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Fractional flow reserve (FFR) determines the functional significance of epicardial stenoses assuming negligible venous pressure (P v ) and microvascular resistance. However, these assumptions may be invalid in end-stage liver disease (ESLD) because of fluctuating P v and vasodilation. Accordingly, all patients with ESLD who underwent right-sided cardiac catheterization and coronary angiography with FFR as part of their orthotopic liver transplantation evaluation between 2013 and 2018 were included in the present study. Resting mean distal coronary pressure (P d )/mean aortic pressure (P a ), FFR, and P v were measured. FFR accounting for P v (FFR - P v ) was defined as (P d  - P v )/(P a  - P v ). The hyperemic effect of adenosine was defined as resting P d /P a  - FFR. The primary outcome was all-cause mortality at 1 year. In 42 patients with ESLD, 49 stenoses were interrogated by FFR (90% were <70% diameter stenosis). Overall, the median model for ESLD score was 16.5 (10.8 to 25.5), FFR was 0.87 (0.81 to 0.94), P v was 8 mm Hg (4 to 14), FFR-P v was 0.86 (0.80 to 0.94), and hyperemic effect of adenosine was 0.06 (0.02 to 0.08). FFR-P v led to the reclassification of 1 stenosis as functionally significant. There was no significant correlation between the median model for ESLD score and the hyperemic effect of adenosine (R = 0.10). At 1 year, 13 patients had died (92% noncardiac in etiology), and patients with FFR ≤0.80 had significantly higher all-cause mortality (73% vs 17%, p = 0.001. In conclusion, in patients with ESLD who underwent orthotopic liver transplantation evaluation, P v has minimal impact on FFR, and the hyperemic effect of adenosine is preserved. Furthermore, even in patients with the predominantly angiographically-intermediate disease, FFR ≤0.80 was an independent predictor of all-cause mortality., Competing Interests: Disclosures Dr. Parikh reports research support from the American Heart Association, consulting fees from Abbott Vascular, and serving on the scientific advisory board (minor equity interest) of Stallion Cardio, DocVocate, and HeartCloud., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Guidelines to evaluate patients for coronary artery disease (CAD) during preoperative evaluation for orthotopic liver transplantation (OLT) are conflicting. Cardiac catheterization is not without risk in patients with end-stage liver disease. No study to date has looked at the utility of non-electrocardiogram-gated chest computed tomography (CT) in the preliver transplant population. Our hypothesis was that coronary artery calcium scores (CACSs) from chest CT scans ordered during the liver transplant workup can identify patients who would benefit from invasive angiography. Nine hundred and fifty-three patients who underwent coronary angiography as part of their OLT workup were considered. Charts were randomly selected and reviewed for the presence of a chest CT performed before coronary angiography during the OLT workup. Agatston and Weston scores were calculated. CACS results were compared with coronary angiography findings. Nine of 54 patients were found to have obstructive CAD by angiography. Receiver-operating characteristic analysis demonstrated that an Agatston score of 251 and a Weston score of 6 maximized sensitivity and specificity for detection of obstructive coronary disease. An Agatston score <4 or Weston score <2 excluded the presence of obstructive CAD; using these thresholds, 13 patients (24%) or 15 patients (28%), respectively, could have theoretically avoided catheterization without missing significant CAD. In conclusion, our data identify the strength of CACS in ruling out coronary disease in patients being evaluated for OLT. Calcium scoring from non-electrocardiogram-gated CT studies may be integrated into preoperative algorithms to rule out obstructive CAD and help avoid invasive angiography in this high-risk population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Significant progress has been made with liver and intestinal transplantation in pediatric patients. Shortage of whole-organ cadaveric grafts has resulted in a high mortality rate for children awaiting transplantation. New surgical procedures such as split-liver transplantation and living-related liver transplantation have evolved over the last decade to maximize donor utilization in pediatric patients., Methods: In this article we review the current indications and contraindications for liver and intestinal transplantation in children, the surgical innovations to expand an exceedingly small cadaveric liver pool, postoperative management, and the impact on patient and graft survival., Results: Reduced-size liver transplantation provides children with much needed small grafts; however, split-liver transplantation may eliminate the need for reduced-size and living-related liver transplantation except in urgent situations., Conclusion: Liver transplantation is a durable procedure that provides excellent long-term survival. The use of living-related and split-liver transplantation has dramatically reduced the waiting periods for children and improved survival. In the past decade significant progress has been made with intestinal transplantation owing to improvements in surgical technique, immunosuppressive agents, and early identification and treatment of postoperative complications.

