Incidence and management of biliary complications after adult‐to‐adult living donor liver transplantation

Kyoden Y, Tamura S, Sugawara Y, Matsui Y, Togashi J, Kaneko J, Kokudo N, Makuuchi M. Incidence and management of biliary complications after adult‐to‐adult living donor liver transplantation.
Clin Transplant 2010: 24: 535–542.
© 2009 John Wiley & Sons A/S. Abstract: Background: There are few detailed reports of biliary complications in a large adult living donor liver transplantation (LDLT) series. Patient and methods: Biliary complications, treatment modalities, and outcomes in these patients were retrospectively analyzed in 310 adult LDLT. Results: One patient underwent retransplantation. Duct‐to‐duct anastomosis was primarily performed in 223 patients (72%). During the observation period (median 43 months), biliary complications were observed in 111 patients (36%); 53 patients (17%) had bile leakage, 70 patients (23%) had bile duct stenosis, and 12 patients (4%) had bile leakage followed by stenosis. A biliary anastomotic stent tube was placed in 266 patients (86%) at the time of transplantation. Univariate analysis of various clinical factors revealed duct‐to‐duct anastomosis as the single significant risk factor (p = 0.009) for biliary complications. The three‐yr and five‐yr overall patient survival rates were 88% and 85% in those with biliary complications, and 85% and 83%, respectively, in those without biliary complications (p = 0.59). Conclusion: Biliary complications are a major cause of morbidity following LDLT. Duct‐to‐duct anastomosis carried a higher risk for bile duct stenosis. With appropriate management, however, there was little influence on overall survival.     

Hepatic artery reconstruction and successful management of its complications in living donor liver transplantation using a right lobe

Kim S‐J, Yoon Y‐C, Park J‐H, Oh D‐Y, Yoo Y‐K, Kim D‐G. Hepatic artery reconstruction and successful management of its complications in living donor liver transplantation using a right lobe.
Clin Transplant 2011: 25: 929–938. © 2010 John Wiley & Sons A/S. Abstract: Background: The aim of the present study was to improve the techniques of hepatic artery (HA) reconstruction and to properly manage arterial complications after living donor liver transplantation (LDLT). Methods: Prospectively collected data collected from 371 patients who underwent adult LDLT using a right lobe from January 2000 to August 2009 were retrospectively reviewed. Results: Of 17 patients (4.6%, 17/371) with double HA stumps in the graft, 12 patients (70.6%) received dual HA reconstruction. HA complications were composed of thrombosis (n = 6), pseudoaneurysm (n = 2), and stenosis (n = 4), showing 3.2% (12/371) of incidence. In patients with HA thrombosis, whereas operative thrombectomies with re‐anastomosis rescued all the grafts in early attack (n = 3, ≤1 wk), angiographic thrombolysis successfully reestablished the flow in patients with late attack (n = 3, >1 wk). In all patients with HA complications, except for one, all of our treatment modalities – operation and angiographic intervention – resulted in successful rescue of grafts and no patient received re‐transplantation because of HA complications. Conclusion: Prompt diagnosis of HA complications by serial post‐operative Doppler ultrasound and corresponding treatment strategies, including operative and radiological intervention, can rescue both grafts and patients without necessitating re‐transplantation.     

Steroid‐free living donor liver transplantation in adults: impact on hepatitis C recurrence

Abstract: Introduction: Although steroid‐free immunosuppression has been proven to be safe and feasible for liver transplantation, its impact on hepatitis C virus (HCV) recurrence remains unknown. We aimed to clarify the impact of steroid‐free immunosuppression on post‐operative HCV recurrence after living donor liver transplantation (LDLT). Patients and methods: Of 32 adult patients with HCV cirrhosis who underwent LDLT between 1999 and 2007 at our hospital, 28 were enrolled in this prospective study. We used steroid‐free immunosuppression, consisting of a calcineurin inhibitor, mycophenolate mofetil and anti‐CD25 antibody in 18 patients (F‐group), and the remaining 10 patients received steroid‐based immunosuppression (S‐group) during the same period. Results: Patient characteristics were similar between the two groups. Steroid‐free immunosuppression was associated with lower incidence of CMV infection (p = 0.049) and higher incidence of instituting preemptive anti‐HCV therapy (p = 0.015) without increasing acute cellular rejection in the F‐group than that in the S‐group. In the early period after LDLT, the serum HCV‐RNA level remained suppressed in the F‐group, whereas it increased rapidly in the S‐group (p < 0.05). HCV recurrence was less frequent in the F‐group (18.1% at one yr) than in the S‐group (46.0%) (p = 0.009). Conclusions: Steroid‐free immunosuppression was confirmed to be safe and feasible for HCV‐positive recipients in LDLT, and was associated with suppressed HCV replication and HCV recurrence after LDLT.     

