Y.K. You

High Mortality Associated With Acinetobacter Species Infection in Liver Transplant Patients

BACKGROUND Acinetobacter species have become increasingly important nosocomial pathogens worldwide and can result in a wide range of infections, including bacteremia, pneumonia, urinary tract infection, peritonitis, among others. The aim of this study was to investigate clinical characteristics, mortality, and outcomes among liver transplant recipients with Acinetobacter species infections. METHODS We retrospectively analyzed 451 subjects who had undergone living donor liver transplantations between January 2001 and May 2010. Pandrug-resistant (PDR) Acinetobacter species were defined as resistant to all commercially available antibiotics except colistin. RESULTS Infectious complications due to Acinetobacter species appeared in 26 patients (5.8%) with a total of 37 episodes. Of the species identified, 34 were Acinetobacter baumannii and 3 Acinetobacter Iwoffiii. The presumed sources of infection were the biliary tract (n = 21, 56.8%), lung (n = 7, 18.9%), intra-abdomen (n = 6, 16.2%), catheter (n = 2, 5.4%), and urinary tract (n = 1, 3.6%). Among the 37 Acinetobacter species, 75.7% (28/37) were PDR species. Age, duration of intensive care unit stay, Child-Pugh score, and Model for End-stage Liver Disease score were not significant risk factors for Acinetobacter species infection. However, the overall mortality among patients with Acinetobacter species infections was 50% (13/26), which was significantly higher than that among those free of infection (50% vs 11.5%, P < .05). Multivariate analysis using a Cox regression model showed that inappropriate antimicrobial treatment was a significant independent risk factor for mortality among patients with Acinetobacter species infections (hazard Ratio = 4.19, 95% confidence interval 1.1-18.7; P = .06). CONCLUSION Patients with Acinetobacter species infections after liver transplantation show a significantly worse prognosis. PDR Acinetobacter species have been a major problem in our center.

Single-Port Laparoscopy-Assisted Donor Right Hepatectomy in Living Donor Liver Transplantation: Sensible Approach or Unnecessary Hindrance?

BACKGROUND Single-port laparoscopic (SPL) surgery has rapidly gained attention worldwide. Since May 2008, we have propagated the use of SPL surgery, mainly for cholecystectomy and appendectomy. Recently, we have used this modality of minimally invasive surgery for various liver surgeries. We hereby discuss our outcomes of SPL-assisted donor right hepatectomies. METHODS The preoperative workup is the same as for a standard donor hepatectomy. We retrospectively reviewed the data of 150 patients who underwent donor right hepatectomy from October 2008 to May 2011. We divided them into 3 groups depending on the type of surgical procedure. RESULTS Among 150 patients, 20 underwent laparoscopy-assisted donor right hepatectomy (LADRH); 40 underwent single-port laparoscopy-assisted donor right hepatectomy (SPLADRH); and 90 underwent open donor right hepatectomy (ODRH). The donor demographics were comparable among the groups. Postoperative complication and reoperation rates revealed no significant differences. The SPLADRH group showed the lowest level of postoperative pain, thereby leading to a better quality of life postoperatively. CONCLUSIONS SPLADRH seems to be a simple, feasible approach.

Extended Criteria for Living Donor Liver Transplantation in Patients With Advanced Hepatocellular Carcinoma

BACKGROUND The purpose of this study was to evaluate the possibility of expanding the selection criteria in living donor liver transplantation (LDLT) to treat hepatocellular carcinoma (HCC). METHODS From October 2000 to December 2010, we retrospectively analyzed 71 patients who had undergone LDLT beyond the Milan criteria (MC), among the entire cohort of 199 HCC patients. We evaluated the tumor biology as well as overall and disease-free survival (DFS), seeking to identify risk factors for recurrence. The median follow-up was 37 months (range 5-124). RESULTS Among the 71 patients beyond the MC were 18 recurrences and 30 deaths. Their 5-year overall and DFS rates were 52.3% and 67.7%, respectively. On multivariate analysis, tumor diameter, tumor number, and E-S grade significantly influenced overall and DFS. According to our new criteria (size≤7 cm, number≤7), 86% of our patients would be included compared with 64% using MC. Five-year DFS and overall survival rates according to our criteria were comparable with the MC: 86.8% and 72.3% versus 86.8% and 73.4%, respectively. CONCLUSION Our criteria appear to achieve useful cut-off values beyond the MC.

Single-port laparoscopic splenectomy: The first three cases

In the past two decades, laparoscopic surgery has replaced open surgery in most abdominal surgeries, including splenectomies for which it has become the standard. Single‐port laparoscopic surgery is a newly emerging surgical technique that decreases postoperative scarring and parietal trauma. Herein we report on three cases of splenectomy in which single‐port laparoscopic surgery technique was applied. Between October 2008 and January 2009, a 13‐year‐old male suffering from grade‐III splenic trauma and two females, aged 33 and 61, respectively, and both diagnosed with immune thrombocytopenic purpura, underwent single‐port laparoscopic splenectomies. Preoperative and postoperative management, including vaccination, was performed in a routine manner. A 3.5 cm transverse incision at the anterior axillary line at umbilicus level was used as a single‐port entry point. The entire procedure took 195, 125 and 133 minutes, respectively. All patients recovered and were discharged without any complications.

