Rod Mateo

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.

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.

Cadaveric organ donor recruitment at Los Angeles County Hospital: improvement after formation of a structured clinical, educational and administrative service

Abstract: Background/Aims: There remains a critical shortage of cadaveric organs. At a large inner city level one trauma centre, several strategies were devised and combined to (a) optimize the physiologic status of potential donors, (b), promote awareness of the donation process among health care professionals and (c) perform quality control on the organ donation system − all in an effort to improve organ donation rates. Resuscitative and maintenance protocols were devised and implemented through a multidisciplinary team approach for patients diagnosed with brain death. We report the effect this approach has had on organ donation in a single centre.

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.

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.

Donation after cardiac death and liver transplantation.

Purpose of reviewThis review discusses recent results and analyses on the use of donation after cardiac death (DCD) allografts in liver transplantation, including outcomes based on donor and recipient risk stratification, as well as associated postoperative complication rates. Recent findingsOutcomes from the use of DCD donors can be improved with selective and appropriate donor–recipient pairings, although the optimum combination remains undetermined. Older DCD donors can be utilized, and arguments are presented for withdrawal of life support processes in the intensive care unit rather than in the operating room. SummaryIncreasing the donor pool for liver transplantation is required to prevent many of the deaths that occur while the patient is on the wait list. Under specific conditions, many studies report positive outcomes from of the use of DCD donors for liver transplantation.

Donor organ preservation effects on the recipient.

The objective of preservation studies is to extend storage times and to minimize ischemic and reperfusion injury in the harvested organ. Clinical studies compare different perfusates and preservation techniques for liver, kidney, pancreas, small bowel, heart, and lung allografts. Although advances in preservation solutions and methods continue to result in outcome improvements for the recipient, the impact of prolonged cold ischemia times and the importance of minimizing its negative effects should not be overlooked.