Is it time to extend liver acceptance criteria for controlled donors after cardiac death?

BACKGROUND: Donation after cardiac death (DCD) has reemerged as potential way to increase donor liver availability. Earlier, programs with DCD liver transplantation used conservative donor criteria to allow safe results. Successful initial outcomes allowed extended DCD criteria to address transplant demand. METHODS: A total of 63 DCD liver grafts were used during the study period in carefully selected recipients. These were divided into two groups: "Standard" DCD within conservative criteria (n=33; age ≤60 years, body mass index <30 kg/m(2), donor warm ischemia time ≤30 min, and cold ischemia time ≤8 hr) and "Extended" DCD beyond these criteria (n=30). We compared donor and recipient characteristics and postoperative outcomes, including patient and graft survival. RESULTS: Both groups had satisfactory initial function; liver graft function at 1, 7, and 30 days after liver transplantation were similar. Median follow-up period was 25 and 18.5 months for Standard and Extended criteria DCD grafts, respectively, with 1-year patient and graft survival of 88% and 82% for the Standard group vs. 90% and 90% for the Extended. Overall, 8 of 63 (13%) patients developed biliary complications; however, the incidence was not different between the Standard and Extended groups. Seven early deaths occurred, four and three in the Standard and Extended groups, respectively. CONCLUSIONS: Recipients of DCDs beyond conventional acceptance criteria have equivalent early outcomes to standard DCD grafts. With careful selection of donors and recipients, these grafts can be safely used to expand the donor pool.

Specialist early and immediate repair of post-laparoscopic cholecystectomy bile duct injuries is associated with an improved long-term outcome.

INTRODUCTION: A majority of bile duct injuries (BDI) sustained during laparoscopic cholecystectomy require formal surgical reconstruction, and traditionally this repair is performed late. We aimed to assess long-term outcomes after repair, focusing on our preferred early approach. METHODS: A total of 200 BDI patients [age 54(20-83); 64 male], followed up for median 60 (5-212) months were assessed for morbidity. Factors contributing to this were analyzed with a univariate and multivariate analysis. RESULTS: A total of 112 (56%) patients were repaired by specialist hepatobiliary surgeons [timing of repair: immediate, n = 28; early (<21 days), n = 43; and late (>21 days) n = 41], whereas 45 (22%) underwent repair by nonspecialist surgeons before specialist referral [immediate, n = 16; early, n = 26 and late, n = 03]. Outcomes after immediate and early repairs were comparable to late repairs when performed by specialists [recurrent cholangitis:11%, 12%, and 10%; P = 0.96, NS; re-stricture:18%,5%, and 29%; P = 0.01; nonsurgical intervention: 14%, 5%, and 24%; P<0.03; redo surgery: 4%, 2%, and 5%; P = 0.81, NS; overall morbidity: 21%, 14%, and 39%; P<0.02]. On multivariate analysis, immediate and early repairs done by nonspecialist surgeons were independent risk factors (P < 0.05) for recurrent cholangitis [50% and 27%], re-stricturing (75% and 61%), redo reconstructions (31% and 61%), and overall morbidity (75% and 84%). CONCLUSION: Immediate and early repair after BDI results in comparable, if not better long-term outcomes compared to late repair when performed by specialists.

Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy.

