HVOO creates significant diagnostic and management dilemmas in pediatric liver transplant recipients, particularly with TVGs (split or reduced-size grafts). Numerous technical variations for the hepatic vein to IVC anastomosis have been described to minimize the incidence of this complication, but no consensus for an optimal anastomotic technique exists. One hundred and thirty-four liver transplants (70 TVGs) were performed in 124 patients between 1994 and 2011. These were divided into two cohorts. Group 1 (95 transplants, 41 TVGs) utilized a continuous running anastomosis. Group 2 (39 transplants, 29 TVGs) implemented a triangulated (three-stitch) anastomosis. All were reviewed for demographics, diagnostics, interventions, and outcome. The overall HVOO incidence was seven of 134 transplants (5.2%) and six of 70 transplants utilizing TVGs (8.6%). Group 1 incidence was five of 41 (12.2%) compared with one of 29 (3.4%; p = 0.20, OR 3.89) in Group 2. Liver Doppler was employed in all patients, and only three suggested HVOO. All patients with HVOO underwent venogram, at a median of 81 days post-transplant. All underwent percutaneous venoplasty and required 1-6 treatments, all resulting in HVOO resolution. Incidence of HVOO has improved since adopting the triangulated anastomosis, although not to a level of statistical significance. US is not adequately sensitive to exclude HVOO. Venogram is recommended in patients with prolonged ascites, and venoplasty has been highly successful in HVOO treatment.

BACKGROUND Neoadjuvant locoregional therapies (LRT) have been widely used to reduce tumor burden or downstage hepatocellular carcinoma (HCC) prior to orthotopic liver transplantation (OLT). We examined the impact of LRT response on HCC recurrence after OLT. STUDY DESIGN We performed a retrospective study of 384 HCC patients treated by OLT. Tumor necrosis was determined by pathologic evaluation. The vascular and lymphatic vessels were localized by immunofluorescence (IF) staining in formalin-fixed, paraffin-embedded tissue; expressions of VEGFR-2 and VEGFR-3 were analyzed by Western Blot. Plasma VEGF-A and VEGF-C levels of a consecutive cohort of 171 HCC patients were detected by ELISA. RESULTS Of the 384 HCC patients, 268 had undergone pre-transplant neoadjuvant LRT. Patients with no tumor necrosis (n=58, 5.2% recurrence) or complete tumor necrosis (n=70, 6.1% recurrence) had significantly lower 5-year recurrence rates than those with partial tumor necrosis (n=140, 22.6% recurrence, p<0.001). Lymphatic metastases were significantly more numerous in patients with partial tumor necrosis than those without tumor necrosis after OLT (p<0.001). With immunofluorescent of peritumor zone, lymphatics were visualized around partially-necrotic tumors, but not around tumors without necrosis. Plasma levels of VEGF-A and VEGF-C were significantly elevated in patients with evidence of tumor necrosis (n=102) compared to those without necrosis (n=69; p<0.001). By Western blot, VEGFR-2 and VEGFR-3 expression in the peritumoral tissue associated with partially necrotic tumors was significantly higher than in peritumoral tissue of no necrosis tumors (n=3/group, p<0.020 and 0.006, respectively). CONCLUSION LRT-induced or spontaneous partially necrotic HCC were associated with an increased risk of lymphatic metastases compared with tumors with no or complete tumor necrosis. Anti-lymphangiogenic agents with neoadjuvant LRT may decrease the pattern of lymphatic metastasis after OLT.

Background The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator was developed to help counsel patients regarding estimated postoperative risk for a variety of surgical complications. This retrospective single institutional study examined the calculator’s ability to accurately predict complications and length of hospital stay (LOS) in patients who had undergone a Pancreaticoduodenectomy (PD) at our institution. Methods 165 patients at Washington University School of Medicine who underwent a PD from 8/2011 to 7/2013 were included. Surgical complication risk as determined by the ACS-NSQIP Surgical Risk Calculator were compared to actual 30 day complications. PD complications not accounted for by the calculator were compared to those without PD-specific complications. Results Overall predicted LOS was significantly shorter than actual duration of hospitalization (median 8.5 vs 8.0 days; p <0.001). 38% patients (n=62) with Whipple-specific complication demonstrated a significant increase in LOS (8.0 vs. 12.2 days; p<0.0001). Discussion A large proportion of complications experienced after PD are pancreas-specific, accounting for the difference in predicted vs actual LOS and providing rationale for future development of PD specific risk models.

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