Efficacy and utility of robotic single-access bilateral nephrectomy (r-SABN) in end-stage renal disease patients.

PURPOSE: Bilateral native nephrectomies are needed in ESRD patients with select indications in a pre-transplant setting. Yet, the perioperative morbidity is significant in this population. Herein we evaluate the efficacy and utility of r-SABN. METHOD: A total of 12 patients were consented at a single center. Of 12 patients, 3 patients did not meet study criteria and were excluded. Preoperative, perioperative, and postoperative data were prospectively collected from 9 patients from electronic health records and administered postoperative surveys. Patients were assessed at 30-180 days postoperatively for follow-up. RESULTS: Mean operative time was 204.3 ± 59.7 min (142.0-314.0) and estimated blood loss during operation was 94.4 ± 87.3 ml (25.0-300.0). The mean length of hospital stay was 2 ± 0.7 days (1-3) for all patients. Total post-operative opioid usage was normalized to morphine dose equivalents (MDE) and calculated to be 56.1 ± 30.4 mg (30.8-101.8). Patients experienced a fourfold and tenfold respective increase in weekly structural and incidental physical activity from 30 to 180 days postoperatively. There were no procedure related intraoperative or postoperative complications reported in the cohort. CONCLUSION: Overall, r-SABN afforded the patients low morbidity. Longitudinal studies are in progress to further assess the efficacy and outcome of this procedure. In a single-center study, we demonstrate r-SABN is viable and provides a novel tool for treatment of ESRD patients requiring this procedure.

Small bowel obstruction caused by a bezoar following an adult simultaneous liver-kidney transplantation: A case report.

BACKGROUND: Small bowel obstructions (SBOs) are common following a large intra-abdominal operation; however, SBOs caused by bezoars are unreported in patients following liver-kidney transplantation procedures, particularly in adults. CASE SUMMARY: A 65-year-old Caucasian female presented with nausea and nonbilious emesis during her postoperative course following a simultaneous liver-kidney transplantation. She developed worsening nausea and vomiting with significant abdominal distension and obstipation. Computed tomography imaging showed a marked abnormal dilation of multiple small bowel loops with a distinct transition point that was suggestive of a small bowel obstruction. An exploratory laparotomy revealed a foreign body in the intestinal track approximately 30 cm from the ileocecal valve. The foreign body was extracted and identified as a bezoar with hair follicles and old digestive contents. Following the operation, the patient demonstrated rapid clinical improvement with resolution of nausea, emesis, and progress in bowel motility. CONCLUSION: SBOs caused by bezoars can occur immediately following a liver-kidney transplantation and should not be discounted as a diagnosis.

Renal hilar block predicts long-term success of renal auto-transplantation for loin pain hematuria syndrome.

PURPOSE: In patients with loin pain hematuria syndrome (LPHS), a response to percutaneous renal hilar blockade (RHB) and a multidisciplinary team (MDT) evaluation predicts patient's potential renal auto-transplantation (RAT) success. METHODS: A pain assessment was performed using a 0-10 numeric pain rating scale prior to a percutaneous RHB under CT guidance. If the pain score was reduced > 50% immediately after the RHB, patients were evaluated for RAT by a MDT. Pre-operative and 1-year post-operative quality-of-life surveys were administered to each RAT patient. RESULTS: 43 LPHS patients were referred for RHB. Of the 38 patients who received a RHB, 31 had > 50% reduction in pain scores. Pre- and post-RHB mean pain scores were 6/10 and 0.7/10, respectively, in patients who had > 50% reduction in pain. 22 of the patients who responded favorably then proceeded to RAT. Twelve patients had at least 1-year follow-up after RAT. All patients had a meaningful decrease in their pain. Mean pain score at 1 year was 0.8/10 for an 85% overall reduction in pain. 92% of patients experienced a ≥ 50% reduction in pain at 1 year. Mean Beck Depression Inventory (BDI) score (0-66) 1 year after RAT decreased from 25.2 pre-op (moderate depression) to 12.8 post-op (minimal depression). CONCLUSIONS: A MDT approach utilizing a RHB should be considered as a tool to select appropriate LPHS patients for RAT to achieve long-term success in reducing chronic pain and depression while increasing quality of life.

