Bogusław Najnigier

1000 liver transplantations at the Department of General, Transplant and Liver Surgery, Medical University of Warsaw--analysis of indications and results.

THE AIM OF THE STUDY was to analyze indications and results of the first one thousand liver transplantations at Chair and Clinic of General, Transplantation and Liver Surgery, Medical University of Warsaw. MATERIAL AND METHODS Data from 1000 transplantations (944 patients) performed at Chair and Clinic of General, Transplantation and Liver Surgery between 1994 and 2011 were analyzed retrospectively. These included 943 first transplantations and 55 retransplantations and 2 re-retransplantations. Frequency of particular indications for first transplantation and retransplantations was established. Perioperative mortality was defined as death within 30 days after the transplantation. Kaplan-Meier survival analysis was used to estimate 5-year patient and graft survival. RESULTS The most common indications for first transplantation included: liver failure caused by hepatitis C infection (27.8%) and hepatitis B infection (18%) and alcoholic liver disease (17.7%). Early (< 6 months) and late (> 6 months) retransplantations were dominated by hepatic artery thrombosis (54.3%) and recurrence of the underlying disease (45%). Perioperative mortality rate was 8.9% for first transplantations and 34.5% for retransplantations. Five-year patient and graft survival rate was 74.3% and 71%, respectively, after first transplantations and 54.7% and 52.9%, respectively, after retransplantations. CONCLUSIONS Development of liver transplantation program provided more than 1000 transplantations and excellent long-term results. Liver failure caused by hepatitis C and B infections remains the most common cause of liver transplantation and structure of other indications is consistent with European data.

Choice of Transplantation Techniques and Indications for Liver Transplantation in Polycystic Liver Disease in Patients With No Signs of End-Stage Liver Disease

OBJECTIVE Since the initiation of the Liver Transplant Program, 500 liver procedures have been performed. Polycystic liver disease (PLD) and polycystic kidney-liver disease (PKLD) have been rare indications for orthotopic liver transplantation (OLT). Only 7 patients (1.4%) underwent transplantation due to PLD and PKLD. MATERIALS AND METHODS The group consisted of 4 patients who underwent OLT (0.8%) and 3 patients who received simultaneous liver kidney transplantation (LKT; 0.6%). Our objective was to analyze the indications for either OLT or combined LKT as well as indications for surgical techniques during OLT among patients with PLD or PKLD. RESULTS The main indication for OLT was massive hepatomegaly causing severe physical handicaps, fatigue, and clinically advanced malnutrition. All 3 patients with indications for combined LKT were dialysis-dependent. None of the patients had symptoms of end-stage liver disease and/or hepatic failure. In 4 cases, a portal bypass was applied, and the piggy-back method used in the other 3 cases. The hepatectomy caused no uncommon difficulty. In cases of simultaneous transplantations, the kidney was implanted separately after OLT. All patients are alive following the transplantation; major surgical complications have occurred. CONCLUSIONS Patients with PLD can undergo OLT safely with good results. They benefit from the relief of abdominal distension and anorexia. Patients with PKLD who are dialysis-dependent should undergo simultaneous LKT. The surgical technique was solely dependent on the intraoperative conditions determined during the dissection phase.

Comparison of the results of liver transplantation for elective versus urgent indications.

The authors present an analysis of early and remote liver transplantation outcomes related to the presence of emergent indications among 196 of the 209 operations performed from 1989 to April 2003; namely 178 elective and 18 emergent transplantations. Perioperative mortality was 15%. The survival rate during the first 12 months was 79.8% and within 3 years 73.5% among patients operated on an elective basis (UNOS 3 and 2B). In contrast, patients with acute liver failure (UNOS 1 and 2A) showed rates of 45%, 50%, and 47%, respectively. Liver transplant outcomes depend primarily on the urgency of an operation. Longterm results are much better among patients operated on electively. Liver transplantation in patients with acute hepatic insufficiency is burdened with a high 45% mortality.

Evolution Of The Results Of 1500 Liver Transplantations Performed In The Department Of General, Transplant And Liver Surgery Medical University Of Warsaw.

