A. Garcia-Sesma

Liver transplantation and transjugular intrahepatic portosystemic shunt

OBJECTIVE Describe the results of liver transplantation after installing Transjugular Intrahepatic Portosystemic Shunt (TIPS) and compare them with those of a control group in a comparative, longitudinal, retrospective study. MATERIALS AND METHODS Between April 1986 and October 2002, we performed 875 liver transplantations. Between January 1996 and October 2002, 26 transplantations were performed on TIPS carriers. This group was compared with a control cohort of 50 randomly selected patients who underwent transplantation in this period (non-TIPS carriers). Both groups were homogeneous with no significant differences between age, sex United Network for Organ Sharing (UNOS) score, Child stage, or etiology. RESULTS Actuarial survival rates at 1 and 3 years: TIPS group 96.15% and 89.29% versus control cohort 87.8% and 81%, respectively. In 73.9%, the TIPS was clearly effective; in 88.9%, a postoperative Doppler revealed normal flow. There were no statistically significant differences compared with time on the waiting list for transplant, duration of the operation, ischemia times, intraoperative consumption of hemoderivates, vascular or nonvascular postoperative complications, duration of stay in the intensive care unit, hospital stay, or retransplantation rate. CONCLUSIONS In our experience, TIPS insertion does not affect either the intraoperative or postoperative evolution and is not associated with an increased time on the liver transplant waiting list.

Conversion from bladder to enteric drainage for complications after pancreas transplantation.

OBJECTIVE Bladder drainage (BD) of exocrine secretions is associated with urological and pancreatitis complications. Herein we have analyzed our experience with conversion from BD to enteric drainage (ED). PATIENTS AND METHODS From March 1995 to September 2008, 118 patients underwent pancreas transplantation. There were 68 men and 50 women of a overall mean age at transplantation of 37.8 years. There were 66 patients with bladder drainage (BD) and 52 with enteric drainage (ED). RESULTS Eight of 66 BD pancreas recipients (12.1%) underwent ED conversion. The mean time from pancreas transplantation to ED conversion was 29.3 +/- 30.6 months (range, 1-91 months). The major indications for conversion were recurrent reflux pancreatitis and chronic urinary tract infections in 7 patients; metabolic acidosis in 8; urethritis with severe perineoscrotal swelling in 1; and duodenocystostomy leak in 1. A comparative analysis of converted ED and not converted BD showed only a significantly prolonged period in the intensive care unit for patients who needed ED conversion (89 vs 47 hours; P < .01). Only 1 patient showed a duodenoenteric leak and peritonitis after conversion that required removal of the pancreas graft. The remaining 7 patients did not develop any postoperative complications and are currently well, showing normal pancreas graft function at a mean follow-up of 51.7 months after ED conversion. Patient and graft survivals were 100% and 87.5%, respectively. After ED conversion all urological complications disappeared; patients discontinued the use of oral bicarbonate. CONCLUSION ED conversion in pancreas transplant recipients with urological and reflux pancreatitis complications was a safe, effective procedure.

Kaposi's visceral sarcoma in liver transplant recipients.

We report three cases of Kaposis sarcoma after orthotopic liver transplantation performed for cirrhosis related to hepatitis C virus (one case), ethanol (one case), or both (one case). All patients displayed disease within the first year after liver transplantation, and only in one case was the diagnosis obtained before the patient died. All three patients were on tacrolimus-steroid therapy, and in one case mycophenolate mofetil was added to treat acute persistent rejection.

Incidence, risk factors and outcome of de novo tumors in liver transplant recipients focusing on alcoholic cirrhosis

Orthotopic liver transplantation (OLT) is an established life-saving procedure for alcoholic cirrhotic (AC) patients, but the incidence of de novo tumors ranges between 2.6% and 15.7% and is significantly increased in comparison with patients who undergo OLT for other etiologies. Tobacco, a known carcinogen, has been reported to be between 52% and 83.3% in AC patients before OLT. Other risk factors that contribute to the development of malignancies are dose-dependent immunosuppression, advanced age, viral infections, sun exposure, and premalignant lesions (inflammatory bowel disease, Barretts esophagus). A significantly more frequent incidence of upper aerodigestive (UAD) tract, lung, skin, and kidney-bladder tumors has been found in OLT recipients for AC in comparison with other etiologies. Liver transplant recipients who develop de novo non-skin tumors have a decreased long-term survival rate compared with controls. This significantly lower survival rate is more evident in AC recipients who develop UAD tract or lung tumors after OLT mainly because the diagnosis is usually performed at an advanced stage. All transplant candidates, especially AC patients, should be encouraged to cease smoking and alcohol consumption in the pre- and post-OLT periods, use skin protection, avoid sun exposure and over-immunosuppression, and have a yearly otopharyngolaryngeal exploration and chest computed tomography scan in order to prevent or reduce the incidence of de novo malignancies. Although still under investigation, substitution of calcineurin inhibitors for sirolimus or everolimus may reduce the incidence of de novo tumors after OLT.

Renal failure associated with intestinal transplantation: our experience in Spain.

