David Calatayud

Superior Preservation of DCD Livers With Continuous Normothermic Perfusion

Objective:Unexpected donation after cardiac death (DCD) donors suffer cardiac arrest suddenly and are maintained with normothermic extracorporeal membrane oxygenation (NECMO) while consent for donation is obtained. The objective of this study was to determine whether ex vivo normothermic machine perfusion (NMP) improves upon the benefits of NECMO in a large-animal model of unexpected DCD liver transplant. Methods:Donor pigs underwent 90-minute cardiac arrest and were divided in to 3 groups. In the first, livers were preserved immediately with cold storage (CS, n = 6). In the other 2 groups, donors underwent 60-minute NECMO followed by CS (NECMO+CS, n = 6) or NMP (NECMO+NMP, n = 6). After 4–hour preservation, livers were transplanted into recipient pigs. Results:Five-day survival was 0 in CS, 83% in NECMO+CS, and 100% in NECMO+NMP. After reperfusion, injury, and inflammatory markers rose significantly among CS grafts, all of which developed primary nonfunction. Sixty minutes of NECMO, however, resulted in only 1 death, whereas NECMO followed by NMP led to no deaths and significant improvements in injury, inflammation, and synthetic function in comparison to NECMO and CS. Conclusion:Although 60 minutes recuperative NECMO is better than CS alone, NMP improves further on NECMO and may have a role in preserving DCD livers in the clinical setting.

Hypothermic Oxygenated Machine Perfusion in Porcine Donation After Circulatory Determination of Death Liver Transplant

Background Livers from donation after circulatory determination-of-death (DCD) donors suffer ischemic injury during a preextraction period of cardiac arrest and are infrequently used for transplantation; they have the potential, however, to considerably expand the donor pool. We aimed to determine whether hypothermic oxygenated machine perfusion would improve or further deteriorate the quality of these livers using a clinically relevant porcine model. Methods Donor livers were subjected to 90 min of cardiac arrest and preserved at 4°C with either static cold storage using University of Wisconsin solution (CS, n=6) or oxygenated machine perfusion using University of Wisconsin machine perfusion solution and 25% physiological perfusion pressures (HMP, n=5). After 4 hr of preservation, livers were transplanted into recipient pigs, which were followed intensively for up to 5 days. Results Five-day survival was 0 in CS and 20% in HMP. Immediately after reperfusion, hepatocellular injury and function were improved in HMP versus CS. However, HMP grafts also demonstrated significant endothelial and Kupffer cell injury, and a progressive lesion developed 24 to 48 hr after reperfusion that led to death in all but one of the recipient animals. Conclusions Although hypothermic oxygenated machine perfusion performed using subphysiological perfusion pressures seems to offer some advantages over cold storage in the preservation of ischemically damaged livers, it simultaneously conditions endothelial and Kupffer cell injury that may ultimately lead to the failure of these grafts.

Optimization of liver grafts in liver retransplantation: A European single-center experience

BACKGROUND Liver retransplantation (ReLT) is the only therapeutic option that offers a chance at long-term survival when a liver graft fails. Careful analysis of the results and potential benefits is needed to justify its role in the current era of donor shortage and economical concerns. We reviewed all retransplants performed in our hospital and tried to determine if there is a high risk group of patients in whom its use would be contraindicated. METHODS Between June 1988 and January 2006, 1,226 liver transplants were performed in 1,118 patients at our institution. Among them, 108 retransplants (8.8%) were performed in 98 patients. Preoperative, intraoperative, and postoperative data were gathered from our prospectively collected liver transplant database. The entire series of patients was divided between two periods of equal duration and patients were also classified according to the interval between retransplantation and the previous transplant. RESULTS Concerning indications, only chronic rejection was a more frequent etiology in the first period versus the second period. When comparing first and second periods, 1-, 5-, and 10-year graft survival was 66%, 45%, and 40% and 76%, 69%, and 69%, respectively (P = .014). No significant differences in post-ReLT survival were found when the indication was HCV recurrence versus other non-urgent causes (1-, 5-, and 10-year graft survival: 70%, 57%, and 57% vs 72%, 50%, and 45%). According to the UNOS Rosen risk score, patients in the low-risk group showed significantly greater survival with respect to patients in the high-risk group though 5-year survival in the high-risk group was still greater than 50%. CONCLUSIONS ReLT indications have changed over time, with better results being achieved in more recent years. Candidate selection in elective ReLT is critical to improve the results, though current criteria do not allow for the identification of a single patient subset in which ReLT would be contraindicated.

