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Background: Outcomes in liver transplantation with organs obtained via donation after cardiocirculatory death (DCD) have been suboptimal compared to donation after brain death, attributed mainly to the high incidence of ischemic cholangiopathy (IC). We evaluated the effect of a 10-year learning curve on IC rates among DCD liver graft recipients at a single centre.Methods: We analyzed all DCD liver transplantation procedures from July 2006 to July 2016. Patients were grouped into early (July 2006 to June 2011) and late (July 2011 to July 2016) eras. Those with less than 6 months of follow-up were excluded. Primary outcomes were IC incidence and IC-free survival rate.Results: Among the 73 DCD liver transplantation procedures performed, 70 recipients fulfilled the selection criteria, 32 in the early era and 38 in the late era. Biliary complications were diagnosed in 19 recipients (27%). Ischemic cholangiopathy was observed in 8 patients (25%) in the early era and 1 patient (3%) in the late era (p = 0.005). The IC-free survival rate was higher in the late era than the early era (98% v. 79%, p = 0.01). The warm ischemia time (27 v. 24 min, p = 0.049) and functional warm ischemia time (21 v. 17 min, p = 0.002) were significantly lower in the late era than the early era.Conclusion: We found a significant reduction in IC rates and improvement in IC-free survival among DCD liver transplantation recipients after a learning curve period that was marked by more judicious donor selection with shorter procurement times.Contexte : L'issue des greffes de foie suite a un don d'organe apres deces cardiocirculatoire (DDC) a ete sous-optimale comparativement aux dons suivant la mort cerebrale. Cela serait surtout attribuable a une forte incidence de cholangiopathie ischemique (CI). Nous avons evalue l'effet d'une courbe d'apprentissage echelonnee sur 10 ans sur les taux de CI chez des receveurs de greffe de foie apres DDC dans un seul centre.Methodes : Nous avons analyse toutes les greffes de foie consecutives a des DDC entre juillet 2006 et juillet 2016. Les patients ont ete regroupes en 2 epoques, la premiere, de juillet 2006 a juin 2011, et la seconde, de juillet 2011 a juillet 2016. Ceux pour lesquels on disposait de moins de 6 mois de suivi ont ete exclus. Les parametres principaux etaient l'incidence de CI et le taux de survie sans CI.Resultats : Parmi les 73 greffes de foie par suite de DDC, 70 receveurs repondaient aux criteres de selection, 32 pour la premiere epoque et 38 pour la seconde epoque. Des complications biliaires ont ete diagnostiquees chez 19 receveurs (27%). La cholangiopathie ischemique a ete observee chez 8 patients (25%) de la premiere epoque et 1 patient (3%) de la seconde (p = 0,005). Le taux de survie sans CI a ete plus eleve pendant la seconde epoque que pendant la premiere (98% c. 79%, p = 0,01). Le temps d'ischemie chaude (27 minutes c. 24, p = 0,049) et le temps d'ischemie chaude fonctionnelle (21 minutes c. 17, p = 0,002) ont ete significativement plus courts durant la seconde epoque que durant la premiere.Conclusion : Nous avons observe une reduction significative des taux de CI et une amelioration de la survie sans CI chez les receveurs de greffes de foie par DDC apres une courbe d'apprentissage qui a ete marquee par une selection plus judicieuse des donneurs et des delais d'obtention plus courts., Recommended strategies to expand the donor pool in liver transplantation and decrease waiting list mortality include using extended-criteria donors and living donation. Encompassed among extended-criteria donors is donation after cardiocirculatory [...]

Background: Early reports of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) outcomes have been suboptimal. The literature has confirmed that learning curves influence surgical outcomes. We [...]

Background: 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. Methods: 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. Results: 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) µmol/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%. Conclusion: 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. Contexte : L'ecart entre le nombre de patients en attente de transplantation d'organe et la disponibilite d'organes de donneurs se creuse chaque annee au Canada. Le don apres la mort cardiaque (DMC) suivant le retrait du maintien des fonctions vitales chez les patients dont le pronostic est sans espoir permet de lutter contre la penurie et pourrait augmenter le nombre d'organes transplantables. Methodes : Nous avons effectue une etude retrospective unicentrique de dossiers portant sur des organes donnes apres la mort cardiaque par le Programme de transplantation d'organes multiples au Centre des sciences de la sante de London entre juillet 2006 et decembre 2007. Au total, on a preleve 34 organes pleins (24 reins et 10 foies) de 12 donneurs en etat de mort cardiaque. Resultats : Les donneurs avaient en moyenne 38 (intervalle de 18 a 59) ans. Les deces avaient ete causes par un traumatisme craniocerebral (n = 7), un accident vasculaire cerebral (n = 4) et une hypoxie cerebrale (n = 1). Les 10 foies ont ete transplantes a notre centre, ainsi que 14 des 24 reins. Les 10 autres reins ont ete transplantes a d'autres centres. L'ischemie froide du rein a dure en moyenne 6 (intervalle de 3 a 9,5) heures. Chez 12 des 14 receveurs d'un rein (86 %), le greffon a commence a fonctionner tardivement, mais tous les reins ont recommence a fonctionner. Au suivi a 1 an, la fonction renale etait bonne, la concentration moyenne de creatinine serique s'etablissait a 145 (intervalle de 107 a 220) µmol/L et la clairance glomerulaire estimative moyenne, a 64 (intervalle de 41 a 96) mL/min. L'ischemie froide du rein a dure en moyenne 5,8 (plage de 5,5 a 8) heures. Il y a eu un cas de non-fonctionnement primitif qui a oblige a proceder a une autre transplantation. Les 9 autres foies ont bien fonctionne. Un patient a presente une stenose anastomotique biliaire qui est disparue apres la pose d'un stent par endoscopie. Tous les receveurs d'un foie etaient vivants apres un suivi moyen de 11 (intervalle de 3 a 20) mois. Depuis le debut de ce programme de don apres la mort cardiaque, le nombre de donneurs diriges a notre centre a augmente de 14 %. Conclusion : Nos premiers resultats se comparent favorablement a ceux de la transplantation d'organes preleves chez des donneurs apres la mort cerebrale. Le don apres la mort cardiaque peut etre un moyen important d'accroitre le nombre d'organes disponibles pour la transplantation. Il faudrait en encourager la generalisation au Canada., The disparity between the number of patients on transplant waiting lists and the number of organs donated from deceased individuals increases each year in Canada. This organ shortage has prompted [...]

Aim: To determine if there is a reasonable prospect of success of a re-use liver transplantation., Methods: We systematically searched for reports of liver graft re-use using electronic searches of PubMed and Web of Knowledge. We performed hand searches of references lists of articles reporting re-use of grafts., Results: A systematic review of the literature reveals 28 liver transplantations using previously transplanted grafts. First and second recipients ranged in age from 4 to 72 years and 29 to 62 years respectively. Liver disease in the first recipient was varied including 5 (18%) patients with fulminant liver failure who died subsequently of cerebral edema. The second transplantation was performed after a median interval of 5 d (one day-13 years). Viral hepatitis was present in 3 (11%) of the initial recipients and in 8 (29%) of final recipients. Hepatocellular carcinoma was present in 6 (21%) of the final recipients. Early survival after the final transplantation was 93%, whereas long-term survival was 78% with a mean follow-up of 23.3 (3-120) mo., Conclusion: Outcomes of transplantation using previously transplanted grafts in this select population are similar to those seen with conventional grafts.