H.-W. Park

Effect of Pulmonary Support Using Extracorporeal Membrane Oxygenation for Adult Liver Transplant Recipients With Respiratory Failure

BACKGROUND Adult liver transplantation (OLT) recipients occasionally show serious acute cardiopulmonary dysfunction, requiring intensive care. We assessed the role of extracorporeal membrane oxygenation (ECMO) support in adult recipients facing acute pulmonary failure and refractory to conventional mechanical ventilation and concurrent nitric oxide gas inhalation. METHODS From January 2008 to March 2011, 18 adult OLT recipients at our institution required ECMO support: 12 due to pneumonia and 6 to adult respiratory distress syndrome. Their mean age was 55.7 ± 6.9 years and mean Model for End-stage Liver Disease score, 24.8 ± 8.5. Twelve patients had undergone living donor and six deceased donor OLT. RESULTS A venovenous access mode and concurrent continuous venovenous hemodiafiltration were used in all patients. There were no procedure-related complications. Eight patients (44.4%) were successfully weaned from ECMO upon the first attempt after a mean support of 11.9 ± 6.1 days, but the other 10 died due to overwhelming infection. Univariate analysis revealed no significant pre-ECMO risk factor for treatment failure but C-reactive protein concentration at the time of ECMO differed significantly among patients who did versus did not survive after ECMO. CONCLUSIONS ECMO as rescue therapy may be a final therapeutic option for OLT recipients with refractory pulmonary dysfunction who would otherwise die due to hypoxemia from severe pneumonia or adult respiratory distress syndrome.

De Novo Malignancies After Liver Transplantation: Incidence Comparison With the Korean Cancer Registry

PURPOSE De novo malignancy is not uncommon after liver transplantation (OLT). We have compared the incidence of novo malignancy following OLT with those among the general Korean population. METHODS Between January 1998 and December 2008, 1952 adult OLT were performed, including 1714 living donor and 238 deceased donor grafts whose medical records were retrospectively reviewed. RESULTS Among the 1952 patients, 44 (2.3%) showed de novo malignancies after a mean posttransplant period of 41 months. Among the 14 types of malignancy the most frequent was stomach cancer (n = 11; 25.0%), colorectal cancer (n = 9; 20.5%), breast cancer (n = 4; 9.1%), and thyroid cancer (n = 3; 6.8%). These patients underwent aggressive treatment, including surgery, chemotherapy, and radiotherapy, except for one patient with an aggressive primary liver cancer. Over a mean follow-up of 45 months after diagnosis of de novo malignancy, 13 patients (29.5%) died; the overall 3-year patient survival rate was 67.5%. The relative risk of malignancy following OLT was 7.7-fold higher in men and 7.3-fold higher in women than the Korean general population. CONCLUSIONS OLT recipients must be checked periodically for de novo malignancy throughout their lives, especially for cancers common in the general population.

More Than 300 Consecutive Living Donor Liver Transplants a Year at a Single Center

BACKGROUND Living donor liver transplantation (LDLT) has been the first option for the patients requiring liver transplantation in East Asia because of the scarcity of cadaveric grafts. We have performed consecutively more than 300 LDLTs per year, and herein report our methods. METHODS In 1997, the first successful adult LDLTs used a left and subsequently a right lobe. However, congestion in the anterior segment of right-lobe grafts prompted us to initiate reconstruction of middle hepatic venous tributaries in 1998. Dual LDLT grafts using 2 left lobes were developed in 2000 to solve graft-size insufficiency and minimize donor risk. The indications for adult LDLT were broadened to near complete obstruction of the portal vein by application of intraoperative cine-portography and portal vein stenting in 2004. ABO-incompatible adult LDLT was initiated in 2008 to overcome the blood group barrier between recipient and donor. RESULTS With various innovations at our institution, 317 LDLTs were performed yearly in 2010 and 2011: 301 in 2010 and 298 in 2011. The most common primary diseases was hepatitis B virus-related liver cirrhosis with or without hepatocellular carcinoma (64.3%). The most common graft types were right hemiliver (82.6%). There has been no donor mortality. ABO-incompatible LDLT cases were 11.0% of the total. In-hospital mortality in 2011 was 2.5% (n = 8; adult 6, pediatric 2). CONCLUSION Innovations in operative techniques and perioperative care as well as dedicated team members have made it possible to perform more than 300 LDLTs per year consecutively with excellent outcomes.

Toward More Than 400 Liver Transplantations a Year at a Single Center

BACKGROUND For the first time at Asan Medical Center (AMC) we performed more than 400 liver transplantations (LTs) per year in 2011, despite same number of living donor liver transplantations (LDLTs). METHODS Our OLT program was started in 1992, but not activated well due to the scarcity of deceased donor organs. Since adult LDLTs using a left lobe and then a right lobe were successfully performed in 1997, we have developed several innovative techniques and approaches for adult LDLT, for example, modified right-lobe graft reconstructing middle hepatic branches in 1998, dual graft LDLT using 2 left lobes in 2000; new criteria for hepatocellular carcinoma (HCC); as well as ABO-incompatible LDLT, the first in the world. As a result, the number of LDLTs has increased rapidly but reached a plateau recently. Nationwide efforts to promote deceased donation increased the number of deceased donor liver transplantation (DDLT). RESULTS We have performed 317 LDLTs per year in 2010 and 2011, respectively. The number of LTs reached 403 in 2011. This large number was possible due to a remarkable increase of DDLTs from 50 in 2010 to 86 in 2011. Seventy-nine patients (68.1%) among 116 patients (28.8%) required an urgent LT receiving a DDLT. LT for HCC or ABO-mismatch comprised 50.3% (n = 150) or 8.7% (n = 35), respectively. In-hospital mortality rate in 2011 was 4.7%. CONCLUSIONS The increased LTs number at AMC was aided by the nationwide campaign.

