Liver transplantation across the ABO barrier remains a controversial issue. Early results were poor, with 5-year graft survivals often as low as 20%. ABO-incompatible (ABO-In) transplants were associated with a high risk of antibody-mediated rejection, severe cell-mediated rejection, vascular thrombosis and ischaemic bile duct complications [1][2][3][4]. However, more recent experiences indicate improving results, with up to 60% 5-year graft survival reported [5][6][7]. Such progress presumably reflects peritransplant management and improving potency of immunosuppression. Protocols appear to have evolved from triple-[1,2] to quadruple-drug immunosuppression with frequent addition of plasmapheresis, splenectomy or intra-vascular infusion of methylprednisolone or prostaglandin E1 [6,8,9]. ABO-incompatible liver transplants have been most frequently utilized for two indications: emergency transplants for acute liver failure or in cases of living-related donor transplants, when no ABO-compatible (ABO-C) donor is available. The risk of rejection in a critically ill patient with acute liver failure, often with concomitant renal dysfunction, is probably lower than in a stable recipient undergoing elective ABO-In living donor transplant. One can thus ponder whether the trend towards more aggressive immunosuppression, especially when including splenectomy or intravascular infusion, should be similarly applied to both ABO-In transplant indications.This study specifically addressed the problem of emergency liver transplant in high status adult patients experi- Summary ABO incompatible (ABO-In) liver transplant remains a controversial solution to acute liver failure in adults. Adult liver recipients with acute liver failure or severely decompensated end-stage disease, intubated and/or in the intensive care unit, were grouped as ABO-In (n ¼ 14), ABO-compatible (n ¼ 29, ABO-C) and ABO-identical (n ¼ 65, ABO-Id). ABO-In received quadruple immunosuppression with antibody-depleting induction agents (except two), calcineurin inhibitors, antimetabolites and steroids. No significant difference of patient and graft survivals was observed among ABO-In, ABO-C and ABO-Id: graft survivals were 64%, 62% and 67%, respectively, in 1 year and 56%, 54% and 60%, respectively, in 5 years; patient survivals 86%, 69% and 67%, respectively, in 1 year and 77%, 61% and 62%, respectively, in 5 years. Three ABO-In grafts were lost (one hyper-acute rejection and two hepatic artery thrombosis). Surgical and infectious complications were similarly distributed between groups, except the hepatic artery thrombosis, more frequent in ABO-In (2, 14%) than ABO-I (1, 1.5%, P < 0.05). In contrast to previous studies, no significant difference of patient and graft survivals could be observed among all ABO-compatibility settings. Our results suggest that ABO-incompatible transplants should be viewed as an important therapeutic option in adult patients with acute liver failure awaiting an emergency procedure.

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HighlightsPrimary carcinosarcoma is a rare neoplasm of the gallbladder.It is characterised by collision of adenocarcinomatous and sarcomatous components.This series shows that complete resection is the only means of extending survival.The role of adjuvant therapy remains unclear.

BackgroundThere is paucity in the literature regarding gallbladder cancer in Saudi Arabia, possibly because it is not among the top 10 cancers diagnosed nationwide according to the Saudi Cancer Registry. Moreover, national or regional data on gallbladder cancer in Saudi Arabia have not been analyzed. The purpose of this study was to describe the presentation, disease stage, histology, and survival rates for gallbladder cancer in Saudi patients at a single institution between January 1, 2010 and December 31, 2017.Materials and methodsThis was a retrospective study of 76 patients who presented to our hospital between January 1, 2010 and December 31, 2017, with established diagnosis of gallbladder carcinoma. The diagnosis was made either histopathologically following simple laparoscopic cholecystectomy or biopsy from metastatic liver lesion in patients with gallbladder mass, or the high suspicion of gallbladder carcinoma based on incidental radiological findings. Presentation, disease stage, histology, and treatment modalities were analyzed using descriptive statistics and frequency distributions. Survival rates were analyzed and presented using Kaplan-Meier curves.ResultsBased on initial analyses the disease was more frequent among women (62.0%) than men (39.0%). Surgical resection was attempted in 40.8% patients. The average age at presentation and diagnosis of gallbladder carcinoma was 62.4 years. The disease had two peaks, one at 51.0 years and the other between 66.0 and 70.0 years. The median survival time for the overall at-risk patients was only 1.0 year, while for stage IVB patients was 7.2 months. Adenocarcinoma not otherwise specified (NOS) was the most common histopathology type (75.0%), with most patients presenting with stage IVB disease (75.0%). Gallbladder carcinoma was incidentally detected in 42.1%, including three cases (3.9%) diagnosed at our hospital.ConclusionsGallbladder cancer is a rare type of cancer in Saudi Arabia, and most patients are treated surgically, despite being mostly diagnosed at the advanced stage of the disease.