Liver transplantation for severe hepatic trauma： Experience from a single center

Liver transplantation has been reported in the literature as an extreme intervention in cases of severe and complicated hepatic trauma. The main indications for liver transplant in such cases were uncontrollable bleeding and postoperative hepatic insufficiency. We here describe four cases of orthotopic liver transplantation after penetrating or blunt liver trauma. The indications were liver failure, extended liver necrosis, liver gangrene and multiple episodes of gastrointestinal bleeding related to portal hypertension, respectively. One patient died due to postoperative cerebral edema. The other three patients recovered well and remain on immunosuppression. Liver transplantation should be considered as a saving procedure in severe hepatic trauma, when all other treatment modalities fail.     

Pediatric liver transplantation outcomes from a single center in Thailand

BACKGROUNDLiver transplantation (LT) has become an acceptable curative method for children with several liver diseases, especially irreversible acute liver failure and chronic liver diseases. King Chulalongkorn Memorial Hospital is one of Thailand’s largest liver transplant centers and is responsible for many pediatric cases.AIMTo report the experience with pediatric LT and evaluate outcomes of living-related vs deceased-donor grafts.METHODSThis evaluation included children who underwent LT between August 2004 and November 2019. Data were retrospectively reviewed, including demographics, diagnoses, laboratory values of donors and recipients, the pediatric end-stage liver disease (PELD) or model for end-stage liver disease (MELD) score, graft source, wait time, perioperative course, postoperative complications, and survival rates. Continuous data were reported using the median and interquartile range. The Mann–Whitney U-test was used to compare the wait time between the living-related and deceased-donor groups. The chi-square or Fisher''s exact test were used to compare the frequencies of between-group complications. Survival rates were calculated using the Kaplan–Meier method.RESULTSNinety-four operated pediatric liver transplant patients were identified (54% were females). The median age at transplantation was 1.2 (0.8-3.8) years. The median PELD and MELD scores were 20 (13-26.8) and 19.5 (15.8-26.3), respectively. Most grafts (81.9%) were obtained from living-related donors. The median wait time for the living donors was significantly shorter compared with the deceased donors at 1.6 (0.3-3.1) mo vs 11.2 (2.1-33.3) mo (P = 0.01). Most patients were diagnosed with biliary atresia (74.5%), and infection was the most common complication within 30 d post-transplantation (14.9%). Without a desensitization protocol, 9% of transplants were ABO-incompatible. Eight hepatitis B core antibodies (anti-HBc)-negative recipients received positive anti-HBc grafts without different observed complications. The overall survival rate was 93.6% and 90.3% at 1 and 5 years, respectively. No graft loss during follow-up was noted among survivors.CONCLUSIONA significant number of pediatric LT cases were reported in Thailand. Based on relatively comparable outcomes, ABO-incompatible and HBc antibody-positive grafts may be considered in an organ shortage situation.     

Microsurgical reconstruction of hepatic artery in living donor liver transplantation:experiences and lessons

BACKGROUND:Hepatic artery(HA) reconstruction is one of the key steps for living donor liver transplantation(LDLT).The incidence of HA thrombosis has been reduced by the introduction of microsurgical techniques under a high resolution microscope or loupe.METHODS:We report our experience in 101 cases of HA reconstruction in LDLTs using the graft-artery-unclamp and posterior-wall-first technique.The reconstructions were completed by either a plastic surgeon or a transplant surgeon.RESULTS:The rate of HA thromb...     

Hepatic reconstruction from fetal porcine liver cells using a radial flow bioreactor

AIM： To examine the efficacy of the radial flow bioreactor （RFB） as an extracorporeal bioartificial liver （BAL） and the reconstruction of liver organoids using embryonic pig liver cells. METHODS： We reconstructed the liver organoids using embryonic porcine liver cells in the RFB. We also determined the gestational time window for the optimum growth of embryonic porcine liver cells. Five weeks of gestation was designated as embryonic day （E） 35 and 8 wk of gestation was designated as E56. These cells were cultured for one week before morphological and functional examinations. Moreover, the efficacy of pulsed adminisbation of a high concentration hepatocyte growth factor （HGF） was examined. RESULTS： Both cell growth and function were excellent after harvesting on E35. The pulsed administration of a high concentration of HGF promoted the differentiation and maturation of these fetal hepatic cells. Microscopic examination of organoids in the RFB revealed palisading and showed that bile duct-like structures were well developed, indicating that the organoids were mini livers. Transmission electron microscopy revealed microvilli on the luminal surfaces of bile duct-like structures and junctional complexes, which form the basis of the cytoskeleton of epithelial tissues. Furthermore, strong expression of connexin （Cx） 32, which is the main protein of hepatocyte gap junctions, was observed. With respect to liver function, ammonia detoxification and urea synthesis were shown to be performed effectively.
CONCLUSION： Our system can potentially be applied in the fields of BAL and transplantation medicine.     

