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BACKGROUND AND AIMS: The Liver Reporting and Data System (LI-RADS) is the standard classification of imaging findings of hepatic abnormalities for hepatocellular carcinoma (HCC) surveillance. We aimed to study the course of LI-RADS 3 and 4 (LR-3 and LR-4) abnormalities through correlations with explant pathology. METHODS: A single center retrospective study of liver transplant recipients between January 2016 and September 2019 with HCC on explant pathology was conducted. Eligible patients were divided into three subgroups based on their LI-RADS classification: LR-3/4, LR-5 only, and combination of LR-3/4/5. RESULTS: There were 116 eligible patients with 99 LR-3/4 observations (60 LR-3 and 39 LR-4); the rest had LR-5 lesions. LR-4 more often than LR-3 observations progressed to LR-5 (36% vs 12%) and with shorter duration during follow-up (median 175 days and 196 days). Mean size growth of LR-3 and LR-4 abnormalities were 2.6 and 3.8 mm; median growth rates were 0.2 and 0.4 mm/month, respectively. Numbers of HCC lesions per explant, largest HCC lesion size, and cumulative size were higher in LR-3/4/5 subgroup than LR-5 subgroup (P = 0.007, 0.007 and 0.006, respectively); 68% of LR-3 and 82% of LR-4 abnormalities were confirmed HCC on explant (P = 0.09). CONCLUSION: Compared to LR-3, more LR-4 abnormalities progressed to LR-5 (12% and 36%, respectively) in a shorter time and with faster growth rate. A high proportion of LR-3 and LR-4 lesions (68% and 82%, respectively) were confirmed HCC on explant, raising the question of whether excluding HCC based on radiologic criteria alone is adequate in those with LR-3/4 abnormalities.

This systematic review and expert panel recommendation aims to answer the question regarding the routine use of T-tubes or abdominal drains to better manage complications and thereby improve outcomes after liver transplantation.Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel to assess the potential risks and benefits of T-tubes and intra-abdominal drainage in liver transplantation (CRD42021243036).Of the 2996 screened records, 33 studies were included in the systematic review, of which 29 (6 RCT) assessed the use of T-tubes and 4 regarding surgical drains. Although some studies reported less strictures when using a T-tube, there was a trend towards more biliary complications with T-tubes, mainly related to biliary leakage. Due to the small number of studies, there was a paucity of evidence on the effect of abdominal drains with no clear benefit for or against the use of drainage. However, one study investigating the open vs. closed circuit drains found a significantly higher incidence of intra-abdominal infections when open-circuit drains were used.Due to the potential risk of biliary leakage and infections, the routine intraoperative insertion of T-tubes is not recommended (Level of Evidence moderate - very low; grade of recommendation strong). However, a T-tube can be considered in cases at risk for biliary stenosis. Due to the scant evidence on abdominal drainage, no change in clinical practice in individual centers is recommended. (Level of Evidence very low; weak recommendation). This article is protected by copyright. All rights reserved.

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

Extremely heterogeneous revision rates in total ankle arthroplasty (TAA) of the upper ankle joint are reported and result to heterogeneous collectives and to short follow-up times. The aim is to investigate revision rates and the underlying reasons, as well as treatment outcome and quality of life after TAA in post-traumatic cases with sufficient follow-up. In 2008–2013, 74 patients with post-traumatic arthrosis were treated using TAA with a Tornier Salto prosthesis, and 60 (35 males and 25 females; mean age 56) were followed-up (mean: 59 months; range 24–91 months). The revision rate after TAA was 42% (n = 25), and it was 8% after 12 months and 18% after 24 months. Twenty percent of the patients had significant symptomatic periprosthetic bone cysts, 5% had impingement, 3% had soft tissue infections, and, in 14%, revision was caused by other factors. The most commonly performed procedures were cyst debridement and autologous spongy bone grafting (20%). Fifteen percent (n = 9) of the prosthetics were explanted or switched to a tibiotalar arthrodesis (TTA). The mean AOFAS (American Orthopaedic Foot and Ankle Society) score was 55.15 (range 12–100) and the mean FAO (Foot and Ankle Outcome) score was 49.6 (range 18–100). The revision subgroup had impaired outcomes (AOFAS 38.84; FAO 35.5) while the non-revision subgroup had improved outcomes (AOFAS 66.8; FAO 60.48). TAA patients undergoing conversion to TTA had worse outcomes (AOFAS 39; FAO 35.29). Total ankle replacement in post-traumatic end-stage arthrosis patients is associated with high revision rates. High rates of symptomatic periprosthetic bone cysts caused high rates of revision surgery and worse outcomes, which were not improved by secondary TTA.

