Search

To improve current data systems for institutional decision-making, the Adult Liver Transplant Registry was established at the Hospital Italiano de Buenos Aires, Argentina. This article describes its design and implementation and reports on the outcomes for patients transplanted since its January 2020 launch. A multidisciplinary team designed the registry by identifying key variables from a literature review while considering balance between data depth and feasibility. Rigorous quality control measures were enforced, including monthly audits and staff training. Benchmark indicators for post-transplant outcomes were established. As of November 2023, the registry included 136 transplants. Its implementation and maintenance were straightforward, with no significant difficulties encountered. Cirrhosis was the predominant indication (77%) for transplant. Only one living donor transplantation was performed. Post-transplant results generally aligned with benchmarks, but rates of biliary complications slightly exceeded the recommended thresholds. The one-year post-transplant survival rate was 87%. The successful registry implementation provides a robust framework for research, treatment management, and patient care enhancement within a liver transplant unit., Competing Interests: Declaration of conflicting interestsThe authors declare there are no conflicts of interest.

Objective: To define benchmark cutoffs for redo liver transplantation (redo-LT)., Background: In the era of organ shortage, redo-LT is frequently discussed in terms of expected poor outcome and wasteful resources. However, there is a lack of benchmark data to reliably evaluate outcomes after redo-LT., Methods: We collected data on redo-LT between January 2010 and December 2018 from 22 high-volume transplant centers. Benchmark cases were defined as recipients with model of end stage liver disease (MELD) score ≤25, absence of portal vein thrombosis, no mechanical ventilation at the time of surgery, receiving a graft from a donor after brain death. Also, high-urgent priority and early redo-LT including those for primary nonfunction (PNF) or hepatic artery thrombosis were excluded. Benchmark cutoffs were derived from the 75th percentile of the medians of all benchmark centers., Results: Of 1110 redo-LT, 373 (34%) cases qualified as benchmark cases. Among these cases, the rate of postoperative complications until discharge was 76%, and increased up to 87% at 1-year, respectively. One-year overall survival rate was excellent with 90%. Benchmark cutoffs included Comprehensive Complication Index CCI ® at 1-year of ≤72, and in-hospital and 1-year mortality rates of ≤13% and ≤15%, respectively. In contrast, patients who received a redo-LT for PNF showed worse outcomes with some values dramatically outside the redo-LT benchmarks., Conclusion: This study shows that redo-LT achieves good outcome when looking at benchmark scenarios. However, this figure changes in high-risk redo-LT, as for example in PNF. This analysis objectifies for the first-time results and efforts for redo-LT and can serve as a basis for discussion about the use of scarce resources., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Sarcopenia is a prevalent condition that predicts prognosis in patients awaiting liver transplantation (LT). The gold standard for the diagnosis of sarcopenia is the assessment of the muscular area at L3 with computed tomography (CT) scan (skeletal muscle index [SMI]), but the routine use of CT scan is limited in clinical practice. Thus, we designed a single-center observational study aimed to evaluate the clinical factors associated with the presence of sarcopenia by SMI, and to build a score capable of predicting or excluding the presence of sarcopenia in patients on the LT waiting list (WL). Binary logistic regression analysis was performed to establish the factors independently associated with sarcopenia, and the Sarcopenia Hospital Italiano de Buenos Aires (HIBA) score was built from the resulting model after internal validation analysis by bootstrapping and correction for optimism. The predictive capability of mortality on the WL was evaluated with competing risk regression analysis. A total of 215 patients with cirrhosis on the LT WL were included. The independent factors associated with the presence of sarcopenia were male sex (odds ratio [OR]: 6.09, p < 0.001), body mass index (OR: 0.74, p < 0.001), Child Pugh (OR: 1.44, p < 0.001), and the ratio creatinine/Cystatin C (OR: 0.03, p = 0.007). The Sarcopenia HIBA score constructed with these variables showed an area under the curve of 0.862. During follow-up, 77 (36%) patients underwent LT, 46 (21%) died, and 92 (43%) remained alive. After adjusting for Model for End-Stage Liver Disease-Sodium, Sarcopenia HIBA score was an independent predictor of WL mortality (subhazard ratio: 1.19; 95% confidence interval 1.01-1.40; p = 0.042). Sarcopenia HIBA score is an easy-to-use, objective, and reliable diagnostic and predictive tool that can be useful to improve the prognostic evaluation and allow identifying a group of patients with a higher risk of death while awaiting LT., (© 2022 The Authors. Hepatology Communications published by Wiley Periodicals LLC on behalf of American Association for the Study of Liver Diseases.)

Purpose: The aim of this study was to report the long-term results of an institutional protocol of percutaneous biliary balloon dilatation (PBBD) on paediatric patients with benign anastomotic stricture after liver transplantation. As a secondary objective, we evaluated risk factors associated with post-treatment re-stricture., Materials and Methods: Fourteen paediatric, post-liver transplant patients with benign anastomotic stricture of Roux-en-Y hepaticojejunostomy were included. All patients underwent the same treatment protocol of three PBBD procedures with 15-day intervals. Clinical outcome was analysed using the Terblanche classification. Primary patency rate was assessed with the Kaplan-Meier test., Results: All patients had an initial successful result (Terblanche grade, excellent/good) after PBBD. At the end of the follow-up time of 35.7 ± 21.1 months (CI95%, 23.5-47.9), 10 patients persisted with excellent/good grading, while the remaining 4 had re-stricture, all of the latter occurring within the first 19 months. Patency rate after percutaneous treatment at 1, 3, and 5 years were 85.7%, 70%, and 70%, respectively. History of major complication after liver transplantation was associated with 5 times higher risk of re-stricture, HR 5.48 [95% CI, 2.18-8.78], p = 0.018., Conclusion: In paediatric patients with benign anastomotic stricture of hepaticojejunostomy after liver transplantation, the "Three-session" percutaneous biliary balloon dilatation protocol is associated with a high rate of long-term success. In this limited series, the history of post-liver transplant major complication, defined as complications requiring a reintervention under general anaesthesia or advanced life support, seems to be an independent risk factor for stricture recurrence., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).)