Cardiac work-up protocol for liver transplant candidates: Experience from a single liver transplant centre

BACKGROUND:

Ischemic cardiac events can cause significant morbidity and mortality postliver transplantation; however, no validated protocols to screen patients before transplantation exist.

OBJECTIVES:

To report the introduction of a noninvasive cardiac screening protocol used at the Liver Unit, University of Calgary (Calgary, Alberta); to determine whether the protocol decreases use of coronary angiograms; and to compare cardiac outcomes using the new protocol with an appropriately matched historical control group.

METHODS:

A new cardiac screening protocol was introduced into the program in 2005, which uses perfusion scintigraphy to screen high-risk cardiac patients, reserving coronary angiograms for abnormal results. Transplanted patients screened using this protocol were compared with matched historical controls. Electronic charts were reviewed for cardiac outcomes intra- and postliver transplantation.

RESULTS:

A total of 396 patients were screened between April 2005 and February 2009. Eighty-two were transplanted by February 2009 and included in the study. Eighty-one patients were successfully matched according to age, sex, cardiac history and presence of diabetes. Twelve of 82 (14.6%) and 11 of 81 (13.6%) in the study and control groups, respectively, underwent coronary angiograms (P=0.85). Coronary artery disease was found in six of 12 (50.0%) study patients and three of 11 (27.3%) control patients who underwent coronary angiography (P=0.27). The mean (± SD) length of the follow-up period was 1.87±0.91 years and 4.45±1.89 years in the study and control groups, respectively. One of 81 in the control group and zero of 82 in the study group experienced an acute coronary syndrome event postoperatively.

CONCLUSIONS:

Coronary events are infrequent in liver transplant recipients. The described protocol is an effective method of coronary artery disease screening before liver transplant but does not reduce the number of cardiac investigations performed.     

Pretransplantation fetal-maternal microchimerism in pediatric liver transplantation from mother

AIM To investigate the rates of pretransplantation fetalmaternal microchimerism(MC) and its effect on rejection in children receiving maternal liver grafts. METHODS DNA or blood samples before liver transplantation(LT) were available in 45 pediatric patients and their mothers. The presence of pretransplantation MC to non-inherited maternal antigens(NIMAs)(NIMA-MC) in the peripheral blood was tested using nested PCRsingle-strand conformation polymorphism analysis for the human leukocyte antigen(HLA)-DRB1 alleles. NIMA-MC was successfully evaluated in 26 of the 45 children. Among these 45 pediatric LT recipients,23 children(51.1%) received transplants from maternal donors and the other 22 from non-maternal donors.RESULTS Among these 26 children,pretransplantation NIMAMC was detected in 23.1%(n = 6),6.1(range,0.8-14) years after birth. Among the children with a maternal donor,the rate of biopsy-proven cellular rejection(BPCR) was 0% in patients with NIMA-MC positivity(0/3) and those with HLA-DR identity with the mother(0/4),but it was 50% in those with NIMA-MC negativity(5/10). Patients with NIMA-MC positivity or HLA-DR identity with the mother showed significantly lower BPCR rate compared with NIMA-MC-negative patients(0% vs 50%,P = 0.04). NIMA-MC-positive patients tended to show lower BPCR rate compared with NIMAMC-negative patients(P = 0.23). CONCLUSION The presence of pretransplantation NIMA-MC or HLADR identity with the mother could be associated with BPCR-free survival in pediatric recipients of LT from maternal donors.     

Outcome of routine use of microsurgical biliary reconstruction in pediatric living donor liver transplantation

Objective

Microsurgical techniques, initially used for hepatic artery reconstruction, have been extended to biliary reconstruction to decrease biliary complications. The routine use of microsurgical biliary reconstruction in pediatric living donor liver transplantation (LDLT) has not been elucidated.