Prospective, double-blind, randomized clinical trial comparing an ERAS pathway with ketorolac and pregabalin versus standard of care plus placebo during live donor nephrectomy for kidney transplant.

Opioid exposure is a concern after live donation for kidney transplant. We theorized that an enhanced recovery after surgery pathway (ERAS) using pregabalin preoperatively to desensitize nerves followed by the nonsteroidal anti-inflammatory drug ketorolac, during and after surgery, can control pain, thus requiring less perioperative narcotics. The aim of this study was to determine if the use of a nonopioid analgesic ERAS protocol for donor nephrectomies could decrease the use of narcotics without an increase in complications compared with standard of care (SOC). This is a single-center, prospective, double-blind, randomized clinical trial involving a total of 62 patients undergoing nephrectomy for live donor kidney transplant. Length of hospital stay (LOS) was significantly reduced by 10% in the ERAS group versus the SOC-plus-placebo group. Morphine dose equivalents were significantly reduced by 40% in the study group versus the SOC-plus-placebo group. The use of this nonopioid analgesic ERAS pathway for donor nephrectomies decreased the use of narcotics without an increase in complications compared with SOC. There was significantly reduced LOS and less narcotic use in the study group versus the SOC-plus-placebo group. (ClinicalTrials.gov registration number: NCT03669081).

A Prospective, Randomized, Phase III Study to Evaluate the Efficacy and Safety of Fibrin Sealant Grifols as an Adjunct to Hemostasis as Compared to Cellulose Sheets in Hepatic Surgery Resections.

BACKGROUND: Local hemostatic agents have a role in limiting bleeding complications associated with liver resection. METHODS: In this randomized, phase III study, we compared the efficacy and safety of Fibrin Sealant Grifols (FS Grifols) with oxidized cellulose sheets (Surgicel®) as adjuncts to hemostasis during hepatic resections. The primary efficacy endpoint was the proportion of patients achieving hemostasis at target bleeding sites (TBS) within 4 min (T4) of treatment application. Secondary efficacy variables were time to hemostasis (TTH) at a later time point if re-bleeding occurs and cumulative proportion of patients achieving hemostasis by time points T2, T3, T5, T7, and T10. RESULTS: The rate of hemostasis by T4 was 92.8% in the FS Grifols group (n = 163) and 80.5% in the Surgicel® group (n = 162) (p = 0.01). The mean TTH was significantly shorter (p < 0.001) in the FS Grifols group (2.8 ± 0.14 vs. 3.8 ± 0.24 min). The rate of hemostasis by T2, T5, and T7 was higher and statistically superior in the FS Grifols group compared to Surgicel®. No substantial differences in adverse events (AE) were noted between treatment groups. The most common AEs were procedural pain (36.2 vs. 37.7%), nausea (20.9 vs. 23.5%), and hypotension (14.1 vs 6.2%). CONCLUSIONS: FS Grifols was safe and well tolerated as a local hemostatic agent during liver resection surgeries. Overall, data demonstrate that the hemostatic efficacy of FS Grifols is superior to Surgicel® and support the use of FS Grifols as an effective local hemostatic agent in these surgical procedures.

Mucocele mimicking a gallbladder in a transplanted liver: A case report and review of the literature.

Biliary mucoceles after deceased donor liver transplantation are a rarity, and mucoceles mimicking a gallbladder from the recipient remnant cystic duct have not been described until this case. We describe a 48-year-old male who presented with right upper quadrant pain and was found to have a recipient cystic duct mucocele 3 mo after receiving a deceased donor liver transplant. We describe the clinical presentation, laboratory and imaging findings (including the appearance of a gallbladder), multidisciplinary approach and surgical resolution of this mucocele originating from the recipient cystic duct, and a review of the literature.

Use of a pulsatile perfusion pump for renal autotransplantation in a patient undergoing thoracoabdominal bypass for malignant hypertension secondary to Takayasu arteritis.

