M. Hosein Shokouh-Amiri

Surgical technique for right lobe adult living donor liver transplantation without venovenous bypass or portocaval shunting and with duct-to-duct biliary reconstruction.

ObjectiveTo report the authors’ experience with adult living donor liver transplantation (ALDLT) without venovenous bypass and to describe modifications that will allow for a direct duct-to-duct biliary reconstruction. Summary Background DataAdult living donor liver transplantation is being evaluated as a method to alleviate the organ shortage. Descriptions of the procedure have emphasized the use of venovenous bypass, portocaval decompression, and the mandatory use of a Roux-en-Y biliary enteric anastomosis. The authors describe a technique for ALDLT without venovenous bypass, portocaval decompression, or caval clamping in 11 recipients and describe the modifications to the procedure that may allow a duct-to-duct biliary reconstruction in certain cases. MethodsBetween March 1999 and March 2000, 11 ALDLTs were performed at the authors’ institution. All procedures were performed without venovenous bypass, portocaval decompression, or caval clamping. After a modification to the procedure, five of the last six recipients underwent biliary reconstruction with a direct duct-to-duct anastomosis. Data regarding donor, recipient, and graft survival, complications, and graft function were collected. ResultsRecipients comprised five women and six men, mean age 48 years. Donors comprised five women and six men, mean age 36.5 years. Donor to recipient relationships included sibling, spouse, son, and daughter. Indications for transplantation were hepatitis C, hepatitis C with hepatocellular carcinoma, primary biliary cirrhosis, primary sclerosing cholangitis, ethanol, and cryptogenic. No case required venovenous bypass or portocaval shunting. The right hepatic vein of the donor graft was anastomosed to the confluence of the left and middle hepatic veins in all cases. All donors are alive and well, with no adverse complications reported. Recipient and graft survival rates were 91% and 82%, respectively, for ALDLT versus 92% and 92% for recipients of cadaveric organs during the same time period. One recipient died of multiple organ failure and sepsis. Biliary reconstruction was performed by Roux-en-Y hepaticojejunostomy in the six cases. In five of the last six recipients, direct duct-to-duct biliary reconstruction with a T tube was used. No anastomotic leaks or strictures occurred in the patients undergoing duct-to-duct reconstruction. ConclusionsAdult living donor liver transplantation can be performed safely and may help alleviate the organ shortage. Neither venovenous bypass nor portocaval shunting is necessary to perform the procedure, and modifications to both the donor and recipient hepatectomy procedures may allow biliary reconstruction to be performed by a direct duct-to-duct anastomosis in selected cases.

A Prospective Comparison of Simultaneous Kidney–Pancreas Transplantation With Systemic-Enteric Versus Portal-Enteric Drainage

ObjectiveTo compare pancreas transplantation with systemic-enteric (SE) versus portal-enteric (PE) drainage in a prospective fashion. Summary Background DataTo improve the physiology of pancreas transplantation, the authors developed a new technique of portal venous delivery of insulin and enteric drainage of the exocrine secretions. MethodsDuring a 26-month period, the authors prospectively alternated 54 consecutive simultaneous kidney and pancreas transplants to either SE (n = 27) or PE (n = 27) drainage. The two groups were well matched for numerous characteristics. Maintenance immunosuppression in both groups consisted of tacrolimus, mycophenolate mofetil, and steroids. ResultsPatient survival rates were 93% SE versus 96% PE; kidney graft survival rates were 93% in both groups. Pancreas transplantation survival (complete insulin independence) was 74% after SE versus 85% after PE drainage with a mean follow-up of 17 months. The mean length of initial hospital stay was 12.4 days in the SE group and 12.8 days in the PE group. The SE group was characterized by a slight increase in the number of readmissions. The incidences of acute rejection (33%) and major infection (52%) were similar in both groups. The incidence of intraabdominal infection was slightly higher in the SE group. However, the early relaparotomy rate was similar between groups. The composite endpoint of no rejection, graft loss, or death was attained in 56% of SE versus 59% of PE patients. ConclusionsThese results suggest that simultaneous kidney and pancreas transplantation with SE or PE drainage can be performed with comparable short-term outcomes.

