Brooke Glessing

Liver regeneration after adult living donor and deceased donor split-liver transplants.

As the number of living donor (LD) and deceased donor (DD) split‐liver transplants (SLTs) have increased over the last 5 years, so too has the interest in liver regeneration after such partial‐liver transplants. We looked at liver regeneration, as measured by computed tomography (CT) volumetrics, to see if there were significant differences among LDs, right‐lobe LD recipients, and SLT recipients. We measured liver volume at 3 months postoperatively by using CT, and we compared the result to the patients ideal liver volume (ILV), which was calculated using a standard equation. The study group consisted of 70 adult patients who either had donated their right lobe for LD transplants (n = 24) or had undergone a partial‐liver transplant (right‐lobe LD transplants, n = 24; right‐lobe SLTs, n = 11; left‐lobe SLTs, n = 11). DD (vs. LDs) were younger (P < 0.01), were heavier (P = 0.06), and had longer ischemic times (P < 0.01). At 3 months postoperatively, LDs had attained 78.6% of their ILV, less than the percentage for right‐lobe LD recipients (103.9%; P = 0.0002), right‐lobe SLT recipients (113.6%; P = 0.01), and left‐lobe SLT recipients (119.7%; P = 0.0006). When liver size at the third postoperative month was compared with the liver size immediately postoperatively, LDs had a 1.85‐fold increase. This was smaller than the increase seen in right‐lobe LD recipients (2.08‐fold), right‐lobe SLT recipients (2.17‐fold), and left‐lobe SLT recipients (2.52‐fold). In conclusion, liver regeneration, as measured by CT volume, seems to be greatest in SLT recipients. LD recipients seem to have greater liver growth than their donors. The reason for this remains unclear. (Liver Transpl 2004;10:374–378.)

Living donor and split-liver transplants in hepatitis C recipients: Does liver regeneration increase the risk for recurrence?

Concern exists that partial liver transplants (either a living donor [LD] or deceased donor [DD] in hepatitis C virus (HCV)‐positive recipients may be associated with an increased risk for recurrence. From 1999 to 2003, at our institution, 51 HCV‐positive recipients underwent liver transplants: 32 whole‐liver (WL) transplants, 12 LD transplants and 7 DD split transplants. Donor characteristics differed in that WL donors were older, and LD livers had lower ischemic times. Recipient characteristics were similar except that mean MELD scores in LD recipients were lower (p < 0.05). With a mean follow‐up of 28.3 months, 46 (90%) recipients are alive: three died from HCV recurrent liver disease and two from tumor recurrence. Based on 1‐year protocol biopsies, the incidence of histologic recurrence in the three groups is as follows: WL, 81%; LD, 50% and DD split, 86% (p = 0.06 for LD versus WL). The mean grade of inflammation on the biopsy specimens was: WL, 1.31; LD, 0.33 and DD split, 1.2 (p = 0.002 for LD versus WL; p = 0.03 for LD versus DD split). Mean stage of fibrosis was: WL, 0.96; LD, 0.22 and DD split, 0.60 (p = 0.07 for LD versus WL). Liver regeneration does not seem to affect hepatitis C recurrence as much, perhaps, as factors such as DD status, donor age and cold ischemic time.

A comparison of surgical outcomes and quality of life surveys in right lobe vs. left lateral segment liver donors.

Concern remains regarding the possibly higher risk to living liver donors of the right lobe (RL), as compared with the left lateral segment (LLS). We studied outcomes and responses to quality of life (QOL) surveys in the two groups.

Endoscopic transluminal drainage and necrosectomy by using a novel, through-the-scope, fully covered, large-bore esophageal metal stent: preliminary experience in 10 patients

