Incidence and management of biliary complications after orthotopic liver transplantation: ten years' experience at King Fahad National Guard Hospital.

BACKGROUND: Despite technical modifications and application of various surgical techniques, biliary tract complications remain a major source of morbidity after orthotopic liver transplantation. We sought to assess the incidence and management of biliary complications at a single liver transplant unit. METHODS: Among 184 consecutive deceased donor liver transplants performed between February 1994 and July 2004, 66 were female patients and 118 male patients of age range 2(1/2) to 69 years. We retrospectively reviewed the data regarding biliary complications in liver transplant recipients, after 115 duct-to-duct anastomoses and 65 hepaticojejunostomy. We analyzed the incidence and type of biliary complications, management sequence, and success rate. We analyzed the correlation between the modality of biliary reconstruction and the type/incidence of biliary complications. RESULTS: Thirty-two patients developed biliary complications, giving an overall incidence of 17.4%. There was a higher incidence of complications among patients in the hepaticojejunostomy group (21.5%) than the duct-to-duct technique (15.1%). Bile leakage occurred in 12 patients, including eight successful cases (66.6%) of endoscopic stent insertion/radiological techniques and surgery in four cases (33.3%). Among the 12 patients with initial leaks, six developed a subsequent stricture (50%). There were 26 cases of biliary stricture, including 22 (84.6%) who were initially managed using nonsurgical techniques with a success rate of 59%. CONCLUSION: Biliary complications remain an important cause of morbidity after orthotopic liver transplantation. They can usually be managed percutaneously or endoscopically; however, tight strictures and major leaks frequently required surgical intervention.

Isolated hepatic tuberculosis in a transplanted liver.

BACKGROUND: The incidence of tuberculosis (TB) has been increasing, especially in immunocompromised patients. It was reported that the overall incidence of TB in solid-organ transplant recipients is 0.8%. Hepatic graft TB was reported once before in a child, who underwent living-related hepatic graft transplantation. CASE REPORT: A 43-year-old man underwent orthotropic liver transplantation (OLT) in October 1999. His pre-transplant work-up was negative for TB (history and PPD skin test). He developed an episode of acute rejection which responded to steroids. He was discharged home on December 1999 with normal liver function tests (LFT). His LFT remained normal during January 2000, but his serum transaminases were found elevated on February 2000 (aspartate aminotransferase [AST] 206, alanine aminotransferase [ALT] 266). A liver biopsy then showed no evidence of TB or cytomegalovirus disease. The patient continued to have stable elevation of his serum AST and ALT until late March 2000 when a repeat liver biopsy showed caseating granuloma. The patient was started on anti-TB medications, with which he was compliant. By mid-May 2000 he was doing well, with significant reduction in his transaminase levels (AST 72, ALT 79). A retrospective inquiry about the donor revealed that he was a healthy young man from India, who died in a road traffic accident. CONCLUSION: To our knowledge our patient appears to be the first case reported of isolated hepatic TB in the OLT patient population. It is likely that the allograft was infected prior to transplantation and the disease was reactivated nearly 3 months after the procedure.

Liver transplantation for hepatitis B cirrhosis: clinical sequela of passive immunization.

UNLABELLED: Aggressive administration of hepatitis B immune globulin (HBIg) has been shown to prevent hepatitis B viral (HBV) infection of the allograft; however, the clinical sequela of such therapy has not been previously described. We reviewed our experience with high dose, intravenous infusion of an intramuscular HBIg preparation to assess the effectiveness and complications of such therapy. Thirty three orthotopic liver transplants (OLTx) were performed in 32 patients with chronic HBV cirrhosis at the University of Virginia between March 1990 and June 1995. Twenty-nine of 32 (91%) patients remain free of HBV recurrence (defined by undetectable serum HBsAg and HBV-DNA) after a mean of 21 months (2-54 months), with one patient requiring retransplantation. Three (10%) patients died of non-HBV causes (two vascular events, one infectious event). Twenty episodes of acute cellular rejection were treated in 18 patients (two had two episodes). Sixteen rejections occurred within 18 d of transplant, 19 by day 120, and one late rejection occurred at 18 months owing to medication non-compliance. Eighteen patients had at least one documented infection. Six patients were treated for CMV infection (five empirically). Eight patients were treated for HSV infections (seven mild herpetic labialis and one herpetic keratitis). Four patients had documented fungal infection (one mucormycosis pneumonia and three minor superficial mucosal infections). With the exception of one necrotizing pneumonia, 11 bacterial infections were successfully treated with conventional antimicrobial agents. No patient developed post-transplant lymphoproliferative disorder. Symptoms associated with HBIg infusion were intermittent but frequent and consisted of myalgias, predominantly back pain (90%), headache (20%) and flushing (5%). No patient experienced anaphylaxis, fever, rash, arthritis or hypotension. Despite the potential for mercury toxicity and HCV transmission in the HBIg formulations currently available in the United States, serum mercury levels remained below standards for industrial exposure (60 micrograms/ml), and only one individual developed post-transplant HCV infection after receiving multiple units of unscreened blood prior to 1991. SUMMARY: High-dose HBIg prevented HBV infection of the allograft in 29 of 32 patients transplanted for HBV cirrhosis with three non-HBV associated deaths. The intravenous infusion of HBIg was frequently associated with minor side effects that were safely tolerated by patients. The risk of HCV transmission and mercury toxicity are minimal, but support the need for a new intravenous formulation of HBIg. HBIg therapy successfully decreased post-OLTx HBV recurrence with no clinical events associated with immunosuppression. Patients did non experience allergic or infusion-related complications that altered or terminated therapy. Manufacturing modifications of HBIg may allow for improved patient tolerance and decreased risks.

Multiple cervical spine fractures without neurologic deficit after a helicopter crash. Case report.

The case of a soldier with multiple cervical fractures without neurologic deficit sustained after a helicopter crash during Operation Desert Storm is presented. The fractures involved the C2 body and the right facet joint and pedicle of C4. This fracture pattern, in association-with lack of neurologic deficit, is the first such case reported in the literature.