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The success of direct-acting antiviral (DAA) therapy has led to near-universal cure for patients chronically infected with hepatitis C virus (HCV) and improved post-liver transplant (LT) outcomes. We investigated the trends and outcomes of retransplantation in HCV and non-HCV patients before and after the introduction of DAA. Adult patients who underwent re-LT were identified in the Organ Procurement and Transplantation Network/United Network for Organ Sharing database. Multiorgan transplants and patients with >2 total LTs were excluded. Two eras were defined: pre-DAA (2009-2012) and post-DAA (2014-2017). A total of 2112 re-LT patients were eligible (HCV: n = 499 pre-DAA and n = 322 post-DAA; non-HCV: n = 547 pre-DAA and n = 744 post-DAA). HCV patients had both improved graft and patient survival after re-LT in the post-DAA era. One-year graft survival was 69.8% pre-DAA and 83.8% post-DAA (P < .001). One-year patient survival was 73.1% pre-DAA and 86.2% post-DAA (P < .001). Graft and patient survival was similar between eras for non-HCV patients. When adjusted, the post-DAA era represented an independent positive predictive factor for graft and patient survival (hazard ratio [HR]: 0.67; P = .005, and HR: 0.65; P = .004) only in HCV patients. The positive post-DAA era effect was observed only in HCV patients with first graft loss due to disease recurrence (HR: 0.31; P = .002, HR 0.32; P = .003, respectively). Among HCV patients, receiving a re-LT in the post-DAA era was associated with improved patient and graft survival.

Enhanced recovery after surgery (ERAS) pathway is a multimodal perioperative care pathway designed to achieve early recovery after surgery. ERAS protocols have not yet been well recognized in kidney transplantation. The aim of this study was to investigate the impact of ERAS pathway on early recovery and short-term clinical outcomes of kidney transplant.This is a single-center retrospective analysis comparing the outcomes of 20 adult kidney transplant recipients subjected to ERAS pathway with 20 adult recipients operated before ERAS with traditional standard of care.There were no significant differences between both groups regarding age, gender, race, dialysis status, living donor percentage, cold ischemia time, and warm ischemia time. Median hospital stay for ERAS patients was 2 d. Overall median pain scores were significantly lower in the ERAS group versus non-ERAS group (morning after surgery pain score 2 versus 5; peak pain score 4.5 versus 10; lowest pain score 0 versus 2;Implementation of ERAS pathway in kidney transplantation is feasible. Using ERAS is associated with less pain, earlier ambulation and advancement of oral nutrition, and short hospital stay.

There is a paucity of data on long-term outcomes following visceral transplantation in the contemporary era. This is a single-center retrospective analysis of all visceral allograft recipients who underwent transplant between November 2003 and December 2013 with at least 3-year follow up data. Clinical data from a prospectively maintained database was used to assess outcomes including patient and graft survival. Of 174 recipients, 90 were adults and 84 were pediatric patients. Types of visceral transplants were isolated intestinal transplant (56.3%), combined liver intestinal transplant (25.3%), multi-visceral transplant (16.1%) and modified multi-visceral transplant (2.3%). 3-, 5-, and 10-year overall patient survival was 69.5%, 66%, and 63%, respectively, while 3-, 5-, and 10-year overall graft survival was 67%, 62%, and 61%, respectively. In multivariable analysis, significant predictors of survival included pediatric recipient (P= 0.001), donor/recipient weight ratio less than 0.9 (P= 0.008), no episodes of severe acute rejection (P= 0.021), cold ischemia time less than 8 hours (P= 0.014) and shorter hospital stay (P= 0.0001). In conclusion, visceral transplantation remains a good option for treatment of end stage intestinal failure with parenteral nutritional complications. Proper graft selection, shorter cold ischemia time and improvement of immunosuppression regimens could significantly improve the long-term survival.

Background Few studies investigated biliary leakage after pancreaticoduodenectomy (PD) especially when compared to postoperative pancreatic fistula (POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management. Methods We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group (1) included patients who developed biliary leakage and group (2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed. Results The study included 555 patients. Forty-four patients (7.9%) developed biliary leakage. Ten patients (1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography (ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients (90.9%). Only 4 patients (9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group (6.8% vs 3.9%, P = 0.05). Conclusions Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

Objectives Intestinal transplantation is an option for permanent intestinal failure with parenteral nutrition intolerance. We sought to determine long-term intestinal graft survival in pediatric patients at our center and to identify factors influencing survival. Methods Retrospective chart review of 86 patients transplanted between 2003 and 2013, targeting potential explanatory variables related to demographics, perioperative factors, and postoperative complications. Results Intestinal graft survival was 71% and 65% after 5 and 10 years, respectively. Five-year graft survival was attained in 79% of patients with a history of anatomic intestinal failure compared with 45% with functional intestinal failure (P = 0.0055). Compared with nonsurvival, 5-year graft survival was also associated with reduced incidences of graft-versus-host disease (2% vs 16%, P = 0.0237), post-transplant lymphoproliferative disorder (3% vs 24%, P = 0.0067), and de novo donor-specific antibodies (19% vs 57%, P = 0.0451) plus a lower donor-recipient weight ratio (median 0.727 vs 0.923, P = 0.0316). Factors not associated with 5-year intestinal graft survival included graft rejection of any severity and inclusion of a liver graft. Factors associated with graft survival at 10 years were similar to those at 5 years. Conclusions In our experience, outcomes in pediatric intestinal transplantation have improved substantially for anatomic but not functional intestinal failure. Graft survival depends on avoidance of severe infectious and immunological complications including GVHD, whereas inclusion of a liver graft provides no obvious survival benefit. Reduced success with functional intestinal failure may reflect inherently increased susceptibility to complications in this group.

