Lea Matsuoka

Pulsatile perfusion reduces the incidence of delayed graft function in expanded criteria donor kidney transplantation.

The use of expanded criteria donors (ECD) has been proposed to help combat the discrepancy between organ availability and need. ECD kidneys are associated with delayed graft function (DGF) and worse long‐term survival. The aim of this study is to evaluate the impact of pulsatile perfusion (PP) on DGF and graft survival in transplanted ECD kidneys. From January 2000 to December 2003, 4618 ECD kidney‐alone transplants were reported to the United Network for Organ Sharing. PP was performed on 912 renal allografts. The prognostic factors of DGF were analyzed using multivariate logistic regression analysis. Risk factors for reduced allograft viability were greater in donors and recipients of PP kidneys. Three‐year graft survival of ECD kidneys preserved with PP was similar to cold storage (CS) kidneys. The incidence of DGF in PP kidneys was significantly lower than CS kidneys (26% vs. 36%, p < 0.001). Despite having a greater number of risk factors for reduced graft viability, the ECD‐PP kidneys had similar graft survival compared to ECD‐CS kidneys. The use of PP, by decreasing the incidence of DGF, may possibly lead to lower overall costs and increased utilization of donor kidneys.

Expanding the Donor Kidney Pool: Utility of Renal Allografts Procured in a Setting of Uncontrolled Cardiac Death

The chronic shortage of deceased kidney donors has led to increased utilization of donation after cardiac death (DCD) kidneys, the majority of which are procured in a controlled setting. The objective of this study is to evaluate transplantation outcomes from uncontrolled DCD (uDCD) donors and evaluate their utility as a source of donor kidneys.

Intraoperative hemodialysis during liver transplantation: A decade of experience

Liver transplantation (LT) for patients with renal dysfunction is frequently complicated by major fluid shifts, acidosis, and electrolyte and coagulation abnormalities. Continuous renal replacement therapy (CRRT) has been previously shown to ameliorate these problems. We describe the safety and clinical outcomes of intraoperative hemodialysis (IOHD) during LT for a group of patients with high Model for End‐Stage Liver Disease (MELD) scores. We performed a retrospective study at our institution of patients who underwent IOHD from 2002 to 2012. Seven hundred thirty‐seven patients underwent transplantation, and 32% received IOHD. The mean calculated MELD score was 37, with 38% having a MELD score ≥ 40. Preoperatively, 61% were in the intensive care unit, 19% were mechanically ventilated, 43% required vasopressor support, and 80% were on some form of renal replacement therapy at the time of transplantation, the majority being on CRRT. Patients on average received 35 U of blood products and 4.8 L of crystalloids without significant changes in hemodynamics or electrolytes. The average urine output was 450 ml, and the average amount of fluid removal with dialysis was 1.8 L. The 90‐day patient and dialysis‐free survival rates were 90% and 99%, respectively. One‐year patient survival rates based on the pretransplant renal replacement status and the MELD status were not statistically different. This is the first large study to demonstrate the safety and feasibility of IOHD in a cohort of critically ill patients with high MELD scores undergoing LT with good patient and renal outcomes. Liver Transpl 20:756‐764, 2014.

The impact of hepatic portoenterostomy on liver transplantation for the treatment of biliary atresia: Early failure adversely affects outcome

Alexopoulos SP, Merrill M, Kin C, Matsuoka L, Dorey F, Concepcion W, Esquivel C, Bonham A. The impact of hepatic portoenterostomy on liver transplantation for the treatment of biliary atresia: Early failure adversely affects outcome.

The Surgical Management of Pancreatic Cancer

There have been significant advances made over the years in the areas of critical care, anesthesia, and surgical technique, which have led to improved mortality rates and survival after resection for pancreatic cancer. The standard of care is currently PD or PPPD for pancreatic cancers of the head, uncinate process, or neck and DP for pancreatic cancers of the body or tail. Resections are performed with the goals of negative margins and minimal blood loss, and referral to high-volume centers and surgeons is encouraged. However, 5-year survival rate after curative resection still remains at less than 20%. In an effort to improve survival and extend the limits of resectability, many centers have attempted extended lymphadenectomy and portal venous and even arterial resection and reconstruction. Extended lymphadenectomy has not led to improved survival for these patients. Portal vein resection has increased the number of patients amenable to resection, with equivalent survival rates compared with those of standard resections. Portal vein invasion is thus no longer considered a contraindication to resection at many large centers. Resection and reconstruction of involved arteries have been rarely performed and are currently not considerations for most patients. It is likely that future improvements in survival lie in the realm of adjuvant therapy. As chemotherapeutic and other tumor-directed agents continue to evolve and advance, this will hopefully lead to improved survival for patients undergoing surgical resection for pancreatic cancer.

