Role of Liver Transplantation in Bilio-Vascular Liver Injury After Cholecystectomy.

BACKGROUND: The aim of this study was to report 2 cases of liver transplantation (LT) for iatrogenic bile-vascular injury (BVI) sustained during cholecystectomy and to review the literature for LT after cholecystectomy. METHODS: Between March 2001 and July 2013, within our institution, 12 patients were treated after cholecystectomy, 3 of 12 received LT, 1 for acute de-compensation in a cirrhotic patient and 2 after iatrogenic lesions. RESULTS: The majority of iatrogenic injury occurred during video-laparocholecystectomy (63,6%; 7/11). Three patients of 12 (25%) received LT: the first patient developed acute de-compensation in chronic and after liver failure. The second patient developed recurrent cholangitis and secondary biliary cirrhosis. The third patient had undergone emergency hepatectomy because of bleeding and subsequent total hepatectomy with porto-caval shunt. Five of 12 (42%) patients were treated with bilio-digestive anastomosis: 1 patient with direct repair on T-tube; 2 patients (17%) with arterial vascular lesion requiring surgical treatment; and 1 patient treated with medical therapy. No deaths occurred. The post-operative morbidity included 1 re-intervention, 3 recurrent cholangitis, 1 anastomotic biliary stricture, 1 anastomotic bile leak, and cholestasis in 3 patients. The overall hospital stays were higher after LT. Median follow-up was 8.25 years (range, 2-14). CONCLUSIONS: The management of iatrogenic injury during cholecystectomy depends on the time of recognition, extent of injury, experience of the surgeon, and the patient's general condition. If safe repair is possible, BVI should be treated promptly, otherwise all patients should be treated in an experienced center.

Predictability and survival in liver replantransplantation: monocentric experience.

Liver retransplantation is the only treatment for patients with hepatic graft failure. Due to the shortage of organs, it is essential to optimize its use. Between 1998-2010, our center performed retransplantations on 48 (12.8%) patients (re-OLT). The data are compared with those for a group of 374 patients who did not receive retransplantations (NO re-OLT). The re-OLT vs NO re-OLT groups did not significantly differ in mean age of recipients (47 vs 51 years), indications for transplantation (hepatitis C virus cirrhosis 54% vs 56%, alcoholic cirrhosis 25% vs 17%, hepatocellular carcinoma 14% vs 22%), mean Model for End-stage Liver Disease (25 vs 20), mean total cold ischemia time (385 vs 379 minutes), or mean age of donors (52 vs 49 years). The main causes of retransplantation were primary graft nonfunction (64%), arterial thrombosis (8%), biliary complications (6%), and hepatitis C virus recurrence (4%). The difference in overall patient survival was not statistically significant. The patient's survival at 1, 3, 5, and 10 years for RE-OLT vs NO-reOLT was 56% vs 63%, 53% vs 60%, 46% vs 57%, and 44% vs 53%, respectively. Multivariate analysis identified Model for End-stage Liver Disease≥23 as a predictor factor of retransplantation (P=.04). Other variables predicting outcome included age of donors (≥65 years vs younger group), age of recipients (≥50 years vs younger group), cold ischemia (≥600 vs <600 minutes), and transplantation indications (hepatitis C virus, hepatitis B virus, alcohol, and others). The retransplantation performed between 8-15 days appeared to have worse results than those in other periods (0-7 days, 16-30 days, 1-6 months, >6 months). The incidence of re-OLT in the series (12.8%) was comparable to that in the literature, and primary graft nonfunction in the study represents the main cause of retransplantation. Our analysis showed that the indication of the first transplant and the age of the donor were not risk factors for re-OLT. Liver retransplantation is a concrete alternative lifesaver for patients with graft failure.

Nocardiosis in a kidney-pancreas transplant.

34-year-old man with chronic renal and pancreas failure in complicated diabetic disease received a kidney-pancreas transplantation. On the 32nd postoperative day, an acute kidney rejection occurred and resolved with OKT3 therapy. The patient also presented refractory urinary infection by E. Fecalis and M. Morganii, and a focal bronchopneumonia in the right-basal lobe resolved with elective chemotherapy. During the 50th post-operative day, an intense soft tissue inflammation localized in the first left metatarsal-phalangeal articulation occurred (Figure 1) followed by an abscess with a cutaneous fistula and extension to the almost totality of foot area. The radiological exam revealed a small osteo-lacunar image localized in the proximal phalanx head of the first finger foot. From the cultural examination of the purulent material, N. Asteroides was identified. An amoxicillin-based treatment was started and continued for three months, with the complete resolution of infection This case is reported for its rarity in our casuistry, and for its difficult differential diagnosis with other potentially serious infections.

Infections after simultaneous pancreas and kidney transplantation: a single-center experience.

