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ABSTRACT: Previous studies have shown a higher incidence of biliary complications following donation after cardiac death (DCD) liver transplantation compared with donation after brain death (DBD) liver transplantation. The endoscopic management of ischemic type biliary strictures in patients who have undergone DCD liver transplants needs to be characterized further.
A retrospective institutional review of all patients who underwent DCD liver transplant from January 2006 to September 2011 was performed. These patients were compared with all patients who underwent DBD liver transplantation in the same time period. A descriptive analysis of all DCD patients who developed biliary complications and their subsequent endoscopic management was also performed.
Of the 36 patients who received DCD liver transplants, 25% developed biliary complications compared with 13% of patients who received DBD liver transplants (P=0.062). All DCD allograft recipients who developed biliary complications became symptomatic within three months of transplantation. Ischemic type biliary strictures in DCD allograft recipients included disseminated biliary strictures in two patients, biliary strictures of the hepatic duct bifurcation in three patients and biliary strictures of the donor common hepatic duct in three patients.
There was a trend toward increasing incidence of total biliary complications in recipients of DCD liver allografts compared with those receiving DBD livers, and the rate of diffuse ischemic cholangiopathy was significantly higher. Focal ischemic type biliary strictures can be treated effectively in DCD liver transplant recipients with favourable results. Diffuse ischemic type biliary strictures in DCD liver transplant recipients ultimately requires retransplantation.
Canadian journal of gastroenterology = Journal canadien de gastroenterologie 09/2012; 26(9):607-10. · 1.21 Impact Factor
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ABSTRACT: To compare the clinical outcome and pathologic features of non-alcoholic steatohepatitis (NASH) patients with hepatocellular carcinoma (HCC) and hepatitic C virus (HCV) patients with HCC (another group in which HCC is commonly seen) undergoing liver transplantation.
Patients transplanted for HCV and NASH at our institution from January 2000 to April 2011 were analyzed. All explanted liver histology and pre-transplant liver biopsies were examined by two specialist liver histopathologists. Patient demographics, disease free survival, explant liver characteristics and HCC features (tumour number, cumulative tumour size, vascular invasion and differentiation) were compared between HCV and NASH liver transplant recipients.
A total of 102 patients with NASH and 283 patients with HCV were transplanted. The incidence of HCC in NASH transplant recipients was 16.7% (17/102). The incidence of HCC in HCV transplant recipients was 22.6% (64/283). Patients with NASH-HCC were statistically older than HCV-HCC patients (P < 0.001). A significantly higher proportion of HCV-HCC patients had vascular invasion (23.4% vs 6.4%, P = 0.002) and poorly differentiated HCC (4.7% vs 0%, P < 0.001) compared to the NASH-HCC group. A trend of poorer recurrence free survival at 5 years was seen in HCV-HCC patients compared to NASH-HCC who underwent a Liver transplantation (P = 0.11).
Patients transplanted for NASH-HCC appear to have less aggressive tumour features compared to those with HCV-HCC, which likely in part accounts for their improved recurrence free survival.
World Journal of Gastroenterology 08/2012; 18(31):4145-9. · 2.47 Impact Factor
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ABSTRACT: An updated definition of early allograft dysfunction (EAD) was recently validated in a multicenter study of 300 deceased donor liver transplant recipients. This analysis did not differentiate between donation after brain death (DBD) and donation after cardiac death (DCD) allograft recipients.
We reviewed our prospectively entered database for all DBD (n=377) and DCD (n=38) liver transplantations between January 1, 2006 and October 30, 2011. The incidence of EAD as well as its ability to predict graft failure and survival was compared between DBD and DCD groups.
EAD was a valid predictor of both graft and patient survival at six months in DBD allograft recipients, but in DCD allograft recipients there was no significant difference in the rate of graft failure in those with EAD (11.5%) compared with those without EAD (16.7%) (P=0.664) or in the rate of death in recipients with EAD (3.8%) compared with those without EAD (8.3%) (P=0.565). The graft failure rate in the first 6 months in those with international normalized ratio ≥1.6 on day 7 who received a DCD allograft was 37.5% compared with 6.7% for those with international normalized ratio <1.6 on day 7 (P=0.022).
