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Renoportal anastomosis (RPA) is an effective technique in cases of complex portal vein thrombosis with the presence of a splenorenal shunt. The objective of this report is to describe the possible complications related to RPA.A 50-year-old man with alcohol-related and hepatitis C-related cirrhosis and 2 hepatocellular carcinomas underwent liver transplant. He presented a portal vein thrombosis Yerdel IV, a splenorenal shunt, and another shunt between the inferior mesenteric vein (IMV) and the perirectal plexus. During surgery, the flow of the left renal vein was 891 mL/min, and this rose to 1050 mL/min after IMV clamping. RPA was made through iliac vein graft interposition, and the IMV was ligated. Portal flow was 832 mL/min but drastically decreased because of mesenteric root compression. After finishing the liver transplant, a renoiliac graft percutaneous transhepatic stent was put in place. The patient presented graft dysfunction and acute kidney injury. On postoperative day +18, a second stent was put in place because of a thrombosis in the splenomesenteric confluence. The patient subsequently presented partial distal rethrombosis and a pancreaticoduodenal arteriovenous fistula, which required several embolizations. The patient developed ascites, recurrent gastrointestinal bleeding, and persistent bacterial peritonitis. Finally, a modified Sugiura procedure (without splenectomy) was performed, achieving a portal flow of 1800 mL/min. However, the patient developed sepsis and multiorgan failure, and died on postoperative day +70.Despite long-term patient and graft survival within accepted limits after LT, RPA is a challenging technique not exempt from complications.

Management of nonsplenorenal spontaneous portosystemic shunts (NSRSPSS) in liver transplant (LT) is controversial. Reports on the influence of its ligation suggest improvements in morbidity and survival.Retrospective study of a single-center series. The objective was to analyze the outcomes and post-LT survival after the closure of NSRSPSS.Between January 2005 and April 2021 a total of 23 patients with NSRSPSS underwent LT. The shunt was superior mesenteric vein-vena cava in 12 (52.2%), inferior mesenteric vein-vena cava in 6 (26.1%), through the left gastric vein in 4 (17.4%), and portocava in 1 (4.3%). Seven patients presented portal vein thrombosis, with thrombectomy being performed in 5. Moreover, 21 patients had portoportal anastomosis, 1 patient required portal reconstruction at the splenomesenteric confluence, and 1 had a coronary-portal anastomosis. The NSRSPSS was closed in 22 cases (95.7%). The mean (SD) portal flow before and after the closure of NSRSPSS was 1395 (572) mL/min and 1773 (583) mL/min (104.4 [47.9] mL/min/100 g and 127.9 [4.9] mL/min/100 g, respectively). Six patients (26.1%) presented primary graft dysfunction, 13 (56.5%) acute kidney injury, and 9 (39%) ascites. Three arterial stenoses (13%), 2 biliary stenoses (8.6%), and 1 intrahepatic portal thrombosis (4.3%) occurred. Median intensive care unit and hospital stay was 5 days (range, 3-8 days) and 15 days (range, 13-21 days). After a mean follow-up of 5.18 (3.2) years, all patients except 1 are alive.The closure of the NSRSPSS during LT can optimize portal flow, with potential influence in morbidity and survival rates.

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p

Background Recent radiologic advances have made endovascular treatment a very successful option for arterial complications after liver transplant. This article presents our experience of using endovascular treatments during the first week after liver transplant. Methods This study is a retrospective, single-center analysis. Liver transplants performed between 2010 and 2018 were analyzed. All patients underwent Doppler ultrasonography on days 1 and 7. Endovascular therapy was indicated in hepatic artery thrombosis diagnosed early after transplant and in stenosis when hepatic narrowing was > 70%. Patients were treated with subcutaneous anticoagulant therapy and with antiplatelet agents after endovascular therapy. Results Seven patients (1.1%) were included in the study. Stenosis was the reason in 5 patients while 2 patients had symptoms of thrombosis. The first 2 patients were initially treated with angioplasty; both had restenosis and were treated with angioplasty and stent placement, respectively. The 5 most recent patients received stenting as a primary treatment. Two of these patients developed a new stenosis. No patient developed any hepatic artery complication related to the procedure, and only 1 patient experienced a postprocedure complication (femoral artery pseudoaneurysm), which was managed conservatively. No patient required retransplant. After a median follow-up of 48 months (range, 35-85 months) 1 patient had died, and the rest were alive and asymptomatic. Conclusions Although there is scant experience of the use of endovascular therapy very shortly after liver transplant, recent advances in interventional radiology have made the technique feasible and safe, and it achieves a high success rate.

