Predictive Factors of De Novo Malignancies After Living-Donor Liver Transplantation: A Single-Center Experience.

BACKGROUND: De novo malignancies are a major reason of long-term mortalities after liver transplantation. However, they usually receive minimal attention from most health care specialists. The current study aims to evaluate our experience of de novo malignancies after living-donor liver transplantation (LDLT). METHODS: We reviewed the data of patients who underwent LDLT at our center during the period between May 2004 and December 2018. RESULTS: During the study period, 640 patients underwent LDLT. After a mean follow-up period of 41.2 ± 25.8 months, 15 patients (2.3%) with de novo malignancies were diagnosed. The most common de novo malignancies were cutaneous cancers (40%), post-transplantation lymphoproliferative disorders (13.3%), colon cancers (13.3%), and breast cancers (13.3%). Acute cellular rejection (ACR) episodes occurred in 10 patients (66.7%). Mild ACR occurred in 8 patients (53.3%), and moderate ACR occurred in 2 patients (13.3%). All patients were managed with aggressive cancer treatment. The mean survival after therapy was 40.8 ± 26.4 months. The mean overall survival after LDLT was 83.9 ± 52.9 months. Twelve patients (80%) were still alive, and 3 mortalities (20%) occurred. The 1-, 5-, and 10-year overall survival rates after LDLT were 91.7%, 91.7%, and 61.1%, respectively. On multivariate regression analysis, smoking history, operation time, and development of ACR episodes were significant predictors of de novo malignancy development. CONCLUSIONS: Liver transplant recipients are at high risk for the development of de novo malignancies. Early detection and aggressive management strategies are essential to improving the recipients' survival.

Dexmedetomidine in a surgically inserted catheter for transversus abdominis plane block in donor hepatectomy: A prospective randomized controlled study.

BACKGROUND: Transversus abdominis plane (TAP) block is a promising technique for analgesia after abdominal surgery. This prospective, randomized controlled trial assessed the effect of adding dexmedetomidine to bupivacaine in TAP block for donor hepatectomy. We hypothesized that this would improve postoperative morphine consumption and reduce analgesia related complication and inflammation. METHODS: A total of 50 donor hepatectomy were enrolled in this study. Patients divided into two equal groups according to drugs used for TAP block. Group (B) received 20 ml of bupivacaine hydrochloride 0.25%, Group (BD) received 20 ml of bupivacaine hydrochloride 0.25% and 0.3 µg/kg dexmedetomidine, on both sides at the end of surgery and every 8 h for 48 h at right side only through inserted catheter. Primary outcome objective was morphine consumption at first 72 h. Secondary outcome objectives were morphine requirement, numbers of intake, time to first intake, pain score numerical analog scale (NAS), postoperative analgesia related complications, recovery of intestinal motility, and inflammatory markers. RESULTS: Data were analyzed, rescue morphine analgesia was significantly lower in (BD) group compared with (B) groups as considering total morphine consumption (B 4 ± 1.9, BD 1.5 ± 0.5, P = 0.03), numbers of morphine intake (P = 0.04), morphine requirement (P = 0.03), and first time of analgesia intake (P = 0.04). NAS was significantly lower in group (BD) compared with group (B) group in the first 12 h (NAS 0 - P = 0.001, NAS 1 - P = 0.03). Adding dexmedetomidine improved gut motility, first oral intake without detectable anti-inflammatory effect. CONCLUSION: Adding dexmedetomidine to bupivacine in a surgically inserted catheter for TAP block in donor hepatectomy reduced morphine consumption without detectable anti-inflammatory effect.

Spontaneous migration of thrombosed synthetic vascular graft to the duodenum after living-donor liver transplantation: A case-report.