BACKGROUND Interventions for necrotizing pancreatitis have undergone a recent paradigm shift toward minimally invasive techniques, including endoscopic transluminal necrosectomy (ETN). The optimal stent for endoscopic transmural drainage remains unsettled. OBJECTIVE To evaluate a novel large-bore, fully covered metal through-the-scope (TTS) esophageal stent for cystenterostomy in large walled-off necrosis (WON). DESIGN Retrospective case series. SETTING Single tertiary care academic center. PATIENTS Ten patients with large (>10 cm) WON collections who underwent endoscopic transmural drainage and ETN. INTERVENTION Initial cystenterostomy was performed by using EUS, and in the same session, a TTS (18 × 60 mm), fully covered esophageal stent was placed to create a wide-bore fistula into the cavity. In 1 or more later sessions, the stent was removed, and ETN was performed as needed. MAIN OUTCOME MEASUREMENTS Technical and clinical success rates and adverse events. RESULTS The TTS stent was successfully deployed at the initial cystogastrostomy in all 10 patients. All patients had large WON (median size 17 cm, range 11-30 cm) and underwent intervention at a median of 30 days (range 12-117 days) after onset of acute pancreatitis. Resolution of WON was achieved in 9 of the 10 patients (90%) after a median of 3 endoscopic sessions. There were no early adverse events. Late adverse events occurred in 3 patients (30%); worsening of infection from stent migration and occlusion of cystogastrostomy (2 patients), and fatal pseudoaneurysmal bleeding from erosion of infected necrosis into a major artery distant from the stent (1 patient). The stent was easily removed in all the cases after resolution or improvement of the necrotic cavity. LIMITATIONS Retrospective, single-center evaluation of a small number of cases. No comparative arm to determine the relative efficacy or cost-effectiveness of these stents compared with conventional plastic stents. CONCLUSIONS Endoscopic therapy using a large-bore TTS, fully covered esophageal stent is feasible for use in the treatment of large WON. Further studies are needed to validate these findings.

Regionwide sharing for status 1 liver patients – beneficial impact on waiting time and pre‐ and posttransplant survival

On August 21, 1999, Region 7 of the United Network for Organ Sharing (UNOS) adopted a policy of regionwide sharing of cadaver livers for UNOS Status 1 recipients. We examined what impact this policy had at our center on their waiting times, waiting list mortality, and outcomes. From January 1, 1995, through December 31, 2002, our center listed 39 patients for an emergent (Status 1) transplant, according to the current criteria for Status 1 listing: patients (adult and pediatric) with fulminant hepatic failure (FHF), hepatic artery thrombosis, or primary nonfunction early after a liver transplant, or critically ill pediatric patients with chronic liver disease. These 39 candidates were analyzed in 2 groups: those listed before regionwide sharing (Group I, n = 19) and those listed after (Group II, n = 20). Patient characteristics did not differ significantly between the 2 groups, including mean donor and recipient age, proportion of pediatric patients, and type of graft used (i.e., living or deceased donor, segmental or whole‐organ). FHF was the most common cause of liver failure in both groups—74% versus 70% (P = ns). The next most common cause in both groups was hepatic artery thrombosis, followed by primary nonfunction. Most transplants used deceased donors; however, 2 of the transplants in Group I versus only 1 in Group II used living donors. Waiting list mortality (the patient death rate before a transplant could take place) was 32% in Group I versus only 5% in Group II (P = .03). The mean number of days on the waiting list was also substantially lower in Group II (2.9 days) than in Group I, (5.8 days) (P = .04). For patients who underwent a transplant, graft and patient survival rates at 6 months posttransplant were 69.2% in Group I versus 89.5% in Group II (P = .03). In conclusion, the introduction of regionwide sharing seems to have been of benefit for Status 1 patients at our center. They have a significantly lower risk of dying while waiting for a transplant and undergo one in a much shorter period of time. (Liver Transpl 2004;10:661–665.)

Pancreatitis of ectopic pancreatic tissue: a rare cause of gastric outlet obstruction

Abstract Inflammation in ectopic pancreatic tissue can clinically present with pain or obstructive symptoms, depending on the location of the ectopic tissue. We present a rare case of gastric outlet obstruction secondary to pancreatitis of ectopic pancreatic tissue in the pylorus.

Novel Use of Long, Large-Caliber, Fenestrated Stents for Endoscopic Transpapillary Gallbladder Stenting for Therapy of Symptomatic Gallbladder Disease

