Due to the shortage of liver allografts and the rising prevalence of fatty liver disease in the general population, steatotic liver grafts are considered for transplantation. This condition is an important risk factor for the outcome after transplantation. We here analyze the characteristics of the donor pool offered to the<i> Charit&#xe9; &#x2013; Universit&#xe4;tsmedizin Berlin</i> from 2010 to 2016 with respect to liver allograft nonacceptance and steatosis hepatis. Of the 2653 organs offered to our center, 19.9&#x25; (n=527) were accepted for transplantation, 58.8&#x25; (n=1561) were allocated to other centers, and 21.3&#x25; (n = 565) were eventually discarded from transplantation. In parallel to an increase of the incidence of steatosis hepatis in the donor pool from 20&#x25; in 2010 to 30&#x25; in 2016, the acceptance rates for steatotic organs increased in our center from 22.3&#x25; to 51.5&#x25; in 2016 (p &#x3c; 0.001), with the majority (86.9&#x25;; p &#x3e; 0.001) having less than 30&#x25; macrovesicular steatosis hepatis. However, by 2016, the number of canceled transplantations due to higher grades of steatosis hepatis had significantly increased from 14.7&#x25; (n = 15) to 63.6&#x25; (42; p &#x3c; 0.001). The rising prevalence of steatosis hepatis in the donor pool has led to higher acceptance rates of steatotic allografts. Nonetheless, steatosis hepatis remains a predominant phenomenon in discarded organs necessitating future concepts such as organ reconditioning to increase graft utilization.

Simon Moosburner

Joseph M. G. V. Gassner

Maximilian N&#xf6;sser

Julian Pohl

David Wyrwal

Felix Claussen

Paul V. Ritschl

Duska Dragun

Johann Pratschke

Igor M. Sauer

Nathanael Raschzok

Prevalence of Steatosis Hepatis in the<i> Eurotransplant</i> Region: Impact on Graft Acceptance Rates

<i>Background</i>. One-third of 5-year survivors after liver resection for colorectal liver metastases (CLM) develop recurrence or tumor-related death. Therefore 10-year survival appears more adequate in defining permanent cure. The aim of this study was to develop prognostic models for the prediction of 10-year survival after liver resection for colorectal liver metastases.<i> Methods</i>. N=965 cases of liver resection for CLM were retrospectively analyzed using univariable and multivariable regression analyses. Receiver operating curve analyses were used to assess the sensitivity and specificity of developed prognostic models and their potential clinical usefulness.<i> Results</i>. The 10-year survival rate was 15.2&#x25;. Age at liver resection, application of chemotherapies of the primary tumor, preoperative Quick&#x2019;s value, hemoglobin level, and grading of the primary colorectal tumor were independent significant predictors for 10-year patient survival. The generated formula to predict 10-year survival based on these preoperative factors displayed an area under the receiver operating curve (AUROC) of 0.716. In regard to perioperative variables, the distance of resection margins and performance of right segmental liver resection were additional independent predictors for 10-year survival. The logit link formula generated with pre- and perioperative variables showed an AUROC of 0.761.<i> Conclusion</i>. Both prognostic models are potentially clinically useful (AUROCs &#x3e;0.700) for the prediction of 10-year survival. External validation is required prior to the introduction of these models in clinical patient counselling.

Ulf Kulik

Mareike Plohmann-Meyer

Jill Gwiasda

Joline Kolb

Daniel Meyer

Alexander Kaltenborn

Frank Lehner

J&#xfc;rgen Klempnauer

Harald Schrem

Proposal of Two Prognostic Models for the Prediction of 10-Year Survival after Liver Resection for Colorectal Metastases