Methods

Sixty-seven pediatric patients underwent primary LDLT. All biliary reconstructions were performed by a single microsurgeon using microsurgical techniques. A biliary stent was not used. The minimum follow-up was 12 months. Thirty-four patients had a minimum follow-up of 36 months. The outcomes of those who underwent microsurgical biliary reconstruction were compared with the outcomes of a cohort of 67 patients who underwent conventional biliary reconstruction.

Results

The demographical and clinical profiles of the two groups were not significantly different. There were 5 anastomotic complications in the conventional and 2 anastomotic complications in the microsurgical reconstruction groups. All complications developed within 90 days after transplant. There were no late biliary complications. Further analysis showed that conventional reconstruction increased the risk of biliary complications by 2.4 times (relative risk: 2.42; attributable risk: 4.5).

Conclusion

The routine use of microsurgical biliary reconstruction in pediatric LDLT is a technical innovation that led to decreased anastomotic biliary complications.     

Hepatic vein in living donor liver transplantation

Right lobe living donor liver transplantation (LDLT) is a major development in adult LDLT that has significantly increased the donor pool by providing larger graft size and by decreasing risk of small-for-size graft syndrome. However, right lobe anatomy is complex, not only from the inflow but also from the outflow perspective. Outflow reconstruction is one of the key requirements of a successful LDLT and venous drainage of the liver graft is just as important as hepatic inflow for the integrity of graft function. Outflow complications may cause acute graft failure which is not always easy to diagnose. The right lobe graft consists of two sections and three hepatic venous routes for drainage that require reconstruction. In order to obtain a congestion free graft, several types of vascular conduits and postoperative interventions are needed to assure an adequate venous allograft drainage. This review described the anatomy, functional basis and the evolution of outflow reconstruction in right lobe LDLT.     

Recent advances in pediatric liver transplantation

Pediatric liver transplantation has matured into a wellestablished, highly successful treatment for advanced pediatric liver disease. Recent 1-year success rates range from 85% to 95%. This unprecedented achievement is the result of careful selection criteria and optimal timing of transplantation, technical advances in surgical technique, and improved treatment following transplant. This report highlights many recent published findings representing advances that have led to current successful approaches.     

Current developments in pediatric liver transplantation

In 1953, the pioneer of human orthotopic liver transplantation(LT), Thomas E Starzl, was the first to attempt an orthotopic liver transplant into a 3 years old patient suffering from biliary atresia. Thus, the first LT in humans was attempted in a disease, which, up until today, remains the main indication for pediatric LT(p LT). During the last sixty years, refinements in diagnostics and surgical technique, the introduction of new immunosuppressive medications and improvements in perioperative pediatric care have established LT as routine procedure for childhood acute and chronic liver failure as well as inherited liver diseases. In contrast to adult recipients, p LT differs greatly in indications for LT, allocation practice, surgical technique, immunosuppression and postoperative life-long aftercare. Many aspects are focus of ongoing preclinical and clinical research. The present review gives an overview of current developments and the clinical outcome of p LT, with a focus on alternatives to full-size deceased-donor organ transplantation.     

40例临床肝移植血管和胆管重建经验

目的：总结第三军医大学西南医院肝移植时血管及胆管重建的经验。方法：回顾性分析40例肝移植时血管重建，胆道重建的方法及效果。结果：本研究肝移植病例围手术期死亡6例，手术病死率为15．0％，并发症为：肺部感染18例，多器官功能衰竭5例；腹腔内出血4例：ARDS8例；肝动脉血栓形成1例，胆漏1例，脑出血1例，存最长的1例为31个月，有15例生存期超过1年。结论：良好的血管和胆管重建技术是确保肝移植手术成功的关键。     

Overview of pediatric liver transplantation

Liver transplantation is a successful and useful therapy for children with chronic or end-stage liver disease and those with a variety of extrahepatic metabolic diseases that can be corrected by liver replacement. Major developments in medical management, donor availability and procurement, operative techniques, and post-operative management all contributed to the dramatic improvement in outcome and growth of liver transplantation from its inception in 1963 [1,7,21]. The excellent long-term outcomes that have been achieved are the product of the coordinated efforts of liver transplant surgeons, specialists in pediatric hepatology and other medical areas, nurses, local practitioners, and the patients and their families. Future advances in transplant immunobiology, organ availability and infection control are likely to lead to still greater improvements in short and long-term outcome [34].     

