Complications In Liver Transplant Patients Research Articles

Surgical and Interventional Radiology Management of Vascular and Biliary Complications in Liver Transplantation: Narrative Review

AbstractLiver transplant patients require a multidisciplinary and personalized approach to optimize outcomes. Posttransplant complications can be devastating for the patient and can jeopardize graft survival. Therefore, a careful evaluation and stepwise decision-making process is necessary to determine the best strategy, whether it is surgical, interventional, or a combination of both. While access to liver transplant interventions in Latin America can be more limited compared with other parts of the world, many countries in the region have made significant progress in developing their liver transplant programs and improving the management of posttransplant complications. For example, in Brazil, specialized transplant centers and multidisciplinary teams have been established to reduce morbidity and improve graft survival rates. The article also explores the latest advancements in interventional radiology techniques, such as angioplasty, stent placement, and embolization, and how they can be used to successfully treat these complications. Overall, this article highlights the importance of a comprehensive approach to managing complications in liver transplant patients and emphasizes how individualized treatment plans can lead to improved outcomes, even in settings with limited resources.

Safety and indications for endoscopic retrograde cholangiopancreatography in liver transplant patients: an analysis of the United States' National Inpatient Sample database.

Endoscopic retrograde cholangiopancreatography (ERCP) is performed to treat biliary complications after a liver transplantation; however, the previously available literature on the safety of ERCP in liver transplant patients is limited. We aimed to study the safety of ERCP in liver transplant patients. We used a National Inpatient Sample database from 2016-2019 to identify patients who underwent ERCP and had a history of a liver transplantation, using the international classification of diseases, 10th revision. Multivariate logistic regression analysis was conducted to determine the odds of post-ERCP complications in liver transplant recipients. Liver transplant patients who underwent ERCP had a higher rate of post-ERCP pancreatitis and bleeding compared to the general adult population (11.39% vs. 9.19%, 0.83% vs. 0.53%, respectively). However, the adjusted odds of post-ERCP pancreatitis (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 0.86-1.49; P=0.36) and bleeding (aOR 1.41, 95%CI 0.58-3.46; P=0.45) were similar in both the liver transplant and no-transplant groups. There was no difference in the odds of post-ERCP cholangitis (aOR 1.26, 95%CI 0.80-2.01; P=0.32), and sepsis (aOR 0.94, 95%CI 0.66-1.34; P=0.76) between liver transplant and no transplant groups. Biliary stricture was the most common indication for ERCP in the liver transplant group, whereas choledocholithiasis was the main reason for ERCP in the general adult population. ERCP is a safe procedure for treating biliary complications in liver transplant patients. The odds of post-ERCP complications (pancreatitis, bleeding, sepsis, cholangitis) in liver transplant patients are comparable to those in patients with no transplantation.

Abstract 132: Incidence and predictors of new onset diabetes after transplant (NODAT) in liver transplant recipients

Background: NODAT (New onset Diabetes after Transplant) is associated with multiple complications in liver transplant patients which has to be diagnosed and treated early to prevent graft failure and cardiovascular morbidity and mortality.Aims and Objectives: To know the incidence and predictors of NODAT.Methodology: This was retro-prospective study of non-Diabetic recipients who underwent Liver Transplantation at Yashoda Hospital, Secundarabad from January 2020 to May 2021. Follow-up duration was 6 months. Total 65 patients were enrolled. All the relevant data was collected and appropriate statistical tests were applied.Results: Total incidence of NODAT in our study was 29.2%. Among them 47.36% were transient NODAT and 52.67% were persistent NODAT. Factors significantly associated with occurrence of NODAT were: Type of Transplant (Living donor liver transplant v/s Deceased donor liver transplant), Donor CT LAI, Presence of IFG, Presence of Post-Operative Hyperglycemia, Pre transplant Magnesium & Immediate post-operative Magnesium level, Post-Operative Albumin, Trough Tacrolimus level At 3 Months, Tacrolimus and steroid dose at 3 months.Conclusions: NODAT is significant entity to be addressed. Robust strategy should be in place for screening of NODAT. Choosing donor with Higher CT LAI and minimizing Tacrolimus level could be effective strategy for prevention of NODAT.

Immediate Postoperative Extubation Decreases Pulmonary Complications in Liver Transplant Patients.

