Viability Assessment in Liver Transplantation—What Is the Impact of Dynamic Organ Preservation?

Based on the continuous increase of donor risk, with a majority of organs classified as marginal, quality assessment and prediction of liver function is of utmost importance. This is also caused by the notoriously lack of effective replacement of a failing liver by a device or intensive care treatment. While various parameters of liver function and injury are well-known from clinical practice, the majority of specific tests require prolonged diagnostic time and are more difficult to assess ex situ. In addition, viability assessment of procured organs needs time, because the development of the full picture of cellular injury and the initiation of repair processes depends on metabolic active tissue and reoxygenation with full blood over several hours or days. Measuring injury during cold storage preservation is therefore unlikely to predict the viability after transplantation. In contrast, dynamic organ preservation strategies offer a great opportunity to assess organs before implantation through analysis of recirculating perfusates, bile and perfused liver tissue. Accordingly, several parameters targeting hepatocyte or cholangiocyte function or metabolism have been recently suggested as potential viability tests before organ transplantation. We summarize here a current status of respective machine perfusion tests, and report their clinical relevance

Epidemiology and Surgical Management of Foreign Bodies in the Liver in the Pediatric Population: A Systematic Review of the Literature

Retention of foreign bodies (FB) in the liver parenchyma is a rare event in children but it can bring a heavy burden in terms of immediate and long-term complications. Multiple materials can migrate inside the liver. Clinical manifestations may vary, depending on the nature of the foreign body, its route of penetration and timing after the initial event. Moreover, the location of the FB inside the liver parenchyma may pose specific issues related to the possible complications of a challenging surgical extraction. Different clinical settings and the need for highly specialized surgical skills may influence the overall management of these children. Given the rarity of this event, a systematic review of the literature on this topic was conducted and confirmed the pivotal role of surgery in the pediatric population

Recovery of renal function in liver transplant alone versus combined liver kidney transplantation: analysis from the NHSBT UK registry

Introduction and Aims: Recovery of renal function after liver transplantation is strongly influenced by pretransplant degree and duration of renal insufficiency, despite imprecise methods for measuring renal dysfunction. Indications for combined liver-kidney transplantation (CLKT) have been defined, but these are still under debate and hepatorenal syndrome (HRS) is a particularly challenging condition given the hardly predictable spontaneous improvement with liver transplant alone (LTA). Methods: We analysed data of 6035 patients (Jan 2001-Dec 2012) from NHSBT UK Transplant Registry. Renal function at 1 years after transplantation was compared between CLKT and LTA with stratification on the basis of glomerular filtration rate (eGFR) at transplant (KDIGO Guidelines) and treatment with renal replacement therapy (RRT). Renal function post-transplantation was classified as eGFR >60, between 59-30 and <30 ml/min/1.73m2, the latter identified as non recovery of renal function. Univariate and multivariable analysis were performed. Results: 5912 patients (98.0%) underwent liver transplant alone (LTA) and 123 (2.0%) patients received a CLKT. 305 (5.2%) of the LTA group were on RRT at time of transplantation, compared to 72 (58.5%) of the CKLT group. No patient with a MELD score <20 received RRT before transplant. No patients with eGFR ≥60 mL/min/1.73m2 received CLKT. 27% of patients receiving CLKT were diagnosed with pre-transplant glomerular/tubular kidney disease, 39% with polycystic disease and 34% were not specified. LTA patients on RRT were more frequently presenting ascites ( p<0.001), variceal bleeding ( p=0.002), higher MELD score ( p<0.001), higher INR ( p<0.001) and bilirubin at transplant ( p<0.001), suggesting the occurrence of HRS (data not available). Patients on RRT experience a significant difference of renal function recovery at 1 year post-transplant when receiving LTA versus CLKT, with the latter group experiencing a higher percentage of non-recovery ( p=0.001; table 1). This difference was not detected for other eGFR stratifications.The univariate analysis identified recipient age >50 years, female gender, RRT in patients with MELD >20, polycystic disease and diabetes as predictive factors for non-recovery of renal function in patients undergoing LTA. In a multivariable model including all clinically relevant variables simultaneously, the independent predictors of renal function non-recovery were female gender (HR 2.76; 95% CI 1.52-4.99, p=0.001), RRT in patients with MELD >20 (HR 3.62; 95% CI 1.44-9.08, p=0.006) and diabetes (HR 2.55; 95% CI 1.38-4.73, p=0.003). Conclusions: Recovery of renal function post-LTA is acceptable for patients with different stratifications of eGFR pre-transplant. RRT, female gender and diabetes may suggest to perform CLKT

Epidemiology and Surgical Management of Foreign Bodies in the Liver in the Pediatric Population: A Systematic Review of the Literature

Retention of foreign bodies (FB) in the liver parenchyma is a rare event in children but it can bring a heavy burden in terms of immediate and long-term complications. Multiple materials can migrate inside the liver. Clinical manifestations may vary, depending on the nature of the foreign body, its route of penetration and timing after the initial event. Moreover, the location of the FB inside the liver parenchyma may pose specific issues related to the possible complications of a challenging surgical extraction. Different clinical settings and the need for highly specialized surgical skills may influence the overall management of these children. Given the rarity of this event, a systematic review of the literature on this topic was conducted and confirmed the pivotal role of surgery in the pediatric population

Adult liver transplantation in the congenital absence of inferior vena cava

Whereas congenital absence of inferior vena cava observed in paediatric population more often than not, as an isolated or syndromic variety, this is seldom encountered in adult liver transplant recipients. There appear few sporadic reports in the literature on experience of such anomaly in adults. Given the rarity of situation, surprising encounters of such anomalies may pose challenge to the unprepared transplant surgeon and unfavourable outcomes may even have resulted in under-reportage of this condition. In this brief report we document our recent experience with two such cases and this is supplemented with extensive reference to the literature on classification of such anomalies with the endeavour to document implications of such in the adult liver transplant setting. (C) 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved

Is routine hepaticojejunostomy at the time of unplanned surgical bypass required in the era of self-expanding metal stents?

Background: Hepaticojejunostomy is routinely performed in patients when inoperable disease is found at planned pancreatoduodenectomy; however, in the presence of self-expanding metal stent (SEMS) hepaticojejunostomy may not be required. The aim of this study was to assess biliary complications and outcomes in patients with unresectable disease at time of planned pancreaticoduodenectomy stratified by the management of the biliary tract.Material and methods: Retrospective analysis of patients undergoing surgery in January 2010-December 2015. Complications were measured using the Clavien-Dindo scale.Results: Of 149 patients, 111 (75%) received gastrojejunostomy and hepaticojejunostomy (double bypass group) and 38 (26%) received a single bypass in the presence of SEMS (single bypass group). Post-operative non-biliary [7 (18%) vs 43 (38%), (p = 0.028)] and biliary [0% vs 12 (11%), (p = 0.037)] complications were lower in the single bypass group. Hospital readmissions were significantly higher in the double bypass group (p = 0.021). Overall survival and the time to start chemotherapy were equivalent (p = n.s.).Conclusions: Complications are more common following double bypass compared to single bypass with SEMS suggesting that gastric bypass is adequate surgical palliation in presence of SEMS. This study adds further evidence that preoperative SEMS should be used in preference to plastic stents for suspected periampullary malignancy