Living related liver transplantation for an infant with biliary atresia

Objective: To sum up the preliminary experience in living related liver transplantation (LRLT). Methods: A 9-month-old male infant with biliary atresia (BA) who had undergone an unsuccessful Kasai operation was defined as a candidate for LR- LT. The donor was his 30-year-old mother. Her la- teral lobe of the left liver was transplanted into the infant's body as the graft. The left branches of the portal vein, left hepatic artery and left hepatic vein of the graft were end-to-end anastomosed to the por- tal vein, hepatic artery proper and hepatic vein of the recipient respectively. Biliary drainage was re- established via Roux-en-Y operation. Results: The donor retained her liver function within 2 weeks after the operation. Steroid and FK506 were prescribed in immunosuppressive therapy for the re- cipient. The blood bilirubin level of the infant de- creased to normal 2 weeks after operation. No acute rejection occurred. Biliary leakage in the early peri- od after the transplantation was controlled by drain- age, and E. coli infection was effectively treated with antibiotics. The donor and recipient are in satisfacto- ry condition to the present. Conclusion: LRLT is advisable for children with bili- ary atresia.

Small-for-size syndrome in adult-to-adult living-related liver transplantation

Small-for-size syndrome (SFSS) in adult-to-adult living-related donor liver transplantation (LRLT) remains the greatest limiting factor for the expansion of segmental liver transplantation from either cadaveric or living donors. Portal hyperperfusion, venous pathology, and the arterial buffer response signif icantly contribute to clinical and histopathological manifestations of SFSS. Here, we review the technical aspects of surgical and radiological procedures developed to treat SFSS in LRLT, along with the pathophysiology of this condition.

Health-related quality of life of 256 recipients after liver transplantation

AIM:To investigate health-related quality of life(HRQoL) and psychological outcomes in 256 adults who had undergone liver transplantation(LT).METHODS:A stratified random sampling method was used in this follow-up multicenter study to select a representative sample of recipients undergoing either living donor liver transplantation(LDLT) or deceased donor liver transplantation(DDLT).HRQoL was measured by using the Chinese version of Medical Outcome Study Short Form-36(SF-36),and psychological outcomes by using the beck anxiety inventory(BAI) and the self-rating depression scale(SDS).Clinical and demographic data were collected from the records of the Chinese Liver Transplant Registry and via questionnaires.RESULTS:A total of 256 patients were sampled,including 66(25.8%) receiving LDLT and 190(74.2%) undergoing DDLT;15(5.9%) recipients had anxiety and four(1.6%) developed severe depression after the operation.Compared with LDLT recipients,DDLT patients had higher scores in general health(60.33 ± 16.97 vs 66.86 ± 18.42,P = 0.012),role-physical(63.64 ± 42.55 vs 74.47 ± 36.46,P = 0.048),roleemotional(61.11 ± 44.37 vs 78.95 ± 34.31,P = 0.001),social functioning(78.60 ± 22.76 vs 88.16 ± 21.85,P = 0.003),vitality(70.30 ± 15.76 vs 75.95 ± 16.40,P = 0.016),mental health(65.88 ± 12.94 vs 71.85 ± 15.45,P = 0.005),physical component summary scale(PCS,60.07 ± 7.36 vs 62.58 ± 6.88,P = 0.013) and mental component summary scale(MCS,52.65 ± 7.66 vs 55.95 ± 10.14,P = 0.016).Recipients > 45 years old at the time of transplant scored higher in vitality(77.33 ± 15.64 vs 72.52 ± 16.66,P = 0.020),mental health(73.64 ± 15.06 vs 68.00 ± 14.65,P = 0.003) and MCS(56.61 ± 10.00 vs 54.05 ± 9.30,P = 0.037) than those aged ≤ 45 years.MCS was poorer in recipients with than in those without complications(52.92 ± 12.21 vs 56.06 ± 8.16,P = 0.017).Regarding MCS(55.10 ± 9.66 vs 50.0 ± 10.0,P < 0.05) and PCS(61.93 ± 7.08 vs 50.0 ± 10.0,P < 0.05),recipients scored better than the Sichuan general and had improved overall QoL compared to patients with chronic diseases.MCS and PCS significantly correlated with scores of the BAI(P < 0.001) and the SDS(P < 0.001).CONCLUSION:Age > 45 years at time of transplant,DDLT,full-time working,no complications,anxiety and depression were possible factors influencing postoperative HRQoL in liver recipients.