Fast-track anesthesia in liver transplantation (LT) has been discussed over the past few decades; however, factors associated with immediate extubation after LT surgery are not well defined. This study aimed to identify predictive factors and examine impacts of immediate extubation on post-LT outcomes. A total of 279 LT patients between January 2014 and May 2017 were included. Primary outcome was immediate extubation after LT. Other postoperative outcomes included reintubation, intensive care unit stay and cost, pulmonary complications within 90 days, and 90-day graft survival. Logistic regression was performed to identify factors that were predictive for immediate extubation. A matched control was used to study immediate extubation effect on the other postoperative outcomes. Of these 279 patients, 80 (28.7%) underwent immediate extubation. Patients with anhepatic time >75 minutes and with total intraoperative blood transfusion ≥12 units were less likely to be immediately extubated (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.26-0.89; P = 0.02; OR, 0.11; 95% CI, 0.05-0.21; P < 0.001). The multivariable analysis showed immediate extubation significantly decreased the risk of pulmonary complications (OR, 0.34; 95% CI, 0.15-0.77; P = 0.01). According to a matched case-control model (immediate group [n = 72], delayed group [n = 72]), the immediate group had a significantly lower rate of pulmonary complications (11.1% versus 27.8%; P = 0.012). Intensive care unit stay and cost were relatively lower in the immediate group (2 versus 3 d; P = 0.082; $5700 versus $7710; P = 0.11). Reintubation rates (2.8% versus 2.8%; P > 0.9) and 90-day graft survival rates (95.8% versus 98.6%; P = 0.31) were similar. Immediate extubation post-LT in appropriate patients is safe and may improve patient outcomes and resource allocation.

Candida Contamination in Kidney and Liver Organ Preservation Solution: Does It Matter?

Introduction: Fungal infections remain a major challenge affecting outcomes after kidney (KT) and liver transplantation (LT). Methods: In this retrospective single center study, the incidence of Candida contamination in renal and hepatic graft preservation solution (PS) was evaluated. In addition, Candida associated infections in recipients and related complications were analyzed. Results: Overall, the PS of 1248 hepatic and 1273 renal grafts were evaluated. The incidence of fungal contamination in the PS of hepatic and renal grafts was 1.2% and 0.86%, respectively. Additionally, the hepatic PS of one patient who underwent a combined liver–kidney transplant had Candida contamination. Candida albicans was the most common organism (70.4%) and 65.4% of the patients received antifungal treatment. Candida-associated complications in the recipients was 19%. Complications in LT patients included Candida peritonitis and Candida sepsis. Two KT recipients with contaminated PS developed a mycotic aneurysm at the anastomotic site resulting in severe bleeding. The 1-year mortality in patients with PS contamination for LT and KT recipients was 33% and 18%, respectively. Although the incidence of fungal contamination of PS was low, contaminated PS was associated with a high mortality. Conclusion: The results of the study suggest that PS should be evaluated for fungal growth.

Complications of Peripherally Inserted, Large-Bore, Rapid-Infusion Catheters in Orthotopic Liver Transplant Patients

BackgroundAt our institution, peripherally inserted, 8.5-French rapid-infusion catheters (RICs) are placed for high-flow administration of intravenous fluids and blood products during liver transplant (LT). We sought to estimate the incidence of RIC placement–associated complications in LT patients. MethodsElectronic health records of all patients who underwent LT from January 2008 through December 2017 were retrospectively reviewed. RIC-related complications were deemed clinically significant if they required surgical consultation or intervention due to infiltration. Univariable and multivariable logistic regression analyses were used to evaluate associations between patient characteristics and RIC complications. ResultsIn total, 839 LT patients who received RICs were identified; of these, 14 (1.67%) had RIC-related complications, and 7 (0.83%) required surgical consultation. No patients needed fasciotomy or wound débridement due to a RIC complication, and no patients had permanent sequelae. In the multivariable logistic regression analysis, only an increase in international normalized ratio (INR) from 1.4 to 2.2 (equivalent to the interquartile range of observed INR values) increased the odds of complications due to RIC placement (odds ratio [95% CI], 1.98 [1.10-3.56]; P = .02). ConclusionsWe observed a low incidence of perioperative RIC-related complications (1.7%). No patients had permanent RIC-related complications.

