Active vaccination to prevent de novo hepatitis B virus infection in liver transplantation

The shortage of organ donors mandates the use of liver allograft from anti-HBc(+) donors, especially in areas highly endemic for hepatitis B virus(HBV) infection. Theincidence of de novo hepatitis B infection(DNH) is over 30%-70% among recipients of hepatitis B core antibody(HBcA b)(+) grafts without any prophylaxis after liver transplantation(LT). Systematic reviews showed that prophylactic therapy [lamivudine and/or hepatitits B immunoglobulin(HBIG)] dramatically reduces the probability of DNH. However, there are limited studies regarding the effects of active immunization to prevent DNH, and the role of active vaccination is not welldefined. This review focuses on the feasibility and efficacy of pre- and post-LT HBV vaccination to prevent DNH in HBsA g(-) recipient using HBcA b(+) grafts. The presence of HBs Ab in combination with lamivudine or HBIG results in lower incidence of DNH and may reduce the requirement of HBIG. There was a trend towards decreasing incidence of DNH with higher titers of HBs Ab. High titers of HBs Ab(> 1000 IU/L) achieved after repeated vaccination could eliminate the necessity for additional antiviral prophylaxis in pediatric recipients. In summary, active vaccination with adequate HBsA b titer is a feasible, cost-effective strategy to prevent DNH in recipients of HBc Ab(+) grafts. HBV vaccination is advised for candidates on waiting list and for recipients after withdrawal of steroids and onset of low dose immunosuppression after transplantation.

Extended central hepatectomy with preservation of segment 6 for patients with centrally located hepatocellular carcinoma

BACKGROUND： In order to preserve functional liver parenchyma, extended central hepatectomy （segments 4, 5, 7 and 8 resection） was proposed for the management of centrally located hepatocellular carcinoma invading the right and middle hepatic veins, reconstructing segment 6 outflow in the absence of the thick inferior right hepatic vein. The present study was to describe our surgical techniques of extended central hepatectomy.METHODS： Between 2008 and 2012, 5 patients with centrally located hepatocellular carcinoma invading or in the vicinity of the right and middle hepatic veins underwent extended central hepatectomy. The thick inferior right hepatic vein was preserved during dissection. Gore-Tex graft was used for segment 6 outflow reconstruction in the absence of the thick inferior right hepatic vein.RESULTS： The mean future remnant liver volume for segments 2 and 3 was 28% versus 45% on segment 6 preservation. The mean tumor diameter was 7.4 cm. The thick inferior right hepatic vein was found in 1 patient. Outflow reconstruction from segment 6 was performed in 4 patients. Postoperative complications included bile leakage （1 patient）, pleural effusion （2） and liver failure （1）. The rate of graft patency was 75%. There was no perioperative mortality.CONCLUSION： Extended central hepatectomy is a safe alternative for extended hepatic resection in selected patients attempting to preserve the functional liver parenchyma.

Interventional radiology in living donor liver transplant

The shortage of deceased donor liver grafts led to the use of living donor liver transplant(LDLT).Patients who un-dergo LDLT have a higher risk of complications than those who undergo deceased donor liver transplantation(LT).Interventional radiology has acquired a key role in every LT program by treating the majority of vascular and nonvascular post-transplant complications,improving graft and patient survival and avoiding,in the majority of cases,surgical revision and/or re-transplant.The aim of this paper is to review indications,diagnostic modalities,technical considerations,achievements and potential complications of interventional radiology procedures after LDLT.

Living donor liver transplantation for Barcelona clinic liver cancer (BCLC) intermediate-stage hepatocellular carcinoma

Background:Barcelona clinic liver cancer(BCLC)stage B(intermediate stage)hepatocellular carcinoma(HCC)is highly heterogeneous;thus,identifying the most effective treatment for individual patients represents a significant clinical challenge.However,transarterial chemoembolization(TACE)is the only recommended treatment option.Therefore,we aimed to investigate the patient characteristics and outcomes of living donor liver transplantation(LDLT)for BCLC stage B HCC.Methods:A total of 516 patients with BCLC stage B HCC who underwent LDLT(n=104)or did not undergo LDLT(non-LDLT;n=412)between 2004 to 2018 were analyzed by propensity score matching(PSM;1:4)analysis.Factors influencing overall survival(OS)and recurrence were analyzed using Cox’s proportional hazards models.Results:Patients treated with LDLT achieved better OS than the non-LDLT group,including liver-and non-liver related survival(all P<0.001).Multivariate Cox regression analysis showed age>60 years(P=0.006),a neutrophil-lymphocyte ratio(NLR)>4(P=0.016)and>3 locoregional therapies(LRT)before LDLT(P<0.001)were independent risk factors for HCC recurrence.In addition,age>60 years(P<0.001)and>3 LRT before LDLT(P=0.001)were independent risk factors for OS.Using a combination of age,NLR,and LRT before liver transplantation(LT),the patients can be divided into low-risk(none of risk),intermediate-risk(one of risk),and high risk(more than two of risk)groups.There were significant differences in the cumulative HCC recurrence(P<0.001)and mortality(P<0.001)rates among the three groups.Conclusions:LDLT may represent a valuable therapeutic option for selected patients with BCLC stage B HCC.

