Transplantation With Renoportal Anastomosis Caused by Spontaneous Reno-Caval Shunts: A Case Report

BACKGROUND

Orthotopic liver transplantation (OLT) in patients with cirrhosis complicated by portal hypertension, portosystemic shunts, and chronic portal vein thrombosis (PVT) has long been challenging. Spontaneous spleno-renal shunts (SRS) allow new surgical techniques to restore portal vein patency and hepatopetal flow. Renoportal anastomosis (RPA) has emerged as an accepted method for transplanting these patients, with good long-term patient and graft survival. Orthotopic liver transplantation with RPA is known to be complicated by recurrent PVT, with few details discussed in the literature.

CASE REPORT

We present a case of a 56-year-old woman with decompensated cirrhosis who underwent deceased donor whole graft OLT using RPA with iliac vein conduit. The postoperative course was complicated by occlusive thrombosis in the portal vein and iliac vein conduit. Venography revealed enlarged left gonadal and lumbar vein varices acting as reno-caval shunts with hepatofugal flow. Embolization of the varices re-established durable venous patency that was confirmed on post-transplant day 68 with no other hemodynamic complications.

DISCUSSION

This showcases an interesting mechanism by which recurrent PVT may occur in patients undergoing OLT with RPA. Because durable portal vein patency can be achieved with Interventional Radiology embolization of reno-caval varices, assessing these communications is an important preoperative consideration for planned OLT with RPA.

Understanding Local Hemodynamic Changes After Liver Transplant: Different Entities or Simply Different Sides to the Same Coin?

Liver transplantation is an extremely complex procedure performed in an extremely complex patient. With a successful technique and acceptable long-term survival, a new challenge arose: overcoming donor shortage. Thus, living donor liver transplant and other techniques were developed. Aiming for donor safety, many liver transplant units attempted to push the viable limits in terms of size, retrieving smaller and smaller grafts for adult recipients. With these smaller grafts came numerous problems, concepts, and definitions. The spotlight is now aimed at the mirage of hemodynamic changes derived from the recipients prior alterations. This article focuses on the numerous hemodynamic syndromes, their definitions, causes, and management and interconnection with each other. The aim is to aid the physician in their recognition and treatment to improve liver transplantation success.

Contemporary Management of Median Arcuate Ligament in Liver Transplantation

Median arcuate ligament (MAL) can impair arterial inflow during orthotopic liver transplantation (OLT). Furthermore, approaches to ensure optimal vascular inflow in the presence of MAL is not standardized.

Methods

We undertook a systematic review according to the Cochrane systematic review protocol and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We analyzed the incidence of MAL, investigations, treatment options, and potential complications associated with MAL intervention in patients undergoing OLT. After the exclusion criteria were implemented, the dataset from the final 21 manuscripts yielded 117 patients who underwent a liver transplant in the presence of MAL.

Results

The incidence of MAL in patients undergoing OLT is between 1.6% and 12%. In 63.2% of cases, an open approach for MAL intervention was undertaken. Hepatic artery thrombosis developed in 17% (7) patients without MAL intervention versus 2.6% (2) after MAL intervention. Seven grafts (5.9%) were lost after OLT in patients with MAL. Three (3.9%) patients developed arterial stenosis post-MAL intervention.

Conclusions

We propose an algorithm for intraoperative assessment and management of liver transplant arterial inflow in the presence of MAL based on the hepatic artery flow changes with respiration, following clamping of the recipient gastroduodenal artery. In the presence of a 30%-50% flow variation on respiration, the arterial inflow should be established preserving additional inflow from the recipient gastroduodenal artery. Consider an open MAL release if the flow remains insufficient. A poor arterial flow with no variation with respiration and lack of evidence of aortoiliac atherosclerosis indicates the need for arterial jump graft.

Multimodality Imaging after Liver Transplant: Top 10 Important Complications

Patients who have undergone liver transplant are now regularly seen in day-to-day radiology practice. All surgical techniques for liver transplant require arterial, portal venous, hepatic venous and caval, and biliary anastomoses. This review is focused on the 10 "not to be missed" complications of liver transplant that affect the health and life of the graft and graft recipient. Arterial complications are the most common and devastating. Early hepatic artery thrombosis may be catastrophic because the biliary tree is solely dependent on the hepatic artery after transplant and collateral vessels have not yet formed. In contrast, delayed hepatic artery thrombosis may be more insidious as collateral arteries develop. US findings of delayed hepatic artery thrombosis may be similar to those of hepatic artery stenosis and celiac artery stenosis. Splenic artery steal syndrome is an increasingly recognized cause of graft ischemia. Venous complications are much less common. Hepatic venous and caval complications are notable for their increased incidence in living-donor and pediatric transplants. Biliary complications often result from arterial ischemia. Biliary cast syndrome is a notable example in which ischemic biliary mucosa sloughs into and obstructs the duct lumens. Neoplasms also may occur within the hepatic graft and may be due to recurrent malignancy, posttransplant lymphoproliferative disorder, or metastases. US is the initial imaging modality of choice, particularly in the acute postoperative setting. Further evaluation with contrast-enhanced US, CT, or MRI; catheter angiography; endoscopic retrograde cholangiopancreatography; and/or nuclear medicine studies is performed as needed. An invited commentary by Bhargava is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Liver Transplant Imaging prior to and during the COVID-19 Pandemic

BACKGROUND

The suspension of the surgical activity, the burden of the infection in immunosuppressed patients, and the comorbidities underlying end-stage organ disease have impacted transplant programs significantly, even life-saving procedures, such as liver transplantation.

