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Background: Living donor kidneys with multiple arteries (MA) are increasingly procured laparoscopically for transplant., Methods: We compare long-term graft function and survival of kidneys with single arteries (SA) and MA over a 10-year period., Results: There were a total of 218 grafts with SA and 60 grafts with MA. The MA group had longer operative and ischemic times than SA group. There was a small increase in ureteral complication (8.3% vs. 2.3% P=0.06) and a significantly higher incidence of rejection (23.3% vs. 10.1%, P=0.01) in MA group than in SA group. Graft function was lower in MA group than SA group. The 5-year graft survival by Kaplan Meier analysis was better in SA group than in MA group (P=0.023). The estimated graft survivals at 1, 3, and 5 year were 94.4%, 90.6%, and 86% for SA group and 89.6%, 83.2%, and 71.8% for MA group. There was a higher percentage of graft loss from chronic allograft nephropathy in MA group than in SA group (16.7% vs. 5.5%, P=0.01). The presence of MA (vs. SA) was an independent risk for acute rejection (OR 3.60, 95% CI 1.59-8.14, P=0.002) and for graft loss (HR 2.31, 95% CI 1.05-5.09, P=0.038)., Conclusion: Laparoscopic procurement of living donor kidneys with SA may be associated with a lower risk of rejection, better function, and superior long-term survival when compared with kidneys with MA.

Hepatocellular carcinoma with extension into the right heart is a recognized, albeit rare occurrence. Patients who present with tumors extending into the heart have generally been considered inoperable and had limited survival, many sustaining tumor embolism and/or sudden death. Resection has been fraught with intraoperative and perioperative mortality as well as considerable postoperative morbidity. We report an exceptional case of a patient with such a tumor successfully treated with an aggressive surgical approach and review the limited published experience.

Background and Objectives: The optimal donor age for transplanting a single pediatric kidney in an adult recipient remains unknown. En block kidney transplantation is usually performed when the donor age is <5 yr., Design, Setting, Participants, & Measurements: We compared the outcomes of adult patients who underwent transplantation with single pediatric kidneys from donors who were younger than 5 yr (group 1, n = 40) and from donors who were aged 5 to 10 yr of age (group 2, n = 39) in our center., Results: The donor kidney sizes were significantly smaller in group 1 than in group 2 (P < 0.001), and group 1 required more ureteral stents than group 2 (73 versus 38%). The surgical complications, delayed graft function, and development of proteinuria were similar in both groups. Group 1 had slightly higher rejection episodes than group 2 (25 versus 18%; P = 0.67), and graft function was comparable in both groups. There were no statistical differences between the two groups in patient (P = 0.73) or death-censored graft (P = 0.68) survivals over 5 yr., Conclusions: Single pediatric kidney transplants from donors who are younger than 5 yr can be used with acceptable complications and long-term outcomes as those from older donors.

The long-term outcome of pancreas transplant (PT) in African Americans (AA) using interleukin-2 receptor antibody induction has not been well documented. We retrospectively analyzed the 7-year outcomes of 45 AA and 73 white recipients of primary PT at our center. All PT were performed with enteric-systemic drainage. Basiliximab induction, tacrolimus, mycophenolic acid, and steroid maintenance were used as the primary immunotherapy. There was no difference by Kaplan-Meier analysis in patient (P = 0.94), pancreas graft (P = 0.76), or death-censored graft survival (P = 0.71) over 7 years between the AA and white groups. Clinically treated pancreas rejection episodes were slightly higher in AA than in white patients. Similarly, cytomegalovirus infection rates and comparable quality of graft function were noted in both groups over 7 years. Excellent long-term patient and pancreas graft survivals can be achieved in AA recipients of PT by using interleukin-2 receptor antibody induction and combination of tacrolimus, mycophenolic acid, and steroid maintenance.

Background: There is insufficient data on the impact of recipient body mass index (BMI) on the long-term graft survival of adult patients transplanted with single pediatric kidneys., Methods: We performed a retrospective analysis of adult patients transplanted with single pediatric kidneys at our center. The recipients were classified into 2 groups: group 1 (BMI > or =30) and group 2 (BMI <30). Donor/recipient demographics, postoperative outcomes and survival rates were compared between the 2 groups., Results: There was no significant difference in donor/recipient demographics between the 2 groups. In group 1, the death-censored graft survival (DCGS) at 1, 3 and 5 years was 90% at all 3 time points, and in group 2 it was 86, 68 and 60%, respectively (p = 0.05). The mean glomerular filtration rate (with standard deviation in parentheses) at 1, 3 and 5 years was, respectively, 55 (15), 59 (19) and 55 (28) ml/min for group 1, compared to 65 (28), 69 (23) and 67 (20) ml/min in group 2 (p = NS). Multivariate analysis revealed a hazard ratio of 5.12 (95% confidence interval 1.06-24.7; p = 0.04) for graft loss in nonobese patients when compared to obese patients. Obese patients had an increased risk for acute rejections within the first month of transplant (p = 0.02)., Conclusion: Patients with a BMI > or =30 transplanted with single pediatric kidneys have better DCGS rates when compared to nonobese patients., (Copyright (c) 2008 S. Karger AG, Basel.)