Multi-slice spiral CT angiography in evaluating donors of living-related liver transplantation

BACKGROUND: During the past years, the number of liver transplantation has increased greatly, but the number of available organs has not increased. In view of the critical shortage of organs, the indications for living-related liver transplantation (LRLT) have broadened since experience with the procedure has been achieved. This study was undertaken to assess the value of multi-slice spiral CT (MSCT) angiography in evaluating the hepatic arterial and veinous anatomy of potential donors for LRLT. METHODS: MSCT was performed after intravenous injection of contrast material at 3 ml/s. The total dose was calculated as 2 ml/kg. Twenty LRLT donors (2 men and 18 women) were subjected to MSCT angiography of hepatic blood vessels. These were generated by volume rendering and maximum intensity projection, while curved planar reformation was added in 5 patients. RESULTS: We identified 10 important hepatic vascular variants in 9 of the 20 donors (4 arterial, 4 venous, and 2 portal venous variants). In hepatic arterial variants, two had a replaced right hepatic artery arising from the superior mesenteric artery, an accessory right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery arising from the left gastric artery. In hepatic venous variants, three had an accessory inferior right hepatic vein and one had two accessory inferior right hepatic veins. In hepatic portal venous variants, two had trifurcation of the main portal vein. CONCLUSIONS: As a non-invasive and reliable method, MSCT angiography is of value in the clinical evaluation of LRLT donors. MSCT angiography should be recommended as a routine preoperative examination for potential LRLT donors.

Health-related quality of life after liver transplantation: the experience from a single Chinese center

BACKGROUND: Few studies have been performed to assess health-related quality of life (HRQOL) in liver transplantation (LT) patients in the mainland of China. This study aimed to investigate the HRQOL of post-LT patients in a single center. METHODS: HRQOL was evaluated by the SF-36 (Chinese version) questionnaire in 60 patients (LT group) who had received LT for benign end-stage liver disease (BELD). Fifty-five patients with BELD (BELD group) and 50 healthy volunteers from the general population (GP group) were also evaluated, and the results were compared among the three groups. RESULTS: There was a significant difference among the three groups in terms of the scores of eight domains in the SF-36 (P<0.01). Patients in the BELD group had lower scores in each domain of the SF-36 in comparison with those in the GP group (P<0.025). The LT group had mental health scores equivalent to those of the BELD group (P>0.025), but higher scores for the remaining seven domains (P<0.025). Compared with the GP group, the LT group scored equivalently for role physical, body pain, vitality, social function and role emotion (P>0.025), but had lower scores for the remaining three domains (P<0.025). Lower family income was found to be associated with reduced physical function and mental health scores (P<0.05). Better education was associated with increased mental health scores (P<0.05). CONCLUSIONS: LT patients generally have a good HRQOL although some respects of their HRQOL remains to be improved. Lower family income and poor education are important factors relating to the poor HRQOL of LT patients.

Living-related liver transplantation in patients with variceal bleeding:outcome and prognostic factors

BACKGROUND:Liver transplantation currently represents the ultimate therapy for bleeding esophageal varices in patients with liver cirrhosis.It is the only therapy that cures both portal hypertension and the underlying liver disease.The outcome of liver transplantation is thought to be correlated with several factors.In this study,the clinical outcome of living-related liver transplantation(LRLT) was evaluated in patients with variceal bleeding,and the prognostic indicators of short-term survival in these patients were identified. METHODS:We reviewed retrospectively 121 patients with a history of variceal bleeding who had received LRLT from 1998 to 2006.The clinical outcomes were analyzed,and the risk factors for short-term survival were defined. RESULTS:The 3-month survival rate of patients with variceal bleeding was 83.4%,while that of non-bleeders was 87%.Sepsis was the commonest cause of death in both groups.Portal vein diameter and blood transfusion were the only independent prognostic factors for short-term survival among variceal bleeders. CONCLUSION:The outcome of LRLT in recipients with variceal bleeding is based on the improvement of portal hemodynamics,by minimizing intraoperative blood loss and subsequent blood transfusion.

