Rate Of Biliary Complications Research Articles

Propensity Score-matched Donor and Recipient Outcomes: Robotic Versus Laparoscopic Donor Right Hepatectomy.

Few studies have examined the long-term outcomes of recipients in minimally invasive donor hepatectomies, particularly comparing robotic and laparoscopic donor procedures. Understanding these outcomes is crucial for optimizing surgical approaches and improving the overall success of living donor liver transplantation. This study aimed to compare the feasibility and safety of robotic donor right hepatectomy (RDRH) and laparoscopic donor right hepatectomy (LDRH) by evaluating total follow-up patient outcomes. This retrospective, single-center study included 117 and 118 donors who underwent RDRH and LDRH between March 2016 and June 2023, respectively. After performing 1:1 propensity score matching, 71 donor-recipient pairs were included in each group. Donor and recipient complications were divided into early (within 90 d) and late (after 90 d) biliary and vascular complications. In the matched cohort, major complication rates of donors were similar in both groups. Bile duct (BD) variation was not significantly different; however, the rates of multiple BD openings (26.8% versus 54.9%; P = 0.001) and major biliary complications in recipients were higher in the LDRH group (22.5% versus 42.3%; P = 0.012). The cumulative biliary complication rate was significantly higher in the LDRH group. Early biliary complications were not significantly different; however, the rate of late biliary complications was higher in the LDRH group (11.3 versus 23.9%; P = 0.047). RDRH demonstrated comparable postoperative complications to LDRH in donors but showed fewer recipient biliary complications. This could be attributed to the precision of robotic dissection and BD division, resulting in fewer multiple BD openings.

Technical refinements to reduce the early biliary complication in living donor liver transplantation

BackgroundBiliary reconstruction is a key factor that affects biliary complication rates. Surgical experience plays a pivotal role, but continuous technical refinement is essential for enhancing biliary outcomes. This study aimed to evaluate the biliary outcomes of LDLTs in patients undergoing microsurgical biliary reconstruction with continual technical refinements. Materials and MethodsThis observational cohort study analyzed data was conducted from 2006 to 2022. Microsurgical biliary reconstruction was performed using various refinements, including selective biliary stent insertion, ipsilateral (anatomical) bile duct anastomosis, use of a figure-of-8 suture over the junction of the graft and recipient bile ducts, and centralization techniques for size discrepancies greater than 2 to 1. Comparison and evaluation of early BC within one year post transplant was performed. Results1780 patients (including 1563 adults and 217 paediatric patients) underwent microsurgical biliary reconstruction in LDLTs at KCGMH between 2006 and 2022. The donor grafts comprised 1109 right liver grafts and 671 left liver grafts. Of the grafts, 23.1 % had multiple bile ducts and 16.1 % had bile duct sizes <3 mm. Duct-to-duct anastomosis was performed in most cases 1417 (79.6 %), while 363 (20.4 %) Roux-en-Y hepaticojejunostomies (RY HJ) was performed. The overall early BCs rate was 10 % and notable improvements were observed, decreasing from 10.35 % between 2006 and 2021 to 6.5 % by 2022. Early BS comprised the most part of 6.1 % as compared to 2.7 % one year after transplantation. Stent insertion in selected cases, ipsilateral anastomosis, and the figure-of-8 suture technique significantly reduced early BCs. Although centralization technique showed promising results, its effect was not statistically significant. ConclusionsContinual technical refinements in MBR can contribute to a substantial reduction in early BCs following LDLT, ultimately leading to improved patient outcomes.

Biodegradable internal biliary stenting in orthotopic liver transplantation – A feasibility study

IntroductionBiliary complications remain a common cause of morbidity after liver transplantation and often require invasive interventions to manage. We aimed to assess the technical feasibility and safety of placement of a biodegradable stent across the biliary anastomosis at the time of liver transplantation in patients having a duct to duct biliary reconstruction. MethodsFor this prospective, single-arm, descriptive study, 10 consecutive patients undergoing whole graft, deceased donor, liver transplantation and duct-to-duct biliary tract reconstruction were enrolled and a biodegradable biliary stent was sutured into the bile duct across the anastomosis. ResultsIn all 10 patients it was technically feasible to place and secure the stent safely during the operation. After >6 months (median of 212 days) follow up, no patients had developed biliary anastomotic stricture. One patient had transient bile leak immediately post-operative that was managed conservatively. One patient required endoscopic intervention for non-anastomotic stricture development and biliary cast material that had resulted in stent dysfunction. DiscussionThe results of this study suggest surgical feasibility of placement of an absorbable biliary stent across the biliary anastomosis at the time of liver transplantation, as well as an acceptable safety profile. Further studies are required to confirm these safety and feasibility findings and to assess efficacy in reducing rates of biliary complications and the need for endoscopic intervention in the early post-transplant period.

