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Bhangui P. Liver transplantation and resection in patients with hepatocellular cancer and portal vein tumor thrombosis: Feasible and effective? Hepatobiliary Pancreat Dis Int 2024; 23:123-128. [PMID: 37880019 DOI: 10.1016/j.hbpd.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/27/2023] [Indexed: 10/27/2023]
Abstract
Patients with locally advanced hepatocellular cancer (HCC) and portal vein tumor thrombosis (PVTT) have a dismal prognosis since limited treatment options are available for them. In recent years, effective systemic therapy, and advances in the understanding of technicalities and effectiveness of ablative therapies especially radiotherapy, have given some hope to prolong survival in them. This review summarized recent evidence in literature regarding the possible role of liver resection (LR) and liver transplantation (LT) in patients with locally advanced HCC and PVTT with no extrahepatic disease. Downstaging therapies have helped make curative resection or LT a reality in selected patients. This review emphasizes on the key points to focus on when considering surgery in these patients, who are usually relegated to palliative systemic therapy alone. Meticulous patient selection based on tumor biology, documented downstaging based on imaging and decrease in tumor marker levels, and an adequate waiting period to demonstrate stable disease, may help obtain satisfactory long-term outcomes post LR or LT in an intention to treat strategy in patients with HCC and PVTT.
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Affiliation(s)
- Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta - The Medicity, Sector 38, Gurgaon, Delhi NCR 122001, India.
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2
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Azoulay D, Desterke C, Bhangui P, Serrablo A, De Martin E, Cauchy F, Salloum C, Allard MA, Golse N, Vibert E, Sa Cunha A, Cherqui D, Adam R, Saliba F, Ichai P, Feray C, Scatton O, Lim C. Rescue Liver Transplantation for Posthepatectomy Liver Failure: A Systematic Review and Survey of an International Experience. Transplantation 2024; 108:947-957. [PMID: 37749790 DOI: 10.1097/tp.0000000000004813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Rescue liver transplantation (LT) is the only life-saving option for posthepatectomy liver failure (PHLF) whenever it is deemed as irreversible and likely to be fatal. The goals were to perform a qualitative systematic review of rescue LT for PHLF and a survey among various international LT experts. METHODS A literature search was performed from 2000 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Population, Intervention, Comparison, Outcome framework, and to this, the authors' experience was added. The international online open survey included 6 cases of PHLF extracted from the literature and submitted to 976 LT experts. The primary outcome was whether experts would consider rescue LT for each case. Interrater agreement among experts was calculated using the free-marginal multirater kappa methodology. RESULTS The review included 40 patients. Post-LT mortality occurred in 8 (20%) cases (7/28 with proven cancer and 1/12 with benign disease). In the long term, 6 of 21 (28.6%) survivors with cancer died of recurrence (median = 38 mo) and 15 (71.4%) were alive with no recurrence (median = 111 mo). All 11 survivors with benign disease were alive and well (median = 39 mo). In the international survey among experts in LT, the percentage agreement to consider rescue LT was 28%-98%, higher for benign than for malignant disease ( P = 0.011). Interrater agreement for the primary endpoint was low, expected 5-y survival >50% being the strongest independent predictor to consider LT. CONCLUSIONS Rescue LT for PHLF may achieve good results in selected patients. Considerable inconsistencies of decision-making exist among LT experts when considering LT for PHLF.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Christophe Desterke
- University of Medicine Paris Saclay, Le Kremlin-Bicêtre, France
- INSERM Unit UMR1310, Villejuif, France
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Eleonora De Martin
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - François Cauchy
- Department of Hepato-biliary and Pancreatic Surgery and Liver Transplantation, University of Geneva, Geneva, Switzerland
| | - Chady Salloum
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Marc Antoine Allard
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Philippe Ichai
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Cyrille Feray
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Olivier Scatton
- Département de Chirurgie et Transplantation Hépatique, Hôpital Universitaire Pitié-Salpêtrière, Sorbonne Université, Paris, France
- Centre de Recherche de Saint-Antoine (CRSA), INSERM, UMRS-938, Paris, France
| | - Chetana Lim
- Département de Chirurgie et Transplantation Hépatique, Hôpital Universitaire Pitié-Salpêtrière, Sorbonne Université, Paris, France
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Rastogi A, Gupta AA, Piplani T, Yadav KS, K V F, Bhangui P, Soin AS. Hilar Anatomy in 3035 Living Liver Donors: A Novel Classification for Donor Surgery and Suitability, Hepatic Surgeries, and Hepatobiliary Interventions. Transplantation 2024; 108:455-463. [PMID: 37953482 DOI: 10.1097/tp.0000000000004807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND This study examines the vascular and biliary variations in 3035 liver donors. We propose a novel classification of hepatic arteries, portal veins, and bile ducts and clinically relevant donor classification. METHODS Preoperative imaging and operative details of 3035 donors from 2005 to 2020 were reviewed. Hilar anatomical variations were identified and grouped on the basis of incidence and clinical relevance. RESULTS Hilar structures are classified according to the numbers supplying or draining the graft: for the hepatic artery, right (R) and left (L), RA1/LA1 (1 artery), RA2/LA2 (2 arteries), and RA3/LA3 (3 arteries), respectively, further defined on the basis of the inflow trunk into C (for common hepatic artery), S (for superior mesenteric artery), and L (for left gastric artery); for the portal vein, RP1 (1 vein) and RP2 (2 veins) for the right lobe; and for the hepatic duct, RB1/LB1 (1 duct), RB2/LB2 (2 ducts), RB3 (3 right ducts), and RB4 (4 right ducts). Donors were classified on the basis of anatomical variations into 3 groups: class 1 and class 2 donors, who can donate liver with acceptable risks, and class 3 donors, who are high-risk donors because they are anatomically unacceptable ( Figures S1 to S4, SDC , http://links.lww.com/TP/C918 ). CONCLUSIONS Defining hilar anatomical variations and donor grouping into anatomy-based clinical classes helps in operative planning of donors, hepatobiliary surgeries, and interventional procedures.
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Affiliation(s)
- Amit Rastogi
- Division of Liver Transplantation and HPB (Hepato-Pancreato-Biliary) Surgery, Institute of Liver Transplantation, Medanta, Gurugram (Delhi NCR), Haryana, India
| | - Ankur A Gupta
- Division of Liver Transplantation and HPB (Hepato-Pancreato-Biliary) Surgery, Institute of Liver Transplantation, Medanta, Gurugram (Delhi NCR), Haryana, India
| | - Tarun Piplani
- Division of Liver and GI Radiology, Institute of Radiology, Medanta, Gurugram (Delhi NCR), Haryana, India
| | - Kamal S Yadav
- Division of Liver Transplantation and HPB (Hepato-Pancreato-Biliary) Surgery, Institute of Liver Transplantation, Medanta, Gurugram (Delhi NCR), Haryana, India
| | - Fysal K V
- Division of Liver Transplantation and HPB (Hepato-Pancreato-Biliary) Surgery, Institute of Liver Transplantation, Medanta, Gurugram (Delhi NCR), Haryana, India
| | - Prashant Bhangui
- Division of Liver Transplantation and HPB (Hepato-Pancreato-Biliary) Surgery, Institute of Liver Transplantation, Medanta, Gurugram (Delhi NCR), Haryana, India
| | - Arvinder S Soin
- Division of Liver Transplantation and HPB (Hepato-Pancreato-Biliary) Surgery, Institute of Liver Transplantation, Medanta, Gurugram (Delhi NCR), Haryana, India
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4
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Kumar A, Acharya SK, Singh SP, Duseja A, Madan K, Shukla A, Arora A, Anand AC, Bahl A, Soin AS, Sirohi B, Dutta D, Jothimani D, Panda D, Saini G, Varghese J, Kumar K, Premkumar M, Panigrahi MK, Wadhawan M, Sahu MK, Rela M, Kalra N, Rao PN, Puri P, Bhangui P, Kar P, Shah SR, Baijal SS, Shalimar, Paul SB, Gamanagatti S, Gupta S, Taneja S, Saraswat VA, Chawla YK. 2023 Update of Indian National Association for Study of the Liver Consensus on Management of Intermediate and Advanced Hepatocellular Carcinoma: The Puri III Recommendations. J Clin Exp Hepatol 2024; 14:101269. [PMID: 38107186 PMCID: PMC10724697 DOI: 10.1016/j.jceh.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/12/2023] [Indexed: 12/19/2023] Open
Abstract
Hepatocellular carcinoma (HCC) presents significant treatment challenges despite considerable advancements in its management. The Indian National Association for the Study of the Liver (INASL) first published its guidelines to aid healthcare professionals in the diagnosis and treatment of HCC in 2014. These guidelines were subsequently updated in 2019. However, INASL has recognized the need to revise its guidelines in 2023 due to recent rapid advancements in the diagnosis and management of HCC, particularly for intermediate and advanced stages. The aim is to provide healthcare professionals with evidence-based recommendations tailored to the Indian context. To accomplish this, a task force was formed, and a two-day round table discussion was held in Puri, Odisha. During this event, experts in their respective fields deliberated and finalized consensus statements to develop these updated guidelines. The 2023 INASL guidelines offer a comprehensive framework for the diagnosis, staging, and management of intermediate and advanced HCC in India. They represent a significant step forward in standardizing clinical practices nationwide, with the primary objective of ensuring that patients with HCC receive the best possible care based on the latest evidence. The guidelines cover various topics related to intermediate and advanced HCC, including biomarkers of aggressive behavior, staging, treatment options, and follow-up care.
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Affiliation(s)
- Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Kaushal Madan
- Clinical Hepatology, Max Hospitals, Saket, New Delhi, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Anil C. Anand
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Ankur Bahl
- Department of Medical Oncology, Fortis Memorial Research Institute, Sector - 44, Opp. HUDA City Center, Gurugram, 122002, India
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Bhawna Sirohi
- Medical Oncology, BALCO Medical Centre, Raipur Chattisgarh, 493661, India
| | - Debnarayan Dutta
- Radiation Oncology, Amrita Institute of Medical Sciences, Ponekkara, AIMS (P.O.), Kochi, 682041, India
| | - Dinesh Jothimani
- Department of Hepatology, Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Dipanjan Panda
- Department of Medical Oncology, Apollo Cancer Centre, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110076, India
| | - Gagan Saini
- Radiation Oncology, Max Institute of Cancer Care, Max Super-Speciality Hospital, W-3, Ashok Marg, near Radisson Blu Hotel, Sector-1, Vaishali, Ghaziabad, 201012, India
| | - Joy Varghese
- Department of Hepatology & Transplant Hepatology, Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai, Tamil Nadu, 600100, India
| | - Karan Kumar
- Department of HPB Sciences and Liver Transplantation, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Manas K. Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, Odisha, India
| | - Manav Wadhawan
- Liver & Digestive Diseases Institute, Institute of Liver & Digestive Diseases, BLK Max Hospital, Delhi, 110 005, India
| | - Manoj K. Sahu
- Department of Medical Gastroenterology, IMS & SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, Odisha 751 003, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Naveen Kalra
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, No. 6-3-661, Punjagutta Road, Somajiguda, Hyderabad, Telangana, 500 082, India
| | - Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Heart Institute & Research Centre, Okhla Road, New Delhi, 110025, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Premashis Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Samir R. Shah
- Department of Hepatology and Liver Intensive Care, Institute of Liver Disease, HPB Surgery and Transplant Global Hospitals, Dr E Borges Road, Parel, Mumbai, 400012, India
| | - Sanjay S. Baijal
- Diagnostic and Interventional Radiology, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shivanand Gamanagatti
- Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Heart Institute & Research Centre, Okhla Road, New Delhi, 110025, India
| | - Subash Gupta
- Centre for Liver & Biliary Sciences, Liver Transplant and Biliary Sciences, Robotic Surgery, Max Super Speciality Hospital, No. 1, 2, Press Enclave Road, Mandir Marg, Saket Institutional Area, Saket, New Delhi, Delhi, 110017, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vivek A. Saraswat
- Department of Gastroenterology and Hepatology, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
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5
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Lai Q, De Stefano C, Emond J, Bhangui P, Ikegami T, Schaefer B, Hoppe‐Lotichius M, Mrzljak A, Ito T, Vivarelli M, Tisone G, Agnes S, Ettorre GM, Rossi M, Tsochatzis E, Lo CM, Chen C, Cillo U, Ravaioli M, Lerut JP. Development and validation of an artificial intelligence model for predicting post-transplant hepatocellular cancer recurrence. Cancer Commun (Lond) 2023; 43:1381-1385. [PMID: 37904670 PMCID: PMC10693300 DOI: 10.1002/cac2.12468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/25/2023] [Accepted: 07/13/2023] [Indexed: 11/01/2023] Open
Affiliation(s)
- Quirino Lai
- General Surgery and Organ Transplantation Unit, AOU Policlinico Umberto ISapienza University of RomeRomeItaly
| | | | - Jean Emond
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of SurgeryWeill Cornell Medicine‐Columbia UniversityNew YorkUS
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative MedicineMedanta‐The MedicityGurgaonIndia
| | - Toru Ikegami
- Department of Surgery and ScienceKyushu UniversityFukuokaJapan
| | - Benedikt Schaefer
- Department of Medicine I, Gastroenterology, Hepatology and EndocrinologyMedical University of InnsbruckInnsbruckAustria
| | - Maria Hoppe‐Lotichius
- Klinik für Allgemein‐, Viszeral‐ und TransplantationschirurgieUniversitätsmedizin MainzMainzGermany
| | - Anna Mrzljak
- Liver Transplant CentreMerkur University of ZagrebZagrebCroatia
| | - Takashi Ito
- Division of Hepato‐Biliary‐Pancreatic and Transplant Surgery, Department of SurgeryGraduate School of MedicineKyotoJapan
| | - Marco Vivarelli
- Unit of Hepatobiliary Surgery and Transplantation, AOU Ospedali RiunitiPolytechnic University of MarcheAnconaItaly
| | - Giuseppe Tisone
- Department of Surgical Sciences and Medical Sciences University of Rome‐Tor VergataRomeItaly
| | - Salvatore Agnes
- Liver Unit, Department of SurgeryCatholic University‐Fondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
| | | | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, AOU Policlinico Umberto ISapienza University of RomeRomeItaly
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health and Royal Free Sheila Sherlock Liver CentreRoyal Free HospitalLondonUK
| | - Chung Mau Lo
- Hong Kong University–Department of SurgeryQueen Mary Hospital, University of Hong KongHong KongP. R. China
| | - Chao‐Long Chen
- Department of SurgeryKaohsiung Chang Gung Memorial Hospital, Chang Gung University College of MedicineKaohsiung, TaiwanP. R. China
| | - Umberto Cillo
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - Matteo Ravaioli
- Department of General Surgery and TransplantationIRCCS, Azienda Ospedaliero‐Universitaria di Bologna, Bologna UniversityBolognaItaly
| | - Jan Paul Lerut
- Institut de Recherche CliniqueUniversité catholique de LouvainBrusselsBelgium
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6
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Kow AWC, Liu J, Patel MS, De Martin E, Reddy MS, Soejima Y, Syn N, Watt K, Xia Q, Saraf N, Kamel R, Nasralla D, McKenna G, Srinvasan P, Elsabbagh AM, Pamecha V, Palaniappan K, Mas V, Tokat Y, Asthana S, Cherukuru R, Egawa H, Lerut J, Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Emond J, Ascher N, Rammohan A, Bhangui P, Rela M, Kim DS, Ikegami T. Post Living Donor Liver Transplantation Small-for-size Syndrome: Definitions, Timelines, Biochemical, and Clinical Factors for Diagnosis: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2226-2237. [PMID: 37749812 DOI: 10.1097/tp.0000000000004770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND When a partial liver graft is unable to meet the demands of the recipient, a clinical phenomenon, small-for-size syndrome (SFSS), may ensue. Clear definition, diagnosis, and management are needed to optimize transplant outcomes. METHODS A Consensus Scientific committee (106 members from 21 countries) performed an extensive literature review on specific aspects of SFSS, recommendations underwent blinded review by an independent panel, and discussion/voting on the recommendations occurred at the Consensus Conference. RESULTS The ideal graft-to-recipient weight ratio of ≥0.8% (or graft volume standard liver volume ratio of ≥40%) is recommended. It is also recommended to measure portal pressure or portal blood flow during living donor liver transplantation and maintain a postreperfusion portal pressure of <15 mm Hg and/or portal blood flow of <250 mL/min/100 g graft weight to optimize outcomes. The typical time point to diagnose SFSS is the postoperative day 7 to facilitate treatment and intervention. An objective 3-grade stratification of severity for protocolized management of SFSS is proposed. CONCLUSIONS The proposed grading system based on clinical and biochemical factors will help clinicians in the early identification of patients at risk of developing SFSS and institute timely therapeutic measures. The validity of this newly created grading system should be evaluated in future prospective studies.