Aortorenal bypass is an effective and durable therapy for autoimmune-induced renovascular hypertension. However, when technical and patient factors preclude this option, renal autotransplantation can be a viable alternative. We present a 32-year-old woman who underwent aortobi-iliac bypass with left renal autotransplantation for malignant hypertension secondary to Takayasu arteritis. This is the first description of using machine preservation with a continuous pulsatile perfusion pump to maintain renal preservation before reimplantation. Our method proved safe to the patient and allowed for protection of the organ from prolonged warm ischemia and intraoperative hypoperfusion during a complex reconstruction.

Minimally invasive aortic valve replacement with orthotopic liver transplantation: report of a case.

Cardiac surgery and liver transplantation (LT) are rarely performed at the same time, because of the potential risks of coupling two such complex surgical procedures [1-3]. This combined surgery is typically reserved for patients with structural heart disease, including multivessel obstructive coronary artery disease and severe valvular disease with heart failure and end-stage liver disease, in whom the untreated organ may decompensate if only one organ is addressed [4]. Combined aortic valve replacement (AVR) and LT is the rarest of such combined surgery, with only ten cases published previously. We present the first reported case of combined minimally invasive AVR and LT and review the literature on similar combined surgery.

Resection of the liver and inferior vena cava for hepatic malignancy.

BACKGROUND: Involvement of the IVC has traditionally been considered a relative contraindication to resection for advanced tumors of the liver. Combined resection of the liver and IVC for malignancy can be performed safely and results in long-term survival in select patients. STUDY DESIGN: Sixty patients undergoing hepatic and IVC resection by the primary author from 1996 to 2012 were reviewed. Median age was 52 years. Resections were carried out for cholangiocarcinoma (n = 26), hepatocellular carcinoma (n = 16), colorectal metastases (n = 13), gastrointestinal stromal tumor (n = 2), hepatoblastoma (n = 2), and squamous cell carcinoma (n = 1). Resections performed included 27 right and 5 left trisegmentectomies and 25 right and 3 left lobectomies, including the caudate lobe. Ex vivo procedures were performed in 6 patients using veno-venous bypass and the other 54 procedures were performed using varying degrees of vascular isolation. In situ cold perfusion of the liver was used in 8 patients. The IVC was reconstructed using a tube graft (n = 38) primarily (n = 8) or with patches (n = 14). RESULTS: There were 5 perioperative deaths (8%). Three patients died of liver failure, 1 patient died of pulmonary hemorrhage, and 1 patient died of massive pulmonary embolism. Nine patients had evidence of postoperative liver failure that resolved with supportive management. Three patients required temporary dialysis. With a median follow-up of 31 months, 14 patients have died of recurrent malignancy between 22 and 44 months, and an additional 4 patients are alive with disease at 16 to 33 months. Actuarial 1- and 5-year survival rates were 89% and 35%, respectively. CONCLUSIONS: Inferior vena cava involvement by malignancy does not obviate liver resection. The procedure's increased risk is balanced by the possible benefits, given the lack of alternative curative approaches.

Perceived benefits of a transplant surgery experience to general surgery residency training.

OBJECTIVES: The benefit of a solid-organ transplant experience during general surgical training has been questioned recently. In 2008, in response to an American Board of Surgery (ABS) directive, a survey was conducted by the Association of Program Directors in Surgery (APDS) in coordination with the American Society of Transplant Surgeons (ASTS) to determine the perceived value of a transplant surgery rotation to program directors and residents. With the aim of providing additional insight, we conducted a separate study, independent of the ABS and ASTS, to ascertain resident perceptions regarding the specific skill sets that they acquire during their transplant surgery rotations and their applicability to other surgical subspecialties. METHODS: A preliminary, 51-item, web-based questionnaire was completed by 69.6% of residents in nationally accredited general surgery programs who accessed the survey. The results were examined using appropriate statistical methods to determine associations between answers. RESULTS: Although only 16.6% of participants responded that they were considering a career in transplantation, 63.4% answered that the skill sets acquired during this rotation would assist them in their surgical careers regardless of their chosen specialty. Most (65.5%) respondents answered that the techniques learned were directly applicable to other specialties, such as vascular, urologic, trauma, and hepatobiliary surgery. Free response questions indicated that the most common criticisms of this rotation were the limited amount of operative participation, lack of teaching by attendings, and lifestyle limitations. CONCLUSIONS: The results of this study indicate that surgery residents are conflicted regarding their transplant surgery experience but regard it as a beneficial addition to their training. Most respondents indicated also that these skills were transferable directly to other surgical specialties.

