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Background: Using SRTR/UNOS data, it has previously been shown that increased liver transplant centre volume improves graft and patient survival. In the current era of health care reform and pay for performance, the effects of centre volume on quality, utilization and cost are unknown. Methods: Using the UHC database (2009-2010), 63 liver transplant centres were identified that were organized into tertiles based on annual centre case volume and stratified by severity of illness (SOI). Utilization endpoints included hospital and intensive care unit (ICU) length of stay (LOS), cost and in-hospital mortality. Results: In all, 5130 transplants were identified. Mortality was improved at high volume centres (HVC) vs. low volume centres (LVC), 2.9 vs. 3.4%, respectively. HVC had a lower median LOS than LVC (9 vs. 10 days, P < 0.0001), shorter median ICU stay than LVC and medium volume centres (MVC) (2 vs. 3 and 3 days, respectively, P < 0.0001) and lower direct costs than LVC and MVC ($90 946 vs. $98 055 and $101 014, respectively, P < 0.0001); this effect persisted when adjusted for severity of illness. Conclusions: This UHC-based cohort shows that increased centre volume results in improved long-term post-liver transplant outcomes and more efficient use of hospital resources thereby lowering the cost. A better understanding of these mechanisms can lead to informed decisions and optimization of the pay for performance model in liver transplantation. © 2012 International Hepato-Pancreato-Biliary Association.

Background Celiac axis invasion by central and distal pancreatic cancers has been considered a contraindication to resection. Appleby first described en-bloc celiac axis resection with total gastrectomy for locally advanced gastric cancer. We present our experience with a modification of this procedure in central pancreatic cancers involving the celiac trunk. Methods Three patients with central pancreatic cancers invading the celiac axis are reviewed. All patients underwent extended pancreatectomy with en-bloc resection of the celiac axis. Results Margins were grossly clear of tumor in all patients. The mean length of stay was 8.3 ± 1.1 days. There was no evidence of clinically significant gastric or hepatic ischemia. All 3 patients remain disease free at 34, 14, and 14 months from surgery, respectively. Comments Extended pancreatectomy with celiac axis resection can result in prolonged survival and should be considered in central and distal pancreatic cancers invading the celiac trunk.

The chronic shortage of deceased kidney donors has led to increased utilization of donation after cardiac death (DCD) kidneys, the majority of which are procured in a controlled setting. The objective of this study is to evaluate transplantation outcomes from uncontrolled DCD (uDCD) donors and evaluate their utility as a source of donor kidneys. From January 1995 to December 2004, 75,865 kidney-alone transplants from donation after brain death (DBD) donors and 2136 transplants from DCD donors were reported to the United Network for Organ Sharing. Among the DCD transplants, 1814 were from controlled and 216 from uncontrolled DCD donors. The log-rank test was used to compare survival curves. The incidence of delayed graft function in controlled DCD (cDCD) was 42% and in uDCD kidneys was 51%, compared to only 24% in kidneys from DBD donors (p < 0.001). The overall graft and patient survival of DCD donors was similar to that of DBD donor kidneys (p = 0.66; p = 0.88). Despite longer donor warm and cold ischemic times, overall graft and patient survival of uDCD donors was comparable to that of cDCD donors (p = 0.65, p = 0.99). Concerted efforts should be focused on procurement of uDCD donors, which can provide another source of quality deceased donor kidneys.

Living donor liver transplantation has come to be an acceptable alternative to deceased donor transplants. Several ethical issues related to living donation have been raised in the face of reported perioperative morbidity and mortality. We report our experience in 13 consecutive Jehovah's Witness (JW) donor hepatectomies. From June 1999 to April 2004, 13 adult JW donors underwent donor hepatectomies at the USC-University Hospital. Nine donors underwent right lobectomy with a 62% mean volume of the liver resected. Four donors underwent a left lateral segmentectomy with a mean volume of 17.8%. Cell scavenging techniques, acute normovolemic hemodilution and fractionated products were used. The mean hospital stay was 6.2 days. All donors are alive and well at a median follow-up time of 3 years and 4 months. Live liver donation can be done safely in JW population if performed within a comprehensive bloodless surgery program.

Background The role of radiofrequency ablation (RFA) in the treatment of hepatic metastases from recurrent ovarian tumors is undefined. Case Three patients with hepatic lesions from recurrent ovarian cancers underwent a combined partial hepatectomy with radiofrequency ablation (RFA) to achieve optimal tumor cytoreduction. Follow-up radiological studies as well as serial tumor markers are consistent with disease-free survival after 39, 13, and 9 months. Conclusion These results demonstrate the feasibility and safety of RFA for metastatic ovarian lesions to the liver in patients previously deemed as poor or non-surgical candidates, and suggest the potential for improvement in survival over unresected patients or in patients resected with residual disease.

T t n the not-so-distant past, encountering the words “bloodless” and “liver transplant” in the same entence was rare. Also uncommon was seeing liver transplant” and “Jehovah’s Witness” toether—unless in reference to the refusal of a ehovah’s Witness (JW) to allow surgery involving lood transfusions. But today, thanks to advanced echnology and innovative physicians, “bloodless iver transplant” and “Jehovah’s Witness” are beoming associated more frequently. Countless ives have been saved because of advances in the loodless-transfusion process, and the medical alernatives for JWs have broadened amazingly ithin the past several years. In addition to the JWs, who will not have transusions because of religious beliefs, there is a much maller number of other patients who cannot have ransfusions (eg, those with antibodies). Also, ome patients fear the possible transmission of iseases via the transfusion process. Surgery, by its ery nature, involves dealing with the patient’s lood system. Surgical transplants, in turn, can esult in higher blood loss than surgery with less ntricate procedures. And liver transplants are mong the most costly of all in terms of lost blood. ontributing to the difficulty and high risk inolved in liver-transplant operations is the fact that ost patients eligible for a transplant are in exremely poor health by the time surgery begins ecause they have waited so long for a donor. The peration is a complex, time-consuming procedure

