Sengstaken Tube Removal under Direct Hemodynamic Monitoring after Post Transplantation Venous Occlusion.

The surgical procedure for orthotopic liver transplantation (OLT) is well standardized, and most groups use the retrohepatic caval preservation or piggyback technique to improve hemodynamic tolerance. However, when a discrepancy between the site in the right upper quadrant of the liver recipient and a small graft is present, this technique can provoke a rotation on the axis of the vena cava and cause an occlusion of the suprahepatic vein drainage. This problem can be detected intraoperatively, and several methods have been described to resolve it by placing different devices to correct the position. Early withdrawal may cause the development of clinical hepatic congestion with ascites unresponsive to medical treatment. We present three cases of OLT who developed obstruction of the venous drainage solved intraoperatively with the placement of a Sengstaken-Blakemore tube. As a novelty, prior to the withdrawal of the device, a transjugular hemodynamic study was performed to ensure the correct position of the liver with adequate venous drainage.

Donor Risk Index Has an Impact in Intraoperative Measure of Hepatic Artery Flow and in Clearance of Indocyanine Green: An Observational Cohort Study.

BACKGROUND: The increase in indications for liver transplantation has led to acceptance of donors with expanded criteria. The donor risk index (DRI) was validated with the aim of being a predictive model of graft survival based on donor characteristics. Intraoperative arterial hepatic flow and indocyanine green clearance (plasma clearance rate of indocyanine green [ICG-PDR]) are easily measurable variables in the intraoperative period that may be influenced by graft quality. Our aim was to analyze the influence of DRI on intraoperative liver hemodynamic alterations and on intraoperative dynamic liver function testing (ICG-PDR). METHODS: This investigation was an observational study of a single-center cohort (n = 228) with prospective data collection and retrospective data analysis. Measurement of intraoperative flow was made with a VeriQ flowmeter based on measurement of transit time (MFTT). The ICG-PDR was obtained from all patients with a LiMON monitor (Pulsion Medical Systems AG, Munich, Germany). DRI was calculated using a previously validated formula. Normally distributed variables were compared using Student's t test. Otherwise, the Mann-Whitney U test or Kruskal-Wallis test was applied, depending on whether there were 2 or more comparable groups. The qualitative variables and risk measurements were analyzed using the chi-square test. P < .05 was considered statistically significant. RESULTS: DRI score (mean ± SD) was 1.58 ± 0.31. The group with DRI >1.7 (poor quality) had an intraoperative arterial flow of 234.2 ± 121.35 mL/min compared with the group having DRI < 1.7 (high quality), with an intraoperative arterial flow of 287.24 ± 156.84 mL/min (P = .02). The group with DRI >1.70 had an ICG-PDR of 14.75 ± 6.52%/min at 60 minutes after reperfusion compared to the group with DRI <1.70, with an ICG-PDR of 16.68 ± 6.47%/min at 60 minutes after reperfusion (P = .09). CONCLUSION: Poor quality grafts have greater susceptibility to ischemia-reperfusion damage. Decreased intraoperative hepatic arterial flow may represent an increase in intrahepatic resistance early in the intraoperative period.

[Arterial complications after liver transplantation: early and late forms]. / Estudio comparativo de las complicaciones arteriales precoces y tardías postrasplante hepático.

Arterial complications after liver transplantation (OLT) was related with high morbimortality rates, with variable consequences on patient and graft survival. 234 patients who underwent 270 liver transplantation between april of 1990 and december 1996 have been evaluated. Arterial complications were detected in 34 patients (12.5%), hepatic artery stenosis in 10 patients (29.4%), thrombosis in 24 (70.6%) and aneurysm in 2 (5.9%). It was considered early artery complications those diagnosed at the first month after OLT, and late complications the latest ones. Diagnosis was realized by Doppler sonography in all cases, and confirmed by celiac arteriography in those with Doppler abnormal findings. Clinical appearance of early artery complications were as acute liver failure (61.1%) or graft disfunction (38.8%). On the other hand, late complications were diagnosed incidentally in 46% of the patients due a programmed Doppler follow up. Actuarial survival at 24 months was higher in patients with late arterial complication (50 vs 30%; p < 0.01). Therapeutic measures applied were retransplantation, surgical artery reconstruction and angioplasty. Early complications required more frequently retransplantation or surgical reconstruction. Risk factors related with artery complications development were analyzed, but not significant differences between both types of arterial complications were found. It is concluded that programmed follow up by Doppler or arteriography is necessary to make an earlier diagnose and to detect silent arterial complications.