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Affiliation(s)
- Alfred Wei Chieh Kow
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore
- Liver Transplantation, National University Center for Organ Transplantation (NUCOT), National University Health System Singapore, Singapore
| | - Jiang Liu
- Department of Surgery, Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- Department of Surgery, LKS Faculty of Medicine, HKU-Shenzhen Hospital, University of Hong Kong, Hong Kong/Special Administrative Region (SAR), China
| | - Madhukar S Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eleonora De Martin
- Department of Hepatology, APHP, Hospital Paul Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, FHU Hepatinov, Villejuif, France
| | - Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Yuji Soejima
- Department of Surgery, Shinshu University, Japan
| | - Nicholas Syn
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore
- Liver Transplantation, National University Center for Organ Transplantation (NUCOT), National University Health System Singapore, Singapore
| | - Kymberly Watt
- Division of Gastroenterology/Hepatology, Mayo Clinic, Rochester, MN
| | - Qiang Xia
- Department of Surgery, Division of Liver Transplantation, Renji Hospital, Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine, China
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-the Medicity, New Delhi, India
| | - Refaat Kamel
- Department of Surgery, Ain Shams University, Cairo, Egypt
| | - David Nasralla
- Department of HPB Surgery and Liver Transplantation, Royal Free London, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Greg McKenna
- Department of Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Parthi Srinvasan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ahmed M Elsabbagh
- Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Vinayendra Pamecha
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Kumar Palaniappan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Valeria Mas
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD
| | - Yaman Tokat
- International Liver Center, Acibadem Healthcare Hospitals, Turkey
| | - Sonal Asthana
- Department of Surgery, Integrated Liver Care Aster CMI Hospital, Bangalore, India
| | - Ramkiran Cherukuru
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Hiroto Egawa
- Hamamatsu Rosai Hospital, Hamamatsu, Shizuoka, Japan
| | - Jan Lerut
- Pôle de chirurgie expérimentale et transplantation, Université Catholique De Louvain, Louvain, Belgium
| | - Dieter Broering
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Hepatology and Liver Transplant Unit, Fundación Para La Investigación Del Hospital Universitario La Fe De La CCVV, IIS La Fe, Ciberehd, University of Valencia, Valencia, Spain
| | - Mark Cattral
- Department of Surgery, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | | | - Chao-Long Chen
- Department of Surgery, Chang Gung Memorial Hospital Kaoshiung, Taiwan
| | - Samir Shah
- Institute of Liver Disease, HPB Surgery and Rransplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Department of HPB Surgery and Liver Transplantation, Beijing Friendship Hospital, Beijing, China
| | - Jean Emond
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Nancy Ascher
- Division of Transplant Surgery, University of California San Francisco, San Francisco, CA
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-the Medicity, New Delhi, India
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Dong-Sik Kim
- Department of Surgery, Korea University Medical Center, Anam Hospital, Seoul, South Korea
| | - Toru Ikegami
- Department of Surgery, Centennial Hall Kyushu University School of Medicine, Kyushu, Japan
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7
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Kirchner VA, Shankar S, Victor DW, Tanaka T, Goldaracena N, Troisi RI, Olthoff KM, Kim JM, Pomfret EA, Heaton N, Polak WG, Shukla A, Mohanka R, Balci D, Ghobrial M, Gupta S, Maluf D, Fung JJ, Eguchi S, Roberts J, Eghtesad B, Selzner M, Prasad R, Kasahara M, Egawa H, Lerut J, Broering D, Berenguer M, Cattral MS, Clavien PA, Chen CL, Shah SR, Zhu ZJ, Ascher N, Ikegami T, Bhangui P, Rammohan A, Emond JC, Rela M. Management of Established Small-for-size Syndrome in Post Living Donor Liver Transplantation: Medical, Radiological, and Surgical Interventions: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2238-2246. [PMID: 37749813 DOI: 10.1097/tp.0000000000004771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Small-for-size syndrome (SFSS) following living donor liver transplantation is a complication that can lead to devastating outcomes such as prolonged poor graft function and possibly graft loss. Because of the concern about the syndrome, some transplants of mismatched grafts may not be performed. Portal hyperperfusion of a small graft and hyperdynamic splanchnic circulation are recognized as main pathogenic factors for the syndrome. Management of established SFSS is guided by the severity of the presentation with the initial focus on pharmacological therapy to modulate portal flow and provide supportive care to the patient with the goal of facilitating graft regeneration and recovery. When medical management fails or condition progresses with impending dysfunction or even liver failure, interventional radiology (IR) and/or surgical interventions to reduce portal overperfusion should be considered. Although most patients have good outcomes with medical, IR, and/or surgical management that allow graft regeneration, the risk of graft loss increases dramatically in the setting of bilirubin >10 mg/dL and INR>1.6 on postoperative day 7 or isolated bilirubin >20 mg/dL on postoperative day 14. Retransplantation should be considered based on the overall clinical situation and the above postoperative laboratory parameters. The following recommendations focus on medical and IR/surgical management of SFSS as well as considerations and timing of retransplantation when other therapies fail.
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Affiliation(s)
- Varvara A Kirchner
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Sadhana Shankar
- The Liver Unit, King's College Hospital, London, United Kingdom
| | - David W Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX
| | - Tomohiro Tanaka
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - Nicolas Goldaracena
- Abdominal Organ Transplant and Hepatobiliary Surgery, University of Virginia Health System, Charlottesville, VA
| | - Roberto I Troisi
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Public Health, Federico II University Hospital, Naples, Italy
| | - Kim M Olthoff
- Department of Surgery, Division of Transplant Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Elizabeth A Pomfret
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nigel Heaton
- The Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Wojtek G Polak
- The Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Ravi Mohanka
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospital, Mumbai, Maharashtra, India
| | - Deniz Balci
- Department of General Surgery and Organ Transplantation Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX
| | - Subash Gupta
- Max Centre for Liver and Biliary Sciences, Max Saket Hospital, New Delhi, India
| | - Daniel Maluf
- Program in Transplantation, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD
| | - John J Fung
- Department of Surgery, University of Chicago Medicine Transplant Institute, Chicago, IL
| | - Susumu Eguchi
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - John Roberts
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Bijan Eghtesad
- Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Markus Selzner
- HPB and Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Raj Prasad
- Division of Transplantation, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mureo Kasahara
- National Center for Child Health and Development, Tokyo, Japan
| | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Institute for Experimental and Clinical Research-Université catholique de Louvain, Brussels, Belgium
| | - Dieter Broering
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Unit, CIBERehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe-Universidad de Valencia, Valencia, Spain
| | - Mark S Cattral
- HPB and Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Chao-Long Chen
- Liver Transplant Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Samir R Shah
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University; and Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Toru Ikegami
- Divsion of Hepatobiliary Surgery and Pancreas Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Jean C Emond
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
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8
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Hakeem AR, Mathew JS, Aunés CV, Mazzola A, Alconchel F, Yoon YI, Testa G, Selzner N, Sarin SK, Lee KW, Soin A, Pomposelli J, Menon K, Goyal N, Kota V, Abu-Gazala S, Rodriguez-Davalos M, Rajalingam R, Kapoor D, Durand F, Kamath P, Jothimani D, Sudhindran S, Vij V, Yoshizumi T, Egawa H, Lerut J, Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Ascher N, Bhangui P, Rammohan A, Emond J, Rela M. Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2203-2215. [PMID: 37635285 DOI: 10.1097/tp.0000000000004769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Small-for-size syndrome (SFSS) is a well-recognized complication following liver transplantation (LT), with up to 20% developing this following living donor LT (LDLT). Preventing SFSS involves consideration of factors before the surgical procedure, including donor and recipient selection, and factors during the surgical procedure, including adequate outflow reconstruction, graft portal inflow modulation, and management of portosystemic shunts. International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplant Society of India Consensus Conference was convened in January 2023 to develop recommendations for the prediction and management of SFSS in LDLT. The format of the conference was based on the Grading of Recommendations, Assessment, Development, and Evaluation system. International experts in this field were allocated to 4 working groups (diagnosis, prevention, anesthesia, and critical care considerations, and management of established SFSS). The working groups prepared evidence-based recommendations to answer-specific questions considering the currently available literature. The working group members, independent panel, and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and evidence-based recommendations provided by working group 2 that can be implemented to prevent SFSS in LDLT patients.
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Affiliation(s)
- Abdul Rahman Hakeem
- Department of Hepatobiliary and Liver Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Johns Shaji Mathew
- Department of GI, HPB & Multi-Organ Transplant, Rajagiri Hospitals, Kochi, India
| | - Carmen Vinaixa Aunés
- Hepatología y Trasplante Hepático, Servicio de Medicina Digestiva, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Alessandra Mazzola
- Sorbonne Université, Unité Médicale de Transplantation Hépatique, Hépato-gastroentérologie, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Felipe Alconchel
- Department of Surgery and Transplantation, Virgen de la Arrixaca University Hospital, Murcia, Spain
- Biomedical Research Institute of Murcia, IMIB-Pascual Parrilla, Murcia, Spain
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, Seoul, South Korea
| | - Giuliano Testa
- Department of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Nazia Selzner
- Multi-Organ Transplant Program, Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Arvinder Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - James Pomposelli
- University of Colorado School of Medicine, Division of Transplant Surgery, Department of Surgery, Aurora, CO
| | - Krishna Menon
- Institute of Liver Diseases, King's College Hospital, London, United Kingdom
| | - Neerav Goyal
- Liver Transplant and Hepato-Pancreatobiliary Surgery Unit (LTHPS), Indraprastha Apollo Hospital, New Delhi, India
| | - Venugopal Kota
- Department of HPB Surgery and Liver Transplantation, Yashoda Hospitals, Secunderabad, Hyderabad, Telangana, India
| | - Samir Abu-Gazala
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Manuel Rodriguez-Davalos
- Liver Center, Primary Children's Hospital; Transplant Services, Intermountain Transplant Center, Primary Children's Hospital, Salt Lake City, UT
| | - Rajesh Rajalingam
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Dharmesh Kapoor
- Department of Hepatology and Liver Transplantation, Yashoda Hospitals, Secunderabad, Hyderabad, Telangana, India
| | - Francois Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy University Paris Cité, Paris, France
| | - Patrick Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Surendran Sudhindran
- Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences, Kochi, India
| | - Vivek Vij
- Department of HPB Surgery and Liver Transplantation, Fortis Group of Hospitals, New Delhi, India
| | | | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Institute for Experimental and Clinical Research (IREC), Université catholique Louvain (UCL), Brussels, Belgium
| | - Dieter Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Unit, Ciberehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Universidad Valencia, Valencia, Spain
| | - Mark Cattral
- Multi-Organ Transplant Program, Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Zürich, Switzerland
| | - Chao-Long Chen
- Liver Transplantation Centre, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Jean Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
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9
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Rela M, Rammohan A, Bhangui P, Emond J. Prediction and Management of Small-for-size Syndrome in Living Donor Liver Transplantation: Methodology of the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2098-2100. [PMID: 37635284 PMCID: PMC10519287 DOI: 10.1097/tp.0000000000004768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Delhi NCR, India
| | - Jean Emond
- Columbia University, New York Presbyterian Hospital, New York, NY
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10
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Chadha R, Sakai T, Rajakumar A, Shingina A, Yoon U, Patel D, Spiro M, Bhangui P, Sun LY, Humar A, Bezinover D, Findlay J, Saigal S, Singh S, Yi NJ, Rodriguez-Davalos M, Kumar L, Kumaran V, Agarwal S, Berlakovich G, Egawa H, Lerut J, Clemens Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Ascher N, Bhangui P, Rammohan A, Emond J, Rela M. Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2216-2225. [PMID: 37749811 DOI: 10.1097/tp.0000000000004803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND During the perioperative period of living donor liver transplantation, anesthesiologists and intensivists may encounter patients in receipt of small grafts that puts them at risk of developing small for size syndrome (SFSS). METHODS A scientific committee (106 members from 21 countries) performed an extensive literature review on aspects of SFSS with proposed recommendations. Recommendations underwent a blinded review by an independent expert panel and discussion/voting on the recommendations occurred at a consensus conference organized by the International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplantation Society of India. RESULTS It was determined that centers with experience in living donor liver transplantation should utilize potential small for size grafts. Higher risk recipients with sarcopenia, cardiopulmonary, and renal dysfunction should receive small for size grafts with caution. In the intraoperative phase, a restrictive fluid strategy should be considered along with routine use of cardiac output monitoring, as well as use of pharmacologic portal flow modulation when appropriate. Postoperatively, these patients can be considered for enhanced recovery and should receive proactive monitoring for SFSS, nutrition optimization, infection prevention, and consideration for early renal replacement therapy for avoidance of graft congestion. CONCLUSIONS Our recommendations provide a framework for the optimal anesthetic and critical care management in the perioperative period for patients with grafts that put them at risk of developing SFSS. There is a significant limitation in the level of evidence for most recommendations. This statement aims to provide guidance for future research in the perioperative management of SFSS.