OBJECTIVES: Whilst there are theoretical benefits from pre-operatively draining the biliary tree prior to pancreatoduodenectomy (PD), the current literature does not support this intervention. The aim of this study was to explore the relationship between pre-operative stenting, bactibilia and outcome in a large United Kingdom tertiary referral practice. METHODS: Patients undergoing PD were identified from a prospectively maintained database. The presence or absence of a stent prior to PD, and the results of bile cultures taken at PD were related to the subsequent post-operative course and the development of complications. RESULTS: 280 patients underwent PD for periampullary malignancies, all of whom presented with jaundice. 118 patients were stented prior to referral (98 ERCP, 20 PTC). Bile cultures were positive more frequently in the stent group (83% vs. 55%; p = 0.000002) and bactibilia was more common after ERCP than PTC (83% vs. 56%; p = 0.006). The overall prevalence of complications was 54% in the stented and 41% in the non-stented group (p = 0.03) with statistical significance achieved for pancreatic leak (p = 0.013) and haemorrhagic complications (p = 0.03). Comparing stent with no stent, there as no difference in the 30-day mortalities (8.5% vs. 6.8%; p = 0.6) or the 1-year mortality rates (35% vs. 28%; p = 0.21). Mortality rates in the infection versus no infection groups were comparable at 30 days (8.5% vs. 5.5%; p = 0.21), and at 1 year (30.7% vs. 26.4%; p = 0.25). CONCLUSIONS: Pre-operative stent insertion prior to PD is associated with increased morbidity but not mortality and this is greatest for stents placed at ERCP.

Pulmonary thromboembolism in liver transplantation: a retrospective review of the first 25 years.

The evidence on the state of 'haemostasis' at the time of liver transplantation (LT) is conflicting, with recent publications that suggest a hypercoagulable state, in contrast to traditionally held views. These findings raise the issue of thrombo-embolic complications after LT, an area of interest which has received little attention in recent published literature. We therefore conducted a retrospective review of our experience of 3000 liver transplants over 25 years. Our prospective transplant database was reviewed to find all patients who were suspected to have had a pulmonary embolism (PE) during or following LT. Paediatric transplants were excluded. A part of this database was cross referenced against hospital records to corroborate its accuracy. Clinical records of all these patients were reviewed and relevant aspects collated and analyzed. Following exclusion of the paediatric recipients, 2 149 adults were reviewed to find 36 patients in whom a PE was suspected (median age 49), 21 of whom were within 90 days of transplant (median duration 22 days). PE was ruled out in 10, unconfirmed in two, confirmed in eight patients; and in one, air embolism was found. All PEs occurred in hospital, but aetiology of liver failure was varied. Of note, two patients died of an on-table PE and one patient of chronic rejection/disease recurrence (Primary Sclerosing Cholangitis). The remaining five are still alive (median survival of 65 months). Although thromboprophylaxis is now routine in our unit, its use in these patients could not be confirmed from records available. Fifteen PE were suspected and confirmed after 90 days from transplant (six within, and nine out with the first year). Acute PE in the setting of LT has an incidence rate in our series of 0.37% that would appear to be lower than previously reported and lower than one would expect after a 'major complex' category operation. This potentially suggests that the overall haemostatic function in these patients is still weighted towards hypocoagulation with the resultant risk of excessive bleeding. Aetiology of liver disease did not seem to confer a higher risk in our series. The prognosis after post-operative PE appears good although sudden death due to an on-table embolism is a rare but significant risk.

Benign disease and unexpected histological findings after pancreaticoduodenectomy: the role of endoscopic ultrasound fine needle aspiration.

INTRODUCTION: We assessed the incidence and outcome of pancreaticoduodenectomy for patients with a pre-operative benign diagnosis and in patients who had an unexpected diagnosis of benign disease following resection. We have also compared how the introduction of endoscopic ultrasound fine needle aspiration (EUS-FNA) has altered our pre-operative assessment. PATIENTS AND METHODS: Between January 1997 and April 2006, 499 patients underwent pancreaticoduodenectomy at the Queen Elizabeth Hospital. Data were collected prospectively. A further 85 patients between 2006 and 2008 had a different diagnostic approach (after imaging these patients have been also studied by EUS-FNA). RESULTS: Overall, 78 (15.6%) patients had no malignant disease on final histology. Out of 459 patients who underwent pancreaticoduodenectomy for presumed malignancy, 49 (10.6%) had benign disease (sensitivity, 97%; positive predictive value, 89%). In a further 40 patients with a pre-operative benign diagnosis, we found 11 cases (27%) of malignancy (sensitivity, 37%; negative predictive value, 72%). Following the introduction of EUS-FNA, the sensitivity and specificity of the diagnostic work were 92% and 75%, respectively (positive predictive value, 93%; negative predictive value, 63%). The median follow-up was 35 months (range, 1-116 months). CONCLUSIONS: Prior to the introduction of EUS-FNA, a significant number of patients, in whom pancreaticoduodenectomy is carried out for suspected benign disease, turn out to have an underlying malignancy. The use of EUS-FNA has improved the specificity of diagnostic work-up.