Hepatic artery reconstruction in living donor liver transplantation: running suture under surgical loupes by cardiovascular surgeons in 180 recipients

Objectives

The aim of our study was to retrospectively investigate the outcomes of hepatic artery (HA) reconstruction by cardiovascular surgeons in adult-to-adult living donor liver transplantation (A-A LDLT).

Methods

From April 2007 to April 2011, 187 recipients underwent A-A LDLT. After excluding seven ABO-incompatible transplant recipients, we reviewed the courses of 180 patients including 125 men and 55 women of mean age 52.5 ± 9.2 years (range = 23-71). One hundred seventy-seven patients received right-lobe grafts with inclusion of middle hepatic vein (MHV); two, right-lobe grafts without MHV; and one, left-lobe graft. A continuous, single-stitch, running suture with the parachute technique was used for HA reconstruction. The anastomosis was performed by cardiovascular surgeons employing surgical loupes with 4.5× magnification.

Results

The mean time for an arterial reconstruction was 10.7 ± 4.0 minutes (median = 10, range = 4-30). Hepatic arterial thrombosis (HAT) was encountered in 3 (1.66%) patients. One HAT that developed on postoperative day 1 was successfully rescued by the intra-arterial infusion of urokinase. Another patient required reoperation due to a redundant kinked HA. A third HAT patient underwent successful retransplantation with a cadaveric graft on postoperative day 6. In our series, no delayed HAT was detected and no recipient deaths were related to HAT.

Conclusion

HA reconstruction with a running suture under surgical loupes is a feasible technique in A-A LDLT. A speedy reconstruction can be performed by an experienced cardiovascular surgeon with a low incidence of HAT.     

Live Donor Liver Transplantation: A Valid Alternative for Critically Ill Patients Suffering From Acute Liver Failure

We report the outcome of live donor liver transplantation (LDLT) for patients suffering from acute liver failure (ALF). From 2006 to 2013, all patients with ALF who received a LDLT (n = 7) at our institution were compared to all ALF patients receiving a deceased donor liver transplantation (DDLT = 26). Groups were comparable regarding pretransplant ICU stay (DDLT: 1 [0–7] vs. LDLT: 1 days [0–10]; p = 0.38), mechanical ventilation support (DDLT: 69% vs. LDLT: 57%; p = 0.66), inotropic drug requirement (DDLT: 27% vs. LDLT: 43%; p = 0.64) and dialysis (DDLT: 2 vs. LDLT: 0 patients; p = 1). Median evaluation time for live donors was 24 h (18–72 h). LDLT versus DDLT had similar incidence of overall postoperative complications (31% vs. 43%; p = 0.66). No difference was detected between LDLT and DDLT patients regarding 1‐ (DDLT: 92% vs. LDLT: 86%), 3‐ (DDLT: 92% vs. LDLT: 86%), and 5‐ (DDLT: 92% vs. LDLT: 86%) year graft and patient survival (p = 0.63). No severe donor complication (Dindo–Clavien ≥3 b) occurred after live liver donation. ALF is a severe disease with high mortality on liver transplant waiting lists worldwide. Therefore, LDLT is an attractive option since live donor work‐up can be expedited and liver transplantation can be performed within 24 h with excellent short‐ and long‐term outcomes.     