Purpose: Almost 50% of patients diagnosed with colorectal cancer (CRC) will develop liver metastasis (LM). Although their only long-term curative treatment is surgery, less than half of these patients can be eventually resected. Therefore, palliative chemotherapy is offered as a definitive option, though with poor results. Recently, the University of Oslo group has published encouraging results in the treatment of these patients with liver transplantation (LT), whereby worldwide interest in this option has been renewed., Methods: A literature review of LT for patients with unresectable colorectal metastasis was performed. This included information regarding patient selection, complications, overall survival (OS) and disease-free survival (DFS), immunosuppression, chemotherapy, and description of the ongoing trials., Results: Improvements in OS and DFS have been observed in consecutive published prospective trials, as patient selection has been refined. Papers reporting OS of patients who randomly presented similar selection criteria also exhibited good results., Conclusion: LT within the available therapeutic options in patients with CRC-LM seems to be a compelling alternative in carefully selected patients. The ongoing trials will provide valuable information regarding selection criteria, immunosuppressive therapy and different modalities of adjuvant chemotherapy, which are, to our knowledge, the vital platform of LT in CRC-LM. Although some of the developing techniques involve living donors, graft availability for these patients remains a matter of major concern.

Objective: To evaluate short- and long-term outcomes after live-donor liver transplantation (LT) with hyper-reduced grafts in low-weight pediatric recipients. LT is an established curative therapy for children with end-stage chronic liver disease or acute liver failure. A major problem in pediatric LT has been the lack of size-matched donor organs. The disadvantage of the use of large-for-size grafts is the insufficient tissue oxygenation and graft compression, which result in poor outcomes. The shortage of suitable donors is most notable in children under 10 kg. To overcome such obstacle, in situ hyper-reduced live-donor liver grafts have been introduced. Available articles in the literature are based on small samples and are deficient in long-term follow-up., Methods: A single-cohort, retrospective analysis was conducted including 59 pediatric patients under 10 kg who underwent hyper-reduced (in situ "a la carte" left lateral segment reduction) live-donor LT (LDLT) between February 1994 and February 2018., Results: The most frequent cause of liver failure was biliary atresia (70%). Median recipient weight was 8 kg. Vascular complications were confirmed in 15% of the sample, while 45% presented biliary complications. Median follow-up time was 40.3 months. Ten-year overall survival rate was 74%. Pediatric end-stage liver disease score > 23 was associated with a higher risk of post-operative complications., Conclusion: LDLT can be undertaken in children with body weight < 10 kg achieving good results in high-volume centers by experienced surgeons.

LT has become the treatment of choice for children with end-stage liver disease. The scarcity of donors and the considerable mortality on waiting lists have propelled the related living-donor techniques, especially in small children. This population need smaller and good quality grafts and are usually candidates to receive a LLS from a related donor. Many times this grafts are still large and do not fit in the receptor's abdomen, so a further hyper-reduction may be required. Despite all advances in LT field, vascular complications still occur in a considerable proportion remaining as a significant cause of morbidity, graft loss, and mortality. Technical issues currently play an essential role in its genesis. The widely spread technique for biliary and vascular reconstruction in living donor LT (LDLT) nowadays implies removal of the portal vein (PV) clamp after the venous anastomosis, then the arterial reconstruction is done, followed by the biliary reconstruction. However, due to the posterior location of the LLS bile duct, for its reconstruction, a rotation of the liver is required risking a potential transient PV occlusion leading to thrombosis afterward. We describe a new technique that involves performing biliary reconstruction after the PV anastomosis and before removing the vascular clamp, thus allowing to freely rotate the liver with less risk of PV occlusion and thrombosis., (© 2019 Wiley Periodicals, Inc.)

Biliary complications after living donor liver transplantation (LDLT) cause severe morbidity and mortality, with biliary anastomotic stricture being the most common form of presentation. Surgical revision is risky, and it is avoided whenever possible. When a Roux-en-Y hepaticojejunostomy (RYHJ) is used for bilioenteric reconstruction, endoscopic approach is more difficult, if not impracticable. Therefore, percutaneous approach remains as a first-line treatment in these patients. In this case presentation, a percutaneous approach was used to recover patency in an intractable, totally occluded RYHJ stricture in an LDLT paediatric recipient, using a Rösch-Uchida needle to access to the collapsed jejunal loop from the bile duct. Once recanalization of the RYHJ was achieved, a biodegradable stent was placed with middle-term patency at follow-up.