Biliary reconstruction with wide-interval interrupted suture to prevent biliary complications in pediatric living-donor liver transplantation

Background/Purpose

Liver transplantation is an established therapy for children with end-stage chronic liver disease or acute liver failure. However, despite refinements of surgical techniques for liver transplantation, the incidence of biliary tract complications has remained high in recent years. Therefore, we suggest our anastomotic technique with wide-interval interrupted suture to prevent biliary complications in pediatric living-donor liver transplantation (LDLT).

Methods

Forty-nine LDLTs were performed on 49 pediatric recipients with end-stage liver disease. Biliary reconstruction was performed using a 2.5× magnifying surgical loupe, via end bile duct to side Roux-en-Y hepaticojejunostomy (n?=?47) and duct-to-duct choledochocholedochostomy (n?=?2) with an external stent. A stay suture with 6-0 absorbable materials was placed at each end of the anastomotic orifice. Two interrupted sutures of the posterior row were performed. After completion of the suture of the posterior row, an external transanastomotic stent tube was inserted into the intrahepatic bile duct and was fixed with posterior row material. Finally, two interrupted sutures of the anterior wall were performed, totaling six stitches. The transanastomotic stent tube emerging out of the blind end of the Roux-en-Y limb was covered with a round ligament and was usually left in place for 1?month after the operation.

Results

The median follow-up period was 58.0?months (range 8?C135?months). In 33 recipients, the bile duct was used to perform the reconstruction with a single lumen. In 5 cases, there were 2 bile ducts that were formed to enable a single anastomosis. In 10 cases, there were 2 separated ducts and each duct was anastomosed with the recipient jejunum. In one case, there were 3 ducts that were formed to enable two anastomoses. Twenty-two percent of the living-donor grafts required 2 biliary anastomoses. Forty-four patients (89.8%) are alive (ranging from 8?months to 11?years), and 5 patients have died. Two patients had biliary complications, an anastomotic stricture in one (2.0%) and bile leakage in one. There were no complications due to anastomotic tubes.

Conclusions

Biliary reconstruction with wide-interval interrupted suture prevents anastomotic strictures and bile leakage in pediatric LDLT.     

Hepatic hemodynamic changes during liver transplantation: A review

Liver transplantation is performed in the recent decades with great improvements not only technically but also conceptually. However, there is still lack of consensus about the optimal hemodynamic characteristics during liver transplantation. The representative hemodynamic parameters include portal vein pressure, portal vein flow, and hepatic venous pressure gradient; however, there are still others potential valuable parameters, such as total liver inflow and hepatic artery flow. All the parameters are correlated closely and some internal modulating mechanisms, like hepatic arterial buffer response, occur to maintain stable hepatic inflow. To distinguish the unique importance of each hepatic and systemic parameter in different states during liver transplantation, we reviewed the published data and also conducted two transplant cases with different surgical strategies applied to achieve ideal portal inflow and pressure.     

A case of living-related partial liver transplantation using the right gastroepiploic artery for hepatic artery reconstruction

A 13-year-old boy with liver cirrhosis underwent living-related partial liver transplantation with a left lobe from his mother. A standard hepatic artery reconstruction using the recipient right hepatic artery was anticipated. Unfortunately, the recipient hepatic artery was found to be severely arteriosclerotic and was unsuitable for reconstruction. Instead, the right gastroepiploic artery, measuring 2.0 mm in diameter, was mobilized and was anastomosed to the left hepatic artery of the graft in an end-to-end fashion. Arterial blood flow was satisfactory. The patient's postoperative course was uneventful, and he was transferred to a floor bed on the 5th postoperative day.     

Doubly-armed short sutures are useful for microsurgical hepatic artery reconstruction in living-related liver transplantation

Although microsurgical hepatic artery reconstruction has become the essential technique in pediatric and living-related liver transplantation, it remains a technical challenge. We describe here our microsurgical hepatic artery reconstruction technique in living-related liver transplantation using a doubly-armed short suture. From August 1998 to March 1999, 8 patients underwent living-related liver transplantation at the Kyushu University. For these 8 patients, microsurgical reconstruction with doubly-armed short sutures were undertaken. After preparing the operative field for microsurgery, operative microscopy with a continuous zoom magnification is introduced. Interrupted sutures using doubly-armed short sutures are performed in a biangular stay-sutured method with a double clip. None of the 8 patients developed hepatic artery thrombosis. We conclude that the use of doubly-armed sutures allows safe and reliable in microsurgical hepatic artery reconstruction in living related liver transplantation.