BACKGROUND Renal failure (RF) is a frequent complication in non-renal solid organ transplants. In the present study, we analyze our experience with intestinal transplants (ITx). METHODS Between 2004 and 2012, we performed 21 ITx in 19 adult patients. Alemtuzumab was used as an induction agent followed by tacrolimus. Renal function was assessed before ITx and during the perioperative period. RESULTS The main cause for transplants was non-resectable desmoids tumors (33.3%), followed by vascular thrombosis (19%) and others. Medical complications were frequent, especially infectious diseases, which were the most common (51%). Surgical complications were also frequent, but most of them (>50%) were mild but leading to a great number of re-operations and prolonged stays in hospital. Acute rejection is very frequent (66.6%) but mild in more than 70% of the cases. Finally, RF was very frequent (68.4%; 13/19 patients) and accounted for 15.6% of all medical complications. Causes were multiple. One patient is awaiting a kidney transplant, but no other patients need renal replacement therapy at the moment. Ileostomy closure was performed in 5 of 12 patients alive, showing improved renal function in 3 of them. CONCLUSIONS RF is a problem in ITx and is always multifactorial. Increases in hospital stay, higher morbidity and is a cause for hospital readmission. Almost all patients had an impaired renal function when discharged. Immunosuppressants and ileostomy closure as soon as possible might prevent RF.

Long-term Outcomes Using Uncontrolled Donors after Circulatory Death (uDCD) for Liver Transplantation. A 10-Year Single Center Experience

Introduction The good results obtained along the years with liver transplantation (LT) have led to an increasing number of candidates on the waiting list, while the number of liver grafts is not enough to attend all patients who need an OLT. That is because many LT teams have proposed to expand the number of available grafts using livers from donors after circulatory death (DCD). The aim of this study is to analyse the use of liver grafts from type 2 uDCD donors for LT, comparing post-OLT complications and recipient outcome at 10-year follow-up with a group of patients who received liver grafts from donors after brain death (DBD). To our knowledge this series represents the largest experience using this kind of donors. Materials and Methods Between January 2006 and December 2016 we performed 783 LT in adult recipients. Seventy-five LT were performed using grafts from uDCD (Maastricht type 2), and 265 LT using livers from DBD donors. We compared the results using uDCD donors vs. DBD donors in adult recipients. Results The mean age of recipients of uDCD donors was 58.8±8 years vs. 54.7±10 (p=0.000) in DBD donors. Comparing both groups of recipients, there were no statistically significant differences in relation with gender, body mass index, Child-Pugh, MELD score, LT indication, and pre-LT laboratory tests. Mean age of uDCD donors was 41.7±10 years vs. 47.8±15 of DBD donors (p=0.001), with a higher frequency use of vasopressors in uDCD group (100%) vs. 48.3% in DBD (p=0.001), and higher significantly levels of AST prior to donation. No differences were found with respect to the presence of esteatosis, preservation injury, and cold ischemia time. Mean warm ischemia time was significantly lower in recipients of uDCD donors: 62±14 min in uDCD vs 70 ±36 in DBD (p=0.010). The units of transfused hemoderivates (packed red blood cells, fresh frozen plasma, platelets and fibrinogen) was significantly higher in recipients of uDCD than in recipients of DBD donors. Primary non-function of liver graft was significantly higher in uDCD group: 8.1% vs 2.1% in DBD group (p=0.031). Retransplant rate was also higher in recipients of uDCD donors: 12% vs. 4.6% in DBD (0.028). Moreover, ischemic cholangiopathy was significantly more frequent in uDCD: 31.1% vs. 5.6% in recipients of DBD liver donors (p=0.000). Patient survival at 1, 3 and 5-year was in recipients of uDCD donors was 81.3%, 70.2% and 68.6%, respectively, while in recipients of DBD donors was 89%, 83.7% and 78.8% (p=0.070). Graft survival at 1, 3 and 5-year in uDCD group was 72%, 62.2% and 60.7%, vs 87.1%, 81.9% and 76.5%, in DBD (p=0.003). Conclusion Even with the associated higher risk of primary non-function of liver graft and higher risk of ischemic cholangiopathy, liver grafts from uDCD donors type 2 constitute a safe source of grafts for LT.

Morbidly Obese Patients Awaiting Liver Transplantation. Sleeve Gastrectomy: Safety and Efficacy from a Liver Transplant Unit Experience

Background The prevalence of obesity has increased dramatically, even in population awaiting a liver transplantation. Despite their associated complications, we cannot consider morbid obesity any longer as an absolute contraindication to liver transplantation. Dietary approaches alone are usually completely ineffective. Bariatric surgery is the gold-standard treatment for morbid obesity, and can be performed before, during or after transplantation. Materials and Methods At our Liver Transplantation Unit we performed a sleeve gastrectomy in 8 patients with liver cirrhosis due to NASH, alcohol or HCV, by a single surgeon. The Child score was A in 6 patients and B in the remaining 2 patients. Two of our patients had portal hypertension with mild esophageal varices. The procedure was performed laparoscopically in 7 cases (87,5%), and in the other case it was performed by open approach due to portal hypertension and according to patient preferences. Results Patients showed no postoperative morbidity or mortality. Mean postoperative BMI of our patients was 37.4/33.3/30.3 kg/m2 at 3/6/12 months after surgery. Mean %EWL of our patients was 42.9%/62.2%/76.3% at 3/6/12 months. Two of the patients have already undergone a successful liver transplant. Conclusion Bariatric surgery in selected patients with compensated cirrhosis and without significative portal hypertension is reasonable. Therefore, there aren´t clear guidelines on the use of bariatric surgery in patients with cirrhosis. In our experience, the sleeve gastrectomy is safe and effective in the treatment of patients with compensated cirrhosis, and in a short time can improve candidacy in morbidly obese patients awaiting transplantation.

