P. Muiesan

Transplantation of Declined Liver Allografts Following Normothermic Ex-Situ Evaluation.

The demand for liver transplantation (LT) exceeds supply, with rising waiting list mortality. Utilization of high‐risk organs is low and a substantial number of procured livers are discarded. We report the first series of five transplants with rejected livers following viability assessment by normothermic machine perfusion of the liver (NMP‐L). The evaluation protocol consisted of perfusate lactate, bile production, vascular flows, and liver appearance. All livers were exposed to a variable period of static cold storage prior to commencing NMP‐L. Four organs were recovered from donors after circulatory death and rejected due to prolonged donor warm ischemic times; one liver from a brain‐death donor was declined for high liver function tests (LFTs). The median (range) total graft preservation time was 798 (range 724–951) min. The transplant procedure was uneventful in every recipient, with immediate function in all grafts. The median in‐hospital stay was 10 (range 6–14) days. At present, all recipients are well, with normalized LFTs at median follow‐up of 7 (range 6–19) months. Viability assessment of high‐risk grafts using NMP‐L provides specific information on liver function and can permit their transplantation while minimizing the recipient risk of primary graft nonfunction. This novel approach may increase organ availability for LT.

Long-term follow-up after endovascular treatment of hepatic venous outflow obstruction following liver transplantation.

Hepatic venous outflow obstruction (HVOO) is a rare complication after liver transplantation (LT) associated with significant morbidity and reduced graft survival. Endovascular intervention has become the first‐line treatment for HVOO, but data on long‐term outcomes are lacking. We have analysed outcomes after endovascular intervention for HVOO in 905 consecutive patients who received 965 full‐size LT at our unit from January 2007 to June 2014. There were 27 (3%) patients who underwent hepatic venogram for suspected HVOO, with persistent ascites being the most common symptom triggering the investigation (n = 19, 70%). Of those, only 10 patients demonstrated either stricture or pressure gradient over 10 mmHg on venogram, which represents a 1% incidence of HVOO. The endovascular interventions were balloon dilatation (n = 3), hepatic vein stenting (n = 4) and stenting with dilatation (n = 3). Two patients required restenting due to stent migration. The symptoms of HVOO completely resolved in all but one patient, with a median follow‐up period of 74 (interquartile range 39–89) months. There were no procedure‐related complications or mortality. In conclusion, the incidence of HVOO in patients receiving full‐size LT is currently very low. Endovascular intervention is an effective and safe procedure providing symptom relief with long‐lasting primary patency.

Outcomes after liver transplantation of patients with Indo-Asian ethnicity.

Background The impact of ethnicity on outcomes after orthotopic liver transplantation (OLT) is unclear. The British Indo-Asian population has a high incidence of liver disease but its contribution to the national deceased donor pool is small. We evaluated access to and outcomes of OLT in Indo-Asians. Methods We compared 182 Indo-Asians with white patients undergoing OLT. Matching criteria were transplantation year, liver disease, age, sex. Donor and recipient characteristics, postoperative outcomes, including patient and graft survival, OLT era (early, 1987–2001; late, 2002–2011) were compared. Survival was also analyzed by underlying disease—acute liver failure (ALF) and chronic liver failure. Results Indo-Asians had higher diabetes incidence. There were no differences in waiting time for transplantation, despite smaller body size and more uncommon blood groups (B, AB) among Indo-Asians. In the early era, patient survival for Indo-Asians with ALF was worse when compared to whites. In the late era, graft and patient survival at 1, 2, and 5 years were similar between groups. Conclusion This study demonstrates that Indo-Asian patients have equal access to OLT and comparable outcomes to whites in the United Kingdom. Survival has improved among Indo-Asian patients; this may be attributable to careful patient selection in case of ALF, though improvement of patient management may have contributed.

The rate of false-positive diagnosis of colorectal liver metastases in patients undergoing resection with the development of a novel, externally validated risk score

Background: Diagnostic error in patients undergoing resection of colorectal liver metastases (CRLM) is unusual but exposes patients to unnecessary risks associated with treatment. The primary aim of this study was to determine the rate of and risk factors for a false‐positive diagnosis of colorectal liver metastases in patients undergoing hepatic resection. The secondary aim was to develop and validate a risk score to predict a false‐positive diagnosis. Methods: Patients were identified from prospectively maintained databases. Patients who underwent a first liver resection for presumed colorectal liver metastases were divided into 2 groups: CRLMPOS (colorectal liver metastases present on histology or appearance of complete pathologic response to preoperative chemotherapy) and CRLMNEG (all others). Univariable analysis and multivariable binary logistic regression were used to identify risk factors for CRLMNEG. Risk scores were developed for CRLMNEG both with and without the use of preoperative carcinoembryonic antigen and were validated on an external cohort. Results: 3.1% of patients in both test and validation cohorts were CRLMNEG (39/1,252 and 59/1,900, respectively). CRLMNEG patients had fewer (P=.006) and smaller lesions (P < .001) with lower serum levels of carcinoembryonic antigen (P < .001), T (P=.031) and N (P < .001) and a lower Dukes’ stage of the primary (P < .001). The risk score performed well (area under the receiver operating characteristic curve 0.869; standard error=0.030; P < .001) with reasonable performance on validation (area under receiver operating characteristic curve 0.743; standard error=0.058; P < .001]). Conclusion: A false‐positive diagnosis of colorectal liver metastases affected the same proportion of patients in 2 unrelated cohorts. This study identified risk factors for false‐positive diagnosis with development of a novel risk score supported by external validation.