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Affiliation(s)
- Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Akila Rajakumar
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Alexandra Shingina
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Dhupal Patel
- Department of Anesthesia and Intensive Care Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Michael Spiro
- Department of Anaesthesia, Royal Devon and Exeter and Department of Anaesthesia and Intensive Care Medicine, The Royal Free Hospital, London, United Kingdom
| | - Pooja Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Li-Ying Sun
- Department of Critical Liver Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - James Findlay
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Sanjiv Saigal
- Centre of Liver and Biliary Sciences, Centre of Gastroenterology, Hepatology and Endoscopy, Max Super Specialty Hospital, New Delhi, India
| | - Shweta Singh
- Department of Anesthesiology and Critical Care, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Nam-Joon Yi
- Division of HBP Surgery, Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Manuel Rodriguez-Davalos
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Lakshmi Kumar
- Department of Anesthesiology, Amrita Hospital, Kochi, India
| | - Vinay Kumaran
- Division of Transplant Surgery, Department of Surgery, VCU Medical Center, Richmond, VA
| | - Shaleen Agarwal
- Centre of Liver and Biliary Sciences, Centre of Gastroenterology, Hepatology and Endoscopy, Max Super Specialty Hospital, New Delhi, India
| | | | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Dieter Clemens Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, La Fe University Hospital and IISLaFe and Ciberehd, Valencia, Spain
| | - Mark Cattral
- Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | | | - Chao-Long Chen
- Liver Transplantation Centre, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Jean Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
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11
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Bhangui P. Impact of the COVID-19 Pandemic on Patients with End-Stage Liver Disease: One Virus-A Plethora of Consequences. J Clin Exp Hepatol 2023; 13:725-727. [PMID: 37693270 PMCID: PMC10482993 DOI: 10.1016/j.jceh.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Affiliation(s)
- Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta – the Medicity, Gurgaon, Delhi NCR, India
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12
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Choudhary NS, Dhampalwar S, Saraf N, Bansal SB, Gadde A, Rastogi A, Bhangui P, Rana A, Rana A, Soin AS. The Renal Histological Correlates of Refractory Renal Dysfunction After Liver Transplantation. J Clin Exp Hepatol 2023; 13:586-591. [PMID: 37440946 PMCID: PMC10333932 DOI: 10.1016/j.jceh.2023.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/21/2023] [Indexed: 07/15/2023] Open
Abstract
Background Kidney dysfunction is common after liver transplantation (LT) and is often attributed to calcineurin inhibitors (CNIs). Very few studies have looked at histological causes. Material and methods The study is a retrospective analysis of histological findings and diagnosis in all patients who underwent a kidney biopsy after LT from 2010 to 2020. Data are shown as mean ± standard deviation or medians (25-75 interquartile range). Results The study cohort consisted of 26 patients (25 males, 1 female), aged 55 ± 7 years at the time of the kidney biopsy. Kidney biopsies were done at 27.5 (6.7-60.7) months after LT. At the time of the kidney biopsy, the median serum creatinine was 2.10 (1.50-2.86) mg/dl and proteinuria was 3.8 (1.8-5.9) gm/day. Twenty-four (92%) patients were on CNIs. The diagnoses on kidney biopsies were diabetic nephropathy (n = 7), focal segmental glomerulosclerosis (n = 4), CNI nephrotoxicity (n = 3), IgA nephropathy (n = 4), chronic glomerulonephritis (n = 3), hypertensive nephropathy (n = 1), membranous glomerulonephritis (n = 1), acute on chronic interstitial nephritis (n = 1), and C1q nephropathy (n = 1), and the sample was inadequate in one patient. A total of sixteen patients had progression of kidney disease. The kidney function remained stable/improved in 6 (23%) patients, follow-up data were not available for 4 patients. Fourteen (53.8%) patients (including one with CNI nephrotoxicity) required hemodialysis at 13.5 (5.7-29) months after the kidney biopsy. Conclusion Although the kidney biopsy diagnosed the cause of unexplained renal insufficiency in LT recipients, the majority of patients progressed to end-stage renal disease despite treatment modifications. The use of CNIs was an uncommon cause of renal impairment.
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Shyam B. Bansal
- Institute of Nephrology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Ashwini Gadde
- Institute of Nephrology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Abhyuday Rana
- Institute of Nephrology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Alka Rana
- Department of Pathology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
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13
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Soin AS, Bhangui P, Rastogi A, Piplani T, Choudhary N, Dhampalwar S, Kollantavalappil F, Yadav K, Gupta A, Gupta N, Sharma N, Bhangui P, Aneja M, Vohra V, Saraf N. Simultaneous 3-way Paired Exchange Liver Transplantation Without Nondirected Donation: Novel Strategy to Expand the Donor Pool. Transplantation 2023; 107:e175-e177. [PMID: 37220342 DOI: 10.1097/tp.0000000000004578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- A S Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Tarun Piplani
- Department of Radiodiagnosis and Interventional Radiology, Medanta-The Medicity, Delhi NCR, India
| | - Narendra Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Swapnil Dhampalwar
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Fysal Kollantavalappil
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Kamal Yadav
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Ankur Gupta
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Nikunj Gupta
- Department of Liver Transplant and GI Anaesthesia, Medanta-The Medicity, Delhi NCR, India
| | - Nishant Sharma
- Department of Liver Transplant and GI Anaesthesia, Medanta-The Medicity, Delhi NCR, India
| | - Pooja Bhangui
- Department of Liver Transplant and GI Anaesthesia, Medanta-The Medicity, Delhi NCR, India
| | - Manish Aneja
- Department of Liver Transplant and GI Anaesthesia, Medanta-The Medicity, Delhi NCR, India
| | - Vijay Vohra
- Department of Liver Transplant and GI Anaesthesia, Medanta-The Medicity, Delhi NCR, India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
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14
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Soin A, Lesurtel M, Bhangui P, Cocchi L, Bouattour M, Clavien PA. Are patients with hepatocellular carcinoma and portal vein tumour thrombosis candidates for liver transplantation? J Hepatol 2023; 78:1124-1129. [PMID: 37208099 DOI: 10.1016/j.jhep.2023.03.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 05/21/2023]
Abstract
In this debate, the authors consider whether patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis are candidates for liver transplantation (LT). The argument for LT in this context is based on the premise that, following successful downstaging treatment, LT confers a much greater clinical benefit in terms of survival outcomes than the available alternative (palliative systemic therapy). A major argument against relates to limitations in the quality of evidence for LT in this setting - in relation to study design, as well as heterogeneity in patient characteristics and downstaging protocols. While acknowledging the superior outcomes offered by LT for patients with portal vein tumour thrombosis, the counterargument is that expected survival in such patients is still below accepted thresholds for LT and, indeed, the levels achieved for other patients who receive transplants beyond the Milan criteria. Based on the available evidence, it seems too early for consensus guidelines to recommend such an approach, however, it is hoped that with higher quality evidence and standardised downstaging protocols, LT may soon be more widely indicated, including for this population with high unmet clinical need.
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Affiliation(s)
- Arvinder Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, India
| | - Mickaël Lesurtel
- Department of HPB Surgery & Liver Transplantation, APHP Beaujon Hospital, University of Paris Cité, 100, bd General Leclerc, 92110 Clichy, France
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, India
| | - Lorenzo Cocchi
- Department of HPB Surgery & Liver Transplantation, APHP Beaujon Hospital, University of Paris Cité, 100, bd General Leclerc, 92110 Clichy, France
| | - Mohamed Bouattour
- Department of Hepatology, APHP Beaujon Hospital, University of Paris Cité, 100, Bd General Leclerc, 92110 Clichy, France
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Pollok JM, Tinguely P, Berenguer M, Niemann CU, Raptis DA, Spiro M, Dominguez B, Muller E, Rando K, Enoch MA, Tamir N, Healy P, Manser T, Briggs T, Chaudhary A, Humar A, Jafarian A, Soin AS, Eghtesad B, Miller C, Cherqui D, Samuel D, Broering D, Pomfret E, Villamil F, Durand F, Berlakovich G, McCaughan G, Auzinger G, Testa G, Klintmalm G, Belghiti J, Findlay J, Lai J, Fung J, Klinck J, Roberts J, Liu L, Cattral M, Ghobrial M, Selzner M, Ramsay M, Rela M, Ascher N, Man NK, Selzner N, Burra P, Friend P, Busuttil R, Hwang S, McCluskey S, Mas V, Vohra V, Vij V, Merritt W, Tokat Y, Kang Y, Chan A, Mazzola A, Hessheimer A, Rammohan A, Hogan B, Vinaixa C, Nasralla D, Victor D, De Martin E, Alconchel F, Roll G, Kabacam G, Sapisochin G, Campos-Varela I, Liu J, Patel MS, Izzy M, Kalisvaart M, Adams M, Goldaracena N, Tinguely P, Hernandez-Alejandro R, Chadha R, Shaker TM, Klair TS, Pan T, Tanaka T, Yoon U, Kirchner V, Hannon V, Cheah YL, Frola C, Morkane C, Milliken D, Lurje G, Potts J, Fernandez T, Badenoch A, Mukhtar A, Zanetto A, Montano-Loza A, Chieh AKW, Shetty A, DeWolf A, Olmos A, Mrzljak A, Blasi A, Berzigotti A, Malik A, Rajakumar A, Davidson B, O'Farrell B, Kotton C, Imber C, Kwon CHD, Wray C, Ahn CS, Morkane C, Krenn C, Quintini C, Maluf D, Mina DS, Sellers D, Balci D, Patel D, Rudow DL, Monbaliu D, Bezinover D, Krzanicki D, Milliken D, Kim DS, Brombosz E, Blumberg E, Weiss E, Wey E, Kaldas F, Saliba F, Pittau G, Wagener G, Song GW, Biancofiore G, Testa G, Crespo G, Rodríguez G, Palli GM, McKenna G, Petrowsky H, Egawa H, Montasser I, Pirenne J, Eason J, Guarrera J, Pomposelli J, Lerut J, Emond J, Boehly J, Towey J, Hillingsø JG, de Jonge J, Potts J, Caicedo J, Heimbach J, Emamaullee JA, Bartoszko J, Ma KW, Kronish K, Forkin KT, Chok KSH, Olthoff K, Reyntjens K, Lee KW, Suh KS, Denehy L, van der Laan LJ, McCormack L, Gorvin L, Ruffolo L, Bhat M, Ramírez MAM, Londoño MC, Gitman M, Levstik M, Selzner M, de Santibañes M, Lindsay M, Parotto M, Armstrong M, Kasahara M, Schofield N, Rizkalla N, Akamatsu N, Scatton O, Keskin O, Imventarza O, Andacoglu O, Muiesan P, Giorgio P, Northup P, Matins P, Abt P, Newsome PN, Dutkowski P, Bhangui P, Bhangui P, Tandon P, Brustia R, Planinsic R, Brown R, Porte R, Barth R, Ciria R, Florman S, Dharancy S, Pai SL, Yagi S, Nadalin S, Chinnakotla S, Forbes SJ, Rahman S, Hong SK, Liying S, Orloff S, Rubman S, Eguchi S, Ikegami T, Reichman T, Settmacher U, Aluvihare V, Xia V, Yoon YI, Soejima Y, Genyk Y, Jalal A, Borakati A, Gustar A, Mohamed A, Ramirez A, Rothnie A, Scott A, Sharma A, Munro A, Mahay A, Liew B, Hidalgo C, Crouch C, Yan CT, Tschuor C, Shaw C, Schizas D, Fritche D, Huda FF, Wells G, Farrer G, Kwok HT, Kostakis I, Mestre-Costa J, Fan KH, Fan KS, Fraser K, Jeilani L, Pang L, Lenti L, Kathirvel M, Zachiotis M, Vailas M, Milan MM, Elnagar M, Alradhawi M, Dimitrokallis N, Machairas N, Morare N, Yeung O, Khanal P, Satish P, Ghani SA, Makhdoom S, Arulrajan S, Bogan S, Pericleous S, Blakemore T, Otti V, Lam W, Jackson W, Abdi Z. Enhanced recovery for liver transplantation: recommendations from the 2022 International Liver Transplantation Society consensus conference. Lancet Gastroenterol Hepatol 2023; 8:81-94. [PMID: 36495912 DOI: 10.1016/s2468-1253(22)00268-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 12/12/2022]
Abstract
There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.
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Affiliation(s)
- Joerg M Pollok
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, NHS Foundation Trust, London, UK
| | - Marina Berenguer
- Liver Unit, CIBERehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe-Universidad de Valencia, Valencia, Spain
| | - Claus U Niemann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA, USA
| | - Dimitri A Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Spiro
- Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, NHS Foundation Trust, London, UK; The Royal Free Perioperative Research Group, Royal Free Hospital, NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK.
