Over the past two decades robotic surgery has been introduced to many areas including liver surgery. Laparoscopic liver surgery is an alternative minimally invasive approach. However, moving on to ...the complexity of living donor hepatectomies, the advantages of robotic versus laparoscopic approach have convinced us to establish the robotic platform as a standard for living donor hepatectomy.
From November 2018 to January 2022, 501 fully robotic donor hepatectomies, including 177 left lateral donor lobes, 112 full left lobes and 212 full right lobes were performed. Grafts were donated to 296 adult recipients and 205 pediatric recipients. Donor age, sex, body weight, body mass index (BMI), graft weight, graft to body weight ratio (GBWR), operative time, blood loss, first warm ischemic time, pain score, length of intensive care unit (ICU) stay and hospital stay, and complications were retrospectively analyzed based on a prospectively kept database. Recipients were evaluated for graft and patient survival, age, sex, BMI, body weight, model of end-stage liver disease score, blood loss, transfusions, operative time, cold ischemic time, length of hospital stay and complications.
There was no donor mortality. Two cases needed to be converted to open surgery. The median blood loss was 60 mL (range 20-800), median donor operative time was 6.77 h (range 2.93-11.53), median length of hospital stay was 4 days (range 2-22). Complication rate in donors classified following Clavien-Dindo was 6.4% (n = 32) with one grade III complication. Three-year actual recipient overall survival was 91.4%; 87.5% for adult recipients and 97.1% for pediatric recipients. Three-year actual graft overall survival was 90.6%; 87.5% for adult recipients and 95.1% for pediatric recipients. In-hospital mortality was 6%, 9.1% (27/296) for adult recipients and 1.4% (3/205) for pediatric recipients. The recipients’ morbidity was 19.8% (n = 99). Twenty-eight recipients (5.6%) had biliary and 22 (4.4%) vascular complications. Six (12.0%) recipients needed to be re-transplanted.
With growing experience it is nowadays possible to perform any donor hepatectomy by robotic approach regardless of anatomical variations and graft size. Donor morbidity and quality for life results are encouraging and should motivate other transplant centers with interest in minimally invasive donor surgery to adopt this robotic technique.
We describe the synthesis and characterization of metal-chelating polymers with a degree of polymerization of 67 and 79, high diethylenetriaminepentaacetic acid (DTPA) functionality, M w/M n ≤ 1.17, ...and a maleimide as an orthogonal functional group for conjugation to antibodies. The polymeric disulfide form of the DPn = 79 DTPA polymer was analyzed by thermogravimetric analysis to determine moisture and sodium-ion content and by isothermal titration calorimetry (ITC) to determine the Gd3+ binding capacity. These results showed each chain binds 68 ± 7 Gd3+ per chain. Secondary goat antimouse IgG was covalently labeled with the maleimide form of the DTPA polymer (DPn = 79) carrying 159Tb. Conventional ICPMS analysis of this conjugate showed each antibody carried an average of 161 ± 4 159Tb atoms. This result was combined with the ITC result to show there are an average of 2.4 ± 0.3 polymer chains attached to each antibody. Eleven monoclonal primary antibodies were labeled with different lanthanide isotopes using the same labeling methodology. Single cell analysis of whole umbilical cord blood stained with a mixture of 11 metal-tagged antibodies was performed by mass cytometry.
In recent years the interest in liver cell therapy has been increasing continuously, since the demand for whole liver transplantations in human beings far outweighs the supply. From the clinical ...point of view, transplantation of hepatocytes or hepatocyte-like cells may represent an alternative to orthotopic liver transplants in acute liver failure, for the correction of genetic disorders resulting in metabolically deficient states, and for late stage liver disease such as cirrhosis. Although the concept of cell therapy for various diseases of the liver is widely accepted, the practical approach in humans often remains difficult. An international expert panel critically discussed the recent published data on clinical and experimental hepatocyte transplantation and the possible role of stem cells in liver tissue repair. This paper aims to summarise the present status of cell based therapies for liver diseases and to identify areas of future preclinical and clinical research.
Purpose
Women represent up to 60 % of students entering the medical profession in many countries in the world. However, the proportion of women to men is not accordingly balanced among surgical ...residents and especially in leadership positions in surgery. Therefore, we investigated the career goals as well as family and lifestyle priorities of female surgeons in German liver transplant centers.
