A Simple and New Device to Avoid Hepatic Venous Outflow Obstruction in Adult Liver Transplantation

Hepatic venous drainage in liver transplantation may be reduced to the level of caval anastomosis producing an obstruction degree and leading to serious vascular complication such as the acute Budd-Chiari syndrome, which may result in organ loss. Outflow obstruction may be caused by lack of technique in caval anastomo-sis or by allograft malposition as a consequence of anatomical graft and recipient conditions. Fixation of the round ligament, placement of bowel loops and use of tissue expanders have been described to stabilize graft position during liver transplantation with related procedure complications. We report our experience of a simple homemade device using a surgical glove expander that allowed us to successfully avoid outflow ob-struction in all of nine treated patients. No device related complications occurred. In malposed liver al-lografts, we strongly suggest the use of this simple and safe device to avoid hepatic venous outflow obstruc-tion on condition that the device is early removed within 48 hours

Liver Transplantation in a Monolung Patient: A Strategy of Sequential Treatments of Multiple Lung Tuberculosis Cavitations and Hepatocellular Carcinoma on Hepatitis B Related Virus Cirrhosis

The presence of extrahepatic infection is a contraindication for liver transplantation, even more if supported by an advanced pulmonary tuberculosis with persistent cavitation not curable with medical treatment. We report a case of a young patient with hepatocellular carcinoma on hepatitis B virus related liver cirrhosis and multiple lung tuberculosis cavitations. The patient was referred to our centre for liver transplantation. We adopted a strategy with sequential treatments. First a left extra-pericardial pneumonectomy was performed without opening the infected cavern, followed by a therapy with rifampicin, isoniazid and ethambutol for a period of nine months. After the cure of tuberculosis, the monolung patient eventually was listed for liver transplantation. An accurate planning of a multistep therapeutical strategy, an appropriate anesthetic man- agement and a meticulous surgical technique allowed to successfully transplant a young patient suffering from three life-threatening diseases: cavitary tuberculosis, hepatitis B virus cirrhosis and hepatocellular car- cinoma. Thirty months after liver transplantation the patient is in good health, with normal liver function, forced expiratory volume in one second of 42% (1.53 liters) and without any tuberculosis disease reactiva- tion

Liver Transplantation and Hepatitis B, C and Delta Viral Diseases

A majority of adults are transplanted because of end-stage acute and chronic liver diseases due to hepatits B (HBV), C (HCV) and Delta (HDV) viral infection.The authors present their experience with 62 HBV-HBV/HDV infected patients and 61 HCV-infected patients who underwent liver transplantation during the period february 1984 - december 1992.The detailed analysis of 48 long-term HBV survivors (> 3 months posttransplant) showed that (1) coinfection is the variable influencing significantly survival rates following liver transplantation ; (2) that the incidence of allograft reinfection can be significantly lowered by adequate immunoprophylaxis ; (3) that liver related mortality (due to viral allograft reinfection) can be significantly lowered by ADIP; (4) that life-long ADIP is necessary to confirm results as well in the chronic as in the fulminant HBV group ; (5) that benefit of ADIP is highest in the chronic HBV patient group and finally (6) that the importance of viral replication at moment of transplantation is overrided by the ADIP ; so replicating patients should not be excluded from the therapeutical option of liver transplantation.The key element in the posttransplant follow-up of HBV patients is the individualized life-long administration of specific anti-HBS immunoglobulins in order to reach a protective level of at least 100 mUI/ml anti-HBs.The question if ADIP together with reduced immunosuppression schemes, especially in relation to steroid use, will allow further improvement of results of liver transplantation for HBV-disease should be answered by prospective studies.The analysis of 56 long-term HCV survivors showed that all grafted patients remain infected and that 62,5% (35/56) of patients reinfected their allograft. Five patients (8,9%) already developed cirrhosis during posttransplant follow-up. The role of different HCV genotypes as well as of immunosuppression on the posttransplant evolution of HCV-infection needs further analysis. Development of reliable immunohistochemical methods and of adequate antiviral therapies is necessary in order to make early and correct diagnosis of HCV allograft infection. This is of particular interest as histological modifications of graft rejection and HCV-reinfection may be simila

Adult liver transplantation and abnormalities of splanchnic veins: Experience in 53 patients