A reaudit of specialist-managed liver trauma after establishment of regional referral and management guidelines.

BACKGROUND: An earlier liver trauma audit (52 patients) noted that 50% were surgically managed at referring hospitals with a high morbidity and mortality, after which a regional referral and management algorithm was implemented in 2001. This study aims to reaudit specialist-managed liver trauma outcomes. METHODS: Prospective analysis of 99 patients (68 male) treated for liver injury (LI) between 2001 and 2008. Patient characteristics, management, and outcome results of these were compared with the results of previous audit. LI severity was determined by computed tomography, operative findings, and classified according to liver Organ Injury Scale. RESULTS: As implementation of guidelines, referrals increased from 5.2 patients/yr to 14.1 patients/yr, while LI profile was unchanged. Fewer patients were managed surgically with lower surgical intervention at referring hospitals (26 of 52 [50%] vs. 29 of 77 [38%]; p = 0.2). There has been a decrease in liver resection rates (14 of 26 [54%] vs. 3 of 37 [8%]; p = 0.0001]), overall mortality rate (12 of 52 [23%] vs. 11 of 99 [11%]; p = 0.059), and postoperative deaths. CONCLUSION: This reaudit confirms the role of nonoperative management of liver trauma. Early use of computed tomography scan with specialist discussion, selective use of perihepatic packing, and transfer to a specialist unit should be standard practice in the management of complex liver trauma.

Reduction in bile leaks following adult split liver transplant using a fibrin-collagen sponge: A pilot study.

INTRODUCTION: Bile leaks are a frequent complication of adult split liver transplantation. We compared surgical complications in patients who had the cut surface of the donor liver treated with a patch to those in whom the cut surface of the liver was treated with fibrin glue. MATERIAL AND METHODS: Two consecutive cohorts of 16 patients undergoing adult right lobe split liver transplant were compared. In the first cohort, the liver surface was treated with fibrin glue and in the second the liver surface was treated with TachoSil fibrinogen-thrombin-collagen patches. Post-operative complications were analyzed. RESULTS: Bile leaks were significantly fewer among patients in whom the cut surface of the liver was treated with fibrin-collagen sponge compared to those where fibrin glue was used on the cut surface: 1/16 (6.25%) vs. 7/16 (43.75%), respectively; p=0.03. There were some differences in biliary anastomotic techniques used in the two groups but 7/8 leaks (87.5%) arose from the cut surface, and only one was from the anastomosis. CONCLUSION: Using a fibrinogen-thrombin-collagen sponge patch may reduce bile leaks from the cut surface of the liver during adult right lobe split liver transplants.

Web-based image transmission: a novel approach to aid communication in split liver transplantation.

BACKGROUND: Split liver transplantation (SLT) is technically demanding and requires good communication between transplant centers. The recipient surgeon receiving a shipped split liver needs detailed information on allocation of inflow and outflow vessels. We describe the first use of an image transmission system to facilitate SLT. METHODS: Twenty cadaver livers undergoing ex situ splitting were studied. Fifteen were shared between the geographically separate Birmingham adult and pediatric centers and five were shared with other UK centers. RESULTS: A total of six to eight images of each split graft were taken with a camera at standardized settings using the National Organ Retrieval Imaging System (NORIS), showing details of appearance, size, and anatomy of allocated inflow and outflow vessels. These were uploaded using a personal digital assistant to a secure website (http://www.noris.org.uk). The remote recipient surgeon then viewed these images by logging onto the password-protected website. Minimum time interval between division of the hilar vessels and completion of the split procedure was two h, allowing remote surgeon to view their allocated "shipped" graft in advance of commencing surgery. CONCLUSION: This advanced yet simple image transmission system has the potential for routine application in transplant surgery, not only for splitting but also for reporting injuries and graft steatosis.