Antiviral Prophylaxis Versus Preemptive Therapy to Prevent Cytomegalovirus Infection and Related Death in Liver Transplantation: A Retrospective Study With Propensity Score Matching

BACKGROUND Cytomegalovirus (CMV), the most significant viral infection in liver transplant recipients, is addressed by 2 methods: Preemptive therapy (PT) or universal prophylaxis (UP). METHODS We analyzed medical records including at least 1 year follow-up of patients who underwent liver transplantation from 2006 to 2009 in 3 tertiary hospitals. PT was used in 2 hospitals (PT group), whereas UP with valganciclovir for 3 months was adopted in the other hospital (UP group). The 2 groups were matched using propensity scoring by perioperative variables. We performed a 1:1 comparison of the efficacy of UP and PT. RESULTS We analyzed 634 liver transplant patients, including 562 matched subjects. Baseline characteristics and underlying liver status were comparable. CMV immunoglobulin G of recipients was positive in 98.9% of the PT group and 99.3% of the UP group. CMV viremia episodes that required administration of an antiviral agent occurred in 26 (9.3%) PT and 37 (13.2%) UP subjects (P = .18). CMV-related mortalities were similar (0.7% vs 1.8%; P = .45), but all-cause mortality was higher in the PT group (18.5% vs 13.2%; P = .08). CONCLUSION The efficacy of PT was similar to UP to prevent CMV disease and related mortality among a group at moderate risk for CMV infection.

Clinical significance of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci colonization in liver transplant recipients

Background/Aims: Liver transplant patients are at high risk for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) colonization. We evaluated patients before and after liver transplant using active surveillance culture (ASC) to assess the prevalence of MRSA and VRE and to determine the effect of bacterial colonization on patient outcome. Methods: We performed ASC on 162 liver transplant recipients at the time of transplantation and 7 days posttransplantation to monitor the prevalence of MRSA and VRE. Results: A total of 142 patients had both nasal and rectal ASCs. Of these patients, MRSA was isolated from 12 (7.4%) at the time of transplantation (group 1a), 9 (6.9%) acquired MRSA posttransplantation (group 2a), and 121 did not test positive for MRSA at either time (group 3a). Among the three groups, group 1a patients had the highest frequency of developing a MRSA infection (p < 0.01); however, group 2a patients had the highest mortality rate associated with MRSA infection (p = 0.05). Of the 142 patients, VRE colonization was detected in 37 patients (22.8%) at the time of transplantation (group 1b), 21 patients (20%) acquired VRE posttransplantation (group 2b), and 84 patients did not test positive for VRE at either time (group 3b). Among these three groups, group 2b patients had the highest frequency of VRE infections (p < 0.01) and mortality (p = 0.04). Conclusions: Patients that acquired VRE or MRSA posttransplantation had higher mortality rates than did those who were colonized pre-transplantation or those who never acquired the pathogens. Our findings highlight the importance of preventing the acquisition of MRSA and VRE posttransplantation to reduce infections and mortality among liver transplant recipients.

Single-port laparoscopic cholecystectomy: A comparative study in 106 initial cases

Introduction: Laparoscopic cholecystectomy has been the standard of care for gallbladder diseases since the late 1980s. Many surgeons have rapidly adopted single‐port laparoscopic cholecystectomy for gallbladder pathologies. The aim of the present study was to analyze the clinical outcome in initial single‐port laparoscopic cholecystectomy.

Effect of donor-recipient age matching in living donor liver transplantation.

BACKGROUND The use of a marginal donor, such as an elderly donor, in liver transplantation has been increasing in response to organ disparity; however, major risk factors for graft and patient survivals have been reported. METHODS We retrospectively reviewed the medical records of 559 patients who underwent living-donor liver transplantation (LDLT) at our hospital from May 2003 to June 2013. Elderly donors were defined as those >50 years old, and elderly recipients were defined as those >60 years old. We evaluated the differences in survival according to donor and recipient ages. Furthermore, we compared post-transplantation outcomes according to donor-recipient age matching. RESULTS The overall 5-year survival rate of the recipients was significantly lower in the elderly donor group than in the younger donor group (84.6% vs 58.2%; P < .001). However, no significant difference in survival rate was observed according to recipient age (P = .908). The survival rate of elderly recipients who received a graft from an elderly donor was significantly lower than those of the other groups (P < .001-.037). The mortality rate was significantly different among the groups (P < .001), and among the causes of death, surgical complications were most frequent cause in the elderly donor group (P < .001). CONCLUSIONS LDLT with the use of elderly donors >50 years of age could result in higher mortality rates than using younger donors. As such, elderly donor livers ideally should be matched with young recipients and attention concentrated on the surgical complications.

Postoperative Doppler Ultrasonography in Liver Transplantation

BACKGROUND Doppler ultrasonography plays an important role in the postoperative management of liver transplantation. We present our initial experiences evaluating liver transplants with the use of postoperative Doppler sonography. METHODS In our hospital, we performed 20 liver transplantations from July 2014 to October 2016. Among 20 patients, we performed 15 deceased-donor liver transplantations (DDLTs) and 5 living-donor liver transplantations (LDLTs). For deceased donors, inferior vena cava anastomoses were performed with the use of the piggyback technique, and for living donors, modified right grafts were used with middle hepatic vein reconstruction by Dacron graft. In the intensive care unit, we performed Doppler ultrasound at least once a day and at every clinical need. We checked hepatic blood flow by means of Doppler ultrasound. RESULTS Eighteen patients underwent Doppler ultrasonography once a day up to postoperative day 6. Of the patients who received LDLT, 2 patients underwent Doppler ultrasonography twice a day because the operator was concerned about the hepatic artery anastomosis. Findings on Doppler ultrasound showed no abnormal wave form in hepatic artery, portal vein and hepatic veins. No patient had abnormal findings on angiographic computerized tomography. There was 1 graft failure in 20 recipients. The graft failure was primary nonfunction, and retransplantation was done. During the hospitalizations, there were no vascular complications. CONCLUSIONS Doppler ultrasonography can be used to evaluate postoperative vascular complications in liver transplant patients. When the operator checks postoperative Doppler ultrasonography, it is possible to differentiate between patients, and it may help to detect the vascular complications earlier.