Journal of Liver Transplantation最新文献

Technical refinements to reduce the early biliary complication in living donor liver transplantation 减少活体肝移植早期胆道并发症的技术改进

Journal of Liver Transplantation

Pub Date : 2024-11-01 DOI: 10.1016/j.liver.2024.100241

Tsan-Shiun Lin , Yeong-Sing Lee , Khee-Ghee Tan , Stephen Matthew B. Santos , Chih-Che Lin , Shih-Ho Wang , Chee-Chien Yong , Wei-Feng Li , Yu-Fan Cheng , Chih-Chi Wang , Chao-Long Chen

Background

Biliary reconstruction is a key factor that affects biliary complication rates. Surgical experience plays a pivotal role, but continuous technical refinement is essential for enhancing biliary outcomes. This study aimed to evaluate the biliary outcomes of LDLTs in patients undergoing microsurgical biliary reconstruction with continual technical refinements.

Materials and Methods

This observational cohort study analyzed data was conducted from 2006 to 2022. Microsurgical biliary reconstruction was performed using various refinements, including selective biliary stent insertion, ipsilateral (anatomical) bile duct anastomosis, use of a figure-of-8 suture over the junction of the graft and recipient bile ducts, and centralization techniques for size discrepancies greater than 2 to 1. Comparison and evaluation of early BC within one year post transplant was performed.

Results

1780 patients (including 1563 adults and 217 paediatric patients) underwent microsurgical biliary reconstruction in LDLTs at KCGMH between 2006 and 2022. The donor grafts comprised 1109 right liver grafts and 671 left liver grafts. Of the grafts, 23.1 % had multiple bile ducts and 16.1 % had bile duct sizes <3 mm. Duct-to-duct anastomosis was performed in most cases 1417 (79.6 %), while 363 (20.4 %) Roux-en-Y hepaticojejunostomies (RY HJ) was performed. The overall early BCs rate was 10 % and notable improvements were observed, decreasing from 10.35 % between 2006 and 2021 to 6.5 % by 2022. Early BS comprised the most part of 6.1 % as compared to 2.7 % one year after transplantation. Stent insertion in selected cases, ipsilateral anastomosis, and the figure-of-8 suture technique significantly reduced early BCs. Although centralization technique showed promising results, its effect was not statistically significant.

Conclusions

Continual technical refinements in MBR can contribute to a substantial reduction in early BCs following LDLT, ultimately leading to improved patient outcomes.

背景胆道重建是影响胆道并发症发生率的关键因素。手术经验起着关键作用，但不断改进技术对提高胆道效果至关重要。本研究旨在评估在不断改进技术的情况下，接受显微外科胆道重建术的 LDLT 患者的胆道治疗效果。显微外科胆道重建术采用了各种改进方法，包括选择性胆道支架插入、同侧（解剖）胆管吻合、在移植物和受体胆管交界处使用8字缝合线，以及大小差异大于2比1的集中化技术。结果 2006 年至 2022 年间，1780 名患者（包括 1563 名成人和 217 名儿童患者）在 KCGMH 接受了 LDLT 显微外科胆道重建手术。供体移植物包括1109例右肝移植物和671例左肝移植物。在这些移植物中，23.1%有多个胆管，16.1%的胆管大小为3毫米。大多数病例都进行了胆管与胆管吻合术，其中有1417例（79.6%），363例（20.4%）进行了Roux-en-Y肝空肠吻合术（RY HJ）。早期肝空肠吻合术的总体比例为10%，并有明显改善，从2006年至2021年的10.35%降至2022年的6.5%。与移植一年后的 2.7% 相比，早期 BCS 占了大部分，为 6.1%。在选定的病例中植入支架、同侧吻合和 8 字缝合技术大大减少了早期 BCs。结论 MBR 技术的不断改进有助于大幅减少 LDLT 后的早期 BC，最终改善患者的预后。

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引用次数: 0

Daratumumab as a rescue therapy for antibody-mediated rejection in super-urgent ABO-incompatible pediatric liver transplantation 达拉单抗作为超紧急ABO血型不相容小儿肝移植中抗体介导排斥反应的解救疗法

