Jason M. Vanatta

Foregut cystic developmental malformation: New taxonomy and classification - Unifying embryopathological concepts

Foregut cystic developmental malformations are rare developmental anomalies. The problems inherent to these malformations are their presentation across specialties that include embryology, anatomy, pathology, thoracic foregut surgery, pediatric surgery and general abdominal surgery. The direct consequence of this variation has resulted in diverse terminology, classification and a failure to identify the correlation. The article aims to summarize and unify the embryological concepts of foregut cystic malformation, to suggest a generic title to the various groups of these interrelated disorders and a uniform use of nomenclature on the basis of unifying concepts of embryopathogeneis.

Liver transplant using donors after cardiac death: a single-center approach providing outcomes comparable to donation after brain death.

OBJECTIVES Organ donation after cardiac death remains an available resource to meet the demand for transplant. However, concern persists that outcomes associated with donation after cardiac death liver allografts are not equivalent to those obtained with organ donation after brain death. The aim of this matched case control study was to determine if outcomes of liver transplants with donation after cardiac death donors is equivalent to outcomes with donation after brain death donors by controlling for careful donor and recipient selection, surgical technique, and preservation solution. MATERIALS AND METHODS A retrospective, matched case control study of adult liver transplant recipients at the University of Tennessee/Methodist University Hospital Transplant Institute, Memphis, Tennessee was performed. Thirty-eight donation after cardiac death recipients were matched 1:2, with 76 donation after brain death recipients by recipient age, recipient laboratory Model for End Stage Liver Disease score, and donor age to form the 2 groups. A comprehensive approach that controlled for careful donor and recipient matching, surgical technique, and preservation solution was used to minimize warm ischemia time, cold ischemia time, and ischemia-reperfusion injury. RESULTS Patient and graft survival rates were similar in both groups at 1 and 3 years (P = .444 and P = .295). There was no statistically significant difference in primary nonfunction, vascular complications, or biliary complications. In particular, there was no statistically significant difference in ischemic-type diffuse intrahepatic strictures (P = .107). CONCLUSIONS These findings provide further evidence that excellent patient and graft survival rates expected with liver transplants using organ donation after brain death donors can be achieved with organ donation after cardiac death donors without statistically higher rates of morbidity or mortality when a comprehensive approach that controls for careful donor and recipient matching, surgical technique, and preservation solution is used.

Donor-derived metastatic melanoma in a liver transplant recipient established by DNA fingerprinting.

Metastatic melanoma is a donor-derived malignancy that has rarely been reported in liver allograft recipients. We present a case of a transmitted donor-derived melanoma to a liver allograft recipient in whom the diagnosis was established by polymerase chain reaction-based DNA fingerprinting. A 52-year-old African-American man underwent a successful orthotropic liver transplant for alcohol-induced cirrhosis. One year after the orthotropic liver transplant, he presented at our institution with diffuse abdominal pain, and a computed tomography scan of the abdomen and chest showed innumerable masses diffusely involving the liver and multiple subcutaneous nodules in the abdominal and chest wall. A liver biopsy confirmed the diagnosis of metastatic melanoma. The origin of melanoma was traced to the donor by DNA fingerprinting of the native liver, the donor liver, and the donor gallbladder. Chemotherapy was initiated with temozolomide (75 mg/m² daily) and thalidomide (50 mg daily), to which he responded within 8 weeks with radiologic improvement in metastatic lesions. Tacrolimus was switched to sirolimus because of renal insufficiency as well as reported effectiveness against melanoma. Our patient survived for 9 months after the diagnosis of metastatic melanoma. He ultimately died of brain metastases. Donor-derived metastatic melanoma is a rare cancer with the highest transmission and mortality rates, which requires better recognition. Prompt diagnosis of donor-derived melanoma is critical and can be achieved reliably with polymerase chain reaction-based DNA analysis. Management options after diagnosis include de-escalation of immunosuppression, with or without urgent organ removal or retransplant. The roles of chemotherapy, immunotherapy, and radiotherapy require further study.

The Advantages and Disadvantages of Perioperative TransesophagealEchocardiography during Liver Transplantation

In the last 50 years of liver transplantation there has been significant improvement in all aspects of the operation, and it has become the standard of care in the treatment of end stage liver disease. Perioperative hemodynamic monitoring during the transplant operation is critical and currently the pulmonary artery catheter (PAC) remains the gold standard for cardiovascular monitoring. Transesophageal echocardiography (TEE), with the ability to visualize cardiac function and provide real-time feedback on the adequacy of intervention has had an increasing use in liver transplantation. The primary advantage of TEE is the ability to visualize cardiac function. Disadvantages of TEE include instrumentation cost, operator use, and familiarity with the information provided by the TEE. TEE provides a useful adjunct to PAC in intraoperative hemodynamic monitoring during liver transplantation, especially in those patients at risk for cardiac complications due to pre-existing cardiovascular disease.

Nonalcoholic fatty liver disease following liver transplantation.