The reported biliary morbidity rate for deceased donor full-size orthotopic liver transplantation is up to 30%. The technique used may be influenced by multiple factors, and in some situations, biliary reconstruction must be carried out through Roux-en-Y hepaticojejunostomy. The aim of our study was to determine the results of the orthotopic liver transplantation according to the technique used in the biliary reconstruction. A retrospective study was performed with the first 1000 orthotopic liver transplants (951 patients) carried out consecutively (1996-2013) with follow-up until 2017. A matched case-control study was designed in 1:3 ratio (47/136) to compare the reconstruction by hepaticojejunostomy vs the end-to-end coledoco-coledocostomy. Hepaticojejunostomy was associated with patients with cholestatic (44.7% vs 3.7%) and ischemic disease (14.9% vs 0%; P .001) and previous transplant (29.8% vs 1.5%; P = .003). The mean biliary duct reconstruction, surgery, and cold ischemia times were also higher. Vascular complications were significantly more frequent in the hepaticojejunostomy group (36.1% vs 10.4%; P .001), mainly because of differences in early arterial complications. Nevertheless, there were no differences in the total biliary complication (21.2% vs 16.9%; P = .5). The biliary leakage rate and the biliary stricture rate were also similar. Hepaticojejunostomy in orthotopic liver transplantation presented longer biliary reconstruction, surgery, and cold ischemia times when compared with end-to-end coledoco-coledocostomy. In addition, it was followed by a higher incidence of arterial complications but had similar biliary complication rate and graft survival. Differences could be explained by the fact that hepaticojejunostomy was used more often in cholestatic or ischemic diseases and in retransplant procedures.

Background & Aims The incidence and outcomes of coronavirus disease 2019 (Covid-19) in immunocompromised patients are a matter of debate. Methods Prospective nationwide study including a consecutive cohort of liver transplant patients with Covid-19 recruited during the Spanish outbreak from February 28th to April 7th, 2020. The primary outcome was severe Covid-19, defined as the need for mechanical ventilation, intensive care, and/or death. Age- and gender-standardized incidence and mortality ratios (SIR and SMR) were calculated using data from the Ministry of Health and the Spanish liver transplant registry. Independent predictors of severe Covid-19 among hospitalized patients were analyzed using multivariate Cox regression. Results A total of 111 liver transplant patients were diagnosed with Covid-19 (SIR=191.2 [95%CI 190.3-192.2]). The epidemiological curve and geographic distribution overlapped widely between liver transplant and general populations. After a median follow-up of 23 days, 96 patients (86.5%) were admitted to hospital and 22 patients (19.8%) required respiratory support. Twelve patients were admitted to the ICU (10.8%). The mortality rate was 18%, being lower compared to the matched general population (SMR=95.5 [95%CI 94.2-96.8]). Thirty-five patients (31.5%) met criteria of severe Covid-19. Baseline immunosuppression containing mycophenolate was an independent predictor of severe Covid-19 (RR=3.94; 95%CI 1.59-9.74; p=0.003), particularly at doses higher than 1,000 mg/day (p=0.003). This deleterious effect was not observed with calcineurin inhibitors or everolimus and complete immunosuppression withdrawal showed no benefit. Conclusions Being chronically immunosuppressed, liver transplant patients have an increased risk of acquiring Covid-19 but their mortality rates are lower than matched general population. Upon hospital admission, mycophenolate dose reduction or withdrawal could help in preventing severe Covid-19. However, complete immunosuppression withdrawal should be discouraged., Graphical abstract, HIGHLIGHTS • The incidence of Covid-19 is increased in liver transplant patients. • Mortality rates are lower than those observed in matched general population. • Immunosuppression withdrawal may not be justified. • Mycophenolate may increase the risk of severe Covid-19 in a dose dependent-manner. • Calcineurin inhibitors and everolimus are not deleterious for Covid-19., In liver transplant patients, chronic immunosuppression increases the risk of acquiring Covid-19 but it could reduce disease severity. Complete immunosuppression withdrawal may not be justified. However, mycophenolate withdrawal or temporary conversion to calcineurin inhibitors or everolimus until disease resolution could be beneficial in hospitalized patients.

