Pulmonary Artery Embolotherapy in a Patient with Type I Hepatopulmonary Syndrome after Liver Transplantation

Although liver transplantation (LT) is the only effective treatment option for hepatopulmonary syndrome (HPS), the post-LT morbidity and mortality have been high for patients with severe HPS. We performed post-LT embolotherapy in a 10-year-old boy who had severe type I HPS preoperatively, but he failed to recover early from his hypoxemic symptoms after an LT. Multiple embolizations were then successfully performed on the major branches that formed the abnormal vascular structures. After the embolotherapy, the patient had symptomatic improvement and he was discharged without complications

In adult-to-adult living donor liver transplantation hepaticojejunostomy shows a better long-term outcome than duct-to-duct anastomosis

Roux-en-Y hepaticojejunostomy (RYHJ) has been the standard biliary reconstruction in adult-to-adult living donor liver transplantation (ALDLT). Recently, duct-to-duct anastomosis (DD) has been introduced. This study compared the outcomes of RYHJ and DD. For 4 years, 74 recipients underwent ALDLT and were followed up for at least 2 years. The patients were divided into three groups, RYHJ group (n = 18), DD with a stent (DD + S) group (n = 35), and DD without a stent (DD - S) group (n = 21). Overall, biliary complications were developed in 32.4% patients. The biliary complication rate was 11.1%, 48.5% and 33.3% in RYHJ, DD + S and DD - S groups, respectively (P = 0.047). Bile leaks occurred in 28.5% of DD + S group. The incidence of biliary stricture was 5.3%, 20.2% and 28.6% in RYHJ, DD + S and DD - S group, respectively. Most complications (83.3%) were resolved nonsurgically. RYHJ has a better long-term outcome than DD in ALDLT. Subgroup analysis of DD group showed that DD - S group had no bile leaks, but still had a higher incidence of bile duct strictures. However, because this study was a retrospective review there are limitations in analyzing the data and confirming the conclusion. A randomized-prospective study will be needed to confirm these findings

Current role of surgery in treatment of early stage hepatocellular carcinoma: resection versus liver transplantation

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and is most commonly associated with hepatitis B infection in Korea. Although liver resection is regarded as a potentially curative treatment option, it is only feasible in less than 20% of patients. The reason for this is that HCC arises in cirrhotic livers and is often multicentric. Liver transplantation (LT) which could be used in the treatment both of the tumor and background liver seems to be a rational approach for early stage patients with decompensated liver cirrhosis. Current good selection criteria of LT for HCC are the Milan criteria: 1 HCC nodule < or =5 cm in diameter or 3 nodules < or =3 cm. By restricting LT to patients within the Milan criteria, the 4-year disease-free survival rate was more than 80%, which is comparable to that of a transplant candidate without HCC. However, there are serious limitations for the wider application of LT for HCC: (1) organ shortage, (2) risk to a live donor, (3) high cost, and (4) lifelong immunosuppression. For this reason, for a patient with early stage HCC and with Child A cirrhosis in whom partial hepatectomy is possible, the choice of primary treatment with curative intent is still under debate

Partial Splenic Artery Embolization for Hypersplenism in Liver Transplant Recipient

Background. Hypersplenism after liver transplantation is a widely recognized clinical complication. Recently partial splenic artery embolization (PSAE) is regarded as a less invasive and effective treatment of hypersplenism. In this report we review the result of PSAE in liver transplant recipient.

Auxiliary partial orthotopic living donor liver transplantation in a patient with alcoholic liver cirrhosis to overcome donor steatosis

The efficacy of auxiliary partial orthotopic liver transplantation (APOLT) to overcome the problems associated with a markedly steatotic graft in a living donor has not been fully explored. We have recently performed APOLT in a patient with alcoholic liver disease, where the only potential candidate donor was affected by 50% macrovesicular steatosis and 30% microvesicular steatosis. The recipient's left liver was resected and the donor's left liver, corresponding to a 0.46% graft-to-recipient weight ratio, was orthotopically transplanted. The postoperative course of this patient was uneventful, except for a transient large amount of ascites. Native liver volume in the recipient serially decreased, and the volume of the graft serially increased after transplantation. Four months after transplantation, the donor and recipient are doing well with a normal liver function. In conclusion, APOLT may be a feasible solution for a markedly steatotic living donor graft in patients with alcoholic liver disease

Liver transplantation for hepatocellular carcinoma in patients who do not meet the Milan criteria