Choice of surgical technique influences perioperative outcomes in liver transplantation.

OBJECTIVE To examine how the choice of surgical technique influenced perioperative outcomes in liver transplantation. SUMMARY BACKGROUND DATA The standard technique of orthotopic liver transplantation with venovenous bypass (VVB) is commonly used to facilitate hemodynamic stability. However, this traditional procedure is associated with unique complications that can be avoided by using the technique of liver resection without caval excision (the piggyback technique). METHODS A prospective comparison of the two procedures was conducted in 90 patients (34 piggyback and 56 with VVB) during a 2.5-year period. Although both groups had similar donor and recipient demographic characteristics, posttransplant outcomes were significantly better for the patients undergoing the piggyback technique. The effect of surgical technique was examined using a stepwise approach that considered its impact on two levels of perioperative and postoperative events. RESULTS The analysis of the first level of perioperative events found that the piggyback procedure resulted in a 50% decrease in the duration of the anhepatic phase. The analysis of the second level of perioperative events found a significant relation between the anhepatic phase and the duration of surgery and between the anhepatic phase and the need for blood replacement. The analysis of the first level of postoperative events found that the intensive care unit stay was significantly related to both the duration of surgery and the need for blood replacement. The intensive care unit stay was in turn related to the second level of postoperative events, namely the length of hospital stay. Finally, total charges were directly related to length of hospital stay. The overall 1-year actuarial patient and graft survival rates were 94% in the piggyback and 96% in the VVB groups, respectively. CONCLUSIONS These data demonstrate that surgical choices in complex procedures such as orthotopic liver transplantation trigger a chain of events that can significantly affect resource utilization. In the current healthcare climate, examination of the sequence of events that follow a specific treatment may provide a more complete framework for choosing between treatment alternatives.

Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation

At the present time the preferred technique for biliary reconstruction in adult living donor liver transplantation (ALDLT) is the Roux-en-Y hepaticojejunostomy (HJ). Patients undergoing HJ are not drained through the normal physiologic route and may suffer from repeated bouts of ascending cholangitis. The inability to evaluate and treat biliary strictures and leaks by endoscopic retrograde cholangiography (ERCP) may complicate the postoperative management of patients undergoing HJ. Modifications aimed at preserving the blood supply to both the donor and recipient bile ducts may allow a direct duct-to-duct (D-D) biliary reconstruction in selected patients, and aid in visualization of the biliary tree and eliminate complications related to reflux cholangitis. Adult living donor liver transplantation, using a right lobe, is emerging as an effective treatment option for selected patients awaiting liver transplantation. Though many variations in technique exist between centers performing this procedure, most surgeons use an HJ as the preferred method for biliary-enteric reconstruction. The rationale for use of the HJ for biliary reconstruction in segmental liver grafts, such as those used in pediatric recipients, derives from the small size of the recipient bile duct and inadequate length of the donor bile duct. In addition, the underlying liver disease (eg, biliary atresia) often mandates an HJ. Finally, there are concerns relating to the vascular integrity of the anastomosis, especially with left-sided grafts, because important blood vessels may arise to the left hepatic duct from segment IV vessels. Although HJ remains the standard of care in pediatric segmental grafts, the use of HJ in adult segmental grafts, such as those used in ALDLT, would not appear to be mandatory for several reasons. First, most adult liver diseases do not prohibit a choledocho-choledochostomy. Second, the size of the adult bile duct is not a restricting factor; and finally, the vascular integrity of the anastomosis can be preserved by careful attention to surgical technique and a greater understanding of the vascular supply to the bile ducts. The fact that a D-D anastomosis is the preferred method for biliary reconstruction in cadaveric liver transplantation relates to its preservation of the normal physiologic sphincter mechanism and consequent reduction in the incidence of reflux cholangitis. In addition, it reduces operative time, allows easier access for radiologic evaluation of the biliary tract by ERCP, and avoids creation of an enteric anastomosis that may leak, cause infection, or act as a site for internal hernias. This article describes a modification of our standard procedure for ALDLT, which allows a well-vascularized and tension-free D-D anastomosis.