Our aim was to study the safety and efficacy of immunosuppression with everolimus (EVL) within the 1st month after orthotopic liver transplantation (LT) when calcineurin inhibitors are not recommended. For this purpose, 28 recipients who had been treated with EVL within the 1st month after adult LT were eligible to enter in a retrospective multicenter study. Patients were followed up for 12 months after LT. EVL therapy was initiated at a median of 14 days (range, 4-24) after LT. The reason for early EVL was neurotoxicity in 14 cases, renal dysfunction in 12, and acute cellular rejection combined with renal impairment in 2. In 23 patients, immunosuppression was EVL + mycophenolate mofetil/mycophenolate sodium + steroids, and EVL + tacrolimus + steroids/mycophenolate sodium was used in 4 cases. Neurotoxicity disappeared in all patients. Renal function in patients with renal impairment improved from a median of 32 mL/min/1.73 m2 at the moment of implementation of EVL to 62 mL/min/1.73 m2 at 1 year. Four patients (14.3%) developed acute cellular rejection. We observed incisional hernia in 4 patients (14.3%), hematologic complications in 6 (21.4%), proteinuria in 2 (7.1%), edema and/or effusions in 8 (28.6%), and dyslipidemia in 12 (42.8%). No arterial complications were observed. EVL was withdrawn in 5 patients during the 1st year after LT. One-year patient survival was 92.7%. In conclusion, use of EVL within the 1st month after LT when calcineurin inhibitors are not recommended seems to be an effective therapeutic option with an acceptable safety profile.

A retrospective cohort multicenter study was conducted to analyze the risk factors for tumor recurrence after liver transplantation (LT) in cirrhotic patients found to have an intrahepatic cholangiocarcinoma (iCCA) on pathology examination. We also aimed to ascertain whether there existed a subgroup of patients with single tumors 2cm (very early) in which results after LT can be acceptable. Twenty-nine patients comprised the study group, eight of whom had a very early iCCA (four of them incidentals). The risk of tumor recurrence was significantly associated with larger tumor size as well as larger tumor volume, microscopic vascular invasion and poor degree of differentiation. None of the patients in the very early iCCA subgroup presented tumor recurrence compared to 36.4% of those with single tumors >2cm or multinodular tumors, p=0.02. The 1-, 3- and 5-year actuarial survival of those in the very early iCCA subgroup was 100%, 73% and 73%, respectively. The present is the first multicenter attempt to ascertain the risk factors for tumor recurrence in cirrhotic patients found to have an iCCA on pathology examination. Cirrhotic patients with iCCA 2cm achieved excellent 5-year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs. This multicenter study analyzes the outcome of patients transplanted for hepatocellular carcinoma who were found to have an intrahepatic cholangiocarcinoma at pathology examination, and focuses on the excellent posttransplant outcome of patients with single intrahepatic cholangiocarcinomas 2 cm.

Despite significant advances in orthotopic liver transplantation (OLT), biliary tract reconstruction is still a major source of complications. Choledochocholedochostomy with a T-tube used to be the standard procedure for biliary reconstruction after OLT. However, many centers currently avoid use of the T-tube because of the high incidence of complications. Our aim was to study the biliary complications occurring at our center when end-to-end choledochocholedochostomy (EE-CC) over a T-tube was used as the standard procedure for biliary reconstruction. A retrospective review was conducted of all patients who underwent liver transplantation from February 1, 1996, to April 30, 2010. Only patients requiring any therapy to treat biliary complications were considered, whereas those with concomitant hepatic artery complications were excluded. The study cohort consisted of 743 patients who had EE-CC with a T-tube. Of these, 73 patients (9.8%) experienced any biliary complication. Anastomotic strictures occurred in 17 patients (2.3%), and non-anastomotic strictures in 2 (0.3%). Fifteen patients with anastomotic strictures were successfully treated by dilatation and stenting. Bile leakage was diagnosed in 39 patients (5.2%). Leakage occurred at the anastomosis in 15 patients (2%), and at the exit site of the T-tube in 24 patients (3.2%). Tube opening was the only treatment used in 30 patients with bile leakage (76.9%). Seven patients experienced leaks after elective T-tube removal (1%). Overall, repeat surgery to manage biliary complications was needed in 9 patients (1.2%). The mortality rate from biliary complications was 0.13%. In conclusion, EE-CC with a T-tube was followed by a low incidence of biliary complications. The complication rate after elective T-tube removal and the repeat surgery rate were extremely low. These results might challenge the current trend to avoid T-tube stenting in OLT.