Outcome of hepatic artery reconstruction in liver transplantation with an iliac arterial interposition graft

BACKGROUND: In case of anomal hepatic arterial inflow, it can be necessary to perform revascularization of the liver allograft by iliac arterial interposition graft. METHODS: We analyzed retrospectively 613 liver transplants in a 16-yr period. The hepatic artery (HA) graft group (n = 101) consisted of patients with arterial inflow based on recipient infrarenal aorta using donor iliac artery graft tunneled through the transverse mesocolon. The control group (n = 512) consisted of patients who underwent liver transplantation with routine HA reconstruction. RESULTS: Both groups are homogeneous and comparable. In case of retransplantation, arterial conduit with iliac graft was adopted more frequently instead of conventional arterial anastomosis (24.8% vs. 9%, p < 0.0001). The 1-, 3- and 5-yr overall survival was 85.41, 79.42, 76.57% in the control group and 76.21, 73.43, 73.43% in the HA graft group, respectively (p = ns). The 1-, 3- and 5-yr graft survival was better in the control group (81.51, 73.66, 69.22% vs. 71.17, 62.50, 53.42%) (p = 0.01). In case of retransplantation, the 1-, 3- and 5-yr overall (57.81, 53.95, 41.96% vs. 60, 51.95, 49.85%) and graft survival (57.52, 53.68, 41.75% vs. 56, 50.4, 40.3%) was similar in control and HA graft group, respectively (p = ns). Hepatic artery thrombosis (HAT) rate is 21.8% vs. 8.6% (p < 0.0001) in HA graft group and control group, respectively. The only factor independently predictive of early HAT resulted arterial conduit (p = 0.001, OR = 3.13, 95% CI: 1.57-6.21). Retransplant procedure, donor age and arterial iliac conduit were found to be a significant risk factors for late HAT, at univariate analysis. At multivariate analysis, donor age >50 yr old resulted the only factor independently associated with late HAT (p < 0.0001, OR = 1.05, 95% CI: 1.02-1.07). CONCLUSION: Iliac arterial interpositional graft is an alternative solution for arterial revascularization of liver allograft in case of retransplantation when the use of HA is not possible. In case of primary transplantation, is better not to perform arterial conduit if it is possible, for poor graft survival and high incidence of early HAT, especially in case of liver donor aged over 50 yr.     

Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis

Kim S‐J, Kim D‐G, Park J‐H, Moon I‐S, Lee M‐D, Kim J‐I, Yoon Y‐C, Yoo Y‐K. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis.
Clin Transplant 2011: 25: 111–118. © 2010 John Wiley & Sons A/S. Abstract: The aim of this study was to improve outcomes in living donor liver transplantation (LDLT) patients with portal vein thrombosis (PVT). Of 246 adult patients who underwent LDLT with a right lobe graft between January 2000 and May 2007, PVT was diagnosed in 50 patients (20.3%), who were further subdivided into partial (n = 39, 78%) and complete (n = 11, 22%) types. Patients with PVT, especially complete PVT, showed high incidences of variceal bleeding (p = 0.021), operative RBC transfusion (p < 0.046) and a post‐transplantation complications related to bleeding (p = 0.058). We also classified PVT according to its location and the presence of collaterals: type I (n = 41, 82%): PVT localized above the confluence of the splenic and superior mesenteric veins (SMV); type II (n = 7, 14%): PVT extending below the confluence with a patent distal SMV; type III (n = 2, 4%): complete portal vein and SMV thrombosis except for a coronary vein. LDLT could be safely undertaken in patients with PVT without increased mortality. In our type II and III PVT, when thrombectomy fails, jump grafting using a cryopreserved vessel may serve as a reliable alternative method to restore portal flow.     

Early hepatic artery thrombosis after liver transplantation: diagnosis and treatment

BACKGROUND: Hepatic artery thrombosis (HAT) occurs in 3% to 9% of all liver transplantations with acute graft failure as a possible sequel. METHODS: Eleven episodes of HAT were identified among 256 orthotropic liver transplantations (whole, LDCT, split) performed on 253 patients between April 1993 and July 2006. HAT was suspected clinically and confirmed by Doppler ultrasonography, magnetic resonance angiography, angiography, or reexploration. One patient was excluded due to poor follow-up. Treatment options included exploration with HA thrombectomy plus thrombolysis, retransplantation, or conservative treatment of hepatic and biliary complications. RESULTS: Among 11 patients of mean age 29.98 +/- 17.14 years (range, 10 months to 56 years). 2 had split right lobe liver transplantations and 9 received whole organs. None of LDLTs were identified to have HAT. The causes of liver cirrhosis among HAT patients were autoimmune hepatitis (n=3), cryptogenic (n=3), Wilson (n=1), PBC (n=1), biliary atresia (n=1), and HBs (n=1). HAT was diagnosed at 5.9 +/- 4.43 (range, 2 to 16) days after operation. Most patients developed right upper quadrant (RUQ) pain at presentation. Two patients developed acidosis, fever, or SIRS and underwent retransplantation. Four underwent exploration of HA and 1 was treated conservatively. Three cases expired due to HAT complications. CONCLUSION: We found RUQ pain to be the presenting sign of early HAT in majority of cases. RUQ pain has been reported to occur in late HAT. Whenever HAT is confirmed, liver transplanted patients should be revascularized or even retransplanted. Intra-arterial thrombolysis and thrombolytic therapy for HAT should be done cautiously due to the potential risk of hemorrhage.     