INTRODUCTION: Spontaneous migration of synthetic grafts had been described after abdominal vascular procedures into the duodenum and small bowel. In the setting of liver transplantation, synthetic grafts are commonly used for overcoming shortened or poor-quality vasculatures. We describe a case of spontaneous migration of thrombosed synthetic vascular graft after living-donor liver transplantation (LDLT). PRESENTATION: A 59 years male patient with end stage liver disease underwent LDLT utilizing a right hemi-liver graft. Drainage of segment V vein was done to inferior vena cava using a vascular graft. Graft patency was confirmed by regular follow up doppler ultrasound. Graft thrombosis was detected on the 4th postoperative month. The patient developed anastomotic biliary stricture 3 months after LDLT, which required repeated endoscopic retrograde cholangio-pancreatography (ERCP). During an ERCP set two and half years after LDLT, the thrombosed graft was seen eroding into the first part of the duodenum. The patient was generally stable and the decision was to follow up the condition. Follow up computed tomography showed disappearance of the graft from the abdomen, and endoscopy revealed a small ulcer at the site of the migrated graft. DISCUSSION: Reports regarding spontaneous migration of synthetic grafts in this setting of LDLT are extremely rare. We report a rare case of spontaneous migration of thrombosed synthetic vascular graft into the duodenum after LDLT. CONCLUSION: We report a rare case of spontaneous migration of thrombosed synthetic vascular graft into the duodenum after LDLT.

Ligation of huge spontaneous porto-systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: A case-report.

INTRODUCTION: In adult living donor liver transplantation (LDLT), maintenance of adequate portal inflow is essential for the graft regeneration. Portal inflow steal (PFS) may occur due to presence of huge spontaneous porto-systemic collaterals. A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT. PRESENTATION: A 52 years male patient with end-stage liver disease due to chronic hepatitis C virus infection. Preoperative portography showed marked attenuated portal vein and its two main branches, patent tortuous splenic vein, multiple splenic hilar collaterals, and large lieno-renal collateral. He received a right hemi-liver graft from his nephew. Exploration revealed markedly cirrhotic liver, moderate splenomegaly with multiple collaterals and large lieno-renal collateral. Upon dissection of the hepato-duodenal ligament, a well-developed portal vein could be identified with a small mural thrombus. The recipient portal vein stump was anastomosed, in end to end fashion, to the graft portal vein. Doppler US showed reduced portal vein flow, so ligation of the huge lieno-renal collateral that allows steal of the portal inflow. After ligation of the lieno-renal collateral, improvement of the portal vein flow was observed in Doppler US. DISCUSSION: There is no accepted algorithm for managing spontaneous lieno-renal shunts before, during, or after liver transplantation, and evidence for efficacy of treatments remains limited. We report a case of surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT. CONCLUSION: Complete interruption of large collateral vessels might be needed as a part of adult LDLT procedure to avoid devastating postoperative PFS.

Hepatic venous outflow obstruction after living donor liver transplantation managed with ectopic placement of a foley catheter: A case report.

INTRODUCTION: The early hepatic venous outflow obstruction (HVOO) is a rare but serious complication after liver transplantation, which may result in graft loss. We report a case of early HVOO after living donor liver transplantation, which was managed by ectopic placement of foley catheter. PRESENTATION: A 51 years old male patient with end stage liver disease received a right hemi-liver graft. On the first postoperative day the patient developed impairment of the liver functions. Doppler ultrasound (US) showed absence of blood flow in the right hepatic vein without thrombosis. The decision was to re-explore the patient, which showed torsion of the graft upward and to the right side causing HVOO. This was managed by ectopic placement of a foley catheter between the graft and the diaphragm and the chest wall. Gradual deflation of the catheter was gradually done guided by Doppler US and the patient was discharged without complications. DISCUSSION: Mechanical HVOO results from kinking or twisting of the venous anastomosis due to anatomical mismatch between the graft and the recipient abdomen. It should be managed surgically by repositioning of the graft or redo of venous anastomosis. Several ideas had been suggested for repositioning and fixation of the graft by the use of Sengstaken-Blakemore tubes, tissue expanders, and surgical glove expander. CONCLUSION: We report the use of foley catheter to temporary fix the graft and correct the HVOO. It is a simple and safe way, and could be easily monitored and removed under Doppler US without any complications.

Problem of living liver donation in the absence of deceased liver transplantation program: Mansoura experience.

We report our experience with potential donors for living donor liver transplantation (LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors (n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion (n = 792). Most of the transplant candidates (82.3%) had an experience with more than one excluded donor (median = 3). Some recipients travelled abroad for a deceased donor transplant (n = 12) and some died before finding a suitable donor (n = 14). The evaluation of an excluded donor is a time-consuming process (median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD (range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.