Anhepatic Period Research Articles

The Effect of Enhanced Recovery After Surgery Nursing on the Recovery in Patients After Liver Transplantation

ObjectiveTo explore the effect of enhanced recovery after surgery nursing on the recovery in patients after liver transplantation. MethodsThis study was performed in 128 patients underwent liver transplantation in our hospital. According to the random number table, these patients were divided into the control group (n = 64) and the experimental group (n = 64). Patients in the control group received traditional nursing, while those in the experimental group received enhanced recovery after surgery nursing. Completion time of the operation, the amount of infused red blood cells during operation, intraoperative anhepatic period, intensive care unit (ICU) stay, the total length of hospitalization, the number of patients reintubated after surgery, the survival rate within 1 year after surgery, and the incidence of postoperative complications were compared between the two groups. ResultsIntraoperative anhepatic period and the amount of infused red blood cells during operation in the experimental group were lower than those in the control group (both P < .05). Postoperative ICU stay, the total length of hospitalization, and the number of patients reintubated after surgery in the experimental group were decreased when compared with the control group, while postoperative ventilator weaning time was increased (all P < .05). The survival rates at 3 months, 6 months, and 1 year after surgery in the experimental group were higher than those in the control group (all P < .05). Compared with the control group, the total incidence of complications in the experimental group was reduced (P < .05). ConclusionThe application of enhanced recovery after surgery nursing in liver transplantation patients contributes to the accelerated recovery of body function, shortened total length of hospitalization and ICU stay, declined complications, and increased survival rate within 1 year.

Efferent blood supply to the right hepatic lobe regarding its transplantation from a living donor: reconstruction features. Part 2

Aim . To present the technical features and results of transplantation of the right hepatic lobe from a living donor with various types of efferent venous anatomy. Materials and methods. 306 liver transplantations from living related donors were performed from 2009 to 2021. Patients with previously described 14 subtypes of efferent vascular anatomy and classified into 3 types, were divided into 4 groups depending on the number of reconstructed vessels. The author analyzed anatomy variants of the right hepatic lobe, duration of surgery and anhepatic period, postoperative morbidity, volume of blood loss, including with allowance for the number of reconstructed vessels, as well as survivability. Results . The study demonstrated the principles and features of the reconstruction of the efferent veins of the graft. Time of surgical intervention, duration of anhepatic period, and postoperative morbidity were greatest with a separate type of blood outflow ( p &lt; 0.05) Blood loss was greatest during reconstruction veins 3 and 4 ( p &lt; 0.05). No difference in blood loss was detected between groups 3 and 4. Survivability within 12, 36, 60 and 120 months accounted for 84%, 83%, 81% and 71%, correspondingly, without any difference between groups. Conclusion . Successful transplantation of the right hepatic lobe requires precision mapping of the venous anatomy of the donor, preserving all potentially important efferent vessels, and commitment to the most complete reconstruction of them, irrespective of the vascular anatomy complexity.

Results of liver retransplantations

Aim. To present the results of repeated liver transplantations performed in a federal center. Materials and methods. The results of 268 orthotopic full-liver postmortem transplantations in 248 patients since 1998 were analyzed. Retransplantation was performed in 20 patients (8.1%) – 10 men and 10 women, 18-64 years old (median age 44.4 years). The median MELD score was 21 (19-24). Observations before 2006 were analyzed retrospectively. Early hepatic artery thrombosis and late biliary complications due to insufficient arterial blood supply to the graft indicated the retransplantation in the majority of patients. Results. The duration of preservation stages was comparable to the primary transplantation. Significant differences were found in the duration of the anhepatic period, the volume of hemotransfusion, the duration of the surgery, the rate of complications and the hospital mortality rate. Currently, 9 of the 20 patients (45%) are alive, with a follow-up period of 7-140 months. Graft function was satisfactory in most recipients. Hospital mortality accounted for 35%. Conclusion. Liver retransplantation is accompanied by considerable technical difficulties, as well as by an increase in surgery duration, volume of blood transfusion, time of stay in the intensive care unit, and incidence of postoperative complications. Infectious complications were the main cause of death. With successful retransplantation, long-term results and survival rates were comparable to those of primary transplantation.

Single-center experience of Ex vivo liver resection and autotransplantation for complex hepatic alveolar echinoccosis.