METHODS

A review of the literature was conducted to explore the challenges faced by transplant programs and the adopted strategies to overcome them, with a focus on indications for imaging in liver transplant candidates.

RESULTS

Liver transplantation relies on an appropriate imaging method for its success. During the Coronavirus Disease 2019 (COVID-19) pandemic, chest CT showed an additional value to detect early signs of SARS-CoV-2 infection and other screening modalities are less accurate than radiology.

CONCLUSION

There is an emerging recognition of the chest CT value to recommend its use and help COVID-19 detection in patients. This examination appears highly sensitive for liver transplant candidates and recipients, who otherwise would have not undergone it, particularly when asymptomatic.

Role of Ultrasound for Chronic Liver Disease and Hepatocellular Carcinoma Surveillance

Ultrasound plays a vital role in the evaluation of patients with chronic liver disease and in hepatocellular carcinoma (HCC) surveillance in populations at risk for developing HCC. Semiannual ultrasound for HCC surveillance is universally recommended by all liver societies around the world. Advanced ultrasound techniques, such as elastography and contrast-enhanced ultrasound, offer additional benefits in imaging evaluation of chronic liver disease. Major benefits of ultrasound include its high safety profile and relatively low cost.

Magnetic Resonance Imaging of Liver Transplant

MR imaging increasingly has been adopted for follow-up imaging post-liver transplantation and for diagnosis of its complications. These include vascular and biliary complications as well as post-transplant malignancies. Interpretation of postoperative MR imaging should take into account the surgical technique and expected post-transplant changes. Contrast-enhanced MR imaging has high sensitivity for identification of vascular complications. MR cholangiopancreatography on the other hand is the most accurate noninvasive method for evaluation of biliary complications.

Diffuse large B-cell lymphoma in the liver accompanied by primary biliary cholangitis: A rare and difficult-to-diagnose tumor with portal venous thrombosis

INTRODUCTION AND IMPORTANCE

The most common liver malignancies are hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic tumors. Hepatocellular carcinoma and intrahepatic cholangiocarcinoma may invade the portal vein (PV). An association between diffuse large B-cell lymphoma (DLBCL) and primary biliary cholangitis (PBC) remains unclear. We herein report a thought-provoking case of a difficult-to-diagnose liver tumor with PV thrombosis in a PBC patient.

PRESENTATION OF CASE

A 66-year-old woman had PBC, systemic sclerosis, diabetes, and osteoporosis. A solitary liver tumor accompanied by macrovascular thrombosis in the PV was detected incidentally. Based on dynamic imaging findings, we considered the tumor to be intrahepatic cholangiocarcinoma, and right lobectomy with lymphadenectomy was performed. Unexpectedly, pathological assessment made a definitive diagnosis of DLBCL that did not invade the vessels and bile duct. In fluorine-18-fluorodeoxyglucose positron emission tomography, abnormal accumulations were clearly observed in the breast tissue and peritracheal, parasternal, mediastinal, and pericardial lymph nodes. The patient achieved complete remission after systemic chemotherapy, and there has been no recurrence 3 years after surgery.

CLINICAL DISCUSSION

Primary lymphoma in the liver is rare, and we did not consider our patient's tumor as primary liver lymphoma. Our case actually showed no tumor thrombosis in the PV. Although autoimmune disorders may increase the risk of non-Hodgkin's lymphoma, an association between DLBCL and PBC is still unclear, and we must remember that DLBCL may develop rarely in a PBC patient.

CONCLUSION

Our case report provides a timely reminder for clinicians and surgeons in the fields of hepatology and hematology.

Comprehensive Analysis of Long-term Splenic Volume Changes in Pediatric Liver Transplant Patients: Does It Correlate With Adverse Graft Outcomes?

OBJECTIVES

Splenomegaly and hypersplenism caused by liver failure increase the mortality and morbidity of patients even after liver transplantation if they do not regress. We evaluated the relation of splenic volume change and transplanted liver function.

MATERIAL AND METHODS

A total of 59 of 207 pediatric patients who had liver transplantation between 2013 and 2018 in our institute were evaluated. The relation of spleen volume changes (splenic volume to standard splenic volume ratio [SV/SSV]) were measured at 0, 1, 6, 12, 24, and 36 months of follow-up by constructing electronic three-dimensional structure of the spleen at dynamic computed tomography (CT), and the course of liver functions were evaluated.

RESULTS

The SV/SSV ratio decreases in the first postoperative 6 months. After 6 months, SV increases and SV/SSV increases gradually. In a normal functioning graft, SV/SSV significantly decreased in all time points (P < .001). In patients with adverse events, SV/SSV started to increase after 6 months. In patients with fulminant hepatic failure, SV/SSV started to increase after postoperative 6 months. Adverse events in patients with fulminant hepatic failure were more than the patients with chronic liver disease (58% vs 28%). There was an inverse correlation between SV/SSV and thrombocyte levels (P < .001).

CONCLUSIONS

SV/SSV seems to be correlated to the adverse events (ie, rejection). Together with thrombocyte levels, it can be used as a noninvasive test for follow-up of transplant patients in terms of adverse events in graft function.