Yu-Hung Lin

Early and long-term results of routine microsurgical biliary reconstruction in living donor liver transplantation.

We describe our early and long‐term experience with routine biliary reconstruction via a microsurgical technique in living donor liver transplantation (LDLT). One hundred seventy‐seven grafts (including 3 dual grafts) were primarily transplanted into 174 recipients. The minimum follow‐up was 44 months. Biliary reconstructions were based on biliary anatomical variations in graft and recipient ducts. The recipient demographics, graft characteristics, types of biliary reconstruction, biliary complications (BCs), and outcomes were evaluated. There were 130 right lobe grafts and 47 left lobe grafts. There were single ducts in 71.8%, 2 ducts in 26.0%, and 3 ducts in 2.3% of the grafts. The complications were not significantly related to the size and number of ducts, the discrepancy between recipient and donor ducts, the recipient age, the ischemia time, or the type of graft. The overall BC rate was 9.6%. The majority of the complications occurred within the first year, and only 1 patient developed a stricture at 20 months. No new complications were noted after 2 years. When the learning‐curve phase of the first 15 cases was excluded, the overall BC rate was 6.79%, and the rate of complications requiring interventions was 2.5%. In conclusion, the routine use of microsurgical biliary reconstruction decreases the number of early and long‐term anastomotic BCs in LDLT. Liver Transpl 19:207‐214, 2013.

Living donor liver transplantation: the Asian perspective.

Preoperative evaluation of donors for living-donor liver transplantation aims to select a suitable donor with optimal graft quality and to ensure donor safety. Hepatic steatosis, a common finding in living liver donors, not only influences the outcome of liver transplantation for the recipient but also affects the recovery of the living donor after partial hepatectomy. Histopathologic analysis is the reference standard to detect and quantify fat in the liver, but it is invasive, and results are vulnerable to sampling error. Imaging can be repeated regularly and allows assessment of the entire liver, thus avoiding sampling error. Selection of appropriate imaging methods demands understanding of their advantages and limitations and the suitable clinical setting. This article describes potential clinical applications for liver fat quantification of imaging methods for fat detection and quantification, with an emphasis on the advantages and limitations of ultrasonography, computed tomography, and magnetic resonance imaging for quantifying liver fat.

Surgical experience of adult primary hepatic sarcomas

BackgroundPrimary hepatic sarcoma (PHS) is a rare primary liver malignancy. The histological types of PHS are diverse, and the clinical outcomes and management mainly depend on the histopathology. This study aims to evaluate the results of surgical intervention.MethodsBetween January 2003 and June 2009, 13 adult patients with pathologically proven PHS were identified by record review. The patients’ demographic profile, tumor characteristics, treatment modalities, and outcomes were reviewed and analyzed. The end of follow-up was December 2014.ResultsNine (69%) underwent curative liver resection and two underwent liver transplantation; the others received non-operative treatments. The pathologic findings were six (46%) angiosarcomas, four (30.7%) undifferentiated sarcomas, one (7.6%) leiomyosarcoma, one (7.6%) malignant mesenchymoma, and one (7.6%) hepatic epithelioid hemangioendothelioma. The median follow-up was 31.4 (2.8 ~ 142.5) months. The 1-, 2-, and 5-year survival of surgical patients were 72.7%, 63.6%, and 36.4%, respectively. Importantly, the 1-, 2-, and 5-year survival rates of non-angiosarcoma patients were superior to those of angiosarcoma (85.7% vs. 33.3%, 71.4% vs. 16.7%, and 57.1% vs. 0%, respectively, P = 0.023).ConclusionsSurgical intervention provides the possibility of long-term survival from PHS. Angiosarcoma is associated with a more dismal outcome than non-angiosarcoma.

Interventional radiology in living donor liver transplant

The shortage of deceased donor liver grafts led to the use of living donor liver transplant (LDLT). Patients who undergo LDLT have a higher risk of complications than those who undergo deceased donor liver transplantation (LT). Interventional radiology has acquired a key role in every LT program by treating the majority of vascular and non-vascular post-transplant complications, improving graft and patient survival and avoiding, in the majority of cases, surgical revision and/or re-transplant. The aim of this paper is to review indications, diagnostic modalities, technical considerations, achievements and potential complications of interventional radiology procedures after LDLT.

Section 13. Short-course pretransplant antiviral therapy is a feasible and effective strategy to prevent hepatitis C recurrence after liver transplantation in genotype 2 patients.