Proton beam therapy for downstaging hepatocellular carcinoma with lobar portal vein tumor thrombosis to living donor liver transplantation

Introduction Liver transplantation(LT)is considered as the definitive standard treatment for hepatocellular carcinoma(HCC)with the advantage of addressing both malignancy and the underlying cirrhosis,thus,providing the best overall and recurrence-free survival.Unfortunately,only 20-25%of patients meet the eligibility criteria for LT.

Peri-operative extracorporeal membrane oxygenation in adult and pediatric living donor liver transplantation:a single-center experience

Background:Extracorporeal membrane oxygenation(ECMO)is a potential rescue therapy for patients with acute cardiopulmonary dysfunction refractory to conventional treatment.In this study,we described the clinical profiles and outcomes of adult and pediatric living donor liver transplantation(LDLT)patients who received ECMO support during the peri-operative period.Methods:From June 1994 to December 2020,eleven out of the 1,812 LDLTs performed at Kaohsiung Chang Gung Memorial Hospital required ECMO support:six for respiratory failure,three for cardiogenic shock,and two for refractory septic shock.Comparison between the survivor and non-survivor groups was made.Results:The survival rate for liver transplantation(LT)patients on ECMO support is 36.4%-40%in adults and 33.3%in pediatrics,while the survival rate per indication is as follows:acute respiratory distress syndrome(ARDS)(50%),cardiogenic shock(33.3%),and sepsis(0%).Shorter durations of LT-to-ECMO and pre-ECMO mechanical ventilation were observed in the survivor group.On the other hand,we observed persistently elevated total bilirubin levels in non-survivors,while none of the survivors had aspartate aminotransferase(AST)/alanine aminotransferase(ALT)levels>1,000 U/L.A higher proportion of non-survivors were on concurrent continuous renal replacement therapy(CRRT).Conclusions:Our experience has proven ECMO’s utility during the peri-operative period for both adult and pediatric LDLT patients,more specifically for indications other than septic shock.Further studies are needed to better understand the factors leading to poor outcomes in order to identify patients who will more likely benefit from ECMO.

What happened in 133 consecutive hepatic artery reconstruction in liver transplantation in 1 year?

Background:The immediate challenges during microvascular reconstruction of hepatic artery(HAR)during liver transplantation(LT)can be many.Hence,in order to give a cross sectional view of these problems this study over a period of 1 year,showing our routine practice,was taken up.Methods:From January 2015 to December 2015,a total of 133 LTs were performed in Kaohsiung Chang Gung Memorial Hospital,Taiwan.All hepatic artery(HA)reconstructions were performed by a microvascular surgeon under an operating microscope.Results:In the 133 patients,one artery was anastomosed in 123(92.5%)patients,two in 9(6.8%)patients and three in 1(0.7%)of the patient.Eleven(8.3%)arteries were less than 2 mm in size(1–1.9 mm).There were intimal dissections(IDs)involving either the donor or the recipient arteries of mild to severe nature in 9(6.8%)patients.Immediately following graft arterial anastomosis,either there was no flow or an intraoperative hepatic artery thrombosis(HAT)was found in nine(7.1%—8 LDLT,4.8%—1 DDLT)patients.Immediate re-do anastomosis was done in all of these patients who did well in the follow-up.The overall post-operative success rate was 99.2%.One patient(0.8%)developed postoperative HAT due to infection during follow up and died due to sepsis.Conclusions:Small vessels or HA injury are the frequently encountered problems by a micro vascular surgeon.The other problems could be ID,need to do multiple reconstructions,immediate HAT and ability to re-do the HAR immediately.

Proton beam therapy to bridge or downstage locally advanced hepatocellular carcinoma to living donor liver transplantation

Introduction Within the last decade,progress in transplant and surgical oncology has been tremendous.In liver oncology alone,there has been concurrent technological innovation across the different adjunct fields and tiers of oncology related to hepatocellular carcinoma(HCC),progressing in quite an unprecedented rate.Significant improvements in our capacity to diagnose and prognosticate HCC with increasing sensitivity,specificity,and predictability is being witnessed.We now better understand that staging,treatment and prognostication cannot be determined on a static basis of tumor burden(i.e.,tumor size and number)alone and a“one size fits all”management.Careful individualized assessment is now mandatory in consideration of intra-and intertumoral heterogeneity and tumor biology in order to more precisely guide diagnostics and treatment options(1).