Purpose: Pediatric living donor liver transplantation (LDLT) in low weight recipients remains one of the most complex surgical procedures, with portal vein (PV) complications occurring in up to 19% of cases. When decreased PV flow is diagnosed intra- or perioperatively, intraoperative stent placement is a good substitute for surgical adjustment. Still, at the present moment, little is known about the technical feasibility, safety, efficacy, and long-term outcome of intraoperative stenting in LDLT., Methods: Between 2006 and 2017, seven pediatric recipients underwent PV stent placement during the transplant or in the immediate post-operative setting. Preoperative, operative, and post-operative parameters were documented retrospectively., Results: In total, nine stents were placed in seven patients. Procedures were technically successful in all patients. During the mean imaging follow-up period of 1313 days, none of the patients showed PV abnormality and PV stent remained patent throughout the post-transplant course. There were no deaths or graft loses during the follow-up period., Conclusions: Intraoperative stenting through the inferior mesenteric vein approach offers both a high feasibility and satisfactory results, with the potential for excellent long-term primary patency despite continued growth in children.

A double-blind randomized controlled trial was performed to compare the safety and efficacy of α-lipoic acid (ALA) in liver transplantation (LT). The grafts were randomized to receive ALA or placebo before the cold ischemia time. Furthermore, patients transplanted with the ALA-perfused graft received 600 mg of intravenous ALA, while patients with the nonperfused graft received the placebo just before graft reperfusion. Hepatic biopsy was performed 2 h postreperfusion. Blood samples were collected before, during and 1 and 2 days after reperfusion. Quantitative polymerase chain reaction (qPCR) analysis was performed on biopsies to assess genes involved in the response to hypoxia, apoptosis, cell growth, survival and proliferation, cytokine production and tissue damage protection. Nine of 40 patients developed postreperfusion syndrome (PRS), but seven of them belonged to the control group. There was a decrease in PHD2 and an increase in alpha subunit of hypoxia-inducible factor-1 (HIF-1α) and baculoviral IAP repeat containing 2 (Birc2) transcript levels in the biopsies from the ALA-treated versus the control group of patients. Additionally, plasma levels of alarmins were lower in ALA-treated patients than control patients, which suggests that ALA-treated grafts are less inflammatory than untreated grafts. These results showed that ALA is safe for use in LT, induces gene changes that protect against hypoxia and oxidative stress and reduces the appearance of PRS., (© 2018 Steunstichting ESOT.)

Background: Adult liver recipients (ALR) differ from the general population with pyogenic liver abscess (PLA) as they exhibit: reconstructed biliary anatomy, recurrent hospitalizations, poor clinical condition and are subjected to immunosuppression. The aim of this study was to identify risk factors associated with PLA in ALR and to analyze the management experience of these patients., Methods: Between 1996 and 2016, 879 adult patients underwent liver transplantation (LT), 26 of whom developed PLA. Patients and controls were matched according to the time from transplant to abscess in a 1 to 5 relation. A logistic regression model was performed to establish PLA risk factors considering clusters for matched cases and controls. Risk factors were identified and a multivariate regression analysis performed., Results: Patients with post-LT PLA were more likely to have lower BMI (p = 0.006), renal failure (p = 0.031) and to have undergone retransplantation (p = 0.002). A history of hepatic artery thrombosis (p = 0.010), the presence of Roux en-Y hepatojejunostomy (p < 0.001) and longer organ ischemia time (p = 0.009) were independent predictors for the development of post-LT PLA. Five-year survival was 49% (95%CI 28-67%) and 89% (95%CI 78%-94%) for post-LT PLA and no post-LT PLA, respectively (p < 0.001)., Conclusion: history of hepatic artery thrombosis, the presence of hepatojejunostomy and a longer ischemia time represent independent predictors for the development of post-LT PLA. There was a significantly poorer survival in patients who developed post-LT PLA compared with those who did not., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

: This multicentric study of 17 high-volume centers presents 12 benchmark values for liver transplantation. Those values, mostly targeting markers of morbidity, were gathered from 2024 "low risk" cases, and may serve as reference to assess outcome of single or any groups of patients., Objective: To propose benchmark outcome values in liver transplantation, serving as reference for assessing individual patients or any other patient groups., Background: Best achievable results in liver transplantation, that is, benchmarks, are unknown. Consequently, outcome comparisons within or across centers over time remain speculative., Methods: Out of 7492 liver transplantation performed in 17 international centers from 3 continents, we identified 2024 low risk adult cases with a laboratory model for end-stage liver disease score ≤20 points, a balance of risk score ≤9, and receiving a primary graft by donation after brain death. We chose clinically relevant endpoints covering intra- and postoperative course, with a focus on complications graded by severity including the complication comprehensive index (CCI). Respective benchmarks were derived from the median value in each center, and the 75 percentile was considered the benchmark cutoff., Results: Benchmark cases represented 8% to 49% of cases per center. One-year patient-survival was 91.6% with 3.5% retransplantations. Eighty-two percent of patients developed at least 1 complication during 1-year follow-up. Biliary complications occurred in one-fifth of the patients up to 6 months after surgery. Benchmark cutoffs were ≤4 days for ICU stay, ≤18 days for hospital stay, ≤59% for patients with severe complications (≥ Grade III) and ≤42.1 for 1-year CCI. Comparisons with the next higher risk group (model for end stage liver disease 21-30) disclosed an increase in morbidity but within benchmark cutoffs for most, but not all indicators, while in patients receiving a second graft from 1 center (n = 50) outcome values were all outside of benchmark values., Conclusions: Despite excellent 1-year survival, morbidity in benchmark cases remains high with half of patients developing severe complications during 1-year follow-up. Benchmark cutoffs targeting morbidity parameters offer a valid tool to assess higher risk groups.

