Surgical implications of a left-sided gallbladder.

BACKGROUND: A left-sided gallbladder in a normally positioned liver is considered to be a very uncommon anomaly. Laparoscopic cholecystectomy can be performed safely, but bile duct injury is not unusual. It is associated with anomalous intrahepatic portal and biliary systems which impacts any form of partial hepatectomy. METHODS: We performed a retrospective review of patients with left-sided gallbladder who were managed by the hepatobiliary surgeons at our institution since 1996. RESULTS: Nineteen patients with left-sided gallbladder underwent a hepatobiliary procedure. Of the 13 patients with gallstones, only 1 was diagnosed before cholecystectomy. Nine operations were completed laparoscopically, whereas 4 required an open procedure. Two patients were referred with bile duct injuries. There was 1 liver resection for a colorectal metastasis. Left-sided gallbladders in 3 deceased organ donors resulted in major implications in the performance of liver transplantation. CONCLUSIONS: Left-sided gallbladders are probably more common than generally believed but are rarely diagnosed before cholecystectomy. Associated bile duct injury appears to be not infrequent. Because of the aberrant vasculobiliary anatomy, any form of liver resection requires careful planning.

Obstacles to the establishment of liver transplantation in Australia.

A quarter of a century ago the commencement of liver transplantation in Australia was controversial and surrounded by medical and political intrigue. The medical opposition to its establishment was led by the Medical Journal of Australia with scathing condemnation, especially with regard to the transplantation of children. Interstate political rivalry, most prominently between the Queensland and Victorian and Federal Governments was at the forefront and was a fertile field for media attention. Despite all the obstacles, liver transplantation came to fruition and the results achieved have more than justified its introduction and continued performance. In addition, contributions from Australia have had a significant impact around the world.

The dilemma of living liver donor death: to report or not to report?

Living donor liver transplantation has become a life-saving alternative for end-stage liver disease patients who have no chance of receiving a deceased donor organ. On the basis of information available to the medical community, mortality risk for the living donor is reviewed and implications of not reporting donor deaths are discussed.

Undetected hepatocellular carcinoma in patients undergoing liver transplantation: is associated with favorable outcome.

BACKGROUND/AIMS: The aim of the study was to define the clinical characteristics and outcome of patients found to have undetected hepatocellular carcinomas (HCC) at liver transplantation. Patients who underwent liver transplantation and were unexpectedly found to have a HCC despite prior workup showing normal alpha-fetoprotein levels and/or no visible radiological lesion were defined as having an undetected HCC. METHODOLOGY: Thirty-two of these patients had a histological diagnosis of HCC in the explanted liver. Undetected HCC was defined as a carcinoma found only on pathological evaluation of the explanted liver, with a pre-OLT workup showing a normal serum alpha-fetoprotein (AFP) level (<20 ng/mL) and/or no suspicious lesion on preoperative radiological evaluation. RESULTS: Nine patients had a tumor that met the criteria for an undetected HCC. The most common cause for transplantation was cryptogenic cirrhosis (44.4%). Tumor size was 2 cm or less in all patients, vascular invasion was detected in 11.1% of the patients, and tumor, node, metastasis (TNM) classification was stage I in 77.8%. Eight patients (88.9%) remained alive at the cessation of the analysis with a mean follow-up of 60 +/- 30.4 months. There was no tumor recurrence in any patient. Statistical analysis showed significant differences between undetected and detected HCCs when causes of pretransplantation liver disease, peak AFP level, tumor size, number of tumors, presence of vascular invasion or pathological differentiation were compared. Undetected HCCs were associated with a better survival rate after liver transplantation (p = 0.008). CONCLUSIONS: Patients with undetected HCCs at OLT have a favorable outcome with tumor-free survival. Most patients had small, early-stage HCCs, but the possibility of finding tumors greater than 2 cm, multifocal lesions, and vascular invasion exist despite thorough investigation. An exhaustive histopathological search of the explant for malignancy will allow for greater accuracy in prognosis.

Living-donor liver transplantation: an overview.