Remodeling of the immunoinflammatory network system in elderly cancer patients: implications of inflamm-aging and tumor-specific hyperinflammation.

Although it is generally accepted that aging increases postoperative morbidity and mortality rates, the underlying mechanism remains unknown. The present review evaluates the clinical implications of remodeling the immunoinflammatory status with reference to inflammaging and tumor-specific hyperinflammation. We conducted a Medline/PubMed search for articles investigating factors related to aging and their effects on postoperative outcomes. Inflamm-aging results in both decreased immunity to exogenous antigens and increased auto-reactivity, whereby the beneficial effects of inflammation devoted to the neutralization of harmful agents early in life become detrimental late in life. Cancer also represents an immunologic challenge, which upregulates the systemic immune response. Thus, tumor-related hyperinflammation and inflamm-aging synergistically lead to the systemic priming of inflammatory mediators preoperatively; then, surgical stress acts as the second hit, increasing the risk of an exaggerated postoperative inflammatory response. Age-related molecular events may place elderly patients at greater risk of postoperative complications which could result in death. For regulating uncontrolled hyperinflammation, the clinical advantages of perioperative immunonutrition or steroids have been advocated; however, double-blind, randomized, controlled trials of pharmacologic modulation therapy are needed.

A randomized phase 2 trial of neoadjuvant chemotherapy in resectable pancreatic cancer: gemcitabine alone versus gemcitabine combined with cisplatin.

BACKGROUND: Survival after surgery for pancreas cancer remains low. This improves with adjuvant chemotherapy, but up to 30% patients do not receive the prescribed treatment. Neoadjuvant therapy may increase the proportion of patients who receive all treatment components, may downstage disease before surgery, and may provide early treatment of micrometastases. This randomized phase 2 study compares gemcitabine-based chemotherapy regimens to identify the most promising regimen for future study. METHODS: Fifty patients with potentially resectable pancreas lesions were enrolled onto the study. Twenty-four patients were randomized to gemcitabine (1000 mg/m(2)) every 7 days for 43 days; 26 patients were randomized to gemcitabine (1000 mg/m(2)) and cisplatin (25 mg/m(2)), 7 to the original schedule (omitting day 22) and 19 to a revised schedule due to neutropenia (omitting days 15 and 36). The primary outcome measure was resection rate. RESULTS: Patients who were allocated to gemcitabine received a median of 85% of the planned dose. Patients who were allocated to combination treatment received a median of 88% and 92% of the planned gemcitabine and cisplatin doses, respectively. There were 10 episodes of grade III/IV hematological toxicity in each group. Twenty-seven patients (54%) underwent pancreatic resection, 9 (38%) in the gemcitabine arm and 18 (70%) in the combination arm, with no increase in surgical complications. To date, 34 patients (68%) have died. Twelve-month survival for the gemcitabine and combination groups was 42% and 62%. CONCLUSIONS: Chemotherapy can be safely administered before pancreatic surgery. Combination therapy with gemcitabine and cisplatin is associated with a high resection rate and an encouraging survival rate, suggesting that further study is warranted.

Outcomes after identical and compatible orthotopic liver transplantation for fulminant hepatic failure: a single center experience in UK.