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Goldaracena N, Bhangui P, Yoon YI, Vargas PA, Spiro M, Raptis DA, Tokat Y. Early removal of drains and lines after liver transplantation to reduce the length of hospital stay and enhance recovery - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14687. [PMID: 35468235 DOI: 10.1111/ctr.14687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/19/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The timing of removing abdominal drains, central venous catheters (CVC), and urinary catheters (UC) on post liver transplantation (LT) outcomes is not well elucidated. OBJECTIVES To provide international expert panel recommendations and guidelines on time of drain and catheter removal as a part of an ERAS protocol to reduce the length of hospital stay and enhance recovery. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Papers considered were those reporting one or more outcomes of interest related to drainage and line removal in the setting of LT. POSPERO Protocol ID: CRD42021238349 RESULTS: On analyzing five relevant studies pertaining to drains in patients undergoing LT (four retrospectives and one prospective), the length of hospital and/or ICU stay was similar or shorter, and postoperative morbidity and mortality were lower in those without drains. No studies pertaining specifically to the time of removal of drains, CVC's, or UC's in LT were found. Studies in patients undergoing major abdominal surgery or hepatectomies recommend early removal of CVC and UC to reduce catheter-associated infections. CONCLUSIONS Based more on expert recommendation, we propose that abdominal drains, if placed during LT, should be removed by postoperative day 5 after LT, based on quantity and fluid characteristics (Quality of Evidence; Low to Moderate | Grade of Recommendation; Strong). Larger studies are needed to more reliably determine indications for early drain and line removal in an ERAS protocol setting.
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Affiliation(s)
- Nicolas Goldaracena
- Department of Surgery, Division of Transplantation, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta - The Medicitiy, Gurugram, Delhi NCR, India
| | | | - Paola A Vargas
- Department of Surgery, Division of Transplantation, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Yaman Tokat
- International Liver Center and Acibadem Healthcare System Hospitals, New Delhi, India
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Choudhary NS, Saraf N, Dhampalwar S, Mishra S, Gautam D, Lipi L, Rastogi A, Bhangui P, Chaudhary RJ, Gupta A, Yadav K, Soin AS. Nonalcoholic Fatty Liver Disease in Living Donor Liver Transplant Recipients: A Histology-Based Study. J Clin Exp Hepatol 2022; 12:1328-1332. [PMID: 36157151 PMCID: PMC9500106 DOI: 10.1016/j.jceh.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022] Open
Abstract
Background Recurrent or de novo nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are common after liver transplantation (LT) and may be associated with rapid progression to fibrosis; however, there is limited data in this regard after living donor liver transplantation (LDLT). Material and methods This is a retrospective study at a high volume LDLT center of all liver biopsies performed in patients with post-transplant NAFLD diagnosed on ultrasound of the abdomen. Liver biopsy was indicated for raised transaminases and/or high liver stiffness on TE. The association between these prebiopsy parameters and inflammation and fibrosis on histology was analyzed. Data are shown as mean ± standard deviation or median (25-75 interquartile range). Results The study cohort consisted of 31 males and 3 females, aged 43 ± 10 years. The LT to liver biopsy interval was 44 (28-68) months. The prebiopsy AST and ALT were 71 (38-119) and 66 (50-156), respectively. The histology suggested no nonalcoholic steatohepatitis (NASH) in 7 (20%), borderline NASH in 15 (44%), and NASH in 12 (35%) patients. A total of 15 patients (44%) had stage 1 or stage 2 fibrosis. The proportion of patients having fibrosis was significantly higher in patients with NASH (83%) compared to patients with borderline NASH (33%) or no NASH (none had fibrosis, P = 0.001). Among 18 patients who underwent TE (on FibroScan), liver stiffness was significantly higher in patients with fibrosis [18.1 (9.7-22.5)] than in those without fibrosis [9.7 (4.0-12.7); P = 0.043]. Conclusion Over a third of the LDLT recipients with post-transplant NAFLD developed NASH, and nearly half, borderline NASH 3-5 years after transplant. Most with established NASH also had fibrosis on histology. Prevention of risk factors and early diagnosis is warranted in these patients.
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Saurabh Mishra
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Dheeraj Gautam
- Department of Pathology, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Lipika Lipi
- Department of Pathology, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Rohan J. Chaudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Ankur Gupta
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Kamal Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
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Azoulay D, Desterke C, Bhangui P, Salloum C, Conticchio M, Vibert E, Cherqui D, Adam R, Ichai P, Saliba F, Elmaleh A, Naili S, Lim C, Feray C. Tumors located in the central column of the liver are associated with increased surgical difficulty and postoperative complications following open liver resection for colorectal metastases. HPB (Oxford) 2022; 24:1376-1386. [PMID: 35437222 DOI: 10.1016/j.hpb.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/13/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To assess the impact of difficult location (based on preoperative computed tomography) of liver metastases from colorectal cancer (LMCRC) on surgical difficulty, and occurrence of severe postoperative complications (POCs). METHODS A retrospective single-centre study of 911 consecutive patients with LMCRC who underwent hepatectomy by the open approach between 1998 and 2011, before implementation of laparoscopic surgery to obviate approach selection bias. LMCRC with at least one of the following four features on preoperative imaging: tumor invading the hepatocaval confluence or retro-hepatic inferior vena cava, centrally located (Segments 4,5,8) and >10 cm in diameter, abutting the supra-hilar area, or involving the paracaval portion or caudate process of Segment 1; were considered as topographically difficult (top-diff). Independent predictors of surgical difficulty assessed by number of blood units transfused, duration of ischemia, and number of sessions of pedicle clamping during surgery and of severe POCs were identified by multivariate analysis before, and after propensity score matching. RESULTS Top-diff tumor location independently predicted surgical difficulty. Severe POCs were associated with the tumor location [top-diff vs. topographically non difficult (non top-diff)], preoperative portal vein embolization, and variables related to surgical difficulty. CONCLUSION LMCRC in difficult location independently predicts surgical difficulty and severe POCs.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France.
| | - Christophe Desterke
- Université Paris-Saclay, Villejuif, France; Inserm UMR-S-MD A9, Hôpital Paul Brousse, Villejuif, France
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Chady Salloum
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Maria Conticchio
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - Philippe Ichai
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Annie Elmaleh
- Service de Radiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, Villejuif, France
| | - Salima Naili
- Département D'Anesthésie-Réanimation, Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Chetana Lim
- Département de Chirurgie Hépato-Biliaire et Transplantation Hépatique, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Cyrille Feray
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
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Bhangui P. Complex open donor hepatectomy. Int J Surg 2022. [DOI: 10.1016/j.ijsu.2022.106273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bhangui P. LDLT-donor: Impact of complex bilio-vascular donor anatomy on donor and recipient morbidity in adult LDLT. Int J Surg 2022. [DOI: 10.1016/j.ijsu.2022.106275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Content available: Audio Recording.
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Affiliation(s)
- Narendra S. Choudhary
- Medanta Institute of Liver Transplantation and Regenerative MedicineMedanta The MedicityGurugramIndia
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative MedicineMedanta The MedicityGurugramIndia
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative MedicineMedanta The MedicityGurugramIndia
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22
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Soin AS, Chaudhary RJ, Bhangui P, Gupta A, Yadav KS, Rastogi A. Comment - Bold policy changes are needed to meet the need for organ transplantation in India. Am J Transplant 2022; 22:324-325. [PMID: 34240543 DOI: 10.1111/ajt.16755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Arvinder S Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India
| | - Rohan J Chaudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India
| | - Ankur Gupta
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India
| | - Kamal S Yadav
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India
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Gupta S, Sudhindran S, Saraf N, Vijai A, Swaminathan S, Panackel C, Mehta NN, Varghese J, Singh S, Reddy MS, M. Sivaramakrishnan V, Bhangui P, Mohanka R, Asthana S, Rohatgi S. Liver Transplant Society of India Guidelines for Liver Transplant During COVID-19 times. J Clin Exp Hepatol 2022; 12:180-185. [PMID: 34429571 PMCID: PMC8378015 DOI: 10.1016/j.jceh.2021.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/15/2021] [Indexed: 12/12/2022] Open
Abstract
Coronavirus disease-2019 (COVID-19) pandemic has affected liver transplantation in many ways. There is risk of infection to the transplant recipients; and COVID-19 is associated with significant risk of mortality in patients on wait list. The Liver Transplant Society of India (LTSI) has prepared guidelines regarding selection of adult and pediatric patients for liver transplantation, transplant for acute liver failure, use of deceased donor organs, transplant techniques and minimally invasive donor hepatectomy, pre- and postsurgery testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related coronavirus disease 2019 in donors and recipients, role of COVID-19 antibody testing, shifting of recipients from COVID-19 to non-COVID-19 areas after recovery, isolation policy of team members exposed to COVID-19 patients, drug therapy of proven or suspected COVID-19 infection early posttransplant, care of SARS-CoV-2 positive donors and recipients and a separate COVID-19 consent for surgery.
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Affiliation(s)
| | | | - Neeraj Saraf
- Medanta The Medicity, Gurgaon, India,Address for correspondence: Neeraj Saraf. Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity Hospital, Sector 38, Gurgaon, Delhi (NCR), India.
| | - Anand Vijai
- GEM Hospital and Research Center, Coimbatore, India
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Choudhary NS, Saraf N, Dhampalwar S, Saigal S, Gautam D, Rastogi A, Bhangui P, Srinivasan T, Rastogi V, Mehrotra S, Soin AS. Poor Outcomes after Recidivism in Living Donor Liver Transplantation for Alcohol-Related Liver Disease. J Clin Exp Hepatol 2022; 12:37-42. [PMID: 35068783 PMCID: PMC8766539 DOI: 10.1016/j.jceh.2021.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/04/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Recidivism in patients who underwent liver transplantation for alcohol-related liver disease (ALD) is shown to be associated with poor survival in some studies. METHODS Living donor liver transplantation (LDLT) recipients for ALD with at least 2 years of follow-up and history of significant alcohol relapse were included. The recipients underwent LDLT from June 2010 to December 2016, and data were analyzed until June 2019. The cohort had a median follow-up of 54 (33-78 IQR) months. Recidivism (significant alcohol intake) was defined as >21 units per week. RESULTS A total of 27 of 463 (5.8%) LDLT recipients (all men), aged 43.5 ± 9.6 years, had significant alcohol intake. A liver biopsy was performed on demand in 14 patients (in the presence of raised levels of liver enzymes or jaundice). The histological diagnoses in these patients were as follows: alcoholic hepatitis in 7 (50%), alcoholic hepatitis and acute cellular rejection or chronic rejection in 4 (28.5%), cirrhosis in 2 (14.2%), and acute cellular rejection and cirrhosis in 1 (7.1%) patient. Four of 5 patients with a biopsy diagnosis of acute or chronic rejection were noncompliant with immunosuppression. Six of these patients died. The mortality after 1 year of transplant was significantly more in patients with recidivism. CONCLUSION Recidivism was associated with significant morbidity and mortality after liver transplantation.
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India,Address for correspondence: Dr Neeraj Saraf, Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Medanta The Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), India. Tel.: +919899077795.
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Dheeraj Gautam
- Department of Pathology, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Thiagrajan Srinivasan
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Vipul Rastogi
- Department of Mental Health, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Saurabh Mehrotra
- Department of Mental Health, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
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25
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Bhangui P, Bhangui P, Aneja M, Sharma N, Gupta N, Soin A, Vohra V. Living Donor Liver Transplantation in a Cohort of Recipients With Left Ventricular Systolic Dysfunction. J Clin Exp Hepatol 2022; 12:1040-1047. [PMID: 35814511 PMCID: PMC9257861 DOI: 10.1016/j.jceh.2022.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Data on feasibility, management, and outcomes of liver transplantation (LT) in patients with pre-existing left ventricular systolic dysfunction (LVSD), severe coronary artery disease (CAD) or cirrhotic cardiomyopathy (CCM) is scarce. METHODS We reviewed outcomes of living donor liver transplantation (LDLT) in recipients with LVSD (ejection fraction [EF] < 50%) from our series of 1946 LDLT's performed between July 2010 and July 2018. RESULTS LVSD was detected in 12 male patients with a mean age, BMI and MELD of 52 ± 9 years, 25 ± 5 kg/m2, and 19 ± 4 respectively. Out of these, 6 patients had CAD (2 with previous coronary artery bypass graft, 1 following recent percutaneous transluminal coronary angioplasty, 2 post myocardial infarction, 1 noncritical CAD), and 6 had CCM. The EF ranged from 25% to 45%. Ethanol was the predominant underlying etiology for cirrhosis (50%). During LDLT, 2 patients developed ventricular ectopic rhythm and were managed successfully with intravenous lidocaine. Stress cardiomyopathy manifested in 3 patients post operatively with decreased EF, of which 2 improved, while 1 needed IABP support and succumbed to multiorgan failure on 8th postoperative day (POD). Another patient died on POD30 due to septic shock. Both these patients had higher MELD scores (actual MELD), extremes of BMI (17.3and 35.8 kg/m2) and were diabetic. There were no long-term cardiac deaths. The 1-year, and 5-year survival were 75%, and 66%, respectively. CONCLUSION Among potential LT recipients with LVSD, those with stable CAD and good performance status, and well optimized CCM patients may be considered for LDLT after careful risk stratification in experienced centers.
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Key Words
- CABG, Coronary artery bypass graft
- CAC, coronary artery calcium score
- CAD, coronary artery disease
- CCM, cirrhotic cardiomyopathy
- CLD, chronic liver disease
- CTP, Child Turcotte Pugh
- DDLT, Deceased donor liver transplantation
- DSE, dobutamine stress echo
- ECG, electrocardiogram
- EF, ejection fraction
- ESLD, end stage liver disease
- GRWR, Graft to recipient weight ratio
- HCC, Hepatocellular carcinoma
- HCV, Hepatitis C virus
- IABP, intra-aortic balloon pump
- ICU, intensive care unit
- LDLT outcomes
- LDLT, Living donor liver transplantation
- LT, Liver transplantation
- LVSD, left ventricular systolic dysfunction
- MELD, Model for End Stage Liver Disease
- METS score, metabolic equivalents score
- NAFLD, nonalcoholic fatty liver disease
- OS, Overall survival
- PAC, pulmonary artery catheter
- PHT, portal hypertension
- PTCA, percutaneous transluminal coronary angioplasty
- TEE, transesophageal echocardiography
- cardiac complications
- cardiac evaluation
- cirrhotic cardiomyopathy
- coronary artery disease
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Affiliation(s)
- Pooja Bhangui
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
- Address for correspondence: Pooja Bhangui, Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurugram, Delhi, 122001, NCR, India.
