The management of the surgical complications of HELLP syndrome.

INTRODUCTION: Complications from HELLP (Haemolysis, Elevated Liver enzymes and Low Platelet) syndrome may present as an emergency to any surgeon. We review the ten-year experience of a tertiary hepatobiliary centre managing HELLP patients. Three selected cases are described to highlight our management strategy and a systematic review of the recent literature is presented. METHODS: All patients with HELLP syndrome were identified from a prospectively maintained database and their details collated. Subsequently, a detailed search of PubMed was carried out to identify all case series of HELLP syndrome in the literature in the English language since 1999. RESULTS: On review of 1,002 cases, 10 patients were identified with surgical complications of HELLP syndrome. Seven of these patients had a significant liver injury. Only three of these required surgical intervention for liver injury although four other patients required surgical intervention for other complications. There was no maternal mortality in this series. Review of the literature identified 49 cases in 31 publications. The management approaches of these patients were compared with ours. CONCLUSIONS: We have presented a large series of patients with surgical complications resulting from HELLP syndrome managed without maternal mortality. This review has confirmed that haemodynamically stable patients with HELLP syndrome associated hepatic rupture can be conservatively treated successfully. However, in unstable patients, perihepatic packing and transfer to a specialist liver unit is recommended.

Comparable outcomes in donation after cardiac death and donation after brainstem death: a matched analysis of renal transplants.

Donation after cardiac death (DCD) donors provide a valuable source of grafts for renal transplantation. They are exposed to an initial warm ischemic insult, which can affect early function. We sought to compare our initial DCD experience in renal transplantation with a case-matched donation after brain death (DBD) cohort from the same period. We included all DCD transplantations in the first 5 years of the program. A control DBD group was matched with a variety of donor and recipient factors. We demonstrated a significantly increased early dysfunction (DGF and primary nonfunction). DCD graft function was poorer than the DBD equivalent at 1- and 3-years. However, medium-term recipient and graft outcomes were comparable. DCD grafts continue to play a vital role in renal transplantation despite evidence of early graft dysfunction.

Predicting donor asystole following withdrawal of treatment in donation after cardiac death.

Donation after cardiac death donation allows donor pool expansion. The period between withdrawal of treatment and donor a systole is extremely variable; its prolongation often results in unsuccessful organ procurement. We sought to assess a variety of donor variables to determine whether they predicted successful organ retrieval. We included all Donation after Cardiac Death (DCD) retrievals between 2002 and 2009, which were grouped as successful (n = 104) versus unsuccessful (n = 42). Factors that predicted unsuccessful organ procurement included older donor age, donor history of hypertension, higher at withdrawal, and absence of inotropic support. On multivariate analysis, mean arterial pressure retained its significance. Prediction of withdrawal-to-asystole time is complex, but our analysis suggested that donor blood pressure at withdrawal is an important predictor of whether retrieval would be successful.

Impact of cold ischemia on renal transplant outcomes following donation after cardiac death.

Donation after cardiac death (DCD) provides grafts in renal transplantation but is associated with increased early graft dysfunction. Cold ischemia time (CIT) is a factor that is thought to affect outcomes in renal transplantation. We sought to assess the impact of the length of CIT among our DCD cohort of renal transplants performed between April 2002 and December 2009. Since the median CIT was 15.5 hours, we formed two groups CIT < 15.5 (n = 100) and CIT > 15.5 hr (n = 98). We demonstrated an increased incidence of DGF among the extended CIT group, but the long outcomes and the mean graft function were otherwise comparable. In conclusion, CIT affects early graft function; every effort should be made to minimize it in renal transplantation using DCD kidneys.

Sequential transplant of paired kidneys following donation after cardiac death: impact of longer cold ischemia time on the second kidney on graft and patient outcome.

The United Kingdom has no national sharing scheme for kidneys received from donation after cardiac death (DCD). Therefore, both kidneys retrieved by a transplant team are implanted at a single unit, often sequentially. This study analyzes the impact of a prolonged cold ischaemia time on the second transplanted kidney and the effects on short-term and long-term outcomes in all our DCD renal implants from 2002 to 2009. Cold ischaemia time was significantly longer with the second kidney (P = .04) as was delayed graft function (P = .02). Acute rejection was increased in the first transplanted kidney (P < .001). Five-year patient survival was comparable between groups, but 5-year graft survival was higher in the second transplanted group (P = .04). The results confirm that, provided recipient centers are willing to accept higher initial rates of delayed graft function, it is acceptable to transplant DCD grafts sequentially without jeopardizing long-term graft or recipient outcome.

Renal transplantation following donation after cardiac death: impact of duration from withdrawal to asystole.

