Marwan Kazimi

Recurrence of non-alcoholic steatohepatitis and cryptogenic cirrhosis following orthotopic liver transplantation in the context of the metabolic syndrome.

Non‐alcoholic steatohepatitis (NASH) and cryptogenic cirrhosis (CC) are increasing indications for orthotopic liver transplantation (OLT). The aim of this study is to describe our outcomes and delineate predictors of recurrence of NASH and CC after OLT.

Mini‐incision right hepatic lobectomy with or without laparoscopic assistance for living donor hepatectomy

Minimally invasive procedures are considered to be safe and effective approaches to the management of surgical liver disease. However, this indication remains controversial for living donor hepatectomy. Between 2000 and 2011, living donor right hepatectomy (LDRH) was performed 58 times. Standard right hepatectomy was performed in 30 patients via a subcostal incision with a midline extension. Minimally invasive procedures began to be used for LDRH in 2008. A hybrid technique (hand‐assisted laparoscopic liver mobilization and minilaparotomy for parenchymal dissection) was developed and used in 19 patients. In 2010, an upper midline incision (10 cm) without laparoscopic assistance for LDRH was innovated, and this technique was used in 9 patients. The perioperative factors were compared, and the indications for minimally invasive LDRH were investigated. The operative blood loss was significantly less for the patients undergoing a minimally invasive procedure versus the patients undergoing the standard procedure (212 versus 316 mL, P = 0.001), and the operative times were comparable. The length of the hospital stay was significantly shorter for the minimally invasive technique group (5.9 versus 7.8 days, P < 0.001). The complication rates were 23% and 25% for the standard technique and minimally invasive technique groups, respectively (P = 0.88). Patients undergoing minilaparotomy LDRH had a body mass index (24.0 kg/m2) similar to that of the hybrid technique patients (25.8 kg/m2, P = 0.36), but the graft size was smaller (780 versus 948 mL, P = 0.22). In conclusion, minimally invasive LDRH can be performed without safety being impaired. LDRH with a 10‐cm upper midline incision and without laparoscopic assistance may be appropriate for donors with a smaller body mass. Laparoscopic assistance can be added as needed for larger donors. This type of LDRH with a 10‐cm incision is innovative and is recommended for experienced centers. Liver Transpl 18:1188–1197, 2012.

Left renal vein ligation: A technique to mitigate low portal flow from splenic vein siphon during liver transplantation

Low portal vein flows in liver transplant have been associated with poor allograft survival. Identifying and ameliorating causes of inadequate portal flow is paramount. We describe successful reversal of significant splenic vein siphon from a spontaneous splenorenal shunt during liver transplant. The patient is a 43‐year‐old male with cirrhosis from hepatitis C and Budd–Chiari syndrome, who had a variceal hemorrhage necessitating an emergent splenorenal shunt with 8 mm PTFE graft. Imaging in 2006 revealed thrombosis of the splenorenal shunt and evidence of a new spontaneous splenorenal shunt. The patient developed hepatocellular carcinoma and underwent transplant in 2009. After reperfusion, portal flows were low (150–200 mL/min). A mesenteric varix was ligated without improvement. Due to adhesions, direct collateral ligation was not attempted. In order to redirect the splenic siphon, the left renal vein was stapled at its confluence with the inferior vena cava. Portal flows subsequently increased to 1.28 L/min. Postoperatively, the patient had stable renal and liver function. We conclude that spontaneous splenorenal shunts can cause low portal flows. A diligent search for shunts with understanding of flow patterns is critical; ligation or rerouting of splanchnic flow may be necessary to improve portal flows and allograft outcomes.