Living-related liver transplantation for multiple liver metastases from rectal carcinoid tumor: A case report

因为 ultrasonography 检测的多重肝肿瘤，一个 42 岁的女人进入我们的医院。结肠镜检查在直肠揭示了粘膜下层肿瘤，它被认为梅毒初期损害。组织病理学说的检查跟随的内视镜的粘膜切除术表明肿瘤是良性肿瘤。肿瘤的 resected 边缘为恶意的房间是积极的。二堂功课到 transcatheter 为肝转移的动脉的化疗是无效的。因此，直肠的肿瘤和变形淋巴结是通过手术 resected。在操作以后的一个月，她从她的儿子收到了肝移植(左侧面的片断和有尾的脑叶) 。没有周期性的损害在肝移植以后在二年被观察了。肝移植应该甚至在良性肿瘤转移的先进情况中被看作一种治疗选择到肝。我们也为变形良性肿瘤肿瘤在肝移植上讨论文学。

Health-related quality of life in living liver donors after transplantation

BACKGROUND:Living donor liver transplantation (LDLT) has recently emerged as an effective therapeutic alternative for patients with end-stage liver disease.In the meantime,the health-related quality of life (HRQoL) of the donors is becoming better appreciated.Here we aimed to review the current literature and summarize the effects of liver donation on the long-term HRQoL of living donors.DATA SOURCES:A literature search of PubMed using 'donors','living donor liver transplantation','health-related quality of life',and 'donation' was performed,and all the information was collected.RESULTS:The varied postoperative outcomes of liver donors are attributive to the different evaluation instruments used.On the whole,donors experienced good long-term physical and mental well-being with a few complaining of compromised quality of life due to mild symptoms or psychiatric problems.The psychosocial dimension has received increasing attention with the vocational,interpersonal and financial impact of liver donation on donors mostly studied.CONCLUSIONS:Generally,donors have a good HRQoL after LDLT.Nevertheless,to achieve an ideal donor outcome,further work is necessary to minimize the negative effects as well as to incorporate recent progress in regenerative medicine.

Living related and living unrelated kidney transplantations:A systematic review and meta-analysis

AIM To compare the outcomes between related and unrelated kidney transplantations.METHODS Literature searches were performed following the Cochrane guidelines. We conducted a systematic review and a meta-analysis, which included 12 trials that investigated outcomes including the long-term(ten years), midterm(one to five years), and short-term(one year) graft survival rate as well as the acute rejection rate. Metaanalyses were performed using fixed and random-effects models, which included tests for publication bias and heterogeneity.RESULTS No difference in graft survival rate was detected in patients who underwent living related kidney transplantations compared to unrelated(P = 0.44) transplantations after ten years. There were no significant differences between the graft survival rate in living related and unrelated kidney transplantations after a short-and midterm follow-up(P = 0.35, P = 0.46). There were no significant differences between the acute rejection rate in living related and unrelated kidney transplantations(P = 0.06).CONCLUSION The long, mid and short term follow-up of living related and unrelated kidney transplantation showed no significant difference in graft survival rate. Also, acute rejection rate was not significantly different between groups.