Journal of Liver Transplantation

Pub Date : 2024-10-11 DOI: 10.1016/j.liver.2024.100245

Zeynep Demir , Jean Paul Duong Van Huyen , Carmen Capito , Julien Zuber , Aline Floch , Muriel Girard , Dominique Debray

引用次数: 0

The effects of underlying inflammatory bowel disease on the outcomes of primary sclerosing cholangitis liver transplant recipients 潜在炎症性肠病对原发性硬化性胆管炎肝移植受者预后的影响

Journal of Liver Transplantation

Pub Date : 2024-10-03 DOI: 10.1016/j.liver.2024.100244

Mausam J. Patel , Bill Y. Zhang , Thomas G. Cotter , Ahmad Anouti

Introduction

Inflammatory bowel disease (IBD) influences primary sclerosing cholangitis (PSC) severity, however, the impact of IBD on PSC liver transplantation (LT) outcomes is poorly understood. We aimed to elucidate the impact of IBD in modulating PSC LT outcomes.

Methods

Using UNOS data from 2010 through 2021, we identified PSC LT candidates with and without (±) IBD. We used adjusted competing-risk regression analysis to evaluate waitlist outcomes, Kaplan-Meier analysis to assess graft survival, and Cox proportional hazards modeling to identify factors associated with graft survival.

Results

Out of 5,586 PSC candidates added to the waitlist, 3,652 patients had IBD. Older age (SHR 1.01; 95 %CI 1.01–1.02) and initial MELD/PELD (SHR 1.03; 95 %CI 1.02–1.04) were associated with increased risk of waitlist mortality, while private insurance (SHR 0.00; 95 %CI 0.00–0.01) with reduced risk. PSC-IBD LT recipients had increased prevalence of cholangiocarcinoma (4.8 % vs 3.4 %, p=0.005). Longer donor cold ischemia times (HR 1.06; 95 %CI 1.03–1.09), presence of recipient diabetes (HR 1.52; 95 %CI 1.13–2.05), and employment (HR 0.75, 95 %CI 0.60–0.94) had an increased risk of graft failure among PSC patients with IBD, not seen in those without IBD.

Conclusion

Regardless of IBD, LT for PSC results in excellent outcomes. Certain clinicodemographic factors impacted waitlist and recipient mortality highlighting potential targets to enhance outcomes.

导言炎症性肠病（IBD）会影响原发性硬化性胆管炎（PSC）的严重程度，然而，IBD对PSC肝移植（LT）结果的影响却鲜为人知。我们旨在阐明 IBD 对 PSC LT 结果的影响。方法利用 2010 年至 2021 年的 UNOS 数据，我们确定了有 IBD 和无（±）IBD 的 PSC LT 候选者。我们使用调整后的竞争风险回归分析来评估候选结果，使用 Kaplan-Meier 分析来评估移植物存活率，使用 Cox 比例危险模型来确定与移植物存活率相关的因素。年龄较大（SHR 1.01; 95 %CI 1.01-1.02）和初始 MELD/PELD（SHR 1.03; 95 %CI 1.02-1.04）与候补名单死亡风险增加有关，而私人保险（SHR 0.00; 95 %CI 0.00-0.01）与风险降低有关。PSC-IBD LT受者的胆管癌发病率增加（4.8% vs 3.4%，P=0.005）。供体冷缺血时间较长（HR 1.06; 95 %CI 1.03-1.09）、受体存在糖尿病（HR 1.52; 95 %CI 1.13-2.05）和就业（HR 0.75, 95 %CI 0.60-0.94）会增加有IBD的PSC患者移植物失败的风险，而没有IBD的患者则没有这种风险。某些临床人口学因素会影响等待者和受者的死亡率，这突出了提高疗效的潜在目标。

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引用次数: 0

Biodegradable internal biliary stenting in orthotopic liver transplantation – A feasibility study 正位肝移植中的生物可降解胆道内支架--一项可行性研究

