Expanding postmortem donor pool using steatotic liver grafts: a new look.

BACKGROUND: Clinical demand for liver transplant steadily grows while organs offer has reached a plateau years ago. To expand the donor liver pool, various options have been considered including acceptance of suboptimal donors and steatotic grafts, with a risk of poorer outcomes. The latter risk and its relation to the grade of liver graft steatosis have been studied in this prospective clinical study. METHODS: One hundred eighteen consecutive liver transplantation (115 patients) performed between May 2002 and March 2008 were prospectively analyzed. According to the grade of steatosis on a 2 hr postreperfusion biopsy, four groups were considered: absence (<5%) (n=34), mild (<30%) (n=40), moderate (30%-60%) (n=23), or severe steatosis (> or = 60%) (n=21). Donors and recipients demographic data, and patients and grafts survival rates were compared among the four groups. RESULTS: Eighty-four (71%) grafts presented some degree of steatosis (macrosteatosis: 19.5%, microsteatosis: 47%, mix type: 33.5%). Patient and graft survival were significant lower in the "severe steatosis" group, as a whole. Grafts with less than 30% predominant macro-, or microsteatosis also had poorer outcomes with lower patient and graft survival rates. CONCLUSION: Steatotic liver grafts were used on a large scale (71%) in this clinical series. The analysis confirms that using grafts with moderate (>30%) and severe steatosis (>60%) have a negative impact on outcomes. The authors conclude that using these grafts allow a significant increase in organ offer that counterbalances the negative outcome for patients who are not offered a transplant, and this supports the need for further clinical research.

Worth continuing doing ex situ liver graft splitting? A single-center analysis.

Grafts for split liver transplantation can be prepared in situ during the retrieval operation, or ex situ on the back table. The in situ technique has theoretical advantages because it minimizes the cold ischemic time and allows excellent hemostasis at the cut surface. However, in situ liver division prolongs the retrieval procedure, may precipitate hemodynamic instability in the donor, and may cause logistical difficulties for some centers. This report is a single-center analysis comparing results of ex situ liver division (group I: 1992-97; and group II: 1998-2001) before and after a new protocol for liver graft division was introduced in our center. Eighty-nine split liver transplants (SLT) were reviewed retrospectively. Vascular complications were less common in group II (3.3% vs. 20%; p = 0.04), and 1-year graft survival increased from 59% to 78% (p = 0.03). Since 1998, 1-year graft survival of SLT has been similar to that of conventional liver graft transplantation in our center (78% and 74%, respectively). In conclusion, good results can be achieved from splitting livers ex situ and this procedure should be considered when the in situ technique is not feasible.

Ex situ preparation of left split-liver grafts with left vascular pedicle only: is it safe? A comparative single-center study.

The procurement of left-lateral-segment grafts from living donors for transplantation in children is performed by retaining only the left branches of the artery and veins. New techniques and the implementation of microsurgery in the transplant operation made this procedure a successful approach. However, controversy persists about using such an approach for division of liver grafts from cadaveric donors, and many teams prefer retaining the main arterial trunk with the left split graft, with or without the main portal vein trunk. Since 1998, in our center, when a donor-liver graft is divided we prefer retaining the main vessels with the right split graft if graft vascular anatomy is favorable. After 1998, 40 liver grafts from cadaveric donors were divided, and all divisions were performed ex situ. This experience was retrospectively reviewed to compare the outcome of left split grafts prepared for implantation with the left vasculature only (group A), or with the main arterial supply (group B). A single vascular complication occurred (one hepatic artery thrombosis in group B). Three patients died (one in group A and two in group B) and three other grafts were lost (one in group A and two in group B). One-year and 3-year graft survival rates were 94% and 86% in group A, and 83% and 83% in group B, respectively (not significantly [NS] different). We conclude that left split grafts can be safely transplanted with the left vascular supply only, provided that division is guided by careful anatomical evaluation and that vascular reconstructions are adequate.

Hepatic vein reconstruction in ex situ split-liver transplantation.

BACKGROUND: Anatomy of the left hepatic vein (LHV) was studied in a series of 53 consecutive cadaveric liver grafts that were divided for transplantation. METHODS: All divisions were performed ex situ and provided a left split graft with only the LHV as the hepatic outflow. The anatomy was categorized into three types: (A) single LHV trunk, (B) two veins closely merging toward the median hepatic vein, or (C) a double outflow. RESULTS: Direct implantation of the graft was performed in type A and was possible in type B after simple plasty of the ostia to create a single orifice. In type C, a venous jump graft could be interposed at bench work to allow direct anastomosis into the recipient. There were no related complications, except one type A case with late outflow obstruction. CONCLUSION: Liver division can be performed safely in liver grafts with variant LHV anatomy, if appropriate techniques for reconstruction are used. Also ex situ liver division has the advantage of allowing a detailed anatomic evaluation before dividing LHV: reconstruction can be performed ex situ, allowing a single-step direct anastomosis in the recipient, thus shortening suturing time.

Adesäo à terapêutica de reposiçäo hormonal no climatério: experiência no ambulatório de menopausa - UNICAMP / Compliance with hormonal replacement therapy in climateric women: experience of menopause clinic - UNICAMP

A adesao à TRH é um ponto crucial no tratamento de mulheres pós-menopausadas e climatéricas, já que os efeitos benéficos dos hormônios podem ser afetados ou mesmo perdidos se as mulheres nao mantiverem o tratamento. Apesar da relevância do assunto, poucas avaliaçoes têm sido realizadas neste sentido. O objetivo deste estudo foi avaliar o esquema de reposiçao hormonal e a adesao ao tratamento, no Ambulatório de Menopausa do CAISM/UNICAMP. Foi avaliado, retrospectivamente, o comportamento de 127 pacientes desta clínica diante da TRH durante o ano de 1992. A média etária das pacientes foi de 5O,6 anos (+ 7,4). O regime de reposiçao hormonal mais utilizado foi a associaçao de estrogênios e progestogênios de forma cíclica. A adesao à TRH nao foi afetada pelo tipo de esquema utilizado e foi considerada alta (86 por cento), talvez devido à assistência multiprofissional e à seleçao das pacientes, uma vez que, de 224 pacientes admitidas no Ambulatório, somente 127 (56,7 por cento) receberam TRH.