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Manish Aneja
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Nishant Sharma
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Nikunj Gupta
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - A.S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Vijay Vohra
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
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26
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Lai Q, Sapisochin G, Gorgen A, Vitale A, Halazun KJ, Iesari S, Schaefer B, Bhangui P, Mennini G, Wong TCL, Uemoto S, Lin CC, Mittler J, Ikegami T, Yang Z, Frigo AC, Zheng SS, Soejima Y, Hoppe-Lotichius M, Chen CL, Kaido T, Lo CM, Rossi M, Soin AS, Finkenstedt A, Emond JC, Cillo U, Lerut JP. Evaluation of the Intention-to-Treat Benefit of Living Donation in Patients With Hepatocellular Carcinoma Awaiting a Liver Transplant. JAMA Surg 2021; 156:e213112. [PMID: 34259797 DOI: 10.1001/jamasurg.2021.3112] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Living-donor liver transplant (LDLT) offers advantages over deceased-donor liver transplant (DDLT) of improved intention-to-treat outcomes and management of the shortage of deceased-donor allografts. However, conflicting data still exist on the outcomes of LDLT in patients with hepatocellular carcinoma (HCC). Objective To investigate the potential survival benefit of an LDLT in patients with HCC from the time of waiting list inscription. Design, Setting, and Participants This multicenter cohort study with an intention-to-treat design analyzed the data of patients aged 18 years or older who had an HCC diagnosis and were on a waiting list for a first transplant. Patients from 12 collaborative centers in Europe, Asia, and the US who were on a transplant waiting list between January 1, 2000, and December 31, 2017, composed the international cohort. The Toronto cohort comprised patients from 1 transplant center in Toronto, Ontario, Canada who were on a waiting list between January 1, 2000, and December 31, 2015. The international cohort centers performed either an LDLT or a DDLT, whereas the Toronto cohort center was selected for its capability to perform both LDLT and DDLT. The benefit of LDLT was tested in the 2 cohorts before and after undergoing an inverse probability of treatment weighting (IPTW) analysis. Data were analyzed from February 1 to May 31, 2020. Main Outcomes and Measures Intention-to-treat death was defined as a patient death that occurred for any reason and was calculated from the time of waiting list inscription for liver transplant to the last follow-up date (December 31, 2019). Four multivariable Cox proportional hazards regression models for intention-to-treat death were created. Results A total of 3052 patients were analyzed in the international cohort, of whom 2447 were men (80.2%) and the median (IQR) age at first referral was 58 (53-63) years. The Toronto cohort comprised 906 patients, of whom 743 were men (82.0%) and the median (IQR) age at first referral was 59 (53-63) years. In all the settings, LDLT was an independent protective factor, reducing the risk of overall death by 49% in the pre-IPTW analysis for the international cohort (HR, 0.51; 95% CI, 0.36-0.71; P < .001), 33% in the post-IPTW analysis for the international cohort (HR, 0.67; 95% CI, 0.53-0.85; P = .001), 43% in the pre-IPTW analysis for the Toronto cohort (HR, 0.57; 95% CI, 0.45-0.73; P < .001), and 48% in the post-IPTW analysis for the Toronto cohort (HR, 0.52; 95% CI, 0.42 to 0.65; P < .001). The discriminatory ability of the mathematical models further improved in all of the cases in which LDLT was incorporated. Conclusions and Relevance This study suggests that having a potential live donor could decrease the intention-to-treat risk of death in patients with HCC who are on a waiting list for a liver transplant. This benefit is associated with the elimination of the dropout risk and has been reported in centers in which both LDLT and DDLT options are equally available.
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Affiliation(s)
- Quirino Lai
- Institut de Recherche Clinique, Université Catholique de Louvain, Brussels, Belgium.,General Surgery and Organ Transplantation Unit, Department of General 3 Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Gonzalo Sapisochin
- Abdominal Transplant and HPB Surgical Oncology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andre Gorgen
- Abdominal Transplant and HPB Surgical Oncology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alessandro Vitale
- Liver Transplantation and Hepatobiliary Surgery, Padua University Hospital, University of Padua, Padua, Italy
| | - Karim J Halazun
- Center for Liver Disease and Transplantation, Columbia University Medical Center, New York Presbyterian Hospital, New York.,Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Samuele Iesari
- Institut de Recherche Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Benedikt Schaefer
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Guragram, Delhi, India
| | - Gianluca Mennini
- General Surgery and Organ Transplantation Unit, Department of General 3 Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Tiffany C L Wong
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Chih-Che Lin
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jens Mittler
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsmedizin Mainz, Mainz, Germany
| | - Toru Ikegami
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Zhe Yang
- Department of Hepatobiliary and Pancreatic Surgery Shulan Hospital, Shulan Health Zhejiang University Hospital, Hangzhou, China
| | | | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery Shulan Hospital, Shulan Health Zhejiang University Hospital, Hangzhou, China
| | - Yuji Soejima
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Maria Hoppe-Lotichius
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsmedizin Mainz, Mainz, Germany
| | - Chao-Long Chen
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Toshimi Kaido
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Department of General 3 Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Arvinder Singh Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Guragram, Delhi, India
| | - Armin Finkenstedt
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Jean C Emond
- Center for Liver Disease and Transplantation, Columbia University Medical Center, New York Presbyterian Hospital, New York.,Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Umberto Cillo
- Liver Transplantation and Hepatobiliary Surgery, Padua University Hospital, University of Padua, Padua, Italy
| | - Jan Paul Lerut
- Institut de Recherche Clinique, Université Catholique de Louvain, Brussels, Belgium
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27
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Soin AS, Choudhary NS, Yadav SK, Saigal S, Saraf N, Rastogi A, Bhangui P, Srinivasan T, Mohan N, Saha SK, Gupta A, Chaudhary RJ, Yadav K, Dhampalwar S, Govil D, Gupta N, Vohra V. Restructuring Living-Donor Liver Transplantation at a High-Volume Center During the COVID-19 Pandemic. J Clin Exp Hepatol 2021; 11:418-423. [PMID: 33052181 PMCID: PMC7543734 DOI: 10.1016/j.jceh.2020.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) pandemic has led to deferral of elective transplants and proactive pretransplant testing of the donor/recipient. The impact of these on living-donor liver transplantation (LDLT) activity and outcome is not known. We performed LDLT only for sick patients or patients with advanced hepatocellular carcinoma in this period, with special COVID protocols. METHODS Patients undergoing LDLT counseling, evaluation, and transplant in the period March to June 2020 (group A) under COVID-19 restrictions and special protocols were included. LDLT activity and outcomes among these patients were compared with those in the same period in 2019 (group B). RESULTS In the period March 15-June 10, we performed 39 and 23 (59%) LDLTs in 2019 and 2020, respectively. The adult patients with cirrhosis in group A (n = 20) had a significantly higher MELD score, 19.8 ± 7.0 versus 16.1 ± 5.6 in group B (n = 36), p = 0.034. Early recipient mortality was similar in 2019 (2/39) and 2020 (2/23). One of 23 post-transplant recipients, 3/71 recipients and donors during evaluation, and 8/125 healthcare workers (HCWs) developed COVID-19, all of whom recovered uneventfully. CONCLUSION LDLT activity substantially reduced during the COVID era. The incidence and outcome of COVID-19 among the waiting or transplanted patients and HCWs were similar to those of the general population. The outcome after LDLT in the COVID era was similar to that in non-COVID times. These data suggest that LDLT may be extended to more stable patients with strict protocols.
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Affiliation(s)
- Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjay K. Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Thiagarajan Srinivasan
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Neelam Mohan
- Paediatric Gastroenterology and Hepatology, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Sujeet K. Saha
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Ankur Gupta
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Rohan J. Chaudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Kamal Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Deepak Govil
- Critical Care, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Nikunj Gupta
- Liver Transplant Anesthesia, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Vijay Vohra
- Liver Transplant Anesthesia, Medanta the Medicity, Gurgaon, Delhi (NCR), India
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28
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Bhangui P. Reply. Liver Transpl 2021; 27:932-933. [PMID: 33567154 DOI: 10.1002/lt.26008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, India
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29
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Mohan N, Raghunathan V, Dhaliwal MS, Bhangui P, Tiwari A, Soin AS. Pediatric ABO-incompatible Living Related Donor Liver Transplantation: Experience from Indian Subcontinent. Indian Pediatr 2021; 58:281-282. [PMID: 33713067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
We present our experience with pediatric ABO-incompatible liver transplantation in India. Data of patients <18 years of age undergoing ABO-incompatible liver transplantation our hospital between January, 2011 and November, 2018 were analyzed. Plasmapheresis was done pre-transplant till antibody titer was <16 units. Rituximab/Intravenous immunoglobulin was used for immunosuppression, in addition to standard drugs (mycophenolate mofetil, steroids, and tacrolimus). Out of 203 patients that underwent liver transplant during this period, 8 underwent ABO-incompatible liver transplantation; 4 (3 boys) had blood group O+ve. Median (range) age was 28 (7-91) mo, PELD score was 24.5 (14-42), and pre-transplant antibody titer range was 1:32-1024. Number of plasmapheresis sessions required ranged from 1-6. Post-operatively two patients had rise in antibody titer >64 requiring plasmapheresis. All 8 patients survived without rejection/biliary issues. Mean (range) of post-transplant hospital stay was 19.1 (13-22) d and follow-up period was 38.1 (7.1-84.4) mo. Pediatric ABO-incompatible liver transplantation can be successfully performed using plasmapheresis with optimal immune-suppression and vigilant post-op monitoring.
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Affiliation(s)
- Neelam Mohan
- Department of Pediatric Gastroenterology and Hepatology, Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India.
| | - Veena Raghunathan
- Pediatric Critical Care, Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Maninder Singh Dhaliwal
- Department of Pediatric Critical Care, Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Prashant Bhangui
- Department of Surgery, Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Aseem Tiwari
- Department of Laboratory Medicine, Pathology and Blood Bank, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Arvinder S Soin
- Department of Surgery, Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
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30
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Bhangui P, Saigal S, Gautam D, Piplani T, Choudhary N, Chaudhary R, Yadav S, Thiagarajan S, Rastogi A, Saraf N, Nundy S, Soin AS. Incorporating Tumor Biology to Predict Hepatocellular Carcinoma Recurrence in Patients Undergoing Living Donor Liver Transplantation Using Expanded Selection Criteria. Liver Transpl 2021; 27:209-221. [PMID: 37160010 DOI: 10.1002/lt.25956] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/09/2020] [Accepted: 11/05/2020] [Indexed: 12/15/2022]
Abstract
Conventional selection criteria for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) are based on tumour size/number only, and do not consider vital surrogates of tumor biology such as alpha-fetoprotein (AFP) and tumor [18 F]fluorodeoxyglucose positron emission tomography ([18 F]FDG PET) avidity. We analyzed survival outcomes, and predictors of HCC recurrence in 405 patients with cirrhosis and HCC (HCC-cirr) who underwent living donor LT (LDLT) using our expanded selection criteria: no extrahepatic disease or major vascular invasion, irrespective of tumor size/number. Fifty-one percent patients had tumours beyond Milan, and 43% beyond the University of California San Francisco [UCSF] criteria. The 5-year overall survival (OS) and recurrence-free survival (RFS) were 64% and 70%, respectively. Three preoperatively available factors predicted recurrence: pre-LT AFP ≥100 ng/mL (P = 0.005; hazard ratio [HR], 2.190), tumor burden beyond the UCSF criteria (P = 0.001; HR, 2.640), and [18 F]FDG PET avidity (P = 0.004; HR, 2.442). A prognostic model based on the number and combination of the aforementioned preoperative risk factors was developed using a competing-risk RFS model. Three risk groups were identified: low (none or a single risk factor present, 9.3% recurrence), moderate (AFP ≥100 ng/mL and [18 F]FDG PET avidity, or beyond UCSF tumor and [18 F]FDG PET avidity, 25% recurrence), and high (AFP ≥100 ng/mL and beyond UCSF, or presence of all 3 risk factors, 46% recurrence). Acceptable long-term outcomes were achieved using our expanded selection criteria. Our prognostic model to predict recurrence based on preoperative biological and morphological factors could guide pretransplant management (downstaging versus upfront LDLT) with the aim of reducing post-LDLT recurrence.
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Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Sanjiv Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Dheeraj Gautam
- Department of Pathology, Medanta-The Medicity, Delhi NCR, India
| | - Tarun Piplani
- Department of Radiodiagnosis and Interventional Radiology, Medanta-The Medicity, Delhi NCR, India
| | - Narendra Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Rohan Chaudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Sanjay Yadav
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - S Thiagarajan
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Gangaram Hospital, New Delhi, India
| | - A S Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
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Choudhary NS, Saraf N, Saigal S, Duseja A, Gautam D, Rastogi A, Bhangui P, Thiagrajan S, Soin AS. Nonalcoholic Fatty Liver in Lean Individuals: Clinicobiochemical Correlates of Histopathology in 157 Liver Biopsies from Healthy Liver Donors. J Clin Exp Hepatol 2021; 11:544-549. [PMID: 34511814 PMCID: PMC8414316 DOI: 10.1016/j.jceh.2021.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 01/24/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Generally diagnosis of non-alcoholic fatty disease is made on imaging, however, mild steatosis is difficult to diagnose on imaging. Liver biopsy is the procedure of choice but is not carried out as it is an invasive procedure. We describe our experience of 157 liver biopsies in living liver donors with normal body mass index (BMI) <23 kg/M2 (lean). MATERIALS AND METHODS The study was conducted at a tertiary care center in north India. Data of lean living donors who underwent a liver biopsy before donation were analyzed. Data are presented as percentage, mean, or median (25-75 interquartile range). RESULTS Of 718 donors who had a liver biopsy before donation, 157 (21.8%) donors were lean (BMI < 23 kg/M2). Seventy-eight percent of lean donors had no or only one metabolic risk factor. Fifty-three (33.7%) of lean donors had nonalcoholic fatty liver (NAFL) in liver biopsy. When donors with NAFL were compared to donors with normal histology, donors with NAFL had significantly higher aspartate transaminase (26.6 ± 7.5 versus 23.7 ± 5.4, p = 0.007), alanine transaminase (33.4 ± 11.7 versus 27.8 ± 10.7, p = 0.003), and gamma glutamyl transpeptidase [25 (16-40.5) versus 18 (14-23), p = 0.003]. Only triglycerides (TGs) were statistically different among metabolic factors in lean NAFL and normal histology groups, 97 (70-161) versus 86 (62.5-114.7), p = 0.043. A total of 30% donors in the lean NAFL group had TGs >150 mg/dl as compared with 12.5% in the normal histology group, p = 0.009. Other metabolic risk factors were not statistically different. CONCLUSION One third of lean donors had NAFL. Among all metabolic risk factors, only higher TGs levels showed a significant association with NAFL.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine transaminase
- AST, aspartate transaminase
- BMI, body mass index
- CT, computed tomography
- GGT, gamma glutamyl transpeptidase
- GRWR, graft-to-recipient weight ratio
- HDL, high-density lipoprotein
- IR, insulin resistance
- LAI, liver attenuation index
- MR, magnetic resonance
- NAFL, nonalcoholic fatty liver
- NAFLD, nonalcoholic fatty liver disease
- PNPLA3, patatin-like phospholipase domain-containing protein 3
- TG, triglyceride
- USG, ultrasound
- biopsy
- metabolic syndrome
- triglycerides
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Affiliation(s)
- Narendra S. Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, Gurgaon, India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, Gurgaon, India,Address for correspondence: Institute of Liver Transplantation and Regenerative medicine, Medanta The Medicity, Sector 38, Gurgaon, Haryana, 122001, India.
