Living Donor Liver Transplantation Procedures Research Articles

Reduction of Recipient Spleen Size after Living Donor Liver Transplantation: A Retrospective Study

Abstract Background Liver transplantation is considered an important solution to patients with end stage liver disease and a glimpse of hope for some patients with terrible quality of life due to the morbidity of such disease. Living donor liver transplantation procedures has now become widely done worldwide and many studies have been done to improve its outcome and improve the quality of the patients’ lives. Objective to help identify the factors that affects the size of spleen after living donor liver transplantation and promotes the reduction in its size which greatly affects the patients’ and graft survival rate. Patients and Methods This is a retrospective study including patients underwent living donor liver transplantation to be conducted in Ain Shams university hospitals to determine the factors promoting reduction of spleen size after living donor liver transplantation. This study was conducted at Ain-Shams University Hospitals, in the period from January 2008 to June 2021. Approval of the Ethical Committee and written informed consent from all participants were obtained. Results In our study we found that from 100 patients who had splenomegaly before transplantation, 54% of patients had persistent splenomegaly after liver transplantation, while 46% of patients had normal spleen size after transplantation within 1 year. The spleen size decreased significantly after transplantation in general, from a range of 13.3- 25 cm with a mean of 18.06 cm +/- 7 pre-op, to a range of 9-18 cm with a mean of 14.1 cm +/- 2.65. By analyzing this data and dividing it into two groups, it has been found that the group with persistent splenomegaly (54% of patients) had higher range of spleen size before transplantation with a range of 16.7-25 cm with a mean of 19.75 cm +/- 2.169, while the group of normal spleen size after transplantation ranged from 13.3-17 cm with a mean of 15.3 +/- 1.018 before transplantation. Also patients with dilated portal vein and portal vein thrombosis have higher chances of persistent splenomegaly post-operative. It has been found that in 93.4% of patients (43 patients)with reduced spleen size after transplantation had patent portal vein with average diameter, while only 6.5% (3 patients) had dilated portal vein and 0 patients with attenuated portal vein. On the other hand, 44.4% of patients with persistent splenomegaly had dilated portal vein, 38.9% had patent portal vein, and 16.67% had attenuated portal vein pre-op. Our study also showed the effect of spleen after transplantation on platelets levels and liver function. The normal spleen size was associated with better recovery of platelets number, in the group of patients with normal spleen size it ranged from 32 -189 10∧3/uL with a mean of 80 10∧3/uL pre-op, it increased to a mean of 163.95 10∧3/uL post op. While in the splenomegaly group the mean platelets count pre-op was 75.27 10∧3/uL in increased to 156.88 10∧3/uL post op. It has also been found that the decrease in spleen size greatly affects the liver functions, where in aspartate aminotransferase AST and Alanine transaminase ALT levels pre- operative in patients with normal spleen with a mean of 38.37 and 57.8 respectively. It decreased to a mean of 27 and 29.7 and difference of 11.2 and 28.1 respectively. Conclusion The spleen size after living donor liver transplantation is affected by the size of the spleen before transplantation and by the diameter portal vein before transplantation. Also the reduction in spleen size after living donor liver transplantation greatly affects the patient and graft survival platelets count and liver functions such as liver enzymes, albumin and coagulation profile.

Outcomes of 6000 living donor liver transplantation procedures: a pioneering experience at ASAN Medical Center.

Living donor liver transplantation (LDLT) has emerged as a favorable alternative to deceased donor liver transplantation, significantly reducing waitlist mortality, particularly in Asian countries with very low deceased organ donation rates. Asan Medical Center (AMC) in South Korea has pioneered innovative LDLT surgical techniques and become established as an extremely high-volume center for LDLT. This retrospective study analyzed 6000 consecutive LDLT procedures, including 510 dual-graft procedures, performed at AMC between December 1994 and January 2021. Of these, 312 LDLT procedures were performed in children aged < 18years. In adult recipients, liver cirrhosis (LC) related to viral hepatitis was the most common indication, occurring in 69.8% of cases. Biliary atresia (46.8%) was the most common indication for pediatric LDLT. This study demonstrated outstanding long-term outcomes, with patient survival rates at 1, 5, 10, and 20years of 92.7%, 85.9%, 82.1%, and 70.9%, respectively, in LDLT group for adults aged 50 and under at the time of LDLT, and 92.9%, 89.0%, 88.1%, and 81.9%, respectively, in the pediatric group. The in-hospital mortality rate of adult recipients was 3.8% (n = 214/5688). This study demonstrates the importance of refined surgical techniques, selection of grafts tailored to the recipient, and comprehensive multidisciplinary perioperative patient care in expanding the scope of LDLT and improving recipient outcomes.

