IMPORTANCE:Ischemic cold storage (ICS) of livers for transplant is associated with serious posttransplant complications and underuse of liver allografts. OBJECTIVE:To determine whether portable normothermic machine perfusion preservation of livers obtained from deceased donors using the Organ Care System (OCS) Liver ameliorates early allograft dysfunction (EAD) and ischemic biliary complications (IBCs). DESIGN, SETTING, AND PARTICIPANTS:This multicenter randomized clinical trial (International Randomized Trial to Evaluate the Effectiveness of the Portable Organ Care System Liver for Preserving and Assessing Donor Livers for Transplantation) was conducted between November 2016 and October 2019 at 20 US liver transplant programs. The trial compared outcomes for 300 recipients of livers preserved using either OCS (n = 153) or ICS (n = 147). Participants were actively listed for liver transplant on the United Network of Organ Sharing national waiting list. INTERVENTIONS:Transplants were performed for recipients randomly assigned to receive donor livers preserved by either conventional ICS or the OCS Liver initiated at the donor hospital. MAIN OUTCOMES AND MEASURES:The primary effectiveness end point was incidence of EAD. Secondary end points included OCS Liver ex vivo assessment capability of donor allografts, extent of reperfusion syndrome, incidence of IBC at 6 and 12 months, and overall recipient survival after transplant. The primary safety end point was the number of liver graft-related severe adverse events within 30 days after transplant. RESULTS:Of 293 patients in the per-protocol population, the primary analysis population for effectiveness, 151 were in the OCS Liver group (mean [SD] age, 57.1 [10.3] years; 102 [67%] men), and 142 were in the ICS group (mean SD age, 58.6 [10.0] years; 100 [68%] men). The primary effectiveness end point was met by a significant decrease in EAD (27 of 150 [18%] vs 44 of 141 [31%]; P = .01). The OCS Liver preserved livers had significant reduction in histopathologic evidence of ischemia-reperfusion injury after reperfusion (eg, less moderate to severe lobular inflammation: 9 of 150 [6%] for OCS Liver vs 18 of 141 [13%] for ICS; P = .004). The OCS Liver resulted in significantly higher use of livers from donors after cardiac death (28 of 55 [51%] for the OCS Liver vs 13 of 51 [26%] for ICS; P = .007). The OCS Liver was also associated with significant reduction in incidence of IBC 6 months (1.3% vs 8.5%; P = .02) and 12 months (2.6% vs 9.9%; P = .02) after transplant. CONCLUSIONS AND RELEVANCE:This multicenter randomized clinical trial provides the first indication, to our knowledge, that normothermic machine perfusion preservation of deceased donor livers reduces both posttransplant EAD and IBC. Use of the OCS Liver also resulted in increased use of livers from donors after cardiac death. Together these findings indicate that OCS Liver preservation is associated with superior posttransplant outcomes and increased donor liver use. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT02522871.

OBJECTIVES:Ascites represents an important event in the natural history of cirrhosis, portending increased 1-year mortality. Umbilical herniation with rupture is an uncommon complication of large-volume ascites that is associated with significant morbidity and mortality. The aim of this study was to describe predictors of outcomes in patients undergoing emergent repair for spontaneous umbilical hernia rupture.MATERIALS AND METHODS:We report a case series of 10 patients with decompensated cirrhosis (mean age 66 ± 9 years, mean Model for End-Stage Liver Disease score of 21 ± 7) who presented with a ruptured umbilical hernia and had emergent repair.RESULTS:Thirty percent (3/10) of patients died or required liver transplant. Factors associated with death or transplant included the development of bacterial peritonitis (P = .03) and the presurgical 30-day Mayo Clinic Postoperative Mortality Risk in Patient with Cirrhosis Score (P = .03).CONCLUSIONS:Emergent repair after umbilical hernia rupture in patients with decompensated cirrhosis carries a poor prognosis with 30% of patients developing poor postsurgical outcomes.