To summarize the single-centre experience of Ex vivo Liver Resection and Autotransplantation (ELRA) to treat end-stage hepatic alveolar echinococcosis (HAE). Retrospective analysis of clinical data and follow-up data of 13 patients admitted to the Affiliated Hospital of Qinghai University from January 2015 to December 1, 2020, with the Ex vivo Liver Resection and Autotransplantation for hepatic alveolar echinococcosis. 13 patients underwent successful total/ semi-ex-vivo liver resection combined with Ex vivo Liver Resection and Autotransplantation with no intra-operative deaths. the median standard liver volume was 1,118 ml (1,085-1,206.5 ml); the median residual liver volume was 634 ml (526.5-1,338 ml); The median weight of the autograft was 845.8 g (619.5-1,020.5 g), the median operation time was 14.5 h (11.5-16.15 h); the median anhepatic period time was 290 min (257-312.5 min). The median intraoperative blood loss was 1,900 ml (1,300-3,500 ml); the median number of erythrocyte suspensions entered was 7.5 u (6-9u). The median length of hospital stay was 32 days (24-40 days). Postoperative complications occurred in 9 patients during hospitalization,with 7 patients graded at grade III or higher by Clavien-Dindo; 4 patients died postoperatively. 1 patient had recurrent abdominal distension with massive thoracoabdominal fluid and coagulation dysfunction 8 months after surgery and was considered to have small liver syndrome. 1 patient developed HAE recurrence during the follow-up, which was considered intraoperative incisional implantation. ELRA is one of the most valuable therapeutic measures for the treatment of end-stage complicated hepatic alveolar echinococcosis. Precise preoperative assessment of liver function, individualized intraoperative duct reconstruction, and precise management of the postoperative disease can achieve better treatment results.

Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study.

Postreperfusion syndrome (PRS) after portal vein reperfusion during liver transplantation (LT) has been reported to cause rapid hemodynamic changes and is associated with a prolonged postoperative hospital stay, renal failure, and increased mortality. Although there are some reports on risk factors for PRS in brain-dead donor LT, there are a few reports on those in living donor LT. Therefore, we retrospectively reviewed the factors associated with PRS to contribute to the anesthetic management so as to reduce PRS during living donor LT. After approval by the ethics committee of our institution, 250 patients aged ≥20 years who underwent living donor LT at our institution between January 2013 and September 2018 were included in the study. A decrease in mean arterial pressure of ≥30% within 5 minutes after portal vein reperfusion was defined as PRS, and estimates and odds ratio (OR) for PRS were calculated using logistic regression. The backward method was used for variable selection in the multivariable analysis. Serum calcium ion concentration before reperfusion (per 0.1 mmol/L increase; OR, 0.74; 95% confidence interval (CI), 0.60-0.95; P < .001), preoperative echocardiographic left ventricular end-diastolic diameter (per 1-mm increase: OR, 0.90; 95% CI, 0.85-0.95; P < .001, men [versus women: OR, 2.45; 95% CI, 1.26-4.75; P = .008]), mean pulmonary artery pressure before reperfusion (restricted cubic spline, P = .003), anhepatic period (restricted cubic spline, P = .02), and graft volume to standard liver volume ratio (restricted cubic spline, P = .03) were significantly associated with PRS. In living donor LT, male sex and presence of small left ventricular end-diastolic diameter, large graft volume, and long anhepatic period are associated with PRS, and a high calcium ion concentration and low pulmonary artery pressure before reperfusion are negatively associated with PRS.

Use of the ligamentum teres hepatis for outflow reconstruction during ex vivo liver resection and autotransplantation in patients with hepatic alveolar echinococcosis: A case series of 24 patients