The treatment of biliary stenosis after pediatric LDLT is challenging. We describe an innovative technique of peripheral IHCJ for the treatment of patients with complex biliary stenosis after pediatric LDLT in whom percutaneous treatment failed. During surgery, the percutaneous biliary drainage is removed and a flexible metal stylet is introduced trough the tract. Subsequently, the most superficial aspect of the biliary tree is recognized by palpation of the stylet's round tip in the liver surface. The liver parenchyma is then transected until the bile duct is reached. A side-to-side anastomosis to the previous Roux-en-Y limb is performed over a silicone stent. Among 328 pediatric liver transplants performed between 1988 and 2015, 26 patients developed biliary stenosis. From nine patients requiring surgery, three patients who had received left lateral grafts from living-related donors due to biliary atresia were successfully treated with IHCJ. After a mean of 45.6 months, all patients are alive with normal liver morphological and function tests. The presented technique was a feasible and safe surgical option to treat selected pediatric recipients with complex biliary stenosis in whom percutaneous procedures or rehepaticojejunostomy were not possible, allowing complete resolution of cholestasis and thus avoiding liver retransplantation., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: In times of modern surgery, transplantation and percutaneous techniques, pyogenic liver abscess (PLA) has essentially become a problem of biliary or iatrogenic origin. In the current scenario, diagnostic approach, clinical behavior and therapeutic outcomes have not been profoundly studied. This study analyzes the clinical and microbiological features, diagnostic methods, therapeutic management and predictive factors for recurrence and mortality of first episodes of PLA., Methods: A retrospective single-center study was conducted including 142 patients admitted to the Hospital Italiano de Buenos Aires, between 2005 and 2015 with first episodes of PLA., Results: Prevailing identifiable causes were biliary diseases (47.9%) followed by non-biliary percutaneous procedures (NBIPLA, 15.5%). Seventeen patients (12%) were liver recipients. Eleven patients (7.8%) died and 18 patients (13.7%) had recurrence in the first year of follow up. The isolation of multiresistant organisms (p = 0.041) and a history of cholangitis (p < 0.001) were independent risk factors for recurrence. Mortality was associated with serum bilirubin >5 mg/dL (p = 0.022) and bilateral involvement (p = 0.014) in the multivariate analysis., Conclusion: NBPLA and PLA after transplantation may be increasing among the population of PLA in referral centers. History of cholangitis is a strong predictor for recurrence. Mortality is associated to hiperbilirrubinemia and anatomical distribution of the lesions., (Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background and Aim: The Up-to-7 criteria on the basis of the explanted liver features categorize patients at higher risk of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT). The aim of this study was to propose a novel pretransplant scoring system to predict recurrence including pre-LT data., Patients and Methods: From 763 consecutive adult patients who underwent transplantation in four LT centers from Argentina, 124 patients with HCC were included. A scoring system was developed in 87 patients from pre-LT risk factors for recurrence as determined by hazard ratios (HRs) from a multivariate Cox regression analysis., Results: Overall survival and recurrence rates at 5 years were 63.3 and 13.7%, respectively, during a follow-up period of 3.5±2.2 years. Variables associated with HCC recurrence on multivariate analysis were α-fetoprotein more than 100 ng/ml (HR=5.6, P=0.001) and tumor beyond Up-to-7 imaging criteria (HR=6.3, P=0.001). Bootstrap validation showed that overfitting was negligible. Scoring points were assigned as follows (0-2 points): pre-LT α-fetoprotein more than 100 ng/ml (presence=1 point, absence=0 point), and tumor beyond Up-to-7 imaging criteria (presence=1 point, absence=0 point). AUROC curve indicated a c-statistic of 0.74 (0.58-0.88, P=0.003). Two distinct subgroups of patients were identified with a cut-off more than or equal to 1 point (62% sensitivity and 82% specificity): low risk (0 point) and high risk (1-2 points). The 5-year recurrence rate was 9.4 and 44.5% (P=0.0001) and the 5-year overall survival was 78.1 and 34.8% (P=0.0001) in the low-risk and high-risk groups, respectively., Conclusion: This scoring model may be a useful additional tool for HCC recurrence risk stratification before LT. Prospective studies are needed to evaluate our model.

Background and Aims: Surveillance during liver transplantation (LT) waiting list has scarcely been reported in South America. We aimed to describe hepatocellular carcinoma (HCC) surveillance during the LT waiting list in the daily practice., Patients and Methods: A multicenter retrospective analysis in cirrhotic patients was carried out. All patients underwent an ultrasound (US) every 6 months and the last pre-LT US was compared with explanted liver findings. A false-negative case was considered when incidentally found HCC (iHCC) was detected, whereas a false-positive case was considered when HCC diagnosed before LT (cHCC) was not confirmed in the explanted liver. US performance was assessed after excluding cHCC patients referred to transplant evaluation., Results: Of 643 patients, 129 had HCC, of whom 92 had cHCC (71.3%) and 37 had iHCC (28.7%). Five patients (5.4%) had nonconfirmed cHCC (n=3 regenerative nodules, n=1 biliary hamartoma, and n=1 cholangiocarcinoma). Patients with iHCC had a higher MELD score (23±10 vs. 15±10; P<0.0001), and were more frequently Child-Pugh C (62.2 vs. 36.6%; P=0.006) compared with patients with cHCC. The number of US performed during waiting list was 1.7±1.6 (median 1.0). During transplant waiting list, the sensitivity and specificity of US were 33 and 99%, with positive and negative predictive values of 0.89 and 0.93, respectively. Multivariate analysis showed that the strongest variable related to iHCC finding was pre-LT Child-Pugh C status (OR 3.5; P=0.004)., Conclusion: Screening for liver cancer remains an important issue during transplant waiting list. However, the US screening method should be reviewed particularly for Child-Pugh C patients.