The efficacy of superselective transcatheter chemoembolization (TACE) and chemoembolization taking advantage of pharmacologic (noradrenaline) flow manipulation was assessed on 21 explanted livers with hepatocellular carcinoma (HCC). There was a high concentration of chemoembolizate in the target area. Correlation of gross anatomical and immunohistochemical findings (gold standard) of tumor volume, necrosis and residual viable tumor to predicted results by multiphasic helical computed tomography (CT) was poor. Tumor markers in explanted livers found free of tumor were low or absent; in livers with residual or recurrent tumor high. However, there did not appear to be a correlation between the degree of tumor necrosis and level of tumor markers. The recurrence-free post-orthotopic liver transplant (OLT) survival in our 21 patients appears to be substantially lower than that reported in the literature. The goal of retaining patients on the liver transplant list by repeated TACE or multimodality therapy (MMT) was achieved (drop out rate of only 16%).

Bone disease after kidney transplantation has a complex pathophysiology and heterogeneous histology. Pre-existing renal osteodystrophy may not resolve completely, but continue or evolve into a different osteodystrophy. Rapid bone loss immediately after transplant can persist, at a lower rate, for years to come. These greatly increase the risk of bone fracture and vertebral collapse. Hypovitaminosis D, hyperparathyroidism and hyperaluminemia may resolve after kidney transplant, but many patients have other risk factors of bone loss, such as steroids usage, hypogonadism, persistent hyperparathyroidism, poor allograft function, aging, and chronic diseases. Clinical management requires a comprehensive approach to address the underlying and ongoing disease processes. Successful prevention of bone loss has been shown with vitamin D analogues, bisphosphonates and calcitonin. Novel approaches to restore the normal bone remodeling and improve the bone quality may be needed in order to effectively decrease bone fractures in kidney transplant recipients.

Pancreas transplantation has been mired in controversy throughout its existence. Arguments have erupted regarding its actual indications, the way the surgical procedure should be performed, its benefits, and today, the concept of pancreas islet cell transplantation remains controversial as well. If diabetic patients had a choice between life long insulin therapy and a major operation with immunosuppression afterward, what would they choose? The answer may not be as easy as one thinks. Pancreas transplantation has come a long way. This manuscript discusses the history of pancreas transplantation, how the indications are starting to be defined, evolution of the surgical procedure, current success rates of this procedure, the current scenario of pancreas islet transplantation, and newer developing technologies.

Background: Alpha interferon in combination with ribavirin is the standard therapy for hepatitis C virus infection. Unfortunately, a significant number of patients fail to eradicate their infection with this regimen. The mechanisms of IFN-resistance are unclear. The aim of this study was to determine the contribution of host cell factors to the mechanisms of interferon resistance using replicon cell lines., Results: HCV replicons with high and low activation of the IFN-promoter were cultured for a prolonged period of time in the presence of interferon-alpha (IFN-alpha2b). Stable replicon cell lines with resistant phenotype were isolated and characterized by their ability to continue viral replication in the presence of IFN-alpha. Interferon resistant cell colonies developed only in replicons having lower activation of the IFN promoter and no resistant colonies arose from replicons that exhibit higher activation of the IFN promoter. Individual cell clones were isolated and nine IFN resistant cell lines were established. HCV RNA and protein levels in these cells were not altered by IFN- alpha2b. Reduced signaling and IFN-resistant phenotype was found in all Huh-7 cell lines even after eliminating HCV, suggesting that cellular factors are involved. Resistant phenotype in the replicons is not due to lack of interferon receptor expression. All the cell lines show defect in the JAK-STAT signaling and phosphorylation of STAT 1 and STAT 2 proteins were strongly inhibited due to reduced expression of Tyk2 and Jak-1 protein., Conclusion: This in vitro study provides evidence that altered expression of the Jak-Stat signaling proteins can cause IFN resistance using HCV replicon cell clones.

Interleukin-2 receptor (IL2R) antibody has emerged as an attractive induction therapy for organ transplant. However, the long-term outcome of basiliximab induction in simultaneous pancreas and kidney (SPK) transplant remains speculative. We retrospectively analyzed the long-term survivals of 91 consecutive SPK recipients with basiliximab as induction, combination of steroid, tacrolimus (TAC) and mycophenolate acid (MFA)--either mycophenolate mofetil (MMF) or sodium mycophenolate (myfortic) as maintenance. At one, three, five, and seven-yr, the actual patient survival rate were 91.2%, 90.3%, 88.1%, and 88.2%, respectively; kidney graft survivals were 90.1%, 84.7%, 78.6%, and 70.6%, respectively; and pancreas graft survivals were 86.8%, 80.6%, 71.4%, and 58.8% respectively. There was a low incidence of rejection and CMV infection. Basiliximab induction with TAC, MFA, and steroid maintenance therapy can provide excellent long-term outcome for SPK recipients.

Compliance with complex immunosuppressant drug therapies in transplant recipients might be improved with regimens that require less frequent dosing. A once-daily extended release (XL) formulation of tacrolimus has been developed that allows a 1:1 conversion from the twice-a-day tacrolimus (TAC) formulation and has a good exposure to trough concentration correlation. In an open-label, multicenter study, stable liver transplant recipients (n=69) were converted from twice-a-day TAC to XL once-daily in the morning, and were maintained for at least 2 years postconversion using the same therapeutic monitoring and patient care techniques employed with TAC. Two years after conversion, the incidence of biopsy-confirmed acute rejection was 5.8% (4 of 69); patient and graft survival was 98.6% (68 of 69). The safety profile of XL was consistent with that previously reported for TAC. Liver transplant recipients can be converted from twice-a-day TAC to once-daily XL and maintained for at least 2 years postconversion with neither unique efficacy nor safety concerns.