Post-transplant, nonalcoholic hepatic steatosis and steatohepatitis are increasingly recognized as a complication of liver transplantation, and the progression of the latter through fibrosis to cirrhosis has been clearly shown. Non-alcoholic steatohepatitis (NASH) is independently associated with an increased risk of death from cardiovascular and liver diseases. While optimal therapy is not yet available in the post-liver transplant setting, knowledge gained in the therapy of NASH in the non-transplant setting can be used to design therapeutic interventions. In addition, early recognition with protocol liver biopsies and an effective preventive strategy by modifying known risk factors implicated in the recurrence of NASH would be the most effective way to curtail the progression of NASH before an effective treatment can be found. Additional rigorous research aimed at elucidating the pathogenesis, natural history, and selection of immunosuppressants for NASH is clearly warranted.

Long-term outcomes of early compared to late onset choledochocholedochal anastomotic strictures after orthotopic liver transplantation

Endoscopic treatment of anastomotic biliary stricture (ABS) after liver transplantation (LT) has been proven to be effective and safe, but long‐term outcomes of early compared to late onset ABS have not been studied. The aim of this study is to compare the long‐term outcome of early ABS to late ABS.

The Benefit of Sirolimus Maintenance Immunosuppression and Rabbit Antithymocyte Globulin Induction in Liver Transplant Recipients That Develop Acute Kidney Injury in the Early Postoperative Period

Published data are limited describing renal outcomes in orthotopic liver transplant (OLT) recipients prescribed sirolimus (SRL) maintenance immunosuppression (MIS) and rabbit antithymocyte globulin (rATG) induction. We investigated whether SRL MIS and rATG induction facilitated recovery of acute kidney injury in the early postoperative period. This retrospective descriptive study screened 308 consecutive OLTs performed between 2006 and 2009. All patients received rATG induction with steroid avoidance. MIS consisted of SRL or TAC with mycophenolate mofetil. A total of 197 patients were included: 168 (85%) received TAC and 29 (15%) received SRL for a median of 365 days. Demographics were similar between groups except for a higher incidence of pretransplant renal dysfunction in the SRL recipients (SRL 59% versus TAC 21%; P < 0.05). The eGFR was significantly (P < 0.05) higher for all time points in the TAC group with the exception of month 2. However, improvement in eGFR was significantly (P < 0.05) greater in the SRL group postoperatively. Our study suggests that rATG induction and SRL maintenance immunosuppression facilitate renal recovery for liver transplant recipients that develop acute kidney injury in the early postoperative period.

Recurrent hepatitis C virus infection and outcome after living-donor liver transplant.

OBJECTIVES In living-donor liver transplant recipients with hepatitis C virus infection, outcomes of recurrent hepatitis C virus infection and fibrosis progression are not well documented. We evaluated fibrosis progression, response to pegylated interferon treatment, and long-term graft survival in living-donor liver transplant recipients who had hepatitis C virus infection. MATERIALS AND METHODS In 48 transplant recipients, including 29 recipients who had follow-up liver biopsy ≥ 6 months after transplant, histology and clinical courses were reviewed. Outcomes were evaluated for patients grouped into slow and rapid fibrosis groups. Treatment with pegylated interferon and ribavirin was assessed in 18 patients. RESULTS Clinical features were similar between recipients with slow or rapid fibrosis. The time interval from transplant to recurrence of hepatitis C virus infection was significantly shorter in the recipients with rapid fibrosis. Recipients with rapid fibrosis had significantly greater confluent necrosis, acidophil bodies, and fibrosis score than recipients with slow fibrosis. Graft survival rates were similar between patients with slow or rapid fibrosis. Cumulative proportion of long-term graft survival was 60% at 7 years after transplant. Sustained virologic response was noted in 5 of 18 patients (28%) who received pegylated interferon and ribavirin. CONCLUSIONS In recipients of living-donor liver transplant with early recurrence of hepatitis C have worse fibrosis progression but graft survival was not affected. Therapy with pegylated interferon and ribavirin achieved sustained virologic response only in a small proportion of the patients.

868 Liver Transplantation for Hepatic Sarcoidosis: Long Term Follow-up and Recurrence After Liver Transplantation, a Single Center Experience

0.002, 95% CI 1.9 17), MELD score ≥ 15 (OR 2.1, p = 0.006, 95% CI 1.24 3.58), and HDL cholesterol < 30mg/dL (OR 2.98, p = 0.001, 95% CI 1.52 5.84). The age, sex, etiology of liver cirrhosis, type of decompensation, serum sodium < 130mEq/L and total cholesterol < 100mg/dL were poor predictors of infection. Mortality rates: First admission 14.3% (43/ 301), at 1 year 39.8% (100/251) and at 3 years 58.1% (91/217). Kaplan Meier survival analysis showed decreased long term survival in patients with infections at first admission for decompensated liver cirrhosis (p <0.001). Conclusions:Community and nosocomial infections have a high incidence at first episode of decompensation of liver cirrhosis and are independent predictors of mortality at hospital admission, at 1 and 3 years. These patients may benefit from intensive treatment and early referral for liver transplantation.