| | - Sanjiv Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, Gurgaon, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dheeraj Gautam
- Department of Histopathology, Medanta, the Medicity, Gurgaon, India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, Gurgaon, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, Gurgaon, India
| | - Srinivasan Thiagrajan
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, Gurgaon, India
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, Gurgaon, India
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Dhampalwar S, Saigal S, Choudhary N, Saraf N, Bhangui P, Rastogi A, Thiagrajan S, Soin AS. Outcomes of Coronavirus Disease 2019 in Living Donor Liver Transplant Recipients. Liver Transpl 2020; 26:1665-1666. [PMID: 33021025 PMCID: PMC7675322 DOI: 10.1002/lt.25909] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/23/2020] [Accepted: 08/27/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Swapnil Dhampalwar
- Institute of Liver Transplantation and Regenerative MedicineMedanta—The MedicityGurugramIndia
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative MedicineMedanta—The MedicityGurugramIndia
| | - Narendra Choudhary
- Institute of Liver Transplantation and Regenerative MedicineMedanta—The MedicityGurugramIndia
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative MedicineMedanta—The MedicityGurugramIndia
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative MedicineMedanta—The MedicityGurugramIndia
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative MedicineMedanta—The MedicityGurugramIndia
| | - Srinivasan Thiagrajan
- Institute of Liver Transplantation and Regenerative MedicineMedanta—The MedicityGurugramIndia
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative MedicineMedanta—The MedicityGurugramIndia
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Choudhary NS, Saraf N, Saigal S, Rastogi A, Bhangui P, Thiagrajan S, Soin AS. Outcome of hepatitis C-related liver transplantation in direct-acting antiviral era. Indian J Gastroenterol 2020; 39:539-543. [PMID: 33230754 DOI: 10.1007/s12664-020-01105-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 09/28/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) has become an easily treatable disease after the introduction of sofosbuvir-based direct-acting antiviral (DAA) regimens. This is a large single center experience of changing severity and outcome profile of HCV-related liver disease after availability of DAAs. METHODS A retrospective analysis of prospectively collected liver transplantation (LT) database of adults (age > 18 years at the time of LT) was performed from June 2010 to July 2018. A total of 410 patients (including 26 co-infection with hepatitis B) underwent LT for hepatitis C-related decompensated cirrhosis and/or hepatocellular carcinoma (HCC) out of 1754 adult transplantation in the defined period. RESULTS The study group comprised of 296 males and 114 females aged 52.1 ± 7.9 years. HCV-related decompensated cirrhosis and/or HCC as indication of LT was present in 289/1016 (28.4%) during 2010-2014, which was reduced to 121/738 (16.3%) during 2015-2018 (p = 0.000). The LT recipients for HCV-related cirrhosis had significantly lower Child's and model for end-stage liver disease (MELD) score during 2015-2018 as compared to that during 2010-2014; Child's score was 7.9 ± 2.2 vs. 8.6 ± 2.1, p = 0.003; MELD score was 13.9 ± 5.3 vs. 17.1 ± 5.8, p = 0.000, respectively. There was a trend towards better survival in HCV patients during 2015-2018 as compared to that during 2010-2014. Significantly more patients had HCV RNA negative status before LT during 2015-2018 (38.8% vs. 13%, p = 0.000); moreover, the proportion of LT for decompensated cirrhosis (without HCC) decreased significantly in the latter period, 64.0% vs. 42.1% (p = 0.000). CONCLUSION In the DAA era, HCV as an indication for LT has decreased and patients have less severe disease at transplantation. There is a trend towards better patient survival.
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Affiliation(s)
- Narendra S Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), 122 413, India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), 122 413, India.
| | - Sanjiv Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), 122 413, India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), 122 413, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), 122 413, India
| | - Srinivas Thiagrajan
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), 122 413, India
| | - Arvinder S Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), 122 413, India
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Raghunathan V, Mohan N, Dhaliwal M, Bhangui P, Vohra V, Soin AS. Pediatric liver transplantation in severe hepatopulmonary syndrome and use of inhaled nitric oxide for post-transplant hypoxemia-a single center experience. Pediatr Transplant 2020; 24:e13792. [PMID: 32881212 DOI: 10.1111/petr.13792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/13/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023]
Abstract
Data on pediatric patients with HPS undergoing LT are limited. Our aim was to study the spectrum and outcomes of pediatric patients with HPS undergoing LDLT. The role ofiNO for post-LDLT refractory hypoxemia was also assessed. Patients (aged < 18 years) undergoing LT were retrospectively studied. HPS was diagnosed based on European Respiratory Society Taskforce 2004 criteria. HPS was graded based on oxygenation criteria and contrast-enhanced echocardiogram. Post-operative course was studied. Refractory post-operative hypoxemia was treated with iNO by institutionally developed protocol. 23/150 pediatric patients undergoing LDLT had HPS. BA was the most common underlying cause (52.2%). By oxygenation criteria, 6 (26.1%) had VS-HPS. VS-HPS was associated with longer LOS (p = .031) and prolonged oxygen requirement (p = .001) compared with other HPS patients. 4/6 patients with VS-HPS had pO2 < 45 mm Hg. Among these, 2 developed ICH post-operatively and 1 died. 3 developed refractory post-operative hypoxemia, successfully treated with iNO. Mean duration of iNO was 26.3 days. In the group of patients with HPS, the incidence of HAT and portal vein thrombosis was 17.3% and 4.3%, respectively. One year post-LDLT survival of patients with HPS was similar to non-HPS patients (86.9% vs 94.4%; p = .88). We concluded that, pediatric patients with VS-HPS, especially those with pre-operative pO2 < 45 mm Hg, have long and difficult post-LT course. Refractory postoperative hypoxemia can be successfully overcome with strategic use of iNO. Vigilant monitoring and good intensive care support are essential.
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Affiliation(s)
- Veena Raghunathan
- Department of Pediatric Critical Care, Medanta The Medicity, Gurgaon, India
| | - Neelam Mohan
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplant, Medanta The Medicity, Gurgaon, India
| | - Maninder Dhaliwal
- Department of Pediatric Critical Care, Medanta The Medicity, Gurgaon, India
| | - Prashant Bhangui
- Institute of Liver Transplant & Regenerative Medicine, Medanta The Medicity, Gurgaon, India
| | - Vijay Vohra
- Institute of Liver Transplant & Regenerative Medicine, Medanta The Medicity, Gurgaon, India
| | - Arvinder Singh Soin
- Institute of Liver Transplant & Regenerative Medicine, Medanta The Medicity, Gurgaon, India
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Chadha R, De Martin E, Kabacam G, Kirchner V, Kalisvaart M, Goldaracena N, Tanaka T, Spiro M, Sapisochin G, Vinaixa C, Hessheimer A, Campos Varela I, Rammohan A, Yoon YI, Victor D, Scalera I, Chan A, Bhangui P. Proceedings of the 25th Annual Congress of the International Liver Transplantation Society. Transplantation 2020; 104:1560-1565. [PMID: 32732832 DOI: 10.1097/tp.0000000000003160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The 25th Annual Congress of the International Liver Transplantation Society was held in Toronto, Canada, from May 15 to 18, 2019. Surgeons, hepatologists, anesthesiologists, critical care intensivists, radiologists, pathologists, and research scientists from all over the world came together with the common aim of improving care and outcomes for liver transplant recipients and living donors. Some of the featured topics at this year's conference included multidisciplinary perioperative care in liver transplantation, worldwide approaches to organ allocation, donor steatosis, and updates in pediatrics, immunology, and radiology. This report presents excerpts and highlights from invited lectures and select abstracts, reviewed and compiled by the Vanguard Committee of International Liver Transplantation Society. This will hopefully contribute to further advances in clinical practice and research in liver transplantation.
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Affiliation(s)
- Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Eleonora De Martin
- Department of Hepatology, AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM 1193, Villejuif, France
| | - Gokhan Kabacam
- Department of Gastroenterology, Ankara Guven Hospital, Ankara, Turkey
| | - Varvara Kirchner
- Department of Surgery, University of Minnesota Medical School and Masonic Children's Hospital, Minneapolis, MN
| | | | - Nicolas Goldaracena
- Department of Abdominal Organ Transplant and Hepatobiliary Surgery, University of Virginia Health System, Charlottesville, VA
| | - Tomohiro Tanaka
- Department of Hepatology, University of Iowa Hospitals and Clinics and Iowa City VA Medical Center, Iowa City, IA
| | - Michael Spiro
- Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, London, United Kingdom
| | - Gonzalo Sapisochin
- Department of Abdominal Transplant and HPB Surgical Oncology, University Health Network, University of Toronto, Toronto, Canada
| | - Carmen Vinaixa
- Hepatology and Liver Transplantation Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Amelia Hessheimer
- Hepatopancreatobiliary Surgery and Transplantation, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Isabel Campos Varela
- Liver Unit, Department of Internal Medicine, Hospital Universitario Vall D'Hebrón, Institut de Recerca, Barcelona, Spain
| | | | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of South Korea
| | - David Victor
- Houston Methodist Hospital, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Methodist University Hospital, Houston, TX
| | - Irene Scalera
- Hepatobiliary and Liver Transplant Unit, A. Cardarelli Hospital, Liver Unit, Cardarelli Hospital, Naples, Italy
| | - Albert Chan
- Division of Liver Transplantation, The University of Hong Kong, Hong-Kong
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
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Hibi T, Wei Chieh AK, Chi-Yan Chan A, Bhangui P. Current status of liver transplantation in Asia. Int J Surg 2020; 82S:4-8. [PMID: 32535264 DOI: 10.1016/j.ijsu.2020.05.071] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/28/2020] [Accepted: 05/19/2020] [Indexed: 02/07/2023]
Abstract
In spite of early adoption of the brain death legislation, and all efforts at promoting deceased donation, various social, economic and cultural factors have acted as road blocks to the furthering of deceased donor liver transplantation (DDLT) in most Asian societies. On the other hand, Asian liver transplant centers have been the pioneers, innovators, and technical advancement catalysts for the world to follow, especially with regards to living donor liver transplantation (LDLT). With some high volume centers performing more than 200 LDLTs a year with good outcomes in the donor and recipient, techniques to expand the living donor pool have also been adopted like ABO-incompatible, paired exchange and dual lobe living donor liver transplants. Although large multicenter, and registry data as regards safety and outcomes of minimally invasive donor hepatectomy are awaited, expert centers have pioneered, and now regularly perform purely laparoscopic and robotic living donor hepatectomies, especially in Korea.
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Affiliation(s)
- Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Alfred Kow Wei Chieh
- Division of HPB Surgery, Department of Surgery, National University of Singapore, Singapore
| | | | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi-NCR, India.
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Bhangui P, Fernandes ESM, Di Benedetto F, Joo DJ, Nadalin S. Current management of portal vein thrombosis in liver transplantation. Int J Surg 2020; 82S:122-127. [PMID: 32387201 DOI: 10.1016/j.ijsu.2020.04.068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/15/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
Nontumoral portal vein thrombosis (PVT) is present at liver transplantation (LT) in 5-26% of cirrhotic patients, and is known to affect post LT outcomes. Up to 31% of patients who are found to have PVT at the time of LT, would have had PVT at the time of initial listing, but others develop PVT during the waiting period. Adequate screening and treatment of the PVT on the waiting list for LT is thus essential so that a portoportal anastomoses can be performed at the time of LT. Early PVT (Yerdel Grade I/II) can be usually managed by thrombectomy, whereas Grade III PVT may require a jump graft from the superior mesenteric vein to the graft PV. Complete portomesenteric thrombosis is a huge challenge, and sometimes a cause for denying a LT in these patients, with multivisceral transplant being the only alternative. The presence of spontaneous, or previously surgically created portosytemic shunts like the leinorenal shunt, may serve as a good inflow option (renoportal anastomosis) in these patients to establish a physiological reconstruction. Although challenging, good outcomes are possible in patients with complex PVT if the appropriate surgical technique is chosen to ensure portal inflow and resolution of PHT post LT.
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Affiliation(s)
- Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi-NCR, India.
| | - Eduardo S M Fernandes
- Department of Gastrointestinal Surgery - Rio de Janeiro Federal University and Liver Transplant Unit - São Lucas Hospital RJ, Brazil
| | - Fabrizio Di Benedetto
- HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Dong-Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Silvio Nadalin
- Department of General, Visceral and Transplantation Surgery, University Hospital Tuebingen, Tübingen, Germany
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Chaudhary RJ, Choudhary NS, Saraf N, Gautam D, Piplani T, Thiagrajan S, Bhangui P, Saigal S, Rastogi A, Soin AS. Delayed Graft Dysfunction due to Invasive Hepatic Mucormycosis After Living Donor Liver Transplantation. J Clin Exp Hepatol 2020; 10:629-632. [PMID: 33311897 PMCID: PMC7719969 DOI: 10.1016/j.jceh.2020.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 04/08/2020] [Indexed: 12/12/2022] Open
Abstract
Mucormycosis is a rare but emerging fungal infection complicating solid organ transplantation. It is associated with a high mortality rate. We describe an unusual case of hepatic mucormycosis in a living donor liver transplant recipient presenting as delayed graft dysfunction, which was successfully treated with combination of liposomal amphotericin B and oral posaconazole therapy, without surgical resection. The patient had clinical improvement with normalization of liver function tests.
