Smoking increases recurrent viral hepatitis after liver transplantation

Smoking is a common behavior among transplant candidates. The aim of this study was to evaluate the effects of smoking on a range of complications after liver transplantation. We reviewed data about patient demographics and various complications after liver transplantation that were recorded in the McGill University Health Centre liver transplant database over a 14-year period. χ(2) and multivariate analyses were performed. Four hundred forty-four liver transplants were performed from 1990 to 2004, and 63 were repeat transplants. Only primary liver transplant recipients were included in our analysis. Smokers (ie, active or former smokers) were more likely to be male (77.9% versus 62.7%, P = 0.009) and Caucasian (88.4% versus 78.0%, P = 0.03). The median survival time was 13.23 years for smokers and was not estimable for nonsmokers because of censoring. The median recurrent viral hepatitis-free survival time was 0.87 years for smokers and 4.10 years for nonsmokers (P = 0.03). The following variables were not found to be associated with the smoking status: patient survival (P = 0.78), time to biliary complications after liver transplantation (P = 0.67), time to the first rejection episode after liver transplantation (P = 0.61), and time to depression after liver transplantation (P = 0.67). A Cox proportional hazards regression showed that recurrent viral hepatitis-free survival was still strongly associated with smoking [HR = 2.04, 95% confidence interval (CI) = 1.13-3.68, P = 0.018] and was marginally associated with East Asian race (HR = 0.26, 95% CI = 0.06-1.06, P = 0.06) and male sex (HR = 0.59, 95% CI = 0.34-1.02, P = 0.06). In conclusion, recurrent viral hepatitis-free survival was decreased for smokers after liver transplantation, likely because of the adverse effects of tobacco on immunological host defenses. Overall, the biliary complication-free, depression-free, and rejection-free survival rates were similar for smokers and nonsmokers. These findings suggest that smoking cessation should be encouraged, particularly in recipients undergoing transplantation for viral hepatitis.     

Recurrent hepatitis C virus disease after liver transplantation and concurrent biliary tract complications: poor outcome

Recurrent hepatitis C virus (HCV) infection is particularly aggressive in the post-liver transplantation setting, with rapid progression of liver fibrosis. Biliary complications remain a significant cause of morbidity following liver transplantation. Post-cholecystectomy biliary strictures are associated with advanced hepatic fibrosis. The aim of this retrospective study was to determine whether the presence of biliary complications affects survival in liver transplant recipients with recurrent HCV disease. The files of liver transplant recipients (53.7% male; mean age 52.7+/-10.3 yr) were reviewed for incidence, type and treatment of biliary complications, and findings were compared between those who developed recurrent HCV disease (n=47, 83.9%) and those who did not (n=9). Twenty-one biliary complications developed in 12 patients with recurrent HCV (25.5%). Treatment with endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography with balloon dilatation and stent placement or surgical revision was successful in nine (75%). Three biliary complications developed in three patients with no recurrence (p=NS). There was no statistically significant association between recurrent HCV disease and biliary complications. However, among those with recurrent disease, the recurrence was severe in nine of 12 recipients with biliary complications (75%) but in only nine of 35 without biliary complications (26%) (p=0.001). Death was documented in eight patients with severe recurrence (44.4%), including three (37.5%) with biliary complications and two (7%) with non-severe recurrence, neither of whom had biliary complications (p=0.003). Antiviral treatment was successful in nine of 25 patients (36%) who received it. On multivariate analysis, biliary complications were a significant predictor of severe recurrence (OR 27.0, 95% confidence interval 2.07-351.4) (p=0.012). Fibrosis stage in the second biopsy was significantly correlated with serum alanine aminotransferase (p=0.01) and with duration of biliary obstruction (p=0.07). In conclusion, biliary complications of liver transplantation strongly affect outcome in patients with recurrent HCV disease despite attempts to relieve the biliary obstruction and to treat the recurrent HCV disease.     