It has been 16 years since the first successful living-donor liver transplant was performed from a parent to a child. The overall recipient and graft survival, together with a low morbidity and mortality in donors, have resulted in the widespread acceptance of the procedure by both the transplant community and the public at large. Adult-to-adult living-donor liver transplantation has been evolving over the past decade. Despite living-donor transplant patients being better-risk candidates than those who receive a graft from a deceased donor, and well-established and experienced units achieving satisfactory results, overall recipient and graft survival recorder by registries can only be described as suboptimal. This, combined with the high morbidity and not-insignificant mortality amongst donors makes expansion of adult-to-adult liver transplantation hard to justify on a risk-benefit analysis.

Outcomes of split versus reduced-size grafts in pediatric liver transplantation.

BACKGROUND: Split-liver transplantation, where two grafts are created from a single donor organ, is a means of overcoming donor organ scarcity. There are few data comparing outcomes of split with reduced-size liver grafts, which is the most common type of cadaveric graft in pediatric liver transplantation. The aims of the present paper were to compare survival and complication rates between split and reduced-size cadaveric grafts in pediatric patients receiving a liver transplant in Brisbane. METHODS: Review of the Queensland Liver Transplant Service database was undertaken. All pediatric patients who received either a cadaveric split or reduced-size graft between 1985 and 2000 were examined. The incidence of patient and graft survival, vascular complications and biliary complications were identified. RESULTS: A total of 251 liver transplants were performed of which 138 were reduced-size grafts and 30 were split grafts. There were no differences in etiology of liver disease, mean age, weight, and urgency of transplant between the two groups. One-year patient and graft survivals were comparable at 73% and 67%, respectively, in both groups. There was no difference in the incidence of vascular complications between groups. Biliary complications were significantly more common after split grafts when compared with reduced-size grafts (21%vs 4%, P < 0.0001) but did not affect patient or graft survival. CONCLUSIONS: Survival and vascular complications after split-liver grafts were comparable to outcomes after reduced-size grafts. Biliary complications occur more commonly with split-liver grafts but did not affect patient or graft survival. It is recommended that every pediatric recipient be considered for a split-liver graft.

[Liver transplantation for primary biliary cirrhosis: retrospective analysis of 52 patients in QLTS].

OBJECTIVE: Retrospectively analyzing post-transplant primary biliary cirrhosis patients to document the actual survival time, the cause of post-transplant death, and recurrences after liver transplantation in patients followed up by the Queensland Liver Transplant Service (QLTS). METHODS: The case notes of all post-piggyback liver transplantation patients followed up by QLTS were reviewed. We analyzed the clinical characteristics of the PBC patients, post-transplant actual survival rates, the causes of post-transplant death, and risk factors of recurrence, and compared the survival rates between patients with and without liver transplantation using a European model. RESULTS: Fifty-two post-transplant patients with 54 transplantations were identified with an average age of 53 years and a mean follow-up time of 55 months. The actual survival times of PBC patients with grafts for 1 years, 5 years and 10 years were 88.4%, 80.1%, 76.9% and 80.9%, 65.4%, 19.8%. The causes of death were MOF intra-abdominal bleeding, renal failure, sepsis and cardiovascular diseases. Comparing the survival rates between with and without transplantation, 8.5% of PBC patients have recurrences with an average recurrent time of 34 months. CONCLUSION: (1) Liver transplantation could improve survival rates, but the optimum time for transplantation should be focused on; (2) A long-term and larger follow-up sampling should be done to understand the effects of recurrences on patient's long-term survival; (3) CsA may play a more important role in preventing recurrence of PBC than Tacrolimus

Validation and refinement of survival models for liver retransplantation.

