Prognostic value of ultrasound in early arterial complications post liver transplant

Liver transplantation is the primary therapeutic intervention for end-stage liver disease.However,vascular complications,particularly those involving the hepatic artery,pose significant risks to patients.The clinical manifestations associated with early arterial complications following liver transplantation are often non-specific.Without timely intervention,these complications can result in graft fai-lure or patient mortality.Therefore,early diagnosis and the formulation of an op-timal treatment plan are imperative.Ultrasound examination remains the pre-dominant imaging modality for detecting complications post liver transplan-tation.This article comprehensively reviews common causes and clinical present-ations of early hepatic artery complications in the post-transplantation period and delineates abnormal sonographic findings for accurate diagnosis of these con-ditions.Overall,ultrasound offers the advantages of convenience,safety,effect-iveness,and non-invasiveness.It enables real-time,dynamic,and precise evalua-tion,making it the preferred diagnostic method for post-liver transplantation assessments.INTRODUCTION Liver transplantation stands as the primary therapeutic approach for end-stage liver disease.Continuous advancements in surgical techniques and the application of novel immunosuppressive agents contribute to ongoing improvements in the success rate and overall survival in patients undergoing liver transplantation procedures.Despite these advan-cements,vascular complications,particularly those involving the hepatic artery,pose significant risks to patients.During the early stages following liver transplantation(within the first 30 d),proper hepatic artery function is crucial for hepatic arterial blood flow.During later stages,collateral circulation,including arteries such as the phrenic artery,right gastric artery,and gastroduodenal artery,becomes important for maintaining hepatic blood supply.It is now understood that the establishment of effective collateral circulation is pivotal for determining the prognosis of hepatic artery complic-ations.The clinical manifestations of these complications are closely linked to factors such as timing,severity,and the specific type of onset.Insufficient hepatic arterial blood flow can lead to abnormal liver function,hepatic infarction,and the formation of hepatic abscesses.Additionally,since the hepatic artery is the sole blood supply to the biliary tract,hepatic artery-related ischemia may result in biliary stricture,obstruction,and the formation of bile ducts.Ultrasound examination remains the primary imaging modality for diagnosing complications post liver transplantation.This article comprehensively reviews common causes and clinical presentations of early hepatic artery complications in the post-transplantation period and outlines abnormal sonographic findings for accurately diagnosing these conditions.NORMAL HEPATIC ARTERY During the intraoperative phase,an ultrasound examination is typically conducted to evaluate the hepatic artery anas-tomosis.The normal internal diameter of the hepatic artery typically ranges from 2 to 5 mm.Two strong echo points are typically identified near the anastomosis.To assess blood flow dynamics,peak systolic velocity,end-diastolic velocity,and resistance index are measured at the donor and recipient sides of the anastomosis following angle correction.Anastomotic stenosis presence and severity can be evaluated by comparing the velocity at the anastomotic site with that at the recipient side.Postoperatively,direct visualization of the anastomosis site through gray ultrasound scans is often challenging.The surgical approach has a significant impact on the proper hepatic artery’s position,resulting in a lower overall success rate of continuous visualization.Color Doppler ultrasound is primarily employed to trace the artery’s path,and spectral measurements are taken at the brightest position of the Color Doppler blood flow signal,primarily used to identify the presence of high-speed turbulence.Hepatic artery spectrum examination plays a crucial role,as a favorable arterial spectral waveform and appropriate hepatic artery flow velocity typically indicate a successful anastomosis,even in cases where the hepatic artery anastomosis cannot be directly visualized by ultrasound.The hepatic artery runs alongside the portal vein,often selected as a reference due to its larger inner diameter.A normal hepatic artery spectrum displays a regular pulsation pattern with a rapid rise in systole and a slow decline in diastole.Parameters for assessing hepatic artery resistance include a resistance index between 0.5 to 0.8 and an artery systolic acceleration of less than 80 ms.Instantaneous increases in the resistance index(RI>0.8)often occur within 2 d after surgery,followed by a subsequent return to normal hepatic arterial parameters.It has been established that the maximum blood flow velocity during systole in the hepatic artery should not exceed 200 cm/s[1].

