Giant mid-esophageal diverticulum. Conservative treatment of postoperative leakage

I diverticoli esofagei medio-toracici sono di riscontro non frequente. Generalmente il trattamento chirurgico è riservato ai soli pazienti sintomatici. La fistola esofagea è una delle complicanze postoperatorie più comuni. Sebbene in letteratura l’approccio chirurgico sia preferito per risolvere tali complicanze, il trattamento conservativo è descritto nel caso di deiscenze non gravi. Descriviamo il caso di un voluminoso diverticolo esofageo medio-toracico operato e complicato da una fistola esofagea post-operatoria. Il paziente è stato trattato con approccio conservativo fino a completa guarigione

Giant mid-esophageal diverticulum. Conservative treatment of postoperative leakage.

Mid-esophageal diverticula are rare entities. Only symptomatic patients usually receive surgical treatment. Esophageal leakage is one of the most common complications after these procedures. Though in literature, operative management is the preferred treatment for esophageal fistula, conservative approach is described in case of small leaks. We report a case of an operated giant mid-esophageal diverticulum complicated with an esophageal fistula. The patient underwent a surgical treatment and recovered completely

Rubber transcystic drainage reduces the post-removal biliary complications in liver transplantation: a matched case-control study

Bile duct (BD) complications continue to be the "Achilles' heel" of liver transplantation, and the utilization of bile duct drainage is still on debate. We describe the results of a less invasive rubber trancystic biliary drainage (TBD) compared to a standard silicone T-tube (TT). The transplanted patients (n = 248), over a period of 5 years with a TBD (n = 20), were matched 1:2 with control patients with a TT (n = 40). Primary end points were the overall incidence of BD complications and graft and patient survival. Secondary end points included the complications after the drainage removal. Although the bile duct leakage rates were not significantly different between both groups, the TT group had a significantly higher rate of overall 1-year BD stenosis (40 versus 10 %) (p = 0.036). Three-year patient/graft survival rates were 83.2/80.1 and 84.4/84.4 % for the TT and TBD groups, respectively. The postoperative BD complications, after drainage removal (peritonitis and stenosis), were significantly reduced (p = 0.011) with the use of a TBD. The use of rubber TBD in liver transplant recipients does not increase the number of BD complications compared to the T-tube. Furthermore, less BD anastomotic stenosis and post-removal complications were observed in the TBD group compared to the TT group

Split liver transplantation for acute Wilson's disease: new option for urgent recipient?

Wilson's disease is a rare metabolic disorder that may lead to fulminant hepatitis and subsequent liver failure. Herein, we present a case of split liver transplantation performed on a patient with acute Wilson's disease. A 27-year-old female with acute presentation of Wilson's disease and advanced neurological impairment, received a Right Split liver Graft (Segments: IV, V, VI, VII and VIII) transplant. The graft was obtained by an in situ splitting technique. The graft implantation was performed in a standard fashion. No acute rejection episodes of the organ occurred. The postoperative course was uneventful. The graft function, ceruloplasmine level and copper levels progressively normalized. The patient totally recovered from neurological symptoms and the Kayser-Fleischer rings disappeared within one month. At 13 months of follow-up, the patient presented with no symptoms and in good condition. The current literature reports high preoperative mortality rate in patients that underwent partial liver graft for acute hepatic failure. However, our experience indicates that in situ split technique of liver may be a feasible and effective alternative to whole graft transplantation in urgent cases. Moreover, to our knowledge, this is the first successfully case of in situ split liver transplantation for acute Wilson's disease described in literature

Reversed Saphenous Bypass for Hepatic Artery Pseudoaneurysm After Liver Transplantation

Background: Hepatic artery pseudoaneurysm (HAP) is found in 1-2% of liver transplantation (LT) patients. The mortality associated with pseudoaneurysm formation after orthotopic LT is reported to be as high as 75%. Because of the rarity of complications, particularly when considered individually, much of the direction for the management of complications is anecdotal. This article discusses the presentation, etiology, types, treatment indications, and vascular procedures used to manage complications with LT. Methods: Between January 2004 and December 2011, 464 LTs were performed at our institution. Of these, 9 (1.9%) consecutive patients underwent surgical treatment of HAP (8 men and 1 woman; median age, 58.4 years [range, 46-67 years]). Four patients underwent transarterial chemoembolization before LT for hepatocellular carcinoma. In all cases, revascularization with a reversed autologous saphenous vein bypass was performed. Results: Four patients had ruptured pseudoaneurysms, and the others were diagnosed as having asymptomatic pseudoaneurysms during the follow-up period. The median delay between LT and the diagnosis of HAP was 39.6 days (range, 22-92 days). All were anatomically extrahepatic. The median diameter was 15.3 mm (range, 9-30 mm). Four patients had a T-tube. In 6 cases, biliary leakage was associated with the LT and, in the remaining 3, mycosis was recorded. After surgery, 1 patient underwent retransplantation because of ischemic cholangitis. Five years later, 5 patients had normal arterial anatomy, and the other 3 patients had stenosis that was successfully treated by stents. All of the patients had normal liver function at follow-up. One patient died 16 months later because of a heart attack. Conclusions: HAP with massive intraperitoneal bleeding is a rare but serious life-threatening complication when it occurs after LT. The majority of HAP cases are associated with bile leakage and mycosis; therefore, surgery must be the treatment of choice. Our conclusions support surgical revascularization with reversed saphenous grafts as a feasible and efficient treatment in cases of HAP