To analyze the outcomes between identical and compatible liver transplantation (OLT) for fulminant hepatic failure (FHF) from September 1984 to November 2005. The patients were divided in three groups; group 1 (identical), group 2 (compatible) and group 3 (incompatible), according to the donor-recipient blood type matching. We analyzed several outcomes regarding mortality, patient and graft survival, incidence of acute graft rejection during the first postoperative month (30 days), incidence of biliary complications and indications of re-transplantation. We also analyzed the relationship of Coomb's positive test with postoperative hemolysis to all the above mentioned factors. During the study period, 168 males and 112 females underwent their first OLT for FHF, with 37.1% overall mortality and 42.1% overall graft failure rate. The results between group 1 (203 patients) and group 2 (73 patients) were comparable. A statistically significant difference was recorded in 1 year and overall graft survival between group 1 and group 2 (P = 0.049 and log-rank = 0.035 respectively). Coomb's positive test did not influence the outcomes. OLT in FHF can be safely carried out whether the donor organs are identical or compatible. Hemolysis (Coomb's positive test) after identical or compatible OLT does not influence the outcomes.

Arginine and urea metabolism in the liver graft: A study using microdialysis in human orthotopic liver transplantation.

BACKGROUND: Arginine is an amino acid having a central role in the metabolism of urea and nitric oxide in the liver. We present our findings of the behavior of these metabolites during the process of transplantation of the liver. METHODS: Urea, arginine, ornithine, citrulline, gamma-aminobutyric acid, glutamate, and glutamine levels in 15 livers were studied during the process of retrieval, following storage during the backtable procedure, and for 48 hours postreperfusion using microdialysis. Arginase levels in donor and recipient serum were also analyzed using an enzyme-linked immunosorbent assay specific for type I human arginase. Data was analyzed using one-way analysis of variance, with post-hoc comparison to the value at two hours using Dunnett's test (P < 0.05 significant). RESULTS: Levels of metabolites measured in the donor liver were seen to decline significantly in the stored liver. Immediately postreperfusion, there was a significant rise in arginase I levels in the recipient serum with low arginine levels recorded in the liver. The high arginase I levels significantly reduced six hours postreperfusion with a corresponding rise in extracellular arginine levels. Urea levels in the graft increased significantly immediately postreperfusion. CONCLUSIONS: Arginine levels were found to be low with correspondingly high serum arginase I levels in the early postreperfusion phase. High serum arginase I levels in early postreperfusion may influence nitric oxide production in this phase since considering Vmax and Km values, arginase I could compete with inducible nitric oxide synthase for arginine. Urea metabolism in the liver recommences immediately postreperfusion.

Conventional versus piggyback technique of caval implantation; without extra-corporeal veno-venous bypass. A comparative study.

Conventional orthotopic liver transplantation (CON-LT) involves resection of recipient cava, usually with extra-corporeal circulation (veno-venous bypass, VVB), while in the piggyback technique (PC-LT) the cava is preserved. Along with a temporary portacaval shunt (TPCS), better haemodynamic maintenance is purported with PC-LT. A prospective, consecutive series of 384 primary transplants (2000-2003) were analysed, 138 CON-LT (with VVB) and 246 PC-LT (54 without TPCS). Patient/donor characteristics were similar in the two groups. PC-LT required less usage of fresh-frozen plasma and platelets, intensive care stay, number of patients requiring ventilation after day 1 and total days spent on ventilator. The results were not different when comparing, total operating and warm ischaemia time (WIT), red cell usage, requirement for renal support, day 3 serum creatinine and total hospital stay. TPCS had no impact on outcome other than WIT (P = 0.02). Three patients in PC-LT group (three of 246;1.2%) developed caval outflow obstruction (P = 0.02). There was no difference in short- or long-term graft or patient survival. PC-LT has an advantage over CON-LT unsing VVB with respect to intraoperative blood product usage, postoperative ventilation requirement and ITU stay. VVB is no longer required and TPCS may be used selectively in adult transplantation.

Interstitial lactic acidosis in the graft during organ harvest, cold storage, and reperfusion of human liver allografts predicts subsequent ischemia reperfusion injury.