Outcomes after liver transplantation in patients achieving a model for end-stage liver disease score of 40 or higher.

Background Patients with Model for End-Stage Liver Disease (MELD) scores of 40 or higher are at high risk for liver transplantation. In some regions, the organ donor shortage has resulted in a substantial increase in the number of patients who underwent transplantation with MELD scores of 40 or higher. The objective of this study was to characterize the outcomes of liver transplantation in these patients. Methods A single-center retrospective study evaluating the outcome of liver transplantation in 38 consecutive patients achieving a MELD score of 40 or higher from January 1, 2006, to November 30, 2010, was conducted. Patient and graft survivals and independent risk factors for postoperative death or graft loss were determined. Results Kaplan-Meier–based 1-, 2-, and 3-year patient survival rates were 89%, 82%, and 77% with 1-, 2-, and 3-year graft survival rates of 84%, 75%, and 70.3%, respectively. One of three recipients was on a vasopressor before transplantation, and 13% were mechanically ventilated. Renal replacement therapy was used before operation in 90% of the recipients. Postoperative length of stay averaged 38 days. There was a 42% incidence of postoperative bacteremia and an 18% incidence of bile duct stricture within 6 months. Univariate analysis identified admission-to-transplantation time and recipient diabetes as risk factors for graft failure and patient death. Multivariate analysis confirmed recipient diabetes as a risk factor for patient survival and admission-to-transplantation time of more than 15 days as a risk factor for graft survival. Conclusions Acceptable outcomes are achievable after liver transplantation in patients with MELD scores of 40 or higher but come at high pretransplantation and posttransplantation resource utilization.

Iatrogenic Pseudoaneurysms of the Extrahepatic Arterial Vasculature: Management and Outcome

BACKGROUND Pseudoaneurysms of the extrahepatic arterial vasculature are relatively uncommon lesions following surgery and trauma. In this report we analyze the presentation, management and outcomes of these vascular lesions. Of the related surgical procedures, the reported incidence is highest following laparoscopic cholecystectomy. We hereby analyze the literature on this subject and report our experience, specifically with extrahepatic pseudoaneurysms, drawing an important distinction from intrahepatic pseudoaneurysms. METHODS From September 1995 until July 2004, six patients, including three males and three females with a mean age of 67 years, were treated for seven extrahepatic arterial pseudoaneurysms. Patients were evaluated by endoscopy, ultrasound, computerized tomography, and angiography. Management included coil embolization or arterial ligation and/or hepatic resection. RESULTS The mean pseudoaneurysm size was 4.9-cm (range 1.0-11.0-cm) and the locations included the right hepatic artery (n = 5), inferior pancreaticoduodenal artery (n = 1), and gastroduodenal artery (n = 1). All six patients had prior surgical or percutaneous procedures. Median latency period between the original procedure and treatment of pseudoaneurysm was 17 weeks (range one month-16 years). Clinical features ranged from the dramatic presentation of hypotension secondary to intraperitoneal aneurysmal rupture to the subtle presentation of obstructive jaundice secondary to pseudoaneurysm mass effect. The range of patient presentations created diagnostic challenges, proving that accurate diagnosis is made only by early consideration of pseudoaneurysm. Management was ligation of the right hepatic artery (n = 4) and embolization of the pseudoaneurysms (n = 2). Post-treatment sequelae included liver failure requiring liver transplant (n = 1), intrahepatic biloma requiring percutaneous drainage (n = 1) and cholangitis with right hepatic duct strictures requiring right lobectomy and biliary reconstruction (n = 1). These complications followed arterial ligation, with no complications resulting from embolization. All six patients are alive and well after a mean follow-up of 53 months. CONCLUSIONS Our six patients demonstrate the diversity and unpredictability with which a pseudoaneurysm of the extrahepatic arterial vasculature may present in terms of initial symptoms, prior procedures, and the latency period between presentation and prior procedure. Through our experience and an analysis of the literature, we recommend a diagnostic and management approach for these patients.