Impact of Baseline Anti-ABO Antibody Titer on Biliary Complications in ABO-Incompatible Living-Donor Liver Transplantation.

Background: Although advancements in desensitization protocols have led to increased ABO-incompatible (ABOi) living-donor liver transplantation (LDLT), a higher biliary complication rate remains a problem. This study evaluated the effect of baseline anti-ABO antibody titers before desensitization on biliary complications after ABOi LDLT. Methods: The study cohort comprised 116 patients in the ABO-compatible group (ABOc), 29 in the ABOi with the low titer (<1:128) group (ABOi-L), and 14 in the high titer (≥1:128) group (ABOi-H). Results: Biliary complications occurred more frequently in the ABOi-H group than in the ABOi-L and ABOc groups (7 [50.0%] vs. 8 [27.6%] and 24 [20.7%], respectively, p = 0.041). Biliary complication-free survival was significantly worse in the ABOi-H group than in the other groups (p = 0.043). Diffuse intrahepatic biliary strictures occurred more frequently in the ABOi-H group than in the other groups (p = 0.005). Multivariable analysis revealed that the high anti-ABO antibody titer (≥1:128) is an independent risk factor for biliary complications (hazard ratio 3.943 [1.635-9.506]; p = 0.002). Conclusions: A high baseline anti-ABO antibody titer (≥1:128), female sex, and hepatic artery complications are significant risk factors for biliary complications.

Effect of donor warm ischemia time during graft extraction in right lobe robotic donor hepatectomy on recipient outcomes—A propensity score matched analysis

One of the concerns specific to minimally invasive donor hepatectomy (MIDH) is the prolonged time required for graft extraction after completion of the donor hepatectomy (donor warm ischemia time [DWIT]). There has never been an objective evaluation of minimally invasive donor hepatectomy-DWIT on allograft function in living donor liver transplantation. We evaluated the effect of DWIT following robotic donor hepatectomy (RDH) on recipient outcomes and compared them with a matched cohort of open donor hepatectomy (ODH). Demographic, perioperative, and recipient’s postoperative outcome data for all right lobe (RL)-RDH performed between September 2019 and July 2023 were analyzed and compared with a propensity score matched cohort (1:1) of RL-ODH from the same time period. Of a total of 103 RL-RDH and 446 RL-ODH, unmatched and propensity score matched analysis (1:1) revealed a significantly longer DWIT in the RDH group as compared to the ODH group (9.33 ± 3.95 vs 2.87 ± 2.13, P < .0001). This did not translate into any difference in the rates of early allograft dysfunction (EAD), biliary complications, major morbidity, or overall 1-and 3-month survival. The receiver operating characteristic curve analysis threshold for DWIT-early allograft dysfunction was 9 minutes (area under receiver operating characteristic: 0.67, sensitivity = 80%, specificity = 53.8%). We show that prolonged DWIT within an acceptable range in RDH does not have deleterious effects on short-term recipient outcomes. Further long-term studies are required to confirm our findings, especially with regard to nonanastomotic biliary complications.

The building of an institutional liver transplant registry: opportunities and challenges.

To improve current data systems for institutional decision-making, the Adult Liver Transplant Registry was established at the Hospital Italiano de Buenos Aires, Argentina. This article describes its design and implementation and reports on the outcomes for patients transplanted since its January 2020 launch. A multidisciplinary team designed the registry by identifying key variables from a literature review while considering balance between data depth and feasibility. Rigorous quality control measures were enforced, including monthly audits and staff training. Benchmark indicators for post-transplant outcomes were established. As of November 2023, the registry included 136 transplants. Its implementation and maintenance were straightforward, with no significant difficulties encountered. Cirrhosis was the predominant indication (77%) for transplant. Only one living donor transplantation was performed. Post-transplant results generally aligned with benchmarks, but rates of biliary complications slightly exceeded the recommended thresholds. The one-year post-transplant survival rate was 87%. The successful registry implementation provides a robust framework for research, treatment management, and patient care enhancement within a liver transplant unit.