Intrahepatic Cholangiocarcinoma in the Liver Explant After Liver Transplantation: Histological Differentiation and Prognosis

BACKGROUND The aim of this study was to evaluate the outcome of patients with intrahepatic cholangiocarcinoma (ICCA) incidentally found in the explanted liver after liver transplantation. MATERIAL AND METHODS We retrospectively reviewed 1188 recipients undergoing liver transplantation from August 2003 to August 2014; 13 patients were found to have ICCA (1.1%). Recurrence-free survival (RFS) rate was compared between ICCA patients and the matched cohort of 39 patients with hepatocellular carcinoma (HCC). We also investigate the relevance of clinical and pathological parameters in recurrence of ICCA. RESULTS ICCA patients showed significantly higher recurrence rate with lower 1-year and 3-year RFS rates than HCC patients (recurrence rate, 12.8% vs. 54.8%; 1-year and 3-year RFS rates, 94% and 84% vs. 67% and 42%). Of the 13 ICCA patients, 4 were diagnosed with a well-differentiated ICCA and 9 with a moderately-differentiated ICCA. There was no recurrence among those with a well-differentiated ICCA, whereas 78% recurred in the moderately-differentiated group. The median RFS time for the moderately-differentiated group was 13.0 months, yielding RFS rates of 56% at 1 year and 22% at 3 years. CONCLUSIONS Liver transplantation in patients with a well-differentiated ICCA yielded excellent outcomes as compared to patients with a moderately-differentiated ICCA. This may allow consideration of transplantation in the setting of a well-differentiated ICCA, and obviate the need for adjuvant systemic treatment. Conversely, a moderately-differentiated ICCA carries a poor prognosis with a prohibitively high recurrence rate and poor survival. Liver transplantation should remain a contraindication in this group.

Deep Vein Thrombosis and Pulmonary Embolism in Liver Transplant Patients: Risks and Prevention.

Introduction Deep vein thrombosis (DVT) and pulmonary embolism (PE) are surgical complications estimated to occur in 5% to 10% of patients. There are limited data regarding DVT/PE in the early postoperative period in liver transplant patients. The aim of this study is to determine risk factors that influence the incidence of DVT/PE and the effectiveness of prophylaxis. Methods We reviewed the records of 999 patients who underwent initial liver transplant between January 2000 and June 2012 at Henry Ford Hospital. In 2011, a standardized prophylactic regimen using subcutaneous (SQ) heparin was initiated. All patients that developed either upper/lower extremity DVT or PE within the first 30 days of transplant formed the cohort of this study. Results On multivariate analysis, only peripherally inserted central catheter (PICC) placement and SQ heparin were associated with DVT/PE. In patients receiving heparin, 3 (1.0%) had DVT/PE versus 25 (3.5%) who did not receive heparin (P = 0.03). Sixteen (6.9%) patients that had a PICC developed DVT/PE compared with 12 (1.6%) patients without a PICC (P < 0.001). In the heparin group, DVT/PE with PICC was reduced to 3 (3.0%) versus 13 (9.9%) in those with a PICC and did not receive heparin (P = 0.03). Mean time from transplant to DVT/PE diagnosis was 12.3 days. Length of hospitalization was significantly longer in patients who developed DVT/PE (18.5 vs 10.0 days, P < 0.001). Conclusions In this study, we demonstrated that PICC placement significantly increases the likelihood of DVT/PE in liver transplant recipients. Prophylactic SQ heparin effectively reduced DVT/PE events in this patient population.

Emergent nonconventional mesosystemic shunt for diffuse portomesenteric thrombosis: sparing patients from liver/multivisceral transplantation.

The surgical treatment of gastrointestinal bleeding resulting from portomesenteric thrombosis can vary and is quite difficult to standardize. Technical challenges are mostly related to wide variations in the venous anatomy and hemodynamic patterns, which dictate the most suitable procedure for collateral decompression. In this setting, surgical shunts have played a major role in the management of patients with portal hypertension and bleeding gastrointestinal varices. Another option for diffuse mesenteric thrombosis is organ transplantation. However, this is a major undertaking in which the recipient’s portomesenteric venous system is completely replaced via multivisceral transplantation. Vianna et al. reported 25 patients with diffuse portomesenteric thrombosis who underwent multivisceral transplantation. They concluded that multivisceral transplantation can be considered when patients experience repeated lifethreatening episodes of gastrointestinal bleeding after all other medical and surgical options have been exhausted. However, the indication of liver or multivisceral transplantation for patients without cirrhosis who have portomesenteric thrombosis remains controversial. We report a patient who had idiopathic, diffuse splenoportomesenteric thrombosis requiring splenectomy and gastric devascularization followed by emergent surgical mesosystemic shunts using saphenous and gonadal veins. This report suggests pursuing a unique surgical idea to spare patients from organ transplantation.

