Charles Winans

Use of tissue plasminogen activator in liver transplantation from donation after cardiac death donors.

Ischemic‐type biliary stricture (ITBS) occurs in up to 50% after liver transplantation (LT) from donation after cardiac death (DCD) donors. Thrombus formation in the peribiliary microcirculation is a postulated mechanism. The aim was to describe our experience of tissue plasminogen activator (TPA) administration in DCD‐LT. TPA was injected into the donor hepatic artery on the backtable (n = 22). Two recipients developed ITBS including one graft failure. Although excessive postreperfusion bleeding was seen in 14 recipients, the amount of TPA was comparable between those with and without excessive bleeding (6.4 ± 2.8 vs. 6.6 ± 2.8 mg, p = 0.78). However, donor age (41 ± 12 vs. 29 ± 9 years, p = 0.02), donor BMI (26.3 ± 5.5 vs. 21.7 ± 3.6 kg/m2, p = 0.03), previous laparotomy (50% vs. 0%, p = 0.02) and lactate after portal reperfusion (6.3 ± 4.6 vs. 2.8 ± 0.9 mmol/L, p = 0.005) were significantly greater in recipients with excessive bleeding. In conclusion, the use of TPA may lower the risk of ITBS‐related graft failure in DCD‐LT. Excessive bleeding may be related to poor graft quality and previous laparotomy rather than the amount of TPA. Further studies are needed in larger population.

Safety and efficacy of sonographic-guided random real-time core needle biopsy of the liver

To determine the safety and efficacy of real‐time, sonographic‐guided, random percutaneous needle biopsy of the liver in a tertiary medical center.

Triple‐phase computed tomography and intraoperative flow measurements improve the management of portosystemic shunts during liver transplantation

Ligation of portosystemic shunts in patients with cirrhosis undergoing liver transplantation has been recommended to avoid insufficient portal vein (PV) flow. Shunts are not always recognized pretransplantation because intraoperative PV flow assessment is not routinely attempted. As a result of a posttransplantation PV thrombosis in a recipient with a large portosystemic shunt and a PV flow <1 L/minute, we employed triple‐phase computed tomography with vascular reconstruction and intraoperative graft flow measurement to determine the need for inflow modification in our next 16 patients with large portosystemic shunts. Subsequently, 6 patients with large portosystemic shunts and PV flows ≤1 L/minute underwent inflow modification at the time of transplantation to improve venous graft inflow. One patient with PV thrombosis had PV replacement without shunt ligation. Two patients with large splenorenal shunts and extensive PV thrombosis had left renoportal bypass. In 7 patients with large portosystemic shunts and PV flow greater than 1 L/minute, inflow modification was not attempted, to avoid excessive venous inflow that could jeopardize hepatic artery flow via the hepatic artery buffer response. In conclusion, sustained good graft function and inflow were achieved in all 16 patients. Liver Transpl 14:96–99, 2008.

Duodenoduodenostomy in pancreas transplantation.

Gunasekaran G, Wee A, Rabets J, Winans C, Krishnamurthi V. Duodenoduodenostomy in pancreas transplantation.

Side‐to‐side cavocavostomy with an endovascular stapler: Rescue technique for severe hepatic vein and/or inferior vena cava outflow obstruction after liver transplantation using the piggyback technique

Venous outflow obstruction is a rare but potentially lethal complication after orthotopic liver transplantation (OLT) with the “piggyback” technique. Therapeutic options include angioplasty with or without stent placement, surgical reconstruction of the venous anastomosis, and retransplantation. Surgical options are technically very challenging and the outcomes discouraging. We describe here two cases of venous outflow obstruction in recipients of piggyback liver grafts, one involving both the vena cava and hepatic veins and the other affecting only hepatic vein outflow. Both patients were treated successfully with side‐to‐side cavo‐cavostomy using an endovascular (endo‐GIA) stapler. This novel technique is fast and effective in resolving the outflow obstruction. Liver Transpl 15:49–53, 2009.

Is impaired hepatic arterial buffer response a risk factor for biliary anastomotic stricture in liver transplant recipients

BACKGROUND Blood flow to the liver is partly maintained by the hepatic arterial buffer response (HABR), which is an intrinsic autoregulatory mechanism. Temporary clamping of the portal vein (PV) results in augmentation in hepatic artery flow (augHAF). Portal hyperperfusion impairs HAF due to the HABR in liver transplantation (LT). The aim of this study is to examine the effect of the HABR on biliary anastomotic stricture (BAS). METHODS In 234 cadaveric whole LTs, PV flow (PVF), basal HAF, and augHAF were measured intra-operatively after allograft implantation. All recipients with a vascular complication were excluded. Buffer capacity (BC) was calculated as (augHAF - basal HAF)/PVF to quantify the HABR. Recipients were divided into 2 groups based on their BC: low BC (<0.074; n = 117) or high BC (> or =0.074; n = 117). RESULTS Of the 234 recipients, 23 (9.8%) had early BAS (< or =60 days after LT) and 18 (7.7%) had late BAS (>60 days after LT). The incidence of late BAS and bile leakage was similar between the groups; however, the incidence of early BAS in the low BC group was greater than that in the high BC group (15% vs 5.1%; P = .0168). In the multivariate analysis, low BC (P = .0325) and bile leakage (P = .0002) were found to be independent risk factors affecting early BAS. CONCLUSION Recipients with low BC who may have impaired HABR are at greater risk of early BAS after LT. Intraoperative measurements of blood flow help predict the risk of BAS.