Incidence and Management of Postoperative Abdominal Bleeding After Liver Transplantation

PURPOSE To assess the incidence and management of postoperative abdominal bleeding after orthotopic liver transplantation (OLT) and to identify risk factors for abdominal bleeding. METHODS We retrospectively reviewed the medical records of 1039 patients who underwent OLT at our institution from January 2008 to December 2010 seeking to identify subjects with posttransplantation abdominal bleeding, defined as any hemorrhage requiring radiologic intervention or laparotomy within the first month. RESULTS Among the 1039 patients, 94 (9%) showed abdominal bleeding, occurring at a mean of 6.1 days (range, day 1 to 21 days). Active bleeding was controlled by endovascular interventional techniques (n = 37; 39%), by surgical ligation or vascular reconstruction (n = 43; 46%), or by sequential combinations of endovascular intervention and surgery (n = 14; 15%). The most frequent bleeding sites for radiologic intervention were the right inferior phrenic artery (n = 14), right and left epigastric arteries (n = 7), intercostal artery (n = 5) and right renal capsular artery (n = 4). The most frequent bleeding sites requiring laparotomy were the hepatic artery (n = 9), diaphragm (n = 8), inferior vena cava (n = 5), abdominal drain insertion site (n = 4), portal vein anastomosis site (n = 4), abdominal wall (n = 3), liver graft cut surface (n = 3), hilar plate (n = 3), and greater omentum (n = 3). Bleeding episodes were associated with greater patient age and increased intraoperative blood loss. CONCLUSIONS The risk of bleeding from coagulopathy and iatrogenic injury is high during the early posttransplantation period. This risk of bleeding can be minimized by meticulous surgical dissection and bleeding control.

Section 15. A desensitizing protocol without local graft infusion therapy and splenectomy is a safe and effective method in ABO-incompatible adult LDLT.

Background The use of rituximab (Rit) to prevent antibody-mediated rejection (AMR) of ABO-incompatible (ABOi) adult living donor liver transplants (ALDLTs) has raised questions about the role of local graft infusion therapy (LGIT) and splenectomy (SPN); however, they are still regarded as essential components of the desensitization (DSZ) protocol. Methods The DSZ protocol consisted of plasma exchange and Rit. None of the patients underwent SPN. The patients were divided into two groups. The patients in Group I (n=20) received LGIT via the hepatic artery or portal vein. The patients in Group II (n=100) did not receive LGIT. Results One hundred twenty ABOi ALDLTs were performed from November 2008 to June 2012, and there was only one case of operative mortality (0.8%). There was no significant difference in the 3-year patient survival rates between patients receiving ABO-compatible and ABOi ALDLT (88.8% vs. 94.8%; P=0.11). LGIT catheter-related complications occurred in six patients (30.0%). There was no statistically significant difference in the 3-year patient survival rates between the groups (90.0% vs. 95.0%; P=0.26). One patient in Group 1 (0.8%) experienced AMR. Diffuse intrahepatic biliary stricture occurred in two patients (10.0%) in Group I and in five patients (5.0%) in Group II, although the difference was not statistically significant (P=0.11). The incidence of biliary stricture was similar in both groups (P=0.06), but the incidence of infection was significantly higher in Group I (P=0.03). Conclusion The DSZ protocol without LGIT and splenectomy is a safe and effective method of attaining a successful outcome of ABOi ALDLT.

Section 6. Management of extensive nontumorous portal vein thrombosis in adult living donor liver transplantation.

Background Patent portal vein (PV) and adequate portal inflow is essential for successful living donor liver transplantation (LDLT). In extensive portal vein thrombosis (PVT) patients, however, complete PV thrombectomy is not feasible particularly at intrapancreatic portion, and subsequently portal flow steal through preexisting sizable collaterals or rethrombosis can occur. To overcome those problems, we introduced interruption of sizable collaterals and intraoperative cine-portogram (IOP), which is useful for diagnosis and treatment of residual PVT and sizable collaterals. Methods Fourteen percent of adult LDLT (188/1399) had PVT from February 2008 to December 2012 and were subdivided into Yerdel’s grades 1, 2, 3, and 4 based on preoperative imaging and operative findings. Considering the severity of PVT and presence of sizable collaterals, the managements were as follows: thrombectomy alone, additional PV plasty, PV stenting, interposition graft, or additional interruption of collaterals. Results The Yerdel’s grade of PVT patients were 1 (42%), 2 (54%), 3 (3%), and 4 (1%). One hundred one (77%) patients underwent interruption of sizable collaterals. The most common management for PVT was thrombectomy alone in grades 1 and 2, thrombectomy plus PV stenting and/or ballooning in grade 3, and interposition graft in grade 4. In LDLT for PVT patients, 1-year mortality was 9%, and PV-related complication occurred in 5%. The severity of PVT made no difference in the outcome. Conclusion Multi-disciplinary approaches including surgical correction of PVT, IOP, and interruption of sizable collaterals resulted in excellent outcome, and it was not affected by the severity of PVT.