Primary cilia as a targetable node between biliary injury, senescence and regeneration in liver transplantation

Biliary complications are a major cause of morbidity and mortality in liver transplantation. Up to 25% of patients that develop biliary complications require additional surgical procedures, re-transplantation or die in the absence of a suitable regraft. Here, we investigate the role of the primary cilium, a highly specialised sensory organelle, in biliary injury leading to post-transplant biliary complications. Human biopsies were used to study the structure and function of primary cilia in liver transplant recipients that develop biliary complications (n= 7) in comparison with recipients without biliary complications (n= 12). To study the biological effects of the primary cilia during transplantation, we generated murine models that recapitulate liver procurement and cold storage, and assessed the elimination of the primary cilia in biliary epithelial cells in the K19CreERTKif3afl/fl mouse model. To explore the molecular mechanisms responsible for the observed phenotypes we used invitro models of ischemia, cellular senescence and primary cilia ablation. Finally, we used pharmacological and genetic approaches to target cellular senescence and the primary cilia, both in mouse models and discarded human donor livers. Prolonged ischemic periods before transplantation result in ciliary shortening and cellular senescence, an irreversible cell cycle arrest that blocks regeneration. Our results indicate that primary cilia damage results in biliary injury and a loss of regenerative potential. Senescence negatively impacts primary cilia structure and triggers a negative feedback loop that further impairs regeneration. Finally, we explore how targeted interventions for cellular senescence and/or the stabilisation of the primary cilia improve biliary regeneration following ischemic injury. Primary cilia play an essential role in biliary regeneration and we demonstrate that senolytics and cilia-stabilising treatments provide a potential therapeutic opportunity to reduce the rate of biliary complications and improve clinical outcomes in liver transplantation. Up to 25% of liver transplants result in biliary complications, leading to additional surgery, retransplants, or death. We found that the incidence of biliary complications is increased by damage to the primary cilium, an antenna that protrudes from the cell and is key to regeneration. Here, we show that treatments that preserve the primary cilia during the transplant process provide a potential solution to reduce the rates of biliary complications.

US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery

Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. cDCD livers were recovered by either NRP or SRR. The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.

The outcomes and biliary complications of a staged biliary reconstruction in living donor liver transplantation: a propensity score matched analysis

BackgroundUncontrolled massive bleeding and bowel edema are critical issues during liver transplantation. Temporal intra-abdominal packing with staged biliary reconstruction (SBR) yields acceptable outcomes in deceased donor liver transplantation; however, data on living donor liver transplantation (LDLT) are scarce. MethodsA retrospective analysis of 1269 patients who underwent LDLT was performed. After one-to-two propensity score matching, patients who underwent LDLT with SBR were compared with those who underwent LDLT with one-stage biliary reconstruction (OSBR). The primary outcomes were graft survival (GS) and overall survival (OS), and the secondary outcomes were postoperative biliary complications. ResultsThere were 55 and 110 patients in the SBR and OSBR groups, respectively. The median blood loss was 6500 mL in the SBR and 4875 mL in the OSBR group. Patients receiving SBR-LDLT had higher incidence of sepsis (69.0% vs. 43.6%; P < 0.01) and intra-abdominal infections (60.0% vs. 30.9%; P < 0.01). Biliary complication rates (14.5% vs. 19.1%; P = 0.47) and 1-and 5-year GS (87.27%, 74.60% vs. 83.64%, 72.71%; P = 0.98) and OS (89.09%, 78.44% vs. 84.55%, 73.70%; P = 0.752) rates were comparable between the two groups. ConclusionsSBR could serve as a life-saving procedure for patients undergoing complex critical LDLT, with GS, OS, and biliary outcomes comparable to those of OSBR.