Comparison of different preoperative objective nutritional indices for evaluating 30-d mortality and complications after liver transplantation

BACKGROUND The nutritional status is closely related to the prognosis of liver transplant re-cipients,but few studies have reported the role of preoperative objective nutri-tional indices in predicting liver transplant outcomes.AIM To compare the predictive value of various preoperative objective nutritional indicators for determining 30-d mortality and complications following liver transplantation(LT).METHODS A retrospective analysis was conducted on 162 recipients who underwent LT at our institution from December 2019 to June 2022.RESULTS This study identified several independent risk factors associated with 30-d mor-tality,including blood loss,the prognostic nutritional index(PNI),the nutritional risk index(NRI),and the control nutritional status.The 30-d mortality rate was 8.6%.Blood loss,the NRI,and the PNI were found to be independent risk factors for the occurrence of severe postoperative complications.The NRI achieved the highest prediction values for 30-d mortality[area under the curve(AUC)=0.861,P<0.001]and severe complications(AUC=0.643,P=0.011).Compared to those in the high NRI group,the low patients in the NRI group had lower preoperative body mass index and prealbumin and albumin levels,as well as higher alanine aminotransferase and total bilirubin levels,Model for End-stage Liver Disease scores and prothrombin time(P<0.05).Furthermore,the group with a low NRI exhibited significantly greater incidences of intraabdominal bleeding,primary graft nonfunction,and mortality.CONCLUSION The NRI has good predictive value for 30-d mortality and severe complications following LT.The NRI could be an effective tool for transplant surgeons to evaluate perioperative nutritional risk and develop relevant nutritional therapy.

Biliary complications following liver transplantation

Biliary tract complications are the most common complications after liver transplantation.These complications are encountered more commonly as a result of increased number of liver transplantations and the prolonged survival of transplant patients.Biliary complications remain a major source of morbidity in liver transplant patients,with an incidence of 5%-32%.Post liver transplantation biliary complications include strictures(anastomotic and non-anastomotic),leaks,stones,sphincter of Oddi dysfunction,and recurrence of primary biliary disease such as primary sclerosing cholangitis and primary biliary cirrhosis.The risk of occurrence of a specific biliary complication is related to the type of biliary reconstruction performed at the time of liver transplantation.In this article we seek to review the major biliary complications and their relation to the type of biliary reconstruction performed at the time of liver tranplantation.

Early respiratory complications after liver transplantation

The poor clinical conditions associated with end-stage cirrhosis,pre-existing pulmonary abnormalities,and high comorbidity rates in patients with high Model for End-Stage Liver Disease scores are all well-recognized factors that increase the risk of pulmonary complications after orthotopic liver transplantation(OLT)surgery.Many intraoperative and postoperative events,such as fluid overload,massive transfusion of blood products,hemodynamic instability,unexpected coagulation abnormalities,renal dysfunction,and serious adverse effects of reperfusion syndrome,are other factors that predispose an individual to postoperative respiratory disorders.Despite advances in surgical techniques and anesthesiological management,the lung may still suffer throughout the perioperative period from various types of injury and ventilatory impairment,with different clinical outcomes.Pulmonary complications after OLT can be classified as infectious or non-infectious.Pleural effusion,atelectasis,pulmonary edema,respiratory distress syndrome,and pneumonia may contribute considerably to early morbidity and mortality in liver transplant patients.It is of paramount importance to accurately identify lung disorders because infectious pulmonary complications warrant speedy and aggressive treatment to prevent diffuse lung injury and the risk of evolution into multisystem organ failure.This review discusses the most common perioperative factors that predispose an individual to postoperative pulmonary complications and these complications’early clinical manifestations after OLT and influence on patient outcome.

