U. Maggi

Fifteen years and 382 extended right grafts from in situ split livers in a multicenter study: Are these still extended criteria liver grafts?

In situ split liver extended right grafts (SL‐ERGs) are still considered marginal grafts. Our aim was to verify this statement at the present time. From 1997 to 2011, a multicenter, retrospective study based on a prospective database was performed at 9 liver transplantation (LT) centers in northern Italy; it included 382 in situ SL‐ERG transplants in adults. There were 358 primary LTs and 24 retransplantations (RETXs). The 1‐, 3‐, and 5‐year overall graft survival rate for LT with in situ SL‐ERGs were 73.5%, 63.3%, and 60.7%, respectively, from 1997 to 2004 and 83.5%, 80.3%, and 80.3%, respectively, thereafter (Pu2009=u20090.0001). A shorter total ischemia time and fewer RETX grafts were the main differences between the characteristics of the 2 periods. From 1997 to 2011, the 1‐, 3‐, and 5‐year graft survival rates showed a significant difference between the 358 primary LT in situ SL‐ERGs and the 24 RETX in situ SL‐ERGs (Pu2009<u20090.001). In a multivariate analysis, the main prognostic factor for 60‐day graft survival was a total ischemia timeu2009<u20098 hours for the 358 primary in situ SL‐ERGs. From 2005 to 2011, in 2473 LTs, the 5‐year graft survival for 184 in situ SL‐ERGs and 2289 whole grafts was 75% and 80% (Pu2009=u20090.3), respectively. Univariate and multivariate studies alike failed to indicate that the type of graft was a prognostic factor for graft survival. A donor ageu2009>u200960 years, RETX grafts, and urgency were the main prognostic factors for failure for all of the grafts. Although caution should be taken regarding the choice of appropriate donors, in situ SL‐ERGs should no longer be considered marginal grafts for experienced LT centers. SL‐ERGs should not be used in RETX settings, and when SL‐ERGs are used as primary grafts, the total ischemia time should be less than 8 hours. Liver Transpl 21:500‐511, 2015.

Hypoperfusion of segment 4 in right in situ split-liver transplantation.

To expand the donor pool, split-liver transplantation has been implemented in recent years. In the classic technique, the arterial axis with the artery for segment 4 (S4) coming from the left hepatic artery (HA) is included with the right graft. To give a surgical advantage to pediatric recipients in our center, the left HA, the common HA, and the celiac trunk are generally retained with the left liver. Thus the artery for S4 is sacrificed. We compared the outcomes of S4 in 290 whole grafts (WG; group A) with 28 right in situ split-liver grafts (SSLG; group B), which were transplanted over the past 10 years (January 1999-December 2009). The rates of major biliary and of hemorrhagic complications were similar. In most of cases (16/24, 66%) S4, on computerized tomographic scan appeared to show signs of hypoperfusion, sometimes with a peripheral aspect of hyperperfusion in the arterial phase. S1 showed signs of hypoperfusion in only 2 cases. A biliary collection near the resection line present in 8 cases was treated in 6 of them with percutaneous drainage and in 2 with laparotomy. These complications did not influence graft or patient survival. Graft survivals at 1, 5, and 10 years for WG and SSLG were not different among the groups: 85%, 74%, and 66% vs 89%, 79%, and 63%, respectively (P = .8). Although our technique cannot be considered to be anatomically correct, the ischemia of S4 did not influence the outcome. The rate of retransplantations for hepatic artery thrombosis was 17.9% in RSSG and 3.4% in WG (P = .001), which was probably due at least in part to the insertion of interposition grafts.

Portal Vein Arterialization for Hepatic Artery Thrombosis in Liver Transplantation: A Case Report, Doppler-Ultrasound Aspects, and Review of the Literature

Portal vein arterialization (PVA) is a salvage procedure for insufficient hepatic arterial or portal vascularization. It plays a role in auxiliary and orthotopic liver transplantation (OLT). In OLT, current indications for PVA include hepatic artery thrombosis (HAT), pre-OLT or post-OLT extended splanchnic vein thrombosis, intraoperative low portal flow, and anatomic variations like the absence of portal and mesenteric veins. Out of the transplantation domain, PVA is used both in extensive surgery for malignancies of the liver, biliary tract, and pancreas and in the treatment of fulminant hepatic failure (FHF) due to intoxications. We describe a case of acute post-OLT HAT successfully treated with PVA as a short bridge to retransplantation. By Doppler ultrasound of clinical PVA we detected an increased intrahepatic portal flow velocity, with disappearance of the arterial spikes, a finding that needs further investigation. PVA represents a rare surgical procedure. In fact, it has been used most of all in urgent conditions or in case of abrupt vascular complications during surgery. According to the literature, PVA emerges as a salvage procedure for poor arterial or portal hepatic flow, both in OLT and in general abdominal surgery. The outcome of this procedure is unpredictable. The aim of the shunt is to gain time, awaiting the onset of collateral arterial vessels or the performance of definitive surgery. Its early thrombosis may be a catastrophic event, due to acute liver ischemia. In contrast, a late occlusion is often well tolerated. Strict surveillance is always useful because sometimes it is mandatory to embolize the arterioportal fistula to treat or to prevent the onset of portal hypertension.