Orthotopic liver retransplantation (re-OLT) is highly controversial. The objectives of this study were to determine the validity of a recently developed United Network for Organ Sharing (UNOS) multivariate model using an independent cohort of patients undergoing re-OLT outside the United States, to determine whether incorporation of other variables that were incomplete in the UNOS registry would provide additional prognostic information, to develop new models combining data sets from both cohorts, and to evaluate the validity of the model for end-stage liver disease (MELD) in patients undergoing re-OLT. Two hundred eighty-one adult patients undergoing re-OLT (between 1986 and 1999) at 6 foreign transplant centers comprised the validation cohort. We found good agreement between actual survival and predicted survival in the validation cohort; 1-year patient survival rates in the low-, intermediate-, and high-risk groups (as assigned by the original UNOS model) were 72%, 68%, and 36%, respectively (P <.0001). In the patients for whom the international normalized ratio (INR) of prothrombin time was available, MELD correlated with outcome following re-OLT; the median MELD scores for patients surviving at least 90 days compared with those dying within 90 days were 20.75 versus 25.9, respectively (P =.004). Utilizing both patient cohorts (n = 979), a new model, based on recipient age, total serum bilirubin, creatinine, and interval to re-OLT, was constructed (whole model chi(2) = 105, P <.0001). Using the c-statistic with 30-day, 90-day, 1-year, and 3-year mortality as the end points, the area under the receiver operating characteristic (ROC) curves for 4 different models were compared. In conclusion, prospective validation and use of these models as adjuncts to clinical decision making in the management of patients being considered for re-OLT are warranted.

The influence of viral genotypes and rejection episodes on the recurrence of hepatitis C after liver transplantation.

PURPOSE: The aim of this study was to report the influence of hepatitis C virus (HCV) genotype and rejection episodes on the outcome of orthotopic liver transplantation (OLT), hepatitis recurrence, and progression to graft cirrhosis after OLT. METHODS: Fifty-three patients who all had undergone OLT for end-stage liver cirrhosis were selected for this study. Hepatitis C genotype was determined. Recurrent hepatitis and rejection were diagnosed based on elevated liver function tests and a liver biopsy. RESULTS: The patients were followed up for a mean of 51.9 +/- 34.3 months. The cumulative survival rate was no different in OLT for hepatitis C and OLT for all other liver diseases. After OLT, serum HCV RNA was detected in 93%. Histological recurrence occurred in 85% of all patients. The 1-, 3-, and 5-year recurrence rates were 48%, 77%, and 85%, respectively. Of the 41 patients with recurrent hepatitis C, 4 (10%) had cirrhosis, 18 (44%) had hepatitis with fibrosis, and 91 (46%) had hepatitis without fibrosis at the end of follow-up. A total of 32% of the patients were infected by HCV genotype 1b and 68% by other HCV genotypes. The recurrence rates were significantly higher in patients infected with genotype 1b than in those with other genotypes ( p = 0.04). Twenty of 48 patients (42%) experienced acute rejection. There was a strong association between the number of rejection episodes and the incidence of HCV-related cirrhosis ( p < 0.01). CONCLUSION: Our findings showed the genotype 1b to result in a higher recurrence rate after OLT. On the other hand, rejection episodes were associated with a more rapid progression to graft cirrhosis.

Liver transplantation for hepatolithiasis.

Hepatolithiasis is frequently encountered in Asia, but is relatively uncommon in Western societies. The improved surgical and stone fragmentation techniques that have evolved over the past decade have reduced the incidence of retained or recurrent stones with a consequent reduction in progressive liver damage and cirrhosis. Nonetheless, disease-related mortality from liver failure, bleeding oesophageal varices and cholangiocarcinoma still exists and a proportion of patients are cirrhotic at their initial presentation. There have been good long-term results following liver transplantation for a variety of cholestatic liver diseases, but transplantation for hepatolithiasis has seldom been reported. This paper reports four patients who underwent successful liver transplantation for hepatolithiasis with secondary biliary cirrhosis.

Liver transplantation as a therapeutic option for hepatocellular carcinoma.

Better outcomes of the patients receiving liver transplantation for viral hepatitis and hepatocellular carcinoma (HCC) are achieved by improved patient selection and perioperative treatment with antiviral agents including lamivudine, ribavirin and interferon. Patient selection is accomplished by high-quality imaging as well as exclusion of patients with large tumors, obvious extrahepatic disease or macroscopic vascular invasion. Using such criteria, a 5-year survival of 92% has been reached in the Queensland Liver Transplant Service on a small number of highly selected patients with HCC. The treatment algorithm of Makuuchi has guided us in recommending resection, estimating to what extent the liver resection can be performed safely, and timing liver transplantation when it is the only option. Adult-to-adult living-donor liver transplantation is being performed safely in many centers worldwide. The transplantation of liver from living donors to HCC patients, when standard criteria for the likelihood of good outcomes are fulfilled, will increase in Japan in the near future.