Salvage living donor liver transplantation for recurrent hepatocellular carcinoma after prior laparoscopic hepatectomy

Salvage liver transplantation(LT)is frequently performed on patients who experience recurrent hepatocellular carcinoma(HCC)after primary hepatectomy for HCC[1,2].The main concern in these patients is the technical feasibility of salvage LT,especially as prior hepatectomy may result in heavy adhesions[3,4].Salvage living donor LT(LDLT)is a more demanding procedure than salvage deceased donor LT(DDLT)using an entire donor graft with a long vascular pedicle[5,6].Because less than optimal dissection of perihepatic adhesions could result in uncontrollable pinpoint bleedings at the dissection surface[1,5],many transplant surgeons avoid performing salvage LDLT.Minimally invasive laparoscopic hepatectomy(LH)results in fewer intraperitoneal adhesions than the open method,reducing the difficulty of surgical dissection during future LT[7–10].To date,however,no study has compared salvage LDLT for recurrent HCC after LH to that after open hepatectomy(OH).

Assessment of pathogens and risk factors associated with bloodstream infection in the year after pediatric liver transplantation

BACKGROUND Bloodstream infection(BSI)is one of the most significantly adverse events that can occur after liver transplantation(LT)in children.AIM To analyze the profile of BSI according to the postoperative periods and assess the risk factors after pediatric LT.METHODS Clinical data,collected from medical charts of children(n=378)who underwent primary LT,were retrospectively reviewed.The primary outcome considered was BSI in the first year after LT.Univariate and multivariate analyses were performed to identify risk factors for BSI and respective odds ratios(ORs).RESULTS Of the examined patients,106(28%)experienced 162 episodes of pathogen-confirmed BSI during the first year after LT.There were 1.53±0.95 episodes per children(mean±SD)among BSIcomplicated patients with a median onset of 0.4 mo post-LT.The most common pathogenic organisms identified were Coagulase-negative staphylococci,followed by Enterococcus spp.and Streptococcus spp.About half(53%)of the BSIs were of unknown origin.Multivariate analysis demonstrated that young age(≤1.3 year;OR=2.1,P=0.011),growth failure(OR=2.1,P=0.045),liver support system(OR=4.2,P=0.008),and hospital stay of>44 d(OR=2.3,P=0.002)were independently associated with BSI in the year after LT.CONCLUSION BSI was frequently observed in patients after pediatric LT,affecting survival outcomes.The profile of BSI may inform clinical treatment and management in high-risk children after LT.

Pacemaker lead induced cardiac perforation presenting with pneumothorax

An 87-year-old male with old myocardial infarction was referred to the hospital due to left femur neck fracture and intermittent dizziness. Significant 2:1 atrioventricular block was demonstrated on initial electrocardiogram (Figure 1). Transthoracic echocardiography showed reduced left ventricular function (LVEF = 47%) with regional wall motion abnormality of right coronary artery (RCA) and left circumflex coronary artery (LCx) artery. Coronary angiography showed patent previous proximal RCA and distal LCx stents. Temporary pacemaker was inserted initially and the patient was planned for permanent pacemaker insertion after the surgery.

Coronary-Cameral Fistula appeared after coronary artery intervention

A 63-year-old male with old myocardial infarction was referred to cardiology department with cardiac arrest.Electrocardiogram revealed Q wave in the precordial leads demonstrating ischemia of anterior left ventricular wall.Mild pulmonary edema was documented on chest X-ray.Transthoracic echocardiography showed severely reduced left ventricular function (EF: 28%) with enlarged left atrium and ventricle.Coronary angiography was performed showing a total occlusion of the proximal portion of the left anterior descending artery (LAD)(Figure 1) with chronic total occlusion in the proximal portion of right coronary artery.Xience stent 2.75 × 23 mm (Abbott) was implanted in the proximal LAD lesion.Coronary angiography after percutaneous coronary intervention (PCI) revealed no definite coronary fistula (Figure 2).Two weeks later,follow-up coronary angiography demonstrated multiple coronary-left ventricular fistulas (Figure 3) which were absent in the previous angiography.