BackgroundPatients with extensive hepatic alveolar echinococcosis might require ex vivo liver resection and autotransplantation to remove the lesion. Patients with extensive vascular invasion will need reconstruction, but the selection of the proper graft is complicated. This study aimed to investigate the effectiveness and adverse events of using the ligamentum teres hepatis as a vascular replacement graft in ex vivo liver resection and autotransplantation. MethodsThis was a retrospective case series of patients with hepatic alveolar echinococcosis who underwent ex vivo liver resection and autotransplantation between August 2010 and October 2018 and in whom the ligamentum teres hepatis was used to repair the remnant liver. The operative outcomes, recurrence, and survival were examined. ResultsTwenty-four patients were included (10 men, 14 women). The anhepatic period was 290 to 672 minutes (median of 450 minutes). The ratio of the remnant liver volume to the standard liver volume was 0.43 to 0.97 (median of 0.71). The blood loss was 1,000 (500–5,000) mL. The postoperative hospital stay was 23 (1–85) days. Of the 24 patients, 3 died after the operation, but those deaths were unrelated to liver vascular complications. ConclusionThe ligamentum teres hepatis could be used as a vascular replacement graft in ex vivo liver resection and autotransplantation. It has the advantages of convenient specimen extraction, no donor site injury, and no immunological rejection, which has promising clinical application prospects.

Fast Vascular Reconstruction With Magnetic Devices in Liver Transplant: A Novel Surgical Technique.

Minimizing the anhepatic period is critical to reduce allograft dysfunction, intestinal bacterial translocation, and acute liver failure among liver transplant (LT) recipients. The current study introduced a new surgical technique for fast major vascular reconstruction by utilization of magnetic devices in recipients. A prospective study was conducted among patients who underwent orthotopic LT using Donation after Cardiac Death (DCD) between November 2018 and December 2019. The procedures of magnetic-assisted LT was clinically performed and introduced. In brief, three pairs of C-shaped magnetic rings and matched base members were placed and fixed in the stump of supra- and infra-hepatic inferior vena cava, as well as portal vein of the donors and recipients. The donor liver was implanted, and the magnet rings at the donor and recipient vessels attached immediately for a rapid reconstruction. Final continuous suture of the vessels was then performed under restoration of the blood flow. A total of six patients were finally enrolled in magnetic-assisted LT. The median age of the recipients was 40.0 (IQR 37.0-49.3) years, and all were male patients as well. The median anhepatic time of patients undergoing magnetic-assisted LT was 10.3 min (IQR 9.5-13.2 min). With a median follow-up of 10.5 (range 7.2-19.8) months, all patients recovered well with normal liver function. Two patients had experienced partial portal vein thrombosis or acute rejection, respectively, which were unrelated to the surgical techniques, and treated successfully. The magnetic-assisted vascular anastomosis shortened the anhepatic phase to only about 10 min during LT. Fast revascularization of the donor liver by using the novel magnetic technique is safe and feasible in LT.

Analysis of Risk Factors for Postoperative Delirium After Liver Transplantation.

PurposeThe study aimed to analyze the incidence of postoperative delirium (POD) and associated risk factors after liver transplantation (LT).Patients and MethodsWe identified and enrolled patients undergoing LT at the Second Xiangya Hospital, Central South University between August 2018 and May 2019. We abstracted their relevant clinical information and assigned the patients into a POD group and non-POD group to compare differences in clinical information. Risk factors of POD were analyzed using logistic regression.ResultsA total of 159 LT patients were enrolled. Forty-two patients exhibited delirium (26.4%). Of the 42 with delirium, 33 (78.6%) had delirium within 3 days postoperatively and a median duration of 5 days (quartile 3–7 days). The results of binary logistic regression are as follows: preoperative ammonia (≥46 vs <46 μmol/L; OR 3.51, 95% CI [1.31–9.46], P<0.05), Model for End-Stage Liver Disease (MELD) score (≥15 vs.<15; OR 3.33, 95% CI [1.27–8.79], P<0.05), presence of hepatic encephalopathy (OR 3.30, 95% CI [1.20–9.07], P<0.05), aspartate aminotransferase (AST) on day 1 postoperatively (OR 1.33, 95% CI [1.06 −1.68], P<0.05), anhepatic period (OR 1.04, 95% CI [1.02 −1.06], P<0.01). The POD group had a longer intubation time (2925.0 vs 1410.0 min, P<0.01), ICU length of stay (6 vs 4 d, P<0.01) and increased medical costs (43.96 vs 33.74 ten thousand yuan, P<0.01).ConclusionThe incidence of POD in LT patients is a significant clinical feature. Ammonia ≥46 μmol/l, MELD score ≥15, hepatic encephalopathy, anhepatic period, and AST at 1 day postoperatively were independent risk factors for POD.

The correlation between conventional coagulation tests and thromboelastography in each phase of liver transplantation.

