Adávio de Oliveira e Silva

Liver transplantation for subacute hepatocellular failure due to massive steatohepatitis after bariatric surgery

New therapeutic options for obesity include restrictive bowel surgery and surgery that promotes malabsorption, such as the Fobi‐Capella (gastric bypass) and Scopinaro (biliopancreatic diversion) techniques. Complications associated with these procedures, such as hepatocellular failure, have been observed with increasing frequency. Reported here are 3 patients who, 7 to 24 months after bariatric surgery, developed hepatocellular failure, for which liver transplantation was considered to be indicated. Liver transplantation was undertaken in 2 of the patients; the third patient died while waiting for this procedure. We discuss the possible causes of this uncommon and poorly understood complication of surgery for obesity. One possibility is that it might arise as a result of progression of steatohepatitis. An alternative concept is that this complication may be secondary to rapid, massive loss of body weight. Liver Transpl 14:881–885, 2008.

Are the imaging findings used to assess the portal triad reliable to perform living-donor liver transplant?

BACKGROUND A crucial aspect of living-donor liver transplant is the risk imposed to the donor due to a procedure performed in a healthy individual that can lead to a high postoperative morbidity rate AIM To correlate the pre- and intraoperative hepatic imaging findings of living adult donors. METHODS From 2003 to 2008 the medical charts of 66 donors were revised; in that, 42 were males (64%) and 24 females (36%), mean age of 30 ± 8 years. The preoperative anatomy was analyzed by magnetic resonance cholangiography to study the bile ducts and by computed tomography angiography to evaluate the hepatic artery and portal vein. Normalcy criteria were established according to previously published studies. RESULTS Anatomic variations of the bile ducts were found in 59.1% of donors, of the artery hepatic in 31.8% and of the portal vein in 30.3% of the cases during the preoperative period. The magnetic resonance cholangiography findings were in agreement in 44 (66.6%) of donors and in disagreement in 22 (33.3%). With regards to hepatic artery, in all donors the findings of the imaging examination were in agreement with those of the intraoperative period. As to the portal vein, the computed tomography findings were in agreement in 59 (89.4%) donors and in disagreement in seven (10.6%). CONCLUSIONS The bile duct anatomic variations are frequent, and the magnetic resonance cholangiography showed moderate accuracy (70%) in reproducing the surgical findings; the computed tomography reproduced the intraoperative findings of the hepatic artery in 100% of donors, and of the portal vein in 89.4% of the cases, thus demonstrating high accuracy (89%).

The presence of bilobar tumor should be considered as a new limit for transplantation beyond the Milan criteria

BACKGROUND: An imprecise estimate of the tumors aggressiveness of the hepatocellular carcinoma especially in transplanted patients beyond the Milan criteria has a poor outcome, although a more reliable criteria including microscopic vascular invasion is difficult to be established before transplantation. AIM: To examine a cohort of patients with hepatocellular carcinoma undergoing liver transplantation to evaluate the preoperative predicting factors for microscopic vascular invasion. METHODS: A series of 46 consecutive cirrhotic patients with hepatocellular carcinoma undergoing transplantation based on Milan criteria or similar criteria in a single center were enrolled between 1993 and 2007. The survival was calculated using Kaplan-Meyers method and a multivariate Cox regression was performed to evaluate survival and factors related to microscopic vascular invasion. RESULTS: Multifocal tumors were present in 39%. Microvascular invasion, tumor relapses and hepatocellular carcinoma beyond the Milan criteria were identified in 33%, 13% and 33%, respectively. Overall 1-, 3-, and 5-year actuarial patient survival rates were 64%, 59% and 45% respectively. Patients who exceeded the Milan criteria had a higher incidence of microscopic vascular invasion and bilobar tumor compared to those who met the Milan criteria (53% vs. 23% and 80% vs. 19%; p<0.05, respectively). After multivariate analysis, the variable identified as independent risk factor for microscopic vascular invasion was the presence of bilobar tumor (hazard ratio, 3.67; 95% confidence interval, 1.01 to 13.34; p<0.05). CONCLUSIONS: The presence of a bilobar tumor is more frequent in hepatocellular carcinoma beyond the Milan criteria and it is an independent predictive factor of a high risk of microscopic vascular invasion. The presence of bilobar tumor in hepatocellular carcinoma beyond the Milan criteria could be used as selection criteria to estimate the risk of hepatocellular carcinoma recurrence, at least until large randomized studies becomes available.