Pulmonary complications following orthotopic liver transplant.

Pulmonary complications after orthotopic liver transplant (OLT) are frequent, involving high morbidity and mortality. We have determined the pulmonary complication incidence in 187 patients submitted to OLT at the General University Hospital "Gregorio Marañón" in the last 4 years, analyzing the type of infection, evolution, diagnostic and therapeutic measures and their influence on OLT mortality. A total of 120 patients had pulmonary complications, the most frequent being pleural effusion (61.94%), pneumonia (43.36%), and pneumothorax (11.5%). Serious pulmonary hypertension was diagnosed by invasive methods in two patients at the time of surgery (unidentified before OLT); both died at early post postoperative times. Pleural effusion was noted in 70 patients, 31.42% of them requiring thoracic tube drainage, complications developing in 22.72%. Thirteen patients were diagnosed of pneumothorax, the most frequent etiologies being percutaneous liver biopsy, thoracic tube drainage for pleural effusion, and postoperative complications in 41.6, 33.3, and 23.3%, respectively. Pneumonia was diagnosed in the 1st month after OLT in 45 patients. Tests to diagnose and identify the etiological agent were made in 71.1% of diagnosed pneumonia patients, identification being obtained in 62.5%. Telescope catheter culture identified the agent in 48%, fiber optic bronchoscopy in 50%, and lung or pleural biopsy in 100%. Respiratory insufficiency was noted in 64 patients (34.22% of transplanted patients). Factors involved in their development were pneumonia (42.18%), graft dysfunction (39.06%, pleural effusion (34.37%), sepsis (28.18%), and poor nutritional status (7.81%). Fifty patients (41.66%) died, pulmonary pathology being the determinant factor in 28.8%. Patient mortality with respiratory insufficiency was greater, especially in those with three factors involved the development of respiratory insufficiency.

[Orthotopic hepatic transplant in chronic hepatopathy of alcoholic origin]. / Trasplante hepático ortotópico en hepatopatía crónica de origen etílico.

Liver transplantation for alcoholic cirrhosis remains controversial at some transplantation centers. We compared resource utilization and outcome in alcoholic and non-alcoholic cirrhotic patients undergoing liver transplantation. From April 1990 to November 1994, 60 patients received orthotopic liver transplants for end-stage alcoholic liver disease, and 119 transplants were performed in 103 patients for non-alcoholic liver disease. No significant differences were noted in resource utilization of the variables examined. The outcome of liver transplantation (early graft function, frequency of sepsis, incidence of rejection, renal function, arterial hypertension...) was equivalent or better in alcoholic patients. Postoperative mortality was higher in non-alcoholic population (25.2% vs 16.7%). One-year and three year actuarial survival was not significantly different, but it was higher in the alcoholic group (77% vs 67% and 74% vs 64% respectively). The recurrence rate of alcohol in take has been 9.09%, with most patients drinking only socially. We conclude that liver transplantation for end-stage alcohol-related cirrhosis provides excellent results and resource utilization appears to be equivalent to that for patients undergoing transplantation for non-alcohol-related cirrhosis.

The deleterious effect of donor high plasma sodium and extended preservation in liver transplantation. A multivariate analysis.