Costs Associated With Early Vascular and Biliary Complications in Liver-Transplanted Patients in a Hospital in Antioquia, Colombia 2019: A Case Series

ObjectivesVascular and biliary complications associated with liver transplants involve high morbidity and mortality as well as cost overrun for health systems. Efforts to prioritize their prevention require not only clinical information but also information on costs that reflect the economic burden on health systems. The objective of this study was to describe cost overrun incurred from early vascular and biliary complications after liver transplant. MethodsThis cases series included liver transplant patients treated at the San Vicente Foundation University Hospital, Rionegro, Antioquia, from January 1, 2013, to December 31, 2018. All liver transplant patients treated during the above period were included; the absence of clinical records on the variables of interest was considered the exclusion criterion. A probabilistic analysis of patient cost was performed. Monte Carlo simulations as well as a 1-way sensitivity analysis per transplant cost component were performed. ResultsRecords from 154 patients were assessed. The average patient age was 56.9 (SD 10.9) years; 42.9% of patients were women. Of all, 36.4% patients were classified as Child C, and the average Model for End-Stage Liver Disease score was 19.6. The average cost for patients without complications was $27 834.82, whereas that for patients with early vascular complications was $36 747.83 and for those with early biliary complications was $38 523.74. ConclusionEarly vascular and biliary complications after liver transplant increase healthcare costs, with the increase being significant in patients with biliary complications.

S0991 Hepatic Artery Complications Post Liver Transplantation in Patients Treated With Pretransplant Transarterial Chemoembolization

INTRODUCTION: The use of locoregional therapy, such as transarterial chemoembolization (TACE), minimizes the risk of hepatocellular carcinoma (HCC) progression in patients with cirrhosis listed for liver transplantation (LT). Previous studies have shown the association of TACE with a higher prevalence of hepatic artery stenosis post LT. In this study, we aimed to compare the prevalence of post-operative hepatic artery complications in LT patients with HCC who received TACE pretransplant versus LT patients with HCC without TACE. METHODS: We conducted a retrospective single-center cohort study of all adult patients who underwent LT at our institute between 2013 and 2018. We collected data on the presence of HCC, receipt of TACE, donor and recipient demographics, graft characteristics, and perioperative variables (Tables 1 and 2). The primary outcome was the development of HAT and HAS. Secondary outcomes were graft failure and mortality. We used univariate and multivariate logistic regression to ascertain the odds of binary outcomes relative to the utilization of TACE. Kaplan Meier estimates were used to compare graft survival and overall survival. RESULTS: We included 145 HCC patients with cirrhosis, out of a total of 341 patients who underwent LT. We compared 91 patients (75.9% males, 61.4 years median age) who received pre-LT TACE with 54 patients (70.3% males, 61 years median age) who did not. The prevalence of HAS was 23.1% in the TACE group and 22.1% in the no TACE group (P = 0.9). The prevalence of HAT was 7.69% in the TACE group and 3.70% in the no TACE group (P = 0.25) (Table 3). Although statistically not significant, the rates of complications after endovascular therapy (EVT) for the treatment of HAS, was higher in the TACE group compared to the no TACE group (5.49% vs. 1.85%, P = 0.41). Four complications were noted in the TACE group (hepatic artery dissections in 3, and one case of stent erosion and extravasation). There was no difference in graft failure and overall mortality between the two groups. CONCLUSION: We found that TACE before LT, did not increase the rate of HAS or HAT post LT. However, we noted higher rates of EVT for HAS related complications in the TACE recipient group. The trauma of arterial instrumentation and arterial wall injury from chemotherapeutic agents may make the patients treated with TACE more prone to vascular complications, particularly after EVT for HAS. Further studies are needed to understand the impact of TACE on post LT vascular complications.Table 1Table 2Table 3