Zusammenfassung Hier wird erstmalig die Behandlung eines Knorpeldefektes im lateralen Talus durch die Implantation von einer chondrotissue ® Matrix durchgefuhrt. In diesem Fallbeispiel werden die klinischen Ergebnisse einer neuen Kombinationsbehandlung aus arthrotomisch durchgefuhrter Mikrofrakturierung und chondrotissue ® nach 7 Monaten gezeigt. Dabei handelt es sich um eine neue zellfreie und chondroinduktive Defektabdeckung aus einem bioresorbierbaren Polymer und Hyaluronsaure, Diese Abdeckung wird nach der Mikrofrakturierung mit einer 6,0-Vicral-Naht im Defekt fixiert und hat die Vorteile, dass sie das darunter liegende Gewebe schutzt und die Hamostase im Defekt induziert. Nach einer klinischen Folgebetrachtungszeit von 7 Monaten fuhrt die Kombination aus chondrotissue ® und Mikrofrakturierung zu einer guten Defektfullung mit knorpelartigem Ersatzgewebe und verbessert dadurch die Knorpelregeneration im Talusdefekt.

This study was undertaken to answer the question: "Is Arnica D4 as efficacious as diclofenac in relation to symptoms and wound healing after foot surgery?"In this randomized double-blinded, parallel-group study (GCP-standard), the efficacy of Arnica D4 10 pillules (taken orally, 3 times per day) and diclofenac sodium, 50 mg (taken orally, 3 times per day) were investigated for equivalence in 88 patients 4 days after hallux valgus surgery. Outcome parameters were (1) postoperative irritation, (2) patient mobility, (3) rated pain, and (4) use of analgesics. The hierarchic equivalence test based on one-sided Wilcoxon-Mann-Whitney-U confidence intervals (CIs) was used. Equivalence was perceived, when the lower margin of the 95% CI was0.36 corresponding to a range of equivalence of 1/2 standard deviation.Arnica D4 and diclofenac were equivalent for wound irritation (lower margin of the 95% CI on day 4: 0.4729 for rubor; 0.3674 for swelling; 0.4106 for calor) and patient mobility (0.4726). A descriptive analysis showed the superiority of Arnica D4 with respect to patient mobility (p = 0.045). With respect to pain, Arnica D4 was inferior to diclofenac (lower margin of the 95% CI 0.026). No significant differences were found regarding the use of additional analgesics during the 4 postoperative days (Dipidolor, Janssen-Cilag, Neuss, Germany; p = 0.54; Tramal, Grünenthal, Aachen, Germany; p = 0.1; and Novalgin, AVENTIS-Pharma, Bad Soden, Germany; p = 0.1). Arnica D4 was significantly better tolerated than diclofenac (p = 0.049). Nine (9) patients (20.45%) of the diclofenac group and 2 (4.5%) of the Arnica D4 group reported intolerance. There was no disturbance in wound healing in any of the patients. Arnica D4 is 60% cheaper than diclofenac.After foot operations, Arnica D4 can be used instead of diclofenac to reduce wound irritation.

Inferior outcomes are consistently observed for recipients of liver retransplantation (re-LT) versus recipients of primary transplants. Few studies have examined the incidence and impact of biliary complications (BCs) on outcomes after re-LT. The aim of this study was to compare patient and graft survival for re-LT recipients with BCs (BC(+) ) and re-LT recipients without BCs (BC(-) ). Additional aims were to determine the impact of biliary reconstruction on the incidence of BCs and to identify risk factors for BCs after re-LT. A single-center, retrospective analysis of all re-LT recipients over a decade was performed. Univariate analyses were performed, and survival was compared with the log-rank method. A multivariate Cox regression analysis was performed to determine independent predictors of death and graft failure. The BC rate was 20.9% (n = 23) for 110 re-LT cases. The average follow-up was 55 months. The survival rates for BC(-) recipients at 3 months and 1, 3, and 5 years were 95.3%, 91.7%, 85.4%, and 80.9%, respectively, whereas BC(+) patients had survival rates of 64.3%, 49.7%, 34.8%, and 29.8%, respectively (P 0.001, log-rank). The graft survival rates at 3 months and 1, 3, and 5 years were 92.0%, 88.5%, 82.4%, and 78.0%, respectively, for the BC(-) group and 60.9%, 43.5%, 30.4%, and 26.1%, respectively, for the BC(+) group (P 0.001, log-rank). BCs, a length of stay ≥ 12 days, and donor age were strongly associated with death and graft failure in a regression analysis, whereas retransplant indications other than chronic rejection and recurrent disease also affected graft failure. In conclusion, BCs significantly affected both patient and graft survival, with an increased risk of death and graft loss among BC(+) recipients. Early recognition, appropriate interventions, and preventative measures for BCs are critical in the clinical management of re-LT recipients.