Perioperative thrombotic complications in liver transplantation

Although the perioperative bleeding complications and the major side effects of blood transfusion have always been the primary concern in liver transplantation(OLT),the possible cohesion of an underestimated intrinsic hypercoagulative state during and after the transplant procedure may pose a major threat to both patient and graft survival.Thromboembolism during OLT is characterized not only by a complex aetiology,but also by unpredictable onset and evolution of the disease.The initiation of a procoagulant process may be triggered by various factors,such as inflammation,venous stasis,ischemia-reperfusion injury,vascular clamping,anatomical and technical abnormalities,genetic factors,deficiency of profibrinolytic activity,and platelet activation.The involvement of the arterial system,intracardiac thrombosis,pulmonary emboli,portal vein thrombosis,and deep vein thrombosis,are among the most serious thrombotic events in the perioperative period.The rapid detection of occlusive vascular events is of paramount importance as it heavily influences the prognosis,particularly when these events occur intraoperatively or early after OLT.Regardless of the lack of studies and guidelines on anticoagulant prophylaxis in this setting,many institutions recommend such an approach especially in the subset of patients at high risk.However,the decision of when,how and in what doses to use the various chemical anticoagulants is still a difficult task,since there is no common consensus,even for highrisk cases.The risk of postoperative thromboembolism causing severe hemodynamic events,or even loss of graft function,must be weighed and compared with the risk of an important bleeding.In this article we briefly review the risk factors and the possible predictors of major thrombotic complications occurringin the perioperative period,as well as their incidence and clinical features.Moreover,the indications to pharmacological prophylaxis and the current treatment strategies are also summarized.

NAFLD fibrosis score:A prognostic predictor for mortality and liver complications among NAFLD patients

AIM:To study whether the severity of liver fibrosis estimated by the nonalcoholic fatty liver disease(NAFLD) fibrosis score can predict all-cause mortality,cardiac complications,and/or liver complications of patients with NAFLD over long-term follow-up.METHODS:A cohort of well-characterized patients with NAFLD diagnosed during the period of 1980-2000 was identified through the Rochester Epidemiology Project.The NAFLD fibrosis score(NFS) was used to separate NAFLD patients with and without advanced liver fibrosis.We used the NFS score to classify the probability of fibrosis as <-1.5 for low probability,>-1.5 to < 0.67 for intermediate probability,and > 0.67 for high probability.Primary endpoints included allcause death and cardiovascular-and/or liver-related mortality.From the 479 patients with NAFLD assessed,302 patients(63%) greater than 18 years old were included.All patients were followed,and medical charts were reviewed until August 31,2009 or the date when the first primary endpoint occurred.By using a standardized case record form,we recorded a detailed history and physical examination and the use of statins and metformin during the follow-up period.RESULTS:A total of 302/479(63%) NAFLD patients(mean age:47 ± 13 year) were included with a followup period of 12.0 ± 3.9 year.A low probability of advanced fibrosis(NFS <-1.5 at baseline) was found in 181 patients(60%),while an intermediate or high probability of advanced fibrosis(NSF >-1.5) was found in 121 patients(40%).At the end of the follow-up period,55 patients(18%) developed primary endpoints.A total of 39 patients(13%) died during the follow-up.The leading causes of death were non-hepatic malignancy(n = 13/39;33.3%),coronary heart disease(CHD)(n = 8/39;20.5%),and liver-related mortality(n = 5/39;12.8%).Thirty patients had new-onset CHD,whereas 8 of 30 patients(27%) died from CHD-related causes during the follow-up.In a multivariate analysis,a higher NFS at baseline and the presence of new-onset CHD were significantly predictive of death(OR = 2.6 and 9.2,respectively;P < 0.0001).Our study showed a significant,graded relationship between the NFS,as classified into 3 subgroups(low,intermediate and high probability of liver fibrosis),and the occurrence of primary endpoints.The use of metformin or simvastatin for at least 3 mo during the follow-up was associated with fewer deaths in patients with NAFLD(OR = 0.2 and 0.03,respectively;P < 0.05).Additionally,the rate of annual NFS change in patients with an intermediate or high probability of advanced liver fibrosis was significantly lower than those patients with a low probability of advanced liver fibrosis(0.06 vs 0.09,P = 0.004).The annual NFS change in patients who died was significantly higher than those in patients who survived(0.14 vs 0.07,P = 0.03).At the end of the follow-up,we classified the patients into 3 subgroups according to the progression pattern of liver fibrosis by comparing the NFS at baseline to the NFS at the end of the followup period.Most patients were in the stable-fibrosis(60%) and progressive-fibrosis(37%) groups,whereas only 3% were in the regressive fibrosis.CONCLUSION:A higher NAFLD fibrosis score at baseline and a new onset of CHD were significantly predictive of death in patients with NAFLD.