Donation after cardiac death (DCD) allows for expansion of the donor pool, however, the process for DCD donation can lead to a donor's physiological instability before asystole. This may have a detrimental effect on graft and patient outcomes. We analyzed all 201 DCD donations at our unit from 2002 to 2009 and compared short versus long durations to asystole around the median time (20 min). Delayed graft function was comparable between the groups (P = .13), primary nonfunction was increased in the long duration to asystole group (P < .0001), and acute rejection was increased in the short duration group (P < .001). Five year patient survival was comparable (P = .6). In conclusion, long duration asystole may have an immediate effect on graft survival, but it has no overall detrimental effect on longer-term outcomes. Further studies are required to investigate the acceptable time to wait from withdrawal to asystole.

The impact of postoperative infection on long-term outcomes in liver transplantation.

INTRODUCTION: Postoperative infection (POI) prolongs inpatient stay, delays return to normal activity, and may be detrimental to long-term survival after cancer resections. This study sought to identify the impact of postoperative infection on liver transplantation outcomes. METHODS: We analyzed our prospective database of 910 adult patients who underwent liver transplantation between 2000 and 2010 in a single UK center. POI was defined as pyrexia plus positive cultures from blood, sputum, urine, wound, or ascitic fluid. Patient demographic features and perioperative variables were analyzed for their effects on POI. The impacts of POI on overall survival (OS) and graft survival were analyzed using Kaplan-Meier curves with log-rank tests for significance, before entry into a multivariate regression analysis. We analyzed the effects of POI on the length of hospital stay (LOS) and the incidence of acute rejection episodes and readmissions within 1 year as secondary outcomes. RESULTS: Patients who developed a postoperative chest or wound infection showed poorer OS at a mean of 7.0 versus 8.8 years (P = .009) and 7.0 versus 8.8 years (P = .003), respectively. Infection in blood, ascitic fluid, or urine showed no significant impact on survival. LOS was significantly increased among patients with a wound (median 21 vs 17 days, P = .011), a sputum (median 24 vs 17 days, P < .001), or a blood infection (median 32 vs 17 days, P < .001). Higher rates of intraoperative blood transfusion were observed among subjects who developed a chest or a wound infection. There was no difference in other variables between those who did versus did not develop an infection. Upon multivariate analysis, wound infection was the strongest independent predictor of OS (P = .007). CONCLUSION: We demonstrated that wound or chest infections were associated with poorer OS. More aggressive prophylactic and/or therapeutic interventions targeting specific sites of infection may represent a simple and cost-effective measure to reduce hospital stay and improve OS.

Transplantation of adult-sized kidneys in low-weight pediatric recipients achieves short-term outcomes comparable to size-matched grafts.

Low-weight pediatric recipients are disadvantaged by scarcity of size-matched donors. ASK have been successfully used for pediatric recipients. We report the results of renal transplantation using ASK in low-weight pediatric recipients and compare outcomes in weight-matched and unmatched donor-recipient pairs. The outcomes of renal transplants using ASK grafts in low-weight (<20 kg) recipients from a single center over a 10-yr period were reviewed. Two groups, comprising recipients of grafts from weight-matched and mismatched donors, were compared. Primary outcome was one-yr graft survival. Secondary outcomes were one- and two-yr calculated eGFR, changes in recipient body weight, perioperative cardiovascular stability, rates of AR and DGF. Twenty-three low-weight recipients were transplanted. Eleven received ASK grafts from high-weight donors and 12 grafts from low-weight donors. One patient in each group had early graft loss. No significant difference was observed in rates of DGF, AR, one-yr graft or patient survival and perioperative cardiovascular parameters. ASK with considerable donor:recipient weight discrepancies can be safely transplanted into small pediatric recipients with comparable outcomes to grafts with less weight discrepancy.

Triangular and self-triangulating cavocavostomy for orthotopic liver transplantation without posterior suture lines: a modified surgical technique.

A modified caval preservation technique with the potential for decreased incidence of venous outflow obstruction and haemorrhage.

Ureteric complications of renal transplantation: the impact of the double J stent and the anterior extravesical ureteroneocystostomy.

The urological complications of renal transplantation are well documented. In 1990, our experience of 507 consecutive renal transplants using the Leadbetter-Politano technique, which was unsplinted in the vast majority of patients, had a ureteric complication rate of 7.7%. Here, we report the long-term incidence and management of our ureteric complications in 1186 consecutive renal transplants done over the following 11 years using an extravesical onlay stented ureteroneocystostomy. We report a considerable reduction in the urological complications of renal transplantation to 3.8%. Furthermore, we were able to use percutaneous radiological techniques to salvage the majority (84.7%) of ureteric complications. Recourse to surgery was required rarely but enabled salvage of all treatment failures.

Progress in living donor liver transplantation.