Evolution in pancreas transplantation techniques: simultaneous kidney-pancreas transplantation using portal-enteric drainage without antilymphocyte induction.

OBJECTIVE To report initial experience with the combination of a novel technique of portal-enteric pancreas transplantation with newer immunosuppressive strategies that eliminate antilymphocyte induction therapy. BACKGROUND A new surgical technique of pancreas transplantation has been developed with portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric). The introduction of potent immunosuppressive agents may allow simultaneous kidney and pancreas transplants (SKPT) to be performed without antilymphocyte induction. METHODS From September 1996 to November 1998, the authors performed 28 primary SKPTs with portal-enteric drainage and no antilymphocyte induction. All patients received triple immunosuppression with tacrolimus, mycophenolate mofetil, and steroids. The study group had a mean age of 38 years and a mean preoperative duration of diabetes of 25 years. Four patients (14%) had prior kidney transplants. RESULTS All patients had immediate renal allograft function. Actual patient, kidney, and pancreas graft survival rates were 86%, 82%, and 82%, respectively, after a mean follow-up of 12 months. Four patients died, three as a result of cardiac events unrelated to SKPT. Five kidney and five pancreas grafts were lost, including five deaths with function and three cases of chronic rejection. The mean length of stay and total charges for the initial hospital stay were 12.5 days and

Observations regarding the use of sirolimus and tacrolimus in high‐risk cadaveric renal transplantation

99,517. The mean number of readmissions was 2.9, and 10 patients (36%) had no readmissions. Six patients (21 %) developed acute rejection, with five (18%) receiving antilymphocyte therapy. Seven patients (25%) underwent relaparotomy, including two (7%) for intraabdominal infection. Nine patients (32%) had major infections, including three (11%) with cytomegaloviral infection. Of the 24 surviving patients, 22 (92%) are both dialysis- and insulin-free. CONCLUSION These preliminary results suggest that SKPT with portal-enteric drainage without antilymphocyte induction can be performed with excellent outcomes.

Allograft pancreatectomy after pancreas transplantation with systemic-bladder versus portal-enteric drainage.

Abstract:  Background:  Balancing the risk of acute rejection (AR) with drug‐induced toxicities complicates the selection of the optimal immunosuppressive regimen, especially in the high‐risk renal transplant recipient. This study was designed to determine the optimal dosage combinations of tacrolimus and sirolimus in a high‐risk cadaveric renal transplant population.

Diagnosis, Management, and Outcome of Late Duodenal Complications in Portal–Enteric Pancreas Transplantation: Case Reports

From 1989 to 1997, we performed 159 pancreas transplantations (PTXs), including 117 simultaneous kidney–PTX (SKPT), 25 PTXs alone (PTA), and 17 sequential PTXs after kidney transplantations (PAKT). A total of 73 PTXs were performed with systemic‐bladder (S‐B) and 86 with portal‐enteric (P‐E) drainage. The need for allograft pancreatectomy (PCTY) may be considered as an index of technical morbidity after PTX. A total of 37 PCTYs (23%) were performed at a mean of 4.7 months after PTX. Twenty‐seven PCTYs were performed within 1 month, 30 (81%) within 3 months, and the remaining seven more than 6 months after PTX. The incidence of PCTY did not differ according to type of transplantation: simultaneous kidney–PTX (SKPT) (23%), PTA (24%), and PAKT (23.5%). Indications for PCTY were thrombosis (23), rejection (9), infection (3), and pancreatitis (2). During the study, a total of 70 pancreas grafts were lost, with PCTY performed in 37 (53%). PCTY was directly related to the timing of graft loss; 77% of grafts lost within 3 months of PTX required PCTY, while 25% of grafts lost after 3 months resulted in PCTY (p<0.01). The incidence of graft failure resulting in PCTY was similar according to type of transplantation: SKPT (55%), PTA (46%), and PAKT (50%). The incidence of PCTY was also similar according to technique of transplantation: 26% S‐B versus 21% P‐E, p=NS. However, the incidence of graft failure resulting in PCTY was higher in P‐E (69%) versus S‐B (43%) (p<0.05) PTX recipients. Patient and kidney graft survival and pancreas retransplant graft survival rates were higher in PTX recipients with P‐E drainage.Conclusions: PCTY is performed in over half of cases of pancreas allograft loss and is directly related to the timing and cause of graft loss. The incidence of PCTY is neither related to the type nor technique of PTX. The lower overall incidence of graft loss after PTX with P‐E drainage is offset by a higher incidence of PCTY in these grafts that fail. These results suggest that whole‐organ PTX with P‐E drainage does not place the patient at an increased risk for PCTY and does not preclude successful pancreas retransplantation.