Vascular complications following liver transplantation:Aliterature review of advances in 2015

Although vascular complications(VCs) following orthotopic liver transplantation(OLT) seldom occur, they are the most feared complications with a high incidence of both graft loss and mortality, as they compromise the blood flow of the transplant(either inflow or outflow). Diagnosis and therapeutic management of VCs constitute a major challenge in terms of increasing the success rate of liver transplantation. While surgical treatment used to be considered the first choice for management, advances in endovascular intervention have increased to make this a viable therapeutic option. Considering VC as a rare but a major and dreadful issue in OLT history, and in view of the continuing and rapid progress in recent years, an update on these uncommon conditions seemed necessary. In this sense, this review comprehensively discusses the important features(epidemiological, clinical, paraclinical, prognostic and therapeutic) of VCs following OLT.

Resective surgery for liver tumor: a multivariate analysis of causes and risk factors linked to postoperative complications

BACKGROUND: In spite of accurate selection of patients eligible for resection, and although advances in surgical techniques and perioperative management have greatly contributed to reducing the rate of perioperative deaths, stress must be placed on reducing the postoperative complication rates reported to be still as high as 50%. This study was designed to analyze the causes and foreseeable risk factors linked to postoperative morbidity on the grounds of data derived from a single-center surgical population. METHODS: From September 1989 to March 2005, 287 consecutive patients, affected either with HCC or liver metastasis, had liver resection at our department. Among the HCC series we recorded 98 patients (73.2%) in Child- Pugh class A, 32 (23.8%) in class B and 4 in class C (3%). In 104 colorectal metastases, 71% were due to colon cancer, 25% rectal, 3% sigmoid, and 1% anorectal. In 49 non-colorectal metastases, 22.4% were derived from breast cancer, 63.2% gastrointestinal tumors (excluding colon) and 14.4% other cancers. We performed 80 wedge resections, 77 bisegmentectomies and/or left lobectomies, 74 segmentectomies, 22 major hepatectomies, 20 left hepatectomies, and 14 trisegmentectomies. RESULTS: The in-hospital mortality rate in this series was 4.5%, and the morbidity rate was 47.7%, because of pleural effusion (30%), hepatic abscess (25%), hepatic insufficiency (19%), ascites (10%), hemoperitoneum (10%), or biliary fistula (6%). The variables associated with the technical aspects of the surgical procedure thatwere responsible for the complications were: a Pringle maneuver length more than 20 minutes (P=0.001); the type of liver resection procedure, including major hepatectomy (P=0.02), left hepatectomy (P=0.04), trisegmentectomy (P=0.04), bisegmentectomy and/or left lobectomy (P=0,04); and a blood transfusion of more than 600 ml (P=0.04). CONCLUSION: The evaluation of causes and foreseeable risk factors linked to postoperative morbidity during the planning of surgical treatment should play the same role as other factors weighed in the selection of patients eligible for liver resection.

Plasma levels of tumor necrotic factor-alpha and interleukin-6, -8 during orthotopic liver transplantation and their relations to postoperative pulmonary complications

