Current state of art management for vascular complications after liver transplantation

Vascular complications by compromising the blood flow to the allograft can have significant and sometimes life-threating consequences for the patient. High level of suspicion and aggressive utilization of diagnostic modalities can lead to early diagnosis and salvage of the allograft. This review will summarize the current trends in the management of vascular complications after liver transplantation. Current trends show an increase in the utilization of endovascular interventions initially to address vascular complications after liver transplantation. Operative repair still has its major role, especially if endovascular procedures fail

Liver transplantation for hepatocellular carcinoma: past, present and future

Hepatocellular carcinoma [HCC] represents one of the most common neoplasms worldwide. Liver trasnplantation [LT] is the treatment of choice for selected group of patients with HCC. LT is actually a consolidated therapeutic option for HCC because it cures both tumor and underlying cirrhosis. In 1996, the publication of a pivotal prospective study on less than 50 patients, transplanted for HCC under predefined criteria [single HCC < 5 cm or 3 HCC < 3 cm each], the so called [Milan criteria], showed a 4-year survival of 75%. However, the indication of LT for HCC treatment has evolved over recent years. The possibility of an extension of Milan criteria as indication for LT is already a debated issue. Living donor LT [LDLT] is an alternative option if waiting list is long and of fers the possibility of a LT after a short time. In this review, the current indications and results of liver transplantion for HCC have been dsicusssed

Current status of liver transplantation

Liver transplantation [LTx] is the treatment of choice for patients with end-stage liver disease [ESLD]. Improvement in outcomes [allograft and patient survival] has led to widespread use of LTx worldwide. However, new problems that include severe organ shortage, recurrence of primary disease, opportunistic infections, and development of de novo malignancies are the major problems further implementation of LTx

Changing pattern of organ donation and utilization in the USA

Organ transplantation has proven highly effective in the treatment of various forms of end-stage organ failure. However, organ shortage is still the greatest challenge facing the field of organ transplantation. To assess the pattern of organ donation and utilization during the past decade in the USA. We studied OPTN/UNOS database for organ donation between January 2000 and December 2009. The retrieved records were then categorized into two time periods from January 2000 to December 2004 [era 1], and from January 2005 to December 2009 [era 2]. There were 65,802 living and 71,401 deceased donors in the US from 2000 to 2009, including 66,518 [93.2%] brain-dead donors and 4,883 [6.8%] donation after cardiac death. Comparing two periods from January 2000 to December 2004 [era 1] and from January 2005 to December 2009 [era 2], the number of deceased donors increased by 25% from 31,692 to 39,709 and living donors decreased by 7.6%. Donation after cardiac death increased from 3.5% to 9.3%. The portion of donors older than 64 years increased from 6.9% in era 1 to 11.3% in era 2 [p=0.03]. The number of donors with a body mass index of >35 kg/m2 was also increased from 6.8% to 11.2%. A significant increase in the incidence of cardiovascular/cerebrovascular as cause of death was also noted from 38.1% in era 1 to 56.1% in era 2 [p<0.001], as was a corresponding decrease in the incidence of death due to head trauma [34.9% vs. 48.8%]. The overall discard rate also increased by 41% from 13,411 in era 1 to 19,516 in era 2. This increase in discards was especially more prominent in donation after cardiac death group which rose by 374% from 440 in era 1 to 2,089 in era 2. The discard rate for livers and kidneys increased by 31% and 68%, respectively, comparing era 1 and era 2. We noted a 78% increase for discarded donation after cardiac death livers and 1,210% for discarded donation after cardiac death kidneys. We detected significant changes in the make-up of the donor pool over the past decade in the US. Over time, donor characteristics have changed with increased numbers of elderly donors and donors with comorbidities, especially donors who died of cardiovascular/cerebrovascular disease. The incidence of donation after cardiac death has increased significantly; brain-dead donors have only increased slightly and living donors have decreased. As the result, the discard rates have increased. The transplant community and policy makers should consider every precaution to safeguard the donor pool and prevent the decay of organ quality in favor of quantity

Liver transplantation in patients with portal vein thrombosis: comparing pre-MELD and MELD era