Thromboelastography (TEG) is gaining increasing acceptance in liver transplantation (LT) with conventional coagulation tests (CCTs) such as prothrombin time (PT), activated partial thromboplastin time (aPTT), antithrombin III (ATIII), platelet count (PLT), and fibrinogen concentration. The purpose of this study was to evaluate the clinical utility of TEG in LT and investigate the correlation between TEG and CCT values during each phase of LT. Medical records of patients who underwent deceased donor LT at a single, university hospital between October 2010 and July 2015 were retrospectively reviewed. Blood samples were obtained at each phase of LT (pre-anhepatic, anhepatic, and neo-hepatic phase) according to our institutional LT protocol and utilized for analysis of TEG and CCTs. The Spearman correlation coefficient between TEG and CCT values were obtained. During the pre-anhepatic phase, the reaction time (R), PT, and aPTT did not correlate with each other, but demonstrated a negative correlation with PLT. Clot formation time (K) demonstrated a similar correlation with R and a negative correlation with fibrinogen. The maximal amplitude (MA) and α-angle (α) were positively correlated with PLT and fibrinogen and inversely correlated with aPTT. During the anhepatic phase, MA was significantly correlated with PLT and inversely correlated with aPTT; other parameters had weak or indistinct correlation. During the neo-hepatic phase, R and K were significantly correlated with aPTT and inversely correlated with PLT and fibrinogen. A correlation of MA and α with PLT, aPTT, and fibrinogen was also observed. Clot lysis at 30minutes and estimated percent lysis were inversely correlated with levels of ATIII and fibrinogen. Conventional coagulation tests and TEG show particularly poor comparability during the anhepatic period of liver transplantation. TEG can be most reliable in the anhepatic phase, during which dynamic hemostatic changes occur.

Successful liver retransplantation due to acute AMR with 18 hours anhepatic period, complicated by the necrotizing pancreatitis

Introduction: This case describes the successful re-LTx (with 18 hours anhepatic period) performed due to severe AMR on the 10th POD. On the 7th day after re-LTx ischemic necrotizing pancreatitis developed. The patient died 20 days after the re-LTx due to the septic shock. Method: The patient S., aged 58, was transplanted due to NASH-related cirrhosis (MELD 23, hepatorenal syndrome). LTx was performed from non-marginal DBD. Result: First four postoperative days (PODs) were uneventful. From 5th till 10th PODs liver graft function progressively deteriorated with the level of AST/ALT of 5500 / 5300 U/l and INR of 3.6 on the 10th POD. Despite the sequential steroid pulse therapy, IVIG infusion and plasmapheresis, performed from the 6th to the 9th PODs, liver graft failure with multi-organ failure was developed on the 10th POD. The recipient was transferred to the operation theatre: the total graft necrosis was revealed (histologically C4d-positive antibody mediated rejection); hepatectomy and temporary portacaval shunt were performed. After this the patient condition was stabilized and the patient has been waiting for the liver graft in the operating theatre. Liver retransplantation from marginal DBD (graft steatosis - 60 %) was performed after 18 hours of anhepatic period. Early postoperative period was complicated by Enterococcus spp serous peritonitis, successfully treated by planned relaparotomies and antibiotic treatment. The second liver graft function was adequate. On the 7th day after re-LTx pancreonecrosis with necrosis of the mesentery of the descending colon was revealed. Despite provided intensive care the patient died 30 days after the 1st LTx. Conclusion: The aim - to verify on what step incorrect tactics was applied (if it was): 1. a) Classic technique vs Piggy-back in patients with severe HRS? b) Should we avoid Tac in patients with RRT in early postoperative period? c) Could we save that sort of patient?

Diamond-shaped patch technique for right hepatic vein reconstruction in living-donor liver transplant: A simple method to prevent stenosis.

