The aim of the present study was to assess whether flushing the donor liver with urokinase immediately before implantation reduces the incidence of nonanastomotic biliary strictures (NASs) after liver transplantation, without causing increased blood loss, analyzed as a historical cohort study. Between January 2005 and October 2012, all liver (re-)transplantations were included. Of the 185 liver transplant recipients included, 63 donor livers between January 2010 and October 2012 received urokinase (study group), whereas the donor liver of 122 consecutive recipients, who served as a historical control group, between January 2005 and January 2010 did not receive urokinase. Basic donor (Eurotransplant donor risk index) and recipient (age, body mass index, laboratory Model for End-Stage Liver Disease score) characteristics did not significantly differ in both groups. Thirty-three recipients developed NASs: 22 in the control group (18%) and 11 (17.5%) in the study group (P 5 0.68). Analyzed separately for donation after circulatory death (P 5 0.42) or donation after brain death (P 5 0.89), there was no difference between the groups in incidence of NAS. Of all the recipients developing NAS, 7 (21%) needed retransplantation and all others were treated conservatively. Autologous blood transfusion requirements did not differ significantly between both groups (P 5 0.91), whereas interestingly, more heterologous blood transfusions were needed in the control group (P < 0.001). This study has its limitations by its retrospective character. A multi-institutional prospective study could clarify this issue. In conclusion, arterial flushing of the liver with urokinase immediately before implantation did not lead to a lower incidence of NAS in this study, nor did it lead to increased blood loss.
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center‐based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End‐Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1‐year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
Purpose Temporary balloon occlusion of the inferior vena cava to lower cardiac output is a relatively infrequently used technique to induce controlled systemic hypotension. In this technical note, we describe the feasibility, reliability, and safety of partial occlusion of right atrial inflow and the effect on systemic blood pressure during the deployment of a thoracic stentgraft. Materials and Methods Twenty consecutive patients undergoing thoracic endovascular aortic repair, with proximal landing in zone 0–3 of the thoracic aorta, were prospectively included. Right atrial inflow occlusion was performed with a compliant occlusion balloon. Results Median time to reach a mean arterial pressure of 50 mmHg was 43 s. Median recovery time of blood pressure was 42 s. Conclusion Partial right atrial inflow occlusion with an occlusion balloon is feasible with reliable results and without procedure-related complications.
The authors compared 100 consecutive donation after circulatory death (DCD) liver transplantations (LT) using a protocol that includes thrombolytic therapy (late DCD group) to a historical DCD group (early DCD group) and a cohort of donation after brain death (DBD) LT. The primary objective of the study was to "present the experience with 100 consecutive DCD LT using a protocol that includes tissue plasminogen activator (tPA) administration."While the team at Ochsner Clinic Foundation, New Orleans, deserves to be congratulated for their excellent results, we do have remarks about the added value of tPA, and we believe its advantages may have been overstated. Bohorquez et al justly recalls that Ischemic-type biliary lesions (ITBL)is the most feared and frequent cause of DCD allograft failure. However, they report a low ITBL rate in the late DCD LT. Noticeable is that the frequency of ITBL in the early versus late DCD LT does not statistically differ (5% vs. 3%, P = .63), and was extremely low in both groups. This makes it likely a result of other improvements, such as the reported short cold ischemia times, also explaining the low peak AST and thus less ITBL, 2 rather than a result of the usage of tPA.Interestingly, a significantly decreased number of retransplantations was shown (1% vs. 18.4%, P = .001). However, only one patient in the early DCD group received a retransplantation for ITBL. Other Lastly, although the clinical safety of using thrombolytic agents in DCD liver transplantation has been supported earlier by our study, in which urokinase (uPA) was used, we could not detect any benefit from the use of uPA, with an unchanged high rate of ITBL in our series (18% in control group vs. 17.5% in urokinase group; P = .68), accompanied by a longer cold ischemia time (572 minutes in control group vs. 535 minutes in study group; P = .09). 5In summary, we remain critical regarding the suggested effect of thrombolytic agents in reducing ITBL, and think that other factors, like the reported short ischemia times, may be the main explanation for the observed extremely low ITBL rates. DISCLOSUREThe authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation. Keywordsclinical research/practice, donors and donation: donation after brain death (DBD), donors and donation: donation after circulatory death (DCD), liver transplantation/hepatology, surgical technique, thrombosis and thromboembolism
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