Background Hepatitis C virus (HCV) recurrence in recipients who are viremic at time of liver transplantation (LT) is universal and carries poor prognosis. Pretransplant antiviral therapy to eradicate HCV reduces recurrence, but withdrawal rate is high. We conducted a short-course (4 weeks) of pegylated interferon alpha-2a (Peg-IFN-&agr;2a) plus ribavirin (RBV) to prevent of HCV recurrence. Patients and Methods From October 2009 to December 2011, eighty-eight consecutive HCV patients for living donor LT with potential living donor at Kaohsiung Chang Gung Memorial Hospital were included. Patients were divided into treatment and nontreatment group depending on presence of HCV-RNA. Fixed dosage of Peg-IFN-&agr;2a (135 &mgr;g/week) plus RBV (10 mg/kg per day) were given for 4 weeks to treatment group who passed the 4-week waiting time according to clinical safety assessment. Results Forty-eight patients with genotypes 1, 2, and 3 (n=29/18/1) were treated with IFN and RBV combination for 4 (range, 1–9) weeks. Serum HCV RNA became undetectable at transplantation in 26 (54%) patients. No difference between genotypes 1 (n= 14, 48%) and 2/3(n=12, 63%, P=0.25) was observed. Most patients experienced cytopenia during treatment, but no mortality was noted. In the treatment group, 13 patients remained free of HCV infection 6 months after transplant. Virologic response at transplantation (48% vs. 100%, P=0.015) and genotype 2/3 (50% vs. 84%, P=0.01) are strong predictors of lower HCV recurrence rate. Multivariate analysis showed that genotype 2/3 was the only independent predictive factor affecting HCV RNA negativity 6 months after liver transplantation (OR:11.25; P=0.014). Conclusions Short-term pretransplant antiviral therapy is a feasible strategy in preventing HCV recurrence after LDLT especially in genotypes 2 and 3 recipients.

Active immunization for prevention of De novo hepatitis B virus infection after adult living donor liver transplantation with a hepatitis B core antigen–positive graft

De novo hepatitis B virus (DNHB) infections may occur in recipients who do not receive prophylaxis after liver transplantation (LT) with antibody to hepatitis B core antigen (anti‐HBc)–positive donor grafts. Active immunization has been shown to prevent DNHB in pediatric recipients. Our aim is to investigate the efficacy of HBV vaccination for preventing DNHB in adult living donor liver transplantation (LDLT). In total, 71 adult antibody to hepatitis B surface antigen (anti‐HBs)–negative LDLT patients who received anti‐HBc+ grafts from 2000 to 2010 were enrolled into this study. Patients were given hepatitis B virus vaccinations with the aim of achieving anti‐HBs > 1000 IU/L before transplant and >100 IU/L after transplant. The cohort was stratified into 3 groups: patients with pretransplant anti‐HBs titer of > 1000 IU/L without the need for posttransplant prophylaxis (group 1, n = 24), patients with pretransplant low titer of <1000 IU/L who were given posttransplant lamivudine prophylaxis and responded appropriately to posttransplant vaccination by maintaining anti‐HBs titers of > 100 IU/L (group 2, n = 30), and low titer nonresponders (anti‐HBs titer of < 100 IU/L despite vaccination), for whom lamivudine was continued indefinitely (group 3, n = 17). All DNHB occurred in group 3 patients with posttransplant anti‐HBs levels of < 100 IU/L, with an incidence rate of 17.6% compared with 0% in patients with posttransplant anti‐HBs levels of > 100 IU/L (P = 0.001). A pretransplant anti‐HBs level of >1000 IU/L was significantly associated with early attainment and a sustained level of posttransplant anti‐HBs of >100 IU/L (P < 0.001). Active immunization is effective in preventing DNHB in adult LDLT if the posttransplant anti‐HBs level is maintained above 100 IU/L with vaccination. Antiviral prophylaxis can be safely discontinued in patients who obtain this immunity. Liver Transplantation 23 1266–1272 2017 AASLD.

The 4-Week Serum Creatinine Level Predicts Long-Term Renal Dysfunction After Adult Living Donor Liver Transplantation

OBJECTIVES Recipients after liver transplantation. (OLT) often experience renal dysfunction. Acute kidney injury (AKI) and chronic kidney disease (CKD) after OLT occur among 20% to 50% and 30% to 90% of recipients, respectively; 2% to 5% of them deteriorate into end-stage renal disease each year. Since the predictable factors for CKD have not been well identified. We sought to investigate the incidence and predictors of CKD at 5 years after OLT. PATIENTS AND METHODS Between August 2002 and December 2005, we enrolled 77 patients who underwent adult living donor OLT with over 2 years of follow-up. The strategies to prevent renal dysfunction included induction with basiliximab to delay the use of tacrolimus: addition of mycophenolate mofetil to reduce the tacrolimus dosage; avoidance of the calcineurin inhibitor using sirolimus or administration of an angiotensin II receptor antagonist. The clinical variables were reviewed for analysis. RESULTS The mean follow-up was 76 ± 14 months. The incidence of AKI (over 50% increase level of creatinine) was 29%. Ten (13.0%) patients developed CKD (creatinine > 2 mg/dL). One (1.3%) subject developed end-stage renal disease requiring hemodialysis. Upon multivariate analysis the development of CKD was significantly associated with the posttransplant 4-week creatinine level: 0.92 ± 0.23 versus 1.37 ± 0.93 mg/dL (P = .008). CONCLUSION The 4-week creatinine value was predictive of the occurence of CKD over 5 years after OLT.