With ever-increasing demand for liver replacement, supply of organs is the limiting factor and a significant number of patients die while waiting. Live donor liver transplantation has emerged as an important option for many patients, particularly small pediatric patients and those adults that are disadvantaged by the current deceased donor allocation system. Ideally there would be no need to subject perfectly healthy people in the prime of their lives to a potentially life-threatening operation to procure transplantable organs. Donor safety is imperative and cannot be compromised regardless of the implication for the intended recipient. The evolution of split liver transplantation is the basis upon which live donor transplantation has become possible. The live donor procedures are considerably more complex than whole organ decreased donor transplantation and there are unique considerations involved in the assessment of any specific recipient and donor. Donor selection and evaluation have become highly specialized. The critical issue of size matching is determined by both the actual size of the donor graft and the recipient as well as the degree of recipient portal hypertension. The outcomes after live donor liver transplantation have been at least comparable to those of deceased donor transplantation. Nevertheless, all efforts should be made to improve deceased donor donation so as to minimize the need for live donors. Transplant physicians, particularly surgeons, must take responsibility for regulating and overseeing these procedures., (Copyright 2006 AASLD)

An end-to-side portocaval shunt has been classically described as the standard procedure that needs to be performed to obtain adequate venous drainage of the foregut in combined liver-intestinal transplant. The transplanted organs are placed en bloc in a piggyback fashion on the recipient's vena cava, and graft's porto-mesenteric venous circulation is left intact. Recurrent portal hypertension with hemorrhage has been reported as a complication after such a procedure. In an effort to improve the technical aspects of this complex operation, we began to perform an end-to-end shunt from the recipient portal vein to the infrahepatic donor cava. Here, we describe this new surgical technique and discuss its potential advantages. The new technique is described in detail. Of the 70 intestinal transplants performed in 67 patients at The Mount Sinai Hospital from 1998 to December 2004, three were multivisceral transplants (MVTx) and 28 were combined liver intestine transplants (LITx), post-surgical outcome including recurrent portal hypertension and the presence of splenomegaly and significant thrombocytopenia was retrospectively review between the group that received the classic end-side vs. the new end-end portocaval shunt. Of the 28 LITx, 23 were done with the classic end-side portocaval shunt and in five (one adult, four pediatric) the end-to-end portocaval shunt described in the present study. One patient in this group died on post-operative day 31 (adult); after a mean follow up of 19.5 months there is a 100% patient and graft survival for the pediatric population. Post-operatively there have been no complications related to this technique. Few modifications have been made to the original description of MVTx. This is the first description of this technique that is relatively simple to perform, creating a large vascular conduit with high flow rates and theoretically less turbulence compared with the end-to-side shunt.

The evidence in favor of transplanting single allografts from cadaveric pediatric donors into adult recipients is equivocal. This study was performed to assess the outcome of transplantation of single kidneys from pediatric donors weighing < 25 kg. Thirty-five adults transplanted by renal allografts from pediatric donors weighing < 25 kg were compared with 30 matched recipients of kidneys from adult donors. Donors in study group were aged 4.2 +/- 2.1 years weighing 16.0 +/- 5.3 kg. In the study group, surgical complications occurred in five of 35 patients, in the control group four of 30. Serum creatinine reached nadir in 47.5 days in study group versus 30 days in controls (P < 0.01). Serum creatinine at 1 and 3 years were comparable in both groups. A 38.9% had proteinuria at 1 year in the study group compared with 22.7% in controls (P = 0.36). One-year graft survival was 91.7% in the study group versus 92.8% for controls. The surgical complications and graft survival in the study group was comparable with that of controls. The incidence of proteinuria may be more frequent, but does not appear to impact graft function. The use of single, as compared with paired, pediatric donor kidneys would allow more patients to be transplanted with equivalent results.

Background: Blood-borne infection is an ever-present fear for medical professionals, especially surgeons and operating room personnel. Safety is paramount, and the reliability and efficacy of surgical gloves are crucial, as gloves are the most important barriers protecting hospital personnel and patients. Unfortunately, glove perforation rates are as high as 78% in high-risk procedures. As well as being efficacious, surgical gloves must be comfortable and easy to don, and when holes are present, it is imperative they be detected expeditiously. The purpose of this double-blind randomized study was to evaluate the ability of participants to locate 30-micron laser holes in surgical gloves while performing simulated surgery and to evaluate the Biogel Indicator Glove System, which reveals punctures., Methods: Twenty glove configurations (eight single, twelve double) were tested, half of which had laser-created holes. Each of the 25 participants tested and evaluated 20 configurations randomly. Simulated surgery terminated when a hole was identified by the participant or at the end of two minutes, whichever occurred first. Participants also rated their perceptions of each glove's features on questionnaires, all of which were returned, with 95.8% being complete., Results: Participants found 84% and 56% of the holes in the two indicator systems, latex and synthetic, in an average of 22 seconds and 42 seconds, respectively. In the worst-performing latex and synthetic glove configurations, participants found only 8% and 12% of the holes at an average of 47 seconds and 67 seconds, respectively. Indicator gloves were highly rated for comfort and ease of use., Conclusions: Double gloving with an indicator system provides the best protection and allows the timeliest identification of perforations. Participants failed to identify most of the holes in the non-indicator gloves.