The aim of this study was to analyze the influence of technical problems resulting from splanchnic venous anomalies on the outcome of orthotopic liver transplantation. From February 1984 until December 1995, 53 (16.3 %) of 326 adults underwent consecutive transplantations whilst having acquired anomalies of the splanchnic veins. These consisted of portal vein thrombosis (n = 32, 9.8 %), thrombosis with inflammatory venous changes (phlebitis; n = 6, 1.8 %) and alterations related to portal hypertension surgery (n = 15, 4.6 %). Because of major changes in surgical technique, i, e., eversion instead of blind venous thrombectomy, immediate superior mesenteric vein approach in cases of extended thrombosis, and piggyback implantation with preservation instead of removal of the inferior vena cava, patients were divided into two groups: those who underwent transplantation during the period February 1984 to December 1990 (group 1) and those transplanted between January 1991 and December 1995 (group 2), Surgical procedures to overcome the anomalies consisted of venous thrombectomy (n = 26), implantation of the donor portal vein at the splenomesenteric confluence (n = 5) or onto a splenic (n = 1) or ileal varix (n = 1), interposition of a free iliac venous graft between recipient superior mesenteric vein and donor portal vein (n = 9,) and interruption of surgical portosystemic shunt (n = 13). All patients had a complete follow-up. The 1- and 5-year actuarial patient survival rates were similar in patients with (n = 53) and without (n = 273) splanchnic venous abnormalities (75.5 % vs 78,1 % and 64.3 % vs 66.9 %, respectively), Early (< 3 months) post-transplant mortality was 24.5 % (13/53 patients). Mortality was highest in the portal vein thrombophlebitis group (5/6, 83.3 %), followed by the portal hypertension surgery group (5/15, 33.3 %) and the portal vein thrombosis group (3/32, 9.4 %). Technical modifications significantly reduced mortality in group 2 (10.3 %. 3/29 vs 41.7 %. 10/24 patients in group 1; P < 0.05) as well as the need for re-exploration for bleeding (13.8 %. 4/29 patients in group 2 vs 15/24, 62.5 % in group 1; P < 0.01). Mortality directly related to bleeding was also significantly lowered (1/29, 3.4 % in group 2 vs 9/ 24, 37.5 % in group 1, P < 0.01). We conclude that liver transplantation can be safely performed in the presence of splanchnic vein thrombosis and previous portal hypertension surgery

Liver transplantation and HBsAg-positive postnecrotic cirrhosis: adequate immunoprophylaxis and delta virus co-infection as the significant determinants of long-term prognosis.

BACKGROUND/AIMS: The place of liver transplantation in hepatitis B viral (HBV)-related diseases remains controversial because of the high rate of reinfection. The aim of this study was to define the determinants of long-term prognosis after transplantation. METHODS: Fifty-eight patients were transplanted during the period February 1984-September 1996. Six patients died during the early ( 3 months) survivors were evaluated in relation to the mode of presentation, viral replication at time of transplantation, absence of hepatocellular cancer at time of transplantation and use of adequate immunoprophylaxis (IP). Adequate immunoprophylaxis, defined as maintenance of anti-HBs levels over 100 mUI/ml, was introduced in December 1989. Intention-to-treat IP analysis compared patients transplanted before and after this date. The median follow-up was 74 months (range 4 to 131). Forty-seven patients (90%) had a minimal follow-up of 3 years. RESULTS: Five-year actuarial survival rates of 58 patients and of 52 long-term survivors were 72 +/- 6% and 80 +/- 6%, respectively. Univariate analysis showed that delta co-infection (n = 25) significantly improved survival (p < 0.001) [96 +/- 4% vs 63 +/- 10% in HBV patients (n = 27) at 5 years] as did absence of hepatocellular cancer (n = 36) (p = 0.020) [89 +/- 5% vs 61 +/- 12% in 16 non-cancer patients]. IP, however, significantly influenced 5-year survival in the HBV-patient group (n = 17) (p = 0.001) [85 +/- 10% vs 30 +/- 14% in 10 patients without IP). Multivariate analysis selected delta co-infection (p = 0.002) and IP (p = 0.01) as the significant determinants of prognosis independently influencing survival. Uni- and multivariate analyses showed that survival without reinfection was significantly influenced by IP (p = 0.002) [73 +/- 8% (n = 31) versus 33 +/- 12% in 15 non-treated patients). CONCLUSIONS: Delta virus co-infection and immunoprophylaxis are the most important prognostic factors after transplantation for postnecrotic HBsAg-positive cirrhosis. Transplantation can be proposed as a therapeutic tool only if life-long adequate adjuvant therapy can be achieved. Under this condition good results can even be obtained if there is viral replication at the time of transplantation