Américo Gusmão Amorim

Orthotopic Liver Transplantation Without Venovenous Bypass Using the Conventional and Piggyback Techniques

INTRODUCTION Orthotopic liver transplantation is a widely used procedure for the treatment of irreversible liver diseases for which there is no possibility of medical treatment. When this procedure is performed by the conventional technique, the retrohepatic vena cava is removed along with the native liver. The inferior vena cava (IVC) remains clamped until the revascularization of the graft, and in this period there is a reduction in the venous return, which may induce a fall by up to 50% in the cardiac output with hemodynamic instability and a fall in renal perfusion pressure. The use of a portal-femoral-axillary venovenous bypass system, in which the blood from the femoral and portal veins returns to the heart via the axillary vein propelled by a centrifugal pump, is intended to minimize the effects of the IVC clamping. In the piggyback (PB) technique, the native liver is removed and the IVC of the recipient is preserved and only partially clamped. We have employed both techniques without the use of venovenous bypass for 10 years. The objective of this study was to compare the results obtained from the use of the two techniques. PATIENTS AND METHODS A retrospective analysis was performed of 195 patients transplanted between 1999 and 2008: 125 by the conventional technique and 70, the PB technique. The intraoperative parameters were analyzed (surgical time, ischemia time, use of blood products, and diuresis), as well as intensive care support (duration of stay in intensive care unit and use of vasoactive drugs), period of intubation, length of hospital stay, renal function, graft function, postoperative complications, retransplantation, and patient survival. RESULTS The PB group showed a reduction in surgical time, warm ischemia time, the use of packed red blood cells concentrates, and fresh frozen plasma, as well as mortality at 30 days (P<.05). There were no differences in relation to cold ischemia time, intraoperative diuresis; length of stay and use of vasoactive drugs in the intensive care unit; the period of intubation; the duration of hospital stay; the renal function; the graft function; the need for reoperation; the incidence of sepsis, biliary complications, vascular complications; need for retransplantation; and 1-year mortality. The cumulative survival rate at 1 year was significantly better among the PB patients. CONCLUSION Orthotopic liver transplantation can be performed without venovenous bypass with good results, using either the conventional technique or the PB technique. Provided that there is no technical contraindication and a long ischemia period is not foreseen, the PB technique should be the technique of choice.

Impact of MELD allocation policy on survival outcomes after liver transplantation: a single-center study in northeast Brazil

OBJECTIVE: To analyze the impact of model for end‐stage liver disease (MELD) allocation policy on survival outcomes after liver transplantation (LT). INTRODUCTION: Considering that an ideal system of grafts allocation should also ensure improved survival after transplantation, changes in allocation policies need to be evaluated in different contexts as an evolutionary process. METHODS: A retrospective cohort study was carried out among patients who underwent LT at the University of Pernambuco. Two groups of patients transplanted before and after the MELD allocation policy implementation were identified and compared using early postoperative mortality and post‐LT survival as end‐points. RESULTS: Overall, early postoperative mortality did not significantly differ between cohorts (16.43% vs. 8.14%; p = 0.112). Although at 6 and 36‐months the difference between pre‐ vs. post‐MELD survival was only marginally significant (p = 0.066 and p = 0.063; respectively), better short, medium and long‐term post‐LT survival were observed in the post‐MELD period. Subgroups analysis showed special benefits to patients categorized as non‐hepatocellular carcinoma (non‐HCC) and moderate risk, as determined by MELD score (15‐20). DISCUSSION: This study ensured a more robust estimate of how the MELD policy affected post‐LT survival outcomes in Brazil and was the first to show significantly better survival after this new policy was implemented. Additionally, we explored some potential reasons for our divergent survival outcomes. CONCLUSION: Better survival outcomes were observed in this study after implementation of the MELD criterion, particularly amongst patients categorized as non‐HCC and moderate risk by MELD scoring. Governmental involvement in organ transplantation was possibly the main reason for improved survival.

