Lee et al. recently published a method for estimating right hemi‐liver volume (RHLV) by using bedside ultrasound measurement of right (R) and left (L) portal vein (PV) diameters and Urata's standard ...liver volume (SLV) formula where RHLV = SLV×R2/(R2+L2). We calculated RHLV by substituting SLV from 15 different published formulas in the worldwide literature. We also modified Lee's method using right anterior (RA) and posterior (RP) where RHLV = SLV×(RA2+RP2)/(RA2+RP2+L2) for donors with unusual PV branching. We compared the calculated RHLV with RHLV estimated with software‐assisted CT (SACT) volumetry and actual graft weight after right‐lobe donation in 200 right‐lobe donors. This study confirmed that accurate estimates of RHLV can be achieved by SACT volumetry or by the simple method of Lee but using the SLV of only 3 of the 15 published formulas (Lin or Vauthey using body weight or body surface area) rather than Urata’s. Our modification of the Lee's formula using RA and RP, PV diameters was also accurate and not different from Lee's formula. These simplified formulas may be used for donor screening for graft size adequacy before expensive evaluation proceeds.
Compared to actual graft weight, accurate hemi‐liver volume can be estimated using right and left portal vein diameter and several standard liver volume formulae.
Currently, patients awaiting deceased‐donor liver transplantation are prioritized by medical urgency. Specifically, wait‐listed chronic liver failure patients are sequenced in decreasing order of ...Model for End‐stage Liver Disease (MELD) score. To maximize lifetime gained through liver transplantation, posttransplant survival should be considered in prioritizing liver waiting list candidates. We evaluate a survival benefit based system for allocating deceased‐donor livers to chronic liver failure patients. Under the proposed system, at the time of offer, the transplant survival benefit score would be computed for each patient active on the waiting list. The proposed score is based on the difference in 5‐year mean lifetime (with vs. without a liver transplant) and accounts for patient and donor characteristics. The rank correlation between benefit score and MELD score is 0.67. There is great overlap in the distribution of benefit scores across MELD categories, since waiting list mortality is significantly affected by several factors. Simulation results indicate that over 2000 life‐years would be saved per year if benefit‐based allocation was implemented. The shortage of donor livers increases the need to maximize the life‐saving capacity of procured livers. Allocation of deceased‐donor livers to chronic liver failure patients would be improved by prioritizing patients by transplant survival benefit.
Although previous consensus recommendations have helped define patients who would benefit from simultaneous liver–kidney transplantation (SLK), there is a current need to reassess published ...guidelines for SLK because of continuing increase in proportion of liver transplant candidates with renal dysfunction and ongoing donor organ shortage. The purpose of this consensus meeting was to critically evaluate published and registry data regarding patient and renal outcomes following liver transplantation alone or SLK in liver transplant recipients with renal dysfunction. Modifications to the current guidelines for SLK and a research agenda were proposed.
The authors report the findings of a summit meeting on simultaneous liver–kidney transplantation, present modifications to the current guidelines and propose directions for future research. See editorial by Feng and Trotter on page 2869.
Rapid allograft infection complicates liver transplantation (LT) in patients with hepatitis C virus (HCV). Pegylated interferon‐α and ribavirin therapy after LT has significant toxicity and limited ...efficacy. The effect of a human monoclonal antibody targeting the HCV E2 glycoprotein (MBL‐HCV1) on viral clearance was examined in a randomized, double‐blind, placebo‐controlled pilot study in patients infected with HCV genotype 1a undergoing LT. Subjects received 11 infusions of 50 mg/kg MBL‐HCV1 (n = 6) or placebo (n = 5) intravenously with three infusions on day of transplant, a single infusion on days 1 through 7 and one infusion on day 14 after LT. MBL‐HCV1 was well‐tolerated and reduced viral load for a period ranging from 7 to 28 days. Median change in viral load (log10 IU/mL) from baseline was significantly greater (p = 0.02) for the antibody‐treated group (range −3.07 to −3.34) compared to placebo group (range −0.331 to −1.01) on days 3 through 6 posttransplant. MBL‐HCV1 treatment significantly delayed median time to viral rebound compared to placebo treatment (18.7 days vs. 2.4 days, p < 0.001). As with other HCV monotherapies, antibody‐treated subjects had resistance‐associated variants at the time of viral rebound. A combination study of MBL‐HCV1 with a direct‐acting antiviral is underway.
Administration of a human monoclonal antibody to HCV E2 glycoprotein during the peritransplant period delays viral rebound after liver transplantation.
Totally laparoscopic living donor hepatectomy is a complex procedure with a steep learning curve requiring experienced teams with a commitment to technical excellence; it is not a random act but ...rather a gradual evolutionary process, decades in the making. See case reports by Samstein et al (page 2462), Soubrane et al (page 2467) and Troisi et al (page 2472).