INTRODUCTION: Patients with Decompensated Cirrhosis requiring Coronary artery bypass grafting (CABG) before liver transplantation are at significant risk of liver failure and death. We discuss a simultaneous CABG and liver transplantation approach to offer the best therapeutic option in such cases. CASE DESCRIPTION/METHODS: Our patient is a 56-year-old male with decompensated cirrhosis related to Ethanol and Fatty liver. He had severe coronary artery disease of the proximal, mid and distal Right coronary artery (RCA) not amenable to PCI. Once a donor liver allograft was found to be suitable, simultaneous CABG with liver transplantation was performed. Initially after procuring the saphenous vein from the right leg, a median sternotomy incision was performed and the pericardium was opened. Single vessel CABG to RCA was performed using the Saphenous vein graft off cardiopulmonary bypass. Chest was left open for the liver transplantation surgery. A bilateral subcostal incision with midline extension was performed. After explantation of the native liver, donor liver implantation was performed in a piggyback fashion where the venocavoplasty formed using middle and left hepatic vein of the recipient was anastomosed with the donor IVC. Venovenous bypass was not used. A Choledochocholedochostomy was performed. There were no major perioperative complications. A month after surgery, he has normal liver function and is recovering at home. DISCUSSION: In advanced liver disease patients needing liver transplantation and with concurrent CAD not amenable to PCI, it is not always possible to perform staged surgeries. In our case the anticipated morbidity and mortality rate was high with either surgery performed alone. Our patient’s probability of post operative mortality one year after major surgery according to the Mayo Clinic risk calculator was 32%. Recipient hepatectomy during liver transplantation in the background of severe CAD and with already reduced systemic pressure could result in major hemodynamic instability and acute coronary ischemia. He underwent simultaneous CABG and liver transplantation successfully. Survival rates of 80% have been reported in case series from more than a decade ago (Table 1). All patients should have preserved ventricular function. Simultaneous CABG and liver transplantation can offer the best therapeutic option with good perioperative and long term survival rate for patients with advanced liver disease who have severe CAD not amenable to PCI.

Management of symptomatic polycystic liver disease (PLD) has remained primarily unchanged since the early 20th century when multiple case reports described management of non-parasitic liver cysts. In 1968, Lin et al. described the fenestration procedure, “aspiration of the cysts, incision, partial excision with or without external drainage, or marsupilization and anastomosis to the gastrointestinal tract”. Further surgical options have included cyst sclerotherapy, laparoscopic cyst aspiration, partial hepatectomy, and orthotopic liver transplant (OLT). Recently there has been discussion of medical management with somatostatin analogs to reduce hepatomegaly in PLD with varying success. There is no current consensus on treatment or standard of care for symptomatic PLD, it is largely up to surgeon preference and ability; however, there has been a movement toward early OLT with Model for End-Stage Liver Disease (MELD) score exception points. This case series reviews two female patients with normal renal and hepatic function with symptomatic PLD treated with transverse hepatectomy. We propose that patients suffering from symptomatic PLD, with retained renal and hepatic function, can be treated with transverse hepatectomy conserving limited donor livers for decompensated patients; moreover, transverse hepatectomy does not disrupt the major suprahepatic vena cava preserving potential surgical access for future OLT.

BACKGROUND:Post-discharge surgical care fragmentation is defined as readmission to any hospital other than the hospital at which surgery was performed. The objective of this study was to assess the impact of fragmented readmissions within the first year after orthotopic liver transplantation (OLT). STUDY DESIGN:The Healthcare Cost and Utilization Project State Inpatient Databases for Florida and California from 2006 to 2011 were used to identify OLT patients. Post-discharge fragmentation was defined as any readmission to a non-index hospital, including readmitted patients transferred to the index hospital after 24 hours. Outcomes included adverse events, defined as 30-day mortality and 30-day readmission after a fragmented readmission. All statistical analyses considered a hierarchical data structure and were performed with multilevel, mixed-effects models. RESULTS:We analyzed 2,996 patients with 7,485 readmission encounters at 299 hospitals; 1,236 (16.5%) readmissions were fragmented. After adjustment for age, sex, readmission reason, index liver transplantation cost, readmission length of stay, number of previous readmissions, and time from transplantation, post-discharge fragmentation increased the odds of both 30-day mortality (odds ratio [OR] = 1.75; 95% CI 1.16 to 2.65) and 30-day readmission (OR = 2.14; 95% CI 1.83 to 2.49). Predictors of adverse events after a fragmented readmission included increased number of previous readmissions (OR = 1.07; 95% CI 1.01 to 1.14) and readmission within 90 days of OLT (OR = 2.19; 95% CI 1.61 to 2.98). CONCLUSIONS:Post-discharge fragmentation significantly increases the risk of both 30-day mortality and subsequent readmission after a readmission in the first year after OLT. More inpatient visits before a readmission and less time elapsed from index surgery increase the odds of an adverse event after discharge from a fragmented readmission. These parameters could guide transfer decisions for patients with post-discharge fragmentation.