Clinical analysis of recurrent hepatocellular carcinoma after living donor liver transplantation

This study aimed to analyze the clinical outcomes and factors influencing the outcome in the recurrence of hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT). Between October, 1997 and September, 2010, 25 (16.0%) of 156 patients who had undergone LDLT for HCC experienced recurrence. All patients with recurrence, with a single exception, were in the high‐risk group. Among patients with recurrence, 76.0% of patients experienced recurrence within one yr after LDLT. One‐ and five‐yr survival rates of recurred patients were 56.0% and 8.6%, respectively. Among them, 32% of patients were treated with curative‐intent treatment, and their one‐ and five‐yr survival rates were 62.5% and 25.0%, respectively. Beyond the Milan criteria at liver transplantation (LT) (p = 0.032), multiple recurrence (p = 0.001), and palliative treatment for recurrent tumors (p = 0.049) were related to poor survival after recurrence. Additionally, the independent prognostic factors included multiple recurrence (p = 0.005) and the Milan criteria at LT (p = 0.047). Because almost all recurrent cases belonged to the high‐risk group and recurred within two yr, the high‐risk group should undergo close follow‐up for early detection and be treated with liver‐directed therapies. Although the prognosis of recurrent HCC after LDLT is poor, long‐term survival can be expected on a single recurrence and curative treatment.     

Liver transplantation for children with Wilson disease: comparison of outcomes between children and adults

Arnon R, Annunziato R, Schilsky M, Miloh T, Willis A, Sturdevant M, Sakworawich A, Suchy F, Kerkar N. Liver transplantation for children with Wilson disease: comparison of outcomes between children and adults.
Clin Transplant 2011: 25: E52–E60. © 2010 John Wiley & Sons A/S. Abstract: Liver transplantation (LT) is lifesaving for patients with Wilson disease (WD) presenting with fulminant hepatic failure (FHF) or chronic liver disease (CLD) unresponsive to treatment. Aim: To determine the outcome of LT in pediatric and adult patients with WD. Methods: United Network for Organ Sharing data on LT from 1987 to 2008 were analyzed. Outcomes were compared for patients requiring LT for FHF and CLD after 2002. Multivariate logistic regression was used to determine risk factors for death and graft loss. Results: Of 90 867 patients transplanted between 1987 and 2008, 170 children and 400 adults had WD. The one‐ and five‐yr patient survival of children was 90.1% and 89% compared to 88.3% and 86% for adults, p = 0.53, 0.34. After 2002, 103 (41 children) were transplanted for FHF and 67 (10 children) for CLD. One‐ and five‐yr patient survival was higher in children transplanted for CLD compared to FHF; 100%, 100% vs. 90%, 87.5% respectively, p = 0.30, 0.32. One‐ and five‐yr patient survival was higher in adults transplanted for CLD compared to FHF; 94.7%, 90.1% vs. 90.3%, 89.7%, respectively, p = 0.36, 0.88. Encephalopathy, partial graft, and ventilator use were risk factors for death by logistic regression. Conclusion: LT is an excellent treatment option for patients with WD. Patients transplanted for CLD had higher patient survival rates than patients with FHF.     

Vascular reconstruction and complications in living donor liver transplantation in infants weighing less than 6 kilograms: the Kyoto experience.