UNLABELLED Liver transplantation is a well-established treatment of patients with end-stage liver disease and selected liver tumors. Remarkable progress has been made over the last years concerning nearly all of its aspects. The aim of this study was to evaluate the evolution of long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw). MATERIAL AND METHODS Data of 1500 liver transplantations performed between 1989 and 2014 were retrospectively analyzed. Transplantations were divided into 3 groups: group 1 including first 500 operations, group 2 including subsequent 500, and group 3 comprising the most recent 500. Five year overall and graft survival were set as outcome measures. RESULTS Increased number of transplantations performed at the site was associated with increased age of the recipients (p<0.001) and donors (p<0.001), increased rate of male recipients (p<0.001), and increased rate of piggyback operations (p<0.001), and decreased MELD (p<0.001), as well as decreased blood (p=0.006) and plasma (p<0.001) transfusions. Overall survival was 71.6% at 5 years in group 1, 74.5% at 5 years in group 2, and 85% at 2.9 years in group 3 (p=0.008). Improvement of overall survival was particularly observed for primary transplantations (p=0.004). Increased graft survival rates did not reach the level of significance (p=0.136). CONCLUSIONS Long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery are comparable to those achieved in the largest transplant centers worldwide and are continuously improving despite increasing recipient age and wider utilization of organs procured from older donors.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

Alveococcosis of the liver - strategy of surgical treatment with special focus on liver transplantation.

Echinococcosis is a zoonosis caused by infestation with any of 4 (of the 16) members of the Echinococcus genus, namely Echinococcus granulosus, Echinococcus multilocularis, Echinococcus oligarthus, and Echinococcus vogelii. The aim of this retrospective analysis was to present the outcomes of patients undergoing liver resection and liver transplantation (LT) for E. multilocularis infection.

Is the Age of Patients with Iatrogenic Bile Duct Injuries Increasing

UNLABELLED Resection of the gall-bladder is still the most common surgical procedure performed at general surgery departments. The laparoscopic method used in the majority of cases offers considerable benefits but at the same time is associated with an increased rate of bile duct complications. So far, a slim female aged 25-50 years was a typical patient with a iatrogenic bile duct injury. The aim of the study was to identify the age of patients with iatrogenic bile duct injuries as well as the clinical course observed in recent years. MATERIAL AND METHODS Gender and age structure of patients admitted to the Department of General, Transplant and Liver Surgery between the beginning of 2011 and June 2014 and treated for iatrogenic bile duct injuries, complications of laparoscopic cholecystectomy, were analysed. The patients were referred to the department as a reference centre. RESULTS In the group of 186 patients, females predominated (69.4%) and the mean age was 52 years. A considerable increase in the mean age of patients treated in 2014 as compared with previous years was seen. This was related to an increased rate of bile duct injuries in patients aged over 70 years, who accounted for about 25% of the group. In previous years, bile duct injuries in patients of such an advanced age happened considerably less frequently. CONCLUSIONS A iatrogenic bile duct injury in an elderly person may prove a fatal complication. A repair surgery, i.e. the biliary-enteric anastomosis, is a major and burdensome procedure, particularly in the case of patients aged over 70 years. Special caution during laparoscopic cholecystectomy is advised in this population, and the slightest doubts should lead to conversion.

Identyfikacja i znaczenie krążących endotelialnych komórek progenitorowych u chorych na raka wątrobowokomórkowego

Cel badan. Badania poświecono identyfikacji i ocenie znaczenia endotelialnych komorek progenitorowych we krwi obwodowej chorych na HCC. Material i metoda. Badania przeprowadzono u 133 chorych na HCC, dotychczas nieleczonych, z ktorych 46 zostalo zakwalifikowanych do resekcji wątroby, 45 do przeszczepienia wątroby i 42 do leczenia paliatywnego. Grupe kontrolną stanowilo 43 osob zdrowych i 42 chorych na marskośc wątroby, bez stwierdzonego raka. Od badanych pobierano probki świezej krwi w objetości 2 ml i niezwlocznie wykonywano badanie fenotypu komorek metodą cytometrii przeplywowej z uzyciem cytometru FACS CANTO II. Frakcje endotelialnych komorek progenitorowych (EPCs) o fenotypie CD34(+)CD133(+)CD45(dim)CD309(+) identyfikowano za pomocą wymienionych markerow powierzchniowych. Populacje hematopoetycznych komorek macierzystych (HSCs) identyfikowano na podstawie fenotypu CD34(+)CD133+)CD45(dim), zgodnie z regulami ISHAGE. Wyniki, przedstawione jako odsetek endotelialnych komorek progenitorowych w populacji hematopoetycznych komorek macierzystych (%EPCs/HSCs) oraz odsetek HSCs w pulileukocytow CD45(+) (%HSCs/WBC) opracowano statystycznie. Wyniki. Badanie wykazalo znamienne roznice we frakcji EPCs i subpopulacji HSCs pomiedzy chorymi na raka i osobami zdrowymi (test U Manna-Whitneya: chisq = –5,92; p < 0,0001 i chisq 3,85; p < 0,0001, odpowiednio) oraz pomiedzy chorymi na raka i na marskośc wątroby (chisq = –6,09; p < 0,0001 i 2,47; p < 0,01, odpowiednio). Roznice te nie byly znamienne pomiedzy chorymi na HCC a chorymi na marskośc wątroby (NS). Wnioski. Wzrost odsetka hematopoetycznych komorek macierzystych i ich frakcji, endotelialnych komorek progenitorowych, wskazuje na role, jaką odgrywają w rozwoju raka wątrobowokomorkowego. Nieistotne roznice pomiedzy chorymi na raka i na marskośc wątroby potwierdzają teze o przedrakowym charakterze marskości.