Clinical trial on the cost‐effectiveness of T‐tube use in an established deceased donor liver transplantation program

Abstract:  The aim of our study was to assess the advantages and disadvantages of T‐tube use in liver transplantation, with also paying attention to the economic costs derived from its use. Patients were prospectively randomized to T tube or no T tube. One hundred and seven patients, 53 with T tube and 54 without T tube, were analyzed. Minimum follow‐up was three months. Nine patients (8.4%) had bile leak: six in the T‐tube group (11.3%) and three in the group without T tube (5.5%), p = ns. Four patients (3.5%) had anastomotic biliary stenosis: one in the T‐tube group (1.8%) and three in the group without T tube, p = ns. Twenty of the 53 patients (37.7%) with T tube had T‐tube‐related complication. The number of diagnostic and therapeutic resources were higher in the T‐tube group compared with non‐T tube (81 and 17 vs. 18 and 10, respectively, p <0.05). The costs of therapeutic procedures required for the treatment of complications were 28 232 € in the T‐tube group vs. 16 088 € in the no T‐tube group, p <0.05. In conclusion, the systematic use of the T tube in biliary reconstruction in liver transplantation cannot be justified.

Importance of the Temporary Portocaval Shunt During Adult Living Donor Liver Transplantation

Adult living donor liver transplantation (aLDLT) is associated with surgical risks for the donor and with the possibility of small‐for‐size syndrome (SFSS) for the recipient, with both events being of great importance. An excessively small liver graft entails a relative increase in the portal blood flow during reperfusion, and this factor predisposes the recipient to an increased risk of SFSS in the postoperative period, although other causes related to recipient, graft, and technical factors have also been reported. A hemodynamic monitoring protocol was used for 45 consecutive aLDLT recipients. After various hemodynamic parameters before reperfusion were analyzed, a significant correlation between the temporary portocaval shunt flow during the anhepatic phase and the portal vein flow (PVF) after reperfusion of the graft (R2 = 0.3, P < 0.001) was found, and so was a correlation between the native liver portal pressure and PVF after reperfusion (R2 = 0.21, P = 0.007). The identification of patients at risk for excessive portal hyperflow will allow its modulation before reperfusion. This could favor the use of smaller grafts and ultimately lead to a reduction in donor complications because it would allow more limited hepatectomies to be performed. Liver Transpl 19:174–183, 2013.

Results of laparoscopic radiofrequency ablation for HCC. Could the location of the tumour influence a complete response to treatment? A single European centre experience

INTRODUCTION In selected patients, radiofrequency ablation (RFA) is a well-established treatment for hepatocellular carcinoma (HCC). However, subcapsular or lesions close to adjacent viscera preclude a percutaneous approach. In this setting laparoscopic-RFA (LRFA) is a potential alternative. The aim of this study was to analyse the safety and feasibility of LRFA in patients with HCC. PATIENTS AND METHODS Retrospective study of patients with HCC meeting strict inclusion criteria who underwent LRFA at a single Institution from December 2000 to March 2013. RESULTS Forty-one patients underwent 42 LRFA of 51 nodules. The median size of the nodule was 2.5 (range 1.2-4.7) cm. Thirty-one tumours were subcapsular and 17 located near the gallbladder. Major complications occurred in 17 patients. The initial complete response (ICR) rate was 94% and was lower among tumours located adjacent to the gallbladder. At the end of the follow-up period, the sustained complete response (SCR) rate was 70% and was lower in tumours adjacent to the gallbladder while increased for subcapsular tumours. The 1-, 3- and 5-year overall survival rate was 92.6%, 64.5% and 43%, respectively. CONCLUSION LRFA of HCC is safe, feasible and achieves excellent results in selected patients. LRFA should be the first-line technique for subcapsular lesions as it minimizes the risk of tumoural seeding and improves ICR. Proximity to gallbladder interferes in treatment efficacy (lower rate of ICR and lower rate of SCR).

Step-by-step guide for a simplified model of porcine orthotopic liver transplant.