The Minimally Invasive Approach to Surgical Management of Pancreatic Diseases

Laparoscopic pancreas surgery has undergone rapid development over the past decade. Although acceptability among traditional surgeons has been low, emerging specialty centers are reporting excellent outcomes for advanced and complex operations, such as pancreaticoduodenectomy. A note of caution is necessary: These outstanding results are from skilled surgeons, many of whom are pioneers in the field, who have overcome the learning curve over many years of innovation. As the procedures gain wider practice, outcomes need to be carefully watched because many of these procedures are extremely demanding technically. Although many have suggested that controlled, randomized studies comparing laparoscopic pancreatic resections with open resections are necessary to establish the efficacy of laparoscopic procedure, the cumulative data on the safety and efficacy of the laparoscopic procedure argues against such an approach. The logistic difficulties of conducting such studies will be considerable given patient preferences, the need for multicenter studies, and the rapid adoption of the laparoscopic procedure among experienced pancreatic surgeons. A more reasonable approach to truly evaluate the safety of these procedures is the establishment of a national registry that can measure progress of the field and record outcomes in the wider, nonspecialty community. Hepatobiliary training programs should also establish a minimal standard of training for many of the advanced procedures, such as the pancreaticoduodenectomy, so that the benefit of laparoscopic surgery can be made available outside of just a few specialty centers.

National Outcomes of Liver Transplantation for Model for End-Stage Liver Disease Score ≥40: The Impact of Share 35

In certain regions of the United States in which organ donor shortages are persistent and competition is high, recipients wait longer and are critically ill with Model for End‐Stage Liver Disease (MELD) scores ≥40 when they undergo liver transplantation. Recent implementation of Share 35 has increased the percentage of recipients transplanted at these higher MELD scores. The purpose of our study was to examine national data of liver transplant recipients with MELD scores ≥40 and to identify risk factors that affect graft and recipient survival. During the 12‐year study period, 5002 adult recipients underwent deceased donor whole‐liver transplantation. The 1‐, 3‐, 5‐ and 10‐year graft survival rates were 77%, 69%, 64% and 50%, respectively. The 1‐, 3‐, 5‐ and 10‐year patient survival rates were 80%, 72%, 67% and 53%, respectively. Multivariable analysis identified previous transplant, ventilator dependence, diabetes, hepatitis C virus, age >60 years and prolonged hospitalization prior to transplant as recipient factors increasing the risk of graft failure and death. Donor age >30 years was associated with an incrementally increased risk of graft failure and death. Recipients after implementation of Share 35 had shorter waiting times and higher graft and patient survival compared with pre–Share 35 recipients, demonstrating that some risk factors can be mitigated by policy changes that increase organ accessibility.

Effects of recipient size and allograft type on pediatric liver transplantation for biliary atresia

The majority of pediatric patients with end‐stage liver disease receive a transplant with a whole liver (WL) allograft. However, smaller recipients with biliary atresia (BA) may have improved outcomes with deceased donor partial liver (DDPL) or living donor allografts. This study compares the national outcomes for liver transplantation in BA, with attention to the interaction between liver allograft type and recipient size. From January 2, 2002 to December 30, 2014, 2123 pediatric patients underwent a primary liver transplant for BA. The majority of transplants (53%) were performed with a WL allograft. Utilization of a WL allograft increased from 42% of recipients weighing ≤ 7 kg to 74% of recipients weighing > 14 kg. The 1‐, 5‐, and 10‐year graft survival in recipients weighing ≤7 kg was significantly superior for living donor liver transplantation (LDLT) (91%, 88%, 84%) and DDPL allografts (90%, 84%, 77%) compared with WL allografts (79%, 75%, 74%; P = 0.005). The 1‐, 5‐, and 10‐year graft survival in recipients weighing >14 kg trended toward being inferior in recipients of DDPL allografts (85%, 85%, 71%) compared with WL allografts (96%, 91%, 86%; P = 0.06). Furthermore, the incidence of vascular thrombosis was highest in WL (13%) compared with LDLT (6%) and DDPL (5%) recipients ≤ 7 kg (P = 0.002). Liver retransplantation was also highest in WL (16%) compared with LDLT (9%) and DDPL (9%) recipients ≤ 7 kg (P = 0.02). In conclusion, strong consideration should be given to the use of technical variant allografts in small recipients with BA requiring liver transplantation. Liver Transplantation 23 221–233 2017 AASLD