Methods
A standardized questionnaire was developed using the web-based survey tool SurveyMonkey®. Questionnaires were distributed electronically to 180 female surgeons in 24 German liver transplant centers. A total of 81 completed questionnaires were analyzed.
Results
Female surgeons in German liver transplant centers are eager to assume leadership positions and do not wish to follow traditional role models. After finishing training, most female surgeons plan to continue working at a university hospital. About 80 % of the respondents intend to continue working full time and wish to combine career and family.
Conclusions
This is the first survey on career intentions of female surgeons in Germany. In the face of gender changes in the medical profession, we were able to demonstrate that female surgeons are willing to fill leadership positions. Individual and institutional creative modifications are necessary if the advancement of women in surgery is to be promoted.
Progressive familial intrahepatic cholestasis (PFIC) is a heterogeneous disease characterized by progressive cholestasis in early childhood. Surgical therapy aims at preventing bile absorption either ...by external or internal biliary diversion (BD). Several different genetic subtypes encode for defects in bile transport proteins, and new subtypes are being discovered ongoingly. Overall, the literature is scarce, however, accumulating evidence points to PFIC 2 having a more aggressive course and to respond less favorable to BD. With this knowledge, we aimed to retrospectively analyze the long-term outcome of PFIC 2 compared to PFIC 1 following BD in children at our center.
Clinical data and laboratory findings of all children with PFIC, who were treated and managed in our hospital between 1993 and 2022, were analyzed retrospectively.
Overall, we treated 40 children with PFIC 1 (
= 10), PFIC 2 (
= 20) and PFIC 3 (
= 10). Biliary diversion was performed in 13 children (PFIC 1,
= 6 and 2,
= 7). Following BD, bile acids (BA) (p = 0.0002), cholesterol (p < 0.0001) and triglyceride (p < 0.0001) levels significantly decreased only in children with PFIC 1 but not in PFIC 2. Three out of 6 children (50%) with PFIC 1 and 4 out of 7 children (57%) with PFIC 2 required liver transplantation despite undergoing BD. On an individual case basis, BA reduction following BD predicted this outcome. Of the 10 children who had PFIC 3, none had biliary diversion and 7 (70%) required liver transplantation.
In our cohort, biliary diversion was effective in decreasing bile acids, cholesterol levels as well as triglycerides in the serum only in children with PFIC 1 but not PFIC 2. On an individual case level, a decrease in BA following BD predicted the need for liver transplantation.
Living donor liver transplantation is the main source of organs in the Middle East. Therefore, well balanced criteria are needed to avoid unnecessary exclusion of potential donors, while prioritizing ...donor safety. We face a high incidence of sickle cell trait (SCT; and disease). Therefore, there is vast experience in general and cardiac surgeries in SCT carriers at our center. After studying their management in detail, we considered accepting SCT carriers as living liver donors, on an exceptional basis. This the first single-center case series of living donor liver transplantation with SCT.
Between January 2012 and September 2021, 20 donors with SCT were reviewed for age, gender, relation to the recipient, hemoglobin, hemoglobin S (HbS), surgical approach, intensive care unit stay, donor and recipients' complications, and graft and recipient survival.
Average age of donors was 28.4 y. Sixteen donated the left lateral segment, 4 the left lobe. Recipients were related children or adults. HbS ranged from 21.2% to 39.9%, being ≥30% in 14 donors. HbS was reduced by phlebotomy or exchange transfusion. We performed 7 open, one laparoscopic, and 12 robotic donor surgeries. Operating room time, blood loss, and intensive care unit stay were comparable to non-SCT donors. There was no SCT-related complication. All donors are alive and free of thromboembolic events. Graft and recipient survival is 100% until follow-up.
Our experience should encourage other countries with high incidence of SCT to report their experience with this donor population.
Adult stem or programmable cells hold great promise in diseases in which damaged or nonfunctional cells need to be replaced. We have recently demonstrated that peripheral blood monocytes can be ...differentiated in vitro into cells resembling specialized cell types like hepatocytes and pancreatic beta cells. During phenotypic conversion, the monocytes downregulate monocyte/macrophage differentiation markers, being indicative of partial dedifferentiation, and are partially reprogrammed to acquire a state of plasticity along with expression of various markers of pluripotency and resumption of mitosis. Upregulation of stem cell markers and mitotic activity in the cultures was shown to be controlled by autocrine production/secretion of activin A and transforming growth factor-beta (TGF-β). These reprogrammed monocyte derivatives were termed “programmable cells of monocytic origin” (PCMO). Current efforts focus on establishing culture conditions that increase both the plasticity and proliferation potential of PCMO in order to be able to generate large amounts of blood-derived cells suitable for both autologous and allogeneic therapies.