Portal vein thrombosis [PVT] used to be a relative contraindication for liver transplantation [LT]. This obstacle has been dealt with following the improvement of LT-related techniques. To compare the outcome of adult patients with PVT who underwent LT before and after adopting MELD. We retrospectively searched our database for deceased donor LT recipients who had PVT, were operated between 1990 and 2009, and were 18 years old or more. The outcome of patients operated in pre-MELD era [1990-2001] was then compared with that of those operated in MELD era [2002-2009]. The incidence of patients undergoing LT with PVT has increased from 1.2% [491/40,730] in pre-MELD era to 6% [2540/42,601] in MELD era [p<0.01]. Patients with PVT in MELD era were older [53.6 vs 50.5], had higher calculated MELD [21.3 vs 18.9], shorter length of hospital stay after LT [25 vs 21.7 days], more likely to develop HCC [14.8% vs 0], and more likely to receive DCD allograft [3.9% vs 0.8%]. Donor risk indices were comparable in both groups [1.9 vs 1.9]. The median waiting time before transplantation decreased during MELD era [71 vs 99 days]. Allograft and patients survival was comparable between the two eras. However, allograft and patients survival rates were lower in patients with PVT compared to those without. In Cox regression analysis, PVT was associated with worse allograft [HR=1.3, 95% CI: 1.2-1.4, p<0.001] and patient survival [HR=1.3, 95% CI: 1.2-1.5, p<0.001] compared to non-PVT patients. The incidence of patients with PVT has increased in MELD era without improvement in outcomes. Donor and recipients characteristics changed in MELD era. PVT is still associated with poor outcomes compared to patients without PVT

Current status of pancreas and islet cell transplantation

Pancreas transplantation has emerged as an effective treatment for patients with diabetes mellitus, especially those with established end-stage renal disease. Surgical and immunosuppressive advances have significantly improved allograft survival. The procedure reduces mortality compared with diabetic kidney transplant recipients and wait listed patients. Improvements in diabetic nephropathy and retinopathy have also been demonstrated. Pancreas transplantation can improve cardiovascular risk profiles, improve cardiac function and decrease cardiovascular events. Lastly, improvements in diabetic neuropathy and quality of life can result from pancreas transplantation. Pancreas transplantation remains the most effective method to establish durable euglycemia for patients with diabetes mellitus

Induction with rabbit antithymocyte globulin following orthotopic liver transplantation for hepatitis C

Hepatitis C [HCV] is the most common indication for liver transplantation in the US. Since steroids are the major stimulus of viral replication, we postulated that steroid-free immunosuppression might be a safer approach. From January 1995 to October 2002, we used steroid plus calcineurin inhibitor [CNI] immunosuppression after liver transplantation for HCV [steroid group, n=81]. From October 2002 to June 2007, rabbit antithymocyte globulin [RATG] induction, followed by CNI and azathioprine [RATG group, n=73] was utilized. There were no differences in 1- and 3-year patient/allograft survival rates. The incidence of acute rejection rate [19% vs. 28%], of biopsy-proven HCV recurrence [70% vs. 75%], and chronic rejection [6% vs. 9%] were comparable. The mean time to develop recurrent HCV was significantly longer in the RATG group [16.2 vs. 9.2 months, p=0.008]. The incidence of severe portal fibrosis appears to be lower in RATG group compared to the steroid group; 14% vs. 4% [p=0.07]. RATG induction is safe and effective after liver transplantation for HCV, but has no impact on the incidence of HCV recurrence and patient/allograft survival. However, a significant delay in time to HCV recurrence and a trend toward less rejection and portal fibrosis was observed

Donor kidney recovery methods and the incidence of lymphatic complications in kidney transplant recipients

Lymphatic leak and lymphocele are well-known complications after kidney transplantation. To determine the incidence of lymphatic complications in recipients of living donor kidneys. Among 642 kidney transplants performed between 1999 and 2007, the incidence of lymphatic com- plications was retrospectively analyzed in recipients of living donor kidneys procured by laparoscopic ne- phrectomy [LP, n=218] or by open nephrectomy [OP, n=127] and deceased donor kidneys [DD, n=297]. A Jackson-Pratt drain was placed in the retroperitoneal space in all recipients and was maintained until the output became less than 30 mL/day. Although the incidence of symptomatic lymphocele, which required therapeutic intervention, was comparable in all groups, the duration of mean +/- SD drain placement was significantly longer in the LP group 8.6 +/- 2.7 days compared to 5.6 +/- 1.2 days in the OP group and 5.4 +/- 0.7 days in the DD group [p<0.001]. Higher output of lymphatic drainage in recipients of LP kidneys could lead to a higher incidence of lymphocele if wound drainage is not provided. More meticulous back table preparation may be required in LP kidneys to decrease lymphatic com- plications after kidney transplantation. These observations also support the suggestion that the major source of persistent lymphatic drainage following renal transplantation is severed lymphatics of the allograft rather than those of the recipient's iliac space

Liver donor partial hepatectomy for liver transplantation: is there a learning curve?

