Maria Stapfer

Risk Factors for Graft Survival After Liver Transplantation from Donation After Cardiac Death Donors: An Analysis of OPTN/UNOS Data

Due to increasing use of allografts from donation after cardiac death (DCD) donors, we evaluated DCD liver transplants and impact of recipient and donor factors on graft survival. Liver transplants from DCD donors reported to UNOS were analyzed against donation after brain death (DBD) donor liver transplants performed between 1996 and 2003. We defined a recipient cumulative relative risk (RCRR) using significant risk factors identified from a Cox regression analysis: age; medical condition at transplantation; regraft status; dialysis received and serum creatinine. Graft survival from DCD donors (71% at 1 year and 60% at 3 years) were significantly inferior to DBD donors (80% at 1 year and 72% at 3 years, p < 0.001). Low‐risk recipients (RCRR ≤ 1.5) with low‐risk DCD livers (DWIT < 30 min and CIT < 10 h, n = 226) achieved graft survival rates (81% and 67% at 1 and 3 years, respectively) not significantly different from recipients with DBD allografts (80% and 72% at 1 and 3 years, respectively, log‐rank p = 0.23). Liver allografts from DCD donors may be used to increase the cadaveric donor pool, with favorable graft survival rates achieved when low‐risk grafts are transplanted in a low‐risk setting. Whether transplantation of these organs in low‐risk recipients provides a survival benefit compared to the waiting list is unknown.

Donor‐derived Coccidioides immitis fungemia in solid organ transplant recipients

We report disseminated coccidioidomycosis in 3 transplant recipients from a donor in an endemic area found to have unrecognized meningeal coccidioidomycosis. All 3 transplant recipients presented within 3 weeks of receipt of their organ. Only 1 organ recipient survived the acute presentation of coccidioidomycosis. Serologic testing for Coccidioides immitis infection should be considered for organ donors residing in endemic areas.

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.

Transfusion-free techniques in pediatric live donor liver transplantation

Patients of the Jehovah’s Witness faith are unwilling for religious reasons to accept transfusion with blood or blood products. In pediatric patients of the Jehovah’s Witness faith, blood products can be used under court mandate if deemed medically imperative. However, transfusion under court order is obviously fraught with concerns for physicians and parents. This report describes medical and surgical techniques that have been used to avoid transfusion in adult Jehovah’s Witness patients and their successful use in two pediatric patients undergoing liver transplantation (1).

Left Extended Hepatectomy for a Metastatic Gastrointestinal Stromal Tumor After a Disease-Free Interval of 17 Years: Report of a Case

Gastrointestinal stromal tumors (GISTs), although rare, are frequently diagnosed with liver metastasis. These metastatic GISTs are poorly responsive to conventional chemotherapy; however, recent studies report improved survival after complete surgical resection of liver metastases. On the other hand, few reports describe the treatment of delayed liver metastasis after resection of a primary GIST. We report the case of a 55-year-old woman found to have liver metastasis from a GIST after a 17-year disease-free interval. The patient underwent a left extended hepatectomy for a complete resection of the metastatic GIST and is alive and well 30 months later. To our knowledge, this is the longest disease-free interval reported in the literature, and emphasizes the importance of considering late metastasis when evaluating patients with a history of GIST. Thus, surgical resection of delayed liver metastasis from a GIST should be considered as primary therapy.

Alternate method to secure the aorta for organ perfusion in donation after cardiac death donors

We read with interest, a method described by Nguyen [1], for rapidly controlling the aorta during organ procurement in donation-after-cardiac-death (DCD) donors. In a similar attempt to minimize the warm ischemia time during a controllable portion of the procurement, we employ a technique for securing a cannulated distal aorta with the use of a releasable cable tie (Fig. 1a). After entrance into the abdomen, the small bowel is displaced cephalad, the distal para-aortic retroperitoneum is incised with the tip of a right-angle clamp, and the aorta is encircled with the tip of the clamp. The clamp is rotated 90 caudad to allow for anterior–posterior displacement of the tip, which is then used to pull the tip of the cable tie through behind the aorta. The cable tie tip is fed into the head to loosely encircle the aorta and is raised to lift the aorta off the retroperitoneum, thus allowing for an aortotomy to insert and position the cannula. Once the cannula is intraluminal, it is positioned for the tip to lie within the cable tie loop. The cable tie is then tightened securely over the aorta and cannula (Fig. 1b). The cable tie used is approximately 20 cm. in length, made from heavy-duty nylon, has a maximum bundle diameter of 44.5 mm, and a tensile strength over 20 kg. Each tie is adjustable, and can accommodate any aortic (and/or cannula) circumference, while the broader area of contact from the band negates the necessity for a cuffed cannula in DCD donors. The ratchet-locking teeth can be released if repositioning is needed, and the band allows for an evenly distributed grip around the aorta, which becomes more useful and effective in donors with moderate to severely atherosclerotic aortas (umbilical tapes can fracture or tear friable aortic walls and clamps can leave gaps between plaques), in obese donors with moderate peri-aortic fat, and in instances where the cannula is significantly smaller than the aorta in diameter. Compared with the use of surgical clamps, e.g. Babcock or Cooley caval occlusion clamps, cable ties are less obtrusive after placement because of its small size and compliance, in particular when small bowel and its mesentery are replaced in the lower abdomen. We initially applied this technique during procurements on stable donation-after-brain-death donors when no assistants were available, as it can be performed singlehandedly. Its success has led us to apply it in case of DCD procurements, and we believe it to have advantage over other methods for securing the aortic cannula (e.g. umbilical tapes, Rumel tourniquets) under atypical conditions. No cannula displacements have been noted after 27 consecutive applications, and our mean incision-to-perfusion time in DCD donors is 4.4 ± 1.1 min.