IMPACT OF ROUTINE USE OF ABDOMINAL DRAINS ON THE DIAGNOSIS, MANAGEMENT AND OUTCOMES OF LIVER TRANSPLANT COMPLICATIONS

Introduction: The routine placement of abdominal drains at the end of the liver transplantation procedure, with one extremity inside the abdominal cavity, close to the liver graft and the anastomosis, and the other one placed on an external closed system, is a common practice in many liver transplantation centers. The rationale for the placement of the abdominal drains is the belief that, in the occurance of surgical complications, such as bleeding or formation of a biliary fistula, the drain will allow for the early diagnosis of that complication, and in some cases may be helpful in the treatment by preventing the accumulation of fluids in the abdominal caviity. However, the placement of abdominal drains can have a negative impact on the outcome of the procedure, either by causing the loss of large amounts of ascitic fluid and worsening electrolyte disturbances, or by increasing the risk of surgical site infections as described by some authors. We have performed an analysis of the impact of the placement of abdominal drains in the liver transplants done in one tertiary center. Materials and Methods: We have reviewed the medical records of 388 liver transplant patients in a single Brazilian hospital, in the period from 2012 to 2019. In the period from 2012 to 2015, drains were routinely placed in all patients. From 2015 onwards, drains were not placed in any patients. Statistical analysis was performed using Yates corrected Pearson’s chi-square for qualitative parameters and t test for quantitative parameters. Results: Of the 388 patients in the study, abdominal drains (AD) were placed on 162 (42%) of patients, while 226 (58%) used no abdominal drain (NAD). There were 21 cases of significant surgical complication in all patients: 16 cases of bleeding, being 5 in the AD group and 11 in the NAD group (p=0.38); and 5 cases of biliary fistula, being 1 in the AD group and 4 in the NAD group (p=0.32). The time for diagnosis and surgical intervention was not statistically different between the two groups, with a mean of 5 days in the NAD group and 2.2 days in the AD group suffering from bleeding (p=0.1); and a mean of 18.75 days in the NAD and 42 days in the AD group suffering from biliary fistula. Mortality was also not significantly different between groups, with 1 case in each group suffering from bleeding (p=0.54) and one case in the NAD suffering from biliary fistula. Discussion: The use of abdominal drains did not significantly reduce the time for diagnosis and intervention in patients suffering from post-operative bleeding or biliary fistula. It also had no impact on the mortalirty of patients suffering from these complications. Conclusions: The use of abdominal drains had no significant impact on the diagnosis, management and outcomes of surgical complications in liver transplant patients. Considering the complications associated with drain placement in other studies, routine placement of abdominal drains in this context may be questioned.

Serum proteomic predicts effectiveness and reveals potential biomarkers for complications in liver transplant patients.

Sophisticated postoperative complications limit the long-term clinical success of liver transplantation. Hence, early identification of biomarkers is essential for graft and patient survival. High-throughput serum proteomics technologies provide an opportunity to identify diagnostic and prognostic biomarkers. This study is aimed to identify serum diagnosis biomarkers for complications and monitor effectiveness. Serum samples from 10 paired pre- and post-liver transplant patients, 10 acute rejection (AR) patients, 9 ischemic-type biliary lesion (ITBL) patients, and 10 healthy controls were screened using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) to explore divergence in polypeptide. Then, we used ELISA and western blot analysis to validate the expression of these potential biomarkers, and studied the correlation of proteomic profiles with clinical parameters. ACLY, FGA, and APOA1 were significantly lower in pre-operative patients compared with healthy controls, and these patients had modest recovery after transplantation. Downregulation of both, ACLY and FGA, was also observed in AR and ITBL patients. Furthermore, bioinformatics analysis was performed and the results suggested that the identified proteins were involved in glucolipid metabolism and the clotting cascade. Together, these findings suggest that ACLY, FGA, and APOA1 could be novel non-invasive and early biomarkers to detect complications and predict effectiveness of liver transplantation.

The role of multislice computerized tomography angiography in assessing postoperative vascular complications in liver transplant patients

Background/aim Vascular complications can be detected in liver transplant patients. Digital subtraction angiography has served as the gold standard to make this diagnosis; however, due to its invasive nature, ultrasonography is used for the preliminary evaluation. The purpose of this study was to evaluate the role of multislice computerized tomography angiography (MSCTA) in the detection of vascular complications of symptomatic and asymptomatic liver transplant patients and to compare the results with Doppler ultrasound (Doppler US) findings. Materials and methods Fifty-three liver transplant patients (6 symptomatic, 47 asymptomatic) underwent Doppler US examination followed by an MSCTA. The findings in each modality were interpreted in a blinded fashion and then compared. Results MSCTA detected 15 abnormalities, none of which were detected by Doppler US. There were hepatic and splenic artery aneurysms (n = 4) and various stenoses (n = 4), infrarenal aortic anastomosis (n = 4), vena cava inferior thrombosis (n = 1), arteriovenous malformation (n = 1), and esophageal varices (n = 1). Conclusion MSCTA detected more lesions and we believe that it should be considered as a road map for Doppler US follow-ups as well as a routine screening modality for early detection of vascular complications in symptomatic and asymptomatic liver transplantation patients that may be missed by Doppler US.

Early circulatory complications in liver transplant patients.