Adult recipients of living donor liver transplantation (LDLT) have a higher incidence of biliary complications than recipients of deceased donor liver transplantation (DDLT). Our objective was to define the intensity of the interventions and the time to resolution after the diagnosis of biliary complications after liver transplantation. We analyzed the management and resolution of posttransplant biliary complications and investigated the comparative effectiveness of interventions in LDLT and DDLT recipients. For the analysis of biliary complications (leaks or strictures), we used a retrospective cohort of patients who underwent liver transplantation at 8 centers between 1998 and 2006 (median follow-up from onset=4.7 years). The numbers, procedure types, and times to resolution were compared for LDLT and DDLT recipients. Posttransplant biliary complications occurred in 47 of the 189 DDLT recipients (25%) and in 141 of the 356 LDLT recipients (40%). Biliary leaks constituted 38% of the post-DDLT biliary complications (n=18) and 65% of the post-LDLT biliary complications (n=91). The median times to first biliary complications were similar for DDLT and LDLT (11 versus 14 days for leaks, P=0.63; 69 versus 107 days for strictures, P=0.34). Overall, 1225 diagnostic and therapeutic procedures, including reoperation and retransplantation, were performed (6.5±5.4 per recipient; 5.5±3.6 for DDLT versus 6.8±5.8 for LDLT, P=0.52). The median number of months to the resolution of a biliary complication (i.e., a tube-, stent-, and drain-free status) did not significantly differ between the DDLT and LDLT groups for leaks (2.3 versus 1.3 months, P=0.29) or strictures (4.9 versus 2.3 months, P=0.61). Although the incidence of biliary complications is higher after LDLT versus DDLT, the treatment requirements and the time to resolution after the development of a biliary complication are similar for LDLT and DDLT recipients.

Candidates with hepatocellular carcinoma (HCC) within the Milan criteria (MC) receive standardized Model for End-Stage LIver Disease (MELD) exception points because of the projected risk of tumor expansion beyond the MC. Exception points at listing are meant to be equivalent to a 15% rusj if 90-day mortality, with additional points granted every 3 months, equivalent to a 10% increased morality risk. We analyzed the United Network for Organ Sharing database (January 1, 2005 to May 31, 2009) to compare the 90-day waitlist outcomes of HCC candidates and non-HCC candidates with similar MELD scores. Two hundred fifty-nine HCC candidates (4.1%) who were initially listed with 22 MELD exception points were removed because of death or clinical deterioration within 90 days of listing, whereas 283 non-HCC candidates (11.0%) with initial laboratory MELD scores of 21 to 23 were removed. Ninety-three HCC candidates (4.6%) with 25 exception points (after 3-6 months of waiting) were removed because of death or clinical deterioration within 90 days, whereas 805 non-HCC candidates (17.3%) with laboratory MELD scores of 24 to 26 were removed. Twenty HCC candidates (3.0%) with 28 exception points (after 6-9 months of waiting) were removed for death or clinical deterioration within 90 days, whereas 646 non-HCC candidates (23.6%) with laboratory MELD scores of 27 to 29 were removed. In multivariate logistic regression models, HCC candidates had significantly lower 90-day odds of waitlist removal for death or clinical deterioration (P0.001). Over time, the risk of waitlist removal for death or clinical deterioration was unchanged for HCC candidates (P = 0.17), whereas it increased significantly for non-HCC candidates. The current allotment of HCC exception points should be re-evaluated because of the stable risk of waitlist dropout for these candidates.

Kidney transplantation at the University of Pennsylvania has grown substantially over the past 11 years. Although our transplant volume has increased primarily as a consequence of multiorgan transplants as well as the utilization of historically "marginal" allografts, our post-transplantation outcomes remain excellent in both children and adults. We attribute these outcomes to technical improvements in tissue typing and donor-recipient crossmatching, modification of immunosuppression protocols, and rigorous donor and recipient selection. In the next decade, we hope to substantially expand our living donor program and refine our overall donor and recipient selection process such that we maintain excellent post-transplant outcomes in the face of aging and increasingly comorbid donors and recipients. We further predict significant changes in post-transplant management of kidney recipients with respect to immunosuppression regimens. In particular, we anticipate the modulation of immunosuppression regimens in recipients with high titers of donor-specific antibody and the integration of B-cell specific immunosuppression into post-transplant patient care. Only time will tell whether such therapies will 1) improve long-term outcomes, 2) allow us to diminish the degree of non-specific pharmacologic immunosuppression currently in use, 3) or even promote donor-specific tolerance in kidney transplant recipients.