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Affiliation(s)
- Rohan J. Chaudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India,Address for correspondence: Dr. Rohan J. Chaudhary, Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Sector 38, Gurugram, Haryana, India.
| | - Narendra S. Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India
| | - Dheeraj Gautam
- Department of Pathology, Medanta the Medicity, Gurugram, Haryana, India
| | - Tarun Piplani
- Department of Radiology, Medanta the Medicity, Gurugram, Haryana, India
| | - Srinivasan Thiagrajan
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India
| | - Sanjiv Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India
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Choudhary NS, Sonavane A, Saraf N, Saigal S, Rastogi A, Bhangui P, Thiagrajan S, Yadav SK, Saha S, Soin AS. Poor Performance Status Predicts Mortality After Living Donor Liver Transplantation. J Clin Exp Hepatol 2020; 10:37-42. [PMID: 32025165 PMCID: PMC6995880 DOI: 10.1016/j.jceh.2019.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 06/27/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Performance status may adversely affect living donor liver transplantation (LDLT) outcomes. We present our data regarding performance status and posttransplantation survival in a large LDLT cohort. METHODS Patients with ABO incompatibility, of pediatric age, with acute liver failure, with hepatocellular carcinoma, and/or who had incomplete data were excluded. Two hundred sixty adults who had decompensated cirrhosis and underwent LDLT from January 2016 to March 2018 were included. Performance status was assessed by Karnofsky Performance Score (KPS). The data are depicted as number, mean (SD), or median (25-75 interquartile range [IQR]). RESULTS The cohort included 232 males and 28 females, aged 48.3 ± 9.8 years. Etiology of liver disease was hepatitis B in 33, hepatitis C in 19, alcohol related in 120, nonalcoholic steatohepatitis/cryptogenic in 68, and other etiologies in 20 patients. The mean Child's score was 9.6 ± 1.7, Model for End-Stage Liver Disease (MELD) score was 18.0 ± 5.8, and donor age was 33.4 ± 9.9 years. Forty-one recipients died at median follow-up of 11 months. The KPS was 100 in 6 (no deaths), 90 in 53 (2 deaths), 80 in 93 (12 deaths), 70 in 69 (14 deaths), 60 in 26 (8 deaths), and 50 in 13 (5 deaths) (P = 0.003). The area under the receiver operating characteristic curve of KPS to predict mortality was 0.698 (P = 0.000, 95% confidence interval [CI] = 0.616-0.780), and the best sensitivity (63%) and specificity (67%) were achieved at KPS ≤70. The survivors and nonsurvivors had a significant difference with respect to KPS (77.6 ± 10.9 versus 69.5 ± 10.9, P 0.000), age of the patient (47.8 ± 9.4 versus 51.1 ± 11.7; P = 0.047), postoperative infections (53.8% versus 85.3%, P = 0.001), and need of packed red cells transfusion. Multivariate analysis (Cox proportional-hazard) showed KPS (hazard ratio [HR] = 0.96, 95% CI = 0.93-0.99, P = 0.007), postoperative infections (HR = 2.3, 95% CI = 1.04-5.1, P = 0.038), and recipient age (HR = 1.03, 95% CI = 1.002-1.07, P = 0.039) as predictors of mortality. CONCLUSION Pretransplant performance status is one of the predictors of mortality after LDLT.
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Affiliation(s)
| | | | - Neeraj Saraf
- Address for correspondence: Dr Neeraj Saraf, Medanta the Medicity Hospital, sector 38, Gurgaon, Delhi (NCR), India.
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40
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Kumar A, Acharya SK, Singh SP, Arora A, Dhiman RK, Aggarwal R, Anand AC, Bhangui P, Chawla YK, Datta Gupta S, Dixit VK, Duseja A, Kalra N, Kar P, Kulkarni SS, Kumar R, Kumar M, Madhavan R, Mohan Prasad V, Mukund A, Nagral A, Panda D, Paul SB, Rao PN, Rela M, Sahu MK, Saraswat VA, Shah SR, Shalimar, Sharma P, Taneja S, Wadhawan M. 2019 Update of Indian National Association for Study of the Liver Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri II Recommendations. J Clin Exp Hepatol 2020; 10:43-80. [PMID: 32025166 PMCID: PMC6995891 DOI: 10.1016/j.jceh.2019.09.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/15/2019] [Indexed: 01/27/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality, and healthcare expenditure in patients with chronic liver disease in India. The Indian National Association for Study of the Liver (INASL) had published its first guidelines on diagnosis and management of HCC (The Puri Recommendations) in 2014, and these guidelines were very well received by the healthcare community involved in diagnosis and management of HCC in India and neighboring countries. However, since 2014, many new developments have taken place in the field of HCC diagnosis and management, hence INASL endeavored to update its 2014 consensus guidelines. A new Task Force on HCC was constituted that reviewed the previous guidelines as well as the recent developments in various aspects of HCC that needed to be incorporated in the new guidelines. A 2-day round table discussion was held on 5th and 6th May 2018 at Puri, Odisha, to discuss, debate, and finalize the revised consensus statements. Each statement of the guideline was graded according to the Grading of Recommendations Assessment Development and Evaluation system with minor modifications. We present here the 2019 Update of INASL Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri-2 Recommendations.
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Key Words
- AFP, alpha-fetoprotein
- AIH, autoimmune hepatitis
- ALT, alanine aminotransferase
- DAA, direct-acting antiviral
- DALY, disability-adjusted life-year
- DNA, deoxyribonucleic acid
- GRADE, Grading of Recommendations Assessment Development and Evaluation
- Gd-BOPTA, gadolinium benzyloxypropionictetraacetate
- Gd-EOB-DTPA, gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid
- HBV, hepatitis B virus
- HBeAg, hepatitis B envelope antigen
- HCC, hepatocellular carcinoma
- HIV, human immunodeficiency virus
- IARC, International Agency for Research on Cancer
- IFN, interferon
- INASL, Indian National Association for Study of the Liver
- MiRNA, micro-RNA
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- PIVKA, protein induced by vitamin K absence
- RFA
- RNA, ribonucleic acid
- SVR, sustained virological response
- TACE
- TACE, trans-arterial chemoembolization
- TARE, transarterial radioembolization
- TNF, tumor necrosis factor
- WHO, World Health Organization
- liver cancer
- targeted therapy
- transplant
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Affiliation(s)
- Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Anil C. Anand
- Department of Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110 076, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Siddhartha Datta Gupta
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, 221 005, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Naveen Kalra
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Suyash S. Kulkarni
- Division of Interventional Radiology, Tata Memorial Hospital, Dr. E Borges Road, Parel, Mumbai, Maharashtra, 400 012, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver & Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Ram Madhavan
- Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita University, Peeliyadu Road, Ponekkara, Edappally, Kochi, Kerala, 682 041, India
| | - V.G. Mohan Prasad
- Department of Gastroenterology, VGM Gastro Centre, 2100, Trichy Road, Rajalakshmi Mills Stop, Singanallur, Coimbatore, Tamil Nadu, 641 005, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver & Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Dipanjan Panda
- Department of Oncology, Institutes of Cancer, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110 076, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, No. 6-3-661, Punjagutta Road, Somajiguda, Hyderabad, Telangana, 500 082, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai, Tamil Nadu, 600 100, India
| | - Manoj K. Sahu
- Department of Medical Gastroenterology, IMS & SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, Odisha 751 003, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Samir R. Shah
- Department of Gastroenterology, Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Praveen Sharma
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Manav Wadhawan
- Liver & Digestive Diseases Institute, Institute of Liver & Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
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Choudhary NS, Saha SK, Saigal S, Gautam D, Saraf N, Rastogi A, Bhangui P, Thiagrajan S, Soin AS. Do Recipients of Genetically Related Donors Have Better Outcomes After Living Donor Liver Transplantation? J Clin Exp Hepatol 2020; 10:334-338. [PMID: 32655237 PMCID: PMC7335709 DOI: 10.1016/j.jceh.2019.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/16/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There are few data on genetic relation of the donor and outcomes in living donor liver transplantation (LDLT) recipients. We compared outcomes of LDLT between recipients of genetically related and unrelated donors in a large single-center series. METHODS The study included 1372 adult, ABO-compatible, primary LDLT recipients, who received a graft from either a first-degree relative (parent, sibling, son, or daughter; n = 756) or unrelated donor (spouse or relative of the spouse; n = 616). RESULTS The mean age of the recipients with a related donor was 50.2 ± 10.8 years compared with 47.3 ± 9.3 years for recipients with unrelated donors (P = 0.000). Chronic rejection was significantly more common in the genetically unrelated donor group than in the genetically related donor group (28 [4.5%] versus 9 [1.1%]; P = 0.000) at a mean follow-up of 37 months (15-95 months). There were no significant differences in other outcomes between the 2 groups. The 12-month and 36-month survival between the unrelated and related groups was 87.6% versus 90%, and 86.3% versus 89.7% respectively (P = 0.115). The multivariate analysis revealed genetically unrelated donors (odds ratio [OR]: 3.88, 95% confidence interval [CI]: 1.80-8.34, P = 0.001) and history of acute cellular rejection (OR: 3.39, 95% CI: 1.68-6.81, P = 0.001) as predictors of chronic rejection. CONCLUSION Although chronic rejection was found to be more common in genetically unrelated donors, the patient survival after LDLT was similar.
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India
| | - Sujeet K. Saha
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India,Address for correspondence: Dr. Sanjiv Saigal Director, Transplant Hepatology Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, 122001, India.
| | - Dheeraj Gautam
- Department of Histopathology, Medanta, the Medicity, Gurgaon, India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India
| | - Srinivasan Thiagrajan
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India
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Choudhary NS, Saigal S, Thummala S, Saraf N, Rastogi A, Bhangui P, Srinivasan T, Yadav SK, Nundy S, Soin AS. Good Long-Term Outcomes in Patients With Primary Sclerosing Cholangitis Undergoing Living Donor Liver Transplantation. J Clin Exp Hepatol 2020; 10:442-447. [PMID: 33029052 PMCID: PMC7527842 DOI: 10.1016/j.jceh.2020.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 02/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a progressive cholestatic disorder with liver transplantation (LT) being the only definitive treatment in end-stage disease. Recurrence of PSC after LT is a significant concern which can lead to graft loss. The aim of this study is to find out the disease recurrence and long-term outcome after living donor liver transplantation (LDLT) in PSC. METHODS We conducted a retrospective review of all patients undergoing LDLT for PSC at our centre. Of 2268 adult LTs from August 2004 to July 2018, 32 (1.4%) patients underwent LDLT for PSC including 6 with PSC and autoimmune hepatitis overlap. The data were reviewed to look for PSC recurrence, complications, and overall survival. All patients received tacrolimus-based immunosuppression. Data are shown as number, percentage, median, and interquartile range (IQR). RESULT The mean age of 32 LDLT recipients was 44 ± 12 years (males 22, females 10). At the time of transplantation, the mean child's score was 9 ± 1.6 and model for end-stage liver disease score was 18.9 ± 6.4. Ulcerative colitis was seen in 7 patients and none had cholangiocarcinoma. Majority of patients (n = 29) received right lobe graft and all but 3 underwent hepaticojejunostomy for biliary reconstruction. PSC recurrence was seen in 6 (20%) patients during a median follow-up of 59 (29-101) months, after exclusion of 2 patients with early mortality. A total of five patients died during follow-up, and one of these deaths was due to PSC recurrence. There were 2 perioperative deaths due to sepsis and 3 deaths on follow-up (sepsis in 2 and PSC recurrence in 1). CONCLUSION LDLT can be performed in PSC with good overall long-term outcomes.
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Key Words
- BMI, body mass index
- CMV, cytomegalovirus
- CT, computed tomography
- DDLT, deceased donor liver transplantation
- LAI, Liver attenuation index
- LDLT
- LDLT, living donor liver transplantation
- LT, liver transplantation
- MRCP, magnetic resonance cholangiopancreatography
- PSC, primary sclerosing cholangitis
- UC, ulcerative colitis
- outcome
- primary sclerosing cholangitis
- recurrence
- survival
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India,Address for correspondence. Dr Sanjiv Saigal MD, DM, MRCP Director Hepatology and Liver Transplantation, Institute of liver transplantation and regenerative medicine, Medanta The Medicity, sector 38, Gurgaon, PIN 122001, Haryana, India
| | - Srikanth Thummala
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Thiagrajan Srinivasan
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Sanjay K. Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | | | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
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Tiwari A, Saigal S, Choudhary NS, Saha S, Rastogi A, Bhangui P, Saraf N, Srinivasan T, Yadav SK, Gautam D, Nundy S, Soin AS. De Novo Malignancy After Living Donor Liver Transplantation: A Large Volume Experience. J Clin Exp Hepatol 2020; 10:448-452. [PMID: 33029053 PMCID: PMC7527845 DOI: 10.1016/j.jceh.2020.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Liver transplantation (LT) recipients such as all organ transplant recipients, have a risk of developing de novo malignancies owing to prolonged immunosuppression. However, there is limited data on this after living donor liver transplantation (LDLT), wherein immunosuppression levels are less than in deceased donor transplantation. We aim to describe experience of de novo malignancies from a predominantly LDLT center. MATERIALS AND METHODS A total of 2100 adults (age >18 years) who underwent LT between January 2006 and December 2017 were retrospectively analyzed from a prospectively collected database. The data were analyzed up to June 2019. Data are shown as number, percentage, mean ± standard deviation, and median (interquartile range). RESULTS Of 2100 patients who underwent LDLT, 21 (1%) patients developed de novo malignancy after transplantation. The de novo malignancy cohort comprised 20 males and 1 female, aged 50 ± 8.8 years. The distribution of de novo malignancies was as follows: 7 oropharyngeal (carcinoma of buccal and oral mucosa), 4 lung, 2 squamous cell carcinoma of skin, 2 lymphoma, 1 each of brain, colonic, gastric; ovary, pancreatic, and prostate. These malignancies were diagnosed at a median follow-up of 42 months (32-73) after LT. Over a median follow-up of 38 months (10-56) after the diagnosis of de novo malignancy, 6 patients (28.5%) died. Patients with de novo malignancy had a higher follow-up after LDLT, 94.3 ± 32.9 versus 62.5 ± 41.8 months, P = 0.000. Patients with alcohol as etiology for LT had higher trend of de novo malignancies (33.3% versus 26.4%), P = 0.46. CONCLUSION The incidence of de novo malignancy was 1% at a median follow-up of 42 (32-73) months. De novo malignancies following LDLT, although uncommon, are associated with significant mortality. A careful screening protocol should be followed after transplantation for early detection of de novo malignancies.