BACKGROUND: To expand the Milan criteria, prognostic factors other than size and number of tumor may be necessary. We analyzed outcome and prognostic factors in patients with hepatocellular carcinoma (HCC) exceeding Milan criteria to select favorable group of patients. METHODS: Between November 1997 and December 2005, 104 cases of liver transplantation for patients with HCC were performed at our center. Twenty-four patients did not meet the Milan criteria preoperatively. Among these 24 patients, 19 had no major vascular invasion at the time of surgery. We analyzed the survival and prognostic factors of these 19 patients. The mean follow-up period was 33 months (range 6-89). RESULTS: Three-year survival rate in 19 patients was 67.4%. Three-year survival rates were significantly higher when preoperative alpha-fetoprotein was less than 400 ng/ml (86.2 vs. 0%, p<0.001) when Edmonson-Steiner's histological grade 1 or 2 (100 vs. 40%, p = 0.036) and when microvascular invasion was absent (78.6 vs. 30%, p = 0.039). CONCLUSION: If vascular invasion is absent in preoperative radiological studies, and the preoperative alpha-fetoprotein is less than 400 ng/ml, our findings suggest a good prognosis after liver transplantation for HCC patients who do not meet the Milan criteria

Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation

BACKGROUND: There is a lack of agreement regarding preexisting portal vein thrombosis (PVT) in patients undergoing living donor liver transplantation (LDLT). We report the results of a single-center study to determine the impact of PVT on outcomes of adult LDLT recipients. METHODS: Of 133 cases of adult LDLT performed between January 2000 and December 2004, a thrombectomy was performed on 22 patients (16.5%) with PVT during the transplant procedure. One hundred eleven patients without PVT (group 1) were compared with those with a thrombosis confined to the portal vein (group 2; n = 15) and patients with the thrombosis beyond the portal vein (group 3; n = 7). RESULTS: The sensitivities of Doppler ultrasound and CT in detecting PVT were 50 and 63.6%. A prior history of variceal bleeding (OR = 10.6, p = 0.002) and surgical shunt surgery (OR = 28.1, p = 0.044) were found to be an independent risk factors for PVT. The rate of postoperative PVT was significantly higher in patients with PVT than in those without (18.2 vs. 2.7%; p = 0.014). In particular, the rethrombosis rate in group 3 was 28.6%. The actuarial 3-year patient survival rate in PVT patients (73.6%) was similar to that of the non-PVT patients (85.3%; p = 0.351). However, the actuarial 3-year patient survival rate in group 3 was 38.1%, which was significantly lower than that in groups 1 and 2 (p = 0.006). CONCLUSION: A thrombosis confined to the portal vein per se should not be considered a contraindication for LDLT

Prognostic Factors Affecting Survival After Recurrence in Adult Living Donor Liver Transplantation for Hepatocellular Carcinoma

Liver transplantation is regarded as an effective treatment for early hepatocellular carcinoma (HOC). However, some patients experience recurrence and subsequently rapid progression of the disease. We investigated prognostic factors affecting survival after recurrence in patients who underwent adult living donor liver transplantation (LDLT) for HOC. From October 1992 to December 2005, 138 adult patients underwent LDLT for HOC. Among these, 28 patients (20.3%) who suffered recurrence were retrospectively reviewed. Univariate and multivariate analyses were performed to analyze factors affecting survival after recurrence. The median time to recurrence was 7.9 months. The median survival time after recurrence was 11.7 months, and the 1- and 3-year survival rates after recurrence were 52.8% and 15.8%, respectively. Initially, 7 patients (25%) showed multiorgan involvement; however, in the follow-up, 21 patients (75%) had multiorgan involvement. On univariate analysis, a pretransplant alpha-fetoprotein level >1000 ng/mL, major vascular invasion, a poorly differentiated tumor, a time to recurrence <= 6 months, unresectable disease, and bony metastases were related to shorter survival after recurrence. The independent prognostic factors by multivariate analysis were major vascular invasion [hazard ratio (HR) = 7.6], a poorly differentiated tumor (HR = 4.3), unresectable disease (HR = 10.4), and bony metastases (HR = 3.2). Two patients survived more than 36 months. One of them underwent retransplantation and survived for 45 months without additional recurrences. In conclusion, after transplantation, recurrent HOC has a tendency to involve multiple organs, and the prognosis is very poor. However, some patients have a good prognosis, and the appropriate treatment can prolong their survival. If the recurrent lesion is locally controllable, surgical resection should be considered. Liver Transpl 16:678-684, 2010. (C) 2010 AASLD.Ito T, 2007, LIVER TRANSPLANT, V13, P1637, DOI 10.1002/It.21281Sotiropoulos GC, 2007, J AM COLL SURGEONS, V205, P661, DOI 10.1016/j.jamcollsurg.2007.05.023Escartin A, 2007, TRANSPL P, V39, P2308, DOI 10.1016/j.transproceed.2007.06.042Ko HK, 2007, KOREAN J RADIOL, V8, P320Fisher RA, 2007, AM J TRANSPLANT, V7, P1601, DOI 10.1111/j.1600-6143.2007.01802.xLLOVET J, 2007, J CLIN ONCOL, V25, pS18Yang SH, 2006, LIVER TRANSPLANT, V12, P1655, DOI 10.1002/lt.20861Zhu AX, 2006, ONCOLOGIST, V11, P790Roayaie S, 2004, LIVER TRANSPLANT, V10, P534, DOI 10.1002/lt.20128Yao FY, 2001, HEPATOLOGY, V33, P1394REGALIA E, 1998, J HEPATO-BILIARY-PAN, V5, P29Mazzaferro V, 1996, NEW ENGL J MED, V334, P693IWATSUKI S, 1991, ANN SURG, V214, P221OLTHOFF KM, 1990, ARCH SURG-CHICAGO, V125, P1261OGRADY JG, 1988, ANN SURG, V207, P373