The recently validated definition of EAD is a valid predictor of patient and graft survival in recipients of DBD allografts. On initial assessment, it does not appear to be a useful predictor of patient and graft survival in recipients of DCD allografts, however a study with a larger sample size of DCD allografts is needed to confirm these findings. The high ALT/AST levels in most recipients of DCD livers as well as the predisposition to biliary complications and early cholestasis make these parameters as poor predictors of graft failure. An alternative definition of EAD that gives greater weight to the INR on day 7 may be more relevant in this population.
Hepatobiliary & pancreatic diseases international: HBPD INT 08/2012; 11(4):372-6. · 1.08 Impact Factor
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ABSTRACT: BACKGROUND: Surgical resection has routinely not been recommended for patients with huge (>15 cm) multinodular lesions and macrovascular invasion (advanced-stage hepatocellular carcinoma [HCC] patients) because of high operative mortality, recurrence rate, and lack of survival benefit. METHODS: A retrospective study of 1425 patients was carried out, of which 1245 patients met EASL/AASLD criteria for hepatic resection (HR-EA group), 116 were surgically treated advanced-stage HCC patients (HR-AS group), and 64 were advanced-stage HCC patients receiving nonsurgical treatments (N-AS group). CONCLUSION: HR may still be suitable for the HCC patients with huge (>15 cm) multinodular lesions and macrovascular invasion in selected cases. Advanced-stage HCC patients without liver cirrhosis and with a tumor-free resection margin could enjoy longer survival and lower recurrence. Preoperative and/or postoperative TACE provides no survival benefits for advanced-stage HCC patients.
Journal of Surgical Research 05/2012; · 2.25 Impact Factor
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ABSTRACT: Tumor necrosis factor-alpha (TNF-α) is a central mediator in the hepatic response to ischemia/reperfusion. Short hairpin RNA (shRNA) has been proven to be an effective means of harnessing the RNA interference pathway in mammalian cells. In the current study, we investigated whether silencing TNF-α gene with shRNA can prevent liver ischemic reperfusion injury (IRI).
Male BalB/c mice were randomized to TNF-α shRNA, scramble shRNA, or sham operation groups. TNF-α shRNA and scramble shRNA groups were injected 48 h before inducing IRI. IRI was induced via microaneurysm clamps applied to the left hepatic artery and portal vein. Six hours after reperfusion, IRI injury was examined by serum level of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), liver histopathology, MPO, and MDA level, as well as by relative quantities of TNF-α mRNA.
TNF-α expression induced by ischemia reperfusion in the liver was significantly suppressed after treatment with TNF-α shRNA compared with the group treated with scramble shRNA (P < 0.001). Mice treated with TNF-α shRNA showed lower peak values of AST and ALT than scramble shRNA treated mice (P < 0.001). On histopathologic slides, mice treated with TNF-α shRNA had significantly less ischemia/reperfusion injury based on Suzuki score than the scramble shRNA group, 3.57 ± 2.30 and 8.83 ± 0.98 respectively (P < 0.001), while the sham group was not significantly different from the TNF-alpha shRNA group, 0 ± 0 and 3.57 ± 2.30, respectively (P = 0.075). Liver tissue MDA levels were significantly lower in mice treated with TNF-α shRNA as compared with the group treated with scramble shRNA (P < 0.01). Immunohistochemical staining for MPO was significantly lower in mice treated with TNF-α shRNA compared with the group treated with shRNA (compared with treated with scramble shRNA group.)
Liver IRI can be minimized through gene silencing of TNF-α. This may represent a novel therapy in the setting of transplantation and in other conditions associated with IRI of the liver.