Background: Incidental hepatocellular carcinoma (iHCC) generates uncertainty over risk of recurrence after liver transplantation (LT)., Aim: To compare recurrence between iHCC and confirmed HCC diagnosed prior to transplant based on imaging criteria (cHCC)., Material and Methods: Fifty-four HCC patients were analyzed from a series of 309 consecutive adult transplanted patients. We developed a recurrence predicting score (RPS) applying ORs based on pathologic risk variables., Results: Incidence of iHCC was 4.8% (n = 15) and overall recurrence 12.9% (cHCC 15.4% and iHCC 7%; P = 0.39). Variables included in the RPS were: microvascular invasion OR 17.8 (1.78-178.97; P = 0.014: 2 points), neural invasion OR 15.5 (1.13-212.17; P = 0.04: 1.5 points), nuclear grade > II OR 9.3 (1.17-74.84; P = 0.035: 1 point), and beyond Up-to 7 criteria OR 13.1 (1.66-103.67; P = 0.015: 1.5 points). Two risk groups were identified: low risk for recurrence (0-1 point) and intermediate-high risk groups (2-6 points). Low risk category remained an independent predictor of recurrence: OR 0.11 (0.01-0.67; P = 0.017); AUROC of 0.75 (0.54-0.96). A tendency towards more patients categorized as low risk group among iHCC patients was observed (69.2%; P = 0.13)., Conclusions: In this series iHCC was not associated to lower risk of recurrence when compared to cHCC. We propose application of an RPS as a clinical tool for recurrence risk estimation.

Liver transplantation success is limited by the availability of donors. To overcome this limitation, anti-core-positive donors are increasingly being accepted, but underutilization of this resource still occurs. We performed the current study to determine the prevalence of anti-core-positive donors in our region and to describe the management of these donors and their recipients. Between January 2005 and July 2011, the national transplant database included 2,262 registered liver donors among whom 106 (4.7%) were anti-core-positive including 59 (56%) discarded and 47 (44%) implanted organs. A median of 14.5 offers (range 4-60) were rejected before harvesting and implanting the accepted grafts. The only difference between the implanted and the discarded grafts was found for the alanine aminotransferase level, which was higher among the discarded ones (50 ± 59 UI/L vs 25 ± 16, P < .05). Among 40 recipients included in the study, 5 (12.5%) did not receive any prophylaxis; 18 (45%) a nucleos(t)ide analog 11 (25.5%), heptitis B immunoglobulin and nucleos(t)ide analogs and 6 (15%) pretransplant hepatitis B vaccination. Over a mean follow-up of 871 ± 585 days, 4 de novo hepatitis B cases were identified at 545, 720, 748, and 1,080 days posttransplantation. None of these patients had received any prophylaxis. In all cases entecavir successfully controlled viral replication. We believe that better utilization of these donors and careful management of their recipients represent safe strategies to expand the liver donor pool in Argentina., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: We had previously described a left lateral segment hyper-reduction technique capable of sizing the graft according to the volume of the abdominal cavity of the recipient., Aim: The purpose of our study was to evaluate our 14-year live-donor liver transplantation experience with in situ graft hyper-reduction in children under 10 kg of weight., Patients and Methods: Between January 1997 and May 2011, we performed 881 liver transplants. Two hundred and seventy-seven (n = 277) involved pediatric recipients, of which 102 (37 %) were from live donors. Thirty-five (n = 35) patients under 10 kg of weight underwent hyper-reduced living donor liver transplants. There were 21 females (60 %) and 14 males (40 %), with a median age of 12 months (range 3-23) and a median weight of 7.7 kg (range 5.6-10)., Results: Median operative time was 350 min (range 180-510). Median cold ischemia time was 180 min (range 60-300). Twenty-six (n = 26) patients required intraoperative transfusion of blood products. There were 49 postoperative complications involving 26 patients (74 % morbidity rate). One-, 3-, and 5-year survival rates were 87, 79, and 74 %, respectively. Twenty-eight patients are currently alive., Conclusions: Hyper-reduced grafts provide an alternative approach for low-weight pediatric recipients. The relatively high immediate postoperative morbidity could be related to the complexity of these patients.

Background: Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of benign disease and a few patients will develop end-stage liver disease (ESLD) requiring a liver transplant (LT)., Objective: Analyse the experience using LT as a definitive treatment of BDI in Argentina., Patients and Methods: A national survey regarding the experience of LT for BDI., Results: Sixteen out 18 centres reported a total of 19 patients. The percentage of LT for BDI from the total number of LT per period was: 1990-94 = 3.1%, 1995-99 = 1.6%, 2000-04 = 0.7% and 2005-09 = 0.2% (P < 0.001). The mean age was 45.7 ± 10.3 years (range 26-62) and 10 patients were female. The BDI occurred during cholecystectomy in 16 and 7 had vascular injuries. One patient presented with acute liver failure and the others with chronic ESLD. The median time between BDI and LT was 71 months (range 0.2-157). The mean follow-up was 8.3 years (10 months to 16.4 years). Survival at 1, 3, 5 and 10 years was 73%, 68%, 68% and 45%, respectively., Conclusions: The use of LT for the treatment of BDI declined over the review period. LT plays a role in selected cases in patients with acute liver failure and ESLD., (© 2011 International Hepato-Pancreato-Biliary Association.)

