Reliability of frozen section in the assessment of allograft steatosis in liver transplantation.

BACKGROUND: Because liver allograft steatosis is an important risk factor of graft dysfunction after liver transplantation, it must be taken into consideration during graft acceptance. The aim of this study was to evaluate the reliability of frozen section in the assessment of liver steatosis before transplantation. METHODS: The retrospective analysis was based on data of 112 liver allograft procurements performed between 2003 and 2012. Hepatic steatosis was assessed in frozen and routine sections. Sensitivity, specificity, and positive and negative predictive values of the frozen section were evaluated with respect to detection of >30% and >50% steatosis. RESULTS: According to routine section assessment, there were 32 (28.6%) cases of steatosis >30% and 16 (14.3%) of >50%. The results of frozen section assessment were underestimated and overestimated in a similar low number of cases, both for the >30% (0.0% and 0.9%, respectively, P < 1.000) and the >50% (4.5% and 0.9%, respectively, P = .221) cutoff. Sensitivity, specificity, positive and negative predictive values of frozen section assessment were 100.0%, 98.8%, 97.0%, and 100.0%, respectively, for detection of >30% steatosis, and 68.8%, 99.0%, 91.7%, and 95.0%, respectively, for >50% steatosis. CONCLUSIONS: Considering high positive predictive value of frozen section assessment in detection of >50% steatosis, it may serve as a base to discard the use of graft for transplantation. However, according to the relatively moderate sensitivity of this method, decision of graft acceptance must also be made on consideration of other well-known factors for poor posttransplant function.

Outcomes following liver transplantation for metastatic neuroendocrine tumors.

INTRODUCTION: Metastatic disease is generally considered as an absolute contraindication for liver transplantation. However, due to relatively low aggressiveness and slow progression rates, liver metastases from neuroendocrine tumors (NETs) form an exception to this rule. Given the scarcity of available data, the purpose of this study was to evaluate long-term outcomes following liver transplantation for NET metastases. MATERIAL AND METHODS: There were 12 primary liver transplantations in patients with NET metastases out of 1334 liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw) in the period between December 1989 and October 2013. Overall survival (OS) and disease-free survival (DFS) were set as primary and secondary outcome measures, respectively. RESULTS: Median follow-up was 7.9 years. For all patients, OS rate was 78.6% at 10 years and DFS rate was 15.5% at 9 years. Intraoperative transfusions of packed red blood cells (P = .021), Ki-67 proliferative index more than 2% (P = .048), and grade 2 tumors (P = .037) were identified as factors significantly associated with worse DFS. Notably, loss of E-cadherin expression (P = .444), mitotic rate (P = .771), extent of liver involvement (P = .548), primary tumor site (P = .983), and recipient age (P = .425) were not significantly associated with DFS. CONCLUSIONS: Excellent long-term OS rates support liver transplantation for unresectable NET metastases despite almost universal post-transplantation tumor recurrence. Selection of patients with G1 tumors with Ki-67 index not exceeding 2% and reducing the requirement for intraoperative blood transfusions might improve DFS rates.

Risk factors of acute renal failure after orthotopic liver transplantation: single-center experience.