Liver transplantation in septuagenarians receiving model for end-stage liver disease exception points for hepatocellular carcinoma: the national experience.

Current liver allocation policy in the United States grants liver transplant candidates with stage T2 hepatocellular carcinoma (HCC) a priority Model for End-Stage Liver Disease (MELD) score of 22, regardless of age. Because advanced age may portend an increase in all-cause mortality after transplantation for any diagnosis, the aim of this study was to examine overall posttransplant survival in elderly patients with HCC versus younger cohorts. Based on Organ Procurement and Transplantation Network data, Kaplan-Meier 5-year survival rates were compared. Recipients undergoing primary liver transplantation were stratified into cohorts based on age (<70 or ≥ 70 years) and the receipt of MELD exception points for HCC. Log-rank and Wilcoxon tests were used for statistical comparisons. In 2009, 143 transplants were performed for patients who were 70 years old or older. Forty-two percent of these patients received a MELD exception for HCC. Regardless of the diagnosis, the overall survival rate was significantly attenuated for the septuagenarians versus the younger cohort. After 5 years of follow-up, this disparity exceeded 10% to 15% depending on the populations being compared. The 1-, 2-, 3-, 4-, and 5-year actuarial survival rates were 88.4%, 83.2%, 79.6%, 76.1%, and 72.7%, respectively, for the patients who were younger than 70 years and 81.1%, 73.8%, 67.1%, 61.9%, and 55.2%, respectively, for the patients who were 70 years old or older. Five-year survival was negatively affected for patients with HCC who were younger than 70 years; this disparity was not observed for patients with HCC who were 70 years old or older. In conclusion, although patients who are 70 years old or older compose a small fraction of transplant recipients in the United States, patients in this group undergoing transplantation for HCC form an even smaller subset. Overall, transplantation in this age group yields outcomes inferior to those for younger cohorts. However, unlike patients who are less than 70 years old and receive MELD exception points, overall liver transplant survival is not affected by HCC at an advanced age.

Recurrent hepatocellular carcinoma in liver transplant recipients with hepatitis C.

PURPOSE: Hepatitis C (HCV) is the most common liver disease in patients transplanted with hepatocellular carcinoma (HCC) in the West. We examined predictors of HCC recurrence in liver transplant recipients with HCV. METHODS: From 1997 to 2006, 53 patients with HCC and HCV underwent liver transplantation. Pre-and post-operative data (including liver biopsies 4 months post-transplant) were collected. Differences between HCC recurrence and non-recurrence groups were detected by Student's t test or chi-square test. Data were analyzed as predictors of HCC recurrence by logistic regression multivariate analysis. Cumulative survival was analyzed by Kaplan-Meier curves and compared by the log-rank test. RESULTS: Eleven of 53 patients (20.8%) developed HCC recurrence at a median interval of 15 months (2 to 55 months). Median Histology Activity Index (HAI) of liver biopsies, AST, and ALT at 4 months were significantly greater in patients with HCC recurrence. Independent predictors of HCC recurrence were HAI ≥ 4 at 4 months, ALT ≥ 100 at 4 months, and vascular invasion. Patients with HCC recurrence had significantly decreased survival. CONCLUSIONS: In this preliminary study, Histology Activity Index and ALT at 4 months, as well as vascular invasion, predicted HCC recurrence in liver transplant recipients with HCV.

Impact of calcineurin inhibitors on hepatitis C recurrence after liver transplantation.