Liver regeneration in living-related donors after harvesting of liver segments II and III or II, III and IV

BACKGROUND CT-assisted volumetry permits an estimation of the volume of the graft in liver transplantation, as well as monitoring the donors liver regeneration. The aim of the study was to observe the restitution of liver tissue in donors after harvesting of the liver fragment for living-related liver transplantation (LRLT). METHODS The size of the whole liver and of segments II, III and IV was assessed by preoperative CT volumetry in 29 living-related liver donors. Segments II and III were harvested in 22 patients, segments II, III and IV in 6 patients. The remnant liver was assessed by CT volumetry on the 7th and 30th postoperative days. RESULTS The correlation between the calculated volume of the graft and its weight was linear (r=0.56, p<0.04). Postoperative CT volumetry of the liver of living-related donors showed a different pattern of volume restoration (regeneration index) at both 7 and 30 days between donors who sacrificed segments II and III and those who sacrificed segments II, III and IV. The mean regeneration indexes were significantly higher in donors of segments II, III and IV as compared with donors of segments II and III (7 days, p<0.02; 30 days, p<0.05). DISCUSSION It is possible that the donors liver displays a different pattern of growth due to the alteration in blood supply to segment IV.

Pushing the age limit and reducing the number of contraindications of liver resections in cancer-bearing patients — a case report

Liver resections are performed in increasing numbers due to oncological indications. Thus, the indications for surgical treatment of liver tumors are constantly expanding. Advanced age and other comorbidities often exclude this group of patients from treatment by liver resection. Patient C.S. (80 y.a., height 166 cm, weight 97 kg, ASA = 4) with risk factors was admitted for resection of metastatic lesions (adenocarcinoma) of the cecum to the liver. The patient was diagnosed with hypertension, atherosclerosis, stable coronary heart disease, type 2 diabetes, chronic renal failure (eGFR = 37), obesity, degenerative spinal lesions, sigmoid colon diverticulitis, dystonic tremor of the head. Previously operated upon and had amputation of the uterus with appendages (2005), cholecystectomy, right hemicolectomy (2012) complicated by respiratory failure with the need for ventilation seven days post-surgery. Prior to surgery, the patient had imaging tests such as ultrasound, CT and MRI scans of the abdomen, which confirmed a 55mm metastatic tumor in the seventh segment of the liver. The results were analyzed during a radiological and surgical consultation in order to prepare the safest available surgical access and the scope of the planned resection. A cardiac echocardiography was performed and the patient had a cardio-, neuro- and anesthetic consultation. The patient was fully informed about the high risk of complications and possible operational failure. During surgery a right hemihepatectomy was performed. The resected lobe weighed 712 g. Blood loss was < 500 ml, 2 units RBC and 2 units FFP were transfused. The surgery and the postoperative period proceeded without serious complications. The only problem was a short-lived biliary fistula, which healed spontaneously. Age and comorbid conditions are often a contraindication for surgery, but with proper medical support, the opportunity to interact with other professionals and thorough preparation of the patient and the team of surgeons, the risk of failure can be significantly minimized. A modern, personalized, multidisciplinary approach towards each patient can expand indications and reduce contraindications for hepatic resection.