Outcomes of surgical repair of bile leaks and strictures after adult‐to‐adult living donor liver transplant

Melcher ML, Freise CE, Ascher NL, Roberts JP. Outcomes of surgical repair of bile leaks and strictures after adult‐to‐adult living donor liver transplant.
Clin Transplant 2010: 24: E230–E235. © 2010 John Wiley & Sons A/S. Abstract: We sought to determine factors that predict the successful surgical repair of biliary complications after adult living donor liver transplantation (ALDLT). Methods: Records of 82 consecutive ALDLT right lobe recipients were reviewed. Operations were performed on 19 recipients for biliary complications. Post‐operative biliary complications were analyzed. Fisher’s exact test was used to identify variables that correlated with successful surgical repair. Results: A total of 29 recipients had biliary complications, of which 19 had a surgical repair. The five recipients, operated on for a stricture without history of leaks, did not develop further complications. However, nine of 14 with a history of a leak developed further complications after surgical repair (p‐value = 0.044). All five who presented with a biliary complication more than 100 d after transplant had successful surgical repair; however, nine out of 13 who presented within 57 d had additional complications after repair. Conclusions: Operations for strictures after ALDLT are more successful than operations for leaks. Recipients with isolated biliary strictures after ALDLT can be managed surgically; however, recipients with history of a leak often require additional interventions after surgical repair.     

肝移植术后胆道并发症病因及预防

目的分析原位肝移植术后胆1道并发症的病因。方法回顾性分析307例尸体供肝和40例活体供肝原位肝移植的临床资料,总结术后胆道并发症的病因。结果40例活体肝移植受体术后胆道并发症的发生率5.0%,307例尸体供肝肝移植受体术后胆道并发症的发生率为18.9%;肝内胆道狭窄和胆道铸型结石形成等严重胆道并发症在活体肝移植和放置“T”管的尸肝移植未发生。结论缺血时间尤其热缺血时间是导致严重胆道并发症的最主要的原因,放置“T”管引流能降低胆道并发症的发生率。     

Outcome of liver transplantation using donors older than 60 year of age

Serrano MT, Garcia‐Gil A, Arenas J, Ber Y, Cortes L, Valiente C, Araiz JJ. Outcome of liver transplantation using donors older than 60 year of age.
Clin Transplant 2010: 24: 543–549.
© 2009 John Wiley & Sons A/S. Abstract: The impact of donor age on liver transplantation has been analyzed in several studies with contradictory results. Our aim was to evaluate graft survival and complications in the first year after liver transplantations with livers from older donors. Methods: Prospective analysis of 149 consecutive primary liver transplantations performed between 2000 and 2005. Transplantations were divided into two groups according to donor age: group A, <60 yr old (n = 102); and group B, ≥60 yr old (n = 47). Results: Chronic and acute rejection, vascular complications, and infections were not statistically different between the groups. Anastomotic biliary strictures were similar in the two groups, but non‐anastomotic biliary strictures (NABS) were clearly more frequent in the older donor group (17% vs. 4.9%; OR 3.9; p = 0.025). NABS with no arterial complication was diagnosed in 10.6% of cases in group B vs. 1% in group A (OR = 12; p = 0.012). Graft survival in the first year was 86.67% in the younger group of donors and 71.43% in the older group (p < 0.05), but patient survival was not different. Conclusions: The use of grafts from donors ≥60 yr decreased graft survival after liver transplantation and was related to a higher frequency of non‐anastomotic biliary strictures.     

Identification of current smokers among renal transplant recipients.

BACKGROUND: In renal transplant recipients, smoking is associated with a high burden of cardiovascular disease and a higher risk of graft loss. Surprisingly, the results of measurement of cotinine serum level, the gold standard for the detection of active smoking, have not been confronted with self-reported smoking history in this group. The aim of our study was to identify and characterize the smoking group of renal transplant recipients. METHODS: Cotinine serum level was measured and all patients were asked to fill out an anonymous questionnaire on smoking history. RESULTS: Out of 233 renal transplant recipients, 106 (45%) reported to be lifetime and current non-smokers: cotinine serum level was below detection limit in all; among the 127 renal transplant recipients (55%) with a lifetime history of smoking, cotinine level was diagnostic of current smoking in 32 (25%). Only 21 of the current smokers (66%) declared to the nephrologist that they had continued smoking whereas 11 (34%) claimed to be non-smokers. Current smokers were younger (P=0.01) than former smokers. CONCLUSION: The identification of current smokers among renal transplant recipients should start with questioning about lifetime history of smoking and if positive, measurement of cotinine serum level. Indeed up to 34% of current smokers do not acknowledge they are active smokers and would otherwise not offer to participate in programmes to stop smoking.     