Patency of the right hepatic vein (RHV) of the liver graft is essential for successful living-donor liver transplant (LDLT). We developed a simple technique for RHV reconstruction that does not require the use of cadaveric veins or additional time to prevent stenosis.Of 159 patients who underwent LDLT at our institution between May 2010 and April 2016, we included 152 in this study. Conventional RHV reconstruction was performed in 100 patients, while the diamond-shaped patch (D-patch) technique was performed in 53. For the D-patch technique, the posterior aspect of the RHV needs to be dissected from the liver parenchyma during donor hepatectomy, which prevents stenosis due to liver rotation after graft regeneration. A D-patch obtained from the hepatic vein of the recipient liver was used on the anterior aspect of the RHV for reconstruction. The Student's t test and χ2 test were used for statistical analysis.Rates of intervention for RHV stenosis during the first month were significantly different between the conventional reconstruction and D-patch groups (19.2% vs 3.8%; P = .01). The time taken to perform the D-patch technique was similar to that for conventional reconstruction (anhepatic period, 104.9 ± 47.3 minutes vs 106.7 ± 42.0 minutes; P = .82).The D-patch technique for RHV reconstruction in LDLT is a simple, fast, and feasible surgical technique that can be performed without using cadaveric or saphenous veins.

Peri-operative management of swine orthotopic liver transplantation

Objective To summarize the peri-operative management experience of swine orthotopic liver transplantation. Methods From September 2013 to August 2016, 62 liver transplantations (LT) were performed with 124 Bama mini-pigs, including 30 cases of standard LT, 10 cases of split LT, 11 cases of donation after cardiac death (DCD) LT, 5 cases of extracorporeal membrane oxygenation (ECMO) repaired DCD LT and 6 cases of normothermic machine perfusion (NMP) repaired DCD LT. Results For all of the 124 pigs, 3 underwent tracheotomy after failed tracheal intubation. Anhepatic time was (22.3±2.6) min (range 18-26 min), similar among the 62 different type LTs. Mean arterial pressure could be mainted ≥ 50 mmHg (1 mmHg=0.133 kPa) through rapid colloid solution infusion without administration of any vasoactive substances.5 receipts of split LTs died during the operation because of bleeding. 14 cases died after operation. 3 were of standard LT, all in the very beginning period when we first build this animal model, 1 died of abdominal bleeding, the other 2 died of bile leak induced severe infection.11 cases from the DCD LT died of model related hepatic failure. Post-operative 5-day survival rates of standard, split, DCD, ECMO-repaired DCD, NMP-repaired DCD were 90%, 50%, 0%, 100%, 100%, respectively. Conclusion Precise peri-operative management is essential for successful swine orthotopic liver transplantation. Skilled trachea intubation and tracheotomy procedure, accurate liquid management, well-practiced animal model are the key points, and anhepatic period should be shortened as much as possible. Key words: Pig; Liver transplantation; Peri-operative management

Impact of psoas muscle index on early postoperative mortality and complications after liver transplantation

Objective: To investigate the relationship between psoas muscle index (PMI) and early postoperative survival rate and the incidence of complications after liver transplantation in adults. Methods: The clinical data of 225 patients (male, n=184; female, n=41) underwent liver transplantation at the Organ Transplantation Department of First Central Clinic Institute of Tianjin Medical University from January 2014 to December 2016 were analyzed, retrospectively.Original disease: hepatitis B liver cirrhosis(44 cases), hepatitis C cirrhosis(10 cases), autoimmune liver cirrhosis(29 cases), other benign liver diseases(24 cases), liver cirrhosis with liver cancer(116 cases), hilar cholangiocarcinoma(1 case) and hepatic vascular sarcoma(1 case). The area of bilateral psoas muscle on the lower edge level of the third lumbar vertebral body was measured through preoperative CT image.The PMI was calculated using this formula: bilateral psoas muscle area (mm(2))/the square of the body height (m(2)). According to the receiver operating characteristic curve and cut-off values, the male and female patients were divided into low PMI group and high PMI group respectively.The χ(2) test, Fisher exact test and t-test was used to compare the differences in perioperative data, survival rate and postoperative complications between the two groups, respectively. Results: There were 44 patients in the low PMI group, and 181 patients in the high PMI group. ICU time was longer (82.5(62.0-128.0) hours vs.69.1(56.0-104.0) hours; P=0.006) and preoperative blood urea nitrogen level (5.86(4.35-15.52) mmol/L vs. 4.94(4.05-7.06) mmol/L; P=0.012) was higher in the low PMI group than those in the high PMI group. Incidence rates of grade 5 complication (18.2%) and grade 4a complication (18.2%) were higher in the low PMI group, and 120-day cumulative survival rate was lower than that in high PMI group(81.8% vs. 95.6%, P=0.001). On the other hand, there were no significant differences in preoperative white blood cell count level, serum creatinine level, operative time, anhepatic period time, intraoperative blood loss, and incidence of postoperative grade 3 complications between the two groups(all P>0.05). Conclusions: There is a significant correlation between PMI and early postoperative survival rate and incidence of complications.Patients with lower PMI has poor prognosis after liver transplantation.

