Surgery Blog for Surgeons

(Ab)Using scientific journals for political purposes

I just read the article "What Liver Transplant Outcomes Can Be Expected in the Uninsured Who Become Insured via the Affordable Care Act?" in the last edition of AJT and would like to share some thoughts about it.

Cohort selection

On page two the authors write:

All charity care candidates were rigorously screened by social workers and neuropsychiatric professionals to ensure that they have 1) a strong social support system, 2) a failsafe transportation mechanism to facilitate access to posttransplant clinics, 3) adequate cognitive function to understand the transplant process, and 4) a personality that predicts that the candidate will be reliable to take medications as prescribed and come to clinic appointments as required.

Besides suggesting high preselection bias of the patients in this group, one would wonder whether the protocols in Alabama don't include this kind of evaluation of all patients and not just of the ones who are uninsured.

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"First pass" mesenteric flow is not necessary - portal vein arterializaton

Portal vein thrombosis (PVT) is such a profound problem that it has been considered to be an absolute contraindication for a liver transplantation (LTx) and I know centers still denying LTx for patients with PVT. In the most cases the donor portal vein is anastomosed with the superior mesenteric vein (SMA) of the recipient using a vascular graft (usually from the same donor). There are some reports about porto-renal anastomoses. The portal vein arterialization (PVA) is the option which recently attracted my interest and I took a look at what was written about this.

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Ultrasound/MRI elastography: non-invasive test for liver fibrosis and cirrhosis

While looking for papers about "small-for-size" liver syndrome, I just stumbled upon a relatively new test called FibroScan©. This is an interesting approach in determine the stiffness of the tissue as this reflects a possible fibrosis/cirrhosis of the liver.

The test is performed by Ultra Sound (US) or MRI (the term "FibroScan©" is the commercial name of the US way only). Both methods rely on measuring the response of the liver tissue to an external vibration.

Here is a nice and short description of the tests. Rowen Zetterman points out some possible limitations:

  • "Advanced fibrosis may be underestimated and patients with macronodular cirrhosis may be classified as noncirrhotic.": I don't see this as a problem in real life because macronodular cirrhosis is easily diagnosed just by plain imaging.
  • "Fibrosis may be overestimated in patients with extrahepatic cholestasis or acute hepatocellular injury due to the effects of these conditions on liver stiffness.": I would add here also CHF as it makes a liver stiff as well.
  • "Ultrasound elastography does not distinguish patients with no fibrosis from patients with minimal fibrosis.": Yes, this is understandable. But there is probably no clinical relevance of this distinction.
  • "Ascites can interfere with the generation of a shear wave through the liver.": At the stage of significant ascites, the patients usually have some sort of diagnosis. But I agree that this is a real limitation of the test.

Having those limitations in mind, I think that overall this is a very nice idea. We are challenged now to get some sensitivity and specificity so that we could find the group of patients who could avoid the biopsy.

Hyperacute rejection in liver transplantation?

The hyperacute rejection in transplant surgery is a devastating event. Prior to the introduction of the crossmatch for kidney transplantation, the hyperacute rejection was not uncommon. However the crossmatch is currently of no importance in the organs other than the kidney.
Despite some published case reports, most transplant surgeons do not even believe in hyperacute (or also antibody-mediated) rejection in liver allotransplantation. In fact, this attitude has been almost supported by most of these papers - they are just not convincing!

Having written the above, I will describe here a case that I have no (other) explanation for its course.

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The process of organ procurement: Liver - the cold dissection

This is the third part of the posting series "The process of organ procurement".
Please start with the first and second parts if you have not done so.

The cold dissection is the part with the most surgical variants and I want to stress again the fact that the described way is the one that I use, well knowing that this is only one of many possible ways to perform an organ procurement in general and a cold dissection in particular.

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The process of organ procurement: Liver - the warm dissection

This is the second part of the posting series "The process of organ procurement".
Please start with the first part if you have not done so.

The preparation in the OR includes placing of two electrocautery ("Bovie") pads and two suction lines.

I usually fixate both arms next to the body unless the anesthesia colleagues have a good reason for extending one or both of them. Shaving and decontamination of the skin I perform only in a line about 5-10 cm on both sides of the midline as I never make lateral incisions.

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The process of organ procurement: prior to the surgery

There are many ways performing most of the surgical procedures. Everyone of the surgeons has established a way to go for a particular surgery that s/he is most familiar with and trusts most. In this series of postings ("The process of organ procurement") I will describe the way I perform the liver and kidney procurements in a Standard Criteria Donation (SCD) situation.

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