Effect of Donors' Biliary Variation on Postoperative Biliary Complications in Living Donor Liver Transplantation: A Single-Center Observational Study in Vietnam

Our study aims to evaluate the biliary anatomy variation according to the Varotti classification and its correlation with surgical outcomes for both donors and recipients undergoing living donor liver transplants (LDLTs). A retrospective analysis of 150 LDLT cases performed at a single center in Vietnam with preoperative radiologic evaluations and intraoperative surgical assessments to identify biliary variant anatomy. Postoperative biliary complications were documented and analyzed. Statistical analysis was performed to determine any significant associations between biliary variations and post-transplant outcomes. One hundred fifty cases of LDLT at 108 Military Central Hospital from October 2017 to December 2022 were included in our study. Among the donors, the mean age was 30.89 ± 7.23, with male predominance (77.3%). The prevalence of type 1 biliary anatomy was 84.67%. Type 2, 3a, 3b, 4a, and 4b accounted for 5.33%, 2.67%, 5.33%, 0.67%, and 1.33% of cases, respectively. Donors' complications were witnessed in 7 cases (4.67%), and all needed intervention (Clavien-Dindo grade 3). Biliary complications were found in 36 (24.0%) recipients, with 22 (14.67%) cases of biliary stenosis and 16 (10.67%) cases of biliary leak, including 2 cases encountering both complications. Age, gender, graft type, preoperative liver function, biliary variant anatomy, number of graft orifices, Model for End-Stage Liver Disease score, and blood loss were not significant risk factors for recipients' biliary complications. Cold ischemia time significantly increased the biliary complication rate. This study shows that biliary variant anatomy is common in living liver donors. Such variations should not be a contraindication to liver donation. However, accurate pre- and intraoperative radiologic and surgical evaluations are fundamental for a careful reconstruction plan.

P358 Impact of end-ileostomy versus ileal pouch-anal anastomosis on graft-survival following liver transplantation for primary sclerosing cholangitis

Abstract Background IBD-PSC patients may require both liver transplantation and ileoanal pouch (IPAA) construction. Recently, concerns have been raised regarding an increased rates of hepatic artery thrombosis, biliary strictures, and graft loss in individuals who underwent IPAA after liver transplantation compared to those who underwent end-ileostomy (EI). We hypothesized that graft survival was not negatively affected by IPAA compared with EI. Methods A prospectively maintained database from a large tertiary center was searched for patients meeting the inclusion criteria for liver transplantation, primary sclerosing cholangitis, ulcerative colitis, and total colectomy with IPAA or EI. Univariate analysis and Kaplan-Meier survival curves were calculated. Results Between January 1990 and December 2023, 55 patients met inclusion criteria. Of these, 46 (83.6%) underwent IPAA, and 9 (16.4%) underwent EI. The average age at colectomy (41.7 vs. 45.7 years; p=0.44), sex distribution (female: 26.1% vs. 22.2%, p=1), and MELD score before transplantation (20.3 vs. 14; p=0.06) were comparable between patients with IPAA and EI patients. The rates of re-transplantation (21.7% vs. 22.2%; p=1), hepatic artery thrombosis (8.7% vs. 0; p=1), episodes of acute rejection (32.6% vs. 44.4%; p=0.7), chronic rejection (4.3% vs. 11.1%; p=0.42), recurrence of primary sclerosing cholangitis (23.9% vs. 22.2%; p=1), and biliary complications (21.7% vs. 33.3%; p=0.43) were similar between the IPAA and EI groups, respectively. None of the EI patients developed parastomal varices. Survival analyses for time to re-transplantation (p=0.97), overall survival (p=0.3), and time to graft loss or mortality (p=0.73) were similar. Conclusion In contrast to a previous study, we observed similar rates of liver transplant graft loss, biliary complications, and recurrent PSC after IPAA compared to those after end-ileostomy. IPAA may be associated with an increased rate of hepatic artery thrombosis.

Highly complex liver resections: Exploring the boundaries of feasibility and safety.