Background: Laparoscopic donor nephrectomy is associated with a higher incidence of ureteral complications. Hand-assisted dissection minimizes the use of instruments for intraoperative retraction and handling of periureteric tissue, and may reduce posttransplant complications., Objective: To assess the outcome of hand-assisted laparoscopic donor nephrectomy, in particular ureteral complications., Methods: Records of 143 kidney transplant recipients who received allografts removed using the hand-assisted laparoscopic technique were retrospectively studied., Results: Total operating time was 2.0 +/- 0.55 (range 1.08-4) hours. Warm ischemia time was 1.45 +/- 0.60 (range 0.58-3.00) minutes. Length of artery, vein, and ureter was 2.4 +/- 0.5 cm, 3.0 +/- 0.5 cm, and 10.3 +/- 2.1 cm, respectively. Estimated blood loss averaged 86.3 +/- 55.6 mL. Intraoperative suction was not needed in 65% of patients. Two donors developed incisional hernias and 1 had a postoperative ileus. Four of 143 (2.8%) recipients developed ureteral complications: reoperations for ureteral necrosis (1), stenting for ureteral stenosis (2), and urethral catheterization for ureterovesical leak (1). Graft loss in the first year after transplantation occurred because of renal vein thrombosis, thrombosis of revised arterial anastomosis, arterial thrombosis due to myocardial infarction, vasculitis, focal segmental glomerulosclerosis, and chronic rejection. Delayed graft function developed in 3 recipients. The acute rejection rate was 14.6%. Mean serum creatinine levels at 1 and 3 years were 134 +/- 61 micromol/L (1.52 +/- 0.69 mg/dL) and 121 +/- 35 micromol/L (1.37 +/- 0.40 mg/dL), respectively., Conclusions: Hand-assisted laparoscopic donor nephrectomy is associated with a low incidence of ureteral complications; may reduce the technical difficulty of the operation and minimize retraction with instruments, resulting in fewer complications for donors and recipients; and minimizes donor blood loss.

Intestinal transplantation is an accepted lifesaving option to treat appropriately selected patients with end-stage failure of the gastrointestinal tract. The evaluation of each candidate involves complex judgments. When to perform an isolated intestinal transplantation versus a combined transplantation with the liver and/or other organs often requires thoughtful considerations and an individualized approach. In addition, performing venous drainage of the isolated graft is potentially complex. We discuss the significant advances in surgical and medical decision making in the evaluation and management of patients with intestinal failure.

A 57-year-old male with a history of hypercholesterolemia and anxiety but otherwise in good health volunteered to donate the right lobe of his liver to his brother. The operation was performed uneventfully, without transfusion. Postoperatively he did well, until he developed tachycardia, profound hypotension, and coffee ground emesis on postoperative day 3. Despite resuscitative measures, he arrested and expired. Autopsy demonstrated gas gangrene of the stomach as the underlying cause of the hemorrhage and numerous colonies of Gram-positive bacilli were identified. Subsequent polymerase chain reaction (PCR) analysis identified these bacteria to be Clostridium perfringens (C. perfringens) type D. This patient's death was devastating, both to his family and his medical team. The impact of his death has transcended that of an individual occurrence. In conclusion, herein we present the facts and discuss this extraordinary example of florid clostridial infection and toxin-mediated shock. It was completely unexpected and probably unpreventable, and its cause was almost inconceivable.

Acute cellular rejection (ACR) after liver transplantation occurs in as much as 70% of patients within the first year. There is very little known about ACR that occurs more than 1 yr after transplant, and it is generally believed that late occurring ACR may be more resistant to medical treatment and is associated with a higher rate of chronic ductopenic rejection and graft loss. A total of 532 recipients with more than 1000 d follow-up and who did not have hepatitis C were identified. Forty-three (8.1%) had biopsy proven late ACR at a mean of 1545 +/- 441 d post-transplant. Additionally, 38 of the 43 (88.4%) patients with late ACR had earlier episodes of ACR before 1000 d post-transplant vs. only 295 of the 488 patients (60.5%) that did not have late ACR (p < 0.01). The incidence of primary sclerosing cholangitis (PSC) was 32.6% among patients with late ACR and 11.1% among patients without late ACR (p < 0.01). The overall patient survival for patients who had late ACR (n = 43) is 81.4% while for patients without late ACR (n = 488) it is 82.0% (p = ns). Patients remain at risk for ACR even after 1000 d post-transplant, particularly those with PSC.

Liver transplantation for the treatment of metastatic neuroendocrine tumors (NETs) is radical. Although cure is not impossible, it is improbable. The reported experience with transplantation for NETs is limited to less than 150 cases with widely varying results and few 5-year disease-free survivors. We reviewed our experience with transplantation for patients with NETs. Fourteen symptomatic patients with unresectable NET liver metastases who had failed medical management were listed for transplantation. Two patients listed for transplantation underwent prior right lobectomies. Three patients were listed but did not undergo transplantation: one was lost to follow-up, one died 14 months after listing, and one remains waiting over 4 years. Eleven patients underwent liver transplantation, three with living donor grafts. There were four men (36.4%) and seven women (63.6%) who had a mean age of 51.2+/-6.3 years. Three patients had distal pancreatectomies and one patient had a Whipple procedure at the time of transplantation. There were six nonfunctioning tumors (54.6%), three carcinoid tumors (27.3%), and two (18.2%) Vipomas. In one patient, with fulminant hepatic failure, the NET was an incidental finding in the explant. The 1- and 5-year survival among transplanted patients is 73% and 36%, respectively, with a mean follow-up of 34+/-40 months (range 0 to 119 months). Of the three patients surviving more than 5 years, only one was disease free. In carefully selected patients with metastatic NETs, liver transplantation may be an appropriate option.