BACKGROUND: The impact of the process of liver transplantation on glucose metabolism in the graft was studied using microdialysis. METHODS: Microdialysis catheters were inserted into 15 human livers to monitor metabolic changes that took place during organ harvest, the process of backtable preparation of the graft, and following implantation in the recipient where it remained in situ for 48 hours. The cannula was perfused with isotonic solution and hourly samples of perfusate were collected and analyzed. RESULTS: Six livers showed serum biochemical evidence of ischemia/reperfusion (IR) injury with 24 hours aspartate transaminase (AST) levels >2000 IU/L (Group A) whereas the remaining patients showed little evidence of IR injury (Group B). In Group A, lactate levels in the donor microdialysate rose to >6 mM (P < 0.05), were significantly higher during backtable preparation of the liver (>15 mM; P < 0.03), and took longer to normalize in the recipient following implantation (18 vs. 8 hours, P < 0.03) than lactate levels of the livers of patients in Group B who did not develop ischemia reperfusion injury. No significant differences were observed in glucose, pyruvate, or glycerol concentrations between the two groups. CONCLUSIONS: Interstitial lactic acidosis in the donor allograft is associated with significant reperfusion injury on implantation.

Multivariate and univariate analysis of prognostic factors following resection in HCC: the Birmingham experience.

BACKGROUND: The aim of this study was to look into our experience of resection for hepatocellular carcinomas (HCCs) in a tertiary Hepatobiliary and Liver Transplant Unit in the UK. METHODS: A retrospective analysis of our prospective database was carried out. RESULTS: 715 cases of HCC were seen. 100 (13.9%) underwent hepatic resection and 159 (22.2%) orthotopic liver transplant. The 1-, 3- and 5-year overall survival following resection was 75.3, 37.0 and 21.5% respectively. Factors affecting long-term survival included resection margin (p < 0.001), recurrence (p < 0.007), alpha-fetoprotein >50 (p < 0.001) and serum albumin (p < 0.03). On multivariate analysis, recurrence (p < 0.001) and histological grade (p < 0.044) were significant. The 1- and 3-year recurrence rates were 27.3 and 72.5% respectively. Histological grade (p < 0.007), alpha-fetoprotein >50 (p < 0.033), female gender (p < 0.016) and portal vein involvement (p < 0.016) were significant in recurrence. CONCLUSIONS: Resection data from the East may not be comparable to the West owing to the higher transplant activity in the latter. Liver function tests and imaging would be sufficient to assess liver function prior to hepatic resection. HCC with cirrhosis should be assessed by a transplant unit prior to any treatment. The MELD (Model for End-Stage Liver Disease) score would be a valuable preoperative tool in the assessment of cirrhotics.

Biliary complications following adult right lobe ex vivo split liver transplantation.

Biliary complications are common following split liver transplantation (SLT). We analyzed the incidence, treatment, and outcome of biliary complications following adult right lobe ex vivo SLT performed between November 1992 and January 2005. There were 72 patients, of which 70 were analyzed. Early postoperative deaths resulted in 2 being excluded from the analysis. There were 44 males (median age, 48 yr; range, 19-70 yr). Biliary reconstruction was by duct-to-duct (DD) anastomosis in 52 (74%) and Roux-en-Y hepaticojejunostomy (RYHJ) in 18 (26%) patients. Until mid-2001, no T-tube was used for DD anastomosis (DD/non-T-tube) in 26 (37%) patients; subsequent to this, DD over a T-tube (DD/T-tube) was performed in 26 (37%) patients. Eighteen (26%) biliary complications occurred in 16 patients. Two anastomotic leaks of RYHJ were associated with hepatic artery thrombosis. The most frequent biliary complication was parenchymal radical leak from the transected liver surface (11%; 8/70), with anastomotic leaks in 6% (4/70) and strictures in 4% (3/70). There were also 2 cases of biliary leaks from T-tube exit site following T-tube removal, and 1 leak from the donor cystic duct stump. DD anastomosis without a T-tube was associated with a higher rate of cut surface and anastomotic biliary leaks (7/26), compared to the DD/T-tube group (1/26; P = 0.05). Six patients (9%) died following biliary complications, including 3 due to cut surface leaks in the DD/non-T-tube group and 2 cases with fatal biliary peritonitis following T-tube removal. A patient in the RYHJ group died due to biliary sepsis associated with hepatic artery thrombosis. In conclusion, biliary complications following right lobe ex vivo SLT are associated with significant morbidity and mortality. Our results suggest that T-tube biliary drainage of DD anastomosis may reduce parenchymal cut surface and biliary anastomotic leaks. However, bile leak following T-tube removal could lead to potentially fatal biliary peritonitis, which should always be anticipated and treated promptly.