Background: Previous studies have shown that minorities and vulnerable populations experience a suboptimal access to kidney transplantation due to cultural, educational and geografic barriers, with discrepancies between potential and actual donation in minorities. We analyzed differences in deceased kidney donation and utilization between different ethnic groups, as surrogate of access to kidney transplantation for adult pts. Material and Methods: Analysis of the SRTR annual data report (public data). Over the analyzed decade (2000/01-2010/11) the overall deceased kidney donation rate ( / 1,000 deaths) has increased from 16.4 to 19.6 with variations between ethnic groups. Donation has remained unchanged for Caucasians (C) from 18 to 19, almost doubled for African Americans (AA) from 9.2 to 17.9, increased from 20.6 to 28 for Hispanic (H), from 3.1 to 5.3 in other/unknown (O/U) ethnicities, unchanged for Asians (A), 6.8 vs 6.3. The overall % of organs discarded has also increased from 12.68 to 17.93, with a trend to higher discard in AA (7.69) and O/U (6.6) compared to C (4.99) and H (4.11). In the same period of time the overall number of active listed patient has increased from 39,564 to 54,001. The percentage of total distribution of pts waiting for kidney transplant shows a decline for C (45.5 to 40.3) overall stability for AA (34.5 to 33.5) and O/U (1.3 to 1.3) and increase for H (12.8 to 17.7) and A (6 to 7.3). Similar trend for newly listed patients in these ethnic groups: C 50.9 to 46.5, AA 29.3 and 29.3, other 1.2 to 1.3, H 13 to 16.5. Even though the total annual number of kidney transplant has increased in all ethnic groups, since 2006 (2006 vs 2011), it has decreased in C (9,005 to 8,388) and O/U (219 to 188) and increased in AA (3,991 to 4,174), H (2,143 to 2,340) and A (843 to 965). Conclusions: These data suggest that the rate of kidney donation/transplantation has increased in minorities and may reflect a possible improvement in kidney transplant care access in these populations. The increase in deceased kidney donation seems to be more pronounced in AA and H. The increased kidney discard may reflects a more aggressive approach in provisional organ acceptance and not necessarily related to a specific ethnic group. Study limitation: data review not capturing multifactorial barriers for different ethnic groups. Patient education remains a key factor to improve access to transplantation for minorities and all other pts.

Background: Transplantation relies on a scarce unique supply; organs. Deceased donations (DD) remains the main source for organs in the US and most of the West World. In the past decade transplant surgeons have increased the donor pool through collaborative initiatives and expanded criteria for organ acceptance (ECD, DCD, high risk CDC), to overcome discrepancy between demand and supply. Rates of organ recovery and transplant (Tx) may not reflect the expansion of the donor pool (total # of Tx also increased). We analyzed organ supply and utilization in the DD population in the US. Material and Methods: Analysis of the SRTR annual data report (public data). Results: Between 2000 and 2011 the total annual # of Tx performed from DD in the US has increased from 17,335 in 2000 to 22,518 in 2011. Donation rate ratio (eligible donor/100 eligible death) has increased since 2009 through 2011 (69.4, 71.7 and 72.9 respectively). The mean # of organs recovered /DD has no changed (3.59 in 2000, 3.54 in 2011), with no significant changes in the SCD (3.88 vs 4.05), ECD (2.67 vs 2.74), DCD (2.45 vs 2.47) groups. Same steady trend in the number of organs transplanted /DD (3.18 vs 3.07) with no significant annual variations when looking at SCD (3.6 vs 3.71), ECD (1.78 vs 1.87) and DCD (1.93 vs 2.07) groups (2000-2011 respectively). Total organ discard rate has remained the same (0.12 in 2000, 0.13 in 2011). Discussion/Conclusions: In addition to discrepancy between demand-supply, organ donation has to face 1. Vehicle-traffic safety regulations implementation (less trauma victims), 2.Increased donor age-comorbidities. Expansion of the donor pool had not significant impact in the mean number of organs recovered and transplanted/donor. These data suggest that we may have reached a plateau in the expansion of the donor pool under the current criteria, with population increasing age and comorbidities as limiting factor in further expansion. Changes in policy and organ donation consent process (e.g. presumed consent) may help to achieve a larger donor expansion. Transplant care providers and policy makers combined efforts, may achieve this goal through pts education and understanding of the organ donation/utilization, across all ethnic groups. Study limitation; review data not capturing ethnic, geographical and multifactorial barriers in organ donation/recovery/utilization. Collaborative national and international studies my provide further data for the expansion and utilization of transplantable organs.

