Bezoar at Jejunojejunostomy Following Liver Transplant: A Case Report.

During pediatric liver transplant, biliary reconstruction is often performed using Roux-en-Y choledoc-hojejunostomy or hepaticojejunostomy due to size mismatch, excessive tension caused by distance between donor and recipient ducts, or for transplant to treat primary biliary pathology. This method can be associated with additional small bowel-related complications compared with end-to-end ductal anastomosis. We report a case of late small bowel obstruction secondary to an impacted bezoar that formed at a patulous jejunojejunostomy portion of the biliary-enteric anastomosis. The patient was a 26-year-old male patient, who underwent deceased donor whole liver transplant for pediatric acute liver failure. Prior to his presentation to our institution with 2 days of abdominal pain, nausea, persistent burping, and intermittent vomiting, the patient reported an uneventful posttransplant course and was followed up at the institution where his transplant was performed. There were no reported changes in diet or lifestyle and no similar episodes during his follow-up. The patient was managed surgically after a brief trial of nonoperative management. At laparotomy, the anastomosis was resected and reconstructed to improve enteric drainage and prevent recurrent bezoar formation. The patient was discharged with no postoperative complications and remained asymptomatic at 11 months follow-up. We describe the clinical course and our technical approach at initial choledochojejunostomy creation and at jejunojejunostomy revision.

Impact of Portable Normothermic Machine Perfusion for Liver Transplantation From Adult Deceased Donors.

OBJECTIVE: To assess how liver allografts preserved using portable normothermic machine perfusion (NMP) compare against those that underwent ischemic cold storage (ICS) in the setting of donation after brain death (DBD) and donation after circulatory death (DCD) liver transplantation (LT). BACKGROUND: Compared with conventional ICS, NMP may offer more homeostatic preservation, permit physiological assessment of organ function, and provide opportunities for graft improvement/modification. We report a single-center US experience of liver NMP. METHODS: A single-center, retrospective analysis of collected data on 541 adult whole LTs from 469 DBD donors [NMP (n = 58) vs ICS (n = 411)] and 72 DCD donors [NMP (n = 52) vs ICS (n = 20)] between January 2016 and December 2022. RESULTS: In DBD LT, male sex [odds ratio (95% CI): 1.83 (1.08-3.09)] and >10% macrosteatosis of the donor liver [1.85 (1.10-3.10)] were statistically significant independent risk factors of early allograft dysfunction (EAD). Donor age >40 years and cold ischemia time >7 hours were independent risk factors of reperfusion syndrome (RPS). One-year, 3-year, and 5-year incidences of ischemic cholangiopathy (IC) did not differ significantly in DBD cases between the NMP and ICS cohorts. In DCD LT, NMP was an independent protective factor against EAD [0.11 (0.03-0.46)] and RPS [0.04 (0.01-0.25)]. The incidence of IC in the DCD cases at 1-year and 3-year time points was significantly lower in the NMP cohort (1.9% compared with 20% in the ICS group). CONCLUSIONS: Compared with conventional ICS, NMP can significantly reduce the incidence of EAD, RPS, and IC after DCD LT.

Donor-derived disorders of hemostasis and thrombosis in liver transplantation: Considerations for deceased donor liver selection.

OLT is known to be associated with a precarious perioperative hemostatic state due to dysregulation of procoagulant and anticoagulant factors, endothelial injury, and inflammation. Transmission of inherited bleeding and clotting disorders from the liver donor to the recipient may further complicate hemostasis during and after transplantation. As a result, consideration of congenital coagulation disorders in the liver donor is a practical concern for donor selection. However, there is no clear consensus regarding the selection of donors with known or suspected thrombophilia or bleeding disorders. While multiple case reports and retrospective studies, subject to reporting bias, describe donor-derived thrombophilic and bleeding disorders, there are no large-scale studies in the adult liver transplant literature that examine the frequency of transmission, utility of donor screening, or clinical impact of donor hemostatic disorders. Based on the reported literature, we summarize our approach for donor selection with an aim to balance improved organ utility and optimal post-transplant outcomes.

Modern glucose-lowering drugs in liver transplant recipients: improvement in weight, glycemic control, and potentially allograft steatosis.

Introduction: Recurrent allograft steatosis occurs in one-third of transplanted livers. Antidiabetic agents like glucagon-like peptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter type-2 (SGLT2) inhibitors are effective in the management of obesity and hepatic steatosis in the general population; however, there is limited evidence supporting their use in allograft steatosis. We aimed to evaluate their effects on steatosis, body weight, and glycemic control in liver transplant recipients at our institution. Methods: In this single-center retrospective cohort study of liver transplant recipients currently on a GLP1RA or SGLT2 inhibitor (transplanted 2015-2022), we compared clinical and radiological data before medication use and at follow-up. Differences were compared using Wilcoxon signed-rank test. Results: Thirty-seven liver transplant recipients were taking the agents. Diabetes was the most common indication (n = 33) followed by obesity (n = 4). Median follow up was 427 days (301,798). Among those with documented steatosis (n = 21), steatosis improved in 5, worsened in 4, remained unchanged in 1, and change could not be evaluated in 11 due to lack of comparable pre and post imaging. Average weight loss was 3.2 kg (p < 0.001) and BMI decreased by 1.2 kg/m2 (p < 0.001). Hemoglobin A1c decreased by 0.6 mmol/mol (p = 0.0014), insulin requirement reduced by 7 units/day (p = 0.02), and there was no change in additional antidiabetic medications. Discussion: GLP1RA and SGLT-2 inhibitors are tolerated in transplant patients and result in weight loss and better glycemic control. They are promising agents to treat recurrent or de-novo liver allograft steatosis, but further research is needed to evaluate long-term outcomes in liver transplant recipients.

The Attending Meritocracy: Implementation of a Novel Team-Based Approach to Provide Effective Resident Feedback.

OBJECTIVE: Providing timely quality feedback is an essential responsibility of teaching faculty and is critical for resident assessment and development throughout training. Numerous evaluation platforms have been created to provide immediate and big picture end-of-rotation feedback. Faculty suffer burnout from electronic documentation demands and workload and as a result, evaluation activity is relegated to a lower priority leading to poor compliance. We implemented a novel team-based Attending Meritocracy (AM)1 program that encompasses monetary, automated reminder, and punitive components, while adding a competition element to further engage faculty. The aim of this study is to determine effectiveness of AM in increasing compliance with resident feedback. DESIGN, SETTING AND PARTICIPANTS: Surgical faculty (n = 36) were divided into 5 teams according to service and subspecialty. Points could be earned by completing surgical (Firefly, MiniCEX) or rotation (New Innovations) evaluations, leaving comments, and other educational tasks. A prize for the highest scoring team was identified as a dinner financed by the non-winning teams. Data from evaluation platforms was extracted. Continuous variables were compared using Mann-Whitney-U test, and categorical variables using chi-squared test. RESULTS: When comparing July 2019 to February 2020 (control period) with July 2020 to February 2021(initial implementation period), we found a 237% increase in submitted NI evaluations (n = 111-374) and a 42.5% decrease in median time to completion from 60.4 (33.2-106.9) days to 34.7 (24.0-64.5) days, (p = 0.001).2 We observed an increase in operative evaluations completed (Mini CEX n = 4-97, Firefly n = 150-1284). CONCLUSIONS: Implementation of a team-based attending meritocracy program is an effective budget neutral method to increase completion of resident evaluations. Further investigation is needed to assess improvement in quality of feedback as well as to explore it's impact on progression of resident autonomy.