Journal of Liver Transplantation

Pub Date : 2024-09-30 DOI: 10.1016/j.liver.2024.100242

Nicholas Dalkie , Jonathan Ng , Peter Lim , Eunice Lee , Ruelan Furtado , Robert Jones , Rhys Vaughan , Marios Efthymiou , Sujievvan Chandran , Marcos V. Perini

Introduction

Biliary complications remain a common cause of morbidity after liver transplantation and often require invasive interventions to manage. We aimed to assess the technical feasibility and safety of placement of a biodegradable stent across the biliary anastomosis at the time of liver transplantation in patients having a duct to duct biliary reconstruction.

Methods

For this prospective, single-arm, descriptive study, 10 consecutive patients undergoing whole graft, deceased donor, liver transplantation and duct-to-duct biliary tract reconstruction were enrolled and a biodegradable biliary stent was sutured into the bile duct across the anastomosis.

Results

In all 10 patients it was technically feasible to place and secure the stent safely during the operation. After >6 months (median of 212 days) follow up, no patients had developed biliary anastomotic stricture. One patient had transient bile leak immediately post-operative that was managed conservatively. One patient required endoscopic intervention for non-anastomotic stricture development and biliary cast material that had resulted in stent dysfunction.

Discussion

The results of this study suggest surgical feasibility of placement of an absorbable biliary stent across the biliary anastomosis at the time of liver transplantation, as well as an acceptable safety profile. Further studies are required to confirm these safety and feasibility findings and to assess efficacy in reducing rates of biliary complications and the need for endoscopic intervention in the early post-transplant period.

导言：胆道并发症仍是肝移植术后常见的发病原因，通常需要进行侵入性干预治疗。我们的目的是评估在进行肝移植时在胆管至胆管重建患者的胆管吻合处放置可降解支架的技术可行性和安全性。方法在这项前瞻性、单臂、描述性研究中，连续选取了10名接受全移植、死亡供体、肝移植和管对管胆道重建术的患者，将生物可降解胆道支架穿过吻合口缝合到胆管中。结果在所有10名患者中，在手术中安全放置和固定支架在技术上是可行的。经过 6 个月（中位 212 天）的随访，没有患者出现胆道吻合口狭窄。一名患者术后立即出现一过性胆漏，经保守治疗后好转。讨论这项研究的结果表明，在肝移植时通过胆道吻合口放置可吸收胆道支架的手术可行性以及可接受的安全性。还需要进一步的研究来证实这些安全性和可行性，并评估其在降低胆道并发症发生率和移植后早期内镜干预需求方面的效果。

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引用次数: 0

Early duct division in type D Portal Vein anatomy for safe donor hepatectomy-a novel technique D 型门静脉解剖中的早期管道分割，实现安全的供体肝切除术--一种新技术

Journal of Liver Transplantation

Pub Date : 2024-09-28 DOI: 10.1016/j.liver.2024.100243

Sreekumar Sreejith , Shaleen Agarwal , Abhishek Agarwal , Ruchi Rastogi , Utkarsh Shah , Aman Chopra , Peush Sahni , Subhash Gupta

Complex portal venous anatomy encountered in adult living donor liver transplantation poses significant technical challenges, primarily concerning donor safety. This complexity necessitates meticulous and time-consuming backbench reconstruction, rendering it a relative contraindication for donation. Advancements in surgical expertise have enabled successful resolution of many of these intricate anatomical challenges. We report a complex type-D portal vein along with type IIIB biliary anatomy in donor during adult living donor liver transplantation, which was tackled by completing the parenchymal transection and dividing the hepatic ducts before the right anterior portal vein could be delineated. The main portal vein, right posterior portal vein and left portal vein were delineated and the transection line was marked after clamping main portal vein and right hepatic artery. The final delineation of portal venous anatomy with looping of the right anterior portal vein was done after completion of parenchymal transection and division of right anterior and posterior sectoral ducts. During the backbench preparation, right anterior and posterior portal vein were anastomosed to a Y-graft obtained from the recipient explant portal vein to create a single portal inflow orifice. Post-operatively, both the donor and recipient recovered well. In exceptional circumstances, consideration of donors with type-D portal vein becomes viable where the surgical expertise is available.