Acute renal failure is a significant risk factor for death in patients with liver failure. The goal of this study was to analyze the impact of peri-transplant dialysis on the long-term mortality of liver transplant recipients. We performed a single-center, retrospective cohort study of 743 adult liver transplants; patients who received first liver transplants were divided into four groups: those who received more than one dialysis treatment (hemodialysis [HD], continuous veno-venous hemodialysis [CVVH]) pre-orthotopic liver transplantation (OLT), post OLT, pre- and post OLT, and those not dialyzed. There was no statistically significant difference in the mean survival time for patients who were not dialyzed or dialyzed only pre-OLT. Mean survival times were markedly reduced in patients dialyzed post OLT or both pre- and post OLT compared with those never dialyzed. Mortality risk in a Cox proportional hazards model correlated with hemodialysis post OLT, intra-operative vasopressin or neosynephrine, donor age50 yr, Cr1.5 mg/dL at transplant, and need for subsequent retransplant. Risk of post-OLT dialysis was correlated with pre-OLT dialysis, intra-operative levophed, pre-OLT diabetes, African American race, pre-OLT Cr1.5, and male gender. We conclude that renal failure requiring hemodialysis post liver transplant, irrespective of pre-transplant dialysis status, is a profound risk factor for death in liver transplant recipients.

Biochemical abnormalities after living-donor hepatectomy are attributed to the loss of liver volume and steatosis or fibrosis. In this study, we evaluated the intraoperative biochemical changes caused by the separation of the hepatic lobes before removal and the impact of those changes on postoperative biochemical abnormalities in patients who underwent adult-to-adult living-donor liver transplantation (LDLT).The extent and postoperative impact of the biochemical changes that occur during hepatic parenchymal transection in adult-to- adult LDLT were studied in 38 patients who underwent that procedure (14 men and 24 women; mean age, 39.6 years; age range, 19.5-58.9 years). Preoperative, intraoperative, and postoperative biochemical values for the first 8 postoperative days were compared.The mean total hepatic volume was 1703.0 mL, the mean weight of the resected mass was 887.0 g (52.6%), and the mean weight of the residual mass was 816.0 g (47.4%). The mean total bilirubin, aspartate amino transferase (AST), and amino alanine transferase (ALT) values were 8.6 U/L, 21.4 U/L, and 27.6 U/L, respectively, before surgery, compared with 27.4 U/L (an increase of 3.2 times), 257.9.2 U/L (an increase of 12.0 times), and 224.64 U/L (an increase of 8.1 times), respectively, after separation of the hepatic lobes. Patients (n = 21) with an intraoperative ALT value ofor= 200 had a significantly higher peak postoperative ALT (P = .001) than did those (n = 17) with an ALT value of200.A significant increase in hepatic biochemical parameters occurs at the completion of hepatic parenchymal transection and before the removal of the right hepatic lobe from the donor. This has an impact on postoperative peak enzyme levels in the donor.

A 46-year-old patient supported by a biventricular assist device (BiVAD) was transferred to our institution for evaluation for heart transplant. The patient was found to have a large intracranial hemorrhage with profound deterioration of neurologic status. The poor prognosis prompted the decision to withdraw care and pursue organ donation. Because the patient did not meet brain death criteria, nonheart-beating donor organ donation was pursued. After the termination of care, the BiVAD was modified: the left side to provide organ preservative solution and the right side to allow drainage. Eight liters of cold University of Wisconsin solution were pumped systemically over 10 minutes, the donor was drained, and the liver was harvested. This technique expedited donor perfusion by eliminating the need to cannulate, minimizing ischemic time for the liver. Although the recipient outcome was poor, and retransplantation was eventually necessary, we believe it was most likely not attributable to the quality of organ preservation. This report discusses the technical aspects of this potentially beneficial procedure.