Journal of Surgical Research 11/2011; 176(2):614-20. · 2.25 Impact Factor
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ABSTRACT: Liver transplantation (LT) is a costly but effective treatment for end-stage liver disease (ESLD). However, there are minimal data on the patterns of and risk factors for hospital readmission after LT. The aim of this study was to determine the frequency of and risk factors for rehospitalization after LT. Consecutive adult patients who underwent LT at a single center (n = 208) were prospectively studied over a 30-month period. Within 90 days of LT, 30.3% of LT recipients were readmitted to the hospital. Recipient and donor age, Model for End-Stage Liver Disease score, cold ischemia time, type of hepatic graft, length of hospitalization after LT, and occurrence of operative/postoperative complications had no association with the risk for readmission (P>.05). The length of stay in intensive care was negatively correlated with readmission (hazard ratio, 0.92; P=.028). ESLD from hepatitis C virus (HCV) infection as an indication for LT was the only factor associated with an increased risk for readmission (hazard ratio, 1.91 ; P=.010). Further studies are needed to explore the reasons for readmission among LT recipients, particularly those with HCV infection, in order to devise cost-savings policies for post-LT care.
Gastroenterology and Hepatology 09/2011; 7(9):585-90.
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ABSTRACT: In hepatitis C virus (HCV) recipients of donation after cardiac death (DCD) grafts, there is suggestion of lower rates of graft survival, indicating that DCD grafts themselves may represent a significant risk factor for severe recurrence of HCV.
We evaluated all DCD liver transplant recipients from August 2006 to February 2011 at our center. Recipients with HCV who received a DCD graft (group 1, HCV+ DCD, n=17) were compared with non-HCV recipients transplanted with a DCD graft (group 2, HCV- DCD, n=15), and with a matched group of HCV recipients transplanted with a donation after brain death (DBD) graft (group 3, HCV+ DBD, n=42).
A trend of poorer graft survival was seen in HCV+ patients who underwent a DCD transplant (group 1) compared with HCV- patients who underwent a DCD transplant (group 2) (P=0.14). Importantly, a statistically significant difference in graft survival was seen in HCV+ patients undergoing DCD transplant (group 1) (73%) as compared with DBD transplant (group 3) (93%)(P=0.01). There was a statistically significant increase in HCV recurrence at 3 months (76% vs. 16%) (P=0.005) and severe HCV recurrence within the first year (47% vs. 10%) in the DCD group (P=0.004).
HCV recurrence is more severe and progresses more rapidly in HCV+ recipients who receive grafts from DCD compared with those who receive grafts from DBD. DCD liver transplantation in HCV+ recipients is associated with a higher rate of graft failure compared with those who receive grafts from DBD. Caution must be taken when using DCD grafts in HCV+ recipients.
Transplantation 08/2011; 92(6):686-9. · 4.00 Impact Factor
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ABSTRACT: A 56-year-old man was on the transplant list with end-stage liver disease secondary to hepatitis C when a donor liver became available at a location 545 km away. The procurement team, consisting of a senior and junior fellow, went on the retrieval, while the staff surgeon remained in the hospital with the recipient. At the time of organ procurement, a suspicious lesion was identified in the left lateral lobe. The transplant fellows took intraoperative pictures of the lesion with a smart phone and sent them to the staff surgeon for advice. A teleconsultation, facilitated by images sent from the smart phone, took place over the next 22 min. The decision was made to proceed with the transplant, as it was felt that the lesion could be resected from the liver allograft. Had the fellows not been able to interact with the staff surgeon in real-time during the surgery, there is a high likelihood that the organ would have been rejected by the staff surgeon due to the unexpected finding. The patient's postoperative course was relatively uneventful with no evidence of infection. The patient was discharged from hospital and continues to do well. We expect that the role of smart phones in remote consultation will continue to expand in future.
Journal of telemedicine and telecare 01/2011; 17(3):158-60. · 0.92 Impact Factor
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ABSTRACT: To compare the long-term outcome of percutaneous vs surgical radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) in dangerous locations.
One hundred and sixty-two patients with HCC in dangerous locations treated with percutaneous or surgical RFA were enrolled in this study. The patients were divided into percutaneous RFA group and surgical RFA group. After the patients were regularly followed up for a long time, their curative rate, hospital stay time, postoperative complications and 5-year local tumor progression were compared and analyzed.
No significant difference was observed in curative rate between the two groups (91.3% vs 96.8%, P=0.841). The hospital stay time was longer and more analgesics were required while the incidence of bile duct injury and RFA-related hemorrhage was lower in surgical RFA group than in percutaneous RFA group (P<0.05). The local progression rate of HCC in dangerous locations was significantly lower in surgical RFA group than in percutaneous RFA group (P=0.05). The relative risk of local tumor progression was 14.315 in percutaneous RFA group.