Living donor liver transplantation (LDLT) has the capacity to reduce the current discrepancy between the number of patients on the transplant waiting list and the number of available organ donors. For pediatric patients, LDLT has clearly reduced the number of waiting list deaths, providing compelling evidence for an increase in LDLT programs. This review discusses many of the recent advances in LDLT.

Pharmacologic monitoring and outcomes of cyclosporine.

Cyclosporine was introduced into clinical transplantation as an immunosuppressive agent 20 years ago. Cyclosporine is a critical dose drug with a narrow therapeutic index and requires monitoring through blood levels to avoid rejection through underexposure or toxicity through overexposure. Traditional monitoring was by measuring the trough level taken 12 hours after an oral dose, but the results correlated poorly with drug dose, toxicity, and outcome. Monitoring cyclosporine by calculating total drug exposure correlated better with outcome but was time consuming and labour intensive. An abbreviated measure of exposure over the first 4 hours after administration was found to predict outcome and allow dose adjustment. This was based on the observation that the majority of variability in the absorption of the drug was during the first 4 hours after administration--the absorption phase--and this was not reflected in the trough level. Cyclosporine exerts its immunosuppressive action by inhibition of calcineurin. The peak of this inhibition occurs during the peak concentration of the drug, which occurs during the absorption phase. On the basis of the fact that as a single time point the 2-hour level was the best surrogate marker of the maximum level, a strategy for monitoring by 2-hour levels (C2) evolved. It was shown in all organ types to be the best single point predictor of exposure and has led to an improvement in outcome both in de novo and in maintenance transplant patients.

Management of blunt liver trauma in a tertiary referral centre.

BACKGROUND: In recent years, several reports from North America have highlighted the success of conservative treatment in patients with blunt liver trauma. The aim of this study was to identify trends in the management of blunt liver trauma in a UK tertiary referral centre dealing with both adults and children over a 10-year period. METHODS: A retrospective case note review was performed on 71 consecutive patients (58 male patients) of median age 25 years admitted to the hepatobiliary unit over the 10-year period from 1992 to 2001 with blunt liver trauma. Data relating to referring source, severity of liver injury, initial and subsequent management and outcome were collected using a standard pro forma. RESULTS: Sixty-two of the 71 patients were referred from other surgical units. Of these, 14 had undergone laparotomy at the referring hospital, with ten having perihepatic packing; the other 48 were managed conservatively. Of the 62 patients transferred to the authors' unit, 12 required surgical intervention for the liver injury. The mean number of patients with blunt liver trauma increased between the first second 5-year periods, from 3.2 to 11.0 patients per year. There was a significant reduction in the proportion of patients requiring surgery for the liver injury in both the authors' unit (from seven of 16 patients in 1992-1996 to seven of 55 in 1997-2001; P = 0.017, chi(2) test) and referring hospitals (from six of 12 to eight of 50; P = 0.014, chi(2) test). The reduction in the mortality rate, from two (12.5 per cent) of 16 in the first period to four (7.3 per cent) of 55 in the second, was not significant (P = 0.880, chi(2) test). CONCLUSION: This study demonstrated a marked increase in the number of patients with blunt liver trauma referred to a regional hepatobiliary centre in recent years. It has confirmed that the majority of such patients can be treated successfully without surgery.

Non-operative management of pyogenic liver abscess.

BACKGROUND: Liver abscess is a serious disease traditionally managed by open drainage. The advances in interventional radiology over the last two decades have allowed a change in approach to this condition. We have reviewed our experience in managing liver abscess over the last 7 years. METHODS: Details of all patients admitted with liver abscess between 1995 and 2002 were prospectively entered onto our database. A review was performed to document the use of imaging and drainage techniques. Aetiology, morbidity, mortality and duration of hospital stay were recorded. RESULTS: Forty-two patients (median age 53 [22-85] years; M:F 18:24) were admitted with liver abscess (multiple abscess 20); 19 cases were of portal tract origin, 16 cases were of biliary tract origin and 7 cases were spontaneous. Forty-one patients were managed non-operatively, all received antibiotics (cephalosporins 76%, metronidazole 88%, quinolones 33%). Diagnosis was made on ultrasound scan (22) or CT (20). Five patients were managed with antibiotics alone. Fifteen patients were managed initially with percutaneous aspiration and five subsequently required percutaneous drainage. Twenty-one patients had primary percutaneous drainage, nine requiring a further procedure (aspiration 3, drainage 6). One patient underwent hepatic resection. Median hospital stay was 16 (6-35) days. There was one death, but no procedure-related morbidity. DISCUSSION: Non-operative management of solitary and multiple liver abscesses is safe and effective.

Improved clinical outcomes for liver transplant recipients using cyclosporine monitoring based on 2-hr post-dose levels (C2).