The aim of this study was to analyze the donor risk factors associated with second orthotopic liver transplantation (reOLT) and graft loss after OLT within 1 month. A total of 649 OLTs performed in 11 centers in Spain during the period from 1992 to 1993 were analyzed retrospectively. Eleven donor and recipient variables were studied. Biochemical evolution of the OLT, biliary and arterial complications, patient status (alive, retransplanted, or dead), and follow-up were also recorded. Bivariate study demonstrated that extended preservation ( > 12 hr) was associated with increased biliary complications (P = 0.02), and lower prothrombin time (P = 0.04). In a logistic model regression for biliary complications, ischemia > 12 hr was an independent risk factor (odds ratio = 2.2, 95% confidence interval [CI] = 1.1-4.3). The multivariate Cox proportional model of potential risk factors showed that only urgent reOLT (relative risk [RR] = 2.7, 95% CI = 1.4-5.4) was independently associated with higher 30-day mortality. Donor plasma sodium > 155 mmol/L (RR = 1.4, 95% CI = 1.0-2.2) and incompatible ABO graft (RR = 3.2, 95% CI = 1.3-7.9) were independently associated with increased rate of reOLT before 30 days. Donor plasma sodium > 155 mmol/L (RR = 2, 95% CI = 1.1-3.6) and incompatible graft (RR = 3.3, 95% CI = 1.4-8.2) were independently associated with graft loss (death or reOLT) before 1 month. We conclude that cold ischemia should be kept less than 12 hr in order to avoid biliary complications. Donors over 60 years old or with plasma sodium > 155 should be carefully evaluated before OLT.

[Arterial revascularization of liver graft with PTFE vascular prosthesis]. / Revascularización arterial de injerto hepático con prótesis vascular de PTFE.

When the hepatic artery is not available in liver transplantation because of its bad quality or low flow, arterial grafts from the donor have to be used to obtain arterial blood flow from the aorta. The case of use of a vascular PTFE prosthesis when no vascular grafts were available is presented, with good outcome 6 months after transplantation.

[Severe complications of percutaneous hepatic biopsy in patients with orthotopic liver transplantation]. / Complicaciones graves de la biopsia hepática percutánea en los pacientes con trasplante hepático ortotópico.

The incidence and type of complications appearing following the performance of liver biopsies were analyzed in the first 166 liver transplants in our hospital. The presence of a severe complications was defined if a patient presented hemoperitoneum, pneumothorax, hemothorax, post biopsy infection or symptomatic puncture of abdominal organs other than the liver. Four hundred thirty-eight liver biopsies were carried out in 129 patients with a mean of 3.4 biopsies per patient. The severe complications were observed in 7 (1.6%), all of which were bleeding episodes. Four hemothorax requiring the placement of a thoracic drainage tube were observed. In two cases thoracotomy was required with death occurring in one patient. Three hemoperitoneum were also seen requiring laparotomy in one and transfusion in the remaining two patients. Out of the non transplanted patients, four presented severe complications (0.7%), 50% of which were hemoperitoneum. No patient presented hemothorax and no deaths were reported. The authors conclude that the incidence of severe post liver biopsy complications in transplanted is low, similar to that reported in non transplanted patients. Nonetheless, there does appear to be a higher incidence of bleeding complications in the transplanted patients.

Stenosis of the inferior vena cava after liver transplantation: treatment with Gianturco expandable metallic stents.

PURPOSE: Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT). METHODS: Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses. RESULTS: One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months. CONCLUSIONS: Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.

[The response to hepatitis B vaccine prior to orthotopic liver transplantation]. / Respuesta a la vacuna de la hepatitis B previa al trasplante hepático ortotópico.

UNLABELLED: HBV hepatitis is a severe complication of orthotopic liver transplantation (OLT) due to the immunosuppression therapy. OBJECTIVES: The aim of this study is to evaluate the efficacy of the active HBV immunization on these patients before OLT. PATIENTS AND METHODS: This was a prospective trial, with 34 patients (20 M and 14 F), that received a double dose (40 micrograms) of HBV surface proteic Ag, on the 0th, 30th and 60th days of the study and posterior control of anti-HBs levels. If there wasn't a response, they received two more doses on the 90th and 120th days. RESULTS: There was a seroconversion in 22 patients (64.7%). Chronic alcoholism determined a lower rate of response than other etiologies (p < 0.05); this was the same in HCV chronic liver disease (p < 0.01). During their follow up, two patients had acute HBV hepatitis: one of them presented a negative response from the beginning, and in the other, anti-HBs developed transiently, when the HBV markers appeared. CONCLUSIONS: Previous HBV active immunization in OLT patients with double dose in a quick sequence, determined a positive response in a high number of patients with a higher rate of seroconversion than in other studies. The response was not so high in patients with chronic alcoholism or HVC chronic liver disease. We conclude that HVB vaccination should be done in these patients.