Hypophosphatemia after live donor right hepatectomy

BACKGROUND: It is known that hypophosphatemia can frequently develop after hepatectomy and may result from an increased renal phosphate leak. However, its clinical significance has not been well defined in live donor right hepatectomy (LDRH). The purpose of this study was to investigate the correlation between postoperative hypophosphatemia and both donor morbidity and the degree of hepatic resection in LDRH. METHODS: In all, 88 live liver donors were enrolled, who had undergone right hemihepatectomy between January 2002 and December 2005. Based on the severity of the postoperative hypophosphatemia, we divided the donors into 3 groups: mild (1.5-2.5 mg/dL, n = 30), moderate (1.0-1.5 mg/dL, n = 41), and severe (<1.0 mg/dL, n = 17), and we compared the incidence of complications among these groups. In addition, we investigated the possible correlation between the nadir phosphorus levels and both remnant liver volume and alkaline phosphate (ALP) levels. RESULTS: All donors developed hypophosphatemia postoperatively. The mean value of the nadir phosphorus levels was 1.4 +/- 0.04 mg/dL. However, no significant difference was observed in the incidence of postoperative complications among the hypophosphatemia groups. The phosphorus level was positively correlated with the remnant liver volume (r = 0.389, P < 0.001), but it was negatively correlated with a postoperative increase in the ALP (r = -0.276, P = 0.014). CONCLUSIONS: Hypophosphatemia developed very frequently after LDRH. However, transient hypophosphatemia was unlikely to lead to severe complications in healthy donors. Therefore, based on the serum level, oral or intravenous phosphorus replacement treatment might be more appropriate than routine aggressive replacement by TPN. In addition, although the factors responsible for posthepatectomy hypophosphatemia have not been identified, they might be substances that are associated with hepatic regeneration

An artificial vascular graft is a useful interpositional material for drainage of the right anterior section in living donor liver transplantation

Congestion in the anterior section in a right liver (RL) without a middle hepatic vein (MHV) may lead to graft dysfunction. To solve this problem, an RL draining MHV branches with autologous or cryopreserved vessels can be introduced. However, these vessels are often unavailable, and their preparation is time-consuming. An expanded polytetrafluoroethylene (ePTFE) graft may be used for anterior section drainage. Between February and November 2005, 26 recipients underwent RL liver transplantation draining MHV branches with an ePTFE graft (group P). Twenty-six ePTFE grafts (6 or 7 mm in internal diameter) drained 35 MHV branches on the back table to the graft right hepatic vein or to the recipient's inferior vena cava. The patency of the ePTFE graft was checked with computed tomography scans of the liver. The outcome of group P was compared with those of an RL group with MHV (group M, n=17) and an RL group without reconstruction of MHV or its tributaries (group R, n=85). The 1-month and 4-month patency rates (PRs) of the ePTFE grafts were 80.8% (21/26) and 38.5% (10/26). All showing early obstruction of the ePTFE graft had congestion in the anterior section, but all showing late obstruction were asymptomatic. The 1-month PRs of group P were comparable to, but the 4-month PRs were lower than, those of group M (both 94.1%; P<0.05). However, 1-year patient and graft survival rates of group P (both 100%) were comparable to those of group M (94.1% and 100%) and better than those of group R (83.5% and 88.2%; P<0.05). In conclusion, the early PR of group P was good, and late obstruction of the ePTFE graft had no impact on congestion in the anterior section or patient survival. Therefore, an ePTFE graft may be a useful interposition material for anterior section drainage in RL transplantation without serious complications