Symptomatic gallbladder disease (SGBD) has a high prevalence in the general population, and early cholecystectomy is considered definitive therapy for patients with symptomatic cholelithiasis [1, 2]. Conservative therapy is recommended for those patients in whom surgery is contraindicated or considered high risk [3–5]. Nonsurgical gallbladder drainage methods include percutaneous and endoscopic drainage techniques [5]. While percutaneous transhepatic gallbladder catheter drainage (PCD) is efficacious, it has risks of puncture-related adverse events and tube dislodgement and results in significant patient discomfort [5, 6]. PCD is usually a temporary step until the patient is fit for surgery, symptoms resolve or drainage can be internalized by endoscopic transpapillary gallbladder stenting (ETGS) which involves placement of an internal transpapillary stent. ETGS has technical and clinical success rates comparable to PCD with the advantage of internal drainage; however, its limitations include the potential for stent migration or occlusion requiring stent exchange, cystic duct or gallbladder perforation, and recurrence of symptomatic biliary disease [5–10]. ETGS has been previously described mainly using rigid, double-pigtail polyethylene plastic stents of diameter 5–7 Fr and length 10–15 cm, with inherent limitations in drainage, flexibility, and patency [5–10]. Johlin pancreatic wedge stents (JS) (Wilson-Cook Medical, Winston-Salem, NC, USA) are made of Sof-Flex material, which is a softer polyurethane and polyethylene blend. They are fenestrated with large, multi-side holes along the length of the stent and are available in 8.5 and 10 Fr diameters and variable lengths up to 22 cm (Fig. 1). JS for ETGS have theoretical advantages over conventional stents, including soft material with conformability to tortuous cystic ducts, the presence of side holes, and large caliber allowing potentially longer patency. We report our initial experience using JS for ETGS.

Endoscopic Drainage of >50% of Liver in Malignant Hilar Biliary Obstruction Using Metallic or Fenestrated Plastic Stents

Objectives:Endoscopic drainage of complex hilar tumors has generally resulted in poor outcomes. Drainage of >50% of liver volume has been proposed as optimal, but not evaluated using long multifenestrated plastic stents (MFPS) or self-expanding metal stents (SEMS). We evaluated outcomes of endoscopic drainage of malignant hilar strictures using optimal strategy and stents, and determined factors associated with stent patency, survival, and complications.Methods:Cross-sectional study was conducted at an academic center over 5 years. MFPS (10 French or 8.5 French) or open-cell SEMS were used for palliation of unresectable malignant hilar strictures, with imaging-targeted drainage of as many sectors as needed to drain >50% of viable liver volume. Risk factors were evaluated using regression analysis. The cumulative risk was assessed using Kaplan–Meier analysis.Results:77 patients with malignant hilar biliary strictures (median Bismuth IV) underwent targeted stenting (41 MFPS and 36 SEMS). Comparing MFPS vs. SEMS, technical success (95.1 vs. 97.2%, P=0.64), clinical success (75.6 vs. 83.3%, P=0.40), frequency of multiple stents (23/41 vs. 25/36, P=0.19), survival and adverse events were similar, but stent patency was significantly shorter (P<0.0001). Factors associated with survival were Karnofsky score and serum bilirubin level at presentation. Outcomes were independent of Bismuth class with acceptable results in Bismuth III and IV.Conclusions:Endoscopic biliary drainage with MFPS or open-cell SEMS targeting >50% of viable liver resulted in effective palliation in patients with complex malignant hilar biliary strictures. Patency was shorter in the MFPS group, but similar survival and complications were found when comparing MFPS and SEMS group.

Rare Subepithelial Mass Diagnosed as Gastric Splenosis via EUS-FNA

A 20-year-old woman was referred for evaluation of a gastric subepithelial mass, noted incidentally on an esophagogastroduodenoscopy performed for evaluation of dyspepsia (Figure 1). She had a past medical history of Diamond-Blackfan syndrome status post bone marrow transplant, and recurrent acute pancreatitis status post total pancreatectomy with splenectomy 4 years before presentation. Endoscopic ultrasound (EUS) revealed the presence of a 21 x 18-mm round, hypoechoic, and homogenous mass in the cardia, with an echogenicity reminiscent of splenic tissue (Figure 2). No other foci of ectopic splenic tissue were found on cross-sectional imaging. Endosonographic borders were well defined, and the lesion appeared to be localized within the muscularis propria without extragastric extension. Cytology smears and hematoxylin and eosin stains fine-needle aspiration biopsies showed a population of polymorphous small lymphocytes, interspersed granulocytes, and frequent hemosiderin laden macrophages (Figure 3). This population was intimately associated with small vessels, highlighted by CD34 and CD8 immunohistochemical stains (Figure 4). Coexpression of CD34 and CD8 is consistent with splenic sinusoids.