Simultaneous pancreas-kidney transplantation (SPKT) is now an accepted therapy for patients with insulin-dependent diabetes mellitus. However, SPKT has an high rate of morbidity and mortality, mainly for infection. From October 1986 to June 2008, in our center 54 patients (18 female; 36 male) affected by diabetes and end-stage renal disease underwent SPKT. The mean duration of diabetes mellitus was 25 +/- 4 years. Only 4 patients had not been treated by dialysis before SPKT. Three operative techniques were used: duct injection (n = 5), bladder diversion (n = 14), and enteric diversion (n = 39). The kidneys were always placed into the left retroperitoneal space. The pancreas was placed extraperitoneally in 5 patients. Thirty-four recipients are alive, including 30 with function of both grafts. Six patients died during the first year after transplantation. Infectious complications were the main cause of death in 3 subjects whereas 98 infections were diagnosed in 51 patients. All patients were treated with immunosuppressive agents: steroids associated with calcineurin inhibitors and mycophenolic acid, or azathioprine. Antibody induction was used in 41 patients with anti-interleukin-2 monoclonal antibody or antithymocyte globulin. We detected 41 episodes of cytomegalovirus infection: systemic (n = 38), bladder (n = 2), and duodenal (n = 1). The 51 bacterial infections were systemic: (n = 10); urinary tract: (n = 22); pulmonary (n = 11); wound (n = 5); intestinal (n = 3). The 5 fungal infections were gastrointestinal tract (n = 3); and arteritis (n = 2). Some patients experienced more than 1 type of infection. The predominant etiology of the systemic infections was bacterial. In conclusion, infectious complications were the main causes of morbidity after SPKT. An early diagnosis of infection, particularly fungal complications, is essential. We recommend administration of broad-spectrum prophylactic antibiotics, antifungals, and antiviral agents.

Renal transplant compartment syndrome: a case report.

An unusual case of early double kidney transplant dysfunction due to abdominal compartment syndrome is herein reported. A 62-year-old woman on peritoneal dialysis underwent dual kidney transplantation. The grafts were positioned extraperitoneally in both iliac possae using standard techniques. Surgical procedures and immediate postoperative period were uneventful. The urine output was immediate and the creatinine decreased, but in a few days she developed severe ascites with reduced urine output, increased creatinine, and progressive changes on Doppler ultrasound. The patient underwent paracentesis: the kidney function recovered as well as the Doppler ultrasound. Kidney biopsy was negative for rejection or renal pathology. Graft dysfunction was related to the presence of ascites. A catheter inserted in the abdomen measured intra-abdominal pressure (IAP) of 14 mm Hg. IAP correlated with renal function showing that IAP probably explained renal flow modifications.

Laparoscopic palliation of unresectable pancreatic cancers: preliminary results.

OBJECTIVE: To assess the feasibility of laparoscopic gastroenteric and cholecystenteric bypass procedures for palliation of inoperable cancer of the pancreas. DESIGN: Prospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 6 patients (4 men and 2 women, range 53-72 years, median 64) who presented between July 1995 and April 1997 with inoperable pancreatic cancer. INTERVENTIONS: Laparoscopic gastroenterostomy for duodenal obstruction. Four patients had already had endoscopic biliary decompression. 2 patients also had laparoscopic cholecystojejunostomy for biliary obstruction at the time of the laparoscopic gastroenterostomy. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The procedure was completed laparoscopically in all patients. There was no perioperative mortality and morbidity was low (1 bleeding from the drain and 1 paralytic ileus). The median postoperative stay was 4.5 days (range 4-6). CONCLUSIONS: Laparoscopic gastroenterostomy, together with cholecystojejunostomy in selected patients with inoperable pancreatic cancer, offers a less invasive alternative to open surgery with a short hospital stay and rapid return to normal activity.

Laparoscopic gastrojejunostomy in the palliation of pancreatic cancer: reflections on the preliminary results.

The aim of this study was to assess the feasibility of laparoscopic gastroenteric and cholecystenteric bypass procedures for palliation of inoperable cancer of the pancreas. Between July 1994 and January 1996, five patients underwent laparoscopic gastroenterostomy for duodenal obstruction due to pancreatic cancer. There were four men and one woman, ranging in age from 53 to 72 years (median 63). Four patients already had endoscopic biliary decompression. One patient underwent laparoscopic cholecystojejunostomy for biliary obstruction at the time of the laparoscopic gastroenterostomy. The procedure was completed laparoscopically in all patients. There was no perioperative mortality, and the morbidity was low. The median post-operative stay was 4 days (range, 4-6). Laparoscopic gastroenterostomy associated with cholecystojejunostomy in selected cases offers a less invasive alternative than open surgery, with a shorter hospital stay and more rapid return to normal activity.

[Intestinal infarct: a critical review of the cases observed in the decade of 1981-1991]. / L'infarto intestinale: revisione critica dei casi osservati nel decennio 1981-1991.

The authors consider the causes of bowel infarction and report the up-to-date diagnostic tools for optional treatment. They verify management and outcome of 97 cases treated during the last decade.

[Original method of the treatment of achalasic megaesophagus with EEA stapler]. / Originale metodica di trattamento del megaesofago acalasico con EEA stapler.

Esophageal sutures require the same general criteria applied for the realization of an intestinal suture. The lack of a serous membrane and the particular vascularization of the organ, though, make this portion of the gastroenteric tract very prone to serious complications. Undoubtedly, the introduction of new systems of suture renders easier, faster and more efficacious the work of the surgeon. In particular, the Authors stress the advantages that staplers can offer for the treatment of achalasic megaesophagus.