Background. There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD. Patients and Method. This is a propensity score–matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay. Results. The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to oral intake, total amount of drainage, and time of nasogastric tube removal. Univariate and multivariate analyses demonstrated 3 independent factors of development of postoperative pancreatic fistula: pancreatic duct 25, and soft pancreas. Conclusion. Surgical loupes 4.0× added no advantage in surgical outcomes of PD with regard to improvement of postoperative complications rate or mortality rate.

Summary Background/Objective The potential benefit of preoperative biliary drainage (PBD) on postoperative outcomes remains controversial. The aim of this study was to elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with PBD and to show the impact of bilirubin level. Methods We retrospectively studied all patients who underwent PD in our center between January 2003 and June 2015. Patients were divided into: Group A (PBD) and Group B (no PBD). The primary outcome was the rate of postoperative complication. Results A total of 588 cases underwent PD. Group A included 314 (53.4%) patients while Group B included 274 (46.6%) patients. The overall incidence of complications and its severity were higher in Group A ( p = 0.03 and p = 0.02). There was significant difference in the incidence of postoperative pancreatic fistula ( p = 0.002), delayed gastric emptying ( p = 0.005), biliary leakage ( p = 0.04), abdominal collection ( p = 0.04), and wound infection ( p = 0.04) in Group A. The mean length of hospital stay was significantly longer in Group A than in Group B (12.86 ± 7.65 days vs. 11.05 ± 7.98 days, p = 0.01). No significant impact of preoperative bilirubin level on surgical outcome was detected. Conclusion PBD before PD was associated with major postoperative complications and stent-related complications.

PURPOSE OF REVIEW This article summarizes the complex interplay between the microbiota and host immune responses, and its impact on intestinal transplantation and allograft rejection. RECENT FINDINGS Recent findings highlight the importance of Paneth cells as crucial producers of antimicrobial peptides that control the intestinal host-microbial interface as well as the essential role of NOD2 as a master regulator of antimicrobial host defenses. Moreover, complex interactions between innate and adaptive immune responses have been shown to critically shape host antimicrobial Th17 responses, which may be key for the pathogenesis of inflammatory bowel diseases and intestinal allograft rejection. SUMMARY A growing body of evidence indicates that crosstalk between the microbiome and innate and adaptive host immunity determines alloimmune responses and outcomes in intestinal transplantation. Elaboration of this emerging field might lead to novel mechanistic insight into these complex interactions and allow for new therapeutic approaches.

Diaphragmatic hernia (DH) after hepatic resection (HR) is a rare and not well-described complication. We report our experience with DH following a high volume of HRs in a tertiary center.Records of patients undergoing major HR for liver tumors between April 1992 and November 2011 were reviewed. The definitive diagnosis of DH was made based on radiologic studies. Primary repair was used for defects10 cm in size. Transthoracic repair was used in patients with recurrent or complex hernias. Univariate analysis was performed to determine risk factors associated with posthepatectomy DH.DH developed in 10 out of 993 patients (1%) at a median time interval of 15 months after HR. DH was not associated with old age (m = 48.5 years), gender (male = 50%), or high body mass index (m = 24.5). However, mean tumor size was large (m = 9.2 cm). The majority of patients presented with symptoms (80 %), small (60%) and right-sided (80%) hernias, and underwent elective repair via an abdominal approach (70%). Large defects (10 cm; 30%) were successfully repaired with prosthetic mesh. Increased incidence of DH was associated with diaphragmatic resection at the time of HR (5.4 vs. 0.7%, p = 0.001). At a median follow-up of 36 months (range, 10-167 months) after hernia repair, recurrence occurred in one patient.Diaphragmatic resection at the time of HR and large tumor size may put patients at risk of developing posthepatectomy DH. Early detection and prompt treatment is associated with low recurrence and offers the advantage of primary repair.