Effect of ulinastatin on acute kidney injury in pediatric patients undergoing living-donor liver transplantation

Objective To evaluate the effect of ulinastatin on acute kidney injury in the pediatric patients undergoing living-donor liver transplantation(LDLT). Methods Forty pediatric patients with congenital biliary atresia, aged 5-14 months, weighing 5.5-10.0 kg, of American Society of Anesthesiologists physical status Ⅲ or Ⅳ, scheduled for elective LDLT, were divided into either control group(group C, n=20)or ulinastatin group(group U, n=20)using a random number table.Ulinastatin 20 000 U/kg was diluted to 10 000 U/ml in normal saline and then intravenously infused in 2 parts(1/2 was given immediately before skin incision; 1/2 at 5 min before portal vein declamping)in group U. The equal volume of normal saline was given instead of ulinastatin at the same time points in group C. Immediately before skin incision(T0, baseline), at 30 min of anhepatic period(T1), at 1 h of neohepatic period(T2), at the end of surgery(T3)and at 24 h after surgery(T4), blood samples from the central vein and urine specimens were collected for determination of creatinine(Cr)and blood urea nitrogen(BUN)concentrations in serum (by colorimetric assay)and β2-microglobulin(β2-MG)concentrations in serum and urine(using immunoturbidimetric method). The urine volume, requirement for dopamine and diuretics and occurrence of adverse cardiovascular events(hypotension, myocardial ischemia, ventricular premature beat)were recorded during surgery.The changing rates of Cr, BUN and β2-MG concentrations in serum and β2-MG concentrations in urine were calculated at T1-4. Results Compared with group C, the urine volume was significantly increased, Cr and β2-MG concentrations in serum, β2-MG concentrations in urine and the changing rates were decreased at T2-4, serum BUN concentrations and the changing rates were decreased at T3, 4(P 0.05). Conclusion Ulinastatin can attenuate acute kidney injury in the pediatric patients undergoing LDLT. Key words: Trypsin inhibitors; Liver transplantation; Child; Kidney; Prognosis

In Situ Procurement of a Recipient's Portal Vein for a Right Lobe Liver Graft With Multiple Venous Orifices: A Case Report

Reconstruction of multiple venous orifices of a right lobe graft is a time-consuming and troublesome procedure in right lobe living-donor liver transplantation. In the current study, we present a new venous reconstruction technique for a right lobe graft with multiple and complex hepatic vein (HV) orifices, in which procurement of the recipient's left portal vein was performed in situ to keep the anhepatic period to a minimum. All of the HV orifices were reconstructed together at the back table, while maintaining patency of the recipient's systemic and splanchnic circulation. A homologous vein graft and veno-venous bypass were not necessary. All HVs were patent during the follow-up and the patient was free from complications. In conclusion, the present technique is readily available for reconstruction of complex and multiple HV tributaries, while avoiding a long anhepatic time and the use of veno-venous bypass.

Pathological characteristics and clinical effect of autoimmune hepatitis after liver transplantation