Congenital extrahepatic portosystemic shunts (CEPS), previously also described as Abernethy malformations, are rare malformations in which the extrahepatic portal system directly communicates with ...the vena cava inferior, thereby bypassing the liver. A hypoplastic portal vein (PV) exists in most cases. CEPS have been associated with the development of liver nodules, ranging from mostly focal nodular hyperplasia (FNH) to hepatic adenoma (HA) and even hepatocellular carcinoma (HCC). Tumor development in CEPS may be due to changes in perfusion pressures, oxygen supply or endocrine imbalances. It is important to rule out CEPS in children with liver tumors, because resection could impede future shunt occlusion procedures, and benign masses may regress after shunt occlusion. Here, we review the case of a 9-years-old male with CEPS and hepatic nuclear Factor 1-alpha (HNF-1-alpha) inactivated HA to raise awareness of this condition and review histopathological changes in the liver of CEPS.
Summary
Organ donor shortage for infant liver transplant recipients has lead to an increase in splitting and living donation. For cases in which even transplantation of the left lateral graft ...(Couinaud’s segments II + III) results in a “large for size situation” with an estimated graft body weight ratio (GBWR) of >4%, monosegmental liver transplantation was developed. This, however, bears complications because of greater parenchymal surface and suboptimal vascular flow. We exclusively use the left lateral graft from living donors or split grafts. Temporary abdominal closure is attempted in cases of increased pressure. We report of 41 pediatric transplants in 38 children ≤10 kg. Within this group, there were 23 cases with a GBWR of ≥4, and 15 cases with a GBWR <4. There was no statistical difference in vascular or biliary complications. Despite a more frequent rate of temporary abdominal closure, we did not find a higher rate of intra‐abdominal infections. Overall, patient and graft survival was excellent in both groups (one death, three re‐transplants). We noticed, however, that the ventro–dorsal diameter of the graft appears to be more relevant to potential graft necrosis than the actual graft size. In conclusion, the usage of monosegmental grafts seems unnecessary if transplantation of left lateral grafts is performed by an experienced multidisciplinary team, and temporary abdominal closure is favored in cases of increased abdominal pressure.
Living donor liver transplantation (LDLT) is regularly performed in small-sized infants. Computed tomography (CT)-based donor liver volumetry is used to estimate the graft size. The aim of our study ...was to assess the results of CT liver volumetry and their impact on the clinical outcome after LDLT in extremely small-sized infants.
In this study, we included all patients with a body weight of ≤10 kg who underwent living related liver transplantation at our centre between January 2004 and December 2014. In all cases of LDLT, a preoperative CT scan of the donor liver was performed, and the total liver and graft volumes were calculated. The graft shape was estimated by measuring the ventro-dorsal (thickness), cranio-caudal, and transversal (width) diameter of segment II/III. We assessed the impact of CT donor liver volumetry and other risk factors on the outcome, defined as patient and graft survival.
In the study period, a total of 48 living related liver transplantations were performed at our centre in infants ≤10 kg 20 male (42%), 28 female (58%). The mean weight was 7.3 kg (range 4.4-10 kg). Among the recipients, 33 (69%) received primary abdominal closure and 15 (31%) had temporary abdominal closure. The patient and graft survival rates were 85% and 81%, respectively. In CT volumetry, the mean estimated graft volume was 255 mL (range 140-485 mL) and the actual measured mean graft weight was 307 g (range 127-463 g). The mean ventro-dorsal diameter of segment II/III was 6.9 cm (range 4.3-11.2 cm), the mean cranio-caudal diameter was 9 cm (range 5-14 cm), and the mean width was 10.5 cm (range 6-14.7 cm). The mean graft-body weight ratio (GBWR) was 4.38% (range 1.41-8.04%). A high graft weight, a GBWR >4%, and a large ventro-dorsal diameter of segment II/III were risk factors for poorer patient survival.
Preoperative assessment of the graft size is a crucial investigation before LDLT. For extremely small-sized recipients, not only the graft weight but also the graft shape seems to affect the outcome.
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