BACKGROUND: Acute renal failure (ARF) is one of the most significant complications of orthotopic liver transplantation (OLT), associated with increased mortality rate and the development of chronic renal dysfunction. The aim of the study was to determine the perioperative risk factors for ARF in patients without previous history of renal disease who are undergoing OLT. MATERIALS AND METHODS: Forty-six patients who developed ARF after OLT performed in 1 transplant center were included in the study, and 52 consecutive patients without that complication served as a control group. Renal dysfunction was defined as a glomerular filtration rate <60 mL/min/1.73 m(2). The data concerning preoperative diseases, perioperative renal function, first-line immunosuppressive therapy, and blood transfusion requirement were retrospectively analyzed and compared among groups. Logistic regression modeling was used to determine risk factors for ARF. RESULTS: Patients who developed ARF were significantly older (mean age 53.3 vs 46.3 years, P = .057), had higher level of preoperative (0.79 vs 0.71 mg/dL, P = .0062) and intraoperative (0.85 vs 0.74 mg/dL, P = .0045) creatinine. The risk factors for ARF were intraoperative and 24-hour post-transplant creatinine level >0.9 mg/dL and high-dose tacrolimus-based immunosuppression. Transfusion of ≤6 units of red blood cells diminished the risk of ARF. Sex and preoperative diseases were not predictive to ARF in our regression models. CONCLUSION: Careful operative technique with low blood loss and immunosuppressive therapy of low nephrotoxic potential should be recommended in older patients to diminish the risk of renal dysfunction after orthotopic liver transplantation. Patients with higher levels of perioperative creatinine should be considered to have first-line immunosuppression without calcineurin inhibitors or with low-dose immunosuppressants of known nephrotoxic potential.

Orthotopic liver transplantation for cholestatic diseases.

BACKGROUND/AIMS: According to the data of the European Liver Transplant Registry (ELTR), liver transplantations (LTx) as a result of bile duct diseases were reported in 12.0% of cases. The aim of this study was to overview retrospective indications for operation and results of patients who underwent LTx for cholestatic diseases. METHODOLOGY: 725 LTx were performed between January 1989 to December 2008, including 173 (23.9%) patients with cholestatic diseases. 80 pts (46.2%) were operated because of PBC, 63 pts (36.4%) with PSC and 12 pts (6.9%) with SBC as a result of iatrogenic bile ducts injuries. In 6 pts (3.5%) Caroli's disease was the reason for transplantation and another 11 pts (6.4%) were operated because of infiltration of alveococcosis into the bile duct. Cholangiocarcinoma (CCC) developed in 6 pts with PSC (9.5%) undergoing LTx. The last patient (0.6%) of our group was operated because of mucoviscidosis. 24 pts (13.9%) underwent unsuccessful surgical treatment prior to the LTx. RESULTS: 142 pts (82.1%) presented good outcome, but complications in postoperative period were present in 31 pts (17.9%). 8 pts (4.6%) required re-laparotomy: 6 pts due to intraperitoneal bleeding and hematoma in the first postoperative week and 2 pts due to liver abscess, 1 month and 3 months after LTx respectivelly. 4 patients (2.3%) died in the first week after LTx (septic complications, acute rejection). 5 patients with CCC died in the period of 7 to 26 months after LTx. This was caused by the recurrence of the cancer. The overall mortality was 8.1% (14 pts). 4 pts (2.3%) underwent ReLTx due to various origins--one case due to hepatic artery thrombosis, another was ischemic type biliary lesion (ITBL) and two patients due to recurrence of PBC and PSC. Cumulative 1, 5 and 10 year recurrence-free survival rates after LTx were: 94.6% / 88.7% / 72.1% in PBC group, 95.3% / 86.5% / 70.2% in PSC group and 73.9% / 69.2% / 59.3% in SBC group of patients. CONCLUSION: There is no doubt that LTx is a good and effective option of treatment for patients with cholestatic diseases. Nevertheless the long-term benefits of LTx depend on precise indications and timing of the operation.

Menstrual function in female liver transplant recipients of reproductive age.