成人活体肝移植中遇到的复杂门静脉解剖给技术带来了巨大挑战，主要涉及供体安全。由于这种复杂性，必须进行细致而耗时的后台上重建，因此成为捐献的相对禁忌症。外科专业技术的进步使许多复杂的解剖难题得以成功解决。我们报告了成人活体肝移植手术中供体复杂的D型门静脉和IIIB型胆道解剖，通过在右前门静脉划定之前完成实质横断和肝管分割来解决这一问题。在夹闭门静脉主干和右肝动脉后，划定门静脉主干、右后门静脉和左门静脉，并标记横断线。在完成实质横断和右前、后扇形导管的分割后，最终划定门静脉解剖结构，并环绕右前门静脉。在后床准备过程中，将右前门静脉和后门静脉与从受体外切门静脉获得的 Y 型移植物吻合，形成单一的门静脉流入口。术后，供体和受体均恢复良好。在特殊情况下，如果有专业的外科技术，可以考虑使用 D 型门静脉供体。

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引用次数: 0

Short-term alcohol abstinence prior to liver transplantation and impact on rejection 肝移植前短期戒酒及其对排斥反应的影响

Journal of Liver Transplantation

Pub Date : 2024-09-24 DOI: 10.1016/j.liver.2024.100240

Kaitlyn Legg , Tracy Sparkes , Ian Booth , Daniel Maluf , Chandra Bhati , Neha Jakhete , Sari Freedman

Background & Aims

Alcohol-associated liver disease (ALD) is a leading indication for liver transplant (LT). Historically, centers implemented 6-month abstinence periods prior to LT listing; however, the impact of this abstinence time on post-transplant rejection outcomes is unclear. This study evaluated if short-term abstinence is associated with increased rejection post-LT.

Methods

This single-center, retrospective, cohort included adult LT recipients from 11/1/2015 to 7/21/2021 with a primary indication of ALD. Patients were grouped by pre-transplant abstinence time of <6 or ≥6-months. The primary endpoint was biopsy proven acute rejection (BPAR) at 12-months post-LT. Secondary endpoints were infection, alcohol relapse, patient and graft survival at 12-months.

Results

Overall, 228 LT recipients met inclusion criteria (<6-months: n = 130; ≥6-months: n = 98). Patients with <6-months of abstinence were younger, had higher MELD scores, and more renal replacement therapy needs. Incidence of BPAR within 12 months of LT was 28 % in the <6-month group vs. 18 % in the ≥6-month group (p = 0.078). Tacrolimus initiation was lower at 7 days post-LT in the <6-month group (77% vs. 89 %; p = 0.029). Delay in tacrolimus initiation past 7 days post-LT was associated with greater BPAR (35% vs. 12 %; p = 0.0001). Increased bloodstream infections (21% vs. 7 %; p = 0.04) and CMV DNAemia (31% vs. 7 %; p = 0.0008) were seen in the <6-month group. Patient and graft survival was similar between groups.

Conclusions

Abstinence time of <6-months was not associated with more BPAR within 12-months post-LT. The <6-month group was sicker at time of LT, which correlates to lower tacrolimus exposure early post-LT and heightened incidence of bacteremia and CMV viremia. Given the high acuity of the <6-month abstinence group, the risk of BPAR must be closely balanced with infection risk.