Morbidity analysis of left hepatic trisectionectomy for hepatobiliary disease and live donor

Background:Despite remarkable advances in surgical techniques and perioperative management,left hepatic trisectionectomy(LHT)remains a challenging procedure with a somewhat high postoperative morbidity rate compared with less-extensive resections.This study aimed to analyze the short-and long-term outcomes of LHT and identify factors associated with the postoperative morbidity of this technically demanding surgical procedure.Methods:The medical records of 53 patients who underwent LHT between June 2005 and October 2019 at a single institution were retrospectively reviewed.The independent prognostic factor of postoperative morbidity was analyzed using the logistic regression model.Results:Hepatocellular carcinoma was the most common indication for surgery(n=21),followed by hilar cholangiocarcinoma(n=14),intrahepatic cholangiocarcinoma(n=10),and other pathologies(including colorectal liver metastasis,hepatolithiasis,gallbladder cancer,living donor,hemangioma,and multilocular biliary cyst;n=8).The rates of postoperative morbidities of Clavien-Dindo grade 3 or higher and 90-day mortality were 39.6% and 1.9%,respectively.The 1-,3-,and 5-year overall survival rates were 81.1%,61.4%,and 44.6%,respectively.Multivariate analysis revealed that preoperative jaundice[hazard ratio(HR)=6.15,95%confidence interval(CI):1.57-24.17,P=0.009]and operative time>420 min(HR=4.66,95%CI:1.27–17.17,P=0.021)were independent predictors of postoperative morbidity.Conclusions:The in-hospital mortality of LHT surgery can be minimalized by a reliable preoperative evaluation of liver function and selection of the dominant anatomic features of right posterior sector,active and appropriate preoperative management for obstructive cholangitis and compensatory hypertrophy of the future remnant posterior sector,and the experience of the surgeon.

Portal vein stenting as a significant risk factor for biliary stricture in adult living donor liver transplantation

BACKGROUND: Although perioperative portal vein (PV) stent implantation is an effective treatment for steno-occlusive disease in adult living donor liver transplantation (LDLT) re-cipients, we experienced high incidence of biliary anastomotic strictures (BAS) after PV stenting. In this study, we sought to clarify the relation between BAS and PV stenting and to suggest the possible mechanism of BAS and measures to reduce its in-cidence. METHODS: We retrospectively analyzed 44 LDLT recipients who underwent PV stent implantation across the line of PV anastomosis regardless of the location of steno-occlusion (stent group) and their matched controls (non-stented LDLT recipients, n=131). RESULTS: The incidence of BAS was higher in patients in the stent group than that in the control group (43.2% vs 17.6%, P=0.001). Cumulative 6-month and 1-, 2- and 5-year BAS rates were 31.8%, 34.1%, 41.4% and 43.2%, respectively, in the stent group and 13.0%, 13.8%, 16.1% and 17.8%, respectively, in the control group (P=0.001). Multivariate analysis revealed that PV stenting was an independent risk factor for BAS. CONCLUSIONS: Although PV stent implantation is a reliable treatment modality for steno-occlusive PV in adult LDLT recipients, innovative methods to prevent the PV stent from crossing the line of PV anastomosis may be necessary to reduce the incidence of postoperative BAS.

Induced atrial fibrillation during defibrillation test on implantation of subcutaneous implantable cardioverter defibrillator

The subcutaneous implantable cardioverter defibrillator(S-ICD)has become an alternative to the transvenous ICD in indicated patients.However,inappropriate shock or failed ventricular tachycardia/fibrillation conversion is the most alarming complication of S-ICD.Therefore,defibrillation test(DFT)is recommended for the S-ICD implantation.

Polymorphic ventricular tachycardia during phase Ⅱ cardiac rehabilitation in a patient with heart failure: a case report

A 67-year-old man with a history of a prior cardiac arrest with ventricular fibrillation(VF)due to myocardial infarction underwent phase I(inpatient)and II(outpatient)cardiac rehabilitation(CR)exercise training.On the 33th CR session,15 min after the start of exercise training,the patient had syncope with evidence of a polymorphic and wide QRS complex tachycardia on electrocardiogram(ECG)monitoring.The initiation of a polymorphic ventricular tachycardia was evidenced by the coupled premature ventricular complex observed in the ECG monitoring screen(Figure 1).