Is Hepatitis C recurrence more severe after split liver graft compared to whole size graft?

Hepatitis C virus (HCV) is the most common indication for liver transplantation (LT).Recently, reports from some centers have suggested that partial liver transplants and moreover living related liver transplantation (LRLT) may be associated with an increased risk for HCV recurrence.The aim of this study is to compare HCV recurrence in adult recipient after in situ Split Liver Transplantation (SLT) versus Whole Liver Transplant (WLT).From June 1998 to February 2004, whitin our institution 220 first liver transplants were performed for adult recipients. Of these 153 (69.5%) were WLT, 56 (25.4%) Adult to Paediatric SLT (SLT A/P) and 11(5%) adult to adult SLT (SLT A/A).Overall HCV cirrhosis accounted for 43.6%; of those we considered the first 64 recipients who recived a LT for HCV-induce liver disease from June 6,1998, to October 10, 2002. Of these 18 (28.1%) received a right liver graft from SLT A/P and 46 (71.8%) received WLT. The mean follow-up was 50.4 months.Donor and recipients patterns were comparable. P value were significant only for increased donor age (P=0.000013) and shorter cold ischemic times (P=0.033) in WLT. The mean Graft recipient weight ratio in SLT group was 1.79.During follow-up HCV RNA resulted positive in 45 (97.8%) of 46 patients undergoing WLT and in all (100%) patients undergoing SLT (P=0.532) Where clinical indicated a liver biopsy were performed and proven histologic recurrence (Ishak Score System) in the two groups were: WLT, 67.3%; SLT, 61.1% (P=0.637). Severe recurrence (SR) presented with clinical decompensation associated or not to biopsy-proven cirrhosis were: 11/64 (24%) in the patients transplanted with WLT and 4/18 (22.2%) of SLT (P=0.853). Re transplantation was needed in 5.5% of SLT group and in 6.5% WLT (P=0.887). At a follow-up period of 50.4 months, in our experience there is no difference in HCV recurrence rate between WLT and SLT groups

Is hepatitis C recurrence more severe after split liver graft compared to whole size graft?

Hepatitis C virus (HCV) is the most common indication for liver transplantation (LT).Recently, reports from some centers have suggested that partial liver transplants and moreover living related liver transplantation (LRLT) may be associated with an increased risk for HCV recurrence.The aim of this study is to compare HCV recurrence in adult recipient after in situ Split Liver Transplantation (SLT) versus Whole Liver Transplant (WLT).From June 1998 to February 2004, whitin our institution 220 first liver transplants were performed for adult recipients. Of these 153 (69.5%) were WLT, 56 (25.4%) Adult to Paediatric SLT (SLT A/P) and 11(5%) adult to adult SLT (SLT A/A).Overall HCV cirrhosis accounted for 43.6%; of those we considered the first 64 recipients who recived a LT for HCV-induce liver disease from June 6,1998, to October 10, 2002. Of these 18 (28.1%) received a right liver graft from SLT A/P and 46 (71.8%) received WLT. The mean follow-up was 50.4 months.Donor and recipients patterns were comparable. P value were significant only for increased donor age (P=0.000013) and shorter cold ischemic times (P=0.033) in WLT. The mean Graft recipient weight ratio in SLT group was 1.79.During follow-up HCV RNA resulted positive in 45 (97.8%) of 46 patients undergoing WLT and in all (100%) patients undergoing SLT (P=0.532) Where clinical indicated a liver biopsy were performed and proven histologic recurrence (Ishak Score System) in the two groups were: WLT, 67.3%; SLT, 61.1% (P=0.637). Severe recurrence (SR) presented with clinical decompensation associated or not to biopsy-proven cirrhosis were: 11/64 (24%) in the patients transplanted with WLT and 4/18 (22.2%) of SLT (P=0.853). Re transplantation was needed in 5.5% of SLT group and in 6.5% WLT (P=0.887). At a follow-up period of 50.4 months, in our experience there is no difference in HCV recurrence rate between WLT and SLT groups