Interventional radiologic procedures in liver transplantation

Postoperative biliary and vascular complications contribute significantly to morbidity and mortality in liver transplantation. Interventional radiologists are an integral part of the multidisciplinary team necessary for optimizing the management of these complications. During a 15-year period, 39 cadaveric and 25 living related liver transplantations were performed at the Chang Gung Memorial hospital, Taiwan. Of 64 liver transplant recipients, 9 (3 adult and 6 pediatric) underwent 13 interventional radiological procedures for the treatment of biliary sludge-casts (n = 2), bile duct occlusion or stenosis (n = 2), hepatic veins thrombosis (n = 1), hepatic veins stenosis (n = 1), portal vein stenosis with splenorenal shunting (n = 1), biloma (n = 1), and infected fluid collection or ascites (n = 4). Antegrade or retrograde interventional approach was used to successfully treat all biliary complications, and all percutaneous drainage procedures were effective in the control of intra-abdominal fluid collections. Portal vein stenosis was treated by balloon dilatation, and the associated splenorenal shunt was closed by metallic coil embolization via transhepatic catheterization of the portal vein. Hepatic vein stenosis was effectively treated by balloon dilatation and expandable metallic stent deployment via transfemoral and jugular venous approaches, respectively. Hepatic vein thrombosis was only partially lysed by transvenous streptokinase administration, and surgical thrombectomy was needed to achieve complete recanalization. The total success rate of the interventional procedures was 92 % with no procedure-related complications. The overall survival rate in this series is 89 %, and all patients who underwent living related liver transplantation maintain to date a 100 % survival rate. We can conclude that interventional radiological procedures are very useful for managing biliary and vascular complications after liver transplantation. These techniques provide a cure in most situations, thus obviating the need for further surgical intervention or re-transplantation. Received: 6 March 2000 Accepted: 5 May 2001     

Donor morbidity in right and left hemiliver living donor liver transplantation: the impact of graft selection and surgical innovation on donor safety

This study investigated adequate liver graft selection for donor safety by comparing postoperative donor liver function and morbidity between the right and left hemilivers (RL and LL, respectively) of living donors. Between April 2006 and March 2012, RL (n = 168) and LL (n = 140) donor operations were performed for liver transplantation at Kyoto University Hospital. Postoperative hyperbilirubinemia and coagulopathy persisted in RL donors, whereas the liver function of LL donors normalized more rapidly. The overall complication rate of the RL donors was significantly higher than that of the LL donors (59.5% vs. 30.7%; P < 0.001). There were no significant differences in severe complications worse than Clavien grade IIIa or in biliary complication rates between the two donor groups. In April 2006, we introduced an innovative surgical procedure: hilar dissection preserving the blood supply to the bile duct during donor hepatectomy. Compared with our previous outcomes (1990–2006), the biliary complication rate of the RL donors decreased from 12.2% to 7.2%, and the severity of these complications was significantly lower. In conclusion, LL donors demonstrated good recovery in postoperative liver function and lower morbidity, and our surgical innovations reduced the severity of biliary complications in living donors.     

Biliary strictures after orthotopic liver transplantation: long-term results of percutaneous treatment in patients with nonfeasible endoscopic therapy

Purpose

The aim of this study was to evaluate our experience with percutaneous treatment of biliary strictures after orthotopic liver transplantation in adult patients without the endoscopic access possibility and to evaluate the technical outcomes and long-term clinical results of this treatment.