Is preoperative weight reduction of living-donor liver transplant recipients and donors harmful to postoperative outcomes?

AimAlthough the incidence of overweight and obese recipients and donors is increasing worldwide, few reports have focused on outcomes of preoperative weight reduction (WR) in living-donor liver transplantation (LDLT). We therefore examined the outcomes and the impact of WR on the postoperative course. MethodsWe analyzed 217 consecutive LDLT procedures performed from 2017 to 2022. We divided the recipients and donors into a WR group and non-WR group. ResultsTwenty-two recipients (10.1%) achieved WR (preoperative recipient WR [RWR] group), reducing their weight by 6.8% ± 6.0% within 2.2 ± 1.4 months with a significant decrease in body mass index (BMI) (p < 0.0001). The RWR group showed no significant differences in short-term postoperative outcomes (operative factors, postoperative liver function tests, amount of ascites, and morbidity) or in the graft survival rate as a long-term outcome (p = 0.24) compared with the non-RWR group. Forty-one (18.9%) donors achieved WR (preoperative donor WR [DWR] group), reducing their weight by 9.7% ± 6.3% within 3.2 ± 5.8 months with a significant decrease in BMI (p < 0.0001). Compared with the non-DWR group, the DWR group showed no significant differences in short-term postoperative outcomes between themselves and recipients or in the graft survival rate (p = 0.49). Furthermore, WR resulted in an increase to 32 donor-eligible and 6 recipient-eligible patients. ConclusionWR in LDLT recipients and donors had no harmful effect on postoperative outcomes and should lead to increase recipients’ chance of undergoing LDLT and to expand the donor pool.

Malignancy After Living Donor Liver Transplantation

ObjectivesDe novo malignancy (DNM) is a major cause of death in long-term recipients of liver transplantation (LT). We herein report our experience with DNM after living-donor LT (LDLT). Patients and MethodsA total of 111 LDLT procedures were performed in our institute from 1999 to 2022. Among them, 70 adult (>13 years old) LDLT recipients who survived for more than 1 year were included in this study. ResultsDuring a median follow-up of 146 (range, 12-285) months, 7 out of 70 recipients developed 8 DNMs, including lung cancer in 4, post-transplant lymphoproliferative disease in 3, and skin cancer in 1. One patient developed metachronal skin cancer and post-transplant lymphoproliferative disease. The pre-LT smoking history rate in patients with DNM was higher than in patients without DNM (P = .004). The survival time after DNM was 6 (1-166) months. Only 2 patients underwent R0 resection. DNM did not recur during follow-up. Other patients who underwent R1 resection and/or chemotherapy and/or radiotherapy all died due to DNMs during the follow-up. The cumulative DNM incidence was 3.5% at 10 years and 18.4% at 20 years after LDLT. The cumulative survival rate in patients with DNM was significantly worse than that in patients without DNM after LDLT (P = .049). ConclusionThe survival rate of patients with DNM was lower than that of those without DNM. A pre-LT smoking history is a risk factor for DNM. R0 resection is effective for improving the prognosis of patients with DNM. Regular cancer screening is important for detecting DNM early after LDLT.