BACKGROUND Based on similar anatomy, physiology, and size to humans, pigs provide an excellent means for studying new therapies related to orthotopic liver transplant (OLT). Techniques that have been described to date, however, are unnecessarily complex and increase the likelihood of morbidity and adverse outcome. MATERIALS AND METHODS Male outbred weanling pigs underwent OLT according to our procedure, with a short anhepatic time (<20 min) and without veno-venous bypass or vasoactive substances during the anhepatic phase. Vascular anastomoses were performed identical to the clinical setting, and a simple stented choledochocholedochostomy was created. RESULTS The authors have performed this procedure 130 times using four transplant models: standard, whole-liver (n = 10), small-for-size (n = 48), donor after cardiac death (n = 44), and donor adenoviral gene transfection (n = 28). The average cold ischemic and anhepatic times were 302 ± 43 and 17 ± 3 min, respectively. Hypotension was successfully treated with intravenous fluids. In all cases, the recipient survived the operation and was extubated. Survival to the end follow-up varied according to the model and was 56% (73/130) for all cases. At autopsy or euthanasia, no vascular thrombosis or outflow obstruction was found. Survival was 100% for pigs transplanted with standard, whole-liver grafts (n = 10). In this group, AST and bilirubin rose during the first 24 h after graft reperfusion, while the Quick prothrombin time (QPT) fell. By the fifth postoperative day, these parameters had returned to baseline. CONCLUSIONS This model is straightforward and reproducible and offers surgeons and researchers the opportunity to perform OLT studies under clinically relevant conditions.

Successful conversion from twice-daily to once-daily tacrolimus in liver transplantation: observational multicenter study

Dopazo C, Rodriguez R, Llado L, Calatayud D, Castells L, Ramos E, Molina V, García R, Fabregat J, Charco R. Successful conversion from twice‐daily to once‐daily tacrolimus in liver transplantation: observational multicenter study. 
Clin Transplant 2012: 26: E32–E37. 
© 2011 John Wiley & Sons A/S.

Beneficial Effect of a Resorbable Biliary Stent in Living Donor Liver Transplantation

Background: Living donor liver transplantation (LDLT) entails a significant number of bile duct complications. We aimed to diminish the biliary complication rate with the use of a resorbable biliary stent (RBS) during LDLT. The objective of this study is to describe the surgical techniques and the associated outcomes, especially in terms of safety, of RBS use in LDLT. Methods: From 2011 to 2014, 12 LDLT recipients were enrolled in a clinical trial with the use of a specifically designed RBS. These patients were followed according to the clinical protocol. Specific complications derived from RBS as well as biliary complications were recorded. Results: One patient underwent early retransplantation due to a small-for-size syndrome. None of the patients had a complication attributable to the placement, remaining in place, or degradation of the stent. Four of the remaining patients presented with a biliary complication: 1 (9.1%) with a biliary leak alone, 1 (9.1%) with a biliary stenosis alone, and 2 (18.2%) with both. However, none of the leaks could be directly attributed to the RBS. Patient and graft 1-year survival was 100 and 91.7%, respectively. Conclusion: The use of an RBS in LDLT is not associated with complications, and initial results regarding efficacy and safety are encouraging. The need for a larger and prospective study is warranted.

Lack of correlation between preoperative and intraoperative liver hemodynamics: a descriptive analysis.

Background Adult living-donor liver transplantation recipients undergo important hemodynamic changes during the procedure, which in turn have proven to be of the upmost importance when dealing with small grafts, to avoid the so-called “small-for-size” syndrome. Methods Back in 2003, we started a hemodynamic monitoring protocol in adult living-donor liver transplantation recipients, which evaluated the hemodynamic status of the patient 24 hr before, during, and 3 days after transplantation. We analyzed the correlation between the same hemodynamic variables measured in the hemodynamic laboratory and those taken in the operating room. Results With the exception of cardiac index and indexed systemic vascular resistance, all the other hepatic and systemic hemodynamic parameters measured before and during the intervention, as well as during and after the intervention, showed a lack of correlation. Conclusion The observed lack of correlation may happen due to many factors, such as the influence of vasoactive and anesthetic drugs, total muscular relaxation, or the presence of an open abdomen. As a result, a direct comparison between hemodynamic values should only be done when measured in the same conditions.