Materials and methods

Thirty percutaneous procedures were performed in adult liver transplant recipients (13 men, 17 women, mean age 46.4 years) in our institution between 1996 and 2010. Patients were treated with balloon dilatation and biliary duct drainage due to anastomotic stenosis (n = 20), nonanastomotic stenosis (n = 7), or due to stenosis caused by lymphoproliferation (n = 3). The percutaneous procedure was the first line of treatment due to hepaticojejunoanastomosis (n = 18) or after unsuccessful endoscopic therapy (n = 12).

Results

Technical success was achieved in 27 patients (90%). The remaining three patients only achieved external drainage with subsequent surgery. There were two complications (6.3%). Long-term clinical success, defined as the absence of clinical, laboratory, or sonographic signs of stricture recurrence was achieved in 22 patients (73.3%) for a mean follow-up of 5.8 years.

Conclusion

Percutaneous treatment—balloon dilatation and biliary duct drainage—is a first-line option to manage biliary duct strictures in liver recipient, when endoscopic treatment is not possible or unsuccessful. It has a high technical success rate and low complication rate with favorable long-term results.     

Steatosis of the hepatic graft as a risk factor for post‐transplant biliary complications

Baccarani U, Isola M, Adani GL, Avellini C, Lorenzin D, Rossetto A, Currò G, Comuzzi C, Toniutto P, Risaliti A, Soldano F, Bresadola V, De Anna D, Bresadola F. Steatosis of the hepatic graft as a risk factor for post‐transplant biliary complications.
Clin Transplant 2009 DOI: 10.1111/j.1399‐0012.2009.01128.x.
© 2009 John Wiley & Sons A/S. Abstract: Background: Despite recent advances in organ preservation, immunosuppression, and surgical techniques, the biliary tree is still considered the Achilles’ heel of liver transplantation. The aim of this study is to retrospectively analyze the incidence of biliary complications and identify risk factors that might predispose to the development of biliary problems. Methods: From January 2004 to December 2007, 117 consecutive liver transplantations were retrospectively analyzed for the development of biliary complications by the review of medical records. Patients were divided into group 1 with biliary complications (n = 43) and group 2 without biliary complications (n = 74). Results: The overall biliary complication rate was 36.8% (leakage 6% and stricture 30.8%). Univariate analysis indicated that significant predictors of biliary complications were the time interval between portal and arterial reperfusion (p = 0.037) and macrovacuolar steatosis of the graft > 25% (p = 0.004). Stepwise logistic regression model demonstrated that a macrosteatosis of the graft > 25% (OR = 5.21 CI 95% [1.79–15.15], p = 0.002) was the only independent risk factor predicting biliary complications after liver transplantation. No differences in patient’s and graft’s survival were noted between the two groups. Conclusion: According to our experience, transplanting a liver with > 25% of steatosis is a risk factor for the development of biliary complication.     

Comparison of biliary complications in adult living‐donor liver transplants performed at two busy transplant centers

Melcher ML, Pomposelli JJ, Verbesey JE, McTaggart RA, Freise CE, Ascher NL, Roberts JP, Pomfret EA. Comparison of biliary complications in adult living‐donor liver transplants performed at two busy transplant centers.
Clin Transplant 2009 DOI: 10.1111/j.1399‐0012.2009.01189.x.
© 2009 John Wiley & Sons A/S. Abstract: Adult living‐donor liver transplantation (ALDLT) has a high rate of biliary complications. We identified risk factors that correlate with biliary leaks and strictures by combining data from two centers. Records of ALDLT right lobe recipients (n = 156) at two centers between December 1998 and February 2005 were reviewed. Leak rate was analyzed in 144 recipients after we excluded those with hepatic artery thrombosis or death within 30 d of transplant. Stricture rate was also analyzed in 132 recipients after we excluded those with graft survival or follow‐up <180 d. Biliary reconstructions were performed using either duct‐to‐duct (DD) or Roux‐en‐Y hepaticojejunostomy and were subclassified by anatomic type, number of anastomoses performed, and stent use. Prevalence of a leak and/or a stricture was 39%; 11% of recipients developed both. Single DD anastomoses between the graft right hepatic duct to the recipient common duct had significantly lower incidence of leaks compared to all other anastomotic types. Early leak was predictive of late stricture development (p = 0.006), but recipient demographics, diagnosis, warm ischemia time, anastomosis type, duct number, year of transplant, stent use, and transplant center were not. The results suggest donors with a single right hepatic duct reconstructed to the recipient common bile duct are the most likely to avoid biliary problems after ALDLT.     

