Burckhardt Ringe

Rescue of a Living Donor with Liver Transplantation

Postoperative liver failure is a rare complication after living donor liver resection. This is a case report of a 22‐year‐old healthy donor who was rescued with liver transplantation 11 days after right hemihepatectomy. Nine months later the patient is alive, and has fully recovered from his multiple organ failure. According to a review of the literature, there are four additional living liver donors, who received a liver transplant. Our own patient is the only survivor, so far. This case demonstrates that even in supposedly healthy living donors postoperative complications cannot be completely prevented. Although liver failure is rare in these patients, timely transplantation may need to be considered as the only life‐saving treatment.

Evaluation of living liver donors using contrast enhanced multidetector CT – The radiologists impact on donor selection

BackgroundLiving donor liver transplantation (LDLT) is a valuable and legitimate treatment for patients with end-stage liver disease. Computed tomography (CT) has proven to be an important tool in the process of donor evaluation. The purpose of this study was to evaluate the significance of CT in the donor selection process.MethodsBetween May 1999 and October 2010 170 candidate donors underwent biphasic CT. We retrospectively reviewed the results of the CT and liver volumetry, and assessed reasons for rejection.Results89 candidates underwent partial liver resection (52.4%). Based on the results of liver CT and volumetry 22 candidates were excluded as donors (31% of the cases). Reasons included fatty liver (n = 9), vascular anatomical variants (n = 4), incidental finding of hemangioma and focal nodular hyperplasia (n = 1) and small (n = 5) or large for size (n = 5) graft volume.ConclusionCT based imaging of the liver in combination with dedicated software plays a key role in the process of evaluation of candidates for LDLT. It may account for up to 1/3 of the contraindications for LDLT.

Sorting through methods of dividing the liver

SummaryBACKGROUND: No doubt, liver surgery has become safer over the past two decades. Many people jump to the conclusion that this increase in safety is due primarily to new methods of dissecting through the liver. METHODS: We did a literature search over the period 1992–2004 and then considered the data within the articles on the basis of device design and our own personal experiences. RESULTS: For resection of malignancies, we rank the Cavitron ultrasonic surgical aspirator (CUSA) number one because of its utility in staying within tissue planes during resections while preserving vessels for ligature. We find the water jet the most useful instrument for living-donor resections because of the minimal necrotic margin. The floating ball has a particular utility in removing tumors from cirrhotic livers. The harmonic scalpel tops the instruments for laparoscopic surgery, primarily because the instrument is designed specifically for laparoscopic surgery and most tumors being removed via the laparoscope are small, benign ones. CONCLUSIONS: Technological innovations have definitely made their mark on liver surgery. However, the skill and experience of the surgeon but not the instruments determine the outcomes of patients after liver resections.ZusammenfassungGRUNDLAGEN: Die Sicherheit der Leberchirurgie hat in den letzten zwei Jahrzehnten zweifelsohne zugenommen. Vielfach wird das vorschnell auf neue Leberresektionsmethoden zurückgeführt. METHODIK: Wir haben die zu diesem Thema von 1992 bis 2004 publizierte Literatur durchgesehen. Bei der Beurteilung der publizierten Daten haben wir die Bauweise der verwendeten Instrumente und unsere eigenen Erfahrungen herangezogen. ERGEBNISSE: Für die Resektion maligner Tumore reihen wir den Cavitron Ultrasonic Surgical Aspirator (CUSA) an die erste Stelle, da er gut zur Durchtrennung von Lebergewebe entlang einer festgelegten Ebene benutzt werden kann und dabei die Gefäße zur Ligatur ausspart. Wir finden, dass der Water-Jet-Dissektor das beste Instrument für Leberresektionen bei Lebendspendern ist, weil damit nur ein minimaler nekrotischer Saum entsteht. Der Floating Ball ist bei der Entfernung von Tumoren aus Zirrhoselebern besonders gut einsetzbar. Das Harmonische Skalpell steht an der Spitze der Geräte für laparoskopische Chirurgie, hauptsächlich deshalb, weil es genau zu diesem Zweck entwickelt wurde und die laparoskopisch entfernten Tumore meist klein und gutartig sind. SCHLUSSFOLGERUNGEN: Innovative Techniken haben die Leberchirurgie nachhaltig beeinflusst. Letztlich wird der Erfolg der Leberresektionen aber nicht von den verwendeten Instrumenten, sondern vom Geschick und der Erfahrung des Chirurgen bestimmt.