Donor safety is the first priority in living donor liver transplantation [LDLT]. To determine the characteristics and outcome of live liver donors who underwent donor hepatectomy from January, 1997 to May, 2007 at Massachusetts General Hospital. 30 patients underwent LDLT between January, 1997 and May, 2007 at our institution. The type of graft was the right lobe [segments 5-8] in 14, left lobe [segments 2-4] in 4, and left lateral sector [segments 2 and 3] in 12 patients. The mean donor age was 36 [range: 26]57] years. The mean follow-up was 48 [range: 18-120] months. No deaths occurred. Overall, 8 [26.6%] patients experienced a total of 14 post-operative complications. Donor complications based on graft type were as follows: left lateral sector [16.7%], left lobed [25%], and right lobe [35.7%]. The experience was divided into two periods 1997-2001 [n=15] and 2002-2007 [n=15]. Overall complications during 2 periods were 40% and 13.3% respectively [p<0.001]. The incidence of grade III complication also significantly decreased; 66.7% vs 33.3% [p<0.01]. Partial hepatectomy in living donors has a learning curve which appears to be approximately 15 cases. This learning curve is not restricted to the surgeons performing the procedure but involves all aspects of patient care

Age of onset of breast cancer among Iranian women

The age of onset of breast cancer in 1888 women in Iran for the years 1989 to 1994 was compared to that of 6000 cases reported from the U.S. for the years 1916 to 1966 .Despite inherent analytical limitations, it seems that cancer of the breast does occur at a younger age among Iranian woman

influence of surgical audit on surgical training

It is assumed but not proven that surgical audit influences surgical training. Too many variables are involved and the relationship appears too direct to require proof. Absolute candor in completely free and open discussion at mortality conferences are often modulated to suit the prevailing climate of medical litigation. In a setting where this last consideration was ignored, surgical deaths were arbitrarily attributed to either patient's disease or some clearly defined "errors ". The impact of weekly audit meetings on the education of surgical residents was assessed over a six year period. Increased autopsy rates and completeness of patient's charts were taken to reflect a positive impact of the adopted audit method on the clinical performance of surgical residents

Is mebendazole any good for hydatid disease?

Sixty patients with Echinococcus granulosus of various organs, and one patient with Echinococcus alveolaris of the liver, were treated with mebendazole at 50 mgr/kg body weight for a minimum of six months, without untoward reactions as determined by monthly CBC, SGOT and SGPT measurements. Results were assessed on the basis of A] clinical response, B] paraclinical tests, and C] surgical findings. Two of these three criteria had to be positive to permit a conclusion that the disease had responded to the treatment in terms of 'cure' [complete elimination of the disease] or control [cessation of growth of the lesion]. On this basis 26 patients [43%] had positive response, and 14 patients including the single patient with Echinococcus alveolaris [23%], had no response whatever. For the remaining 20 patients [33%] no clear cut decision could be reached

pressure within hydatid cysts

The internal fluid pressure of 62 echinococcal hydatid cysts in various organs was measured intraoperatively in 36 patients. Growing hydatid cysts, whether intact univesicular, or previously ruptured multivesicular, demonstrated a fluid pressure distinctly higher than that of surrounding tissues, reflecting viability of the parasitic elements within the cyst. The highest pressure of 98 cm of water, was recorded for a univesicular cyst in the superior portion of the liver. Lung and intra-abdominal cysts registered lower internal pressure. Degenerating cysts showed little or no internal pressure. Relief of its internal fluid pressure seems a logical preliminary step in the surgical management of hydatid cysts

new surgical approach to esophageal cancer

A new method of surgical treatment of cancer of the esophagus is proposed based on atraumatic removal of the normal esophageal mucosa and passage of stomach or colon through the remaining esophageal muscular tunnel. The method obviates the need for thoracotomy for cancers of the distal and cervical easophagus but not for mid-esophageal cancer. In all cases a cervical anastomosis is carried out. The proposed approach is palliative in nature and the extent of tumor resection is the same as in techniques currently used for esophageal resection