The 2007 American Society of Transplant Surgeons’ (ASTS) State‐of‐the‐Art Winter Symposium entitled, ‘Solving the Organ Shortage Crisis’ explored ways to increase the supply of donor organs to meet ...the challenge of increasing waiting lists and deaths while awaiting transplantation. While the increasing use of organs previously considered marginal, such as those from expanded criteria donors (ECD) or donors after cardiac death (DCD) has increased the number of transplants from deceased donors, these transplants are often associated with inferior outcomes and higher costs. The need remains for innovative ways to increase both deceased and living donor transplants. In addition to increasing ECD and DCD utilization, increasing use of deceased donors with certain types of infections such as Hepatitis B and C, and increasing use of living donor liver, lung and intestinal transplants may also augment the organ supply. The extent by which donors may be offered incentives for donation, and the practical, ethical and legal implications of compensating organ donors were also debated. The expanded use of nonstandard organs raises potential ethical considerations about appropriate recipient selection, informed consent and concerns that the current regulatory environment discourages and penalizes these efforts.
The 2007 Winter ASTS Symposium examined the practical and ethical issues involved in traditional and innovative strategies to increase the supply of transplantable organs including the use of non‐standard donors and financial incentives to donors or donor families.
Introduction
Obese patients with congestive heart failure (CHF) are often denied access to heart transplantation until they obtain significant weight loss to achieve a certain BMI threshold, often ...less than 35 kg/m
2
. It is unknown whether the rapid weight loss associated with bariatric surgery leads to improved waitlist placement, and as such improved survival for morbidly obese patients with CHF.
Methods
A decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with CHF who were deemed ineligible to be waitlisted for heart transplantation unless they achieved a BMI less than 35 kg/m
2
. Life expectancy following medical weight management (MWM), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) was estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m
2
. Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review.
Results
RYGB improved survival compared with both SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 2.1 additional years of life compared with patient’s who underwent SG and 7.4 additional years of life compared with MWM. SG patients gained 5.3 years of life compared with MWM.
Conclusions
When strict waitlist criteria were applied, bariatric surgery improved access to heart transplantation and thereby increased long-term survival compared with MWM. Morbidly obese CHF patients who anticipate need for heart transplantation should be encouraged to pursue surgical weight management strategies, necessitating discussion between bariatric surgeons, cardiologists, and cardiac surgeons for appropriate perioperative risk management.
The number of liver transplants performed yearly has slowly and steadily increased over the last 10 years, reaching 6441 procedures in 2005. The number of living donor liver transplants performed ...rose steadily from 1996 to 2001, when it peaked at 519; since 2003 there have been approximately 320 such procedures performed each year. The continual increase in the size of the waiting list for a liver transplant, which peaked in 2001 at 14 897 patients, was interrupted in 2002 by the implementation of the allocation system based on the model for end‐stage liver disease and pediatric end‐stage liver disease (MELD/PELD). Activity in all areas of intestinal transplantation continues to increase. One‐year patient and graft survival following intestine‐alone transplantation now seem to be superior to outcomes following liver‐intestine transplantation. Other topics covered here include the recent ‘Share 15’ component of the MELD allocation system; liver transplantation following donation after cardiac death; simultaneous liver‐kidney transplantation and waiting list and post‐transplant outcomes for both liver and intestine transplantation, broken out by a variety of clinical and demographic factors.
Objectives: To determine the relationship between perioperative glucose control and postoperative nosocomial infection rate in 100 consecutive diabetic patients undergoing elective surgery. Design ...and Patients: One hundred initially uninfected diabetic patients undergoing elective surgery were prospectively monitored for perioperative glucose control and postoperative nosocomial infection rate. Glucose control was determined by the attending surgeon or diabetologist. Setting: A large tertiary care hospital that serves as the in-patient facility for a local diabetes center. Main Outcome Measures: All patients were screened for infection preoperatively. Only initially uninfected patients were enrolled, and all patients received perioperative antibiotic coverage. Perioperative glucose control and postoperative nosocomial infection rate were monitored prospectively. APACHE II scores were determined on all patients. Patients were stratified into two groups: those with relatively "good" perioperative glucose control (all values ≤220 mg/dL) and those with "poor" control (at least one value >220 mg/dL). Contingency tables were generated, comparing nosocomial infection rates vs perioperative glucose control. Correlation coefficients between APACHE II score and maximum and mean glucose values were also determined. Results: A serum glucose >220 mg/dL on postoperative day one (POD 1) was a sensitive (87.5%) but relatively nonspecific (33.3%) predictor of the later development of postoperative nosocomial infection. In patients with hyperglycemia (>220 mg/dL) on POD 1, the infection rate was 2.7 times that observed (31.3% vs 11.5%) in diabetic patients with all serum glucose values <220 mg/dL. When minor infection of the urinary tract was excluded, the relative risk for "serious" postoperative infection increased to 5.7 when any POD 1 blood glucose level was >220 mg/dL. On the basis of correlation coefficients between serum glucose values and APACHE II score, only 18% of the variance in the highest serum glucose could be explained by disease severity alone. Conclusions: We conclude that diabetic patients undergoing major cardiovascular or abdominal surgery have an increased risk of infection that is further exacerbated by early postoperative hyperglycemia. The high rate of nosocomial infection observed in diabetic patients with poor glucose control suggests that hyperglycemia itself may be an independent risk factor for the development of infection. Efforts to improve perioperative glucose homeostasis in diabetic patients may reduce the incidence of nosocomial infection and thereby improve outcome. (Journal of Parenteral and Enteral Nutrition
22:77-81, 1998)
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