A retrospective analysis of patients with gallbladder cancer: surgical treatment and survival according to tumor stage

INTRODUCTION gallbladder cancer is the most common biliary neoplasm and the sixth most common tumor of the digestive system. The disease has an ominous prognosis, with a 5-year survival rate of approximately 5%. It is usually diagnosed late and surgical resection is the only potential cure. METHODS a retrospective study was carried out in 92 patients with a pathological diagnosis of gallbladder cancer from January 2000 to January 2016. RESULTS the mean age of cases was 72 ± 11 years; 64 subjects were females and 28 were males. Symptoms at admission included abdominal pain (78%), anorexia (77%), nausea (76%) and jaundice (45%). Surgery was indicated in 92 (100%) patients and 59 (64%) underwent a curative/intent resection. The initial surgical procedures included simple cholecystectomy in 69 (75%) cases and extended cholecystectomy in eleven (11%) subjects. Rescue surgery was performed in 15 patients with tumor tissue in the cholecystectomy specimen; ten individuals underwent an R0 curative resection. Adjuvant therapy was administered in 30 (33%) patients. The median survival in our series was 12.5 months, with survival rates of 57%, 30% and 20% at one, three and five years, respectively. CONCLUSION to conclude, surgical treatment with a complete tumor resection should be considered for all patients, provided that their clinical status allows it.

Outcome of patients with hemodialysis or peritoneal dialysis undergoing simultaneous pancreas-kidney transplantation. Comparative study

Controversy remains with regard to the higher risk of intra‐abdominal infections and lower patient and graft survival when peritoneal dialysis (PD) rather than hemodialysis (HD) is used in simultaneous pancreas‐kidney transplantation (SPKT).

Successful Treatment of Ischemic Cholangiopathy in Maastricht Type II Donors after Cardiac Death (DCD) Liver Recipients: 1821

Introduction: The increased number of patients in the waiting list and the donor shortage leads us to consider alternative sources of organs for our liver transplant candidates. One of these organ sources are donors from cardiac death (DCD). An increased incidence of ischemic cholangiopathy (IC) has been reported when these grafts are transplanted on. This complication could lead to severe graft dysfunction or even graft loss. The aim of our study is to analyze the patient and graft outcomes whenever ischemic cholangiopathy is diagnosed and what available treatment options we can offer these patients. Methods: From January 2006 to December 2010, 289 OLT were performed at our hospital. 44 of them (15.2%) were from DCD Maastrich tipe II. The most common cause of end stage liver disease was Hepatitis C, alone or associated with alcohol abuse and/or hepatocellular carcinoma. We defined ischemic cholangiopathy in patients who developed nonanastomotic strictures and dilatations involving the hepatic confluence or the intrahepatic biliary tree, in the absence of arterial thrombosis. The diagnosis was performed on the basis of radiological tests. Liver biopsy was performed in order to confirm it, when necessary. Thus, 14 patients (31.81%) were diagnosed of ischemic cholangiopathy. The average time between transplantation and diagnosis was 6.15 months (± 4.49). Results: The average age of the recipients and donors were 59.14 (± 8.2) and 40.43 (±10.1) years, respectively. 71.4% of our recipients were male. The average MELD value was 14 (± 3.4). Fourteen patients of 44 transplanted with DCD (31.81%) developed IC. Two of these patients (14.28%) did not require any treatment since no symptom or laboratory test deranging was observed, and other 2 patients (14.28%) required retransplant because of sever graft dysfunction. On the other hand most of these patients (12 recipients, 85.7% of those who were found to suffer IC) required radiological treatment by transparietohepatic cholangiography. Seven of the 14 patients (50%) with IC experienced resolution of the biliary complication at the moment, after an average number of procedures performed of 4.75 (± 4.1). We cannot consider cured 4 of the seven patients which have not experienced radiological resolution yet (28.5%) although a minimal impact on graft function has been observed in these cases. The other 3 patients (21.5%) have died (two of them because of HCV recurrence). The overall recipient and graft survival with IC was at 1, 3 and 5 years of follow up was 85.7%, 78.57%, 71.42%, and 85.7%, 64.28%, 57.14%, respectively. Conclusions: The most important complication in DCD transplant is ischemic cholangiopathy. However, a great number of our patients with ischemic cholangiopathy experiments good outcomes with radiologic treatment and even get cured. Not all the patients with ischemic cholangiopathy require retransplant or treatment, but a good multidisciplinary management may be the best solution of this problem in a great percentage of cases. 1809