Transjugular intrahepatic portosystemic shunt following liver transplantation: can outcomes be predicted?

El Atrache M, Abouljoud M, Sharma S, Abbass AA, Yoshida A, Kim D, Kazimi M, Moonka D, Brown K. Transjugular intrahepatic portosystemic shunt following liver transplantation: can outcomes be predicted?

Thrombolysis of portal vein thrombosis after splenectomy following liver transplantation

Splenectomy is indicated after orthotopic liver transplantation (OLT) for various reasons, including leftsided portal hypertension, trauma, and hemorrhage prevention in patients with splenic artery aneurysms. Complications of splenectomy may include infections, bleeding, and portal vein thrombosis (PVT). The incidence of symptomatic postsplenectomy PVT ranges from 0.7% to 2%, whereas the incidence of asymptomatic PVT can reach 7% to 10%. There is, however, limited literature pertaining to postsplenectomy PVT in recipients of OLT. The sequelae of PVT are particularly serious in OLT recipients. The reduction of the portal vein flow severely compromises allograft and patient survival. In patients who have not undergone OLT, acute portal or mesenteric vein thrombosis is usually managed with anticoagulation alone, and this leads to recanalization in more than 90% of patients. Alternatively, thrombolysis or thrombectomy is performed, but this has not been widely reported and is not the standard of care. There are few studies addressing the management of postsplenectomy PVT in OLT recipients. Here we describe a case of acute postsplenectomy PVT in an OLT recipient who was successfully treated with both mechanical thrombolysis and directed and systemic anticoagulation. The patient was a 54-year-old male who suffered from end-stage liver disease secondary to complications from hepatitis C and alcohol abuse. He underwent OLT on March 5, 2007. The piggyback technique was used with a biliary duct-to-duct anastomosis. The operation and the postoperative course both went well without complications. Approximately 2 years later, he presented with increasing left upper quadrant pain. A computed tomography (CT) scan revealed an enlarged spleen with a calcified cyst that measured 17 cm. Therapeutic options were discussed with the patient, and splenectomy was planned. He received subcutaneous heparin perioperatively as deep venous thrombosis prophylaxis. The operation lasted 2 hours and was performed through an extension of the left subcostal incision from the initial OLT. An Endo GIA stapler was used to divide the hilum. Pathology revealed a 960-g spleen measuring 18.2 cm 3 14.3 cm 3 10.2 cm with capsular fibrosis indicating perisplenitis. Postoperative laboratory tests revealed a 5-fold rise in transaminase levels. An ultrasound examination of the liver was performed and revealed an absence of flow in the portal vein. Dual-phase CT of the liver showed complete thrombosis of the splenic and portal veins with extension into both right and left portal vein branches. The superior mesenteric vein was spared. An intravenous infusion of heparin was initiated. Complete thrombosis of the intrahepatic portal vein branches precluded percutaneous transhepatic cannulation of the portal system. The patient was taken immediately to the operating room in an attempt to salvage the hepatic allograft. A peripheral mesenteric venous branch was located and cannulated with a 5-Fr Fogarty catheter. An initial portogram confirmed the CT finding and revealed complete thrombosis of the main portal vein with some residual flow within the intrahepatic branches (Fig. 1A). Thrombectomy of the main portal vein was attempted via the catheter. With the assistance of interventional radiology, an infusion catheter was placed. Tissue plasminogen activator (t-PA) was injected through the catheter at a rate of 2.5 mg every 15 minutes. After the administration of a total of 16 mg of t-PA, only partial recanalization of the main portal vein was achieved (Fig. 1B). The catheter was withdrawn, the venotomy was ligated, and the abdomen was closed. The patient was extubated and then monitored in the intensive care unit. A postoperative ultrasound examination demonstrated no flow in the portal system. A follow-up CT scan revealed a filling defect in the portal vein and