Management of patients with hepatocellular carcinoma (HCC) recurrence after liver transplantation (OLT) is not well established. We conducted a retrospective analysis of our results in the treatment of HCC recurrence after OLT Patients. The 23 HCC recurrences developed after 182 OLT performed for HCC within Milan criteria, had an average follow-up of 60 months.The median time to recurrence was 23.4 months. Surgical resection of the recurrence was possible in 11 patients, but an R-0 resection was obtained in 8 patients. Four of these 8 patients developed another recurrence, with 3 succumbing due to tumor recurrence and 1 alive at 12 months with recurrence. The other 4 patients without recurrences, include 3 who are alive at 19, 31, and 86 months and 1 who died at 32.6 months due to hepatitis C recurrence. The 3 patients with palliative resections developed recurrences. Twelve patients were rejected for surgery: 8 were treated symptomatically, 2 with systemic chemotherapy, and 2 with everolimus and sorafenib. This last treatment was also prescribed for 2 patients after R-0 surgery who are alive at 19 and 31 months and for 1 patient after R-1 surgery who is alive at 19 months. Of 15 patients who died, 13 succumbed to HCC recurrence. The average survival from transplantation was 61.7 +/- 37.5 and 48 +/- 34.3 months for patients without and with recurrence, respectively (P.001). The survival from the recurrence was significantly higher among patients with R-0 surgery: 32.3 +/- 21.5 versus 11.9 +/- 6.9 months (P = .006).HCC recurrence after OLT of patients within Milan criteria was low but had a great impact on survival. Few cases are amenable to R-0 resection, but when possible it was associated with a significantly increased survival, although with an high incidence of a new recurrence. There is a rationale for the use of sorafenib and mammalian target of rapamycin based immunosuppression, which warrants randomized studies.

Objetivo Describir las complicaciones infecciosas y tiempo de presentacion en los 120 primeros trasplantes hepaticos consecutivos realizados en nuestro centro. Metodos Estudio prospectivo de las complicaciones infecciosas que presentaron 120 pacientes adultos consecutivos que recibieron trasplante hepatico ortotopico en el Hospital de Cruces entre febrero de 1996 y noviembre de 1998. Dos pacientes recibieron simultaneamente trasplante renal. En todos los pacientes se realizaron los mismos controles de vigilancia y los criterios para definir las infecciones fueron los descritos por otros autores. Resultados. Del grupo total, 95 eran varones y 25 mujeres. La edad oscilo entre 20 y 66 anos (media: 54 ± 9 anos). Las indicaciones de trasplante fueron: cirrosis alcoholica (47%), cirrosis por virus de la hepatitis C (VHC) (20%), carcinoma hepatocelular (17,5%), hepatitis fulminante (6%), cirrosis biliar primaria (2,5%) y otras indicaciones (7%). Tres pacientes precisaron retrasplante. Se diagnostico histologicamente rechazo agudo en 38 pacientes (31%). Ninguno presento rechazo corticorresistente. Cincuenta y un pacientes (42,5%) desarrollaron 76 episodios de infeccion grave, que correspondian: infeccion bacteriana, 48 episodios en 33 pacientes (27,5%); tuberculosis, 7 pacientes (6%); infeccion fungica, 9 episodios en 8 pacientes (7%), y enfermedad por citomegalovirus (CMV) el 8,5% de los pacientes. Ningun paciente desarrollo infeccion por Pneumocystis carinii. Fallecieron 15 (12,5%): seis (40%) con infeccion activa y en cuatro de ellos la infeccion se considero causa mayor de la muerte. Conclusiones. La tasa de infecciones por bacterias y hongos es similar a la recogida en la literatura. Encontramos una tasa alta de tuberculosis, que se corresponde posiblemente con la alta incidencia de esta enfermedad en la poblacion general. La baja incidencia de enfermedad por CMV la asociamos con el tratamiento anticipado con ganciclovir. La profilaxis con trimetropin-sulfametoxazol es altamente eficaz frente a Pneumocystis carinii.