Objective To investigate the pathological characteristics and clinical effect of autoimmune (AIH) after liver transplantation. Methods The retrospective descriptive cross-sectional study was adopted. The clinicopathological data of 14 patients with AIH who underwent liver transplantation at the First Affiliated Hospital of Xi′an Jiaotong University between June 2011 and December 2015 were collected. Fourteen patients underwent orthotopic liver transplantation, specimens of total liver resection from 14 patients and aspiration specimens from liver allografts of 6 patients with severely abnormal liver function after liver transplantation were collected and detected by hematoxylin-eosin (HE) staining. Specimens of total liver resection continued to detect by reticular fiber staining and immunohistochemistry. The tissues construction was observed by light microscopy. Observation indicators included (1) intra- and post-operative situations, (2) results of pathological examination, (3) follow-up. The follow-up using outpatient examination and telephone interview was performed to detect the situations of immuno-suppressive therapy and survival of patients up to March 2016. Measurement data were represented as average (range). Results (1) Intra- and post-operative situations: all the 14 patients with AIH underwent successful liver transplantation without perioperative death. The operation time, duration of anhepatic period of liver transplantation, volume of intraoperative blood loss and duration of hospital stay were 402 minutes (range, 353-405 minutes), 50 minutes (range, 42-60 minutes), 2 800 mL (range, 1 325-4 050 mL) and 19 days (range, 12-24 days), respectively. Of 14 patients with AIH after liver transplantation, 6 were complicated with pulmonary infection, 2 with acute rejection, 2 with bile duct strictures and 1 with acute renal failure, and they were improved by symptomatic treatment. (2) Results of pathological examination: HE staining of specimens of total liver resection showed that different levels of hepatitis were detected in 14 patients, lymphocytes penetration phenomena in 14 patients, lymphoplasmacytic interface hepatocyte necrosis in 9 patients, infiltration of plasma cells in 9 patients, spotty and piecemeal necroses in 5 patients and rosettes-like structure in 4 patients. HE staining of specimens of liver allografts showed that lymphoplasmacytic interface hepatocyte necroses were detected in 4 patients, rosettes-like structure in 4 patients, cholestatic cirrhosis in 3 patients, mildly acute rejection in 2 patients and recurrence of AIH in 1 patient. Reticular fiber staining: fibrous tissues were proliferative in the portal area and then separated and surrounded hepatocytes to form pseudolobule structure. Immunohistochemistry: inflammatory cells infiltrated by liver tissues were composed of T cells with mainly positive CD3 and CD8 and with few positive CD4. (3) Follow-up: 14 patients were followed up for 26 months (range, 3-57 months). Fourteen patients received regular immuno-suppressive therapy. During follow-up, 1 patient was complicated with primary transplants nonfunction, 2 had AIH recurrence and 3 were dead. Conclusions Patients with AIH should enhance hormone therapy due to high incidences of bile duct complications and pulmonary infection after liver transplantation. Lymphoplasmacytic interface hepatocyte necrosis and rosettes-like structure probably have worse prognosis. Dysfunction of Regulatory T cells (T-reg) may be a prognosis predictor for AIH after liver transplantation. Key words: Autoimmune hepatitis; Liver transplantation; Pathology; Prognosis

Systemic-to-pulmonary artery pressure ratio as a predictor of patient outcome following liver transplantation.

AIMTo assess the value of the mean systemic-to-pulmonary artery pressure (MAP/mPAP) ratio for predicting outcomes following orthotopic liver transplant (OLT).METHODSA retrospective data analysis was performed and data (mean arterial blood pressure, mean pulmonary artery pressure and Cardiac Index) were collected at several points during OLT. Outcomes evaluated were duration of postoperative endotracheal intubation [ET; minutes after intensive care unit (ICU) arrival], length of ICU stay, total hospitalization and frequency of immediate postoperative complications. A total of 91 patients were included in the data analysis. Based on the intraoperative course of the MAP/mPAP ratio, 2 hemodynamic responses were identified: Group 1 (MAP/mPAP ratio increase during anhepatic period with postreperfusion recovery, n = 66); and Group 2 (MAP/mPAP ratio with no change during anhepatic period or decreased without recovery, n = 25).RESULTSThe main finding was that the lack of increased MAP/mPAP ratio in the anhepatic period was associated with: (1) longer intubation times; and (2) prolonged ICU stays and total hospitalization time, when compared to patients with an increase in MAP/mPAP ratio during the anhepatic period.CONCLUSIONThe data from this retrospective study should raise awareness to the mean systemic to pulmonary artery pressure ratio as a potential indicator for poor outcome after OLT. Further prospective studies are needed for validation.