Hepatic artery thrombosis following orthotopic liver transplantation: a 10-year experience from a single centre in the United Kingdom.

Hepatic artery thrombosis (HAT) occurs in 3-9% of all liver transplants and acute graft loss is a possible sequelae. We present our experience in the management of HAT over a 10-year period. Prospectively collected data from April 1994 to April 2004 were analyzed. There were 1,257 liver transplants, 669 males, median age 51 (16-73) years. There were 61 (4.9%) cases of HAT. Early HAT occurred in 21 (1.8%). Thirty six had graft dysfunction, 11 required a regraft, and 14 died. Positive CMV serology in the donor, cold ischemia time, duration of operation, transfusions of more than 6 units of blood, and 15 units of plasma, an aortic conduit for arterial reconstruction, Roux-en-Y biliary reconstructions, regrafts and relaparotomy were associated with HAT. At multivariate analysis, type of biliary anastomosis was the only significant factor associated with HAT. Split or reduced liver graft were not risk factors for HAT. Number of hepatic arteries requiring multiple arterial anastomosis was not a risk for HAT. HAT resulted in a reduction in overall survival post liver transplantation. The incidence of HAT was 4.9%; with 1.8% early HAT and HAT impacted on survival. Surgical technique was not an aetiological factor for HAT. In conclusion, while a Roux-en-Y biliary reconstruction was an independent risk factor for HAT, cold ischemia and operative times, the use of blood and plasma and the use of aortic conduits in arterial reconstruction were associated with HAT. Regrafts and reoperation were also identified risk factors.

Arterial conduits for hepatic artery revascularisation in adult liver transplantation.

Arterial complications after orthotopic liver transplantation (OLT), including hepatic artery thrombosis (HAT), are important causes of early graft failure. The use of an arterial conduit is an accepted alternative to the utilisation of native recipient hepatic artery for specific indications. This study aims to determine the efficacy of arterial conduits and the outcome in OLT. We retrospectively reviewed 1,575 cadaveric adult OLTs and identified those in which an arterial conduit was used for hepatic revascularisation. Data on the primary disease, indication for using arterial conduit, type of vascular graft, operative technique and outcome were obtained. Thirty-six (2.3%) patients underwent OLT in which arterial conduits were used for hepatic artery (HA) revascularisation. Six of these were performed on the primary transplant, while the rest (n=30) were performed in patients undergoing re-transplantation, including six who had developed hepatic artery aneurysms. The incidence of arterial conduits was 0.4% (6/1,426 cases) in all primary OLTs and 20.1% (30/149 cases) in all re-transplants. Twenty-nine procedures utilised iliac artery grafts from the same donor as the liver, six used iliac artery grafts from a different donor, and a single patient underwent a polytetrafluoroethylene (PTFE) graft. Two techniques were used: infra-renal aorto-hepatic artery conduit and interposition between the donor and recipient native HAs, or branches of the HAs. The 30-day mortality rate for operations using an arterial conduit was 30.6%. Three conduits thrombosed at 9, 25 and 155 months, respectively, but one liver graft survived without re-transplantation. The arterial conduits had 1- and 5-year patency rates of 88.5% and 80.8%. The 1- and 5-year patient survival rates were 66.7% and 44%. We can thus conclude that an arterial conduit is a viable alternative option for hepatic revascularisation in both primary and re-transplantation. Despite a lower patency rate than that of native HA in the primary OLT group, the outcomes of arterial conduit patency and patient survival rates are both acceptable at 1 and 5 years, especially in the much larger re-OLT group.