Fat malabsorption is common after SBT. To identify whether anatomic variant transplants differ in occurrence of exocrine pancreatic insufficiency that could contribute to fat malabsorption, we measured FPE repeatedly in 54 recipients of a SBT, ages 6.2 to 320 months. FPE determination most distant from SBT was 6.1 years. Of the 54, 39% received an isolated intestinal graft (native pancreas only), 48% received an en bloc liver-intestinal-pancreas graft (native and graft pancreas), and 13% received a multivisceral graft (graft pancreas only). Initial FPE was normal (>200 μg/g) in 15 of the 54 at a median of 22 (11-61) days after SBT. Recipients of a liver-intestine-pancreas transplant were more likely to have normal FPE within 30 days after SBT than were isolated intestinal or multivisceral transplant recipients (47%, 19%, and 0%, respectively, P = .049). Of the remaining 39 patients, 34 eventually demonstrated a normal FPE at a median of 168 (31-943) days after SBT. Type of SBT did not influence the likelihood of achieving a normal FPE level or time when it occurred. Five (9%) patients failed to achieve normal FPE, including 3 who died within 2 years after SBT. In conclusion, possessing both graft and native pancreas as in transplantation of an en bloc liver-intestinal-pancreas graft facilitates early normalization of FPE that eventually occurs in most patients irrespective of transplant type. Failure to recover normal pancreatic function may be associated with severe post-transplant complications.

Background Data on rate, risk factors, and consequences of early reoperation after liver transplantation are still limited. Study design Single-center retrospective analysis of data of 428 patients, who underwent liver transplantation in period between January 2009 and December 2014. Univariate and multivariate analysis were used to study the risk factors of early reoperation and its impact on graft survival. Results Of 428 patients, 74 (17.3%) underwent early reoperation. Of them, 46 (62.2%) underwent reoperation within the first week and 28 (37.8%) underwent reoperation later than 1 week after transplantation. With multivariate analysis, significant risk factors of early reoperation included pretransplant ICU admission, previous abdominal surgery and diabetes. Early reoperation itself was not found to be an independent predictor of graft loss. However, early reoperation later than 7 days from transplant was found to be independent predictor of graft loss (odds ratio [OR] = 5.125; 95% CI, 1.358-19.552; P = .016). In our series, other independent predictors of graft loss were MELD score (P = .010) and operative time (P = .048). Conclusions This analysis demonstrates that early reoperations later than a week appear to negatively impact the graft survival. The timing of early reoperation should be a focus of additional studies.

We present a case of a 2-year-old child who underwent a combined en bloc liver and pancreas transplant following complications of WRS. WRS is characterized clinically through infantile insulin-dependent diabetes mellitus, neutropenia, recurrent infections, propensity for liver failure following viral infections, bone dysplasia, and developmental delay. Usually, death occurs from fulminant liver and concomitant kidney failure. Few cases with WRS are reported in the literature, mostly from consanguineous parents. To the best of our knowledge, combined en bloc liver and pancreas transplant has not been performed in small children.

Background Split liver transplantation allows for expansion of the pool of organs available for pediatric liver transplantation. The impact of sharing segments of the same liver between centers has not been studied. Study Design Retrospective analysis of 24 pediatric split liver transplant cases in a recent cohort. We evaluated the outcomes of pediatric recipients who shared organs with adult patients in our own center (group A) compared to recipients who shared organs with adult patients in other centers. (group B). Results 1-, 3-, and 5-year graft survival for group A was 100%, 100%, and 100% versus 83%, 71%, and 57% for group B (P= 0.039). Postoperative complications included biliary complications (41.7% in group A vs. 50% in group B, P=0.682), vascular complications (8.3% in group A vs. 41.7% in group B, P=0.059), postoperative bleeding (16.7% in group A vs. 25% in group B, P =0.615). High grade Clavien-Dindo complications were 0% in group A vs. 33.3% in group B, P= 0.028. Conclusions Organ sharing between centers appears to be associated with significantly poorer graft survival. Possible explanations include greater procurement related injury or suboptimal vessel distribution. Future larger studies focused on this area may be helpful to formulate policy considerations. This article is protected by copyright. All rights reserved.

Background The esophagogastric cancers (EGCs) are rapidly increasing in Western countries. This study was conducted to elucidate the distribution and surgical outcomes of EGC. Patients and methods We retrospectively studied 90 patients who underwent curative surgery for esophagogastric junction cancer according to Siewert's classification during the period between January 2005 and July 2014. The collected information included preoperative, operative, and postoperative data. We also compared these data among the EGC subtypes. Results A total of 90 patients were eligible and were included in the study. The median follow-up period was 17.68 (0.2-130.92) months. Thirty-five patients had type I (38.9%), 32 had type II (35.6%), and 23 patients had type III tumors (25.6%). There were no significant differences in age, sex, and Borrmann macroscopic types between the three subtypes. Thoracotomy was used most often in type I tumors (74.3%) as compared with type II (28.1%) and type III (13%) tumors (P = 0.0001). Multivariate analysis confirmed that only tumor size (P = 0.023) and lymph node metastasis (P = 0.020) and presence of Borrmann macroscopic appearance of type II tumor (0.039) were significant and independent prognostic indicators for survival after curative resection for EGC. Conclusion The selection of the surgical approach for resection of EGC carcinoma should be tailored and achieving tumor-free safety margin. Tumor size and lymph node metastasis and presence of Borrmann macroscopic appearance of type II tumor were significant and independent prognostic indicators for survival after curative resection for EGC.