The incidence of severe postoperative complications and local tumor progression is lower after surgical RFA than after percutaneous RFA.
World Journal of Gastroenterology 01/2011; 17(1):123-9. · 2.47 Impact Factor
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Annals of hepatology: official journal of the Mexican Association of Hepatology 10/2010; 9(4):473-4. · 1.81 Impact Factor
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ABSTRACT: The long-term outcomes of radiofrequency ablation (RFA) vs. surgical resection in cirrhotic patients with hepatocellular carcinoma (HCC) remain controversial. One thousand sixty-one cirrhotic HCC patients were included into a retrospective study. Four hundred thirteen received RFA and 648 received surgical resection.
Overall (OS), recurrence-free (RFS), and tumor-free survival (TFS) were compared between the two groups and in subgroup analyses. The 5-year OS and corresponding RFS as well as DFS were significantly higher in the surgical resection group compared with the RFA group (p < 0.001, p < 0.001, p < 0.001). In subgroup analyses of solitary HCC ≤3 cm, there was no significant difference in RFS between the two groups (p = 0.719). Nonetheless, surgical resection was superior to RFA for OS and TFS in this subgroup as well as for OS, RFS, and TFS in subgroup analyses for solitary lesions 3 cm < HCC < 5 cm and multifocal HCC. Serum AFP was the only significant predicting factor for all survival analyses.
When treating Childs A cirrhotic patients with solitary HCC larger than 3 cm but less than 5 cm, or with two or three lesions each less than 5 cm, surgical resection provides a better survival than RFA. When treating Childs A cirrhotics with solitary HCC ≤ 3 cm, RFA has a comparable RFS to surgical resection, but RFA is less invasive.
Journal of Gastrointestinal Surgery 10/2010; 15(2):311-20. · 2.83 Impact Factor
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Roberto Hernandez-Alejandro,
Yves Caumartin,
Cameron Chent,
Mark A Levstik,
Douglas Quan,
Norman Muirhead,
Andrew A House,
Vivian McAlister,
Anthony M Jevnikar,
Patrick P W Luke,
William Wall
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ABSTRACT: The disparity between the number of patients waiting for an organ transplant and availability of donor organs increases each year in Canada. Donation after cardiac death (DCD), following withdrawal of life support in patients with hopeless prognoses, is a means of addressing the shortage with the potential to increase the number of transplantable organs.
We conducted a retrospective, single-centre chart review of organs donated after cardiac death to the Multi-Organ Transplant Program at the London Health Sciences Centre between July 2006 and December 2007. In total, 34 solid organs (24 kidneys and 10 livers) were procured from 12 DCD donors.
The mean age of the donors was 38 (range 18-59) years. The causes of death were craniocerebral trauma (n = 7), cerebrovascular accident (n = 4) and cerebral hypoxia (n = 1). All 10 livers were transplanted at our centre, as were 14 of the 24 kidneys; 10 kidneys were transplanted at other centres. The mean renal cold ischemia time was 6 (range 3-9.5) hours. Twelve of the 14 kidney recipients (86%) experienced delayed graft function, but all kidneys regained function. After 1-year follow-up, kidney function was good, with a mean serum creatinine level of 145 (range 107-220) micromol/L and a mean estimated creatinine clearance of 64 (range 41-96) mL/min. The mean liver cold ischemia time was 5.8 (range 5.5-8) hours. There was 1 case of primary nonfunction requiring retransplantation. The remaining 9 livers functioned well. One patient developed a biliary anastomotic stricture that resolved after endoscopic stenting. All liver recipients were alive after a mean follow-up of 11 (range 3-20) months. Since the inception of this DCD program, the number of donors referred to our centre has increased by 14%.
Our initial results compare favourably with those from the transplantation of organs procured from donors after brain death. Donation after cardiac death can be an important means of increasing the number of organs available for transplant, and its widespread implementation in Canada should be encouraged.
Canadian journal of surgery. Journal canadien de chirurgie 04/2010; 53(2):93-102. · 1.05 Impact Factor