BACKGROUND: Pulmonary complications after orthoto- pic liver transplantation (OLT) include high morbidity and mortality. Experimental data have suggested hepatic ische- mia and reperfusion are induced by pro-inflammatory cyto- kines. The high level of inflammatory cytokines might ad- ditionally influence pulmonary cappillary fluid filtration. The objectives of this study were to measure the concentra- tions of tumor necrotic factor-alpha (TNF-α), interleukin- 6 (IL-6) and interleukin-8 (IL-8) during OLT and to in- vestigate the relationship between these cytokines and post- operative pulmonary complications. METHODS: Twenty-two patients undergoing OLT were divided into two groups according to whether they had postoperative pulmonary complications: group A consis- ting of 8 patients with postoperative pulmonary complica- tions , and group B consisting of 14 patients without post- operative pulmonary complications. Enzyme-linked im- munoassay (ELISA) was used to determine serum TNF-α, IL-6 and IL-8. Blood samples were taken at the beginning of operation (T0 ), clamping and cross-clamping of the in- ferior cava and portal vein (T1, T2 ), 90 minutes and 3 hours after reperfusion (T3 , T4 ) and 24 hours after opera- tion (T5). RESULTS: The level of PaO2/FiO2 in group A was lower than that in group B ( P <0. 05 ). The concentrations of TNF-α, IL-6 and IL-8 in the two groups increased rapidly at T2 , peaked at T3 , decreased rapidly after T3 until 24 hours after operation. The concentrations of TNF-α, IL-6 and IL-8 in group A were higher than those in group B at T2, T3, and T4(P<0.05). CONCLUSION: After un-clamping of the inferior cava and portal vein, the serum concentrations of TNF-α, IL-6 and IL-8 increased may be related to pulmonary injury after he- patic ischemic reperfusion.

Neoplastic disease after liver transplantation: focus on de novo neoplasms

De novo neoplasms account for almost 30% of deaths 10 years after liver transplantation and are the most common cause of mortality in patients surviving at least 1 year after transplant. The risk of malignancy is two to four times higher in transplant recipients than in an age- and sex-matched population, and cancer is expected to surpass cardiovascular complications as the primary cause of death in transplanted patients within the next 2 decades. Since exposure to immunosuppression is associated with an increased frequency of developing neoplasm, long-term immunosuppression should be therefore minimized. Promising results in the prevention of hepatocellular carcinoma(HCC) recurrence have been reported with the use of m TOR inhibitors including everolimus and sirolimus and the ongoing open-label prospective randomized controlled SILVER. Study will provide more information on whether sirolimus-containing vs m TOR-inhibitorfree immunosuppression is more efficacious in reducing HCC recurrence.

Advances in endoscopic management of biliary complications after living donor liver transplantation: Comprehensive review of the literature

Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation(LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.

Risk of cardiovascular,cardiac and arrhythmic complications in patients with non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease(NAFLD)has emerged as a public health problem of epidemic proportions worldwide.Accumulating clinical and epidemiological evidence indicates that NAFLD is not only associated with liver-related morbidity and mortality but also with an increased risk of coronary heart disease(CHD),abnormalities of cardiac function and structure(e.g.,left ventricular dysfunction and hypertrophy,and heart failure),valvular heart disease(e.g.,aortic valve sclerosis)and arrhythmias(e.g.,atrial fibrillation).Experimental evidence suggests that NAFLD itself,especially in its more severe forms,exacerbates systemic/hepatic insulin resistance,causes atherogenic dyslipidemia,and releases a variety of pro-inflammatory,pro-coagulant and pro-fibrogenic mediators that may play important roles in the pathophysiology of cardiac and arrhythmic complications.Collectively,these findings suggest that patients with NAFLD may benefit from more intensive surveillance and early treatment interventions to decrease the risk for CHD and other cardiac/arrhythmic complications.The purpose of this clinical review is to summarize the rapidly expanding body of evidence that supports a strong association between NAFLD and cardiovascular,cardiac and arrhythmic complications,to briefly examine the putative biological mechanisms underlying this association,and to discuss some of the current treatment options that may influence both NAFLD and its related cardiac and arrhythmic complications.