From abernethy to APOLT

We read with great interest the recent case report by Emre et al. about auxiliary partial orthotopic liver transplantation (APOLT) in a young patient with Abernethy malformation and hepatopulmonary syndrome. Because Abernethy malformation is a very rare condition, experience with liver transplantation is limited. Only 11 cases have been reported in the literature so far, including this one and two of our own patients reported recently. Indications for transplant may include biliary atresia, hepatic encephalopathy, and liver tumors. The concept of APOLT was introduced by the senior author’s group in 1991 to temporarily bridge well-selected patients with potentially reversible acute hepatic failure. Obviously, this technique has been successfully applied in hepatically based metabolic diseases and other indications. As we have come a long way in 200 years from Abernethy to APOLT, we would like to briefly comment on Dr. Emre’s interesting article. The predominant clinical feature of Abernethy malformation is a portosystemic shunt causing a broad spectrum of significant secondary manifestations, such as hyperammonia, pulmonary hypertension, and heart failure. In his original presentation on February 14, 1793, John Abernethy described a 10-month-old girl with multiple congenital malformations, including a complete end-to-side portocaval shunt, and no venous inflow to the liver. In recognition of the first accurate description of this condition, Howard and Davenport suggested that the congenital diversion of portal blood away from the liver, by either end-to-side or side-to-side shunt, should be known as Abernethy malformation. Morgan and Superina proposed a functional classification system for portosystemic vascular anomalies based on complete or partial hepatic diversion of portal blood (defined as types I and II). There seems to be a high variability regarding the exact anatomic connections between the portal and systemic venous systems (for example, extrahepatic or intrahepatic) and association with other abnormalities. In type Ia, the superior mesenteric vein and the splenic vein do not join to form a confluence; this is a syndrome also known as congenital absence of the portal vein (CAPV). In type Ib, a confluence of superior mesenteric and splenic veins is usually present but does not supply the liver. The denomination of this confluence as portal vein would probably be correct, especially because it contains portal venous blood (Fig. 1). As described by Emre et al., their patient had “a portosystemic shunt from the main portal vein to the inferior vena cava” and “no evidence of an intrahepatic portal venous system” or “extrahepatic portal venous inflow”; this clearly characterized Abernethy type Ib malformation but no CAPV. The authors further mentioned an anastomosis of the “left portal vein of the recipient to the left portal vein of the donor,” which is actually a prerequisite for the technique of APOLT as suggested by our group: without adequate portal blood supply, the auxiliary liver would atrophy. By definition, in Abernethy type I, the liver is not perfused with portal blood because there is a complete shunt. Obviously, their patient had an anatomic variant of Abernethy type Ib, as we had observed before in one of our own two transplant recipients. Because of the complex embryologic development of the portal venous system, many variations of classic anomalies as described before are conceivable. However, only in type Ia is the portal vein absent, so it would be misleading to refer to CAPV in every case of Abernethy malformation. APOLT has been suggested by Soejima et al. as the ideal procedure for CAPV patients because portal vein diversion is not necessary, and it does seem technically feasible if the anatomy is appropriate. The question is whether APOLT really has an advantage over total hepatectomy combined with standard or partial liver transplantation in these patients. The observation of hepatic tumors or tumorlike lesions such as hepatoblastoma, hepatocellular carcinoma, focal nodular hyperplasia, hepatocellular adenoma, or nodular regenerative hyperplasia in patients with congenital or surgical portosystemic shunts is clearly significant and of concern. What the true underlying pathophysiologic mechanisms and prognosis of these morphologic changes are remains unclear at this time. Interestingly, however, in 5 of the 11 transplant recipients reported, regenerative hyperplasia or neoplasms were found. We have seen a patient with Budd-Chiari syndrome developing multiple de novo hepatic lesions consistent with focal nodular hyperplasia 33 months after side-to-side portocaval shunt. Long-term follow-up of the two patients with

An Imaging Biomarker for Assessing Hepatic Function in Patients With Primary Sclerosing Cholangitis