BACKGROUND AND AIMS: The aim of this retrospective study is to assess the impact of calcineurin inhibitors on hepatitis C virus recurrence following liver transplantation. METHODS: A total of 396 patients underwent liver transplantation for hepatitis C virus-induced liver disease between 1991 and 2005 at a single center. We examined the pre- and post-operative characteristics of patients who received either cyclosporine (n = 126) or tacrolimus (n = 270) as maintenance immunosuppression. In addition, we compared the postoperative course, including patient, graft and hepatitis C virus recurrence-free survival between the two groups. RESULTS: There were no significant differences between the two groups in either post-operative hepatitis C virus-ribonucleic acid or histological fibrosis score (performed within 6 months after transplant per protocol). The graft and patient survivals did not differ between the two groups (logrank p = 0.34 and 0.15, respectively). Histologic hepatitis C virus recurrence-free survival, however, was significantly higher in the cyclosporine group than in the tacrolimus group (55.4 vs. 30.8% at 1 year, 18.6 vs. 10.3% at 3 years, 16.7 vs. 8.1% at 5 years, p < 0.001). CONCLUSIONS: Patients transplanted for hepatitis C virus and treated with cyclosporine versus tacrolimus may have a higher recurrence-free survival.

Liver transplantation in a 7-month-old girl with Caroli's disease.

Caroli's disease (including Caroli's syndrome) is a rare autosomal recessive disorder of the liver characterized by diffuse cystic dilatation of the intrahepatic bile ducts. The disease may present at any age and is characterized by recurrent episodes of biliary obstruction, cholangitis, hepaticolithiasis, and liver abscesses. Caroli's syndrome is further associated with congenital hepatic fibrosis and portal hypertension. Patients with recurrent complications or cirrhosis may die because of recurrent infection, portal hypertension, liver failure, or cholangiocarcinoma. Liver transplantation is the treatment of choice for these complicated patients. Here we describe the youngest reported patient with Caroli's syndrome treated successfully using liver transplantation and review the recent literature.

Adult post-transplant lymphoproliferative disease in the liver graft in patients with recurrent hepatitis C.

AIM: The aim of this study is to clarify the association between hepatitis C virus (HCV) infection and post-transplant lymphoproliferative disease (PTLD) in the liver allograft. METHODS: Of the 933 adults who underwent liver transplantation (LT) between 1990 and 2005, 10 patients developed PTLD. Seven of the 10 patients that were HCV(+) (group 1) were compared with three HCV-negative recipients (group 2). RESULTS: The mean time between LT and PTLD was 24.5 months. There were no differences between in Epstein-Barr virus antibody status or tumor lymphocyte subsets. In five of the seven HCV-positive recipients who developed PTLD, PTLD recurred preferentially in the liver allograft, whereas none of the three HCV-negative patients who developed PTLD did so in the liver (71.4 vs. 0%, respectively, P=0.038). In all five patients with graft PTLD, HCV recurred within 12 months followed by PTLD. There were significant differences between groups 1 and 2 in mean lymphocyte infiltrate scores (6.0±2.1 vs. 2.0±0.7, P=0.037), fibrosis stage (2.4±0.5 vs. 0.7±0.5, P=0.029), and frequency of lymphoid follicles in portal areas (33.6±14.8% vs. 1.1±2.3%, P=0.0002). CONCLUSION: When PTLD occurs in patients with HCV recurrence after LT, it does so preferentially in the liver allograft.

Portal vein resection in management of hilar cholangiocarcinoma.

BACKGROUND: Vascular reconstruction along with major liver resection in the setting of liver dysfunction caused by biliary obstruction can be associated with increased risk. The purpose of this report is to assess the role of portal vein resection and reconstruction in the surgical management of hilar cholangiocarcinoma. STUDY DESIGN: Ninety-five patients with hilar cholangiocarcinoma who underwent resection between 1999 and 2010 were reviewed. Liver resections performed along with biliary resection included 84 trisegmentectomies (63 right, 21 left) and 11 lobectomies (8 left, 3 right). Thirteen patients also had simultaneous pancreaticoduodenectomy performed. Forty-two patients underwent portal vein resection and reconstruction. Five patients required reconstruction of the hepatic artery. Preoperative portal vein embolization was used in 38 patients. RESULTS: Patients undergoing resection had a 5% mortality rate, with an overall morbidity rate of 36%. Patients who underwent portal vein resection had perioperative mortality and morbidity similar to those who did not have portal vein resection. Median survival was 38 months (95% CI, 29-51 months), with a 5-year survival rate of 43%. There was no difference in long-term survival between those patients who had portal vein resection and those that did not. Negative margins were achieved in 84% of cases and were associated with improved survival (p < 0.01). Five-year survival rate in patients undergoing R0 resection was 50%. Patients with positive lymph nodes appeared to have a worse 5-year survival rate than patients with node-negative status (23% versus 49%); however, only negative margin status was associated with improved survival by multivariate analysis. CONCLUSIONS: Surgical resection of hilar cholangiocarcinoma that requires resection of the portal vein can be performed safely and should not be a contraindication to resection.