Complications arising in simple and polycystic liver cysts

Liver cysts are common,affecting 5%-10% of the population.Most are asymptomatic,however 5% of patients develop symptoms,sometimes due to complications and will require intervention.There is no consensus on their management because complications are so uncommon.The aim of this study was to perform a collected review of how a series of complications were managed at our institutions.Six different patients presenting with rare complications of liver cysts were obtained from Hepatobiliary Units in the United Kingdom and The Netherlands.History and radiological imaging were obtained from case notes and computerised radiology.As a result,1 patient admitted with inferior vena cava obstruction was managed by cyst aspiration and lanreotide;1 patient with common bile duct obstruction was first managed by endoscopic retrograde cholangiopancreatography and stenting,followed by open fenestration;1 patient with ruptured cysts and significant medical co-morbidities was managed by percutaneous drainage;1 patient with portal vein occlusion and varices was managed by open liver resection;1 patient with infected cysts was treated with intravenous antibiotics and is awaiting liver transplantation.The final patient with a simple liver cyst mimicking a hydatid was managed by open liver resection.In conclusion,complications of cystic liver disease are rare,and we have demonstrated in this series that both operative and non-operative strategies have defined roles in management.The mainstays of treatment are either aspiration/sclerotherapy or,alternatively laparoscopic fenestration.Medical management with somatostatin analogues is a potentially new and exciting treatment option but requires further study.

Major complications after radiofrequency ablation for liver tumors:Analysis of 255 patients

AIM:To investigate the major complications after radiofrequency ablation(RFA) for the treatment of liver tumors and analyze possible risk factors that precipitate these complications.METHODS:From March 2001 to April 2008,255 patients with liver tumors(205 male,50 female;age range,18-89 years;mean age,56.0 years) who received RFA were enrolled in this study.Of these patients,212 had hepatocellular carcinoma,39 had metastatic liver tumors and four had cholangiocellular carcinoma.One hundred and forty eight patients had a single tumor,and 107 had multiple tumors.Maximum diameter of the tumors ranged 1.3-20 cm(mean,5.1 cm).All patients were treated with a cooled-tip perfusion electrode attached to a radiofrequency generator(Radionics,Burlington,MA,USA).RFA was performed via the percutaneous approach(n = 257),laparoscopy(n = 7),or open surgical treatment(n = 86).The major complications related to RFA were recorded.The resultant data were analyzed to determine risk factors associated these complications.RESULTS:Among the 255 patients,425 liver tumors were treated and 350 RFA sessions were performed.Thirty-seven(10%) major complications were observed which included 13 cases of liver failure,10 cases of hydrothorax requiring drainage,three casesof tumor seeding,one case of upper gastrointestinal bleeding,one case ofintrahepatic abscess,one case of bile duct injury,one case of cardiac arrest,and five cases of hyperglycemia.Seven patients had more than two complications.Liver failure was the most severe complication and was associated with the highest mortality.Eleven patients died due to worsening liver decompensation.Child-Pugh classification(P = 0.001) and choice of approach(P = 0.045) were related to post-treatment liver failure,whereas patient age,tumor size and number were not significant factors precipitating this complication.CONCLUSION:RFA can be accepted as a relatively safe procedure for the treatment of liver tumors.However,attention should be paid to possible complications even though the incidences of these complications are rare.Careful patient selection and the best approach choice(percutaneous,laparoscopy,or laparotomy) will help to minimize the incidence and morbidity rate of complications which occur after RFA.

Neurologic complications after liver transplantation

Neurologic complications are relatively common after solid organ transplantation and affect 15%-30%of liver transplant recipients.Etiology is often related to immunosuppressant neurotoxicity and opportunistic infections.Most common complications include seizures and encephalopathy,and occurrence of central pontine myelinolysis is relatively specific for liver transplant recipients.Delayed allograft function may precipitate hepatic encephalopathy and neurotoxicity of calcineurin inhibitors typically manifests with tremor,headaches and encephalopathy.Reduction of neurotoxic immunosuppressants or conversion to an alternative medication usually result in clinical improvement.Standard preventive and diagnostic protocols have helped to reduce the prevalence of opportunistic central nervous system(CNS)infections,but viral and fungal CNS infections still affect 1%of liver transplant recipients,and the morbidity and mortality in the affected patients remain fairly high.Critical illness myopathy may also affect up to 7%of liver transplant recipients.Liver insufficiency is also associated with various neurologic disorders which may improve or resolve after successful liver transplantation.Accurate diagnosis and timely intervention are essential to improve outcomes,while advances in clinical management and extended post-transplant survival are increasingly shifting the focus to chronic post-transplant complications which are often encountered in a community hospital and an outpatient setting.