• Although careful selection of transplant candidates, the risk of cardiovascular events is still present after transplantation. • Hemodynamic instability represents a leading cause of post-transplant morbidity and mortality. • Different strategies are reported to prevent and manage these events.

Abstract No. 544 Percutaneous cholangiographic and cholangioscopic interventions through Hutson loops: a single-center experience in liver transplant patients

Percutaneous transhepatic cholangiography (PTC) interventions are not without risks to the liver transplant (LT) (e.g., bleeding, infection) [1]. An alternative option for biliary access involves surgical affixation of the afferent Roux limb to the anterior abdominal wall, known as the Hutson loop. We present our institutional experience in managing biliary anastomotic pathology via the Hutson loop. With IRB approval, we report 11 cases of percutaneous biliary interventions through Hutson loops for diagnostic/therapeutic benefit. Procedure indications, technical success, complications, and need for subsequent PTC were assessed. Hutson loops were created during living donor LT in 6 and deceased donor LT in 5 patients. Patients had Roux-en-Y choledochojejunostomies (3 patients) or hepaticojejunostomies (single: 6 patients; multiple: 2 patients). The indication was stricture [6 (55%)], anastomotic leak [3 (27%)], and other [2 (18%)]. All procedures were performed with monitored anesthesia care. 4 (36%) patients had diagnostic cholangiograms through the Hutson loop demonstrating no leak/stricture with no subsequent need for PTC/complex ERCP. A stricture was identified in 4 (36%) patients and was managed by cholangioplasty [3 (27%)], stenting [2 (18%)], and/or drainage [3 (27%)]. A leak was identified in 1 (9%) patient and was managed via the Hutson loop with plastic stents. The stents were retrieved by IR (via the Hutson loop) after the leak resolved. The biliary system could not be opacified in 1 (9%) patient necessitating PTC. 0.018” wire PTC access was used to place a retrograde biliary drain (via Hutson loop). Bowel injury occurred in 1 (9%) patient requiring surgical repair. 8 different patients where Hutson loop access was not successful were subsequently managed via the PTC route. Cholangiography/cholangioscopy via the Hutson loop is an effective intervention to address biliary anastomotic pathology in patients with Roux-en-Y. As with any new intervention, there is a learning curve. Our newly established multidisciplinary protocol to address biliary complications in LT patients aims to increase safety/efficacy of these interventions.

Postoperative Doppler Ultrasonography in Liver Transplantation

BackgroundDoppler ultrasonography plays an important role in the postoperative management of liver transplantation. We present our initial experiences evaluating liver transplants with the use of postoperative Doppler sonography. MethodsIn our hospital, we performed 20 liver transplantations from July 2014 to October 2016. Among 20 patients, we performed 15 deceased-donor liver transplantations (DDLTs) and 5 living-donor liver transplantations (LDLTs). For deceased donors, inferior vena cava anastomoses were performed with the use of the piggyback technique, and for living donors, modified right grafts were used with middle hepatic vein reconstruction by Dacron graft. In the intensive care unit, we performed Doppler ultrasound at least once a day and at every clinical need. We checked hepatic blood flow by means of Doppler ultrasound. ResultsEighteen patients underwent Doppler ultrasonography once a day up to postoperative day 6. Of the patients who received LDLT, 2 patients underwent Doppler ultrasonography twice a day because the operator was concerned about the hepatic artery anastomosis. Findings on Doppler ultrasound showed no abnormal wave form in hepatic artery, portal vein and hepatic veins. No patient had abnormal findings on angiographic computerized tomography. There was 1 graft failure in 20 recipients. The graft failure was primary nonfunction, and retransplantation was done. During the hospitalizations, there were no vascular complications. ConclusionsDoppler ultrasonography can be used to evaluate postoperative vascular complications in liver transplant patients. When the operator checks postoperative Doppler ultrasonography, it is possible to differentiate between patients, and it may help to detect the vascular complications earlier.