Background: Hepatic artery thrombosis (HAT) after liver transplantation for biliary atresia (BA) is a serious complication that most often leads to retransplantation (re-OLT). The purpose of the present study was: (1) to identify risk factors associated with HAT and (2) to analyze the impact of recently introduced microsurgical hepatic arterial reconstruction (MHR) on the incidence of HAT, subsequent need for re-OLT, and patient survival., Methods: A retrospective review of 194 patients transplanted for BA was performed. One hundred and sixty-six patients (group 1) underwent conventional arterial reconstruction and 28 (group 2) had MHR., Results: Actuarial survival for patients with HAT was significantly worse than for patients without HAT at 1, 2, and 5 years (71%, 61%, and 57% versus 85%, 85%, and 85%, P = 0.0007). Stepwise logistic regression analysis revealed that the risk of HAT correlated best with the type of arterial reconstruction (P = 0.007) followed by pretransplant bilirubin concentration (P = 0.04) and the number of acute rejection episodes (P = 0.03). In group 1, 32 patients developed HAT (19%), and of these, 18 underwent re-OLT for HAT. No patient in group 2 developed HAT (P = 0.006 versus group 1). One-year actuarial patient survival was 81% in group 1 and 100% in group 2 (P = 0.02)., Conclusions: In OLT for BA, (1) the predominant risk factor for HAT is the technique of arterial reconstruction, and (2) MHR markedly reduces the incidence of HAT and the need for re-OLT while improving patient survival.

Unlabelled: BACKGROUND AND DEMOGRAPHICS: Clinical course was reviewed for 19 whole organ pancreas transplant recipients at UCLA between 11/14/93 and 5/31/95, 18 of which were simultaneous pancreas kidney transplants and 1 of which was an isolated pancreas after kidney transplant. The initial 4 pancreatic grafts were procured by classical warm dissection techniques while the remaining 15 were procured by rapid en bloc technique. Mean recipient age, duration of diabetes, and daily insulin requirements were 38 years, 25 years, and 45 units, respectively. Bladder drainage of exocrine secretions was used primarily in 18 cases and primary enteric drainage in one., Results: All recipients manifested immediate dialysis and insulin independence. Actuarial patient and graft survival were 100% and 89%, respectively, at a mean follow-up of 396 days (range, 150-660 days). Mean maximal serum amylase on the first postoperative day was 366 U/dL. There were no instances of pancreatic graft vascular thrombosis. Three patients experienced pancreatic leaks (16%), 1 of which resulted in graft loss. Six month posttransplant Hgb A1c was within normal range and significantly lower than pretransplantation values (5.1 vs 10.7, P = 0.002). Mean length of initial hospitalization was 15 days, with 100% of patients requiring at least one read mission. Fifty-eight percent of patients experienced rejection episodes. Ninety-one percent of patients responding to a quality of life survey reported improvement in general sense of well-being after transplantation., Conclusions: It is concluded that high rates of success may be possible with whole organ pancreas transplantation, even in new programs. Rapid en bloc dissection is a safe, expeditious method of pancreas procurement. Successful pancreatic transplantation is associated with freedom from exogenous insulin administration, normalization of glycated hemoglobin, and subjective improvement in quality of life. However, this modality is associated with higher rates of rejection and readmission, and longer duration of hospitalization when compared with isolated kidney transplantation.

Based on the experience reported herein, the following conclusions have been made: (1) Although nonoperative means, including sclerotherapy, have an important role in the management of bleeding varices, they are not definitive means of treating recurrent variceal hemorrhage. (2) Because of the maintenance of hepatopetal flow and splanchnic venous hypertension, a selective shunt is associated with a lower incidence of encephalopathy and provides a better quality of life than does a nonselective shunt. Thus, an elective distal splenorenal shunt is the elective operation of choice for recurrent variceal hemorrhage. (3) Nonselective shunts can be performed with similar expectation of patient survival as selective shunts, but because of increased encephalopathy, should be reserved for emergency operations, in cases of unsuitable venous anatomy, and in those patients with intractable ascites. (4) A well-conceived elective shunt procedure can be performed with low operative mortality and long-term patency, results in significant survival, and is still considered the "gold standard" for treatment of variceal bleeding.