Background: Acute renal failure (ARF) occurs in 5-50% of patients undergoing orthotopic liver transplantation (OLT). The aim of this study was to determine factors that might predict the development of end stage renal disease (ESRD) in patients who had ARF after OLT., Methods: We studied all OLT recipients between 9/1/1988 through 12/31/2000., Results: A total of 1602 patients underwent OLT during the study period. About 350 patients (22%) developed ARF requiring dialysis post-operatively. One hundred and twenty-three (39.8%) died within a year after OLT. Median follow up was 5.8 yr (range 1-12 yr). Forty-three patients (23%) developed ESRD over median of 3.79 yr (range 1-8 yr). Multivariate logistic regression analysis revealed creatinine levels > 1.7 mg/dL at 1 yr (p < 0.001), cyclosporine as immunosuppression (p = 0.026), and the presence of diabetes pre-OLT (p < 0.001) to be associated with the development of ESRD. The development of ESRD did not decrease patient survival (p = 0.111). ESRD patients who received subsequent kidney transplantation had significantly improved survival rates (p = 0.005)., Conclusions: Serum creatinine levels at 1 yr, cyclosporine as immunosuppression, and the presence of diabetes pre-OLT are independent predictive factors for the development of ESRD. ESRD patients who received kidney transplantation had higher 10-yr survival rates when compared with patients maintained on dialysis.

Posttransplantation allograft malignancy of donor origin is a rare complication after liver transplantation. In the case described, subjective fevers and nonspecific abdominal complaints nearly 6 months following cadaveric liver transplantation in a young woman prompted an evaluation which was remarkable for a large central liver mass. A poorly differentiated squamous cell carcinoma was diagnosed, but was unresectable at exploration. The tumor was confined to the liver. Histocompatibility testing using polymerase chain reaction (PCR) amplification techniques identified both donor and recipient HLA alleles. The patient was treated with chemoembolization, systemic chemotherapy and cessation of immunosuppression. Repeat biopsy 2 months later showed the tumor to be completely necrotic. With decompensated liver disease, she was relisted and retransplanted. More than 2 years later she remains disease-free with complete pathological remission. This is the only reported case of squamous cell carcinoma of donor origin arising in a transplanted liver.

Background: Accurate preoperative radiologic imaging is essential to assess the vascular and biliary anatomy of right-lobe living donors and to ensure their safety. Volumetric magnetic resonance cholangiography (MRCP) using Mangafodipir trisodium (Mn-DPDP) contrast has been recently proposed to evaluate the biliary anatomy of living donor candidates., Methods: During their preoperative evaluation, 18 right-lobe (RL) living donors underwent 3D Mn-DPDP-enhanced MRCP in addition to the standard thin- and thick-slab MRCP imaging. Immediately prior to hepatectomy all 18 RL donors underwent intraoperative cholangiography (IOC) via the cystic duct. We compared the efficacy of these different radiologic techniques to actual intraoperative IOC findings., Results: Sixty-eight intrahepatic bile ducts were identified on IOC, 67(98.5%) by Mn-DPDP-enhanced 3D MRCP, 41 (60%) by thick-slab SSFSE imaging, and 35 (51%) by thin-slice SSFSE imaging. Mn-DPDP-enhanced 3D MRCP detected 100% (n = 5) of the anomalous origins of the right bile duct, and thick-slab MRCP detected 20% (n = 1) and thin-slab MRCP detected 0%. Anterior and posterior right intrahepatic bile ducts were identified by MnDPDP-enhanced 3D MRCP 100% of the time, by thick-slab SSFSE imaging 35% of the time, and by thin-slice SSFSE imaging only 12% of the time., Conclusions: Mn-DPDP-enhanced 3D MRCP imaging was highly sensitive and specific in identifying variants of the intrahepatic bile ducts. This technique should be included in the standard protocol of preoperative radiologic evaluation of RL living donor candidates.

Patients with short-gut syndrome may develop total parenteral nutrition-associated liver disease, which may preclude them from isolated intestinal transplantation and require combined liver and intestinal transplantation. Traditionally, these multiorgan transplantations are performed using en bloc liver and intestinal grafts that share portal, hepatic, and mesenteric blood supplies. In the event that severe intestinal rejection occurs, it is prohibitive in these cases to remove the intestinal portion of the graft. Herein we present the case of a patient with short-gut syndrome caused by volvulus and severe cholestatic liver disease who underwent simultaneous intestinal and liver transplantation using separate grafts from the same cadaveric donor. We discuss the technical aspects of the case and the benefit of such an approach.

We evaluated the influence of portal and hepatic venous hemodynamics on the immediate and 3-month postoperative function of living donor right lobe grafts. Portal velocity was measured prospectively by ultrasound in 14 consecutive donor/recipient pairs. Velocity was converted to flow with the Moriyasu formula. Measurements were taken in donors in the operating room and in recipients at 1 hour after reperfusion and 3 months after transplant. Recipient liver function tests were measured postoperatively. Prereperfusion and postreperfusion liver biopsies were evaluated and correlated with the hemodynamic and biochemical results. There were 11 male (78.6%) and 3 female donors (mean age, 38.9 +/- 9.8 years) for 10 male (71.4%) and 4 female recipients (mean age, 49.3 +/- 14 years). The mean graft/recipient weight ratio was 1.22 +/- 0.3. The mean right portal vein pressure was 8 +/- 1.8 mm Hg in donors versus 13 +/- 4.7 mm Hg in recipients (P < .05). The mean peak flow velocity (Vmax) in the portal vein in donors was 47.6 +/- 12.8 cm/sec (normal, 44 cm/sec). One hour after graft reperfusion in the recipient, the mean portal Vmax was significantly higher at 94.7 +/- 28.4 cm/sec (P = .004), but by 3 months follow-up, mean portal Vmax had fallen to 58.8 +/- 37.8 (P = .01). Recipient portal vein Vmax highly correlated with portal flow (r = 0.7, P = .01). Increased recipient total bilirubin on postoperative day 2 correlated highly with higher recipient portal flow one hour after transplant (r = 0.6; P =.03). Portal vein velocity/flow dramatically increases after reperfusion, returning to baseline about 3 months after transplant. Evaluation of hepatic and portal venous flow is a relatively easy skill to acquire. Intraoperative ultrasound may enable the surgeon to predict graft dysfunction and possibly, may be used to implement pre-emptive therapies.