<i>Background</i>. Since local tumor infiltration to the mesenteric-portal axis might represent a challenging assignment for curative intended resectability during pancreatic surgery, appropriate techniques for venous reconstruction are essential. In this study, we acknowledge the falciform ligament as a feasible and convenient substitute for mesenteric and portal vein reconstruction with high reliability and patency for local advanced pancreatic tumor.<i> Methods</i>. A retrospective single-center analysis. Between June 2017 and January 2018, a total of eleven consecutive patients underwent pancreatic resections with venous reconstruction using falciform ligament. Among them, venous resection was performed in nine cases by wedge and in two cases by full segment. Patency rates and perioperative details were reviewed.<i> Results</i>. Mean clamping time of the mesenteric-portal blood flow was 34 min, while perioperative mortality rate was 0&#x25;. By means of Duplex ultrasonography, nine patients were shown to be patent on the day of discharge, while two cases revealed an entire occlusion of the mesenteric-portal axis. Orthograde flow demonstrated a mean value of 34 cm/s. All patent grafts on discharge revealed persistent patency within various follow-up assessments.<i> Conclusion</i>. The falciform ligament appears to be a feasible and reliable autologous tissue for venous blood flow reconstruction with high postoperative patency. Especially the possibility of customizing graft dimensions to the individual needs based on local findings allows an optimal size matching of the conduit. The risk of stenosis and/or segmental occlusion may thus be further reduced.

T. Malinka

F. Klein

T. Denecke

U. Pelzer

J. Pratschke

M. Bahra

The Falciform Ligament for Mesenteric and Portal Vein Reconstruction in Local Advanced Pancreatic Tumor: A Surgical Guide and Single-Center Experience

<i>Objective</i>. We are trying to investigate the possibility, safety, and benefits of replacing the role of T-tube by another more safe and effective procedure for biliary decompression in the case of common bile duct (CBD) exploration.<i> Methods</i>. Our present study includes fifty consecutive patients who underwent a traditional CBD exploration due to choledocholithiasis. Patients were divided into 2 equal groups. In the 1<sup>st</sup> group, a spontaneously expelled Nelaton tube is placed in the CBD to aid in bile drainage to the duodenum, while in the 2<sup>nd</sup> group, a conventional T-tube is placed to decompress the CBD in the early postoperative (PO) days to a drainage bag. Operative and PO data as well as PO hospital stay time were recorded. All data were collected and statistically analyzed.<i> Results</i>. The mean operative time and PO hospital stay days were significantly low (p value &#x3c; 0.05) in the Nelaton tube drainage group compared with the T-tube drainage group. On the other hand, the mean time needed for the abdominal drain removal was significantly higher in the T-tube drainage group (p value &#x3c; 0.05).<i> Conclusion</i>. Nelaton tube with internal biliary drainage is effective and safer than T-tube drainage and it helps in reduction of the PO hospital stay time. In addition, it avoids all short-term complications of T-tube.

Ashraf M. Abdelkader

Ahmed M. Zidan

Mohamed T. Younis

Temporary CBD Stenting with a Nelaton Tube Is a More Practical and Safer Option Than T-Tube Drainage after Conventional CBD Exploration for Choledocholithiasis