Pancreatoduodenectomy for periampullary cancer and biliary obstruction: impact of a pathway to avoid preoperative biliary drainage

Abstract Background Randomised trials have shown that preoperative biliary drainage (PBD) causes more harm than a straight to surgery approach for patients with jaundice and periampullary malignancy. However, it remains standard practice in many centres for jaundiced patients to undergo PBD. The aim of this study was to review the impact of a pathway to avoid PBD before pancreatoduodenectomy on clinical outcomes. Methods A pathway to avoid PBD was implemented at the start of the study period (August, 2015). A dedicated nurse specialist and surgeon visited each referring trust to raise awareness of the pathway. Inclusion criteria were patients with resectable periampullary cancers and jaundice; patients were selected for surgery without PBD if they had not undergone PBD before referral and bilirubin concentration did not exceed 450 μmol/L. Time from initial CT scan to referral to multidisciplinay team discussion to specialist clinic and surgery were recorded. Findings Over 12 months, 61 and 32 patients underwent pancreatoduodenectomy with and without PBD, respectively. 58 patients in the PBD group (95%) had undergone PBD before referral. There was no difference in demographic data or tumour types between the two groups. The duration of key intervals from referral to surgery were all shorter in the no PBD group than in the PBD group (median total duration 16 days [IQR 8–39] vs 65 [9–181], p vs 46/61, p=0·009) and venous resection (10/31 vs 4/46, p=0·014) in the no PBD group than in the PBD group. The sensitivity of initial staging CT for correctly staging resectable locally advanced disease was 91% and 50% in the no PBD and PBD groups, respectively (p=0·042). The accuracy of the initial CT scan to define locally advanced resectable disease was worse in the PBD group, presumably related to the difference in time between CT and surgery. Furthermore, average costs of treatment between presentation and surgery were £3178 cheaper in the no PBD group. Interpretation Early surgery to avoid PBD is possible within the National Health Service. By reducing the time to surgery more patients undergo potentially curative surgery and costs of treatment are reduced. An understanding about why surgery without PBD is not done routinely is needed, as is the development of strategies to support its more widespread practice. Funding Pancreatic Cancer UK.

Characterization of ischemic changes in small bowel after normothermic regional perfusion: Potential to consider small bowel grafts from DCD donors?

D after circulatory death (DCD) has been proven to be a useful source of organs when transplant waiting list requirements cannot be met by donations after brain death (DBD). DCD intestinal grafts are currently not regarded suitable for small bowel transplantation, due to dismal results in an animal model of DCD intestinal transplantation. DCD donors constitute up to 40% of the donor pool in countries that have adopted the use of DCD organs next to DBD, and are the sole source of postmortem organs in societies where the concept of brain death has not been accepted in organ donation. Normothermic regional perfusion (NRP) is a new technique that involves a period of in situ extracorporealmembrane oxygenation and aims to reverse deleterious effects of warm ischemia and to increase organ yield inDCDdonors (Figure 1A). Pilot results forNRP in liver, kidney, and pancreas transplantation are encouraging. Strikingly, in our experience of NRP, we noted vital bowel sustaining normal peristalsis throughout these procedures, and we hypothesize that NRP may potentially enable DCD small bowel transplantation. In a DCD donor, procurement of liver and kidneys with abdominal NRP and simultaneous cold perfusion of lungs was performed (approved byNovel Therapeutics Committee of Queen Elizabeth Hospital Birmingham, UK). Consent

Management of a pseudo-aneurysm in the hepatic artery after a laparoscopic cholecystectomy.

Introduction Symptomatic hepatic-artery pseudoaneurysm (HAP) after bile-duct injury (BDI) is a rare complication with a varied (but clinically urgent) presentation. Methods A prospectively maintained database of all patients with BDI at laparoscopic cholecystectomy (LC) referred to a tertiary specialist hepatobiliary centre between 1992 and 2011 was searched systematically to identify patients with a symptomatic HAP. Care and outcome of these patients was studied. Results Eight (6 men) of 236 patients with BDI (3.4%) with a median age of 65 (range: 54?6) years presented with symptomatic HAP. Median time of presentation of the HAP from the index LC was 31 (range: 13?16) days. Bleeding was the dominant presentation in 7 patients. One patient presented late (>2 years) with abdominal pain alone. Computed tomography angiography was the most useful investigation. Angioembolisation was successful in 7 patients. One patient died, and another patient developed liver infarction. Three patients (38%) developed biliary strictures after embolisation. Seven patients are alive and well at a median follow-up of 66 months. Conclusions Presentation of HAP is often delayed. A high index of suspicion is necessary for the diagnosis. Computed tomography angiography is the first-line investigation and selective angioembolisation can yield successful outcomes.