Liver transplantation has become mainstream surgical therapy for patient with end-stage liver disease with an operative mortality of less then 5% and 1- and 5-year survival rates 85% and 65%, respectively. 1-5 The disproportionate increase in patients awaiting liver transplant compared to the number of available organs 6,7 has led to the development of new techniques, including “living donor liver transplants” (LDLT), “split liver transplants,” and more recently, the reintroduction of “non-beating-heart liver donors.” 8 In the United States, the total number of liver transplants performed as of today is 58,507, of which 2,065 are from live donors and 56,442 are from cadavers, 9 which is a ratio of 1:27 live-donor to cadaveric liver transplants. The first successful living-donor liver transplantation was performed in 1989, with transplantation of a left hepatic lobe. Because of cultural beliefs discouraging cadaveric transplants in Asia, extensive development in the field of living-donor liver transplant was performed in the early 1990s; almost all liver transplantations performed in Asia involved living donors, whereas in the United States relatively few living-donor liver transplantations were performed until recently. It was mainly performed on children and used a left hepatic lobe (or one or more of its segments) from a parental donor. In the United States, adult lefthepatic-lobe transplantation was attempted in the 1990s, but without much success. The smaller left hepatic lobe provides insufficient hepatic mass for most adult Americans, who are physically larger than most Asians and consequently, the outcome of adult-to-adult left-hepatic-lobe transplantation in the United States was poor, and the procedure was seldom performed. 10 The first successful adult right LDLT was reported by Fan et al in 1997; 11 since then, right LDLT is the preferred adult LDLT.

As part of the spectrum of renal replacement therapies, kidney transplantation has been successful in providing the end-stage renal disease patient with a long-term, medically sound, and economically advantageous alternative to chronic dialysis. 1 The applicability of its success, however, has been limited by the ever-widening disparity between the steadily increasing number of eligible candidates and the relatively fixed number of available donors per year. This trend was partially offset in 2001, when the number of living kidney donors surpassed that of cadaveric donors. 2 In an effort to increase the availability of live donors, new techniques focused on facilitating the donation process through the use of laparoscopy. Adjunctive efforts were also directed toward overcoming previous immunologic barriers between donors and recipients, such as transplantation across “ABO incompatible” pairs. Renal insufficiency and an allocation policy change in the livertransplant recipient impact the supply of cadaveric donor kidneys and directly affect the renal healthcare worker; the perioperative management of these patients is discussed.

Objectives. To present a series of 5 patients with solitary metastatic renal cell carcinoma (RCC) to the pancreas after radical nephrectomy at our institution and review the published reports of this rare event. Methods. A retrospective review of the records of 5 patients with histologically confirmed RCC metastatic to the pancreas after radical nephrectomy was performed. A total of 5 patients (4 men, 1 woman) with a median age of 56 years (range 54 to 68) underwent radical nephrectomy for primary RCC. The pathologic stage was Robson I (n = 3) or Robson III (n = 2), with a left-sided tumor occurring in 3 patients and a right-sided tumor in 2 patients. The median interval from nephrectomy to the diagnosis of the pancreatic metastasis was 12 years (range 4 to 15). All patients were symptomatic at presentation, including weight loss (n = 3), abdominal pain (n = 3), early satiety (n = 1), steatorrhea (n = 1), and/or hemosuccus pancreaticus (n = 1). Results. All pancreatic metastases were hypervascular on imaging studies, and surgical removal was accomplished by pancreaticoduodenectomy (n = 3), partial pancreatectomy (n = 1), or subtotal pancreatectomy (n = 1). One patient died of disseminated disease 12 months after pancreatic resection. Two other patients had recurrences in the lung (n = 1) at 5 months or the pancreas/liver (n = 1) at 48 months. Both of these patients underwent a second resection and were disease free at 2 and 12 months afterward. The two remaining patients were disease free at 7 and 24 months after pancreatic resection. Conclusions. RCC is an unpredictable tumor that may demonstrate very late metastases even from early-stage lesions. Aggressive surgical management of isolated pancreatic lesions offers a chance of long-term survival.

Concomitant abdominal aortic aneurysms and cirrhosis that need surgical attention are rare. Currently there are no guidelines with regards to the appropriate timing of the repair of these aneurysms and transplantation. In addition it also raises the issue of which procedure takes precedence. With the advent of endovascular repairs, this issue was resolved with relative ease, by doing the orthotopic liver transplantation (OLT) first and subsequent endovascular stenting on post-operative day 7 during the same hospitalization. This is the first case report of stenting an abdominal aortic aneurysm (AAA) in a liver transplant recipient. The rationale for the OLT and then AAA repair are discussed and formal guidelines are offered.

One possibility to increase the organ pool is to use grafts from hepatitis B virus (HBV) surface antigen (HBsAg)-positive donors, but few data are currently available in this setting. Herein, we reviewed the outcome of 92 liver transplantations using allografts from HBsAg-positive donors in the United States (1990-2009). They had experienced HBV-related (n = 68) or HBV-unrelated disease (n = 24). There was no difference between patients who received HBsAg-positive versus HBsAg-negative allografts based on age, Model for End-stage Liver Disease (MELD) score, length of stay, wait time, and donor risk index. HBsAg-positive allografts were more likely to be imported and used in MELD exceptional cases. Allograft and patient survival were comparable between the two groups. HBsAg-positive allografts deserve consideration when no other organ is available in a suitable waiting time in the present era of highly effective antiviral therapy.