Impact of hepatitis C virus status in pancreas transplantation: a case controlled study

BACKGROUND Enteric drainage (ED) of pancreas allografts is an alternative to the bladder drainage (BD) technique and eliminates unique metabolic complications seen in the BD pancreas transplant recipients. Little longterm data has been reported in ED pancreas transplants. STUDY DESIGN Of 53 patients who underwent pancreas transplantations performed with ED drainage of the exocrine secretion to a Roux-en-Y limb, who had more than 6 months graft function, four patients were identified with late duodenal segment complications (more than 6 months after transplantation) and are presented as case reports. RESULTS The duodenal segment complications occurred between 8 and 48 months after simultaneous pancreas-kidney transplantation. Three patients were diagnosed with leakage from the duodenal segment. All were managed operatively. The fourth patient developed a distal stricture of the transplant duodenum occluding the anastomosis between the duodenum and the Roux-en-Y limb and also had a pancreatic pseudocyst. Drainage via a cyst-jejunostomy resulted in graft salvage. The mean followup after operative management of the duodenal-related complications was 15 months (range, 3-24 months). The patient, pancreas and kidney graft survival are 100%. CONCLUSIONS Late duodenal complications occurred in 8% of pancreas transplant recipients with ED. Operative intervention in all four patients resulted in excellent graft and patient outcome and is recommended for these complications.

Neuropsychiatric complications after liver transplantation: role of immunosuppression and hepatitis C.

Available data suggest that hepatitis C virus positive (HCV+) renal transplant patients may be at an increased risk of morbidity and mortality compared with HCV− patients. Limited data are available regarding the impact of HCV status in pancreas transplant patients. We compared the outcomes of 10 HCV+ patients undergoing pancreas transplantation (seven simultaneous kidney‐pancreas, one pancreas after kidney, two pancreas alone) between 1/96 and 10/99 with 20 HCV− recipients that were matched for age, race, gender, timing of transplant, type of pancreas transplant, and surgical technique. Length of follow‐up was not significantly different between the HCV+ group compared with the HCV− group (24 ± 14 vs. 20 ± 13 months; p=0.45). There was a trend toward a higher incidence of all cause mortality in HCV+ recipients compared with HCV− recipients, 30 vs. 10%, respectively (p=0.17). Additionally, the HCV+ recipients had a trend toward a higher incidence of sepsis‐related mortality compared with HCV− recipients, 20 vs. 5%, respectively (p=0.19). Renal allograft survival was 50% in the HCV+ group compared with 94% in the HCV− group (p=0.02). Pancreas allograft survival was not significantly different between the groups, 60 vs. 80%, respectively (p=0.24). At 3, 6, 12 months, and end of follow‐up, there were no differences in serum creatinine, amylase, C‐peptide, or fasting glucose levels. However, there was a significantly higher incidence of proteinuria at last follow‐up in the HCV+ recipients with a renal allograft when compared with HCV− recipients, 50 vs. 12.5%, respectively (p=0.05). In order to maintain comparable glycemic control between the groups, there was a significant increase in oral hypoglycemic requirement in HCV+ recipients compared with HCV− recipients, 33 vs. 0%, respectively (p=0.01). These data suggest that HCV+ pancreas transplant patients may be at an increased risk of graft dysfunction and morbidity. Further studies with more patients and longer follow‐up are needed to fully define the impact of HCV status on pancreas graft survival and function.