A primary hepatic neuroendocrine tumor disguised as hepatocellular carcinoma

In a 72-year-old female patient,a 2 cm large lesion over liver segment 7(S7)was incidentally diagnosed during a hepatitis C follow-up.The patient was asymptomatic and had an unremarkable physical examination.Her past medical history consists of chronic hepatitis C,diabetes mellitus type 2 and arterial hypertension.

Prevent bile duct injury by indocyanine green guide fluorescent imaging during laparoscopic cholecystectomy in liver transplantation recipient

Cholecystolithiasis with acute cholecystitis is a rare,late biliary complication occurring in liver transplantation(LT)recipients who received the liver graft with preserved donor’s gallbladder.Although laparoscopic cholecystectomy(LC)is not contraindicated after upper abdominal surgery,misunderstanding of the biliary anatomy due to inflammatory phenomena or severe adhesion might increase the risk of bile duct injury(BDI)(1).

Bilateral proficiency over time leads to reduced donor morbidity in living donor hepatectomy

Background:Although left-lobe donation is considered safer,right-sided donor hepatectomy predominatesin adult living donor liver transplantation(LDLT).We hypothesized that bilateral proficiency with donorhepatectomy reduces overall donor complications.Methods:A retrospective review of 834 adult LDLT donors(221 left lobes)from January 2004 toDecember 2014 was performed,dividing cases into two eras based on left-graft experience.Donorcomplications within 6 months were investigated,focusing on graft side and surgical era.Results:The overall complication rate was 17.6%,and was higher in right-lobe donors.In Era 2,duringwhich left-lobe donation rates were three times higher,total complications decreased(14.7%vs.20.9%,P=0.02).A significant reduction in postoperative ascites accounted for the lower overall complication rate.The proportion of major biliary complications(BCs)was halved from 62.5%to 25.0%.Right-lobe donorcomplications also decreased significantly(15.8%vs.22.9%,P=0.032),demonstrating that it was not onlyincreased left-lobe donations leading to lowered complication rates,but also greater experience with donorhepatectomy in general.Conclusions:Accumulating experience with bilateral donor hepatectomy leads to decreased donormorbidity and comparable outcomes for right and left lobes,further enhancing the goal of donor safety whilebalancing recipient needs.

Segment 6 monosegment-preserving hepatectomy for hepatoblastoma:individualizing treatment beyond the resectability criteria

Monosegment-preserving hepatic resections are very rarely considered in patients with locally advanced tumors given the high risk of liver failure from an inadequate liver remnant(1,2).Where this is considered,the associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)technique,a two-staged procedure in order to induce remnant volume hypertrophy,have been reported(1,2).However,ALPPS has been known to have a high complication rate,hence even more infrequently,this complicated technique has been contemplated for pediatric patients(2).In the case we present,we identified an infant with a locally advanced hepatoblastoma with a unique anatomic presentation,that certainly precludes the possibility of ALPPS,but which otherwise provided the team with the opportunity to perform a single-staged monosegment-preserving hepatectomy with curative intent,in lieu of the alternative of liver transplantation(LT).

Segment 8 hepatic vein reconstruction in a living donor after left hepatectomy

Liver transplantation(LT)has been accepted worldwide as standard of treatment for end-stage liver disease.Due to expanding indications for LT and shortage of cadaveric donors,living donor liver transplantation(LDLT)has emerged as an important alternative to augment the donor pool(1).Justifiably,donor safety is the fundamental priority in LDLT.

Staged ligation of large portosystemic collaterals in living donor liver transplantation using a small-for-size graft

The success of using a partial graft for liver transplantation depends highly on portal venous flow as it is the primary determinant of graft regeneration.Portosystemic collaterals(PSCs)are not uncommon,with an incidence reported to be as high as 40%amongst liver transplant candidates(1).

Complete portal vein occlusion after cyanoacrylate sclerotherapy in biliary atresia treated by living donor liver transplantation with intraoperative portal vein stenting via segment 4 portal vein stump

IntroductionLiving donor liver transplantation(LDLT)is a durable treatment for end-stage liver disease due to biliary atresia(BA)with excellent graft and patient survivals as shown in our previous study(1).Vascular complications are a major cause of graft failure in LDLT,particularly in children,where size disparity between donor and recipient vessels is often unavoidable.