Magnetic resonance cholangiopancreatography for the accurate diagnosis of biliary complications after liver transplantation: comparison with endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography - long-term follow-up

Biliary complications after liver transplantation remain a serious cause of morbidity and mortality. Direct invasive cholangiographic techniques, endoscopic retrograde cholangiography (ERCP) or percutaneous transhepatic cholangiography (PTC), have procedure-related complications. Magnetic resonance cholangiopancreatography (MRCP) is non-invasive, safe, and accurate. The aim of this study was to evaluate MRCP in detecting biliary complications following liver transplantation and comparing findings with ERCP and PTC. Twenty-seven consecutive liver transplant recipients who presented with clinical and biochemical, ultrasonographic, or histological evidence of biliary complications were evaluated with MRCP. Patients were followed up for a median period of 36 months. The presence of a biliary complication was confirmed in 18 patients (66.6%): anastomotic biliary stricture in 12 (66.6%); diffuse intrahepatic biliary stricture in 5 (27.7%): ischemic (n = 3), recurrence of primary sclerosing cholangitis (n = 2), and choledocholithiasis in one. In nine patients (33.3%), MRCP was normal. Six patients underwent ERCP, and eight PTC. There was a statistically significant correlation between the MRCP and both ERCP and PTC (p = 0.01) findings. The sensitivity and specificity of the MRCP were 94.4% and 88.9%, respectively, and the positive and negative predictive values, 94.4% and 89.9%, respectively. MRCP is an accurate imaging tool for the assessment of biliary complications after liver transplantation. We recommend that MRCP be the diagnostic imaging modality of choice in this setting, reserving direct cholangiography for therapeutic procedures.     

�ھ������ڸ���ֲ���󵨵�����֢�еĵ�λ������

目的 探讨内镜治疗在肝移植术后胆道并发症中的地位和作用。方法 对1993年4月至2002年12月实施的210例肝移植病人临床资料进行回顾性分析。结果 共确诊29例肝移植术后胆道并发症。胆道并发症发生率为13．8％，与胆道并发症相关的病死率为1．4％。内镜治疗占53．3％(24／45)。结论 内镜下逆行胰胆管造影(ERCP)对胆道并发症既能准确诊断，又能提供有效的介入治疗手段。ERCP治疗吻合口漏、吻合口狭窄和胆总管结石的疗效理想，对缺血性胆管病变的诊断作用大于治疗作用。     

Biliary complications and management in pediatric living donor liver transplantation for underlying biliary atresia

Background

Biliary complications are a major problem in pediatric liver transplantation. The aim of this study was to evaluate the management and outcomes of biliary complication after pediatric living donor liver transplantation (LDLT).

Methods

From 1994 to 2010, 157 pediatric LDLT due to biliary atresia were performed in our center. Doppler ultrasound was initially performed daily for 2 weeks postoperatively to evaluate biliary and vascular complications. Computed tomography and or magnetic resonance cholangiography were performed when complications were suspected. They were treated using radiological or surgical interventions.

Results

Among the 157 cases, we observed 10 (6.3%) biliary complications, which were divided into three groups: bile leakage (n = 3); biliary stricture without vascular complication (n = 4); and biliary stricture with vascular complication (n = 3). The three cases bile leakages recovered after interventional procedures. The seven biliary strictures underwent percutaneous transhepatic cholangial drainage (PTCD). All cases without vascular complications were completely cured after PTCD or a subsequent surgical re-anastomosis. In the vascular complication group, early recorrection of the HA occlusion with successful PTCD treatment were performed in two cases, but one other case with diffuse ischemic biliary destruction had a poor result.