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Affiliation(s)
- Anisha Tiwari
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India,Address for correspondence. Dr Sanjiv Saigal MD, DM, MRCP, Director Hepatology and Liver Transplantation, Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Sector 38, Gurgaon, Haryana, 122001, India.
| | - Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Sujeet Saha
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Thiagrajan Srinivasan
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Sanjay K. Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
| | - Dheeraj Gautam
- Department of Histopathology, Medanta The Medicity, Gurugram, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India
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Soin AS, Yadav SK, Saha SK, Rastogi A, Bhangui P, Srinivasan T, Saraf N, Choudhary NS, Saigal S, Vohra V. Is Portal Inflow Modulation Always Necessary for Successful Utilization of Small Volume Living Donor Liver Grafts? Liver Transpl 2019; 25:1811-1821. [PMID: 31436885 DOI: 10.1002/lt.25629] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/05/2019] [Indexed: 02/07/2023]
Abstract
Although the well-accepted lower limit of the graft-to-recipient weight ratio (GRWR) for successful living donor liver transplantation (LDLT) remains 0.80%, many believe grafts with lower GRWR may suffice with portal inflow modulation (PIM), resulting in equally good recipient outcomes. This study was done to evaluate the outcomes of LDLT with small-for-size grafts (GRWR <0.80%). Of 1321 consecutive adult LDLTs from January 2012 to December 2017, 287 (21.7%) had GRWR <0.80%. PIM was performed (hemiportocaval shunt [HPCS], n = 109; splenic artery ligation [SAL], n = 14) in 42.9% patients. No PIM was done if portal pressure (PP) in the dissection phase was <16 mm Hg. Mean age of the cohort was 49.3 ± 9.1 years. Median Model for End-Stage Liver Disease score was 14, and the lowest GRWR was 0.54%. A total of 72 recipients had a GRWR <0.70%, of whom 58 underwent HPCS (1 of whom underwent HPCS + SAL) and 14 underwent no PIM, whereas 215 had GRWR between 0.70% and 0.79%, of whom 51 and 14 underwent HPCS and SAL, respectively. During the same period, 1034 had GRWR ≥0.80% and did not undergo PIM. Small-for-size syndrome developed in 2.8% patients. Three patients needed shunt closure at 1 and 4 weeks and 60 months. The 1-year patient survival rates were comparable. In conclusion, with PIM protocol that optimizes postperfusion PP, low-GRWR grafts can be used for appropriately selected LDLT recipients with acceptable outcomes.
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Affiliation(s)
- Arvinder Singh Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Sanjay Kumar Yadav
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Sujeet Kumar Saha
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Thiagarajan Srinivasan
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Narendra S Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Sanjeev Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
| | - Vijay Vohra
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi, India
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Bhangui P, Lim C, Levesque E, Salloum C, Lahat E, Feray C, Azoulay D. Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation. J Hepatol 2019; 71:1038-1050. [PMID: 31442476 DOI: 10.1016/j.jhep.2019.08.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/25/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.
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Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Levesque
- Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel
| | - Cyrille Feray
- Department of Hepatology, Paul Brousse Hospital, Villejuif, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France; Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel.
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Choudhary NS, Saigal S, Gautam D, Saraf N, Rastogi A, Goja S, Bhangui P, Thiagrajan S, Yadav SK, Mehrotra S, Rastogi V, Soin AS. Good outcome of living donor liver transplantation for severe alcoholic hepatitis not responding to medical management: A single center experience of 39 patients. Alcohol 2019; 77:27-30. [PMID: 30772702 DOI: 10.1016/j.alcohol.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION There are limited data on outcomes of living donor liver transplantation (LDLT) for patients with severe alcoholic hepatitis. METHODS The study included LDLT recipients for severe alcoholic hepatitis (n = 39) who did not improve with medical treatment and compared their outcomes with patients who underwent LDLT for alcoholic liver disease (n = 461). The diagnosis of severe alcoholic hepatitis was based on both clinical and explants data. No patients had psychiatric contraindications for liver transplant and all had good family support. The data are shown as number, mean (SD), or median (25-75 interquartile range). RESULTS All transplant recipients were males, aged 42 ± 8 years. The patients with alcoholic hepatitis were abstinent for a duration of 4 ± 1.8 months at the time of LDLT. All patients underwent LDLT with a graft to recipient weight ratio of 0.95 ± 0.17. The post-transplant ICU and hospital stay were 5.4 ± 1.3 and 17.6 ± 8.4 days, respectively. When patients with alcoholic hepatitis (n = 39) were compared to patients who underwent LDLT for alcoholic liver disease without alcoholic hepatitis (n = 461), patients with alcoholic hepatitis were significantly younger (43.2 ± 8.5 vs. 48.2 ± 9.1 years, p = 0.001) and had higher Child's (10.9 ± 1.5 vs. 9.8 ± 1.8) and MELD scores (22.1 ± 4.5 vs. 18.4 ± 5.9, p = 0.000). Post-operative infections were also significantly more common in the alcoholic hepatitis group (71.7% vs. 51.6%, p = 0.018). Fungal infections developed in 23% of alcoholic hepatitis patients as compared to 14% in the rest of the alcoholic patients (p = 0.247). Six recipients (15.7%) died at a median follow-up of 28 (6-37) months due to infections, and five (12.8%) patients had relapse of alcohol drinking. Survival was not different between the two groups. CONCLUSION Living donor liver transplantation can be successfully performed with good survival for patients with severe alcoholic hepatitis.
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Affiliation(s)
- Narendra S Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjiv Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India.
| | - Dheeraj Gautam
- Department of Histopathology, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Amit Rastogi
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjay Goja
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Srinivasan Thiagrajan
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjay K Yadav
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Saurabh Mehrotra
- Department of Mental Health and Quality of Life, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Vipul Rastogi
- Department of Mental Health and Quality of Life, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
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Yadav SK, Saraf N, Choudhary NS, Sah JK, Sah SK, Rastogi A, Bhangui P, Saigal S, Soin AS. Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure. Liver Transpl 2019; 25:459-468. [PMID: 30536705 DOI: 10.1002/lt.25395] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 11/24/2018] [Indexed: 02/07/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of previously diagnosed or undiagnosed liver disease with organ failure(s) with high short-term mortality. This study was conducted to report the outcomes of living donor liver transplantation (LDLT) in ACLF and assess the survival benefit of liver transplantation (LT) in these patients. It was a retrospective study of 218 ACLF patients on the basis of European Association for the Study of the Liver (EASL)-chronic liver failure criteria from January 2014 through November 2017. Patients were considered for LDLT if there was no improvement on standard medical therapy for 5-10 days. Prior to LDLT, active sepsis was excluded/treated, and renal, circulatory, and respiratory failures were improved to the greatest extent possible. The mean age was 42.9 years, and 181 patients were male. Sepsis was the most common acute precipitating event followed by alcohol. Of the patients, 35 (16.1%), 66 (30.3%), and 117 (53.7%) were classified into ACLF grades 1, 2, and 3, respectively. Although 80% of the ACLF 1 group and 72.7% of the ACLF 2 group underwent LDLT, only 35% of the ACLF 3 group could undergo LDLT. The circulatory and respiratory failures at admission were significantly higher in the nontransplant group with poor subsequent response to standard medical therapy, exclusion from LDLT, and poor outcomes. None of the patients on high support for circulatory and respiratory failure underwent LDLT. Posttransplant survival at 1 year was comparable among different grades of ACLF (92.9%, 85.4%, and 75.6%; P = 0.15). Among patients in the ACLF 3 group, survival at 90 days was extremely poor in those who could not undergo LDLT (5.9% versus 78%; P < 0.001). In conclusion, LDLT results in good survival with acceptable post-LT morbidity in patients with ACLF.
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Affiliation(s)
- Sanjay Kumar Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
| | - Narendra S Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
| | - Jayant Kumar Sah
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
| | - Sujeet Kumar Sah
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
| | - Arvinder Singh Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India
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Goja S, Yadav SK, Yadav A, Piplani T, Rastogi A, Bhangui P, Saigal S, Soin AS. Accuracy of preoperative CT liver volumetry in living donor hepatectomy and its clinical implications. Hepatobiliary Surg Nutr 2018; 7:167-174. [PMID: 30046567 DOI: 10.21037/hbsn.2017.08.02] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background An accurate preoperative volumetric assessment of donor liver is essential for successful living donor liver transplant by ensuring adequate remnant and graft recipient weight ratio (GRWR). Methods The study cohort consisted of 744 right lobe (RL), 65 left lobe (LL) and 33 left lateral sector (LLS) grafts from July 2010 to January 2014. A semi-automated interactive commercial software called AW Volume share 6 was used for volumetry. Bland Altman plot was used for assessing the agreement between estimated graft weight (EGW) and actual graft weight (AGW). Results There was no statistically significant difference between EGW and AGW for RL graft weight (722±134 vs. 717±126 gm; P=0.06). Although Bland Altman graph showed that 95% limits of agreement was more in LL (-164 to +110) than RL (-156 to +147) and LLS grafts (-137 to +239), CT scan significantly overestimated LL graft weight (EGW =460±118 gm vs. AGW =433±102 gm; P=0.003) and underestimated LLS graft weight (EGW =203±48 gm vs. AGW =254±49 gm; P<0.001). Conclusions CT volumetry overestimate LL graft and underestimate LLS graft weight. This should be factored in when selecting LL graft by taking higher GRWR.
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Affiliation(s)
- Sanjay Goja
- Institute of Liver Transplant and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjay Kumar Yadav
- Institute of Liver Transplant and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi (NCR), India
| | - Amardeep Yadav
- Institute of Liver Transplant and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi (NCR), India
| | - Tarun Piplani
- Department of Radiology and Nuclear Medicine, Medanta, The Medicity, Gurgaon, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplant and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplant and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjiv Saigal
- Institute of Liver Transplant and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder Singh Soin
- Institute of Liver Transplant and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi (NCR), India
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Yadav SK, Saigal S, Choudhary NS, Saha S, Sah JK, Saraf N, Kumar N, Goja S, Rastogi A, Bhangui P, Soin AS. Cytomegalovirus infection in living donor liver transplant recipients significantly impacts the early post-transplant outcome: A single center experience. Transpl Infect Dis 2018; 20:e12905. [PMID: 29668120 DOI: 10.1111/tid.12905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 12/26/2017] [Accepted: 01/07/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is the most common viral infection in liver transplant recipients that influences the outcomes of liver transplantation. However, its impact on early outcomes following living donor liver transplantation (LDLT) is not fully defined in the Indian subcontinent. This study was done to assess the impact of CMV infection on early post-transplant outcomes in LDLT recipients. METHODS Out of 272 LDLTs performed from January 2012 to April 2013, 151 recipients underwent CMV viral load analysis in plasma within 90 days post LDLT based on clinical suspicion. Patients with CMV infection (n = 55) were compared with those without CMV infection (n = 96). RESULTS The median time interval of CMV infection from LDLT was 25 days (range 2-90 days). The mean age of study population was 48.92 years. About 116 (76.8%) of the patients were male. Hepatitis C virus (HCV) (39.1%)-related chronic liver disease (CLD) was most common indication for liver transplant. No statistically significant difference was observed in etiology of liver disease (P = .38), Chid-Turcotte-Pugh (CTP) (P = .41), and Model for End-stage Liver Disease (MELD) (P = .12) scores between the groups. Patients with CMV infection had significantly higher incidence of acute cellular rejection (16.1% vs 5.4%, P = .02); longer ICU stay (P = .01); and a higher overall 90-day mortality (24.2% vs 6.7%, P = .001). Bacteremia and fungemia were significantly more common in the CMV infection group. CONCLUSION Cytomegalovirus infection significantly influences the early post LDLT outcomes and contributes to increased overall mortality.
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Affiliation(s)
- Sanjay Kumar Yadav
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Narendra Singh Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Sujeet Saha
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Jayant Kumar Sah
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Naveen Kumar
- Department of Microbiology, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Sanjay Goja
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
| | - A S Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, Delhi, India
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Gomez Gavara C, Bhangui P, Salloum C, Osseis M, Esposito F, Moussallem T, Lahat E, Fuentes L, Compagnon P, Ngongang N, Lim C, Azoulay D. Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients. Liver Transpl 2018; 24:505-515. [PMID: 29266668 DOI: 10.1002/lt.24999] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 11/02/2017] [Accepted: 12/03/2017] [Indexed: 02/07/2023]
Abstract
The management of large spontaneous portosystemic shunt (SPSS) during liver transplantation (LT) is a matter of debate. The aim of this study is to compare the short-term and longterm outcomes of SPSS ligation versus nonligation during LT, when both options are available. From 2011 to 2017, 66 patients with SPSS underwent LT: 56 without and 10 with portal vein thrombosis (PVT), all of whom underwent successful thrombectomy and could have portoportal reconstruction. The SPSS were either splenorenal (n = 40; 60.6%), left gastric (n = 16; 24.2%), or mesenterico-iliac (n = 10; 15.1%). Following portoportal anastomosis, the SPSS was ligated in 36 (54.4%) patients and left in place in 30 (45.5%) patients, based on the effect of the SPSS clamping/unclamping test on portal vein flow during the anhepatic phase. Intraoperatively, satisfactory portal flow was obtained in both groups. Primary nonfunction (PNF) and primary dysfunction (PDF) rates did not differ significantly between the 2 groups. Nonligation of SPSS was significantly associated with a higher rate of postoperative encephalopathy (P < 0.001) and major postoperative morbidity (P = 0.02). PVT occurred in 0 and 3 patients in the ligated and nonligated shunt group, respectively (P = 0.08). A composite end point, which included the relevant complications in the setting of SPSS in LT (ie, PNF and PDF, PVT, and encephalopathy) was present in 16 (44.4%) and 22 (73.3%) patients of the ligated and nonligated shunt group, respectively (P = 0.02). Patient (P = 0.05) and graft (P = 0.02) survival rates were better in the ligated shunt group. In conclusion, the present study supports routine ligation of large SPSS during LT whenever feasible. Liver Transplantation 24 505-515 2018 AASLD.
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Affiliation(s)
- Concepcion Gomez Gavara
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Delhi National Capital Region, India
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Michael Osseis
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Francesco Esposito
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Toufic Moussallem
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Liliana Fuentes
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France.,Université Paris-Est Créteil, Créteil, France.,INSERM, U955, Créteil, France
| | - Norbert Ngongang
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France.,Université Paris-Est Créteil, Créteil, France.,INSERM, U955, Créteil, France
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