Background: In 2005, the model of end-stage liver disease (MELD)-based allocation system was adopted to assess potential liver transplant (LT) recipients in Argentina. The aim of the present study was to revise the activity of the MELD Exception Experts Committee., Methods: Between 2005 and 2009, 1623 patients were listed for LT. Regulation provides extra-MELD points for amyloidosis, hepatopulmonary syndrome (HPS) and T(2) hepatocellular carcinoma (T(2) HCC). Centres could also request priority for other situations. Using a prospective database, we identified patients in whom priority points were requested. Pathology reports of explanted livers were analysed for patients with T(2) HCC., Results: From 234 out of 1623 (14.4%) requests, the overall approval rate was 60.2% including: 2 amyloidosis, 6 HPS, 111 T(2) HCC and 22 non-regulated situations. Of the 111 patients with T(2) HCC, 6 died (5.4%), 8 had tumour progression (7.2%), 94 were transplanted (84.2%) and 3 are still waiting. An explants correlation showed that presumed diagnosis of T(2) HCC was incorrect in 20/94 (22%) and was correct in only 41/94 (43%) cases being T(1) HCC in 9 and T(3) HCC in 23., Conclusions: MELD exceptions are frequently requested in Argentina. Unfortunately, most receiving priority points for T(2) HCC benefited by medical error or imaging limitations. An intense review process is urgently needed to maintain equity and justice in the allocation system., (© 2010 International Hepato-Pancreato-Biliary Association.)

Background: In July 2005, Argentina was the first country after the United States to adopt the MELD system. The purpose of the present study was to analyse the impact of this new system on the adult liver waiting list (WL)., Methods: Between 2005 and 2009, 1773 adult patients were listed for liver transplantation: 150 emergencies and 1623 electives. Elective patients were categorized using the MELD system. A prospective database was used to analyse mortality and probability to be transplanted (PTBT) on the WL., Results: The waiting time increased inversely with the MELD score and PTBT positively correlated with MELD score. With scores >/= 18 the PTBT remained over 50%. However, the largest MELD subgroup with <10 points (n = 433) had the lower PTBT (3%). In contrast, patients with T(2) hepatocellular carcinoma benefited excessively with the highest PTBT (84.2%) and the lowest mortality rate (5.4%). The WL mortality increased after MELD adoption (10% vs. 14.8% vs. P < 0.01). Patients with <10 MELD points had >fourfold probability of dying on the WL than PTBT (14.3% vs. 3%; P < 0.0001)., Conclusions: After MELD implementation, WL mortality increased and most patients who died had a low MELD score. A comprehensive revision of the MELD system must be performed to include cultural and socio-economical variables that could affect each country individually.

Background: Although data about the incidence and management of biliary complications after deceased-donor liver transplantation (DDLT) are well defined, those pertaining to adult living-donor liver transplantation (LDLT) are conflicting., Methods: We retrospectively compared endoscopic retrograde cholangio-pancreatography (ERCP) findings in 30 LDLT vs. 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction. LDLT and DDLT recipients were followed up for median durations of 30.5 and 36.0 months after the last ERCP, respectively., Results: Postoperative biliary complications were more frequently identified at ERCP after LDLT versus DDLT (10/30 [33.3%] vs. 34/357 [9.5%]; P<0.001). Complications mainly consisted of anastomotic biliary strictures (10/30 [33.3%] vs. 27/357 [7.6%]; LDLT vs. DDLT recipients, respectively; P<0.001) and biliary leaks (4/30 [13.3%] vs. 6/357 [1.7%]; LDLT vs. DDLT recipients, respectively; P=0.005; some patients had both complications). Stricture dilation was successful in 4/10 (40%) LDLT vs. 27/27 (100%) DDLT recipients (P<0.001), and bile ducts remained patent up to the end of follow-up without further intervention in 2/10 (20.0%) vs. 21/27 (77.8%) patients, respectively (P=0.002). Endoscopic treatment of bile leaks was successful in 3/4 (75.0%) vs. 5/6 (83.3%) LDLT versus DDLT recipients, respectively (NS)., Conclusions: Biliary complications were more frequent after LDLT compared with DDLT. Endoscopic treatment of anastomotic biliary strictures was successful in a minority of patients after LDLT, in contrast with DDLT. Most biliary leaks were successfully treated at endoscopy after LDLT or DDLT.

Unlabelled: Primary sclerosing cholangitis is frequently associated with inflammatory bowel disease., Objective: to evaluate the evolution of IBD in patients transplanted for PSC and the incidence of severe dysplasia/carcinoma., Patients and Methods: we included 32 patients transplanted between 1988 and 2006 for PSC. Median follow-up: 8.7 years (1-20 y). All patients were evaluated pre-OLT with colonoscopy and multiple intestinal biopsies. Post-OLT surveillance colonoscopies were performed every 12 months., Results: of 32 patients included, 26 had inflammatory bowel disease pre-OLT (ulcerative colitis 25, Crohn's disease 1). 12 patients had active intestinal disease pre-OLT and 2 patients had moderate dysplasia but were not surgically treated due to the severity of their liver disease. Among the 26 patients with IBD pre-OLT, 2 died in the postoperative period due to complications related to the transplantation procedure. Among the other 24 patients, 16 had a quiescent colonic disease post-OLT. Among them, 12 had quiescent disease pre-OLT and 4 showed improvement in their colonic symptoms after transplantation. Eight patients were symptomatic pre-OLT and had a transitory improvement in their symptoms post-OLT, with worsening of their intestinal disease by 5.7 +/- 2.8 months after transplantation. Three patients developed severe dysplasia or colonic cancer., Conclusions: over half of patients transplanted for PSC presented with quiescent intestinal disease. Yet, there was a group of patients that worsened their colonic symptoms and had a high incidence of dysplasia/carcinoma. It is necessary to maintain an adequate colonic surveillance even in the absence of colonic symptoms or active disease.