Conclusion

Successful interventional radiographic approaches are effective for anastomotic biliary complications but with poor results in diffuse ischemic biliary destruction.     

Biliary tract reconstruction: comparison of different techniques after 187 paediatric liver transplantations

Biliary complications after liver transplantation are common and cause significant morbidity and mortality. In order to evaluate the complications related to differents sort of biliary reconstruction, from January 1984 to July 1992 we retrospectively analysed 187 consecutive liver transplants in 136 paediatric patients at Addenbrooke's Hospital, Cambridge. There were 51 (27.2%) retransplantations. Biliary reconstruction consisted of: type 1 —common bile duct — Roux loop (CBD-RL); n=90 (48.1%); type 2 —gallbladder conduit — Roux loop (GC-RL), n=51 (27.2%); type 3 —gallbladder conduit — common bile duct (GC-CBD), n=20 (10.6%); type 4 — common bile duct — common bile duct (CBD-CBD), n=18 (9.6%); and type 5 — common bile duct — common bile duct+gallbladder drainage (CBD-CBD+GB), n=8 (4.2%). There were, in all 26 biliary complications (14%). Of these 26 complications, biliary stricture was the most common (17/26; 65.3%) and 6 out of these 17 (35.2%) were associated with chronic rejection. Hepatic artery thrombosis was directly related to biliary leakage in 6 out of 26 (23.1%) biliary tract complications. This series demonstrated that type 1 and type 4 reconstructions were related to fewer biliary complications (9/90, 10% and 2/18; 11%, respectively) than the other techniques: 8/51 (16%) for GC-RL 5/20 (25%) for GC-CBD and 2/8 (25%) for CBD-CBD+GB (P=0.09).     

Fungal complications after Candida preservation fluid contamination in liver transplant recipients

Donor‐derived fungal infections can be associated with severe complications in transplant recipients. Donor‐derived candidiasis has been described in kidney transplant recipients where contamination of the preservation fluid (PF) was a commonly proposed source. In liver transplantation, these fungal infections have been less explored. The aim of this study was therefore to determine the incidence and clinical relevance of Candida contamination of preservation fluid in the context of liver transplantation. A 5‐year (2008–2012) retrospective multicentre study involving six French liver transplantation centers was performed to determine the incidence of Candida PF contamination. Postoperative clinical features, outcomes in recipients, and risk factors for Candida‐related complications of liver transplantation were studied. Candida sp. was isolated from 28 of 2107 preservation fluid samples (1.33%). Candida albicans was the most common yeast (n = 18, 64%). Twenty‐two recipients (78.5%) received antifungal therapy (echinocandins in 68%) for 7–37 days. Eight patients developed yeast‐related complications (28.6%) including hepatic artery aneurysms (n = 6) and Candida peritonitis (n = 2). The 1‐year mortality rate among patients after a yeast‐related complication was 62.5%. The incidence of Candida PF contamination was low, but was associated with dramatic postoperative complications and high mortality. Close radiological follow‐up may enable early recognition of the arterial complications associated with PF contamination by Candida.     

De novo malignancies and liver transplantation

INTRODUCTION: De novo tumors (DNTs) are the leading cause of late death among liver transplant recipients with an incidence of 5% to 15%, which is significantly greater than the general population. In this retrospective study, we compared this complication in liver transplant recipients to sex- and age-matched controls. PATIENTS: Among 410 patients who received liver allografts between March 1986 and December 2000, 32 (7.8%) developed a DNT. Epidermoid tumors were the most frequent histologic lineage. A complete response was observed in 19 patients (59.4%), a partial response in eight (25%), and no response in five (15%). Survival was lower among liver transplant recipients than controls, a difference that was statistically significant. Treatment consisted of surgery in 76.7%, radiotherapy in 16.7%, chemotherapy in 13.3%, and reduction of immunosuppression in 10%. RESULTS: The mean survival time in transplant patients of 122.97 months (95% CI; range 98-147 months) was significantly shorter than controls, 156.5 months (95% CI; range 141-171 months). About 50% of patients were smokers (active or ex-smokers), compared to 20.7% of controls (P=.049). Significant differences were also found when the three subgroups (smokers, previous smokers, and nonsmokers) were analyzed separately (P=.013). Patients were smokers (active or nonactive) among 45% of cases of skin tumors; 60% of hematological tumors; 71.4% of epidermoids; and 33% of sarcomas. CONCLUSIONS: DNTs, a complication of long-term immunosuppression in patients after liver transplantation, most frequently presented as skin tumors and PTLD. Occurrence of a DNT was an adverse prognostic factor for survival. Smoking represents an independent risk factor for these tumors.     