[The liver transplant program of the Hospital General Universitario Gregorio Marañón: an analysis of the first 100 patients]. / Programa de trasplante hepático del Hospital General Universitario Gregorio Marañón: análisis de los 100 primeros pacientes.

During a 3-year period between 1990 and 1993, 100 patients received orthotopic liver transplantation at the "Gregorio Marañón" University General Hospital. The mean age of the patients was relatively high (46.9 +/- 10 years), with an important number of cirrhotic patients (91%). The rate of primary liver failure was relatively low (4.5% of transplantations) although 12 cases with more than 55 years were included in the present series. Eleven retransplantations were performed, 8 for early failure of the graft and 3 for chronic failure. Postoperative complications of the graft were vascular in 9 cases, biliary in 17 cases, and acute rejection (cellular) in 70 patients, although only 50 of these patients required treatment with steroid boluses. Infections were diagnosed in 60 cases with 80% of major infections, 6 of them caused by Aspergillus fumigatus that were lethal in all the cases. Postoperative survival was 82%, 72%, 69% and 69% at 1 month, 6 months, 1 year and 2 years respectively.

[Epithelioid hemangioendothelioma: a rare indication for liver transplantation?]. / Hemangioendotelioma epitelioide: una indicación infrecuente de trasplante hepático?

A clinical case of epithelioid hemangioendothelioma without extrahepatic involvement treated with liver transplantation is presented. The patient remains alive 42 months thereafter without tumor recurrence. A review of cases reported to date was carried out with special reference being made to the therapy undertaken and the follow-up.

[Chemoembolization and posterior liver transplantation as therapeutic strategy for hepatocarcinoma]. / Quimioembolización y posterior trasplante hepático como estrategia terapéutica del hepatocarcinoma.

Orthotopic Liver Transplantation (OLT) is the only surgical approach to non-resectable hepatocellular carcinoma (HCC) but, so far its results has been poor. During 41 months 112 patients underwent 123 OLT, nine of them had HCC over cirrhosis with a mean age 60 years. The etiology of cirrhosis was: alcohol in 1 and viral hepatitis in 8. Child's grade: A in 4, B in 5. HCC was: 5 cm or less in 5 and more in 4. According pTNM staging: I in one, II in 5, II in 2 and IVb in 1. Differentiation degree: low in 1, moderate in 4, and well in 3 (one case with complete necrosis after embolization). Eight patients were previously embolized with lipiodol, adriamycin and gelfoam, obtaining central necrosis without viable features in periphery. There were no postoperative deaths, and all the patients were discharged from the hospital. During follow up, 3 recurrences were observed, one massive with death of the patient after 6 months, and the other was surgically removed (segmentectomy V, VI) after 4 months after OLT without recurrence at 18 months of resection. In the third case a focal lesions was detected in the U.S. and T.C. study, 4 months after OLT, but in wasn't possible to obtain a biopsy because its posterior location; no treatment was made, and she's alive today. In conclusion, OLT is a good surgical option for non resectable HCC complicating cirrhosis if the patient is adequately selected. Chemoembolization has a good local effect, obtaining tumoral necrosis, but it does not decrease the posterior growth of the tumor in other localizations.

[Resection of recurrent hepatocarcinoma on a transplanted liver]. / Resección de hepatocarcinoma recidivante sobre hígado trasplantado.