背景& 目的酒精相关性肝病（ALD）是肝移植（LT）的主要适应症。从历史上看，肝移植中心都会在肝移植手术前实施 6 个月的禁酒期；然而，这种禁酒期对移植后排斥反应结果的影响尚不清楚。这项研究评估了短期禁欲是否与LT术后排斥反应增加有关。方法这项单中心回顾性队列研究纳入了2015年1月11日至2021年7月21日期间主要适应症为ALD的成年LT受者。患者按移植前禁欲时间<6或≥6个月分组。主要终点是LT术后12个月时活检证实的急性排斥反应（BPAR）。结果共有228名LT受者符合纳入标准（<6个月：130人；≥6个月：98人）。禁欲6个月的患者更年轻，MELD评分更高，需要更多的肾脏替代治疗。LT术后12个月内BPAR的发生率在<6个月组为28%，而在≥6个月组为18%（P = 0.078）。LT术后7天内开始使用他克莫司的比例在<6个月组中较低（77%对89%；p = 0.029）。LT术后7天后才开始使用他克莫司与BPAR升高有关（35%对12%；p = 0.0001）。6个月组的血流感染（21% 对 7%；p = 0.04）和 CMV DNA 血症（31% 对 7%；p = 0.0008）增加。结论停药时间为6个月与LT术后12个月内更多的BPAR无关。6个月组患者在LT时病情较重，这与LT后早期他克莫司暴露量较低、菌血症和CMV病毒血症发生率较高有关。鉴于禁欲 6 个月组患者的病情严重，BPAR 风险必须与感染风险密切平衡。

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引用次数: 0

Masked kidney allograft failure after simultaneous liver and kidney transplantation: A case report 同时进行肝脏和肾脏移植手术后的掩蔽性肾脏同种异体移植失败：病例报告

Journal of Liver Transplantation

Pub Date : 2024-08-14 DOI: 10.1016/j.liver.2024.100237

Kasra Shirini , Ujwal Gautam , Hiba Ahmed , Raphael P.H. Meier , Cinthia Drachenberg , Abdolreza Haririan

Kidney utilization for simultaneous liver-kidney transplantation (SLK) has seen a significant increase in recent years, driven by the rising prevalence of renal dysfunction among liver transplant candidates. However, a substantial proportion of SLK recipients experience native kidney function recovery post-transplant, rendering the kidney transplant unnecessary. This case report presents a remarkable instance of native renal function recovery in a SLK recipient, discovered eleven years after transplantation, when the transplanted kidney was found to have undergone extensive fibrosis and atrophy, masked by native kidney recovery. This case highlights the challenges posed by evaluation of SLK candidates and the need for improved tools to predict native kidney recovery. Safety net mechanism for those who do not recover kidney function should be utilized more to avoid the unnecessary utilization of scarce kidney allografts, which are critically needed for waitlisted patients with kidney failure.

近年来，由于肝移植候选者中肾功能不全的发病率不断上升，肝肾同时移植（SLK）的肾脏利用率显著增加。然而，相当一部分肝肾同时移植受者在移植后会出现肾功能恢复，从而导致肾移植的不必要。本病例报告介绍了一例显著的原生肾功能恢复病例，该病例是在 SLK 受体移植 11 年后发现的，当时发现移植肾发生了广泛的纤维化和萎缩，被原生肾功能恢复所掩盖。这个病例凸显了评估 SLK 候选者所面临的挑战，以及需要改进工具来预测原生肾脏的恢复情况。对于那些肾功能未恢复的患者，应更多地利用安全网机制，以避免不必要地使用稀缺的同种异体肾脏，因为肾衰竭候选患者急需同种异体肾脏。

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引用次数: 0

Going with the flow: High-flow nasal cannula for management of post-transplant hypoxemia in hepatopulmonary syndrome 顺其自然：高流量鼻插管用于治疗肝肺综合征移植后低氧血症

Journal of Liver Transplantation

Pub Date : 2024-08-07 DOI: 10.1016/j.liver.2024.100235

Hilary M. DuBrock

引用次数: 0

Antibody-mediated rejection in post-liver transplant clinical care: Are we there yet for timely diagnosis and treatment? 肝移植术后临床护理中的抗体介导排斥反应：我们还能及时诊断和治疗吗？

