This retrospective study indicates that, in addition to RBC, platelet transfusions are an independent risk factor for survival after OLT. These findings have important implications for transfusion practice in liver transplant recipients.

Nonanastomotic biliary strictures (NAS) are a serious complication after orthotopic liver transplantation (OLT). The exact pathogenesis is unclear. Purpose of this study was to identify risk factors for the development of NAS after OLT. A total of 487 adult liver transplants with a median follow-up of 7.9 years were studied. All imaging studies of the biliary tree were reviewed. Cholangiography was routinely performed between postoperative days 10-14 and later on demand. Localization of NAS at first presentation was categorized into 4 anatomical zones of the biliary tree. Severity of NAS was semiquantified as mild, moderate, or severe. Donor, recipient, and surgical characteristics and variables were analyzed to identify risk factors for NAS. NAS developed in 81 livers (16.6%). Thirty-seven (7.3%) were graded as moderate to severe. In 85% of the cases, anatomical localization of NAS was around or below the bifurcation of the common bile duct. A large variation was observed in the time interval between OLT and first presentation of NAS (median 4.1 months; range 0.3-155 months). NAS presenting early (Յ1 year) after OLT were associated with preservation-related risk factors. Cold and warm ischemia times were significantly longer in patients with early NAS compared with NAS presenting late (Ͼ1 year) after OLT (694 minutes vs. 490 minutes, P ϭ 0.01, and 57 minutes vs. 53 minutes, P Ͻ 0.05, respectively), and early NAS were more frequently located in the central bile ducts. NAS presenting late (Ͼ1 year) after OLT were found more frequently in the periphery of the liver and were more frequently associated with immunological factors, such as primary sclerosing cholangitis, as the indication for OLT (24% vs. 45%, P Ͻ 0.05). By separating cases of NAS on the basis of the time of presentation after transplantation, we were able to identify differences in risk factors, indicating different pathogenic mechanisms depending on the time of initial presentation. Liver Transpl 13:708-718, 2007.

The exact frequency and clinical consequences of surgical hepatic injuries during organ procurement are unknown. We analyzed the incidence, risk factors, and clinical outcome of surgical injuries in 241 adult liver grafts. Hepatic injuries were categorized as parenchymal, vascular, or biliary. Outcome variables were bleeding complications, hepatic artery thrombosis (HAT), and graft survival. In 82 livers (34%), 96 injuries were detected. Most injuries were minor, but clinically relevant injuries were detected in 6.6% (16/241) of the livers. Fifty (21%) liver grafts had some degree of parenchymal or capsular injury, 40 (17%) had vascular injury, and 6 (2%) had an injury to the bile duct. Procurement region was the only risk factor significantly associated with surgical injury. The rate of hepatic artery injury was significantly higher in livers with aberrant arterial anatomy. Bleeding complications were found in 18% of patients who received livers with a parenchymal or capsular injury in contrast to 9% without parenchymal injury (P ϭ 0.065). HAT was found in 23% of the patients who received a liver with arterial injury compared to 4% without arterial injury (P ϭ 0.001). Overall graft survival rates were not significantly different for grafts with or without anatomical injury. In conclusion, surgical injuries of donor livers are an underestimated problem in liver transplantation and can be observed in about one-third of all cases. Clinically relevant injuries are detected in 6.6% of all liver grafts. Arterial injuries are associated with an increased risk of HAT.

This study assesses the relation between the anhepatic phase duration and the outcome after liver transplantation. Of 645 patients who underwent transplantation between 1994 and 2006, 194 were recipients of consecutive adult primary piggyback liver transplants using heart-beating donors. The anhepatic phase was defined as the time from the physical removal of the liver from the recipient to recirculation of the graft. Other noted study variables were the cold and warm ischemia times, donor and recipient age, donor and recipient body mass index, perioperative red blood cell (RBC) transfusion, indication for transplantation, and Model for End-Stage Liver Disease score. The primary outcome parameter was graft dysfunction, which was defined as either primary nonfunction or initial poor function according to the Ploeg-Maring criteria. The median anhepatic phase was 71 minutes (37-321 minutes). Graft dysfunction occurred in 27 patients (14%). Logistic regression analysis showed an anhepatic phase over 100 minutes [odds ratio (OR), 4.28], a recipient body mass index over 25 kg/m 2 (OR, 3.21), and perioperative RBC transfusion (OR, 3.04) to be independently significant predictive factors for graft dysfunction. One-year patient survival in patients with graft dysfunction was 67% versus 92% in patients without graft dysfunction (P Ͻ 0.001). A direct relation between the anhepatic phase duration and patient survival could, however, not be established. In conclusion, this study shows that liver transplant patients with an anhepatic phase over 100 minutes have a higher incidence of graft dysfunction. The shortage of donor organs, in combination with an increasing number of patients on the waiting list for transplantation, urges professionals involved in liver transplantation to strive for optimal utilization of liver grafts. An important issue in this process is minimizing the amount of damage induced during the cold ischemia time (CIT), warm ischemia time (WIT), and reperfusion, which are indissolubly connected to transplantation of a liver graft.Immediately after procurement of the liver of a deceased donor, cold storage is used to minimize ischemic injury. This cold ischemia phase usually lasts for several hours and ends the moment that the graft is taken from ice for implantation. Additionally, during the subsequent warm ischemia phase, the graft is extremely susceptible to ischemic injury. 1 The influence of the length of both CIT and WIT on the outcome of liver transplantation has been extensively studied.1-3 Recent studies even show a cumulative negative effect induced by prolonged CIT and WIT. 2,4 The length of the CIT is mainly determined by logistic factors, such as the distance and availability of operation facilities and personnel. The length of the WIT is less variable. It is mainly dependent on the quality and configuration of the recipient vessels and to a lesser extent the experience of the surgeon.The influence of the length of the anhepatic phase on the outcome of transplantation is less well studied. The ...