<i>Introduction</i>. The success of liver transplantation has been limited by the unavailability of suitable donor livers. The current organ preservation technique, i.e., static cold storage (SCS), is not suitable for marginal organs. Alternatively, normothermic machine perfusion (NMP) promises to recreate the physiological environment and hence holds promise for the better organ preservation. The objective of this systematic review is to provide an overview of the safety, benefits, and insight into the other potential useful parameters of NMP in the liver preservation.<i> Material and Methods</i>. We searched the current literature following registration in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number <a target="_blank" href="http://www.crd.york.ac.uk/PROSPERO/display&#x5f;record.php?ID=CRD42018086034">CRD42018086034</a> for prospective trials comparing the role of NMP device to SCS in liver transplant by searching the PubMed, EMBASE, Cochrane, BIOSIS, Crossref, and Scopus databases and clinical trial registry.<i> Results</i>. The literature search identified five prospective clinical trials (four being early phase single institutional and single randomized multi-institutional) comparing 187 donor livers on NMP device to 273 donor livers on SCS. The primary outcome of interest was to assess the safety and graft survival at day 30 after transplant following NMP of the donor liver. Secondary outcomes included were early allograft dysfunction (EAD) in the first seven days; serum measures of liver functions as bilirubin, aspartate aminotransferase (AST), alanine amino transferase (ALT), alkaline phosphatase (ALP), and international normalized ratio (INR) on days 1&#x2013;7; major complications as defined by a Clavien-Dindo score &#x2265; 3; and patient and graft survival and biliary complications at six months. The peaked median AST level between days 1 and 7 in the five trials was 417&#x2013;1252&#x2009;U/L (range 84&#x2013;15009&#x2009;U/L) while on NMP and 839&#x2013;1474&#x2009;U/L (range 153&#x2013;8786&#x2009;U/L) in SCS group. The median bilirubin level on day 7 ranged within 25&#x2013;79&#x2009;<i>&#xb5;</i>mol/L (range 8&#x2013;344&#x2009;<i>&#xb5;</i>mol/l) and 30&#x2013;47.53&#x2009;<i>&#xb5;</i>mol/l (range 9&#x2013;340&#x2009;<i>&#xb5;</i>mol/l) in NMP and SCS groups, respectively. A single case of PNF was reported in NMP group in the randomized trial while none of the other preliminary studies reported any in either group. There was intertrial variability in EAD which ranged within 15&#x2013;56&#x25; in NMP group while being within 23&#x2013;37&#x25; in SCS group. Biliary complications observed in NMP group ranged from 0 to 20&#x25;. Single device malfunction was reported in randomized controlled trial leading to renouncement of transplant while none of the other trials reported any machine failure, although two user related device errors inadvertent were reported.<i> Conclusion</i>. This review outlines that NMP not only demonstrated safety and efficacy but also provided the favourable environment of organ preservation, repair, and viability assessment to donor liver prior to the transplantation with low rate of posttransplantation complication as PNF, EAD, and biliary complication; however further studies are needed to broaden our horizon.

Kumar Jayant

Isabella Reccia

Francesco Virdis

A. M. James Shapiro

The Role of Normothermic Perfusion in Liver Transplantation (TRaNsIT Study): A Systematic Review of Preliminary Studies