Systematic review with meta-analysis on transplantation for alcohol-related liver disease:Very low evidence of improved outcomes

BACKGROUND Alcohol-related liver disease(ALD) is a leading cause of liver failure and indication for liver transplantation that arises in the setting of alcohol use disorder(AUD). Previous reviews of transplantation for ALD are limited in scope of outcomes and type of ALD studied. A comprehensive systematic review could improve use of transplantation in ALD and improve future research. We hypothesize that while transplanting ALD may improve mortality and relapse,findings will be limited by pre-specified causes of heterogeneity-assessment and treatment of AUD, definition of ALD, spectrum of ALD studied, assessment and rates of relapse, and study quality and bias.AIM To optimize liver transplantation for ALD, understanding existing research to guide future research, we conducted a systematic review with meta-analysis.METHODS We conducted a systematic review, comparing liver transplant to no-transplant in patients with ALD, with a primary outcome of both short-and long-term mortality and relapse. We performed a comprehensive search of MEDLINE,EMBASE, Web of Science, and The Cochrane Library databases for peer-reviewed journal articles comparing use of liver transplant in ALD to no-transplant. Two reviewers independently conducted screening, full text review, and data extraction according to the PRISMA guidelines. We report the quality of the evidence according to the GRADE criteria.RESULTS We analyzed data from 10 studies. Of 1332 participants, 34.2%(456/1332) had undergone liver transplantation, while 65.8%(876/1332) had not. While random effects meta-analysis suggested transplant in comparison to no-transplant had an association of reduced mortality that did not reach statistical significance, relative risk(RR) = 0.51(0.25-1.05), but not relapse risk, RR = 0.52(0.18-1.53), significant heterogeneity limited these findings. When restricted to prospective data,transplant compared to no-transplant significantly reduced mortality, RR = 0.25(0.13-0.46, P < 0.01), and relapse, RR = 0.25(0.14-0.45, P < 0.01), with insignificant heterogeneity but persistent small-study effects. The overall quality of the evidence was Very Low. Heterogeneity analysis suggested that AUD assessment and treatment was often not reported while ALD, relapse assessment and rate,and data collection were institutionally rather than standardly defined.CONCLUSION Systematic review of liver transplantation for ALD suggests reduced mortality and relapse in heterogeneous, institution-specific populations with inherent bias.To understand efficacy of transplanting ALD, our research approach must change.

Anesthesia Management of Living RelatedLiver Transplantation(A case report)

Objective To investigate the effects of anesthesia management on living related liver transplantation. Methods The donor was given procaine fentanyl balanced anesthesia; the recipient was given thiopentol fentanyl atracurium intravenous balanced anesthesia. ECG, P ET CO 2,SpO 2, blood gas, glucose and potassium were monitored. Results Cardiovascular system and respiratory system of the recipient during operation were stable. Conclusion Fentanyl intravenous balanced anesthesia may be used to manage living related liver transplantion. But, the following problems shoud be paid to attention. ①Citrate and lactic acid might accumulate causing metabolic acidosis. ②Hyperkalemia might be developed as the donated liver was reperfused. ③As the liver was an important place for glycogenesis, glycogenolysis, blood glucose was carefully observed and insulin was given to the liver transplantation patient.④As the living related liver was translated, reperfusion syndrome could develop.⑤ The patient was monitored carefully postoperation. Analgesic was given if needed.

A comparative study of pancreatic endocrine function and related metabolism after long-term survival between the patients with combined kidneypancreas transplantation vs those with combined en bloc ' liver-pancreas transplantation

Objective To compare the effects of combined en bloc liver - pancreas transplantation ( LPT) with portal vein drainage and simultaneous combined kidney - pancreas transplantation ( KPT) with systemic venous drainage on the pancreatic endocrine function and related me-

Application of donor dendric cell mediated recipieut lymphocyte reaction after related kidney transplantation in individualized immunosuppressive therapy

Objective To explore the feasibility of mediating recipient lymphocyte reaction with donor dendritic cells ( Dcs) in renal allograft recipients to guide individualized immunosuppressive therapy. Methods From Jan. 2008 to Jan. 2010,30 recipients received living related kidney transplantation were successively and divided into

Biliary tract injury caused by different relative warm ischemia time in liver transplantation in rats