BACKGROUND: A prospective, open-label, study was conducted at 29 centers in 9 countries, involving 307 de novo liver transplant patients to compare the clinical usefulness of monitoring 2-hr post-dose cyclosporine (CsA) levels (C2) with conventional trough cyclosporine blood levels (pre-dose) (C0). METHODS: Neoral oral therapy was initiated at 15 mg/kg/day and dose adjusted according to predetermined C2 or C0 target level ranges. The primary efficacy variable was treatment failure at 3 months, where evaluation was based on a composite endpoint of biopsy-proven rejection, treatment for rejection, graft loss, death, or premature withdrawal/discontinuation from the study. RESULTS: Baseline characteristics were similar between groups. Graft loss at 12 weeks (retransplantation or death) occurred in 6.8% C2 and in 7.0% C0 patients. Overall incidence of treated acute rejection was lower for C2 (23.6%) than C0 patients (31.6%) (P=0.144, Cochran-Mantel-Haenszel [CMH] test). In hepatitis C virus (HCV)-negative patients, the incidence of rejection in the C2 group was significantly less than in the C0 group (21.2% vs. 33.0%; P<0.05), whereas in HCV-positive patients, the rejection rate was similar in both groups (26.7% for C2 group vs. 27.3% for C0 group: P=0.81). C2 patients (n=16) who reached minimum target CsA levels by day 3 had a notably low incidence of rejection (12.5%), whereas there was no difference in the incidence of rejection in C0 patients, irrespective of time to reach target level. For biopsy-proven acute rejections (21.6% for C2 vs. 30.4% for C0), the incidence of moderate and severe histological diagnosis was significantly lower in the C2 group than in the C0 group (47% vs. 73%; P=0.01). Safety profiles were similar between the two groups, with few patient withdrawals due to adverse events (9.5% for C2; 7.0% for C0). CONCLUSIONS: Using C2 monitoring, the overall incidence of acute cellular rejection was lower compared with the C0 group, and the histological severity of acute rejections was shown to be significantly milder for the C2 group, indicative of good long-term prognosis. These data demonstrate that the use of C2 monitoring is superior to C0 and results in a reduction in the incidence and severity of acute cellular rejection without detrimental effect on the drug safety profile.

Laser Doppler flowmetry is useful in the clinical management of small bowel transplantation. The Liver Transplant Group.

OBJECTIVE: Laser Doppler flowmetry (LDF) has been used as a research tool to measure splanchnic perfusion. In this report, we aim to demonstrate the clinical value of this technique in perioperative monitoring of transplanted small bowel. METHODS: A 24 year old man underwent small bowel transplantation using a previously described technique. Microvascular blood flow in the transplanted bowel was measured using an LDF splanchnic probe. Postoperatively this was applied to the stoma facilitating direct measurements of graft mucosal flow. Measurements (perfusion units (PU)) were documented prior to implantation, post-reperfusion, postoperatively, during graft ischaemia, and in response to therapeutic interventions (dopexamine and phenylephrine infusions). RESULTS: Prior to transplantation, biological zero was established. Flow at five, 15, and 60 minutes after reperfusion was 74 (1.9) PU, 87.5 (3.3) PU, and 141.5 (2.5) PU, respectively. Postoperative mucosal flow was 141.6 (2.9) PU. Subsequent LDF measurement detected absence of flow even though clinical signs suggested only moderate reduction. This was confirmed on surgical re-exploration and facilitated prompt resection of a non-viable segment. Fluid and dopexamine administration resulted in a dose dependent improvement in flow, independent of blood pressure. Addition of phenylephrine increased total mucosal flow and unmasked a cyclical component. CONCLUSION: This case demonstrates the clinical value of LDF as an "alarm" to indicate graft perfusion failure and as a monitor for therapeutic interventions. Phenylephrine and dopexamine may both be of value in improving mucosal flow in the transplanted small bowel.

Small bowel transplantation.

The development of small bowel transplantation has long been hindered by the immunological and infectious barriers peculiar to the small bowel. Gradual progress has been achieved during the past decade with the use of tacrolimus and the availability of better anti-infection prophylaxis. The current status of small bowel transplantation as a life-saving option for patients failing on total parenteral nutrition and those who have developed irreversible liver failure is undisputed. Small bowel transplantation can be performed as either an intestine-only graft or as part of a composite graft with the liver and, on occasion, other organs. The various techniques of donor and recipient operations are relatively standardized. Despite the progress made, the most common causes of death and graft loss continue to be sepsis, rejection, and lymphomas. Further progress can be achieved by development of more effective immunosuppressive and immunomodulatory strategies. The role of inducing chimerism by adjuvant donor-specific bone marrow transfusions to promote graft tolerance is uncertain. Until the mortality and graft losses are further reduced, the role of small bowel transplantation will be limited to a salvage procedure for failure of total parenteral nutrition rather than a primary treatment of intestinal failure.