Objective. Postoperative infection is considered one of the most important causes of morbidity and mortality after liver transplantation. We prospectively studied the incidence and significance of infections in preservation solutions for liver transplantation. Materials and Methods. From March 2007 to March 2008, we cultured the University of Wisconsin preservation solution for 60 consecutive liver transplantations. Fluid samples were obtained at the beginning and at the end of the back table procedure. Our posttransplant infection prophylactic protocol consisted of ampicillin and cefotaxime for 48 hours. Results. Cultures were positive in 59 patients (98.4%). Seventy-five percent of the isolates were superficial saprophytic flora (SSF; Staphylococcus coagulase negative, Streptococcus viridans, and Corynebacterium), nevertheless in 15 cases (25.1%) we isolated high virulence pathogens (Staphylococcus aureus, Klebsiella, Escherichia coli, Enterobacter, and Pseudomonas aeruginosa). There were neither anaerobic nor fungal isolates. Sixteen patients (36%) from the group with SSF developed postoperative fever, including 12 with negative posttransplant cultures, while 4 patients showed positive cultures for various microorganisms distinct from those isolated from the preservation solution. Five patients (30%) with high virulence pathogens in the preservation solution developed posttransplant fever, although no pathogen was isolated. Conclusions. Positive cultures of preservation fluids were observed in 98% of patients, although most of them (75%) were SSF. Microorganisms isolated from posttransplant cultures did not match the ones obtained from the preservation solution. Our results did not support routine culturing of the preservation solution provided that one administrator an adequate posttransplant antibiotic prophylactic regimen.

Introduction Posttransplant hepatitis C virus (HCV) recurrence has been shown to negatively impact graft and patient survivals. It has been suggested that HCV recurrence among HIV- and HCV-coinfected transplant recipients is even more aggressive. Objective To compare the histological severity and survival of posttransplant HCV recurrence between HIV- and HCV-coinfected and HCV-monoinfected patients. Patients and methods Among 72 adult patients who underwent primary liver transplantation at our institution for HCV-related cirrhosis between October 2001 and April 2007. We excluded one coinfected patient who died on postoperative day 5 leaving 12 HIV- and HCV-coinfected patients for comparison with 59 monoinfected patients. When listed, all coinfected patients fulfilled the criteria of the Spanish Consensus Document for transplantation in HIV patients. Immunosuppression did not differ between the two groups: all were treated with tacrolimus + steroids (slow tapering). Aggressive HCV recurrence was defined as cholestatic hepatitis and/or a fibrosis grade ≥2 during the first posttransplant year. Results Coinfected patients were younger than monoinfected patients: 45 ± 6 years vs 55 ± 9 years (P = .0008). There were no differences in Child score, Model for End-stage Liver Disease score, donor age, graft steatosis, ischemia time, HCV pretransplant viral load or genotype between the groups. Significant rejection episodes were also equally distributed (25% vs 14%; P = .38). Seven coinfected patients and 29 monoinfected patients developed aggressive HCV recurrences (58% vs 49%; P = .75). Median follow-up was 924 days. Global survival at 3 years was 80%. Survivals at 1, 2, and 3 years were 83%, 75%, 62% in the coinfected vs 98%, 89%, 84% in the monoinfected patients, respectively (log-rank test = 0.09). Conclusions The severity of histological recurrence was similar among HIV- and HCV-coinfected and monoinfected HCV liver recipients in the first posttransplant year. Mortality attributed to recurrent HCV was similar in the groups. There were no short-term (3-year) differences in survival between the two groups of patients.