Stenosis of the hepatic vein anastomosis after liver transplantation: treatment with a heparin-coated metal stent.

Delayed-onset fibrotic stenosis of the hepatic-vein anastomosis following liver transplantation resulted in ascites and abnormal liver-function tests. The stenosis was treated with balloon dilatation resulting in a clinical improvement; however, this had to be repeated four times in the 9 months after transplantation due to recurrent stenosis. The stenosis was eventually successfully treated with percutaneous insertion of a metal stent. Aspirin 50 mg daily was prescribed for 1 month. The patient was not anticoagulated. The patient remains clinically well at follow up after 18 months.

Management of biliary tract complications following liver transplantation.

BACKGROUND: A review of biliary tract complications was performed in 32 patients who underwent liver transplantation by the Western Australian Liver Transplantation Service during a 2-year period. METHODS: A review was made of patient data collected prospectively, and confirmed by retrospective casenote review. RESULTS: A total of 30 patients (31 grafts) survived more than 2 days after transplantation, and of these 28 had an end-to-end biliary anastomosis. Analysis of these 28 patients found that eight of 17 patients with T-tubes had complications: three leaks at T-tube removal; two strictures and leaks; and three strictures. Six of 11 patients without a T-tube had complications: one leak; three strictures and leaks; and two strictures. Predisposing factors were present in eight of the 14 patients with biliary tract complications: hepatic artery stenosis in three; and one each with hepatic artery thrombosis; biliary calculi; donor-recipient bile duct mismatch; severe cellular rejection: and prolonged postoperative hypotension. Acute rejection, steroid-resistant rejection and cytomegalovirus infection were all significantly more common in those patients with biliary tract complications compared with those without. There was no difference in cold ischaemic time or donor age. Twelve of the 14 patients with biliary complications required endoscopic stenting with or without balloon dilation, and eight patients required radiological percutaneous drainage of bile collections. Only one patient required biliary reconstruction and two patients required re-transplantation. One patient died of uncontrolled infection. Of three patients who underwent choledochojejunostomy, biliary leak developed in two patients, both of whom required operative biliary and hepatic repair. One of the three patients died from disseminated Aspergillus infection. The median total hospital stay of patients with biliary complications was 61 days (range: 30-180 days) compared with 33.5 days (range: 22-70 days) for patients without. Of patients with end-to-end biliary anastomosis, 50% had biliary tract complications and more than half of these had predisposing factors. The majority of biliary complications were managed without the need for surgery. CONCLUSION: A total of 50% of patients with end-to-end biliary anastomosis had biliary tract complications. Biliary strictures presented later than leaks, and the majority of these complications were managed without the need for surgery.

Acute pulmonary embolism: diagnosis with MR angiography.

PURPOSE: To prospectively evaluate pulmonary magnetic (MR) angiography as a diagnostic examination for acute pulmonary embolism (PE). MATERIALS AND METHODS: Thirty-six consecutive patients (19 women, 17 men; age range, 28-84 years) underwent pulmonary digital subtraction angiography (DSA) and pulmonary MR angiography. MR angiograms were obtained during suspended respiration and the pulmonary arterial phase of gadolinium-based contrast medium injection. A steady-state gradient-recalled-echo sequence with free induction decay sampling was used. DSA studies were interpreted for the presence of acute PE by two independent radiologists; an adjudicator made the final decision on discordant interpretations. RESULTS: By using DSA, a total of 19 acute pulmonary emboli were depicted in 13 patients. Prospectively, 13 of these emboli were depicted by using MR angiography. MR angiography missed six emboli: Four required the DSA adjudicator to make the decision, and one was in a patient whose MR angiogram was acquired during breathing. Four of these six emboli were small subsegmental emboli, and two were segmental. CONCLUSION: Performed without pulmonary arterial catheterization, iodinated contrast media, or ionizing radiation, pulmonary MR angiography had a high accuracy for depicting lobar and segmental emboli, but was unable to depict four of five subsegmental emboli.

Liver transplantation in Western Australia: improved services to an isolated population.

