Laparoscopy After Liver Transplant: Result of an Initial Series.

UNLABELLED: There are few reports about laparoscopic approach after liver transplantation (LT). The aim of this paper is to analyze in terms of feasibility and therapeutic effectiveness an initial experience with laparoscopy in patients who have had a liver transplantation. METHODS: Laparoscopic procedures were divided into "early" and "late" laparoscopy. RESULTS: A total of 10 laparoscopic procedures after LT were performed in 9 patients: 3 early and 7 late. The early laparoscopic procedures were performed in 3 patients who had a torpid evolution in their liver transplant: 2 were diagnostic only and 1 was also therapeutic. There were no intraoperative events or conversions. We recorded 2 complications. In 7 patients a late laparoscopy was performed: 4 in the upper abdomen and 3 in the lower abdomen. Of the 4 in the upper abdomen, 3 were liver procedures and 1 was in the transverse colon, on the other side; in addition, 2 laparoscopic inguinal hernia repairs and 1 laparoscopic appendectomy also were performed. None of these 7 cases was converted, and there were no intraoperative events. CONCLUSIONS: The early postoperative period, in critically ill patients diagnostic and eventually therapeutic laparoscopy was feasible and effective in our cases. Late laparoscopy in the upper abdomen is difficult due to adhesions and adds to the risk of poor graft function, but was feasible for both diagnostic and therapeutic purposes. Late laparoscopy in the lower abdomen with good graft function has the same safety and efficacy as those performed on nontransplanted patients.

Effect of robotic assistance on the "learning curve" for laparoscopic hand-assisted donor nephrectomy.

BACKGROUND: The number of living-related donor kidney transplantations have increased since the advent of minimally invasive surgery. Robotic technology has emerged as a promising alternative to laparoscopic techniques. The authors reviewed their institution experience with robotic hand-assisted donor nephrectomies (RHADNs). METHODS: Between August 2000 and April 2006, 273 robotically assisted left donor nephrectomies were performed using a hand-assisted technique. Prospectively collected information for 214 patients regarding complications, hospital stay, blood loss, warm ischemia time, operative time, and outcomes is presented. RESULTS: The cohort of donors included 110 men and 104 women with a mean age of 36 years (range, 18-61 years). These donors included 86 African Americans, 46 Caucasians, 74 Hispanics, and 8 of other races. Left renal artery anomalies were found in 61 patients (29%). Four patients underwent conversion to open surgery. The hospital stay was 2.3 days (range, 1-8 days), the blood loss 82 ml (range, 10-1,500 ml), and the mean warm ischemia time 98 s (range, 50-200 s). The operative time was 201 min (range, 100-320 min) for the first 74 cases, 129 min (range, 65-240 min) for the second 70 cases, and 103 min for the last 70 cases (p < 0.001), for an overall average of 150 min. Complications decreased significantly after the first 74 cases. The 1-year patient survival rate was 100%, and the 1-year graft survival rate was 98%. The average recipient creatinine at 6 months was 1.4 mg/dl. CONCLUSIONS: Specific changes in operative technique over time have improved patient safety and diminished complications with RHADN. Currently, RHADN can be performed expeditiously with a minimal rate of complications and conversion to open procedure by a surgical team with appropriate training and experience.

Hepatic ischemia/reperfusion injury can be modulated with thymoglobulin induction therapy.

BACKGROUND: Thymoglobulin induction therapy has been shown to ameliorate delayed graft function and possibly decrease ischemia reperfusion injury in cadaver renal transplant recipients. This controlled randomized trial was designed to assess whether thymoglobulin also protects liver transplant recipients from ischemia reperfusion injury. PATIENTS AND METHODS: Twenty-two cadaver liver transplant recipients were randomized to receive either thymoglobulin (1.5 mg/kg per dose) during the anhepatic period and two doses every other day or no thymoglobulin. No differences in recipient or donor demographics were present. Maintenance immunosupression consisted of tacrolimus (or cyclosporine) and steroids for both groups. Donor biopsies were obtained during organ procurement, cold storage, and 1 hour after revascularization. Postoperative liver function tests were monitored. Early graft function, length of stay, patient and graft survival rates, incidence of primary nonfunction, and rate of rejection were assessed. RESULTS: Patient and graft survival at 3 months was 100%. There was no incidence of primary graft nonfunction and no need for retransplantation. The incidence of acute rejection was similar between the two groups. Although donor livers randomized to thymoglobulin had less optimal preimplantation biopsies, these recipients had significant decreases in ALT at day 1 compared to the control group (P = .02), near significant decreases of total bilirubin at day 5, and shorter length of hospitalization. CONCLUSION: Thymoglobulin allowed for more compromised liver grafts to be transplanted with less clinical evidence of ischemia reperfusion injury and improved function.

Failed antireflux surgery: what have we learned from reoperations?

HYPOTHESIS: Factors that lead to failures in antireflux procedures can be identified, and dealing with them at the initial operation may decrease the number of such failures. DESIGN: Analysis of symptoms, 24-hour esophageal pH monitoring, manometry, upper gastrointestinal tract radiographs, and correlation with operative anatomic findings. SETTING: University referral center. PATIENTS: Forty-eight patients who previously underwent antireflux surgery (Nissen fundoplication, 29; Hill fundoplication, 7; Angelchik prosthesis, 1; multiple, 5; unknown, 6) and had symptoms of foregut disease. MAIN OUTCOME MEASURES: Determination of the cause of failure of previous operations and identification of factors that may prevent recurrence. RESULTS: Fourteen patients (29%) presented with symptoms of an incompetent cardia (heartburn and regurgitation), 15 patients (31%) presented with symptoms of defective esophageal emptying (dysphagia), 13 (27%) had symptoms of both, and 6 (13%) had other symptoms. All patients were initially treated medically and/or with dilation. A reoperation was performed in 31 patients (65%) whose symptoms persisted. Reoperation was completed laparoscopically in 28 patients (90%). At reoperation we identified 3 main types of failure: type 1, patients in whom the gastroesophageal junction was herniated through the hiatus, either with the wrap (IA) or without it (IB). There were 13 patients (43%) classified as having type IA, and 5 patients (16%) classified as having type IB. Type II failure involved a paraesophageal component resulting from a redundant wrap in 5 patients (16%), and type III involved a malformation (defective position or construction) of the wrap in 2 patients (6%). The remainder had a failed Hill fundoplication (3 patients), a herniated Angelchik prosthesis (1 patient), and normal postoperative anatomy (2 patients). CONCLUSIONS: Failure of the crural closure and malformation of the wrap are the main reasons for failure of antireflux procedures. Use of proper surgical techniques including meticulous closure of the crura and appropriate construction and fixation of the wrap at the first operation will help prevent recurrence.