CAN WE EXPAND LIVER DONOR POOL USING DONATION AFTER CARDIAC DEATH IN THE UNITED STATES?: 2090

Introduction. For patients with end-stage liver disease, liver transplantation is life-saving procedure. In efforts to increase donor pool, the annual number of liver transplants using grafts from donation after cardiac death (DCD) donors has been increasing. This study evaluates the outcome of recent DCD liver transplants in the United States and the potential risk factors that affect graft outcome. Materials and Methods: From January 1, 2002 to December 31, 2008, 36,076 deceased donor (DD) liver transplants were reported to the OPTN/UNOS as of May 2009. We excluded recipients younger than 18 years old, multiple organ transplant, or split liver transplant. Of these, 34,642 donation after brain death (DBD) and 1,434 DCD liver transplants were identified. The outcome of DCD liver transplants was compared with those of DBD. The multivariate analyses were performed using the Cox regression model. The log-rank test was used for comparison of two survival curves. Results: Overall (unadjusted) graft survival rates of DCD (76.1% at 1-yr, 62.9% 3-yr, and 55.6% 5-yr) were significantly inferior to those of DBD (83.7% at 1-yr, 74.0% 3-yr, and 66.9% 5-yr, log-rank P<0.001). However, overall patient survival rates of DCD (86.0% at 1yr, 75.7% 3-yr, and 72.1% 5-yr) were slightly lower than those of DBD (87.7% at 1-yr, 79.0% 3-yr, and 72.3.% 5-yr, log-rank P=0.025). Incidence of primary graft failure was 5.4% for DCD compared with 3.1% for DBD (P<0.001). Incidence of biliary tract complication observed in recipients of DCD (3.8%) was significantly higher than that of DBD (0.8%, P<0.001). In table, longer cold ischemia time (CIT) and higher MELD score resulted in more deleterious effect on graft survival of DCD liver transplants compared with those of DBD group (CIT>12, RR=1.69 for DCD vs 1.22 DBD; MELD>30, RR=1.60 for DCD vs 1.40 DBD). Conclusion: Liver allografts from DCD donors may be used to increase the cadaveric donor pool especially if these grafts are transplanted in a low-risk setting such as shorter cold ischemia time and for urgent patients with low MELD score. Table. Results of Cox Regression Analyses

Management of duodenal perforation after endoscopic retrograde cholangiopancreatography

ObjectiveTo evaluate the authors’ experience with periduodenal perforations to define a systematic management approach. Summary Background DataTraditionally, traumatic and atraumatic duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical management, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a selective approach have not elaborated distinct management guidelines. MethodsA retrospective chart review at the authors’ medical center from June 1993 to June 1998 identified 14 instances of periduodenal perforation related to endoscopic retrograde cholangiopancreatography (ERCP), a rate of 1.0%. Charts were reviewed for the following parameters: ERCP findings, clinical presentation of perforation, diagnostic methods, time to diagnosis, radiographic extent and location of duodenal leak, methods of management, surgical procedures, complications, length of stay, and outcome. ResultsFourteen patients had a periduodenal perforation. Eight patients were initially managed conservatively. Five of the eight patients recovered without incident. Three patients failed nonsurgical management and required extensive procedures with long hospital stays and one death. Six patients were managed initially by surgery, with one death. Each injury was evaluated for location and radiographic extent of leak and classified into types I through IV. ConclusionsClinical and radiographic features of ERCP-related periduodenal perforations can be used to stratify patients into surgical or nonsurgical cohorts. A selective management scheme is proposed based on the features of each type.