Recurrence of hemolytic uremic syndrome (HUS) after kidney transplantation is frequent, occurring almost exclusively in patients with atypical HUS, which is not caused by Escherichia coli gastroenteritis and in which diarrhea is absent. Calcineurin inhibitors are associated with recurrence of HUS. In two children who underwent living donor kidney transplantation for atypical HUS, we pre-emptively employed sirolimus in a calcineurin inhibitor-free immunosuppression regimen. Both children had excellent early graft function, yet both developed severe recurrent disease and subsequently lost their grafts. Avoidance of calcineurin inhibitors did not prevent recurrence of severe HUS and graft loss. Transplantation for severe atypical HUS remains problematic.

Late technical complications of composite liver/small bowel transplantation procedures are often complex and have not been well defined. Here we describe the unusual presentation and management of two cases of recurrent thrombocytopenia due to hypersplenism resulting from portacaval shunt stenosis. Both patients presented with portal hypertension late after composite liver/small bowel transplantation. One patient presented with recurrent bouts of upper gastrointestinal hemorrhage and was ultimately found to have a stenosis of her native portacaval shunt. After unsuccessful balloon dilatation of the anastomosis, a successful side-to-side distal splenorenal shunt was performed. The second patient presented with severe thrombocytopenia, the etiology of which was determined to be a short segment occlusion of the inferior vena cava between the native portacaval shunt and the piggyback outflow anastomosis of the liver graft. Total caval occlusion prevented balloon dilatation; the patient was relisted for transplantation but died of chronic rejection four months later. Recurrent portal hypertension is challenging in patients who have had combined liver/small bowel transplantation. Surgeons performing intestinal transplantation need to be increasingly aware of these possible late complications.

Introduction: Small bowel transplantation has been limited by high rates of rejection and graft loss. In June 2000, we began using sirolimus, an immunosuppression agent with proven efficacy in kidney transplantation. We reviewed results among intestinal transplant recipients before and after the introduction of sirolimus., Methods: Thirty-one intestinal transplants were performed in 29 patients at our center between July 1998 and April 2001. All patients were followed for at least 30 days posttransplant. In the first 19 transplants (group 1), patients received tacrolimus, steroids, and antibody induction therapy (either daclizumab or OKT3). In the next 12 consecutive transplants (group 2), patients received tacrolimus, steroids, basiliximab, and sirolimus., Results: Eighteen children (7 males and 11 females, mean age 2.1+/-2.2 years) and 11 adults (9 males and 2 females, mean age 38.1+/-12.4 years) underwent transplantation. All patients survived transplantation. The overall reoperation rate was 1.7 procedures per patient in group 1 and 1.1 procedures per patient in group 2. The most common indications were abscess (n=7), planned second look (n=7), leaks/fistulas (n=6), dehiscence (n=6), obstruction (n=4), ischemic bowel (n=3), perforations (n=3), stomal complications (n=3), and graft removal (n=3). The incidence of biopsy-proven rejection in the first 30 days was 73.7% in group 1 and 16.7% in group 2 (P<0.002). Sirolimus was temporarily held or discontinued in 66.7% of patients. Actuarial 1-year graft survival was 91.7% with sirolimus and 57.9% without sirolimus (P<0.04). Actuarial 1-year patient survival was 91.7% with sirolimus and 79% without sirolimus (P=0.12)., Conclusions: An immunosuppressive regimen that includes sirolimus has improved graft survival. Furthermore, this regimen has significantly decreased the incidence of early rejection and has eliminated early graft loss caused by fulminant rejection.

We report upon a patient with multiple, progressive episodes of temporary monocular blindness associated with acute thrombosis and a critical internal carotid artery stenosis. Carotid angiography demonstrated an anatomically compelling situation consisting of a critical reduction of flow distal to a preocclusive internal carotid artery stenosis accompanied by intraluminal thrombus. The patient was managed successfully by urgent thrombectomy and carotid endarterectomy. This case report highlights principles in management of patients with the unstable neurologic condition of temporary monocular blindness associated with an anatomically compelling situation demonstrated on angiography.

Objective: To summarize the evolution of a living donor liver transplant program and the authors' experience with 109 cases., Summary Background Data: The authors' institution began to offer living donor liver transplants to children in 1993 and to adults in 1998., Methods: Donors were healthy, ages 18 to 60 years, related or unrelated, and ABO-compatible (except in one case). Donor evaluation was thorough. Liver biopsy was performed for abnormal lipid profiles or a history of significant alcohol use, a body mass index more than 28, or suspected steatosis. Imaging studies included angiography, computed tomography, endoscopic retrograde cholangiopancreatography, and magnetic resonance imaging. Recipient evaluation and management were the same as for cadaveric transplant., Results: After ABO screening, 136 potential donors were evaluated for 113 recipients; 23 donors withdrew for medical or personal reasons. Four donor surgeries were aborted; 109 transplants were performed. Fifty children (18 years or younger) received 47 left lateral segments and 3 left lobes; 59 adults received 50 right lobes and 9 left lobes. The average donor hospital stay was 6 days. Two donors each required one unit of banked blood. Right lobe donors had three bile leaks from the cut surface of the liver; all resolved. Another right lobe donor had prolonged hyperbilirubinemia. Three donors had small bowel obstructions; two required operation. All donors are alive and well. The most common indications for transplant were biliary atresia in children (56%) and hepatitis C in adults (40%); 35.6% of adults had hepatocellular carcinoma. Biliary reconstructions in all children and 44 adults were with a Roux-en-Y hepaticojejunostomy; 15 adults had duct-to-duct anastomoses. The incidence of major vascular complications was 12% in children and 11.8% in adult recipients. Children had three bile leaks (6%) and six (12%) biliary strictures. Adult patients had 14 (23.7%) bile leaks and 4 (6.8%) biliary strictures. Patient and graft survival rates were 87.6% and 81%, respectively, at 1 year and 75.1% and 69.6% at 5 years. In children, patient and graft survival rates were 89.9% and 85.8%, respectively, at 1 year and 80.9% and 78% at 5 years. In adults, patient and graft survival rates were 85.6% and 77%, respectively, at 1 year., Conclusion: Living donor liver transplantation has become an important option for our patients and has dramatically changed our approach to patients with liver failure. The donor surgery is safe and can be done with minimal complications. We expect that living donor liver transplants will represent more than 50% of our transplants within 3 years.