Right Gastroepiploic Artery Is the First Alternative Inflow Source for Hepatic Arterial Reconstruction in Living Donor Liver Transplantation

BACKGROUND Sufficient arterial flow after living donor liver transplantation (LDLT) is closely related to graft survival and prevention of postoperative complications. However, some unfavorable hepatic arterial conditions in recipients preclude reconstruction, requiring alternative stumps. We have used the right gastroepiploic artery (RGEA) as a first alternative for hepatic inflow. METHODS From January 2006 to December 2008, we performed 754 LDLTs including 28 cases of RGEA among hepatic arterial anastomoses. The arterial anastomosis was performed by an single surgeon under 859 a microscope using an end-to-end interrupted suture technique. RGEA was mobilized over 15 cm from the greater curvature of stomach and greater omentum. RESULTS The indications for RGEA use included severe hepatic arterial injury from previous transarterial chemoembolization (n=14), need for additional arterial flow in dual-grafts LDLT (n=13), poor blood flow from the recipient hepatic artery (n=3), and arterial injury during hilar dissection (n=3). The mean diameter of the isolated RGEA was 2.0±0.2 mm (range: 1.0-2.5). Most hepatic arterial anastomoses were performed with a significant size discrepancy of more than twofold. All reconstructed hepatic arterial flowes showed good; no complication was identified during the mean follow-up period of 56 months to date. CONCLUSIONS Using RGEA as an alternative arterial inflow is a simple, reliable procedure for situations of inadequate recipient hepatic or multiple graft arteries.

Long-Term Outcomes of Portal Y-Graft Interposition for Anomalous Right Portal Veins in Living Donor Liver Transplantation

BACKGROUND Anomalous portal vein (PV) branching in living donor livers is not uncommon and usually leads to double PV orifices of the right lobe grafts. We have assessed the long-term outcomes of portal Y-graft interposition for adult living donor liver transplantation (LDLT). METHODS We retrospectively assessed the outcomes of 79 right-lobe LDLTs using portal Y-graft interposition among the 2001 adult LDLTs performed at our institution from January 2002 to December 2010. RESULTS Donor PV types were type III except for one case of type II. Sources of Y-grafts were recipient autologous PV in 76 LDLTs, fresh iliac vein allografts in two, and patch plasty using recipient greater saphenous vein in one. Detailed procedures included a portal Y-graft resection with Y-limbs, corner stay sutures, tying of suture materials under direct mechanical dilatation, and direct edge-to-edge anastomosis to the recipient remnant main PV. Early PV stenting was necessary in five patients (6.3%) due to stenosis or buckling deformity. During a mean follow-up of 42 months, all PVs remained patent until patient death or censoring. Overall 1-, 3-, and 5-year patient survival rates were 93.6%, 88.3%, and 85.5%, respectively. None of the 79 donors experienced major complications requiring reoperation or therapeutic intervention. CONCLUSIONS Due to their technical feasibility and excellent long-term outcome, portal Y-graft interposition should be considered a standard procedure for reconstruction of right-lobe grafts with double PV orifices.

Restoration of portal flow using a pericholedochal varix in adult living donor liver transplantation for patients with total portosplenomesenteric thrombosis

In total portosplenomesenteric thrombosis patients, cavoportal hemitransposition (CPHT) is indicated but rarely applicable for adult‐to‐adult (A‐to‐A) living donor liver transplantation (LDLT) because partial liver graft requires splanchno‐portal inflow for liver graft regeneration. If intra‐ & peri‐pancreatic collaterals draining into pericholedochal varix were present, pericholedochal varix may provide splanchnic blood flow to the transplanted liver and also relieve recipients portal hypertension. To date, however, there is no successful report using pericholedochal varix in liver transplantation (LT). We successfully performed A‐to‐A LDLTs using pericholedochal varix for those 2 patients. The surgical strategies are followings: (a) dissection of hepatic hilum to isolate left hepatic artery using for arterial reconstruction of implanted right lobe graft, (b) en‐mass clamping of the undissected remaining hilum if we can leave adequate length of stump from the clamping site, and then hilum is divided, (c) delay the donor hepatectomy until the feasibility of the recipient operation is confirmed. Portal flow was established between the sizable pericholedochal varix (caliber > 1cm) and graft portal vein, but the individually designed approaches were used for each patients. Currently, they have been enjoying normal life on posttransplant 92 and 44 months respectively. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins might be an useful inflow to restore portal flow and secure good outcome in A‐to‐A LDLT. Liver Transpl 20:612–615, 2014.