Duct-to-duct biliary reconstruction in patients with primary sclerosing cholangitis undergoing liver transplantation

BACKGROUND Reconstruction of biliary drainage after liver transplantation (LTx) in patients with primary sclerosing cholangitis (PSC) has been a matter of controversy. Over recent years, the traditional method of Roux-en-Y hepaticojejunostomy (RY) has been challenged by duct-to-duct (DD) biliary reconstruction. METHODS This study represents a retrospective review of biliary complications, patient and graft survival after LTx in PSC patients based on type of biliary reconstruction. Outcomes of DD reconstruction in this group of patients and non-PSC patients are compared. RESULTS A total of 53 primary LTx procedures were performed for PSC between August 2005 and July 2010. Seven patients were excluded because unexpected cholangiocarcinoma was found in the explants (n=3) or because they received partial livers (n=4). Biliary reconstruction was performed as DD in 18 patients and RY in 28 patients. There were no bile leaks. Anastomotic stricture occurred in two (11%) patients in the DD group and one (4%) in the RY group. Two (7%) patients in the RY group developed non-PSC intrahepatic strictures and one had recurrence of PSC. Rates of 1- and 3-year patient and graft survival in the RY and DD groups were 96.7% and 96.7%, and 100% and 94.5%, respectively. In a group of 34 randomly selected patients transplanted for a non-PSC diagnosis with DD reconstruction during the same period, the anastomotic stricture rate was 9% and 1- and 3-year patient and graft survival rates were 97.0% and 88.5%; differences were not significant. CONCLUSIONS Duct-to-duct biliary reconstruction at the time of LTx in selected PSC patients is both effective and safe, and shows outcomes comparable with those of RY reconstruction in these patients and those of DD reconstruction in non-PSC patients.

Split liver transplantation using Hemiliver graft in the MELD era: a single center experience in the United States.

Under the “sickest first” Model for End‐Stage Liver Disease (MELD) allocation, livers amenable to splitting are most often allocated to patients unsuitable for split liver transplantation (SLT). Our experience with SLT using hemilivers was reviewed. From April 2004 to June 2012, we used 25 lobar grafts (10 left lobes and 15 right lobes) for adult‐sized recipients. Twelve recipients were transplanted with primary offers, and 13 were transplanted with leftover grafts. Six grafts were shared with other centers. The data were compared with matched whole liver grafts (n = 121). In 92% of donors, the livers were split in situ. Hemiliver recipients with severe portal hypertension had a greater graft‐to‐recipient weight ratio than those without severe portal hypertension (1.96% vs. 1.40%, p < 0.05). Hemiliver recipients experienced biliary complications more frequently (32.0% vs. 10.7%, p = 0.01); however, the 5‐year graft survival for hemilivers was comparable to whole livers (80.0% vs. 81.5%, p = 0.43). The secondary recipients with leftover grafts did not have increased incidences of graft failure (p = 0.99) or surgical complications (p = 0.43) compared to the primary recipients. In conclusion, while routine application is still controversial due to various challenges, hemiliver SLT can achieve excellent outcomes under the MELD allocation.

Isolated right hepatic vein obstruction after piggyback liver transplantation

The “piggyback” technique for liver transplantation has gained worldwide acceptance. Still, complications such as outflow obstruction have been observed, usually attributable to technical errors such as small‐caliber anastomosis of the suprahepatic vena cava, twisting, or kinking. Iatrogenic Budd‐Chiari syndrome after piggyback liver transplantation has been reported as a consequence of obstruction involving the entire anastomosis (usually the 3 hepatic veins). Here we describe technical issues, clinical presentation, diagnosis, and treatment of 3 cases in which outflow obstruction affected only the right hepatic vein. In conclusion, all 3 patients developed recurrent ascites requiring angioplasty and/or stent placement across the right hepatic vein to alleviate the symptoms. Liver Transpl 12:808–812, 2006.

Expanding the donor pool: Safe transplantation of a cadaveric liver allograft with a 10cm cavernous hemangioma – A case report

The donor was a 65-year-old male, who was declaredbrain dead following a massive intracranial bleed. Hismedicalhistoryincludeda10x8x9cmrightlobehepaticmasscompatiblewithagianthemangioma.Thiswascon-firmed by an abdominal ultrasound performed at the ad-mitting hospital and a prior CT scan provided by thefamily members. The patient was otherwise a good organdonor, with normal liver function tests and normal serumsodium level. In particular, there was no evidence of co-agulopathy, with a platelet count of 162,000 uL, pro-thrombintime12.0seconds,andINR1.2.Duringsurgeryon the donor, a large hemangioma was identified occupy-ing segments VIII and VII, representing approximately20% of the total liver volume. A smaller hemangiomameasuring 1.5x2cmwasnoted within the left lobe. Thesurrounding liver parenchyma was of normal color andsoft consistency, with normal vessels free of atherosclero-sis. The liver was recovered by a standard technique (14)and flushed with Histidine-Tryptophan-Ketoglutarate(HTK) solution.At this time, a decision was made to use the graft fortransplantation into a 53-year-old male with end-stageliver disease secondary to hepatitis C and hepatocellu-lar carcinoma outside of the Milan criteria. His tumorhad been unresponsive to 3 courses of radiofrequencythermal ablation but did respond to bilateral chemoem-bolization with mitomycin, adriamycin and cisplatin.Triple phase CT scans documented the response totreatment and ruled out liver vascular or extra hepaticinvasion. He had given informed consent for transplantwith an extended criteria liver donor. A standard ortho-topic liver transplant procedure