Skin and soft-tissue infections that usually follow minor traumatic events or surgical procedures are caused by a wide spectrum of bacteria. Less frequently, the infections occur spontaneously, which often is clinically confusing and leads to delays in diagnosis. Most of the infections are self-limited and easily treated with local measures and/or antibiotics. Others are life-threatening, requiring prompt diagnosis and aggressive surgical debridement in addition to the wise choice of antibiotic agents to limit tissue loss and preserve life. Many survivors experience critical tissue losses that may require changes in lifestyle as well as major reconstructive cosmetic surgery. Involvement of antibiotic-resistant gram-positive microorganisms in these infections only increases the difficulty of their treatment and may have a significant influence on the ultimate outcome.

Biliary cystadenoma is a very rare cystic neoplasm of the liver. This tumor is insidiously progressive and usually presents in white females in their fifth decade. It has a characteristic appearance on ultrasound, computed tomography, and angiography. The exact etiology of these tumors is unknown, but several theories have been proposed. Historically these cystic tumors have been treated by a variety of techniques including aspiration, fenestration, internal drainage, and resection. Previously reported series have confirmed a >90 percent recurrence rate with anything less than complete excision. In addition biliary cystadenoma is a premalignant lesion and only surgical excision can differentiate it from its malignant counterpart, biliary cystadenocarcinoma.

Background: Recurrence of hepatitis C after liver transplantation is an almost universal occurrence. T-cell derived cytokines have an important role in the development of liver damage associated with chronic hepatitis C, their post-transplant levels, however, have not been correlated with histologic recurrence of the disease., Aims: We sought to analyze levels of TNF-alpha, soluble IL-2 receptor, IL-4 and IL-10 at 1 month, 6 months and 1 year after transplantation in 27 patients undergoing transplantation for hepatitis C related end-stage liver disease., Methods: HCV RNA levels were monitored by a branched-chain DNA signal amplification assay. Diagnosis of recurrent hepatitis was based on 1-year protocol biopsies and on biopsies performed for liver enzyme elevations., Results: Recurrent hepatitis C was detected in 52% (n=14) of the 27 patients. HCV RNA levels rose over time in all patients regardless of histologic recurrence. TNF-alpha, and IL-4 levels, although elevated, did not show specific patterns over time or in correlation with recurrence. Similarly, the early elevation followed by a gradual decrease over the first year in the amount of soluble IL-2 receptor was not related to histologic recurrence. We observed a significant increase in circulating IL-10 levels over the first year in patients with biopsy-proven recurrence, while patients with no signs of histologic recurrence displayed increased, but steady levels., Conclusions: These results suggest that while these cytokines are associated with post-transplant recurrence of hepatitis C, their production may be altered by additional factors.

Background: Experimental models of liver transplantation use normal recipients, although most patients undergoing liver transplantation suffer from acute or chronic liver failure. This study was designed to analyze the outcome of orthotopic liver transplantation in compromised rat hosts., Methods: Recipient animals were either rats with D-galactosamine-induced acute or rats with chronic liver failure secondary to common bile duct ligation. Liver damage was evaluated by monitoring enzymes, bilirubin, ammonia levels, prothrombin, thrombin time, and cytokines. In vivo function of hepatocytes and sinusoidal endothelial cells were evaluated by indocyanine green and hyaluronic acid uptake. Transplantation was performed in normal, acute, and chronic liver failure rats at different time points using either freshly harvested or cold-preserved syngeneic livers., Results: Survival with fresh grafts decreased significantly when transplants were performed 48 hr after the induction of acute liver failure. No rats with acute liver failure survived transplantation with grafts stored for 12 or 24 hr although in chronic failure survival was more 80%. Survival of acute liver failure rats receiving 6 hr preserved grafts was 16.6% compared with 83.3% observed with fresh grafts transplanted at the same time point after D-galactosamine injection. Elevated tumor necrosis factor-alpha and interleukin-1beta levels as well as impaired sinusoidal endothelial cell function were detected in acute liver failure rats with 6 h preserved grafts., Conclusion: These results suggest that preoperative status and different host factors have a significant effect on outcome and graft function after liver transplantation in rats.