BACKGROUND & AIMS: We aimed to evaluate the potential of hepatobiliary phase magnetic resonance imaging (MRI) as parameter for assessment of hepatocellular function in patients with primary sclerosing cholangitis (PSC). METHODS: We collected data from 111 patients (83 male, 28 female; median, 44 years old), from March 2012 through March 2016, with a confirmed diagnosis of PSC who underwent MRI evaluation before and after injection (hepatobiliary phase) of a hepatocyte‐specific contrast agent (gadoxetate disodium). Signal intensities were measured in each liver segment. Mean relative enhancement values were calculated and correlated with findings from liver functions tests, prognostic scoring systems (model for end‐stage liver disease [MELD] score; Mayo risk score; Amsterdam‐Oxford‐PSC score), abnormalities detected by endoscopic retrograde cholangiopancreatography (using the Amsterdam cholangiographic classification system), and clinical endpoints (liver transplantation, cholangiocarcinoma, liver‐related death). Our primary aim was to associate relative enhancement values with liver function and patient outcomes. RESULTS: Most patients had moderate‐stage disease and had intermediate levels of risk (median MELD score, 8 and median Mayo score, 0.27). Clinical endpoints were reached by 21 patients (6 developed cholangiocarcinoma, 8 underwent liver transplantation, and 7 patients died). The highest levels of correlations were observed for relative enhancement 20 min after contrast injection and level of alkaline phosphatase (r = –0.636), bilirubin (r = –0.646), albumin (r = 0.538); as well as international normalized ratio (r = 0.456); MELD score (r = –0.587); Mayo risk score (r = –0.535), and Amsterdam‐Oxford model score (r = –0.595) (P < .0001). Relative enhancement correlated with all clinical endpoints (all P < .05). A cutoff relative enhancement value of 0.65 identified patients with a clinical endpoint with 73.9% sensitivity 92.9% specificity (area under the receiver operating characteristic curve, 0.901; likelihood ratio, 10.34; P < .0001). CONCLUSIONS: In an analysis of 111 patients with PSC, we found MRI‐measured relative enhancement, using a hepatocyte‐specific contrast agent, to identify patients with clinical outcomes with 73.9% sensitivity 92.9% specificity. Long‐term, multicenter studies are needed to further evaluate this marker of PSC progression.

M1892 Endoscopic Retrograde Cholangiopancreatography in the Pre-Operative Evaluation of Living Related Liver Transplant Donors

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is routinely used to assess donors for living related liver transplantation (LRLT). This procedure helps to map the biliary anatomy and reveal any anomalies that may alter the surgical approach or exclude patients from donating. It has been shown to be more sensitive than MRCP although it carries substantially more risk. Aim: Determine whether pre-operative ERCP in LRLT donors uncovers clinically significant biliary anomalies with acceptable risk to patients. Methods: We performed a retrospective chart review of all LRLT donors evaluated at our institution since the programs inception 5 years ago. ERCP images were deemed adequate if secondorder branches of the biliary tree were visualized. The biliary anatomy was classified based on the Couinaud system. Complications of ERCP and liver transplant were determined based on the medical record. Results: Thirty patients were evaluated for LRLT between 9/1/02 and 9/1/07. Five were excluded because they did not undergo ERCP: 3 were deemed to be unsuitable donors and 2 underwent emergent transplants. Of the 25 patients who underwent pre-operative ERCP, 4 had failed cannulations. Of the 21 donors who had adequate ERCPs, 8 patients (38%) had abnormal biliary anatomy, including 3 (14%) with triple confluence of the ducts, 2 (10%) with anomalous drainage of the right posterior segmental duct, 3 (14%) with drainage of the right hepatic duct into the cystic duct, and 1 (5%) with an accessory duct. In addition, 2 had aberrant insertion of the cystic duct and 1 had small ducts. MRCP detected 2 out of 8 of these anomalies. There were 3 complications related to ERCP, including self-limited pain (2) and pancreatitis (1) (peak Amylase of 1,153ng/mL). The surgical approach was altered in 1 patient with extension of the cutting plane. Of the 30 recipients, 23 (64%) received segments 5-8, 6 (27%) received segments 2-3, and 1 (5%) received segments 2-4. There were 9 complications in the recipients, including 4 biliary complications. Two complications occurred in patients with normal anatomy, 1 bile stricture occurred in a patient with triple confluence, and 1 bile leak occurred in a patient with an accessory duct but did not involve that segment. Overall, the rate of biliary complications was lower in donors with aberrant anatomy compared to those with normal anatomy (11% vs. 31%). Conclusion: Biliary anomalies were found in 38% of patients undergoing preoperative ERCP for LRLT, only 25% of which were detected by MRCP. However, these anomalies had little impact on the surgical approach and did not correlate with posttransplant biliary complications.