Background: Multifactorial barriers seem to affect access to transplantation in minorities. Acuity of disease, availability of non-transplant chronic organ replacement therapy, different criteria for organ listing with less importance of waiting time (MELD), may affect patients' disease awareness, referral and evaluation for liver transplant in minorities. We analyzed differences in adult liver transplant from deceased donor (DDLTx) listing as possible surrogate of access to liver transplantation in these populations. Material and Methods: Analysis of the SRTR annual data report (public data). Results: In the analyzed decade (2000/01-2010/11) the annual number of DDLTx has increased from 4,181 to 5,617 (2001/11). Since introduction of the MELD system in 2002 the overall waiting time has decreased with small list variations (%) between ethnic groups: Caucasians (C) from 74.7 to 69.8, African American (AA) from 7.2 to 8.1, Hispanic (H) from 13.1 to 16.3, Asian (A) from 4.5 to 4.8, Other / Unknown (O/U) from 0.5 to 1 (increased trend for H, AA, O/U). The distribution (%) of new listed pts shows a decreasing trend for C (from 73 to 69.7), increase for AA (from 7.1 to 9.6), H (14.1 to 15.3), O/U (from 0.5 to 1), no changes for A (4.5 and 4.4). Pre-transplant mortality rate (per 100 pt-years waiting time) has decreased in C (13.2 to 11.4), AA (17.6 to 14.2), H (14.9 to 11.5), A (14.1 to 8.6) remaining unchanged for O/U (14.8 and 14.5). However the total number of pts removed from the list because too ill to be transplanted increased from 260 (in 2009) to 482 (in 2011). The number (%) of pts receiving a DDLTx within 5 years (between 2001-2006), has increased in all ethnic groups: C (43.2 to 58.6), H (38.6 to 52.8), A (44.1 to 57.1), O/U (45.1 to 57.5) with the a more substantial increase for AA (42.5 to 65.4). The rate of deceased donation (/1000deaths) has remained unchanged for C, A, O/U, with an increase in H (10.7 to 13.4), almost doubled in AA (5.2 to 9.4) (2001/11 respectively). Conclusions: These data suggests that minorities may have overall benefit from the introduction of the MELD system, in term of access to DDLTx, pre-transplant care and liver transplant within 5 years. This may have contributed to the increased rate of donation in H and AA. Study limitation: data review not capturing DDLTx list withdrawal by ethnicity and other multifactorial barriers related to specific ethnicity. Further studies may provide further data in regard to access to DDLTx for minorities.

A 31–year-old woman, with a past medical history significant for hypertension, uterine fibroids, chronic anemia, obesity, and end stage renal disease secondary to IgA nephropathy, presented to our medical center for living donor renal transplantation. The patient's 35-year-old sister was the proposed donor. The patient underwent peritoneal dialysis for 2 years, with urine production of 500 mL daily before the transplant. As part of her pretransplant workup, she had laboratory studies that revealed creatinine 16.7 mg/dL, blood urea nitrogen (BUN) 34 mg/dL, hemoglobin level 9.8 gm/dL, and a platelet count of 272 k/uL. Preoperative crossmatch of the recipient's living-related donor showed a one haplotype + match with the donor and 0% panel-reactive antibody. She was scheduled for transplant without any concerns or issues.