Complications of e-PTFE Grafts in LDLT; Evaluation of Case Series

The expanded polytetrafluoroethylene (ePTFE) grafts are used to drain anterior sector veins during the living donor liver transplantation procedure. We aimed to analyze the potentially life-threatening complications, such as the infection and migration of ePTFE grafts. A total of 1264 liver transplantations (LTs) were performed for 1097 adult and 167 pediatric liver failure cases. In total, 1169 living and 95 cadaveric liver transplantation procedures were performed between 2011 and 2021. Right liver transplantation was performed in 1016 cases, including 1002 living donors and 14 cadaveric split right livers. Cadaveric LT was performed in 81 cases. For 1002 right living liver grafts, 905 vascular grafts were used during the backtable for anterior sector outflow venoplasty. The most commonly drained segments were 5 and 8 (472 cases); there were isolated (5 or 8) and multiple drained segments. Vascular graft migration was described in 7 of 905 (0.77%) patients. Although complication rates regarding ePTFE grafts are low, there are serious life-threatening causes of morbidity and mortality. We recommend cushioning the vascular graft with the omentum, which is effective in preventing graft migration.

Multiple Graft Bile Ducts Do Not Affect the Postoperative Outcomes of Right Lobe Living Donor Liver Transplantation

Multiple graft duct openings are associated with a high incidence of biliary complications (BCs), and biliary reconstruction for multiple graft bile ducts (BDs) remains a surgical challenge during living donor liver transplantation (LDLT). In particular, biliary reconstruction using "high biliary radicals (HBR)" of recipients for multiple graft BDs has a high probability of BCs. Herein, we analyzed outcomes by retrospectively reviewing 283 patients who underwent right lobe LDLT from January 2013 to September 2019. In total, 112 LDLT procedures using grafts with multiple BDs have been performed under our policies. In recent cases with 2 orifices located on the same hilar plate, we did dunking with a mucosal eversion technique instead of ductoplasty. When 2 orifices are located far apart on different hilar plates, we attempted to perform separate duct-to-duct anastomosis (DDA) using HBR of the recipient instead of hepaticojejunostomy. Among patients with multiple graft BDs, 20 underwent ductoplasty, 50 were treated using dunking with mucosal eversion technique, and 40 underwent separate DDA using HBR (HBR group). The incidence rates of biliary leakage and stricture were 8.9% and 10.7% in the multiple BD group, respectively, congruent with the outcomes of the single BD group. In subgroup analysis, we compared clinical outcomes between the HBR and single BD groups; the incidence of BCs in the HBR group was 15.0%, comparable to that of the single BD group. In conclusion, multiple graft BDs do not negatively impact the BC rate compared with single-graft BD when applying our technique to prevent BCs.

The Role of Pretransplant Infections in Pediatric Receiving LDLT in Indonesia: A 7-y Retrospective Study.

This is an observational, retrospective cohort study. A total of 56 children were recruited between April 2015 and May 2022. Patients were categorized into 2 according to the presence of pretransplantation infections requiring hospitalization before the surgery. Diagnosis of posttransplantation infection was observed for up to 1 y based on the clinical features and laboratory parameters. The most common indication for LDLT was biliary atresia (82.1%). Fifteen of 56 patients (26.7%) had a pretransplant infection, whereas 73.2% of patients were diagnosed with a posttransplant infection. There was no significant association between pretransplant and posttransplant infection in all 3-time points (≤1 mo, 2-6 mo, and 6-12 mo). The most common organ involvement posttransplantation was respiratory infections (50%). The pretransplant infection did not significantly affect posttransplant bacteremia, length of stay, duration of mechanical ventilation, initiation of enteral feeding, hospitalization cost, and graft rejection. Our data showed that pretransplant infections did not significantly affect clinical outcomes in post-LDLT procedures. A prompt and sufficient diagnosis and treatment before and after the LDLT procedure is the best way to obtain an optimal outcome.

Liver Transplant Complications—A Pictorial Review

AbstractLiver transplantation is the most definitive treatment for decompensated chronic liver diseases, acute hepatic failure, and localized hepatocellular carcinomas. With the widespread use of extensive preop evaluation and advanced surgical techniques, the success rate of liver transplantation has dramatically risen over the decade. In a world of increasing demand for liver donors from brain dead donors, a rising trend is seen in the acceptance of living donor liver transplantation procedures. However, postoperative surveillance needs a lower threshold for early imaging to identify the most dreaded complications for salvaging the graft. This pictorial essay aims to categorize the postliver transplantation complications and various imaging findings to diagnose them. The complications can be broadly classified into vascular and nonvascular complications. The most important concern among vascular complications is hepatic artery thrombosis, which frequently results in graft failure. The nonvascular complication comprises biliary origin, infection, and immune response. Multimodality imaging is the need of the hour, which includes ultrasound as the primary tool for gross evaluation, followed by triphasic computed tomography and magnetic resonance imaging (MRI). Newer techniques in MRI, like diffusion-weighted imaging, arterial spin labeling, diffusion kurtosis imaging, blood oxygenation-level dependent, and magnetic resonance elastography, can also be used to diagnose these complications. Interventional management through minimal access has become the first line of management in certain vascular and nonvascular complications, which can salvage the graft.