Central retinal artery occlusion usually results in blindness. The association between central retinal artery occlusion and extracranial carotid disease has not been clearly delineated. We reviewed the case reports of 62 patients with central retinal artery occlusion, 25 of whom underwent carotid angiography as part of the diagnostic evaluation. Fourteen of the 25 (56 percent) were found to have ipsilateral extracranial carotid disease. These patients did not generally have carotid bruits and had normal noninvasive carotid tests. Ten patients underwent ipsilateral carotid endarterectomy; these patients had either embologenic ulcerated plaque or tight stenosis of the carotid artery. There were 11 patients who showed no abnormalities on angiography. Thirteen patients who did not undergo angiography showed clinical evidence of etiologic factors, including vasculitis, an embolism of cardiac origin, and trauma. The remaining 24 patients had no diagnostic workup. Follow-up data were available in six of those patients who underwent carotid endarterectomy for a mean of 34 months; no strokes were reported. In conclusion, over half of patients with central retinal artery occlusion who undergo carotid angiography will have a carotid lesion on the ipsilateral side. This suggests that central retinal artery occlusion is a significant marker for extracranial carotid disease and should be an indication for complete carotid evaluation.

Aneurysms of the extracranial carotid arteries are rare vascular lesions that produce a high incidence of unfavorable neurologic sequelae. In the past 24 years, 19 patients at UCLA Hospital were treated for angiographically demonstrable extracranial carotid arterial aneurysms. These cases were reviewed to determine the natural history of these lesions as influenced by various modes of therapy in order to develop a logical treatment plan for these difficult patients. Because of the varied location of these lesions, proper treatment requires a diversity of techniques. Gratifying results can be achieved when a carefully selected operative approach is undertaken.

Reoperation to remove an aortic graft was performed in 18 patients. The need for removal was infection in the majority. A changing flora was seen in aortic graft infection with gram-negative organisms predominating. Despite a standardized approach with total graft removal, aortic closure, and extraanatomic reconstruction, amputation and mortality rates remain unacceptably high. A new approach to this problem is needed, and further trials with autogenous reconstruction appear warranted.

The incidence of significant restenosis after carotid endarterectomy was studied with ocular pneumoplethysmography. Of 105 operations, symptomatic restenosis occurred in 4.8 percent and asymptomatic restenosis in 6.6 percent. No preoperative factors were identified to be associated with subsequent recurrence. However, technical problems with the end-point of the endarterectomy were associated with restenosis. Half of the restenoses occurred in the first 6 months of operation. The results focus on the need for special attention to the technical management of end-point problems and the need for early noninvasive follow-up to detect a substantial proportion of early restenoses.

Fatal mushroom poisoning has long been recognized as a major health problem in western Europe and more recently in the United States. The majority of deaths are attributable to the genus Amanita. Amanita phalloides (death cap) has been found with increasing frequency across the United States and presents a significant health hazard in this country to those who pick and consume wild mushrooms. This article discusses the pharmacologic basis and clinical manifestations of Amanita intoxication. It outlines the rationale of various treatment modalities and, from these, summarizes a protocol that the authors believe will be useful to the clinician. In addition, two patients are presented who underwent successful orthotopic liver transplantation for fulminant hepatic failure secondary to Amanita poisoning. The role of liver transplantation both acutely and as treatment for chronic active hepatitis secondary to severe intoxication is discussed.

A 50-year-old man with idiopathic myelofibrosis had development of extensive cutaneous extramedullary hematopoiesis after undergoing splenectomy. Treatment with hydroxyurea was not effective, but electron-beam irradiation controlled the cutaneous infiltration. This rare clinical manifestation of idiopathic myelofibrosis can be confused with cellulitis, and diagnosis depends upon biopsy.

Necrotizing soft tissue infections are classified by the type of infecting organism, the presenting clinical picture, and the treatment required. However, reliance on this schema is impractical since it often leads to an inordinate delay in appropriate surgical therapy with an unwarranted loss of a limb or life. Since 1958, 21 patients were treated at the UCLA Medical Center with necrotizing soft tissue infections. Unifocal ulcerations and nonspreading infections were excluded. Of the 21 patients, the initial classification of the infections included necrotizing fasciitis in 38 percent, clostridial gangrene in 38 percent, bacterial synergistic gangrene in 19 percent, and streptococcal hemolytic gangrene in 5 percent. Diabetes or evidence of immunosuppression was found in 71 percent of the patients. The course could be traced to either a perforated viscus in 43 percent or a traumatic injury in 43 percent. No single clinical sign, including tissue gas, was diagnostic for a specific type of necrotizing soft tissue infection. Culture revealed a polymicrobial flora in 76 percent. Overall mortality was 52 percent and the amputation rate was 36 percent. Mean time to appropriate surgical therapy was 1.9 days. Operations performed more than 24 hours after recognition of infection resulted in a 70 percent mortality versus a 36 percent mortality when operations were performed less than 24 hours after recognition. A lesser operation to conserve tissue resulted in a 71 percent mortality versus a 43 percent mortality with initial radical surgery which encompassed all devitalized tissue. Based on these data, we conclude that classification of necrotizing soft tissue infections should be simplified to clostridial and nonclostridial infections. Radical operative debridement, regardless of tissue loss, should be carried out immediately after fluid resuscitation, and antibiotic coverage must be broad spectrum from the time of onset due to the polymicrobial nature of these infections.