Background: Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI., Methods: Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan-Meier test., Results: Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24-152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively., Conclusion: Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.

Background: Elevated intracranial pressure (ICP) is a common cause of death in acute liver failure (ALF) and is determinant for decision-making regarding the timing of liver transplantation. The recommended type ICP monitoring device is controversial in ALF patients. Epidural devices had less risk of hemorrhagic complications, but they are less reliable than intraparenchymal ones., Method: Twenty-three patients with ALF were treated, and 19 of them received a liver transplant. Seventeen patients had ICP monitoring because of grade III-IV encephalopathy. All patients received fresh plasma (2-3 units) before and during placing the intraparenchymal device., Results: Eleven cases (64.7%) had elevated ICP, and 6 patients (35.2%) had normal values. One patient (5.9%) had an asymptomatic small intraparenchymal haemorrhage<1cm3 in CTscan, which did not prevent the liver transplantation., Conclusion: In our experience, intraparenchymal ICP monitoring in patients with ALF seems to be an accurate method with a low risk of complications.

Chagas' disease is an endemic zoonosis of South America caused by a protozoan parasite Trypanosoma cruzi. About 30% of infected people develop the disease. This disease is known to reactivate in immunocompromised hosts, such as patients with acquired immunodeficiency syndrome, leukemia, and transplantation. There is some experience with transplantation of infected renal grafts into negative recipients, resulting in an index of transmission of 35%. No cases have been reported involving other organ transplants up to 2002, when the Centers for Disease Control and Prevention reported 3 cases of Chagas' disease transmission to 3 recipients (liver, kidney, and pancreas-kidney) from a single chagas infected donor. Here we report on a case of orthotopic liver transplant from a chagas infected donor into a negative recipient in clinical emergency status. The recipient was monitored by direct parasitological Strout method and serological tests with detection of transmission on the 84 th day by both studies, without clinical signs. The patient was put on benznidazole with rapid clearance of the parasitemia. However, we propose that chagas infected donors may be accepted for liver transplant recipients only in emergency status.

Catastrophic antiphospholipid syndrome (CAPS) is an acutely devastating situation characterized by widespread thrombotic microangiopathy in the presence of elevated titers of antiphospholipid antibodies. We describe a 57-year old woman who underwent liver transplantation for primary sclerosing cholangitis and developed this malignant variant of the antiphospholipid syndrome.

A shortage of liver donors for low-weight transplant recipients has prompted the development of procedures for liver-reduction, split-liver, and living related donor transplantations. For pediatric recipients weighing less than 10 kg, the left lateral segment is often still too large. We describe the procedure of monosegmental transplantation using segment II after segment III was resected in situ from a living related donor. Successful monosegmental transplantation is technically feasible and is a valid alternative to be considered for cases of size discrepancy between the recipient's volume and the donor's left lateral segment.

Systemic and splanchnic hemodynamic parameters were evaluated in 12 patients with cirrhosis before and 3 and 6 months after liver transplantation. Results were compared with those obtained in 8 healthy subjects. Three months after liver transplantation recipients had an increase in mean arterial pressure (98 +/- 7 v 78 +/- 9 mmHg; P < .05), an insignificant decrease in cardiac index (3. 4 +/- 0.6 v 4.0 +/- 1.0 L . min-1 . m-2), and a marked increase in peripheral vascular resistance (1,563 +/- 308 v 800 +/- 205 dyne . s . cm-5; P < .05) compared with pretransplantation values. Portal blood flow was also significantly increased (1,494 +/- 200 v 829 +/- 130 mL/min; P < .05). These hemodynamic changes were more pronounced 6 months after transplantation (mean arterial pressure, 100 +/- 8 mmHg; cardiac index, 3.0 +/- 1.0 L . min-1 . m-2; P < .01; peripheral vascular resistance, 1,680 +/- 405 dyne . s . cm-5; portal blood flow, 1,520 +/- 180 mL/min). Systemic hemodynamics 6 months after liver transplantation were similar to those observed in the healthy control group (mean arterial pressure, 95 +/- 6 mmHg; cardiac index, 2.9 +/- 0.9 L . min-1 . m-2; peripheral vascular resistance, 1,480 +/- 380 dyne . s . cm-5). However, portal blood flow was still significantly higher than in healthy controls at 6 months (1,520 +/- 180 v 910 +/- 140 mL/min; P < .05). This study shows that systemic hemodynamics are normalized after liver transplantation. However, an increase in portal blood flow occurs and persists for at least 6 months after liver transplantation. Further studies are needed to clarify the cause of the abnormally high portal flows., (Copyright 1998 W.B. Saunders Company.)

The authors present the case of a 14-year-old boy with secondary portal hypertension caused by arterio-portal fistulae. Ascites, edema, severe abdominal pain, and steatorrhea developed in the patient. In an attempt to decrease arterioportal flow the authors carried out vascular embolization that was partially successful. A liver transplant was performed as a last therapeutic resource in view of the fact that it constitutes an accepted therapy for patients with severe liver disease. Orthotopic liver transplantation may be considered as another possible treatment of arterio-portal fistulae.