Emprego do escore MELD para a predição da sobrevivência pós-transplante hepático

OBJECTIVE To assess the overall accuracy of the preoperative MELD score for predicting survival after liver transplantation (LT) and appraise medium-term (24 months) predictors of survival. METHODS We conducted a cross-sectional study including patients transplanted by the Department of General Surgery and Liver Transplantation of the Oswaldo Cruz University Hospital, University of Pernambuco, between July 15th, 2003 and July 14th, 2009. We used analysis of area under ROC (receiver operating characteristic) as a summary measure of the performance of the MELD score and assessed predictors of medium-term survival using univariate and multivariate analysis. RESULTS The cumulative survival of three, six, 12 and 24 months of the 208 patients studied was 85.1%, 79.3%, 74.5% and 71.1%, respectively. The preoperative MELD score showed a low discriminatory power for predicting survival after TH. By univariate analysis, we identified intraoperative transfusion of red blood cells (p <0.001) and platelets (p = 0.004) and type of venous hepatocaval anastomosis (p = 0.008) as significantly related to medium-term survival of the patients studied. However, by multivariate analysis only red blood cell transfusion was a significant independent predictor of outcome. CONCLUSION The MELD score showed low overall accuracy for predicting post-transplant survival of patients studied, among which only intraoperative transfusion of red blood cells was identified as an independent predictor of survival in the medium term after TH.

Reconstruction of Venous Outflow of Domino Liver Graft Using Deceased Donor Iliac/Cava Veins

The double piggyback technique has been proposed for domino liver transplantation. To make this possible, it is necessary to reconstruct the venous outflow of the domino liver graft on the back table. The authors describe the technical details of this procedure in three consecutive cases. A deceased donor cava-iliac bifurcation segment was used. The iliac veins were anastomosed to the ostia of the right and middle-left hepatic veins, and the graft cava vein was anastomosed to the ostium of the three hepatic veins of the recipient. In all cases anatomic compatibility was observed; the outcome of the patients was satisfactory.

Transplante de fígado a partir de doadores em assistolia: resultados iniciais do grupo de transplante de fígado do Hospital Oswaldo Cruz, Universidade de Pernambuco

BACKGROUND: The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Hepatic allografts from non-heart-beating donors have been cited as a means to expand the supply of donor livers. METHODS: We reviewed the medical records of six patients who had undergone orthotopic liver transplantation from non-heart-beating donors at Oswaldo Cruz University Hospital, Pernambuco University, Brazil, between October 2002 and September 2004. RESULTS: Primary graft non-function, vascular or biliary complications were not observed. Re-transplantation was not required. All patients were discharged from hospital in good clinical conditions. CONCLUSION: Although more experience is required, good initial results have been obtained with non-heart-beating livers donors by the Oswaldo Cruz University Hospital Group.

Postoperative kidney injury does not decrease survival after liver transplantation

PURPOSE To explore the effect of acute kidney injury (AKI) on long-term survival after conventional orthotopic liver transplantation (OLT) without venovenous bypass (VVB). METHODS A retrospective cohort study was carried out on 153 patients with end-stage liver diseases transplanted by the Department of General Surgery and Liver Transplantation of the University of Pernambuco, from August, 1999 to December, 2009. The Kaplan-Meier survival estimates and log-rank test were applied to explore the association between AKI and long-term patient survival, and multivariate analyses were applied to control the effect of other variables. RESULTS Over the 12.8-year follow-up, 58.8% patients were alive with a median follow-up of 4.5-year. Patient 1-, 2-, 3- and 5-year survival were 74.5%, 70.6%, 67.9% and 60.1%; respectively. Early postoperative mortality was poorer amongst patients who developed AKI (5.4% vs. 20%, p=0.010), but long-term 5-year survival did not significantly differed between groups (51.4% vs. 65.3%; p=0.077). After multivariate analyses, AKI was not significantly related to long-term survival and only the intraoperative transfusion of red blood cells was significantly related to this outcome (non-adjusted Exp[b]=1.072; p=0.045). CONCLUSION The occurrence of postoperative acute kidney injury did not independently decrease patient survival after orthotopic liver transplantation without venovenous bypass in this data from northeast Brazil.

Orthotopic liver transplantation without venovenous bypass: 125 cases from a single center.

AIM This study analyzed a 10-year single-center experience in orthotopic liver transplantation (OLT) without venovenous bypass (VVB). METHODS We retrospectively analysed a nonrandomized series (1999-2008) of 125 adult OLT patients without VVB. RESULTS The main causes of liver failure were viral hepatitis (n = 39), alcoholic liver disease (n = 22), and liver cancer (n = 17). One-year survival was 76.4%. The most common postoperative complications were bile duct stenosis (n = 12), postoperative bleeding (n = 8), hepatic artery thrombosis (n = 7), and primary liver failure (n = 6). Twelve patients required hemodialysis and four underwent retransplantations of the liver. Fourteen patients died before postoperative day 30(th). Univariate analysis showed significant differences between patients who did and did not survive 30 days among donor death diagnoses (P = .05), red blood cell units transfused (P = .03), aspartate aminotranferase on the first postoperative day (P = .002), ABO type (P = .04), time of orotracheal intubation (P = .001), hemodialysis (P = .001), and period of postoperative vasoactive drug use (P = .006). The total length of orotracheal tube intubation showed a significant independent association with mortality before 30 days (P < .001). CONCLUSION OLT without VVB can be safely performed even in severe cases of chronic liver failure.