Smaller-size infants undergoing living-donor liver transplantation (LDLT) are at increased risks of vascular complications because of their smaller vascular structures in addition to vascular pedicles of insufficient length for reconstruction. Out of 585 child patients transplanted between June 1990 and March 2005, 64 (10%) weighing less than 6 kg underwent 65 LDLTs. Median age and weight were 6.9 months (range: 1-16 months) and 5 kg (range: 2.8-5.9 kg), respectively. Forty-five lateral segment, 12 monosegment, and 8 reduced monosegment grafts were adopted, and median graft-to-recipient weight ratio was 4.4% (range: 2.3-9.7). Outflow obstruction occurred in only 1 patient (1.5%). Portal vein complication occurred in 9 (14%) including 5 with portal vein thrombosis. Hepatic artery thrombosis (HAT) occurred in 5 (7.7%). Patient and graft survivals were 73% and 72% at 1 yr, and 69% and 68% at 5 yr after LDLT, respectively. Thirteen of 22 grafts (58%) lost during the follow-up period occurred within the first 3 months posttransplantation. Overall graft survival in patients with and without portal vein complication was 67% and 65%, respectively (P = 0.54). Overall graft survival in patients with and without HAT was 40% and 67%, respectively. HAT significantly affected graft survival (P = 0.04). In conclusion, our surgical technique for smaller-size recipients resulted in an acceptable rate of vascular complications. Overcoming early posttransplantation complications will further improve outcomes in infantile LDLT.     

Long‐Term Outcomes of Pediatric Living Donor Liver Transplantation in Japan: An Analysis of More Than 2200 Cases Listed in the Registry of the Japanese Liver Transplantation Society

The Japanese Liver Transplantation Society (JLTS) was established in 1980 in order to characterize and follow trends in patient characteristics and graft survival among all liver transplant patients in Japan. This study analyzed the comprehensive factors that may influence the outcomes of pediatric patients who undergo living donor liver transplantation (LDLT) by evaluating the largest cohort in the world. Between November 1989 and December 2010, 2224 pediatric patients underwent LDLT in Japan. There were 998 male (44.9%) and 1226 female donors (55.1%) without donor mortalities related to transplant surgery. There were 946 male (42.5%) and 1278 female (57.5%) recipients with a median age of 4.0 years (range: 13 days to 17.9 years). Cholestatic liver disease was the leading indication for LDLT (n = 1649; 76.2%), followed by metabolic disorders (n = 194; 8.7%), acute liver failure (n = 192; 8.6%) and neoplastic liver disease (n = 66; 3.0%). The 1‐, 5‐, 10‐ and 20‐year patient survival rates were 88.3%, 85.4%, 82.8% and 79.6%, respectively. Blood‐type incompatibility, recipient age, etiology of liver disease and transplant era were found to be significant predictors of overall survival. We are able to achieve satisfactory long‐term pediatric patient survival outcomes in the JLTS series without compromising the living donors.     

活体肝移植术后早期肝动脉血栓形成的诊断与治疗

目的探讨活体肝移植术后早期肝动脉血栓形成的诊断与治疗。方法2006年9月至2009年8月天津市第一中心医院单一外科组共实施110例活体肝移植,移植术后7d内每日用彩色多普勒超声(彩超)监测肝动脉血流,怀疑肝动脉血栓形成行肝动脉造影或腹部CT检查,确诊者予介入治疗或手术治疗。结果该组3例术后5～6d发生肝动脉血栓,肝动脉血栓发生率2.7%(3/110)。其中1例再次手术行肝动脉取栓,术后血流正常;2例行介入治疗,放置支架,术后1例再次血栓形成,1例血流流速偏低,2例均发生胆道并发症,但肝功能正常。3例均存活。结论术后早期用彩超监测对肝动脉血栓的诊断至关重要,及时手术取栓或介入放置支架效果良好。     

The impact of renal replacement therapy before or after living donor liver transplantation

