Ailton Sepulveda

Liver Transplantation With Older Donors: A Comparison With Younger Donors in a Context of Organ Shortage.

Background Older liver grafts have been considered in the past decade due to organ shortage. The aim was to compare outcomes after liver transplantation with either younger or older donors. Methods Patients transplanted in our center between 2004 and 2014 with younger donors (younger than 60 years; n = 253) were compared with older donors (older than 75 years; n = 157). Multiorgan transplantations, split grafts, or non–heart-beating donors were not included. Results Donors in the older group were mostly women deceased from stroke, and only 3 patients had experienced cardiac arrest. Liver tests were significantly better in the older group than in the younger group. There was no difference regarding cold ischemia time, model for end-stage liver disease score, and steatosis. There was no significant difference regarding primary nonfunction and dysfunction, hepatic artery and biliary complications, and retransplantation rates. Graft survival was not different (65% and 64% in the older and younger groups, P = 0.692). Within the older group, hepatitis C infection, retransplantation, and emergency transplantation were associated with poor graft survival. Conclusions Provided normal liver tests and the absence of cardiac arrest in donors, older liver grafts (>75 years) may be safely attributed to non–hepatitis C-infected recipients in the setting of a first and nonurgent transplantation.

Preliminary report of major surgery in liver transplant recipients receiving m-TOR inhibitors without therapeutic discontinuation.

IntroductionMammalian target rapamycin inhibitors (m-TORi) are increasingly used in patients undergoing liver transplantation (LT). Yet, there is rising concern that they also could impair wound healing and favor the development of several surgical complications. This report was designed to evaluate both feasibility and safety of major surgery in liver transplant recipients receiving m-TORi–based immunosuppression without therapeutic discontinuation.MethodsFrom 2007 to 2012, six liver transplant recipients underwent nine major abdominal or thoracic surgical procedures without m-TORi discontinuation or specific dosage adjustment. Their characteristics and postoperative outcomes were retrospectively analyzed.ResultsIndications for m-TORi were de novo or recurrent malignant disease in five patients and calcineurin inhibitors related neurologic toxicity in one patient. Abdominal procedures, thoracic procedures, and combined thoracic and abdominal procedures were performed in six, two, and one cases respectively. Emergency surgery was performed in one case and elective procedures were performed in eight cases, including five for malignant disease and three for late surgical complications following LT. No patient died postoperatively. One major complication was observed, but no patient required reoperation. No evisceration, incisional surgical site infection, or lymphocele occurred.ConclusionsMajor surgery in liver transplant recipients receiving m-TOR inhibitors appears both feasible and safe without therapeutic discontinuation or specific dosage adjustment.

Negative wound therapy to manage large-for-size liver graft mismatch

Liver volume matching in liver transplantation (LT) is of paramount importance. There is no agreement for its definition, ranging from a graft-to-recipient-weight-ratio greater than 4% in paediatric to less than 2.5% in adult LT. Advances have been obtained to avoid small for size grafts, but management of large grafts remains a major challenge in this setting. Consequences include difficult anastomosis, poor vascular alignment, difficult wound closure, graft compression and necrosis. We report on two patients who underwent LT with large grafts and develop major liver graft injury. Technical solutions used in these two cases are presented and discussed. Negative wound therapy allowed a rapid closure of abdominal wall and salvage of the graft.

Pure laparoscopic management of early biliary leakage after liver transplantation: Abdominal lavage and T-Tube placement: Letter to the Editor

Mart ınez-Ortega et al. reported an innovative approach in the treatment of early biliary leakage (EBL) after liver transplantation (LT). We congratulate them and agree that laparoscopy is an efficient tool to achieve faster clinical recovery and diminish postoperative morbidity in immunosuppressed patients. We were, however, surprised by the decision of a T-tube insertion, given the potential risk of complications related to its use (eg, biliary peritonitis at removal and cholangitis). Recently, endoscopic management has been proven to be a safe and effective option to treat EBL after LT with good results. This endoscopic approach has become our standard approach for both anastomotic stricture and biliary leakage during the last 5 years. On this basis, we applied a totally endoscopic approach (TEA) in 5 patients who were affected by EBL after LT between October 2013 and March 2015. Like the strategy described by Mart ınez-Ortega et al., our approach included laparoscopic washout but differed by endoscopic insertion of a plastic or selfexpandable covered biliary metallic stent to treat the biliary leakage. Laparoscopy was feasible in all cases without conversion. We did not find any limitation due to intra-abdominal adhesions, probably because of postoperative ascites and immunosuppressive regimen. In this series, endoscopic management was always possible and efficient. The authors hypothesized that endoscopic retrograde cholangiopancreatography (ERCP) could worsen the clinical condition, leading to ascites infection. This latter reason was an argument to use T-tube drainage rather than endoscopic stenting. In our series, median delay between laparoscopy and ERCP

Computer-assisted liver graft steatosis assessment via learning-based texture analysis

PurposeFast and accurate graft hepatic steatosis (HS) assessment is of primary importance for lowering liver dysfunction risks after transplantation. Histopathological analysis of biopsied liver is the gold standard for assessing HS, despite being invasive and time consuming. Due to the short time availability between liver procurement and transplantation, surgeons perform HS assessment through clinical evaluation (medical history, blood tests) and liver texture visual analysis. Despite visual analysis being recognized as challenging in the clinical literature, few efforts have been invested to develop computer-assisted solutions for HS assessment. The objective of this paper is to investigate the automatic analysis of liver texture with machine learning algorithms to automate the HS assessment process and offer support for the surgeon decision process.MethodsForty RGB images of forty different donors were analyzed. The images were captured with an RGB smartphone camera in the operating room (OR). Twenty images refer to livers that were accepted and 20 to discarded livers. Fifteen randomly selected liver patches were extracted from each image. Patch size was

Transplantation hépatique à partir d’un donneur vivant

100\times 100

Further to the Right: Piggyback Anastomosis on the Right Hepatic Vein Facilitates the Implantation of Small Liver Grafts (The 1-vein Technique)

100×100. This way, a balanced dataset of 600 patches was obtained. Intensity-based features (INT), histogram of local binary pattern (