We report the results of a large series of chain transplantations that were facilitated by a multicenter US database in which 57 centers pooled incompatible donor/recipient pairs. Chains, initiated by nondirected donors, were identified using a computer algorithm incorporating virtual cross-matches and potential to extend chains. The first 54 chains facilitated 272 kidney transplants (mean chain length = 5.0). Seven chains ended because potential donors became unavailable to donate after their recipient received a kidney; however, every recipient whose intended donor donated was transplanted. The remaining 47 chains were eventually closed by having the last donor donate to the waiting list. Of the 272 chain recipients 46% were ethnic minorities and 63% of grafts were shipped from other centers. The number of blood type O-patients receiving a transplant (n = 90) was greater than the number of blood type O-non-directed donors (n = 32) initiating chains. We have 1-year follow up on the first 100 transplants. The mean 1-year creatinine of the first 100 transplants from this series was 1.3 mg/dL. Chain transplantation enables many recipients with immunologically incompatible donors to be transplanted with high quality grafts.

Limb salvage in oncologic surgery with endoprosthetic reconstruction results in infection in 5.7--15% of patients. These infections result in subsequent amputation in 46--87% of patients. Through literature review, we evaluated the statistically associated factors, treatments, outcomes and future trends regarding endoprosthetic infection. Infection was more prevalent in periacetabular and proximal tibial reconstructions. Coagulase-negative Staphylococcus was the most common pathogen in seven of eight case series. Factors associated with increased initial and persistent infection included myeloma, radiation therapy, poor soft-tissue condition, revision surgeries, and cementless fixation. Infection was noted to significantly increase 10-year survival in osteosarcoma patients. Recommendations on treatment were mixed, the only significant association with cure was early surgical intervention, and increased salvage rates were seen with both limited one-stage and extensive two-stage procedures. All studies agreed that clinicians and researchers should direct intensive efforts toward the prevention of infection. A number of recent studies showed promising in vitro and in vivo effects of antimicrobial implant surfaces, specifically silver and vancomycin, in retarding the establishment of periprosthetic infection. Infections of oncologic endoprostheses remain challenging problems, with no recent advances in the treatment of established infections. Associated factors have been established, although most are unavoidable in the course of cancer treatment. Most promise comes with the ongoing development of antimicrobial implant surfaces that aim to prevent the establishment and persistence of these difficult infections.

In 2002 there were more than 5,000 liver transplantations performed in the United States. As of February 2004 there were more than 17,000 registrations for liver transplantation. As more organs are transplanted and surgical techniques improve, unique causes of morbidity and mortality will become apparent. We describe three cases of postoperative nonischemic dilated cardiomyopathy in patients who underwent orthotopic liver transplantation (OLT), one of whom underwent diagnostic myocardial biopsy. This paper will discuss the three patients, including biopsy results, and briefly review the relevant literature. (Liver Transpl 2005;11:573–578.)

Background. Multiple studies have shown acute isovolemic hemodilution (AIH) to be safe and effective during liver resection to limit the use of banked blood. However, no studies to date have studied AIH in living donor right hepatectomy. Conventional right hepatectomies for living donors is not identical to non-donor right hepatectomies. Since division of the parenchyma is often performed without devascularization of the right lobe, blood loss may be significantly higher. Methods. Ten consecutive patients undergoing living donor right hepatectomies (LDRH) and ten consecutive patients undergoing nondonor right hepatectomies (NDRH) were compared using AIH.Results.There was no mortality or morbidity related to the use of AIH. No allogeneic blood transfusions were required in either group, intra-operatively or post-operatively. There was no significant difference in post-operative hematocrit, average estimated blood loss, and average fluid replacement. Average hospital length of stay and operating room time were longer for the LDRH. Conclusion. AIH can be performed safely and effectively in both LDRH and NDRH without subjecting patients to unnecessary risks of allogeneic blood transfusions.

Background. We describe a rare case of necrotizing fasciitis involving Candida albicans, an organism that has been reported to have a minimal potential for invasive soft tissue infection. In this case, Immunosuppression, chronic renal failure, and a history of diabetes mellitus were predisposing factors.Methods. The medical record and histopathologic material were examined. The clinical literature was reviewed for previous cases of C albicans necrotizing fasciitis.Results. A review of the literature showed that in solid organ transplant recipients, localized fungal soft tissue infection is infrequent, with only 35 cases reported between 1974 and 1992. Necrotizing fasciitis caused by C albicans is extremely rare in the modern era of solid organ transplantation.Conclusions. The management of transplant patients at risk for invasive fungal infection warrants a high index of suspicion for fungal necrotizing fasciitis in the setting of wound infection and merits a, thorough investigation for atypical pathogens.