In select clinical scenarios, advanced techniques for volume manipulation and vascular reconstruction are needed for complete hepatic tumor removal. These highly complex liver resections (HCLRs) entail a heightened risk of severe complications. Here, we describe the results of HCLR performed in a 3-year time period. We conducted a retrospective analysis encompassing patients who underwent hepatic resections between June 15, 2020, and June 15, 2023. HCLR was defined according to previously established criteria, and included associating liver partition and portal vein ligation for staged hepatectomy.The outcomes of HCLR were compared to all non-HCLR performed within the same time frame. Among 167 hepatic resections, 26 were considered HCLR, and all were major resections. Five utilized total vascular exclusion, with venovenous bypassin three, and hypothermic liver perfusion in three. Five resections included vascular reconstructions, and one included hypothermic circulatory arrest for extraction of a tumor extending to the right atrium. Of the non-HCLR, 38 (26.9%) were major, and 49 (34.7%) were performed laparoscopically. The rates of overall major postoperative complications were comparable between those who underwent HCLR versus non-HCLR. HCLR was associated with increased rates of biliary complications, readmissions, and reoperation. However, no postoperative 90-day mortality was documented within patients that underwent HCLR compared to two in the non-HCLR group. In expert hands, HCLR can be performed with acceptable complication profile, akin to that of major non-HCLR. Those with questionable resectability should be referred to tertiary hepato-pancreato-biliary centers.

Hepatic Duct Division During Robotic Living Donor Hepatectomy: A Comparison Between the Novel Triple C (Clip-Clamp-Cut) and the Cut-Suture Techniques.

Background: In robotic donor hepatectomy (RDH), hepatic duct division (HDD) and its stump closure technique are of paramount importance in avoiding postoperative biliary complications in both donors and recipients. We describe our novel triple C ("clip-clamp-cut") technique of HDD. Methods: Out of 4016 living donor liver transplant (LDLT) (2004-October 2023), we have performed 208 RDH cases since December 2019. This study is a retrospective analysis of the first 160 RDH cases. After excluding the first 20 RDH cases (learning curve) and 3 left-sided RDH cases, 137 cases with no exclusion criteria were included. We divided these 137 donors into the "cut and suture" (CS) group (n = 33) and the "triple C" technique group (n = 104). We compared intraoperative details and postoperative outcomes. Results: All 137 robotic donors and 128/137 recipients are currently well. Donor biliary leak rate was significantly lower among the triple C group (n = 3, 2.9%) compared to the CS group (n = 5, 15.2%) (p=0.009). No other differences in postdonation morbidity were observed among the two groups. Recipient biliary complication rate was lower in the triple C group than in the CS group although not statistically significant (10.6% vs. 15.1%; p=0.537), despite more multiple biliary anastomoses in the former. No significant differences in post-transplant recipient morbidity and mortality were observed. Conclusions: Our simple yet novel triple C technique enables clean, precise, bloodless HDD resulting in lower donor and potentially recipient biliary complication rates. The ease and reproducibility make it ideal for widespread adoption.

Mini-incision Right Hepatectomy for Living Donor Hepatectomy.

The application of a minimally invasive technique to graft procurement in living donor liver transplantation has minimized skin incisions and led to early recovery in donor hepatectomy while ensuring donor safety. This study aimed to evaluate the safety and feasibility of mini-incision living donor right hepatectomy compared with conventional open surgery. The study population consisted of 448 consecutive living donors who underwent living donor right hepatectomy performed by a single surgeon between January 2015 and December 2019. According to the incision type, the donors were divided into 2 groups: a right subcostal mini-incision group (M group: n = 187) and a conventional J-shaped incision group (C group: n = 261). A propensity score matching analysis was conducted to overcome bias. The estimated graft volume and measured graft weight were significantly lower in the M group ( P = 0.000). The total of 17 (3.8%) postoperative complications were identified. The readmission rate and overall postoperative complication rate of donors was not significantly different between the groups. The biliary complication rates in the recipients were 12.6% and 8.6% in the C group and M group, respectively ( P = 0.219). Hepatic artery thrombosis requiring revision developed in 2 patients (0.8%) in the C group and 7 patients (3.7%) in the M group ( P = 0.038). After propensity score matching, these complications were not significantly different between the groups. Mini-incision living donor right hepatectomy shows comparable biliary complications to open surgery and is considered a safe and feasible operative technique.

Favorable experience of transplant strategy including liver grafts from COVID-19 donors: One-year follow-up results.