Doppler evaluation of hepatic hemodynamics after living donor liver transplantation in infants.

Objective: The aim of this study was to explore the hemodynamic changes of hepatic artery and portal vein detected by Doppler ultrasound (DU) in infants who underwent living donor liver transplantation (LDLT). Methods: The data of 41 infant patients (22 Males, 19 Females, median age of 5 months) were collected in the Children’s Hospital affiliated to the Chongqing Medical University from May 2018 to December 2019. The patients underwent left lateral segment LDLT (LLS -LDLT) because of biliary atresia (BA). Hemodynamic parameters, including the peak systolic velocity (PSV), resistivity index (RI) of the hepatic artery (HA), portal vein velocity (PVV), and portal vein flow (PVF) were recorded from Doppler ultrasound on the day before the operation, and on the 1st, the 7th, the 14th and the 30th day after LDLT procedures. The changes of PSVHA, RIHA, PVV and PVF before and on the 1st day after transplantation were analyzed by paired t-test. The comparison of the data between different postoperative time points were assessed by ANOVA. Results: Compared with the parameters measured before LDLT, PSVHA, and RIHA decreased, and PVV and PVF increased significantly (p < 0.001) on the 1st day after LLS-LDLT. As for PSV, there was no significant difference between the 7th day and the 1st day after transplantation (POD7 VS POD1, p = 0.167) while there was a substantial difference between the 14th, 30th and 1st day after LT (POD14 vs. POD1, p = 0.003) (POD30 vs. POD1, p < 0.001). And there was a significant difference between the 14th, 30th, and 7th days after LT (POD14 vs. POD7, p = 0.014) (POD30 vs. POD7, p < 0.001). There was no significant difference between 30th and 14th after transplantation (POD30 vs. POD14, p = 0.092). As for RIHA and PVV, the decrease was slow within the first month after the operation, and there was no significant difference at different times. Conclusion: We have identified major hepatic flow changes that occurred in 41 infants who underwent LLS -LDLT due to BA. The data could be used for future studies of LDLT in infants including hemodynamic modeling, liver regeneration and clinical management.

Paired exchange Living Donor Liver Transplantation: A Nine-Year Experience from North India