The risk factors of splenic arterial steal syndrome after orthotopic liver transplantation

To discuss the risk factors of splenic arterial steal syndrome (SASS) after orthotopic liver transplantation. Twenty-four cases who confirmed SASS after liver transplantation in Tianjin First Central Hospital between June 2005 and June 2013 were analyzed retrospectively. Another 96 cases were selected randomly from those patients of the same time with no complication of SASS patients postoperatively as control group. Clinical data of two groups including diameter of splenic artery and hepatic artery preoperatively, weight of graft, weight of recipients, cold/warm ischemia time, an hepatic period and operation time and so on were collected. Others including hepatic artery peak systolic velocity (PSV), end diastolic velocity (EDV), blood flow resistance index and portal vein average velocity (PVF) on the first day after liver transplantation, the day before diagnosis, the day when diagnosed, the 1, 3, 7 days after treatment in SASS group and on 1, 3, 7, 9, 11, 14 days after liver transplantation in control group. Statistical analysis were made between two groups. The splenic artery/hepatic artery ratio preoperatively and weight of donor liver,and the GRWR in SASS group and control group were 1.26 and 1.00, 1 032 g and 1 075 g, (1.40±0.30)% and (1.82±0.21)% respectively, with significantly statistical differences (Z=-6.40, Z=-2.22, t=-6.50; all P<0.05). The warm ischemia time, the cold ischemia time, the anhepatic period and operation time in SASS group and control group were 3.5 minutes and 4.0 minutes, 10.25 hours and 10.10 hours, 43 minutes and 45 minutes, 8.7 hours and 8.7 hours, with no significantly statistical differences (all P>0.05). RI of hepatic went up gradually in the early time after transplantation while dropped obviously when spleen artery spring coils embolization was received (P<0.01) and trended to stable two weeks later. Splenic artery/hepatic artery ratio and GRWR are the positive and negative risk factors respectively for SASS. The gradual rising of hepatic RI in the early time after transplantation may be the warning signal SASS and spleen artery spring coils embolization is the effective strategy for SASS after liver transplantation.

The Comparisons of Hepatitis C Virus RNA Level Between Intraoperative Blood Salvage (Cell Saver) and Systemic Hepatitis C Virus RNA Kinetics During Liver Transplantation

BackgroundCell Saver (CS; Haemonemic Corp, Braintree, Mass, United States) is frequently used to decrease transfusion requirements of homologous blood during liver transplantation (OLT). However, the use of CS in hepatitis C virus (HCV)-infected recipients is still debated owing to the potential elevation of HCV RNA level. In this study, we compared HCV RNA levels of CS blood with a series of blood samples obtained from HCV-infected OLT recipients. MethodsTwelve HCV-infected patients with >50,000 copies/mL of HCV RNA were enrolled. HCV RNA was measured immediately after induction (I), at the end of anhepatic period (II), at the end of operation (III), and from the first returned blood in CS (CSb). HCV RNA level at each time period was compared. ResultsHCV RNA levels ranged from 77,931 to 9,072,000 copies/mL at I. When compared to I, HCV RNA levels were reduced to 11.1% ± 13.0% and 0.7% ± 1.0% at II and III, respectively. Also, the RNA level reduced to 3.0% ± 2.0% of I after CS processing. The HCV RNA level at I was significantly higher than the levels at II, III, and CSb (P = .012, each), and the level at II was significantly higher than the level at III (P = .012). The HCV RNA level at CSb showed no statistical difference with the levels at II, but it was significantly higher than the level at III (P = .042). ConclusionsThe use of CS in HCV-infected OLT recipients seems to carry no additional risk with respect to intraoperative HCV RNA kinetics.

Long-term survival after 66 hours of anhepatic time with no neurological deficit

Intractable intraoperative hemorrhage is a rare complication of liver transplantation. Rescue hepatectomy with portocaval shunting can be used as a bridging procedure until a new organ donor becomes available. During the anhepatic period, however, there is a substantial risk of developing end-organ damage, the brain being particularly susceptible to insult. A 66-year-old male underwent liver transplantation due to non-alcoholic steatotic hepatitis and hepatocellular carcinoma. The transplantation was complicated by perioperative intractable bleeding. Despite attempts to control the bleeding, the patient became hemodynamically unstable and a rescue hepatectomy with portocaval shunting was performed. The patient remained anhepatic for 66 hours in an intensive care unit until a second donor organ was found. He made a good recovery and had no neurological deficit. Rescue hepatectomy with portocaval shunting is a viable short-term solution until a suitable donor organ is found. During this period, inotrope infusion and continuous veno-venous hemofiltration within an intensive care unit setting can be used as supportive measures. Nevertheless, a prolonged anhepatic time increases the risk of multiple organ failure and should be kept to a minimum due to metabolic disturbance and the build-up of toxic metabolites.