Since November 2020, Italy was the first country to carry out a protocol and use liver from COVID-19 donors. We aimed to evaluate the medium-term outcome of patients who underwent liver transplant (LT) with those grafts. We consecutively enrolled 283 patients who underwent first LT from November 2020 to December 2022 in our Center (follow-up 468 days). Twenty-five of 283 (8.8%, study population) received a graft from donors with previous (4%) or active (96%) SARS-CoV-2 infection, and 258/283 (91.2%, control group) received a graft from COVID-19-negative donors. SARS-CoV-2-RNA was tested on graft tissue of COVID-19 donors and their recipients underwent weekly evaluation of SARS-CoV-2-RNA in nasal swabs for the first month after LT. One-year and 2-year patient survival was 88.5% and 88.5% in study group versus 94.5% and 93.5% in control group, respectively (p = .531). In study population there was no evidence of donor-recipient virus transmission, but three (12%) patients (vs. 7 [2.7%] of control group, p = .048) developed hepatic artery thrombosis (HAT): they were SARS-CoV-2-RNA negative at LT and 1/3 grafts tested SARS-CoV-2-RNA positive on liver tissue. COVID-19 donor was independently associated with HAT (odds ratio (OR) = 4.85, 95% confidence interval (CI) 1.10-19.15; p = .037). By comparing study population with control group, acute rejection and biliary complication rates were not significantly different (16%vs. 8.1%, p = .26; 16%vs. 16.3% p = .99, respectively). Our 1-year results of transplant strategy including liver grafts from COVID-19 donors were favorable. HAT was the only complication with significantly higher rate in patients transplanted with COVID-19 donors compared with control group.

Live donor liver transplantation for pediatric acute liver failure: challenges and outcomes.

This study aimed at studying the challenges and outcomes of live-donor liver transplantation (LDLT) for pediatric acute liver failure (PALF). A total of 315 patients with PALF were treated over a period of 11years. 42 underwent LT (41 LDLT and one DDLT), constituting 38% (41/110) of all pediatric transplants during this duration. The outcomes of LDLT for PALF were analyzed. All the 41 children who underwent LT met the Kings College criteria (KCC). The etiology was indeterminate in 46.3% (n = 19) children. 75.6% (n = 31) were on mechanical ventilation for grade 3/4 hepatic encephalopathy. There was presence of cerebral edema on a computed tomography scan of the brain in 50% of the children. One-third of our children required hemodynamic support with vasopressors. Systemic inflammatory response syndrome and sepsis were observed in 46.3% and 41.4% of patients, respectively. Post-LDLT 1- and 5-yr patient and graft survival were 75.6% and 70.9%, respectively. The survival in children satisfying KCC but did not undergo LT was 24% (38/161). Vascular and biliary complication rates were 2.4% and 4.8%, respectively. No graft loss occurred because of acute rejection. In multivariate analysis, pre-LT culture positivity and cerebral edema, persistence of brain edema after transplantation, and resultant pulmonary complications were significantly associated with post-LT death. Thirteen (32%) children who underwent plasmapheresis prior to LT had better post-LT neurological recovery, as evidenced by early extubation. LDLT for PALF is lifesaving and provides a unique opportunity to time transplantation. Good long-term survival can be achieved, despite the majority of patients presenting late for transplantation. Early referral and better selection can save more lives through timely transplantation.

Reduced-Size Left Lateral Segment Grafts in Infants Weighing

Live donor liver transplantation for infants weighing <10 kg has unique complexities, as patient/graft size discrepancies may cause vascular perfusion deficiencies. Failure of the abdominal closure further complicates this already challenging procedure. To overcome these potential problems, several techniques for graft size reduction-either anatomic or nonanatomic-have been proposed in the literature. Technically easier and less time-consuming, nonanatomic size reductions have the advantage of avoiding the risk of injury to the portal pedicle. This study aimed to evaluate and compare the effects of nonanatomic graft size reduction in infants weighing <10 kg with a large estimated preoperative graft recipient weight ratio. We enrolled 106 infants weighing <10 kg. Of these infants, 50 received reduced-size grafts. The outcomes were compared between the groups. No difference was observed between the groups according to survival and vascular or biliary complications. None of the patients required an open abdomen or mesh closure. Nonanatomic size reduction of left lateral segment grafts can be safely applied without compromising vascular supply, graft function, and patient survival with comparable vascular and biliary complication rates. This technique is safe and efficient in overcoming the complications caused by large-for-size syndrome in infants weighing <10 kg.

Biliary complications post liver resection for pediatric liver tumors

ObjectiveTo review biliary complications following liver resection for liver tumors in children and their associated risk factors.MethodsRetrospectively, we reviewed children who underwent liver resection for liver tumors from 2010 to...