OBJECTIVE: To assess performance of the Western Australian Liver Transplantation Service in the light of debate about whether small transplant centres can produce optimal outcomes. DESIGN: Review of patient data collected prospectively and confirmed by retrospective casenote review. SUBJECTS: All patients referred to the Western Australian Liver Transplantation Assessment Panel. Those who underwent transplantation at the Western Australian Liver Transplantation Service (to June 1996) were compared with those referred to other transplant centres before the elective service was established in July 1994. OUTCOME MEASURES: Numbers of referrals and transplants; characteristics of the transplantation procedure; and patient outcomes. RESULTS: Annual referrals for liver transplant in Western Australia (WA) increased from 12 (1985-1993) to 41 (July 1994-June 1996), with five deaths on the "activated" list before July 1994, but none after. To June 1996, 30 patients had received 31 transplants by the Western Australian Liver Transplantation Service (two emergency transplants in 1992 and 1993, respectively, and 28 elective transplants and one retransplant after June 1994), with median operation time of 5.5 hours (range, 3-10.5), median red cell transfusion of 4 units (range, 0-55) and median hospital stay of 24 days (range, 12-128). There was no severe primary graft dysfunction. Major complications included hepatic artery thrombosis or stenosis (5 patients, one requiring retransplant), biliary stricture not associated with hepatic artery pathology, bile leak and perihepatic abscess (4 each), and cytomegalovirus infection (3). Patient survival was 83% and graft survival 81% at a mean follow-up of 13 months, compared with 86% and 83%, respectively, at one year for WA patients who received transplants elsewhere before July 1994. CONCLUSIONS: Performance of the Western Australian Liver Transplantation Service compares favourably with national and international standards, and WA patients receiving liver transplants have increased dramatically since the service was established. This supports the viability of committed liver transplantation centres with only 10-15 patients a year and argues the need for nationally decentralised services.

Intra-abdominal fluid collections after liver transplantation.

Fluid collections are commonly seen following orthotopic liver transplantation. The majority of these collections are not infected and resolve spontaneously. However, infected collections are associated with significant morbidity and mortality and usually require drainage. Clinical signs of infection are frequently masked following transplantation due to immunosuppression. Intrahepatic collections usually represent abscesses or bilomas and invariably require intervention. Altered anatomical relationships result in signs that frequently help to differentiate these from loculated fluid within hepatic fissures. Other imaging features indicating infection include the presence of gas where none was seen previously, the development of a discrete wall and changes in the surrounding liver.

The Hutson loop and prosthesis: clinical uses in hepato-biliary intervention.

A number of method of making a Roux-en-Y hepaticojejunostomy have been advocated to help the radiologist gain access to the biliary system. We have found markers and rings unsatisfactory and therefore designed and tested our own prosthesis. Reliable rapid access is easily achieved using this device with a much reduced radiation dose to both patient and radiologist. The prosthesis has been used for the past 3 years, and the last 23 patients are reviewed. Seven patients have required repeated interventions via the loop and we present the findings and our results.

Computed tomography demonstration of mosaic oligaemia in pulmonary embolism.

Previous reports on computed tomography findings in pulmonary embolism have concentrated on describing large peripheral wedged-shaped opacities thought to represent infarcts, and filling defects in the central vessels presumed to represent emboli. Two cases are presented of mosaic oligaemia with areas of apparent increase in density initially though to represent infiltrates.

The use of ultrasound in the venous assessment of lower limb Klippel-Trenaunay syndrome.

Colour Doppler ultrasound was used to study the affected lower limbs of a group of patients with the Klippel-Trenaunay syndrome. The abnormal lateral venous channel characteristic of this syndrome was examined, together with its deep venous connections and deep venous patency established if present. Seventeen patients (18 limbs) were studied. Ultrasound demonstrated calf vein patency in 15 out of 17 limbs and deep venous patency from the popliteal vein to the inferior vena cava in 17 out of 17 limbs. Ultrasound was also effective in demarcation of the abnormal lateral venous channel, together with its deep connections (13 out of 16 limbs). We conclude that ultrasound is superior to the more established venographic techniques in the investigations of patients with the Klippel-Trenaunay syndrome. From this study, the deep venous aplasia said to occur in the condition would appear to be less common than previously thought.

Pictorial review: the imaging features of lower limb Klippel-Trenaunay syndrome.

The Klippel-Trenaunay syndrome is a rare mesodermal abnormality causing venous anomalies, cutaneous capillary naevi with bone and soft tissue hypertrophy of one or more limbs. In this pictorial review we illustrate the plain film, venographic, ultrasound and magnetic resonance imaging features of Klippel-Trenaunay syndrome affecting the lower limb.