The value of color Doppler ultrasonography in monitoring normal orthotopic liver transplantation and postoperative complications

OBJECTIVE: To assess the value of color Doppler ultrasonography in monitoring normal orthotopic liver transplantation and postoperative complications. METHODS: Forty-one patients after orthotopic liver transplantation were examined by using color Doppler flow imaging to observe the hepatic blood flow and change of ultrasonography of the hepatic parenchyma and bile duct. The measured indexes included maximum blood flow velocity, time-average blood flow velocity (TAV), resistance index (RI) and diameter of the bile duct. RESULTS: Among 41 patients, 17 (41.5%) suffered from liver transplant rejection. Of the 17 patients, 13 (76.4%) showed decrease of TAV of the portal vein, 15 (88.25%) low-amplitude single-phase serrated wave or negative biphasic wave of the hepatic vein, 9 (52.9%) increased hepatic arterial RI, and 5 (29.4%) slightly dilated bile duct. Sonography showed disappearance of the hepatic artery blood flow around the portal vein in 5 (12.2%) of the 41 patients with hepatic artery thrombosis in the postoperative period. Slight dilatation of the intrahepatic bile duct was found in 3 (7.3%) of the 41 patients in the early postoperational period and it normalized within 2 weeks. Ultrasonography of 20 patients (48.8%) revealed a visible dilatation of the intrahepatic bile duct, which was worsening gradually. The causes of bile duct dilatation included biliary stricture in 2 patients (10%), stone in 15 patients (75%) and others in 3 patients (15%). CONCLUSIONS: Color Doppler ultrasonography is valuable for monitoring normal liver transplantation and postoperative complications.

Endoscopic management of biliary complications after orthotopic liver transplantation

BACKGROUND: Biliary complications are a serious problem in patients after liver transplantation and often require reoperation. This study was conducted to summarize the endoscopic diagnosis and management of biliary complications after orthotopic liver transplantation (OLT). METHODS: From December 2000 to November 2003, twelve endoscopic retrograde cholangiopancreatographies(ERCPs) were performed in 7 patients after OLT at Digestive Endoscopic Center of Changhai Hospital in Shanghai, China. The therapeutic maneuvers included endoscopic sphincterotomy (EST), biliary stent placement, balloon and basket extraction, irrigation, and nasobiliary tube placement. A retrospective study was made to determine the types of biliary tract complications after OLT. The success of ERCP and therapeutic maneuvers was also evaluated. RESULTS: Biliary tract complications including biliary stricture, biliary leak, biliary sludge, and stump leak of the cyst duct were treated respectively by endoscopic sphincterotomy with sludge extraction, stricture dilation or endoscopic retrograde biliary drainage. Two of the 3 patients with proximal common bile duct stricture were successfully treated with ERCP and stent placement. Four patients with anastomotic stricture and/without bile leak were treated successfully by dilation and stent placement or endoscopic nosobiliary drainage. No severe ERCP-related complications occurred. CONCLUSIONS: ERCP is an effective and accurate approach for the diagnosis of biliary tract complications after OLT, and placement of a stent is a safe initial treatment for biliary complications after liver transplantation.

Neuroendocrine neoplasms of liver-A 5-year retrospective clinico-pathological study applying World Health Organization 2010 classification