Combined resection of the liver and pancreas for malignancy.

BACKGROUND: Combined resection of both the liver and pancreas for malignancy remains a controversial procedure. To many, the need for such an extended procedure implies an extent of disease that is usually not amenable to surgical control, and the extent of the procedure exposes the patients to substantial operative risks. The purpose of this study was to assess our results with combined resection of the liver and pancreas. STUDY DESIGN: Forty patients underwent combined liver and pancreas resection from 1996 to 2009. Patient ages ranged from 39 to 69 years (mean 53 years). Underlying diagnoses were neuroendocrine tumor (13), cholangiocarcinoma (13), gallbladder carcinoma (9), gastrointestinal stromal tumor (3), colorectal cancer (1), and metastatic ocular melanoma (1). Pancreatic resections included 26 pancreaticoduodenectomies (PD) and 14 distal pancreatic resections. Liver resections included 18 trisectionectomies (13 right, 5 left), 10 lobectomies (8 right, 2 left), and 12 segmental resections. RESULTS: There was no perioperative mortality. One patient who underwent PD with right trisegmentectomy for gallbladder cancer developed postoperative liver failure that improved with supportive management. Two patients developed bile leaks that resolved with conservative management. One patient developed a pancreatic leak/hemorrhage and required a completion pancreatectomy. Mean hospital stay was 14 days (range 7 to 42 days). Median follow-up was 30 months (range 3 to 76 months). Patients undergoing resection for neuroendocrine tumors had a better 5-year survival than those with hepatobiliary malignancies (100% vs 37% p = 0.01). CONCLUSIONS: Combined resection of the liver and pancreas can be performed safely. The need for combined partial hepatectomy and pancreatectomy to remove malignancy should not be considered a contraindication to resection in selected patients.

A pilot prospective randomized trial of postoperative epoetin alfa in patients undergoing major operation for upper gastrointestinal malignancy.

INTRODUCTION: Strategies to reduce red blood transfusion utilization in cancer patients undergoing operation are needed. HYPOTHESIS: Postoperative epoetin alfa (40,000 units subcutaneous on postoperative days 1 and 7) is associated with improved hematologic parameters in patients undergoing major abdominal surgery for malignancy. MATERIALS AND METHODS: Prospective, blinded, randomized trial of epoetin alfa (40,000 units subcutaneous on postoperative days 1 and 7) versus placebo in patients undergoing major abdominal operation for malignancy. Primary endpoints were immature reticulocyte fraction, reticulocyte count, and hemoglobin, which were measured on postoperative days 4, 7, and between 14 and 20. Secondary endpoints were transfusions and complications in the 2 groups. RESULTS: Forty patients were enrolled. There were no significant differences in immature reticulocyte fraction (P = 0.78), reticulocyte count (P = 0.42), or hemoglobin (0.35) in patients randomized to receive epoetin alfa versus placebo. There was no significant difference in red blood cell transfusion rate or postoperative complications in patients who received epoetin alfa compared with placebo. DISCUSSION: The use of postoperative epoetin alfa (40,000 units subcutaneous on postoperative days 1 and 7) in patients undergoing major operation for abdominal or pelvic malignancy is not supported by this randomized trial.

Duplicate gallbladder arising from the left hepatic duct: report of a case.

Gallbladder duplication is a rare congenital biliary anomaly with different morphologies depending on events at embryogenesis. This case report describes a symptomatic duplicate gallbladder arising from the left intrahepatic duct 10 years after an open cholecystectomy: this is the rarest form of gallbladder duplication. The symptoms resolved following a second open cholecystectomy. This case illustrates the importance of preoperative imaging, intraoperative cholangiography, and a high index of suspicion of anomalous gallbladder anatomy in the diagnosis and management of this rare condition. We discuss the classification of anomalous gallbladder anatomy and review previous cases, to propose a modification of the common classification scheme.