Ikegami T, Shirabe K, Soejima Y, Taketomi A, Yoshizumi T, Uchiyama H, Harada N, Maehara Y. The impact of renal replacement therapy before or after living donor liver transplantation.
Clin Transplant 2012: 26: 143–148.
© 2011 John Wiley & Sons A/S. Abstract: Introduction: The impact of renal replacement therapy (RRT) in living donor liver transplantation (LDLT) has not yet been investigated. Methods: Among 253 LDLT patients, RRT was started before (RRT‐Pre, n = 9), or after (RRT‐Post, n = 27) LDLT. The clinical outcomes were reviewed. Results: The one‐yr graft survival rate was 94.1% without RRT, and 63.9% and in those with RRT (p < 0.0001). Among the RRT patients, the RRT‐Pre patients exhibited acute liver failure, hepatorenal syndrome and high model for end‐stage liver disease score (35 ± 12), whereas the RRT‐Post patients had sepsis as a comorbidity. The one‐yr graft survival rate was 100.0% in the RRT‐Pre patients vs. 51.9% in the RRT‐Post patients (p < 0.01). The duration of RRT was significantly shorter in the RRT‐Pre patients than that in the RRT‐Post patients (5.3 ± 2.1 vs. 17.8 ± 14.1 d, p = 0.02). The mean duration between starting RRT and LDLT was 2.1 ± 0.7 d in the Pre‐RRT patients. Conclusion: The RRT‐Pre patients had excellent outcomes because the severe condition was primarily treated by LDLT after short‐term pre‐transplant RRT. Post‐transplant uncontrollable sepsis was the major cause of graft loss in patients who receive RRT after LDLT.     

Thrombosis Confined to the Portal Vein Is Not a Contraindication for Living Donor Liver Transplantation

BACKGROUND: There is a lack of agreement regarding preexisting portal vein thrombosis (PVT) in patients undergoing living donor liver transplantation (LDLT). We report the results of a single-center study to determine the impact of PVT on outcomes of adult LDLT recipients. METHODS: Of 133 cases of adult LDLT performed between January 2000 and December 2004, a thrombectomy was performed on 22 patients (16.5%) with PVT during the transplant procedure. One hundred eleven patients without PVT (group 1) were compared with those with a thrombosis confined to the portal vein (group 2; n = 15) and patients with the thrombosis beyond the portal vein (group 3; n = 7). RESULTS: The sensitivities of Doppler ultrasound and CT in detecting PVT were 50 and 63.6%. A prior history of variceal bleeding (OR = 10.6, p = 0.002) and surgical shunt surgery (OR = 28.1, p = 0.044) were found to be an independent risk factors for PVT. The rate of postoperative PVT was significantly higher in patients with PVT than in those without (18.2 vs. 2.7%; p = 0.014). In particular, the rethrombosis rate in group 3 was 28.6%. The actuarial 3-year patient survival rate in PVT patients (73.6%) was similar to that of the non-PVT patients (85.3%; p = 0.351). However, the actuarial 3-year patient survival rate in group 3 was 38.1%, which was significantly lower than that in groups 1 and 2 (p = 0.006). CONCLUSION: A thrombosis confined to the portal vein per se should not be considered a contraindication for LDLT.     

Outcomes of liver transplantation for glycogen storage disease: a matched-control study and a review of literature

Maheshwari A, Rankin R, Segev DL, Thuluvath PJ. Outcomes of liver transplantation for glycogen storage disease: a matched‐control study and a review of literature.
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01549.x.
© 2011 John Wiley & Sons A/S. Abstract: Background: The clinical characteristics and outcomes of patients with glycogen storage disease (GSD) who undergo liver transplantation (LT) have not been well defined. In this study, our objective was to determine the outcome of LT in patients with GSD and compare it with a comparable group of patients without GSD (matched controls). Methods: UNOS data from 1986 to 2007 were used for this study. For each GSD patient (n = 95; men 62%) who was transplanted, three patients (n = 285, men 60%) without GSD (case controls) matched for age ± five yr, year of transplantation and donor risk index (DRI) ± 0.2 were identified from the UNOS database in a random manner. Unadjusted patient survival was determined by Kaplan–Meier survival analysis and significance determined by log‐rank test. Results: The mean age of the group was 17.9 yr. GSD patients had lower BMI (22 vs. 24, p = 0.002), lower serum bilirubin (2.7 vs. 13.5 mg/dL, p < 0.0001), higher serum albumin (3.7 vs. 3.1 g/dL, p < 0.0001), and higher wait‐list time (239 vs. 74 d, p < 0.0001) compared to case controls. Recipient age and DRI were similar between the groups. Tumors were more common in GSD group (13.7% vs. 5%). Patient survival was significantly better (p = 0.024) in GSD group at one, five, and 10 yr (82%, 76%, and 64%) than non‐GSD (73%, 65%, and 59%) group. Conclusions: In this matched‐control study, patients who underwent LT for GSD had a better long‐term survival than a comparable group of patients without GSD.     