Introduction: Liver paired exchange donation (LPD) or swap transplantation is an evolving strategy to overcome ABO incompatibility and other barriers like small for size syndrome that confront patients with end-stage Liver disease undergoing Living donor liver transplantation (LDLT). At the same time, for the transplant team to carry out 4 major operations simultaneously is a Herculean effort. Herein, we analyze our experience with LPD program over the past 9 years. Methods: This prospective study includes a total of 2340 LDLTs performed from May 2012 to April 2021. We started the Paired exchange LDLT program in May 2012. LPDs constituted approximately 1.45% (34 of 2340) of the total LDLT procedures. The reasons for LPD were ABO incompatibility in all (n=34) patients. The first and second recipient of each swap pair were divided into R1 and R2 groups for comparative analysis. Results: All patients included in paired exchange LDLT program were Indian citizens and donors were “near” relatives. After donor reassignment through 2-by-2 paired exchange with directed donors, the ABO matching status changed to A to A (n=17) and B to B (n=17) and this made all matches ABO-identical. Donor survival was 100%. The recipient’s (n=34, age 45.5 [11 -59] years; 31 men), UNOS status were 2b (n=5) and C (n=29) and they all underwent elective LDLT surgery with 4 OTs running simultaneously on the same day. The baseline clinical, peri-operative parameters, post-operative complications, median ICU/hospital stay, early deaths were comparable (P>0.1) between the R1 and R2 groups (Table 1). The overall recipient survival was 85.3 % (n=29) over the median follow up period of 20 (0-108) months. Conclusion: Our experience suggests that with careful attention to ethical and logistical issues, LPD program can expand the living donor liver pool and can facilitate a greater number of LDLTs. Keywords: Donor Exchange, Swap Liver Transplantation, Living Donor Liver Transplantation; ABO incompatibilityTable 1Comparative data between R1 and R2 groups of swap liver transplant recipients (n = 34).Parameters (Mean±SD)R1 (n=17)R2 (n=17)P valueAge (years)44.0 (±10.1)47.0 (±5.3)0.296MELD score21.8 (±11.1)19.4 (±6.3)0.445CTP score9.5 (±2.3)10.3 (±2.1)0.294Graft weight (grams)711 (±141.2)796 (±119.8)0.067GRWR1.01 (±0.34)1.18 (±0.26)0.136Warm ischemia time (minutes)32.7 (±7.8)36.1 (±7.1)0.257Cold ischemia time (minutes)109.7 (±61.2)112.6 (±40.9)0.870ICU stay (days)12.4 (±4.6)14.4 (±10.5)0.654Hospital stays (days)16.7 (±4.6)21.6 (±4.7)0.197Complications n (%)Bleeding01 (5.9%)1.00Bile leak02 (11.8%)0.485Acute rejection1 (5.9 %)1 (5.9 %)1.00Hepatic artery thrombosis01(5.9%)1.00Hepatic vein thrombosis2 (11.8%)1(5.9%)0.542Sepsis2 (11.8%)5 (29.4%)0.398Early mortality (Within 1 month)1 (5.8%)3(17.6%)0.6011 year survival16 (100 %)13 (92.8%)0.335Median follow up in months (IQR)27 (8-39)27 (8-43)1.00CTP, Child-Turcot-Pugh; GRWR, graft to recipient weight ratio; ICU, intensive care unit; IQR, inter quartile range; MELD, model for end stage liver disease. Open table in a new tab CTP, Child-Turcot-Pugh; GRWR, graft to recipient weight ratio; ICU, intensive care unit; IQR, inter quartile range; MELD, model for end stage liver disease.

Pediatric living-donor liver transplantation using right posterior segment grafts

BackgroundThe right posterior segment (RPS) graft was introduced to overcome graft size discrepancy in living donor liver transplantation (LDLT). However, it was very rarely used in pediatric patients. Here we presented 4 pediatric LDLT cases receiving RPS graft between January 2015 and April 2020 in our center. A total of 1868 LDLT procedures were performed in this period.MethodsRecipients included 1 boy and 3 girls with a median age of 45 months (range from 40 to 93 months). They were diagnosed with progressive familial intrahepatic cholestasis, propionic academia, ornithine transcarbamylase and biliary atresia, respectively. Four donors were all mothers with a median age of 32.5 years (31–38 years). Computer tomography angiography indicated posterior right branches branched off separately from main portal veins (type III variation). Three of these donor livers had 1 orifice of right hepatic veins (RHV). In the remaining 1 donor liver, the RHV showed 3 orifices and an outflow patch plastic was performed. Inferior right hepatic veins weren’t found in four donor grafts. The median graft weight was 397.5 g (352–461 g) and the median graft-to-recipient weight ratio was 2.38% (1.44–2.80%).ResultsPostoperative complications occurred in neither donors nor recipients. Within the median follow-up duration of 29 months (14–64 months), four children are all alive with normal liver function.ConclusionIn summary, for older children weighed more than 15 kg with donors’ variation of type III portal veins, the use of RPS grafts could be a feasible and favorable option.