Living Donor Liver Transplantation for Combined Hepatocellular Carcinoma and Cholangiocarcinoma: Experience of a Single Center

BACKGROUND Because the outcome of liver transplantation for cholangiocarcinoma is often poor, cholangiocarcinoma is a contraindication for liver transplantation in most centers. Combined hepatocellular carcinoma and cholangiocarcinoma is a rare type of primary hepatic malignancy containing features of hepatocellular carcinoma and cholangiocarcinoma. Diagnosing combined hepatocellular carcinoma and cholangiocarcinoma pre-operatively is difficult. Because of sparse research presentations worldwide, we report our experience with living donor liver transplantation for combined hepatocellular carcinoma and cholangiocarcinoma. MATERIAL AND METHODS A total of 710 patients underwent living donor liver transplantation at our institution from April 2006 to June 2014; 377 of them received transplantation because of hepatocellular carcinoma with University of California San Francisco (UCSF) staging criteria fulfilled pre-operatively. Eleven patients (2.92%) were diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma confirmed pathologically from explant livers; we reviewed these cases retrospectively. Long-term survival was compared between patients diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma and patients diagnosed with hepatocellular carcinoma. RESULTS The mean age of the patients in our series was 60.2 years, and the median follow-up period was 23.9 months. Four patients were diagnosed with a recurrence during the follow-up period, including one intra-hepatic and three extra-hepatic recurrences. Four patients died due to tumor recurrence. Except for patients with advanced-stage cancer, disease-free survival of patients with combined hepatocellular carcinoma and cholangiocarcinoma compared with that of patients with hepatocellular carcinoma was 80% versus 97.2% in 1 year, and 46.7% versus 92.5% in 3 years (p<0.001), and overall survival was 90% versus 97.2% in 1 year, and 61.7% versus 95.1% in 3 years (p<0.001). CONCLUSIONS Outcomes of liver transplantation for patients with combined hepatocellular carcinoma and cholangiocarcinoma were worse than those for patients with hepatocellular carcinoma in this study. Combined hepatocellular carcinoma and cholangiocarcinoma are presumed to be a relative contraindication for liver transplantation.

Safe One-to-One Dosage Conversion From Twice-Daily to Once-Daily Tacrolimus in Long-Term Stable Recipients After Liver Transplantation.

BACKGROUND Once-daily tacrolimus provides better compliance for transplant recipients. However, the conversion strategies of dosage and concentration from twice- to once-daily are not well studied. The aim of this study was to investigate the dosage of conversion, follow-up strategy, and safety of conversion to once-daily tacrolimus in stable and long-term recipients after living donor liver transplantation (LDLT). MATERIAL AND METHODS From January 2011 to November 2012, we selectively converted 35 stable LDLT recipients to once-daily tacrolimus based on 1-to-1 daily dose. The tacrolimus dosage, trough level, liver and renal function before conversion, 1 month, 3 months, 6 months, and 1 year after conversion were recorded. RESULTS Tacrolimus trough level dropped significantly after conversion (2.72±1.65 to 1.85±1.25 ng/mL, p<0.001). No biopsy-proved rejection was detected during 1-year follow-up. However, 1 recipient (2.9%) had a 0.5 mg increase due to elevated liver enzymes and clinically diagnosed rejection. No other patients required dose adjustment due to dropped tough level after conversion. CONCLUSIONS One-to-one dosage conversion in stable LDLT recipients is a safe strategy. Dropped trough level is expected and dose adjustment is rarely required.

Donor Transmitted Bacterial Infection in Deceased Donor Liver Transplantation: Experience of Southern Taiwan Medical Center

BACKGROUND Bacterial Infection is the most important source of mortality and morbidity in liver transplantation recipients. Donor transmitted bacterial infection is rare but one of the most important infection sources. This kind of infection is difficult to identify, causing treatment dilemma. PATIENTS AND METHODS In this article, we retrospectively reviewed our deceased donor liver transplants performed from January 2014 to December 2016. Forty-two recipients in Kaohsiung Chang Gung Memorial Hospital receiving liver grafts from 35 deceased liver donors were evaluated. The demography, donor transmitted infection, and outcomes were evaluated. RESULT Two patients had probable donor transmitted bacterial infection and 1 patient died of suspected transmitted infection. CONCLUSION Early identification of donor infection and adequate antibiotic treatment for the donor and recipient are the keys to preventing donor transmitted bacterial infection. Donor infection is not an absolute contraindication for organ donation in the area of organ shortage. Organ procurement organizations or similar authorities may establish the platform for sharing the data about donor and recipient infections.