Intraarterial thrombolytic treatment for hepatic artery thrombosis immediately after living donor liver transplantation

Hepatic artery thrombosis (HAT) following living donor liver transplantation (LDLT) remains one of the major causes of graft failure and mortality in liver transplant recipients. This complication requires early diagnosis and revascularization to avoid graft loss. We have reported herein two cases of successful urokinase intraarterial thrombolytic treatment for HAT in the immediate postoperative period after LDLT. Significant elevation of liver transaminases was noted 6 and 4 hours after LDLT and HAT confirmed by three-dimensional computed tomogram and angiogram. Both patients were treated successfully with intraarterial thrombolysis using an urokinase infusion (a total dose of 200,000 to 250,000 IU over 20 to 25 minutes) immediately after HAT was confirmed. One patient underwent laparotomy and bleeder ligation owing to hepatic arterial anastomotic site bleeding after thrombolysis. These two patients remain in good condition without any ischemic graft sequelae at 7 and 8 months follow-up. In conclusion, intraarterial thrombolysis using an urokinase infusion could be considered as one of the treatment modalities of acute HAT following LDLT even in the immediate postoperative period.     

Transplant tourism – a dangerous journey?

Polcari AJ, Hugen CM, Farooq AV, Holt DR, Hou SH, Milner JE. Transplant tourism – a dangerous journey?
Clin Transplant 2011: 25: 633–637. © 2010 John Wiley & Sons A/S. Abstract: Introduction: While the ethical aspects of transplant tourism have received much attention recently, less has been written about the medical safety of this practice. We retrospectively evaluated the outcomes of patients who purchased organs internationally and presented to our center for follow‐up care. Methods: Baseline demographic characteristics were recorded. Post‐operative outcomes including patient survival, graft survival, five‐yr graft function, and complications were assessed. Results: Eight patients who purchased international organs for transplant were identified. The country of transplant was China (n = 3), Pakistan (n = 3), India (n = 1), and the Philippines (n = 1). All patients were born in either Asia or the Middle East and traveled to the region of their ethnicity for transplantation. The mean time to presentation was 49 d post‐operatively. The overall one‐ and two‐yr patient survival rates were 87% and 75%, respectively. One patient died of miliary tuberculosis and another of Acinetobacter baumanii sepsis. There was one case of newly acquired hepatitis B infection. At last follow‐up, all six surviving patients had functioning grafts with a mean creatinine level of 1.26 mg/dL at five yr. Conclusion: Although intermediate‐term graft function is acceptable, the early morbidity and mortality among transplant tourists is high. These results suggest that the associated risks may not justify the trip.     

Vascular complications in the first 100 liver transplantations in Saudi Arabia

Vascular complications are a significant cause of morbidity and mortality following liver transplantation. The purpose of this study is to determine the impact of vascular complications on the patient and graft survival. One hundred liver transplant procedures were performed on 92 patients between January 1994 and June 1998 at King Fahad Hospital (Riyadh, Saudi Arabia). Patients' data were analyzed retrospectively with special emphasis on vascular complications. Vascular complication occurred in 19 procedures (19%), including HAT (n = 8), IVC stenosis (n = 3), PVT (n = 2), HAS (n = 2), rupture HA mycotic aneurysm (n = 1), and celiac artery stenosis (n = 1). Combined vascular complication occurred in 2 patients (HAT and PVT, and HAS and IVC stenosis). The only significant risk factor for the development of vascular thrombosis in our study was pediatric age. The use of low-dose heparin was found to be a protective factor against HAT (P = 0.03). Complications were managed by thrombectomy (n = 2), thrombectomy followed by retransplantation (n = 3), retransplantation (n = 2), and revision (n = 2). Nonsurgical approaches included angioplasty (n = 6) and observation (n = 4). The overall survival rate was 65% (13 of 20). HAT is the most serious complication following liver transplantation; it may lead to death. Timely retransplantation may salvage some patients, and angioplasty is useful in the management of vascular stenoses.