Changing perspectives on liver transplantation in 1988.

After liver transplantation for cancer, there is a high incidence of disease recurrence within 18 to 36 months for most tumors, although there are a small number of long-term survivors. An extended resection of the upper abdominal viscera with replacement by a liver-pancreas cluster is being tried in Pittsburgh for lesions which have not been successfully managed with liver transplantation alone. Despite a high incidence of graft reinfection after liver transplantation for hepatitis B virus (HBV) related disease, a significant proportion of patients achieve long-term survival. Hyperimmune globulin and interferon have been of little benefit in preventing reinfection. Clinical trials with a human monoclonal antibody to HBsAg are in progress. Transplantation for alcoholic liver disease has been considered controversial. However, survival after liver transplantation for Laennec's cirrhosis is comparable to survival after liver transplantation for other chronic, benign, and non-HBV related liver diseases. Sclerotherapy followed by liver transplantation is the treatment of choice for patients with acute hemorrhage from esophageal varices and end-stage liver disease. Sclerotherapy alone or followed by selective shunting is an appropriate alternative in patients with good hepatic reserve. Only 25% of infants with biliary atresia benefit from portoenterostomy. To meet the demand for small infants waiting for transplantation, several transplant programs have successfully expanded their efforts to use partial (reduced) liver grafts. Cyclosporine and low-dose prednisone remain the basis for immunosuppression after liver transplantation. However, nephrotoxicity and hypertension are frequent and troublesome side effects of cyclosporine. Triple and quadruple drug regimens have been increasingly popular in an effort to minimize cyclosporine toxicity. Phase 1 clinical trials with a new drug, FK506, recently began in Pittsburgh. Hyperacute rejection of the liver has been demonstrated in animal models and has been strongly suspected in recent clinical descriptions of acute hemorrhagic necrosis after liver transplantation. So far, only transplantation across an ABO incompatibility has been identified as a risk factor for hyperacute rejection. The new preservation solution developed by Belzer and associates at the University of Wisconsin has significantly extended the preservation time for liver grafts, and improved the quality of liver preservation

Liver resection for metastatic colorectal cancer

From 1975 to 1985, 60 patients with isolated hepatic metastases from colorectal cancer were treated by 17 right trisegmentectomies, five left trisegmentectomies, 20 right lobectomies, seven left lobectomies, eight left lateral segmentectomies, and three nonanatomic wedge resections. The 1-month operative mortality rate was 0%. One- to 5-year actuarial survival rates of the 60 patients were 95%, 72%, 53%, 45%, and 45%, respectively. The survival rate after liver resection was the same when solitary lesions were compared with multiple lesions. However, none of the seven patients with four or more lesions survived 3 years. The interval after colorectal resection did not influence the survival rate after liver resection, and survival rates did not differ statistically when synchronous metastases were compared with metachronous tumors. A significant survival advantage of patients with Dukes' B primary lesions was noted when compared with Dukes' C and D lesions. The pattern of tumor recurrence after liver resection appeared to be systemic rather than hepatic. The patients who received systemic chemotherapy before clinical evidence of tumor recurrence after liver resection survived longer than those who did not

Surgical complications in human orthotopic liver transplantation.

Between March 1, 1980 and December 31, 1984, 393 orthotopic liver transplantations (OLT) were performed in 313 consecutive recipients. Technical complications were responsible for a substantial morbidity (41/393 allograft loss--10.4%) and mortality (26/313 patient loss--8.3%). Failure of the biliary tract reconstruction, mainly expressed as leakage and obstruction, is the most frequent complication of OLT (52/393 grafts--13.2%). Biliary tract complication (BTC) was directly responsible for 5 deaths (9.6%). Reliance upon standardized methods of direct duct-to duct repair with T-tube (CC-T) and Roux-Y choledocho-jejunostomy (RYCH-J), appropriate postoperative investigation and treatment will reduce morbidity and mortality of BTC. A complicated CC-T will be conversed to a RYCH-J; a complicated RYCH-J needs surgical correction. Hepatic artery thrombosis (HAT) has become the "Achilles heel" of OLT. HAT is expressed by three different patterns: fulminant hepatic necrosis, delayed bile leakage and relapsing bacteremia. Diagnosed in 27 grafts (6.8%), HAT was responsible for 16 deaths (16/25 pat: 64%). The only chance to rescue patients presenting HAT is an early diagnosis and prompt retransplantation before occurrence of septic complications. Aneurysm of the hepatic arterial supply (4/393 grafts--1%) also needs aggressive surgery because of the high rate of fatal rupture (3/4 pat--75%). The incidence of thrombosis of the reconstructed portal vein (PVT) was only 2.2% (7 pat.), three inferior vena caval thromboses (0.9%) (CVT) were diagnosed after OLT. Four of the 7 patients whose portal veins clotted are alive. Three have their original graft. One patient, presenting both PVT and CVT, was rescued by prompt retransplantation. PVT was responsible for 3 patient (3/7 pat--42.8%) and 4 graft losses (4/7 pat--57%). The rate of graft (3/3) and patient loss (2/3) was even higher after CVT

A simplified technique for revascularization of homografts of the liver with a variant right hepatic artery from the superior mesenteric artery

A simplified technique for conversion of a complex hepatic arterial supply into a common channel is described. This technique permits single vessel anastomosis in the recipient of a liver transplant