A patient with intractable chylous ascites after a successful Warren shunt procedures is presented. The general incidence, etiology, pathophysiology, and treatment modalities of chylous ascites are discussed. Chylous ascites is a serious postoperative complication of the Warren shunt and should be considered in the differential diagnosis of a patient with ascites subsequent to this procedure.

Eighteen cases of primary adenocarcinoma of the small intestine have been reviewed, which demonstrated the relative frequency of symptoms common to this disease. The clinical features, pathology, and treatment of small bowel adenocarcinoma have been presented and the literature reviewed.

Fulminant hepatic failure is a clinical syndrome with a high mortality rate when traditional supportive therapy is used as treatment. Orthotopic liver transplantation has been proposed as a therapeutic option. Clinical and logistic difficulties include the rapid deterioration of the patients, unpredictable recovery, and the immediate need for a donor organs. Including this series, a total of 41 patients with fulminant hepatic failure have been transplanted, with a survival rate of 61 percent. We have reported eight liver transplantations carried out in six patients. Four of the patients survived (66 percent). Death was due to irreversible neurologic dysfunction in one patient and fungal sepsis in one patient. These results indicate that orthotopic liver transplantation is a practical therapeutic option for fulminant hepatic failure which should be considered early, before neurologic deterioration becomes irreversible.

The development of a liver transplantation program requires a multidisciplinary approach which can only be provided in a large tertiary referral medical center. Preparation for the clinical program involves training of all team members, both in the animal laboratory and at an established liver transplant center. A special commitment from the medical center to the program is essential and involves medical, nursing, and administrative divisions, blood bank, social service, and operating room personnel, and intensive care unit facilities. With careful planning, a successful liver transplant program can be realized from the onset. In the first 2 years of UCLA's liver transplant program, 62 transplants in 50 patients were performed. The overall survival rate was 72 percent with no operative deaths. Thirty-four of 36 surviving patients have returned to useful, productive lives after orthotopic liver transplantation.

A matched control study was conducted to compare the effects of portacaval shunting with those of distal splenorenal shunting in patients with advanced hepatic cirrhosis and bleeding gastroesophageal varices. Patients in whom distal splenorenal shunts were performed had significantly less postoperative encephalopathy and hepatic failure and a significantly longer survival than did patients who underwent portacaval shunts.

The consequences of failure in 235 femoropopliteal and femorotibial operations are reviewed and compared with the benefits of success so that an accurate perspective of risk-benefit analysis can be achieved. In 72 operations performed for claudication, 10 grafts thrombosed early. The cost included nine reoperations to achieve eight patent grafts and a 12 day average increase in hospital stay. There were no deaths. The benefit obtained was 70 of 72 (97 percent) asymptomatic limbs. In 163 grafts placed for limb salvage, there were 58 initial thromboses. Reoperation in 28 produced an additional 14 patent grafts. The cost of thrombosis was an increase in mortality from 5.6 to 10.7 percent, a 12 day average increase in hospital stay, and raising of preoperative predicted amputation level from below to above the knee in 11 patients with thrombosed grafts whose distal anastomoses were below the knee. This contrasted with a 73 percent limb salvage rate in 104 patients whose preoperative predicted amputation level was below the knee, and a 54 percent limb salvage and a 12 percent lowering of amputation level in 39 patients whose preoperative amputation level was above the knee. Of patients with patent grafts, 89 percent achieved limb salvage. We conclude that the benefits of success in attempted vascular reconstruction for threatened limb loss far outweigh the risks of failure and that the combined results were far superior to the expected outcome in comparable patients undergoing primary amputation.

The course of 200 patients who recently underwent appendectomy at UCLA for acute appendicitis has been reviewed to determine the efficacy of preoperative systemic antibiotic prophylaxis in reducing septic morbidity after surgery. Among those with nonperforated appendicitis who were given gentamycin and clindamycin preoperatively, a reduction of infection rate from 10.2 to 5.3 per cent was found when compared with patients who received no antibiotics.