Renal failure is a common finding in patients undergoing orthotopic liver transplantation. The aim of the present study was to evaluate the incidence, prognostic value of pre, intra and postoperative factors and severity of renal dysfunction in patients who undergo liver transplantation. Therefore, the records of 38 consecutive adult patients were reviewed. Renal failure was defined arbitrarily as an increase in creatinine (> 1.5 mg/dl) and/or blood urea (> 80 mg/dl). Three patients were excluded of the final analysis (1 acute liver failure and 2 with a survival lower than 72 hs.) Twenty one of the 35 patients has renal failure after orthotopic liver transplantation. Six of these episodes developed early, having occurred within the first 6 days. Late renal impairment occurred in 15 patients within the hospitalization (40 +/- 10 days) (Mean +/- SD). In he overall series, liver function, evaluated by Child-Pugh classification, a higher blood-related requirements and cyclosporine levels were observed more in those who experienced renal failure than those who did not (p < 0.05). Early renal failure was related with preoperative (liver function) and intraoperative (blood requirements) factors and several causes (nephrotoxic drugs and graft failure) other than cyclosporine were present in patients who developed late renal impairment. No mortality. No mortality was associated with renal failure. We conclude that renal failure a) is a common finding after liver transplantation, b) the pathogenesis of this complication is multifactorial and, c) in not related with a poor outcome.

Background: Liver retransplantation (re-LT) represents the only treatment for patients with irreversible graft failure. Objective: The aim of the current study was to describe the outcomes of both, patient and graft, after re-LT, at a high-volume referral center. Methods: Our population consisted of patients, with liver disease, who underwent re-LT in our institution between January 1996 and December 2019. Results: 49 patients met the inclusion criteria. The patient's overall survival (OS) for the first year was 85% (Confidence Intervals (CI) 71-92) and 70% at five years (CI 53-82). In our population, three (6.12%) patients presented loss of graft and were included again in the transplant list; of these, one agreed to a new transplant while the remaining two died. This gave us graft survival results similar to those obtained for the re-LT patient; 85% at one year (CI 71-92) and 70% at 5 years (CI 53-82). Conclusion: Our study shows that re-LT is a valid and safe treatment for both early graft dysfunction and for transplanted patients who again present end-stage liver disease, showing a satisfactory long-term evolution, with parameters comparable to primary transplantation. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy is the treatment of choice for gallbladder stones. In the current study, this approach was associated with a higher incidence of biliary injuries. The authors evaluate their experience treating complex biliary injuries and analyze the literature.Methods: In a 15-year period, 169 patients with bile duct injuries (BDIs) resulting from open and laparoscopic cholecystectomies were treated. The patients were retrospectively evaluated through their records. Biliary injury and associated lesions were evaluated with imaging studies. Surgical management included therapeutic endoscopy, percutaneous interventions, hepaticojejunostomy, liver resection, and liver transplantation. Postoperative outcome was recorded. Survival analysis was performed with G-Stat and NCSS programs using the Kaplan-Meier method.Results: Of the 169 patients treated for BDIs, 148 were referred from other centers. The injuries included 115 lesions resulting from open cholecystectomy and 54 lesions resulting from laparoscopic cholecystectomy. A total of 110 patients (65%) fulfilled the criteria for complex injuries, 11 of whom met more than one criteria. Injuries resulting from laparoscopic and open cholecystectomies were complex in 87.5% and 72% of the patients, respectively. The procedures used were percutaneous transhepatic biliary drainage for 30 patients, hepaticojejunostomy for 96 patients, rehepaticojejunostomy for 16 patients, hepatic resection for 9 patients, and liver transplantation projected for 18 patients. Hepaticojejunostomy was effective for 85% of the patients. The mean follow-up period was 77.8 months (range, 4-168 months). The mortality rate for noncomplex BDI was 0%, as compared with the mortality rate of 7.2% (8/110) for complex BDI. Mortality after hepatic resection was nil, and morbidity was 33.3%. The actuarial survival rate for liver transplantation at 1 year was 91.7%.Conclusions: Complex BDIs after laparoscopic cholecystectomy are potentially life-threatening complications. In this study, late complications of complex BDIs appeared when there was a delay in referral or the patient received multiple procedures. On occasion, hepatic resections and liver transplantation proved to be the only definitive treatments with good long-term outcomes and quality of life. [ABSTRACT FROM AUTHOR]

Background Intra-operative bile duct injuries (IBDI) are potentially severe complications of the treatment of benign conditions, with unpredictable long-term results. Multiple procedures are frequently needed to correct these complications. In spite of the application of these procedures, patients with severe injuries can develop irreversible liver disease. Liver transplantation (LT) is currently the only treatment available for such patients, but little information has been published concerning the results of LT. Methods Eight patients with LT for end-stage liver disease for IBDI were studied retrospectively. They had failure of multiple previous treatments and experienced recurrent episodes of cholangitis, oesophageal variceal bleeding, severe pruritus, refractory ascites and spontaneous peritonitis. Results Mean recipient hepatectomy time was of 243 minutes (range 140–295 min), the complete procedure averages 545 minutes (260–720) and intraoperative red-blood-cells consumption was 6.5 units (1–7). One patient required reoperation due to perforation of a Roux-en-Y loop, and three developed minor complications (2 wound infections, 1 inguinal lymphocele). One patient died due to nosocomial pneumonia (mortality rate 12.5%). One patient required retransplantation due to delayed hepatic artery thrombosis. At follow-up 75% of patients are alive with normal graft function and an excellent quality of life. Conclusions LT represents a safe curative treatment for end-stage liver disease after IBDI, albeit a major undertaking in the context of a surgical complication in the treatment of benign disease. The complications of the surgical procedure and the long-standing immunosupression impart a high cost for resolutions of these sequelae but LT represents the only long-term effective treatment for these selected patients. [ABSTRACT FROM AUTHOR]