Robert R. Selby

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.

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.

A comparison of sirolimus vs. calcineurin inhibitor-based immunosuppressive therapies in liver transplantation

Background  Sirolimus is a potent immunosuppressive agent whose role in liver transplantation has not been well‐described.

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.

Blood-Management Programs: A Clinical and Administrative Model with Program Implementation Strategies

Any Israelite or any alien living among them who eats any blood—I will set my face against that person who eats blood and will cut him off from his people. For the life of a creature is in the blood, and I have given it to you to make atonement for yourselves on the altar; it is the blood that makes atonement for one’s life. Therefore I say to the Israelites, “None of you may eat blood, nor may an alien living among you eat blood.” —Leviticus 17:10, 12, Old Testament, New International 1

Pediatric liver transplantation for hepatocellular cancer and rare liver malignancies: US multicenter and single‐center experience (1981‐2015)

A tenth of all pediatric liver transplantations (LTs) are performed for unresectable liver malignancies, especially the more common hepatoblastoma (HBL). Less understood are outcomes after LT for the rare hepatocellular carcinoma, nonhepatoblastoma embryonal tumors (EMBs), and slow growing metastatic neuroendocrine tumors of childhood. Pediatric LT is increasingly performed for rare unresectable liver malignancies other than HBL. We performed a retrospective review of outcomes after LT for malignancy in the multicenter US Scientific Registry of Transplant Recipients (SRTR; n = 677; 1987‐2015). We then reviewed the Childrens Hospital of Pittsburgh (CHP; n = 74; 1981‐2014) experience focusing on LT for unresectable hepatocellular cancer (HCC), EMBs, and metastatic liver tumors (METS). HBL was included to provide reference statistics. In the SRTR database, LT for HCC and HBL increased over time (P < 0.001). Compared with other malignancies, the 149 HCC cases received fewer segmental grafts (P < 0.001) and also experienced 10‐year patient survival similar to 15,710 adult HCC LT recipients (51.6% versus 49.6%; P = 0.848, not significant [NS], log‐rank test). For 22 of 149 cases with incidental HCC, 10‐year patient survival was higher than 127 primary HCC cases (85% [95% confidence interval (CI), 70.6%‐100%] versus 48.3% [95% CI, 38%‐61%]; P = 0.168, NS) and similar to 3392 biliary atresia cases (89.9%; 95% CI, 88.7%‐91%). Actuarial 10‐year patient survival for 17 EMBs, 10 METS, and 6 leiomyosarcoma patients exceeded 60%. These survival outcomes were similar to those seen for HBL. At CHP, posttransplant recurrence‐free and overall survival among 25 HCC, 17 (68%) of whom had preexisting liver disease, was 16/25 or 64%, and 9/25 or 36%, respectively. All 10 patients with incidental HCC and tumor‐node‐metastasis stage I and II HCC survived recurrence‐free. Only vascular invasion predicted poor survival in multivariate analysis (P < 0.0001). A total of 4 of 5 EMB patients (80%) and all patients with METS (neuroendocrine‐2, pseudopapillary pancreatic‐1) also survived recurrence‐free. Among children, LT can be curative for unresectable HCC confined to the liver and without vascular invasion, incidental HCC, embryonal tumors, and metastatic neuroendocrine tumors. Liver Transplantation 23 1577–1588 2017 AASLD.

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.

Prospective study of therapeutic spiral enteroscopy in patients with surgically altered anatomy

BackgroundSpiral enteroscopy is rapidly emerging, along with double- and single-balloon enteroscopy, as a paramount method to evaluate lesions in the deep small bowel. While the latter two methods have been used to manage patients with surgically altered anatomy, there are few reports on the role of spiral enteroscopy in this group. Our principal aim was to characterize the therapeutic uses of spiral enteroscopy in patients with surgically altered anatomy.Methods and resultsPatients with surgically altered anatomy who failed management with conventional endoscopic methods for therapeutic indications were included in this prospective series at our tertiary referral center. The spiral technique was used to control variceal bleeding, dilate enteral anastomotic narrowing, and perform pancreaticobiliary interventions in seven patients. The cases were performed quickly and effectively and the need for surgery was obviated in all cases.ConclusionThe spiral enteroscopy system has significant therapeutic potential in patients with surgically altered anatomy.

Living related donor nephrectomy in transfusion refusing donors.

Many transplant programs are averse to evaluate potential kidney donors with preferences against accepting human blood products. We examined the donor and graft outcomes between our transfusion‐consenting (TC) and transfusion‐refusing (TR) live kidney donors to determine whether a functional or survival disadvantage resulted from the disallowance of blood product transfusion during live donor (LD) nephrectomy. From July, 1999 to August, 2005, 82 live donor nephrectomies were performed, eight of who were TR donors (10%). Blood conservation techniques were utilized in TR donors. Demographics, surgical and functional outcomes, admission and discharge hematocrit, and creatinine were compared between TC and TR donors. No donor mortalities occurred. Two TC donors received blood transfusions (2.7%), and each study group experienced a single, <1‐year graft loss. Intra‐operative blood losses were significantly less in TR donors (298 ± 412 vs. 121 ± 91 ml, P < 0.03). No differences were noted between donor demographics, intra‐operative events, and graft and patient survival. Successful donor nephrectomy from TR patients has the potential to expand the kidney allograft pool to include the TR donor population. Precautionary blood conservation methods allow the informed and consenting TR individual to donate a kidney with acceptable risk and without compromise to donor or graft outcomes.