Recurrence of hepatocellular carcinoma is rarely treated by surgical resection and has not been reported in the main series of liver transplantation. In this paper we present the case of a patient transplanted for hepatocellular carcinoma on cirrhosis who developed a tumoral recurrence in the transplanted liver four months later. The new tumor was removed by hepatectomy and the patient is free of tumor 24 months after resection. Surgical resection should be considered a treatment of tumoral recurrence after liver transplantation as is done after hepatectomy.

[Effect of antibiotic prophylaxis with vancomycin on methicillin-resistant Staphylococcus aureus infection following liver transplantation]. / Efecto de la profilaxis antibiótoca con vancomicina sobre la infección por Estafilococo aureus resistente a meticilina tras el trasplante hepático.

An epidemic outbreak of Methicillin-resistant Staphylococcus Aureus (MRSA) infections affecting liver transplantation patients was detected in our hospital. In this study we describe the special characteristics of the infections and the results of prophylactic treatment with Vancomycin. Between april 1990 and december 1991, 47 patients with mean age of 54.4 +/- 10 years underwent liver transplantation. The patients were included in two chronological groups: 1) Group I: 20 patients not treated prophylactically with Vancomycin; 2) Group II: 27 consecutive patients treated with Vancomycin. Systematical cultures of body fluids for bacteria and fungi were done in every patient, and were repeated after 24 hours. The cultures were repeated again in case of sepsis. Group I patients had a significantly higher frequency of MRSA infections than group II patients. Furthermore, in patients with MRSA infection, independently of the group, duration of transplantation (p < 0.01), reoperations (p < 0.001) and prophylactic treatment with Vancomycin (p < 0.001) were significative factors. In conclusion, Vancomycin appears to be an elective prophylactic antibiotic in case of high risk of MRSA sepsis after liver transplantation.

Two-clamp method to avoid portal anastomotic stenosis in liver transplantation.

We developed a two-clamp technique to avoid stenoses in portal anastomoses during liver transplantation. A portal anastomosis is created with a continuous polypropylene suture. A second vascular clamp is placed on the donor portal vein before release of the recipient vein clamp. After release of the proximal clamp, the vein is allowed to distend to its maximal diameter, and the suture is gently tied. This technique was used in both portal and arterial anastomoses in 43 consecutive liver transplant recipients. No cases of postoperative stenosis or thrombosis were observed.

[A biliary fistula after T-tube removal in the transplant patient: its diagnosis by Tc-99m-HIDA]. / Fístula biliar tras la retirada del tubo en T, en el paciente trasplantado: diagnóstico mediante HIDA Tc-99m.

The Tc-99m HIDA scan is a valuable study after liver transplantation, associated with other image techniques. We have used this technique as a reliable and objective diagnostic method for biliary fistula after removal of the T-tube in 5 liver transplantation patients with pain after T-tube removal. All five patients who developed fistula not only were diagnosed immediately but, furthermore, the surgical technique was indicated by the gammagraphic study. After this experience, we propose to remove the T-tube during the Tc-99 HIDA scan.

Salvage of angioaccess after late thrombosis of radiocephalic fistulas for hemodialysis.

A retrospective study of 44 surgical procedures performed in 39 patients with late occlusions of radiocephalic fistulas for hemodialysis is reported. In 6 cases (13.6%) no apparent anatomical cause was found, and a simple thrombectomy was performed as a corrective procedure. Some sort of arterial and/or venous stenosis was present in the other 38 cases. In 11 cases with evidence of mild localized vascular stenosis we performed a thrombectomy and then an endoluminal angioplasty with a balloon catheter and Bakes dilators. In 26 cases, with more severe degrees of stenosis, we made a proximal new fistula in the distal portion of the forearm, bypassing the vascular stenosis, either end-to-end radiocephalic or with interposition of a short segment of PTFE graft. The best results were achieved with the creation of a proximal new fistula, which resulted in almost 50% cumulative patency rates at 2 years, with no immediate failures. We think that an attempt at angioaccess salvage should be made in every case of late thrombosis of radiocephalic fistulas.