Spatulated end-to-end bile duct reconstruction in orthotopic liver transplantation

Biliary complications continue to be a major source of morbidity following orthotopic liver transplantation. The aim of this study was to analyze the incidence and management of biliary complications related to the technique of bile duct reconstruction. The patients were stratified into two groups: group I (n = 39) had bile duct reconstruction performed by an end-to-end single interrupted suture choledochocholedochostomy (EE-CDCD) and group II (n = 38) had a spatulated end-to-end CDCD (spEE-CDCD) reconstruction; both groups had an intraductal stent. The groups were similar in age, gender, liver transplant indications and Pugh score. Ten biliary complications (26%), including five bile leaks (13%) and five biliary strictures (13%), were observed in the EE-CDCD group, while one biliary stricture (2.6%) occurred in the spEE-CDCD group (p < 0.05). Subsequent imaging studies and endoscopic retrograde cholangiopancreatography were performed less often in patients undergoing spEE-CDCD reconstruction (p < 0.05). The technique of a spatulated end-to-end bile duct reconstruction provides a significant improvement in lowering biliary complication rates in liver transplant patients. Despite the modest number of cases in this study this technique shows promise and has become the technique of choice in our institution.     

Characteristics of biliary reconstruction, using a T-tube, as compared to those with other methods, in left-lobe adult living-donor liver transplantation

Background/Purpose Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living-donor liver transplantation. The aim of this study was to analyze the clinical implications of three different methods of biliary reconstruction in left-lobe adult living-donor liver transplantation. Methods We retrospectively compared three groups of patients: those who had Roux-en-Y hepaticojejunostomy (HJ; n = 11) biliary reconstruction, those who had duct-to-duct hepaticohepaticostomy (HH) with external stent (n = 11), and those who had HH with a T-tube (n = 6). Median follow-up for each group was 31, 30, and 10 months, respectively. Results Bile leaks were observed in 45.5% of the patients in both the HJ group and the HH with external stent group. Biliary anastomotic strictures occurred in 9% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with external stent. No biliary complications were observed in the HH with a T-tube group (P = 0.049). Conclusions Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up period, these encouraging preliminary results may warrant further studies of this biliary reconstruction technique in left-lobe adult living-donor liver transplantation.     

Former smoking and early and long‐term graft outcome in renal transplant recipients: a retrospective cohort study

Smoking is associated with unfavourable outcome in solid‐organ transplant recipients. Nicotine may predispose to kidney injury by increasing oxidative stress. We hypothesized that former smoking negatively affects graft outcome in kidney transplant recipients and especially those with delayed graft function (DGF). We included adult recipients of a kidney transplant between 1 January 2003 and 1 October 2015 at Ghent University Hospital and recorded outcomes until 31 October 2015. We used Kaplan–Meier and multivariable Cox proportional hazard analysis to examine the relationship between former smoking at the time of transplantation and the incidence of 10‐year graft loss with and without censoring for death in 1013 participants. We evaluated mean differences in eGFR over time by a random intercept and slope model, considering a linear time effect. After adjusting for potential confounders, a history of smoking was associated with an increased hazard of graft loss (adjusted hazard ratio (aHR) 1.60; 95% CI: 1.17–2.17; P = 0.003) and death‐censored graft loss (aHR 2.29; 95% CI: 1.41–3.72; P = 0.001). The linear time trend of eGFR was different between former and never smokers (P = 0.001). To conclude, former smoking exerts long‐lasting negative effects on graft outcome and this independent of DGF.