Post‐hepatitis primary disease does not influence 6‐year survival after liver transplantation beyond 1 year

Abstract Orthotopic liver transplantation (OLT) is used as a definitive treatment for enD‐stage liver disease and prolonged posttransplant survival has already been reported. The incidence of late mortality and graft morbidity is, however, not well defined and the role of primary viral disease in the long‐term follow‐up results is not clear. Data of posttransplant follow‐up in 213 patients, 156 adults and 57 children, who survived at least 1 year were reviewed in order to define causes of graft dysfunction, graft loss and death. In 98 patients, 103 persistent graft dysfunctions were found. Thirty‐four grafts were later lost [28 deaths and 6 successful re‐transplantations (re‐OLT)]. The results were reviewed grouping patients according to their age and viral hepatitis status at the time of the transplantation. HBV‐positive patients (51) showed 4 re‐OLT (1 HBV), 3 liver‐related deaths (2 HBV), 24 graft dysfunctions (8 HBV, 5 HCV), and 85.2% 6‐year survival (based on 100% survival at 1 year). HCV‐positive adults (28) showed 1 re‐OLT, 3 HCV‐related deaths, 24 graft dysfunctions (19 HCV), and 68.8 % 6‐year survival. HBV‐HCV‐positive patients (14) showed no graft loss and death, 10 graft dysfunctions (7 HCV, 1 HBV, 2 HBV‐HCV), and 81.8 % 6‐year survival. HBV‐HCV‐negative adults (63) showed 3 non‐hepatitis‐related re‐OLT, 5 liver‐related deaths (2 HCV), 24 graft dysfunctions (6 HCV, 2 HBV), and 83.1 % 6‐year survival. HBV‐HCV‐negative children (49) showed no re‐OLT, 1 HCV‐related death, 14 graft dysfunctions (3 HCV), and 92.6% 6‐year survival. HCV‐positive children (8) showed 1 HCV‐related re‐OLT, 2 HCV‐related deaths, 4 graft dysfunctions (3 HCV), and 81.3% 6‐year survival. The main cause of graft dysfunction was hepatitis (45 HCV and 13 HBV), followed by technical complications (21), rejection (16), recurrent alcoholism (3), HIV infection (1), and unknown causes (4). In this long‐term post‐transplant follow‐up series, viral hepatitis led to graft dysfunction in 58/103 (56.3%) cases, late graft failure was viral hepatitis‐related in 11/20 (55 %) cases, and, as a total, HCV infection was present in 45/58 (77.5 %) cases of viral hepatitis‐related graft damage. Looking at the timing of hepatitis‐related graft failure, in 70% of cases death occurred after the 5th post‐transplant year. In our experience, the occurrence of hepatitis, particularly HCV induced, was common and led to abnormal graft function, but the 6‐year post‐transplant survival (based on 100% survival at 1 year) in patients surviving for at least 1 year did not differ on the basis of the pretransplant viral hepatitis status. This finding may be consistent with the slow progression of the viral damage and longer follow‐up results remain to be established. Nevertheless, data from the present study suggest that in long‐term liver transplant survivors, the risk of deteriorating liver damage and eventual failure after 5 years remains only in those patients experiencing a viral hepatitis infection.

Thrombotic Storm in a Teenager With Previously Undiagnosed Ulcerative Colitis

Venous thrombosis can complicate inflammatory bowel diseases, both in adult and pediatric patients, and a few adult cases of thrombotic storm, ie, thrombosis at multiple sites occurring over a period of a few days to a few weeks, have been described. However, venous thrombosis as the first manifestation of an inflammatory bowel disease is extremely rare. We report the case of a 14-year-old girl presenting with ascites and marked hypertransaminasemia resulting from hepatic vein occlusion (Budd-Chiari syndrome). Despite anticoagulant therapy, in the following days she developed criteria suggestive of thrombotic storm to include cerebral vein, right atrial thrombosis, and bilateral pulmonary embolism. Thrombolytic treatment with recombinant-tissue plasminogen activator was started, with resolution of all venous thromboses and without bleeding complications. Additional examinations revealed a severely active ulcerative pancolitis, which did not respond to medical treatment and required surgery. No thrombophilia abnormality nor other risk factors for thrombosis were detected. We conclude that an underlying inflammatory state, such as ulcerative colitis, should be suspected in pediatric patients with venous thrombosis storm.

A risk score and a flowchart for liver retransplantation.

Rates of overall graft survival after liver retransplantation (RETX) are still 20% lower than those after primary liver transplantation (TX). On the basis of previous mathematical approaches from other authors who tried to identify prognostic variables for survival and prognostic risk scores for liver RETX, we studied 12 categorical and 17 continuous variables from the donor, the recipient, and the surgical procedure, among patients who underwent liver retransplantation. Data were retrieved in a retrospective study over the last 12 years, in order to overcome the possible gap of other series that often included RETX performed many years ago. We considered 394 consecutive cadaveric liver TXs in adult patients, namely, 351 primary TXs and 43 RETXs. Using multivariate logistic regression, we calculated the following equation for 1-year risk of death for patients undergoing liver RETX: log(Odds)= -4.81+2.23 x Recipient Sex + 1.86 x Donor Age + 1.60 x MELD Score (where: Recipient Sex: F=0, M=1; Donor Age (years): <40=0, 40-59=1; 60+ =2; MELD Score: <26=0, 26+ =1). With this formula, we built a decision tree to predict the individual risk of death based on the subjects profile. Keeping in mind that mathematical models can only help our decisional process and are not conclusive, our data needs to be validated on a larger scale.