Using Glissonian sheath as an alternative way to prevent biliary stricture in living-donor liver transplantation

/Objective: The aim of this study was to report a single-institution experience involving a Glissonian sheath-to-duct method for biliary reconstruction in living donor liver transplantation, focusing on the association between surgical techniques and biliary stricture rates. Three hundred and twenty adult right lobar living donor liver transplantation procedures were analyzed through a comparison of 200 Glissonian sheath-to-duct (GD) reconstructions and 120 duct-to-duct (DD) reconstructions in biliary anastomosis. At a mean follow-up period of 60.8 months, the GD group had a significantly lower biliary stricture rate (13.5%, 27/200) than the DD group (26.7%, 32/120) (p=0.003). In biliary anastomosis with single duct anastomosis, the incidence of biliary stricture was significantly greater for the DD group (17/79, 21.5%) than for the GD group (14/141, 9.9%) (p=0.018). This study has shown that GD anastomosis of the bile duct produced outstanding results with respect to the reduction of biliary stricture. The GD technique can therefore be suggested as an alternative method for biliary reconstruction in LDLT.

Preoperative prediction score of hepatocellular carcinoma recurrence in living donor liver transplantation: Validation of SNAPP score developed at Asan Medical Center

Preoperative prediction score of hepatocellular carcinoma recurrence in living donor liver transplantation: Validation of SNAPP score developed at Asan Medical Center

Anesthetic Fluid Management of Patients With Hyponatremia Undergoing Living Donor Liver Transplantation

ObjectiveThe objective of this study is to evaluate the changes in serum sodium levels in adult recipients with and without hyponatremia undergoing living donor liver transplantation (LDLT) without using hypertonic solution. MethodsPatients were divided into 2 groups according to serum sodium level higher (GI) or lower (GII) than 130 mEq/L. The changes of serum sodium levels during an LDLT procedure and total sodium loads were compared between groups by using the Mann-Whitney U test, while the changes in the same group were paired by using the Student t test. A P value <.005 was considered significant. ResultsThe total sodium load for GI (n = 438) and GII (n = 28) were 2737 ± 2159 mEq and 4017 ± 2830 mEq, respectively. Although GI received a significantly lower sodium load than GII, the serum sodium levels during the procedure were always within a normal range and higher than GII at all the measured time points; however, the changes of serum sodium level in GI from one point to the next measured point in the same group were unremarkable, while that of GII increased significantly between the 2 measured time points during the procedure. The mean total increase of serum sodium in GII was 5.57 ± 4.9 mEq/L in 14 hours of the LDLT procedure. None of the patients developed central pontine myelinosis (CPM) postoperatively. ConclusionPatients with hyponatremia can be managed safely without using a hypertonic solution during liver transplantation. The mean increase of serum sodium of GII was of 5.57 ± 4.9 mEq/L, which was still within the acceptable and safe level. No postoperative CPM was observed in our GII patients.

Hepatitis B virus recurrence after living donor liver transplantation of anti-HBc-positive grafts: A 22-year experience at a single center.

The use of hepatitis B core antibody (anti-HBc)-positive grafts is one strategy for expanding the donor pool for liver transplantation (LT). The aim of this study was to determine the risk factors associated with hepatitis B virus (HBV) recurrence after living donor LT (LDLT) of anti-HBc-positive grafts. From January 1996 to December 2018, a total of 609 LDLT procedures were performed at our center. A retrospective review was performed for 31 patients (23 males and 8 females; median age = 47 years) who underwent LDLT for HBV-unrelated liver disease from anti-HBc-positive donors. The factors associated with HBV recurrence were evaluated and compared between the HBV recurrence and non-recurrence groups. The median follow-up period after LT was 135 months (range, 6-273 months). Four of 31 patients (12.9%) developed post-LT HBV recurrence. All four cases were HBV-naïve patients (anti-HBc-negative and Hepatitis B surface antibody-negative). The median interval between LDLT and HBV recurrence was 42 months (range, 20-51). The overall actuarial rates of HBV recurrence at 1, 3, 5, 10, and 20 years were 0%, 7.2%, 15.7%, 15.7%, and 15.7%, respectively. Although there were no significant differences between the HBV recurrence and non-recurrence groups, HBV recurrence tended to occur in HBV-naïve recipients (P = 0.093). HBV-naïve status may contribute to HBV recurrence after LDLT for HBV-unrelated liver disease from anti-HBc-positive donors. Careful monitoring for serological HBV markers is needed, particularly in this group.