Another Tool in the Quest for the Perfect Living Liver Donor Operation.

Living donor surgeons must balance donor safety with regard to bleeding, vascular injury, and biliary complications while minimizing short-term pain and long-term abdominal wall function. At the same time, living donor patients are usually deeply concerned about the recipient’s outcomes. Reduced donor morbidity at the cost of increased recipient complications is not acceptable. In this issue, Park et al report their experience with 448 consecutive donors who underwent living donor right hepatectomy by a single surgeon over the course of 5 y.1 One hundred eighty-seven of these donors underwent a mini-incision compared with the conventional J-shaped incision. The team functions within a center that performed more than 1600 donor right hepatectomies over the 5-y period. Right hepatectomy is a physiologically significant operation with risks related to loss of hepatic parenchyma. Many donor surgeons have argued that due to the risks of the surgery including hepatic failure, vascular injury, and biliary complications, the open approach should remain the primary approach.2 However, minimally invasive approaches have been introduced starting with Cherqui et al in 20023 and for right hepatectomies in 2013.4 Although a few centers have embraced the full laparoscopic approach for near donors, adoption broadly in the community of donor surgeons has been slow. Ten years after the initial right hepatectomy reports, fully laparoscopic donor hepatectomy surgery remains isolated to a few centers.5,6 As the authors mention, mini-incision, laparoscopy-assisted and hand-assisted approaches, have been introduced to minimize abdominal wall injury while reducing the learning curve associated with fully laparoscopic approach. Park et al show that excellent outcomes can be achieved for the donors and the recipients using an 8.5- to 13-cm right subcostal incision. They demonstrated low rates of biliary and vascular complications for both donors and recipients. Authors note that when they started mini-incision living donor right hepatectomy, they avoided larger liver and higher body mass index patients or patients with large inferior right hepatic veins. Later in their experience, they develop increased comfort with higher body mass index patients. Interestingly, at the authors’ institution, only 5% of the right hepatectomies are performed laparoscopically, and 3 of the 5 performing donor hepatectomies only perform mini-incision on selected patients. This rigorous selection of patients highlights challenges for broader application of smaller incisions even at the most experienced centers in the world. Making a minimally invasive donor operation safer, more easily reproducible, and with a shortened learning curve is the ideal all donor surgeons should be striving toward. Park et al have shown that mini-incision right donor hepatectomy can be part of that toolbox but likely the perfect operation is still out there waiting to be developed.

Where to Draw the Line in Ex-Situ Split Liver Transplantation for Adult Recipients? – A Benchmarking Analysis

Abstract Background A comprehensive outcome analysis of ex situ right split liver graft transplantation (RSLT) is currently lacking. Aims Benchmarking outcomes of RSLT against best achievable results from whole LT offers a novel comparative approach. Methods This retrospective study includes all consecutive ex-situ RSLT for adult recipients performed from 2014-2019 at 4 high volume transplant centers (&amp;gt;70 LT/year). Outcomes including overall morbidity expressed by the comprehensive complication index (CCI) and graft related complications were compared to the published benchmark cutoffs for whole graft LT. Results We included 129 ex-situ RSLT with 76% H45678 (n=98) and 24% (n=31) H5678 grafts. The median follow-up was 4.8 years. Overall and severe 1-year morbidity expressed by the CCI were within established whole graft LT benchmarks. Biliary complication rates were slightly higher than the benchmark due to the occurrence of cut-surface leaks. The arterial thrombosis rate was outside the benchmark cutoff (7% vs ≤4.4%) leading to a higher retransplantation rate. However, overall 1-year graft and recipient mortality were well within the benchmark cutoffs, resulting in a 5-year overall recipient survival of 88.5%. Selecting benchmark cases for RSLT defined by low-risk recipient-donor criteria including static cold storage time ≤10h and recipient MELD≤20 points, did not significantly reduce overall morbidity nor arterial complication rate. In contrast, the type of split graft (H45678 vs.H5678) did impact on both arterial and biliary complications. Conclusions This large multicenter series of ex-situ right split grafts disclosed an overall 1-year morbi-mortality comparable to the best achievable results in whole graft LT. The results show that the main morbidity burden in adult RSLT is related to technical criteria rather than graft-recipient matching.