Infectious Complications in Liver Transplant Patients Exposed to Vedolizumab for the Treatment of Inflammatory Bowel Disease

Introduction: Vedolizumab, a gut-selective antibody to α4β7 integrin, received FDA approval in May 2014 for the treatment of moderate to severe ulcerative colitis (UC) and Crohn's disease (CD). While integrated safety data from 6 trials of vedolizumab found low incidence of serious infections, there has yet to be published reports of infectious complications in an immunosuppressed population. Methods: Retrospective analysis of all patients with inflammatory bowel disease (IBD) who underwent liver transplant for primary sclerosing cholangitis (PSC) was performed. Patients exposed to vedolizumab post-liver transplant for the treatment of UC or CD were included. Data collected included patient demographics, IBD characteristics, vedolizumab treatment and duration, immunosuppression regimens for prevention of liver rejection, and infectious complications during vedolizumab therapy. Results: A total of 9 patients (6 UC, 3 CD) were included (Table 1). Eight (89%) were male; median age was 51 years (IQR 42 to 57). Indication for liver transplantation was PSC (n=6) or PSC-related cholangiocarcinoma (n=3). Patients were most commonly on tacrolimus (n=8, 89%) with or without prednisone (n=4, 67%) for prevention of rejection. Vedolizumab was initiated a median of 6 years (IQR 2-12 years) following liver transplantation. Patients had a median exposure time of 5 months (IQR 4.5-11.5 months) to vedolizumab at the time of data collection; the majority of patients (n=6, 67%) were on maintenance therapy as defined by receiving > 4 doses. Concurrent use of steroids and immunomodulator was 33% (n=3) and 0%, respectively. During exposure to vedolizumab, 6 patients (67%) experienced a total of 11 infections (Table 2): acute cholangitis (n=2, 4 infections), Clostridium difficile infection (n=2, 2 infections), and 5 other infections each with one occurrence. Three patients experienced infections that required four hospitalizations and one surgery: acute cholangitis requiring common bile duct stent placement (1) and ERCP for stent exchange (1), C. difficile infection requiring intravenous antibiotics, and a small bowel perforation with resultant fecal peritonitis and intra-abdominal abscess requiring surgical repair of perforation drainage of abscesses.Table: Table. Baseline characteristics of individuals with inflammatory bowel disease post-liver transplant on vedolizumabTable: Table. Infections in individuals with inflammatory bowel disease post-liver transplant on vedolizumabConclusion: Two-thirds of immunosuppressed IBD patients in our cohort of post-liver transplant individuals experienced infectious complications after initiation of vedolizumab. Larger case-control studies are needed to assess the risk of infectious complications in IBD patients receiving concurrent immunosuppressive therapy.

Pathomechanism of progression of ocular and CNS amyloidosis in liver-transplanted familial amyloid polyneuropathy (FAP) patients

Background: Amyloid oculopathy and cerebral amyloid angiopathy are serious de novo complications in liver-transplanted patients with transthyretin (TTR)-related FAP. However, little has been known about the precise pathomechanism of posttransplantation ocular and CNS amyloid formation.

Efficacy and Optimal Duration of Metallic Stent in the Management of Refractory Anastomotic Stricture After Liver Transplantation

Anastomotic bile duct stricture (ABS) remains as one of the most common complications in liver transplant patients. Current practice of endoscopic retrograde cholangiopancreatography (ERCP) with insertion of plastic stent often requires multiple procedures before achieving stricture resolution. To date, studies using covered self-expandable metallic stent (cSEMS) in ABS management reported varying degrees of efficacy. The aim of this study was to analyze long-term efficacy of cSEMS in patients with ABS and identify factor(s) influencing the probability of stricture resolution. Liver transplant patients with ABS who received cSEMS were identified by query of our endoscopic database. The rate of stricture resolution, duration of stricture-free interval, factors associated with stricture resolution, and adverse outcomes were analyzed. Among 44 liver transplant patients with refractory ABS who underwent ERCP-cSEMS, stricture resolution was observed in 33 patients (75%). Longer duration of cSEMS insertion was the only variable associated with increasing probability of stricture resolution. There was 20% increase in odds of stricture resolution for every additional week cSEMS was in place. Among 33 patients with initial stricture resolution, 26 patients (78.8%) maintained bile duct patency throughout the follow-up period. The most common adverse outcome was internal migration of cSEMS, which occurred in 11 patients (25%). The rate of ABS resolution observed with cSEMS placement in a single ERCP session appears to be comparable with that of multiple ERCPs with plastic stent placement reported previously. Longer stent insertion period is associated with higher likelihood of ABS resolution.