BACKGROUND AND AIM: End-stage liver failure is associated with severe abnormalities in menstrual and reproductive function. These abnormalities may be reversed by successful orthotopic liver transplantation (OLT). The aim of the study was to investigate menstrual patterns and sex hormone profiles among female liver transplant recipients of reproductive age. METHODS: The study group consisted of 24 women of reproductive age with end-stage liver failure who underwent successful OLT. Menstrual patterns and sex hormone profiles were analyzed before as well as 3 and 12 months after OLT. Twenty-seven healthy women of reproductive age served as controls. Biochemical parameters of liver function were assessed before and after OLT. RESULTS: Amenorrhea was the most commonly observed abnormality of menstrual cycle in women with end-stage liver failure (71% of patients). The recurrence of regular menstrual cycles was observed in 35% of patients 3 months after OLT. The percentage increased to 70% at 1 year after grafting and was clearly associated with stabilization of liver function. Similar levels of follicle stimulation hormone (FSH), luteinizing hormone (LH), prolactine (PRL), and testosterone (T) as well as lower levels of estradiol (E(2)), dehydroepiandrostendione sulphate (DHEA-S), and progesterone, (P) were observed in patients with liver failure compared with healthy women. We observed normalization of E(2) and DHEA-S levels after OLT. CONCLUSIONS: Amenorrhea, the most common menstrual disturbance in women with end-stage liver failure, may be reversed by OLT. One year after OLT menstrual bleedings were noted in 74% of patients of reproductive age. The recurrence of reproductive function indicated the need for effective and safe family planning methods in that group of patients.

Orthotopic liver transplantation for fulminant hepatic failure.

This paper presents the results of liver transplantation for fulminant hepatic failure in 31 patients qualified as UNOS-1 class (extra-urgent indication for transplantation), operated from January 1989 to April 2005. Twenty-one patients (61.8%) survived the 3-month postoperative period. Three-year survival rate with good liver graft function was 52.9% (18 patients). Before the transplantation, eight patients (23.5%) underwent hepatic dialysis using Fractionated Plasma Separation and Adsorption (FPSA) with the use of a Prometheus 4008H System. Liver transplantation remains the only life-saving procedure for the treatment of fulminant liver failure, regardless of its cause.

Comparison of the results of liver transplantation for elective versus urgent indications.

The authors present an analysis of early and remote liver transplantation outcomes related to the presence of emergent indications among 196 of the 209 operations performed from 1989 to April 2003; namely 178 elective and 18 emergent transplantations. Perioperative mortality was 15%. The survival rate during the first 12 months was 79.8% and within 3 years 73.5% among patients operated on an elective basis (UNOS 3 and 2B). In contrast, patients with acute liver failure (UNOS 1 and 2A) showed rates of 45%, 50%, and 47%, respectively. Liver transplant outcomes depend primarily on the urgency of an operation. Longterm results are much better among patients operated on electively. Liver transplantation in patients with acute hepatic insufficiency is burdened with a high 45% mortality.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation.

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

Biliary tract complications following liver transplantation.

INTRODUCTION: Biliary tract complications, which occur in 5.8% to 24.5% of adult liver transplant recipients, remain one of the most common problems following transplantation. The aim of this study was to evaluate these problems and analyze methods of treatment. MATERIAL AND METHODS: From 1989 to 2003, 36 (18.7%) among 193 patients who underwent orthotopic liver transplantations in our center developed biliary complications. Biliary strictures that developed in 18 cases (9.3%) were the most common complications. Clinical manifestations of strictures developed at 2 to 24 months after transplantation. Bile leaks occurred in 10 patients (5.2%), and were diagnosed in along the T-tube 4 cases and was not accompanied by any clinical manifestation. Bile leak to the peritoneum after T-tube removal occurred in 2 patients (1.1%). Solitary gallstone formation in one case (0.5%) was removed with the use of ECPW. One patient required retransplantation within 3 months after transplantation, because of the most severe complication-ischemic necrosis of biliary tract. RESULTS: Uneventful recovery was achieved in 34 patients in the analyzed group (94.4%). There was no case of recurrence during outpatient follow up. Two patients died in late follow-up of unrelated causes: namely, gastrointestinal bleeding due to a duodenal ulcer and multi-organ failure (MOF) due to a third severe episode of acute liver transplant rejection. CONCLUSIONS: Biliary complications remain an important problem in liver transplantation. Endoscopic and radiologic management are effective in the majority of cases. Surgical intervention is obligatory in selected cases.