Successful Living Donor Liver Transplantation in a Case of Mean Pulmonary Arterial Pressure of 52 mmHg

Introduction Pulmonary hypertension (PH) is defined as an elevated mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest. The perioperative management can be complicated by hemodynamic instability resulting in severe hypoxemia, acute right heart failure/circulatory collapse and death. Portal hypertension is a curable cause for PH. However, Krowka et al reported that mPAP of 50 mmHg or greater was associated with 100% cardiopulmonary mortality in liver transplantation (LT) setting. Materials and Methods A 45 years old male patient underwent LDLT for HBV + alcoholic cirrhosis and HCC. MELD score was 28. Echocardiography performed 2 months before the operation showed right ventricular systolic pressure (RVSP) 62 mmHg and maximum tricuspid regurgitant jet velocity (TRVmax) 3.8m/sec, suggesting moderate resting PH. During anesthetic induction, pulmonary vascular resistance (PVR) was measured as 246 dynes/sec/cm-5 and mPAP as 52mmHg. One hour later, they were 217 and 40, respectively, with infusion of Isosorbide 1mcg/Kg/min. Vital signs were stable and PaO2 level was 223 mmHg. So we decided to proceed with surgery despite of moderate PH. Results Graft weighed 550g and GRWR was 0.74. The living donor LT procedure was done with modified right lobe graft. Additionally portal vein endthrombectomy, direct ligation of a large splenorenal shunt and splenic artery ligation was done. The operation took 850 minutes and 24 pints of RBC, 16 pints of FFP, 8 pints of PC and 10 pints of cryoprecipitate. PVR and mPAP were in the range of 217~149 and 46~31, respectively. Alprostadil 7mcg/hr was started just after finishing arterial anastomosis and was infused for 7 days thereafter. Extubation was done 9 hours after the operation and liquid diet was begun 2 days after the operation. The day after LT, RVSP was 96 mmHg and TRVmax 4.9m/sec. And 5 days after LT, he complained of dyspnea and Beraprost (prostacyclin pathway agonist) was given orally. Even with mild dyspnea, the patient was discharged on foot 19 days after LT. 6 weeks after LT RVSP was measured as 84 mmHg and TRVmax 4.0m/sec. mPAP was 63 mmHg on right heart catheterization. On CT scan, there was marked hepatic congestion resulting from pulmonary hypertension. Endothelin receptor antagonist Ambrisentan was given orally. The patient's breathing difficulty almost disappeared soon. Now, 3 months after the operation, he returned to work. Conclusion The authors conducted LDLT in a case of severe pulmonary hypertension with mean PAP 50 mmHg successfully by careful intraoperative monitoring and postoperative management. When encountered a case of moderate to severe pulmonary hypertension during LT, initial response to anesthetic management might dictate whether to proceed with LT or not.

Improved portal vein venoplasty with an autogenous patch in pediatric living donor liver transplantation.

A stenotic or hypoplastic portal vein (PV) represents a challenge for PV reconstruction in pediatric living donor liver transplantation (LDLT). Several PV venoplastic techniques have been developed. However, we still seek improved venoplastic techniques with better efficacy and compatibility. From June 2016 to July 2017, 271 LDLT procedures were performed at the Department of Liver Surgery, Renji Hospital. A total of 16 consecutive children with stenotic and sclerotic PVs underwent a novel technique-the autogenous PV patch plastic technique. Vessel patches were procured from the left branch (LB), or the bifurcation of the right branch and LB of the PV in the native liver. Then, the PVs were enlarged by suturing the patches along the longitudinal axis from the confluence of the PV and coronary vein (CV). In this series, 15/16 achieved good intraoperational PV flow, and 1 showed low PV flow but was treated with stent placement. Within a median follow-up of 11 months (1-18 months), 15 patients were alive and had normal graft function, whereas 1 child died from lung infection 1 month after transplantation. No PV complications were detected. In conclusion, the autogenous patch venoplasty technique using the PV-CV confluence is simple and safe. This novel venoplastic reconstruction technique could serve as a surgical option to achieve satisfactory outcomes, especially those with stenotic PV (<4.5 mm) and dilated CV (>3.0 mm). Liver Transplantation 2018 AASLD.