BACKGROUND: There is a controversy over the degree of liver and biliary injury caused by the period of secondary warm ischemia. A liver autotransplantation model was adopted because it excludes the effects of infection and immunological rejection on bile duct injury. This study was undertaken to assess biliary tract injury caused by relative warm ischemia (secondary warm ischemia time in the biliary tract) and reperfusion. METHODS: One hundred and two rats were randomly divided into 5 groups: group I (control); groups 11 to V, relative warm ischemia times of 0 minute, 30 minutes, I hour and 2 hours. In addition to the levels of serum alkaline phosphatase, and total bilirubin, pathomorphology assessment and TUNEL assay were performed to evaluate biliary tract damage. RESULTS: Under the conditions that there were no significant differences in warm ischemia time, cold perfusion time and anhepatic phase, group comparisons showed statistically significant differences. The least injury occurred in group H (portal vein and hepatic artery reperfused simultaneously) but the most severe injury occurred in group V (biliary tract relative warm ischemia time 2 hours). CONCLUSIONS: Relative warm ischemia is one of the factors that result in bile duct injury, and the relationship between relative warm ischemia time the bile injury degree is time-dependent. Simultaneous arterial and portal reperfusion is the best choice to avoid the bile duct injury caused by relative warm ischemia. (Hepatobiliary Pancreat Dis Int 2009; 8: 247-254)

New strategies for prevention and treatment of splenic artery steal syndrome after liver transplantation

AIM:To explore a prophylactic procedure to prevent splenic artery steal syndrome(SASS),as well as a therapeutic intervention to correct it.METHODS:Forty-three liver transplant patients were enrolled in a non-randomized controlled trial,with the eligible criterion that the diameter of the splenic artery is more than 5 mm and/or 1.5 times of the diameter of the hepatic artery.The procedure of splenic artery banding was performed in 28 of the 43 patients,with the other 15 patients studied as a control group.SASS and other complications were compared between these two groups.A new therapeutic intervention,temporary incomplete blockade of the splenic artery with a balloon,was performed to treat SASS in this study.RESULTS:The incidence of SASS was decreased by banding the splenic artery(0/28 vs 5/15,P = 0.006),and the same result was observed in total complications associated with prophylactic procedures(2/28 vs 6/15,P = 0.014).Five patients in the control group developed SASS within 5 d after OLT,2 of whom were treated by coil embolization of the splenic artery,whereas the other 3 by temporary blockade of the splenic artery.Reappeared or better hepatic arteries with improved systolic amplitude and increased diastolic flow were detected by Doppler ultrasonography in all the 5 patients.Local splenic ischemic necrosis and nonanastomotic biliary stricture were diagnosed respectively in one patient treated by coil embolization,and no collateral complication was detected in patients treated by temporary blockade of the splenic artery.CONCLUSION:SASS should be avoided during the operation by banding the splenic artery.Temporary blockade of the splenic artery is a new safe and effective intervention for SASS.

Reasons and effects of the decline of willing related potential living kidney donors

BACKGROUND Although the availability of related living donors(LDs)provides a better chance for receiving kidney transplantation(KT),the evaluation protocols for LD selection remain a safeguard for the LD’s safety.These protocols are variable from one center to another,resulting in variable rates of decline of the potential LDs(PLDs).The decline of willing PLDs may occur at any stage of evaluation,starting from the initial contact and counseling to the day of operation.AIM To identify the causes of the decline of PLDs,the predictors of PLD candidacy,and the effect on achieving LDKT.METHODS A retrospective study was performed on the willing PLDs who attended our outpatient clinic for kidney donation to their related potential recipients between October 2015 and December 2022.The variables influencing their candidacy rate and the fate of their potential recipients were studied.Two groups of PLDs were compared:Candidate PLDs after a completed evaluation vs non-candidate PLDs with a complete or incomplete evaluation.A multivariate logistic regression was performed to assess the factors contributing to the achievement of PLD candidacy.RESULTS Of 321 willing PLDs,257 PLDs(80.1%)accessed the evaluation to variable extents for 212 potential recipients,with a mean age(range)of 40.5±10.4(18-65)years,including 169 females(65.8%).The remaining 64 PLDs(19.9%)did not access the evaluation.Only 58 PLDs(18.1%)succeeded in donating,but 199 PDLs(62.0%)were declined;exclusion occurred in 144 PLDs(56.0%)for immunological causes(37.5%),medical causes(54.9%),combined causes(9.7%),and financial causes(2.1%).Regression and release occurred in 55 PLDs(17.1%).The potential recipients with candidate PLDs were not significantly different from those with non-candidate PLDs,except in age(P=0.041),rates of completed evaluation,and exclusion of PLDs(P<0.001).There were no factors that independently influenced the rate of PLD candidacy.Most patients who failed to have KT after the decline of their PLDs remained on hemodialysis for 6 mo to 6 years.CONCLUSION The rate of decline of willing related PLDs was high due to medical or immunological contraindications,release,or regression of PLDs.It reduced the chances of high percentages of potential recipients in LDKT.