As a result of donation after circulatory death liver grafts’ poor tolerance to cold storage, there has been increasing research interest in normothermic machine perfusion. This study aims to systematically review the current literature comparing normothermic perfusion to cold storage in donation after circulatory death liver grafts and complete a meta-analysis of published large animal and human studies. A total of nine porcine studies comparing cold storage to normothermic machine perfusion for donation after circulatory death grafts were included for analysis. There was a significant reduction in AST (mean difference −2291 U/L, CI (−3019, −1563);<i> P </i><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-1.11981pt" id="M1" height="8.89449pt" version="1.1" viewBox="-0.0498162 -7.77468 7.75925 8.89449" width="7.75925pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g117-93" d="M531 71V127L115 310L531 494V550L57 335V285L531 71ZM531 -40V10H57V-40H531Z"/></g></svg> 0.00001) and ALT (mean difference −175 U/L, CI (−266, −85); <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="19.289pt" style="vertical-align:-0.2064009pt" id="M2" height="8.8423pt" version="1.1" viewBox="-0.0498162 -8.6359 19.289 8.8423"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-81" d="M600 480C600 590 528 650 384 650H143L137 622C222 614 225 607 210 531L130 127C113 41 106 36 23 28L17 0H294L300 28C204 36 195 42 212 127L243 284L314 263C327 263 339 263 352 264C465 271 600 337 600 480ZM508 481C508 351 402 304 329 304C289 304 265 311 250 317L295 559C302 594 310 606 323 611C335 616 350 619 367 619C455 619 508 573 508 481Z"/></g><g transform="matrix(.013,0,0,-0.013,11.658,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="34.445pt" style="vertical-align:-0.2064009pt" height="8.8423pt" version="1.1" viewBox="22.8711838 -8.6359 34.445 8.8423"><g transform="matrix(.013,0,0,-0.013,22.921,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.013,0,0,-0.013,29.161,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,32.125,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.365,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,44.605,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,50.845,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g></svg></span>), for normothermic perfusion relative to static cold storage, with moderate (<svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-0.04979992pt" id="M3" height="11.6412pt" version="1.1" viewBox="-0.0498162 -11.5914 10.6309 11.6412" width="10.6309pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-74" d="M405 650H141L135 622C222 616 230 610 215 535L133 116C118 41 113 33 29 28L23 0H289L295 28C209 33 205 40 219 116L298 535C312 609 317 616 399 622L405 650Z"/></g><g transform="matrix(.0091,0,0,-0.0091,5.567,-5.741)"><path id="g50-51" d="M414 144C384 79 371 75 317 75H135L276 221C367 316 408 376 408 465C408 570 327 635 237 635C179 635 131 609 100 575L42 494L67 471C94 510 138 565 205 565C277 565 321 517 321 435C321 348 258 270 195 195C146 137 88 81 33 26V0H411C423 44 433 88 446 135L414 144Z"/></g></svg> = 61%) and high (<svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-0.04979992pt" id="M4" height="11.6412pt" version="1.1" viewBox="-0.0498162 -11.5914 10.6309 11.6412" width="10.6309pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-74"/></g><g transform="matrix(.0091,0,0,-0.0091,5.567,-5.741)"><use xlink:href="#g50-51"/></g></svg> = 96%) heterogeneity, respectively. Total bile production was also significantly higher (mean difference = 174 ml, CI (155, 193); <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="19.289pt" style="vertical-align:-1.11981pt" id="M5" height="9.75571pt" version="1.1" viewBox="-0.0498162 -8.6359 19.289 9.75571"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-81"/></g><g transform="matrix(.013,0,0,-0.013,11.658,0)"><use xlink:href="#g117-93"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="40.708pt" style="vertical-align:-1.11981pt" height="9.75571pt" version="1.1" viewBox="22.8711838 -8.6359 40.708 9.75571"><g transform="matrix(.013,0,0,-0.013,22.921,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,29.161,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,32.125,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.365,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,44.605,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,50.845,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,57.085,0)"><use xlink:href="#g113-50"/></g></svg></span>). Further research focusing on standardization, performance of this technology following periods of cold storage, economic implications, and clinical trial data focused on donation after circulatory death grafts will be helpful to advance this technology toward routine clinical utilization for these grafts.

Jordan J. Nostedt

Daniel T. Skubleny

Sandra Campbell

Darren H. Freed

David L. Bigam

Normothermic Ex Vivo Machine Perfusion for Liver Grafts Recovered from Donors after Circulatory Death: A Systematic Review and Meta-Analysis

<i>Background.</i> Plexiform neurofibroma (PNF) in the porta hepatis (PH) is an unusual manifestation of neurofibromatosis-1 (NF-1). Resection is often recommended given the risk of malignant transformation. We encountered a challenging case in clinical practice which prompted us to report our findings and perform a systematic review on the management of these tumors.<i> Methods.</i> We reported the case of a 31-year-old woman with NF-1 and PNF of the PH. PRISMA 2009 guidelines were followed for systematic review.<i> Results.</i> Our patient was found to have unresectable disease at exploration. After &#x3e;5 years of follow-up, she continued to have stable disease on imaging. We identified 12 studies/case reports including 10 adult and 6 pediatric patients with PNF of PH. None of the 7 adult patients with NF-1 and PNF of PH underwent a successful tumor resection. All pediatric patients were managed with surveillance alone. All but one pediatric patient had NF-1. None of the reported cases of PNF of PH had malignant transformation.<i> Conclusion.</i> Our findings suggest that PNFs of PH in the setting of NF-1 are often unresectable and may have an indolent course. Surveillance alone may be a reasonable option in some patients; however, further studies are needed.

Natesh Yepuri

Rana Naous

Camille Richards

Dilip Kittur

Ajay Jain

Mashaal Dhir

Nonoperative Management May Be a Viable Approach to Plexiform Neurofibroma of the Porta Hepatis in Patients with Neurofibromatosis-1

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