O doador marginal: experiência de um centro de transplante de fígado

RACIONAL: Desde que o uso de enxertos marginais e solucao aceita para escassez de orgaos para transplante, ele tornou-se muito comum em todo mundo e a literatura vem mostrando efetividade desses enxertos no transplante de figado. OBJETIVO: Apresentar a experiencia do Servico de Transplante Hepatico do Hospital Universitario Oswaldo Cruz, em transplante de figado com o uso de doadores marginais. METODOS: Estudo retrospectivo em 137 transplantes ortotopicos de figado, usando enxertos marginais entre 1999 e 2006, com acompanhamento minimo de 180 dias. Os receptores foram classificados de acordo com a funcao inicial do enxerto no pos-operatorio como normal (FN) e disfuncao primaria (DP). RESULTADOS: Nao foi observada diferenca estatisticamente significante entre os grupos FN e DP com os seguintes parâmetros dos doadores: idade, sodio serico, tempo de protrombina, esteatose hepatica, transaminases serica, pressao sanguinea, drogas vasoativas, indice de massa corporea, parada cardiaca antes da doacao de orgao, doador em assistolia e tempo de isquemia quente. Analise da curva de sobrevida (Kaplan-Meier) de pacientes e de enxertos de figado de pacientes que receberam figado de doadores ideais versus doadores marginais nao mostrou diferenca com significância estatistica. CONCLUSAO: Pode ser recomendado o uso de enxertos marginais para transplantes hepaticos, inclusive os provenientes de doadores com o coracao parado.

A veia gástrica esquerda como alternativa de revascularização portal no transplante hepático

Trombose ou hipoplasia da veia porta nao tem sido, ainda, considerados contra-indicacoes para o transplante ortotopico de figado. Contudo, permanecem com obstaculos associados com aumento da frequencia de falha primaria e a longo prazo do transplante de figado. Existem alguns fatores de risco tais como: sexo masculino, cirrose avancada, doenca hepatica alcoolica e cirurgia previa para hipertensao portal. Os autores relatam o caso de uma crianca de 4 anos, do sexo feminino, que sofria de doenca terminal do figado resultante de atresia de vias biliares e que tinha submetido, sem sucesso, a uma operacao de Kasai. Ela se submeteu a um transplante ortotopico de figado por cirrose biliar secundaria. Durante a cirurgia uma hipoplasia portal severa do receptor foi encontrada. Uma anastomose entre a veia gastrica esquerda do receptor e a veia porta do doador foi feita. Reperfusao hepatica e subsequente funcao do figado foram excelentes. A paciente recebeu alta hospitalar no trigesimo dia. A veia gastrica esquerda pode ser uma alternativa para revascularizacao portal no transplante hepatico.

UPPER MIDLINE INCISION IN RECIPIENTS OF DECEASED-DONORS LIVER TRANSPLANTATION

ABSTRACT Background: Liver transplant (LT) is the only effective and long-lasting option for patients with end-stage liver disease. Innovations and refinements in surgical techniques occurred with the advent of transplants with partial grafts and laparoscopy. Despite these modifications, the abdominal incision remains with only few changes. Aim: Demonstrate the experience with the upper midline incision in LT recipients with whole liver grafts from deceased donors. Methods: Retrospective study with patients submitted to LT. Data were collected from the recipients who performed the surgical procedure through the upper midline incision. Results: The upper midline incision was used in 20 LT, 19 of which were performed in adult recipients. The main cause was liver disease secondary to alcohol. Male, BMI>25 kg/m² and MELD greater than 20 were prevalent in the study. Biliary complications occurred in two patients. Hemoperitoneum was an indication for reoperation at one of the receptors. Complication of the surgical wound occurred in two patients, who presented superficial surgical site infection and evisceration (omental). Two re-transplant occurred in the first postoperative week due to severe graft dysfunction and hepatic artery thrombosis, which were performed with the same incision, without the need to increase surgical access. There were two deaths due to severe graft dysfunction after re-transplant in 72 h and respiratory sepsis with multiple organ dysfunction in the third week. Conclusion: The upper midline incision can be safely used in LT recipients with whole grafts from deceased donors. However, receptor characteristics and hepatic graft size should be considered in the option of abdominal surgical access.