Anatomical basis for pancreas transplantation via isolated splenic artery perfusion:A literature review

The variability of vascular anatomy of the pancreas underlines the difficulty of its transplantation.Research regarding the consistency of anatomical variations shows splenic arterial dominance in most cases.This can significantly improve transplantation success.A systematic literature review was performed according to the quality standards described in the AMSTAR measurement tool and the PRISMA guidelines.We valuated existing literature regarding the vascularization and blood perfusion patterns of the pancreas in terms of dominance and variability.The collected data was independently analyzed by two researchers.Variance of vascular anatomy was seen to be underreported in literature,though significant findings have been included and discussed in this study,providing valuable insight into the dynamics of pancreatic perfusion and feasibility of transplantation on several different supplying arteries.The splenic artery(SA)has a high percentage of consistency in all found studies(over 90%).High frequency of anastomoses between arterial pools supplying the pancreas can mediate sufficient blood supply through a dominant vessel,such as the SA,which is present in most cases.Pancreatic transplantation with isolated SA blood supply can provide sufficient arterial perfusion of the pancreas for stable transplant viability due to high anatomical consistency of the SA and vast communications with other arterial systems.

Small for size syndrome following living donor and split liver transplantation

The field of liver transplantation is limited by the availability of donor organs. The use of living donor and split cadaveric grafts is one potential method of expanding the donor pool. However, primary graft dysfunction can result from the use of partial livers despite the absence of other causes such as vascular obstruction or sepsis. This increasingly recognised phenomenon is termed "Small-for-size syndrome" (SFSS). Studies in animal models and humans have suggested portal hyperperfusion of the graft combined with poor venous outflow and reduced arterial flow might cause sinusoidal congestion and endothelial dysfunction. Graft related factors such as graft to recipient body weight ratio < 0.8, impaired venous outflow, steatosis > 30% and pro- longed warm/cold ischemia time are positively predictive of SFSS. Donor related factors include deranged liver function tests and prolonged intensive care unit stay greater than five days. Child-Pugh grade C recipients are at relatively greater risk of developing SFSS. Surgi- cal approaches to prevent SFSS fall into two categories: those targeting portal hyperperfusion by reducing inflow to the graft, including splenic artery modulation and portacaval shunts; and those aiming to relieve paren-chymal congestion. This review aims to examine thecontroversial diagnosis of SFSS, including current strate-gies to predict and prevent its occurrence. We will also consider whether such interventions could jeopardize the graft by compromising regeneration.

Orthotopic liver transplantation in treatment of 77patients with end-stage hepatic disease

Objective: To summarize the experience of human or-thotopic liver transplantation(OLTx) in treatment ofpatients with end-stage hepatic disease and their peri-operative management.Methods: A retrospective analysis was made on OLTxperformed in 77 patients from April 1993 to September2001 in our department included combined liver-kid-ney transplantation (6 patients) and living related livertransplantation (2). Among them, 76 were adults and1 was infant (67 males and 10 females) . The donors in-cluded 7S non-heart beating donors and 2 living re-lated donors. Veno-venous bypass was used only in 45cases during the operation. Immunosuppressive agentsconsisted of cyclosporine, cellcept, ALG corticosteroidsand FK506.Results: The one-year survival rates of grafts and re-cipients with benign hepatic disease were 75%. Therecipients this year are surviving with good function ofgrafts.Conclusion: Liver transplantation is the best therapeu-tic method for a large number of patients with end-stage hepatic disease in China.