Study of Early Postoperative Doppler Changes Post Living Donor Liver Transplantation and Their Impact on Early Mortality and Small-for-Size Syndrome: A Retrospective Study.

BACKGROUND: Adult-to-adult living donor liver transplantation (LDLT) has been a common practice because of the deficiency of deceased donor liver transplants. Liver hemodynamics differ substantially between cases with end-stage liver disease undergoing LT because of various degrees of hepatic affection, nature of implicated causative factors, and pathogenesis of the hepatic disorder. The present retrospective study primarily aimed to study the early postoperative doppler changes after adult to adult LDLT. The secondary aim was to assess these hemodynamics' impact on early in-hospital deaths and small for size syndrome (SFSS) development. METHODS: This retrospective work was done on 123 adult cases with end-stage liver disease for whom adult LDLT was performed after exclusion of pediatric patients and those with vascular complications. RESULTS: Postoperative (PO) mean portal vein velocity (PVV), hepatic artery (HA) peak systolic velocity (PSV), and HA resistivity index (RI) declined gradually but significantly post adult LDLT. Phasicity of hepatic veins changes towards the triphasic waveform gradually in the early PO period. There is a notable negative relationship between PO mean PVV with PO mean HA PSV. Higher PO HA RI affected PO mortality, while higher PO PVV and lower HA PSV increased the incidence of SFSS. CONCLUSION: Early postoperative Doppler changes post-LDLT (PO PVV, HA RI, and HA PSV) can affect both mortality and SFSS development.

Alpha-Fetoprotein as a Modifier of Anatomic Criteria for Transplantation of HCC Patients.

BACKGROUND: The current listing criteria (Milan, University of California San Francisco [UCSF]) for orthotropic liver transplants (OLT) in hepatocellular carcinoma (HCC) patients emphasize the anatomic features of the tumor such as size, burden, and multiplicity. Recent reports showed that patients with large tumors may have equivalent survival to Milan criteria patients. This suggests that differences in biologic behavior of tumors may contribute to the outcome. AIM: The aim of this article is to understand the impact of biologic modifiers such as alpha-fetoprotein (AFP) on survival in both Milan and UCSF HCC patients. METHODS: We reviewed all liver transplants reported to the United Network for Organ Sharing between 2002 and 2013. We analyzed the survival of patients transplanted for HCC who fit the Milan criteria and those transplanted with tumors beyond Milan and within UCSF criteria. We tested various AFP level cutoffs in both groups in relationship to the 1-, 3-, and 5-year survival rates below and above the proposed cutoffs. RESULTS: Survival difference was significant between Milan patients with AFP ≤ 2500 ng/mL and those with AFP > 2500 ng/mL (59.1% vs 37.4%; P < .001). The mean 5-year survival was 55% for beyond Milan within UCSF patients with AFP ≤ 150 ng/mL and 35.7% for those with AFP > 150 ng/mL (P = .003). CONCLUSION: AFP level should be incorporated in the selection criteria for HCC patients considered for OLT. Milan patients with an AFP level exceeding 2500 ng/mL have reduced survival. Patients with tumors beyond Milan and within UCSF criteria whose AFP ≤ 150 ng/mL achieve acceptable 5-year survival and are good candidates for OLT.

Study of factors affecting Small for Size Syndrome Post-Adult living donor liver transplantation.

AIM: Recently, increasing evidence showed that small-for-size syndrome (SFSS) is a multifactorial disease which is precipitated by various perioperative factors other than graft size. We conducted the current work to evaluate perioperative effectors, which can increase the risk of SFSS following adult living-donor liver transplantation (LDLT). METHODS: This is a retrospective study on 110 adult cirrhotic cases (mean age of 48.4 ± 6.9 years old) who underwent adult LDLT. Most cases were males (89%). Cases were categorized into two groups based on the occurrence of SFSS. The groups were compared regarding preoperative (gender, age, comorbidities, baseline investigations), intraoperative (mean blood pressure and glucose; mean operation time; number of packed red cells, plasma, platelets, and cryoprecipitate units; time of cold and warm ischemia, and anhepatic phase; preclamping and post-reperfusion portal pressures), and postoperative factors (relevant investigations, hospital stay). RESULTS: Postoperatively, 23 patients developed SFSS (20.9%). SFSS group had significantly lower preoperative graft recipient weight ratio (GRWR) (0.76 ± 0.1% versus 1.03 ± 0.15, respectively; p < 0.001), and elevated MELD scores (19 ± 2.1 versus 17.9 ± 4; p = 0.024). Preclamping and post-reperfusion portal pressures of ≥22.5 and 17.5 mmHg, exhibited a sensitivity of 95.7% and 91.3% and specificity of 87.4% and 88.9% respectively, for SFSS prediction. CONCLUSION: SFSS risk is significantly linked to GRWR, MELD score, and intraoperative portal haemodynamics. Intraoperative portal haemodynamics exhibited good diagnostic accuracy for SFSS prediction and represented promising indicators for the prediction of SFSS.

Portal venous pressure and proper graft function in living donor liver transplants in 69 patients from an Egyptian center.

BACKGROUND: Several studies have defined the optimal portal pressure suitable for adequate graft renewal in liver transplantation (LT) but none have studied an Egyptian population to our knowledge. OBJECTIVES: Determine the level of portal venous pressure (PVP) for adequate graft function, and study the effect of PVP modulation on the outcome of LT in an Egyptian population. DESIGN: Cross-sectional, prospectively collected data. SETTING: Liver transplantation unit. PATIENTS AND METHODS: The study included adult cirrhotic pa.tients who underwent right lobe liver donor living transplantation (LDLT) at our transplantation center. Intraoperative Doppler was performed on all LDLT patients. Two PVP measurements were obtained during the recipient operation: before PV clamping and after graft re-perfusion. These PVP measurements were correlated with the results of intraoperative and postoperative Doppler findings and graft function. Mortality in the early postoperative period ( less than 1 month) and development of small-for-size syndrome (SFSS) were recorded. MAIN OUTCOME MEASURES: PVP, graft injury, and the effect of PVP modulation on the outcome of LT were the primary outcome measures. Secondary outcome measures were to correlate PVP to portal vein hemodynamics and intraoperative mean hepatic artery, peak systolic velocity, and also to correlate PVP with the postoperative graft function and mean postoperative platelet count. SAMPLE SIZE AND CHARACTERISTICS: 69 adult patients with end-stage liver disease. RESULTS: Post-reperfusion PVP was lower than pre-clamping PVP. The mean pre-clamping and post-reperfusion values were higher in patients who experienced early mortality and in patients with smaller grafts. A PVP greater than 16.5 mm Hg at the end of the operation predicted the development of SFSS (sensitivity=91.7% and specificity=50.5%). Cases of high PVP that were modulated to a lower level had a smooth and uneventful postoperative outcome. CONCLUSION: PVP is a significant hemodynamic factor that influences the functional status of the transplanted liver, including the development of SFSS, in the Egyptian population. PVP modulation may improve the outcome of LDLT. LIMITATIONS: Further study with a larger sample is needed to confirm these results. CONFLICT OF INTEREST: None.