Journal of Liver Transplantation

Pub Date : 2024-07-30 DOI: 10.1016/j.liver.2024.100236

Kevin H. Toomer , Ahmet Gurakar , Kiyoko Oshima

With improvements in medical management and surgical technique in the field of solid organ transplantation, many historically prominent causes of liver allograft injury have been ameliorated or, in the case of Hepatitis C virus, eliminated altogether. In this transformed clinical landscape, antibody-mediated rejection (AMR) has emerged as a defining barrier to maintenance of long-term liver allograft function. The liver's unique anatomy, high regenerative capacity, and tolerogenic immunological environment tend to mitigate the severest AMR manifestations. Consequently, the clinical importance of AMR in the liver has been recognized more slowly than for other solid organ allografts. Significant strides have been made in elucidating clinical and histopathologic features of acute and chronic liver AMR, with the Banff 2016 criteria among the most notable. However, current histopathologic definitions of AMR are lacking in sensitivity and specificity. C4d staining is an imperfect biological surrogate for antibody-mediated injury, and suffers from significant technical limitations. The frequent co-occurrence of T cell mediated rejection and non-immunologic allograft damage (including recurrence of primary disease) also hinders definitive identification of AMR and results in misattribution of its effects. The goal of this review is to summarize the current understanding of AMR in the context of liver transplantation, including risk factors, pathogenesis, and current diagnostic and treatment strategies. Potential directions of future research are also addressed.

随着实体器官移植领域医疗管理和手术技术的改进，许多历史上导致肝脏同种异体移植损伤的主要原因已得到改善，或（就丙型肝炎病毒而言）已被完全消除。在这一转变的临床环境中，抗体介导的排斥反应（AMR）已成为肝脏异体移植长期功能维持的决定性障碍。肝脏独特的解剖结构、高再生能力和耐受性免疫环境往往能减轻最严重的AMR表现。因此，与其他实体器官异体移植相比，人们对肝脏AMR临床重要性的认识较为缓慢。在阐明急性和慢性肝脏AMR的临床和组织病理学特征方面取得了重大进展，其中最引人注目的是班夫2016标准。然而，目前对AMR的组织病理学定义缺乏敏感性和特异性。C4d 染色是抗体介导损伤的一种不完善的生物学替代物，存在很大的技术局限性。T 细胞介导的排斥反应和非免疫性异体移植损伤（包括原发疾病复发）经常同时出现，这也阻碍了 AMR 的明确鉴定，并导致对其影响的错误归因。本综述旨在总结目前对肝移植AMR的认识，包括风险因素、发病机制以及目前的诊断和治疗策略。同时还探讨了未来研究的潜在方向。

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引用次数: 0

Success of high-flow nasal cannula oxygen therapy for the treatment of severe hypoxemia after liver transplantation in a patient with severe hepatopulmonary syndrome 高流量鼻导管供氧疗法成功治疗了一名肝移植术后严重低氧血症的重症肝肺综合征患者

Journal of Liver Transplantation

Pub Date : 2024-07-11 DOI: 10.1016/j.liver.2024.100234

Moustapha Hussein , Agathe Chenal , Edouard Virot , Camille Besch , Guillaume Martin , Matthieu Canuet , Romain Kessler , Marianne Riou

Hepatopulmonary syndrome (HPS) is a rare pulmonary complication of cirrhosis for which the only curative treatment is liver transplantation (LT). Patients with severe HPS prior to LT are at high risk of postoperative complications and mortality, and may develop refractory HPS after LT. To date, no therapeutic strategy has been validated for these patients. To our knowledge, we describe the first case of successful use of high-flow nasal cannula oxygen therapy for severe post-LT hypoxemia in a 23-year-old adult.

肝肺综合征（HPS）是肝硬化的一种罕见肺部并发症，唯一的根治性治疗方法是肝移植（LT）。肝移植前患有严重肝肺综合征的患者术后并发症和死亡率风险很高，而且可能在肝移植后出现难治性肝肺综合征。迄今为止，还没有针对这些患者的治疗策略得到验证。据我们所知，我们描述了第一例成功使用高流量鼻插管氧疗治疗LT术后严重低氧血症的23岁成人患者。

引用次数: 0