AIM To study the clinicopathological characteristics of neuroendocrine neoplasms(NEN) on liver samples and apply World Health Organization(WHO) 2010 grading of gastroenteropancreatic(GEP) NEN.METHODS Clinicopathological features of 79 cases of NEN of the liver diagnosed between January 2011 to December 2015 were analyzed. WHO 2010 classification of GEP NEN was applied and the tumors were graded as G1, G2 or G3. Two more categories, D1/2(discordant 1/2) and D2/3(discordant 2/3) were also applied. The D1/2 grade tumors had a mitotic count of G1 and Ki-67 index of G2. The D2/3 tumors had a mitotic count of G2 and Ki-67 index of G3. The follow up details which were available till the end of the study period(December 2015) were collected.RESULTS Of the 79 tumors, 16 each were G1 and G2, and 18 were G3 tumors. Of the remaining 29 tumors, 13 were assigned to D1/2 and 16 were D2/3 grade. Male preponderance was noted in all tumors except for G2 neoplasms, which showed a slight female predilection. The median age at presentation was 47 years(range 10-82 years). The most common presentation was abdominal pain(81%). Pancreas(49%) was the most common site of primary followed by gastrointestinal tract(24.4%) and lungs(18%). Radiologically, 87% of the patients had multiple liver lesions. Histopathologically, necrosis was seen in only D2/3 and G3 tumors. Microvascular invasion was seen in all grades. Metastasis occurred in all grades of primary NEN and the grades of the metastatic tumors and their corresponding primary tumors were similar in 67% of the cases. Of the 79 patients, 36 had at least one follow up visit with a median duration of follow up of 8.5 mo(range: 1-50 mo). This study did not show any impact of the grade of tumor on the short term clinical outcome of these patients.CONCLUSION Liver biopsy is an important tool for clinicopathological characterization and grading of NEN, especially when the primary is not identified. Eighty-seven percent of the patients had multifocal liver lesions irrespective of the WHO grade, indicating a higher stage of disease at presentation. Follow up duration was inadequate to derive any meaningful conclusion on long term outcome in our study patients.

Postoperative complications after liver transplantation with cavoportal hemitransposition

BACKGROUND: Extensive portal vein thrombosis (PVT) in the recipient of liver transplantation increases postoperative morbidity and mortality. Cavoportal hemitransposition (CPHT) has been described as a salvage technique in the presence of extensive portal and superior mesenteric venous thrombosis. METHODS: We report three patients who underwent this procedure, review the literature, and discuss the postoperative complications of CPHT. RESULTS: Fifty-six patients with extensive PVT who underwent CPHT have been reported. Seventeen patients have died to date. The common complications of CPHT were ascites (55.4%), renal insufficiency (48.2%), variceal bleeding (30.4%), or thrombosis of cavoportal anastomosis or portal branch (14.3%). CONCLUSION: CPHT is a salvage measure to maintain the patency of portal inflow to the liver graft in the presence of extensive PVT.

Assessment of Complications after Liver Surgery: Two Novel Grading Systems Applied to Patients Undergoing Hepatectomy

Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. The absence of a definition and a widely accepted ranking system to classify surgical complications has hampered proper interpretation of the surgical outcome. This study aimed to define and search the simple and reproducible classification of complications following hepatectomy based on two therapy-oriented severity grading system: Clavien-Dindo classification of surgical complications and Accordion severity grading of postoperative complications. Two classifications were tested in a cohort of 2008 patients who underwent elective liver surgery at our institution between January 1986 and December 2005. Univariate and multivariate analyses were performed to link respective complications with perioperative parameters, length of hospital stay and the quality of life. A total of 1716(85.46%) patients did not develop any complication, while 292(14.54%) patients had at least one complication. According to Clavien-Dindo classification of surgical complications system, grade Ⅰ complications occurred in 150 patients(7.47%), grade Ⅱ in 47 patients(2.34%), grade Ⅲa in 59 patients(2.94%), grade Ⅲb in 13 patients(0.65%), grade Ⅳa in 7 patients(0.35%), grade Ⅳb in 1 patient(0.05%), and grade Ⅴ in 15 patients(0.75%). According to Accordion severity grading of postoperative complications system, mild complications occurred in 160 patients(7.97%), moderate complications in 48 patients(2.39%), severe complications(invasive procedure/no general anesthesia) in 48 patients(2.39%), severe complications(invasive procedure under general anesthesia or single organ system failure) in 20 patients(1.00%), severe complications(organ system failure and invasive procedure under general anesthesia or multisystem organ failure) in 1 patient(0.05%), and mortality was 0.75%(n=15). Complication severity of Clavien-Dindo system and Accordion system were all correlated with the length of hospital stay, the number of hepatic segments resected, the blood transfusion and the Hospital Anxiety and Depression Scale-Anxiety(HADS-A). The Clavien-Dindo classification system and Accordion classification system are the simple ways of reporting all complications following the liver surgery.