Hepatitis C virus (HCV) is not directly cytopathic to the hepatocytes; however, host immune response against the virus does cause hepatic injury. Production of the HCV antibody is a host immune response to a viral antigen. The currently used HCV antibody assay is a qualitative, not quantitative, assessment. In this study, we sought to quantitatively estimate HCV antibody levels in patients who had undergone liver transplantations at the University of Rochester Medical Center, Rochester, New York, and correlate these levels with HCV RNA viral load, genotype, severity of recurrence, and anti-HCV treatment.From 39 liver transplantation patients, we obtained 141 blood samples for quantitative HCV RNA to measure HCV antibody levels quantitatively.Most antibody levels were within a narrow range with a mean of 32.9+/-5.1. Samples with undetectable RNA had a mean antibody level of 31.4+/-8.0, and samples with a positive RNA had mean level of 33.0+/-4.6. The mean antibody levels were significantly higher for patients with genotype 1 (n=33) compared with those with genotype 2 (n=5) (33.2 vs 29.1; P=.007). No correlation was found between antibody levels and severity of hepatic injury with regard to hepatitis activity index or fibrosis score. Six patients with no response to anti-HCV treatment had no change in their mean antibody levels (33.7 vs 34.5). Ten patients who responded to anti-HCV therapy had lower mean levels after therapy, but the changes were not significant (34.2 vs 30.4).Antibody levels in this study did not correlate with viral load or hepatic injury. However, genotype-2 patients had significantly lower levels compared with genotype-1 patients, and patients who responded to anti-HCV therapy demonstrated decreased antibody levels.

University of Wisconsin solution has twice the cold hepatic preservation time as does Euro-Collins solution. Histidine-tryptophan-ketoglutarate has a lower potassium content than does University of Wisconsin solution and is used more frequently. To date, however, studies comparing University of Wisconsin and histidine-tryptophan-ketoglutarate in live-donor liver transplantation are lacking. We therefore sought to examine the hepatic function of live-donor liver transplantation allografts preserved in University of Wisconsin solution as compared with those preserved in histidine-tryptophan- ketoglutarate solution.Between July 2003 and August 2004, 33 live-donor liver transplantations were performed at the University of Rochester Medical Center, Rochester, NY, USA. University of Wisconsin solution was used for the first 9 allografts, and histidine-tryptophan-ketoglutarate was used for the subsequent 24 allografts. Daily total bilirubin, aspartate amino transferase, amino alanine transferase, alkaline phosphatase, gamma glutamyl transpeptidase, and international normalized ratio levels were measured for the first 8 postoperative days. Peak values were compared between the groups.There was no primary graft nonfunction in either group. Two patients in the histidine-tryptophan- ketoglutarate group developed hepatic artery thromboses and underwent a retransplantation. Mean peak aspartate amino transferase and amino alanine transferase levels were higher in patients in the histidine-tryptophan-ketoglutarate group (aspartate amino transferase, 661+/-801 U/L; amino alanine transferase, 696+/-964 U/L) than they were in patients in the University of Wisconsin group (aspartate amino transferase, 439+/-415 U/L; amino alanine transferase, 464+/-376 U/L); however, this difference was not significant. Mean total bilirubin, alkaline phosphatase, and gamma glutamyl transpeptidase levels, and international normalized ratios were similar in both groups.University of Wisconsin and histidine-tryptophan- ketoglutarate solutions are both effective in preserving live-donor liver allografts. In the current study, patients in the histidine-tryptophan-ketoglutarate group had higher peak aspartate amino transferase and amino alanine transferase levels initially, but these became almost identical by postoperative day 8.

Mycophenolate mofetil (MMF) is used in liver transplantation (LTx) to reduce rejection, nephrotoxicity, neurotoxicity, and the need for steroids. Lower trough concentrations and bioavailability have been reported with oral MMF in first week after LTx. These parameters improve after the first month postoperatively. Previously published studies have used oral formulations of MMF. In this study, we sought to examine survival, rejection, and nephrotoxicity rates using IV MMF in live donor liver transplantation (LDLT).Twenty-eight patients (mean age, 50.1 years; 15 men, 13 women) were examined between January 2000 and January 2004 with a mean follow-up of 17 months for survival, rejection, and renal function.Four patients died at 2, 5, 8, and 18 months after LDLT from sepsis (n = 3) and recurrent hepatocellular carcinoma (n = 1). There were no retransplants; hence, patient and graft survival rates were the same (82.4%). Three patients (10.7%) experienced acute cellular rejection requiring treatment. The mean serum creatinine level prior to LDLT was 0.9 +/- 0.4 mg/dL, which remained stable throughout the study. One patient required hemodialysis during the perioperative period for 8 days.In the current study, we demonstrate a new strategy of IV MMF administration with low-dose tacrolimus that provides for lower rates of acute rejection, better preservation of renal function, and one that is better tolerated compared with historical treatments after LTx.