Comparison of Core Temperature Changes Between Pediatric Patients Lying on Regular Operating Room Linen Drapes and Water-Repellent Sheepskin Rug in Living Donor Liver Transplantation

ObjectivesThe aims of this study were to compare the core temperature changes between pediatric patients lying on regular operating room linen drapes and a water-repellent sheepskin rug during living donor liver transplantation (LDLT) and to evaluate the effectiveness of using a water-repellent sheepskin rug in preventing profound hypothermia due to fluid overflow from the abdominal cavity during LDLT. Patients and MethodsThe operative records of pediatric patients who underwent LDLT from June 1994-September 2003 were reviewed retrospectively. The nasopharyngeal temperature (NT) changes during the LDLT procedure between patients lying on regular operating room drapes (GI) and water-repellent sheepskin rug (GII) were compared and analyzed using the Mann-Whitney U test. A P value <.05 was regarded as significant. ResultsThirty-two patients were included in GI and 56 in GII. Profound hypothermia was not observed in any recipients lying on a water-repellent sheepskin rug (GII). The NT after induction and the following 4 hours into the LT procedure were significantly higher in GII than GI. ConclusionPediatric patients lying on water-repellent sheepskin preserved their core temperature better in comparison to patients lying on linen drapes. The use of a water-repellent sheepskin rug seems to be effective in preventing profound hypothermia related to physical contact with abdominal fluid overflow during the LDLT.

Effect of informed consent on patients undergoing gastrointestinal surgery and living donor liver transplantation and on their relatives in a developing country.

BackgroundInformed consent is a systematic process for obtaining permission before conducting a healthcare intervention. In a developing country, gaining informed consent is generally perceived to be a ritual only to comply with legal requirements. The present study examined this by assessing the process of informed consent in patients undergoing gastrointestinal surgery or living donor liver transplantation (LDLT) and their relatives, based on their comprehension and overall satisfaction, in India.MethodsAll patients undergoing any gastrointestinal surgery or LDLT procedure between August 2015 and July 2016 and their relatives were included, and were administered a structured questionnaire 5 days after the procedure.ResultsThe majority of patients (94·2 per cent) could recall the nature of their disease, the surgery performed (81·6 per cent) and anticipated complications (55·6 per cent). Among their relatives, these proportions were 97·8, 87·3 and 58·5 per cent respectively. Recall was associated with age, occupation and education among both patients and relatives. Patients undergoing LDLT, their donors and their relatives had better recall than those who had other gastrointestinal procedures (P < 0·001). Many patients found the process of informed consent useful and reassuring.ConclusionThe details and risks of an operation were understood by most of the patients, especially those undergoing liver transplantation. Patients from developing countries can generally understand ‘informed consent’, and value it.

Successful Blood Transfusion Management of a Living Donor Liver Transplant Recipient in the Presence of Anti-Jra: A Case Report

A 48-year-old Japanese woman was diagnosed with Budd-Chiari syndrome and transferred for possible living donor liver transplantation (LDLT). Examinations before LDLT revealed that the recipient had anti-Jra and preformed donor-specific anti–human leukocyte antigen (HLA) antibodies (DSA). Rituximab was administrated at 16 days prior to the patient's scheduled LDLT for the prophylaxis of antibody-mediated rejection by DSA. The clinical significance of anti-Jra has not been clearly established because of the rarity of this antibody, so we discussed blood transfusion strategy with the Department of Blood Transfusion Service and prepared for Jra-negative packed red blood cells (RBCs). Intraoperative blood salvage was used during LDLT procedures to reduce the use of packed RBCs. Although post-transplantation graft function was excellent, a total of 44 U of Jra-negative RBCs were transfused during the entire perioperative period. Because sufficient amounts of Jra-negative packed RBCs were supplied, Jra mismatched blood transfusion was avoided. The patient was discharged from our hospital on postoperative day 102 without clinical evidence of any blood transfusion–related adverse events. Although there are some controversies of blood transfusion related to anti-Jra antibodies, the current strategies of blood transfusion for liver transplantation with anti-Jra are as follows: (1) sufficient supply and transfusion of Jra-negative matched packed RBCs and (2) application of intraoperative blood salvage to reduce the total amount of rare blood type RBCs. These strategies may be changed when the mechanism of anti-Jra alloimmunization is fully understood in the future.