Pregnancy outcomes in liver transplant patients, a population-based study

Objective: To determine the incidence of pregnancy in liver transplant (LT) patients in a large population-based cohort and to determine the maternal and fetal risks associated with these pregnancies.Methods: We conducted an age-matched cohort study using the US Healthcare and Utilization project–Nationwide Inpatient Sample from 2003–2011. We used unconditional logistic regression, adjusted for baseline characteristics, to estimate the likelihood of common obstetric complications in the LT group compared with age-matched nontransplant patients.Results: There were 7 288 712 deliveries and an estimated incidence of 2.1 LTs/100 000 deliveries over the nine-year study period. LT patients had higher rates of maternal complications including hypertensive disorders (OR 6.5, 95% CI: 4.4–9.5), gestational diabetes (OR 1.9, 95% CI: 1.0–3.5), anemia (OR 3.2, 95% CI: 2.1–4.9), thrombocytopenia (OR 27.5, 95% CI: 12.7–59.8) and genitourinary tract infections (OR 4.2, 95% CI: 1.8–9.8). Deliveries among women with LT had higher risks of cesarean section (OR 2.9, 95% CI: 2.0–4.1), postpartum hemorrhage (OR 3.2, 95% CI: 1.7–6.2) and blood transfusion (OR 18.7, 95% CI: 8.5–41.0). Fetal complications in LT patients included preterm delivery (OR 4.7, 95% CI: 3.2–7.0), intrauterine growth restriction (OR 4.1, 95% CI: 2.1–7.7) and congenital anomalies (OR 6.0, 95% CI: 1.1–32.0).Conclusion: Although pregnancies in LT recipients are feasible, they are associated with a high rate of maternal and fetal morbidities. Close antenatal surveillance is recommended.

Liver Transplantation to the Active Smoker: Transplant Provider Opinions and How They Have Changed

Awareness of smoking complications in liver transplantation patients is increasing. No study in the past 15 years has addressed attitudes toward offering transplantation to smokers. Our aim was to determine smoking policies nationwide. We conducted a survey of liver transplantation centers. The seven-question survey was sent to medical and surgical directors of liver transplantation. Results were analyzed in R 3.1.1 using two-tailed t testing and ANOVA. Fifty one of 110 centers (46 %) responded. Volume transplanted annually ranged from 10 to 190. Most respondents acknowledged a policy on smoking (38/51, 75 %). Most centers with policies required cessation (32/38, 84 %). All other centers did encourage attempts at cessation (19/19, 100 %). Whether smoking cessation was required differed by region (p = 0.02). Southern programs more commonly required smoking cessation (87.5 vs. 38.4 %, p < 0.001). The highest rates of smoking cessation were noted in the Southwest (90.0 %) and the lowest in the Northeast (26.2 %). There was a trend toward requiring cessation in larger-volume centers. Most respondents had a tobacco policy and tended to require abstinence; however, ultimately centers were divided on requiring cessation. Regional differences were noted, with the South more commonly requiring cessation. Our results indicate lack of consensus among transplantation centers regarding access of smokers to liver transplantation.

Differences in risk factors for early-onset and late-onset biliary complications in liver transplant patients

Context: Despite the use of advanced surgical techniques, the incidence of biliary complications (BCs) after liver transplantation (LT) is high. Hence, there may be additional unidentified causes of BC. Aims: To identify the risk factors for BCs occurring within 6 months or beyond 6 months after LT. Materials and Methods: We enrolled 237 patients who underwent LT from August 2001 to December 2012. Of the 237 patients, 173 did not have BCs (no BC group), 42 had BCs within 6 months after LT (early-onset BC group), and 22 had BCs beyond 6 months after LT (late-onset BC group). Statistical Analysis Used: Patients' demographic, clinical, and biochemical data were analyzed using the Mann-Whitney U-test, Chi-square test, Fisher's exact test, and multiple logistic regression analysis. Results: Multivariate analysis indicated that only partial liver graft (odds ratio [OR], 2.741; 95% confidence interval [CI], 1.236-6.077; P=0.013) was an independent risk factor for early-onset BC after LT, whereas acute rejection (OR, 6.556; 95% CI, 2.380-18.056; P ＜ 0.001), multiple bile ducts (OR, 4.227; 95% CI, 1.212-14.740; P=0.024), and pre-LT serum albumin level (OR, 2.234; 95% CI, 1.178-4.238; P=0.014) were the independent risk factors for late-onset BC after LT. Conclusion: Early-onset and late-onset BCs after LT are associated with different risk factors. Partial liver graft is a risk factor for early-onset BC, whereas pre-LT serum albumin level, multiple bile ducts, and acute rejection are the risk factors for late-onset BC. As it is easily controllable, prevention of acute rejection may help to reduce the incidence of BCs.