Nearly 2000 liver transplants have been performed over the past 12 years at Mount Sinai, with a recent exponential growth in living donor surgeries. Living-donor liver transplantation has emerged as an important option for our patients with end-stage liver disease. We are only beginning to recognize fully the advantages that 'scheduled' liver transplantation can offer. In this era of severe cadaver organ shortages, living donation offers patients the option of liver replacement in a timely fashion, before life-threatening complications of hepatic failure and/or carcinoma progression prohibit transplantation. The next era of transplantation at Mount Sinai will bring significant increases in the number of transplants performed with living donors, with projections of over 50% of the total transplants each year expected to involve living donations. We are committed to offering this option while recognizing that donor safety remains paramount and cannot be overemphasized. Proper donor and recipient selection, as well as surgical experience are imperative to success with this technically demanding procedure. Recurrent disease after transplantation, particularly with hepatitis C, remains a challenge clinically. Further investigations into the pathogenesis of the rapid progression of recurrent hepatitis C need to be addressed. Living donor transplantation could be an important option for these patients and would allow timely transplantation and the potential for improved survival in patients with hepatocellular carcinoma.

We reviewed our initial experience with helical computed tomography (CT) angiography in the evaluation of living kidney donors which, until now, has necessitated arteriography. Nineteen donors (12 women, 7 men) have had their renal anatomy evaluated solely by CT angiography preoperatively. All scans demonstrated normal collecting systems and single ureters. Five donors (26%) had supernumerary renal arteries. Fourteen donors had single, 4 donors had two, and 1 donor had three renal arteries. Helical CT demonstrated small polar vessels in several donors. Two donors (10%) had supernumerary renal veins. Accuracy of vascular anatomy defined on CT was 90% when confirmed at operation. Anatomically all CT findings were consistent with operative findings except in 1 donor who was found to have a 0.8 cm lesion near the renal hilum. At our institution, the total charges for selective renal arteriography are $3845 and for helical CT with three-dimensional (3-D) reconstruction are $1546. The amount of contrast dye (approximately 100 mL) is equivalent. Patients uniformly reported that the CT scan was a convenient and painless procedure. The accuracy of helical CT angiography is equivalent to arteriography in assessing renal vascular anatomy (with the additional benefit of imaging venous and parenchymal anatomy). Charges for helical CT are 59% less. There is greater patient acceptance and potentially less morbidity associated with the non-invasive nature of helical CT. We believe that CT angiography is the radiologic procedure of choice for the assessment of renal anatomy in potential living kidney donors.

Background: The injury resulting from cold preservation/reperfusion primarily affects sinusoidal endothelial cells, while hepatocytes are thought to be less vulnerable; morphological changes and increased cytokine release suggest that Kupffer cells are activated. We evaluated the extent of functional damage to the different cell types in the liver after cold preservation and transplantation. Additionally, we analyzed in vivo the patterns of functional recovery of all three cell types over the first week after transplantation in Lewis rats., Methods: We evaluated the in vivo uptake of hyaluronic acid, indocyanine green, and radio-labeled sulphur colloid to assess the function of sinusoidal endothelial cells, hepatocytes, and Kupffer cells, respectively. Measurements were performed immediately after transplantation using syngeneic grafts preserved in University of Wisconsin solution for different periods. Functional recovery was monitored in animals receiving grafts preserved for 24 hr over the first postoperative week., Results: We found that hepatocyte were less affected compared with the profoundly damaged endothelial cells. The phagocytic ability of Kupffer cells was, however, also seriously compromised, which suggests a selective down-regulation. Functional recovery occurs in a differential manner during the first postoperative week starting with hepatocytes followed by sinusoidal endothelial cells. Phagocytic function further deteriorates after transplantation before showing improvement., Conclusions: In viable liver grafts, all cell types recover from preservation/reperfusion injury by the end of the first week after transplantation. The differential time courses of the recovery suggest that successful sinusoidal endothelial cell recovery may depend upon prior hepatocyte regeneration and may involve a paracrine interaction, via cytokines and growth factors.

Background: This study was designed to evaluate the effect of donor hyperosmolarity secondary to diabetes insipidus, an almost universal occurrence among brain-dead patients, on hepatic function., Methods: In vitro (isolated liver perfusion) and in vivo (hyaluronic acid and indocyanine green uptake, arterial ketone body ratio, orthotopic liver transplantation) experiments were conducted using Brattleboro rats, with hereditary hypothalamic diabetes insipidus, and Sprague-Dawley rats, with normal pituitary function. ATP content and recovery after cold preservation were measured during the perfusion., Results: Cold-preserved livers from hyperosmolar rats were observed to have elevated hepatic enzyme release and decreased bile production compared with normosmolar controls. Moreover, in these livers, the recovery of ATP after cold preservation was completely absent. Transmission electron microscopy of liver biopsies collected from hyperosmolar rats demonstrated profound ultrastructural changes, particularly in the mitochondria, that were not evident in the biopsies from normosmolar rats. All the experimental groups demonstrated similar hyaluronic acid uptake, whereas indocyanine green uptake was markedly impaired in the hyperosmolar group, suggesting that hepatocyte and not sinusoidal endothelial cell function is adversely affected by hyperosmolarity. The arterial ketone body ratio was profoundly compromised by chronic and, to an even greater degree, by acute hyperosmolarity. Survival after transplantation using hyperosmolar donors was not affected in this study., Conclusions: These results are an important step toward understanding the mechanism whereby brain death, a complicated pathophysiologic phenomenon, adversely affects the hepatic allograft.

Blunt trauma can cause a wide range of injuries to the cartilaginous framework of the larynx. The severity of injury that is required to cause a permanent disorder of vocal function if left untreated has not been defined. A study using excised canine and human larynges was undertaken to identify the effects of minimal displacement or malalignment in simulated thyroid cartilage fractures on selected voice production measurements. These fractures were found to cause changes in glottal configuration sufficient to affect glottal resistance as well as amplitude and noise content of the voice signal produced by each larynx. Therefore, relatively minor injuries of the thyroid cartilage may cause potentially serious disorders of phonation.