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The impact of donor age on liver transplantation: influence of donor age on early liver function and on subsequent patient and graft survival.

BACKGROUND The urgent need to increase the organ donor pool has led to the expansion of criteria for donor selection. The aim of this study was to analyze the influence of donor age on early graft function, subsequent graft loss, and mortality after liver transplantation (LT). METHODS Data on LT were evaluated retrospectively in a population-based cohort of 400 LTs in 348 patients. Of these, 21 (5%) were from donors >70 years old. Pretransplantation donor and recipient characteristics and the evolution of recipients were analyzed. The influence of donor age as a risk factor was assessed using univariate and multivariate analyses. RESULTS Actuarial graft survival was 89% at 1 month after LT, 81% after 6 months, and 59% after 60 months. Multivariate analysis demonstrated that only donor age (>70 years old) was associated with a higher risk of long-term graft loss (relative risk [RR]=1.4, 95% confidence interval [CI]=1-1.9; P=0.03) and mortality (RR=1.7, 95% CI=1.2-2.3; P=0.01). Graft survival of septuagenarian livers was 80% at 1 month after LT, 56% after 6 months, and 25% after 54 months. Actuarial survival analysis (Kaplan-Meier curves) also demonstrated worse evolution in recipients of livers from old donors (log-rank test, P<0.001). CONCLUSIONS Advanced donor age is associated with lower graft and recipient survival.

Liver transplantation in patients with hepatic hydrothorax

Hepatic hydrothorax is a uncommon complication of cirrhotic patients and the results of liver transplantation (OLT) in patients with this complication are not well defined. We studied postoperative complications and survival of 28 patients with hepatic hydrothorax transplanted at our center during a period of 12 years, comparing them with a control group of 56 patients transplanted immediately before and after each case. There were no differences between hydrothorax group and control group in days of mechanical ventilation after surgery, transfusion requirements, postoperative mortality and long‐term survival (70% vs. 55% at 8 years, P = 0.11). Long‐term evolution was similar between patients with refractory hepatic hydrothorax or spontaneous bacterial empyema and those with noncomplicated hepatic hydrothorax. Hepatic transplantation is an excellent therapeutic option for patients with hepatic hydrothorax. Presence of hepatic hydrothorax does not imply more postoperative complications, and long‐term survival is similar to other indications of hepatic cirrhosis.

Results Of Using The Recipient's Splenic Artery For Arterial Reconstruction In Liver Transplantation In 23 Patients

BACKGROUND Arterial reconstruction is essential in liver transplantation. In some patients there may be an inadequate flow as a result of stenosis, intimal dissection, or anomalies of the hepatic artery. METHODS This study analyzes our experience with 23 patients in whom arterial anastomosis was performed using the splenic artery due to the inadequacy of the hepatic artery. During the same period an aortoiliac conduit was used in 12 liver transplantations due to the same problem. RESULTS No splenic infarction, pancreatitis, or other related complications were found. Artery thrombosis developed in only two patients in the aortoiliac conduit group. One- and three-year patient actuarial survival were 78% vs. 80% and 72% vs. 80%, respectively, for the splenic artery group and the aortoiliac conduit group. CONCLUSIONS Anastomosis with the splenic artery is an alternative in liver transplantation and is particularly suitable when splenomegaly is present.

Extra‐anatomic venous graft for portal vein thrombosis in liver transplantation

Sir: We read with interest the article by J. P. Lerut et al. about liver transplantation (OLT) and portal vein anomalies [2]. This paper analyzes a very large (53 patients), but quite heterogeneous, group of patients. Preoperative portal vein thrombosis (PVT), phlebitis, and previous surgery for portal hypertension are difficult situations in OLT, and it is our opinion that the surgical management is not the same for all of them. With regard to PVT, it can be concluded from Lerut et al.’s study that blind or, more recently, eversion portal venous thrombectomy is the preferred surgical technique in 26 out of 32 cases (81 %). Mortality after this procedure was high (4/26; 15 %), and severe intraand postoperative bleeding were frequent complications (7/26; 27 %). Portal vein rethrombosis is another complication that has been frequently reported after this procedure [3,5]. Their experience with splenomesenteric confluence dissection is even worse, with 80 % mortality (4/5).

Análisis de 500 trasplantes hepáticos en el Hospital de Bellvitge

Fundamento Se presenta la experiencia del programa de trasplante hepatico del Hospital de Bellvitge en 500 trasplantes realizados durante 15 anos, con el objetivo de poner de manifiesto los cambios que se han producido y exponer los resultados a largo plazo de esta terapeutica. Pacientes y metodo Se consideraron y compararon 5 grupos de 100 trasplantes consecutivos (I-V). Resultados Las indicaciones mas frecuentes fueron el hepatocarcinoma (23%), la cirrosis alcoholica (22,8%) y la hepatopatia cronica por virus C (18,8%). En 59 pacientes se llevaron a cabo 65 retrasplantes (13%), cuyas indicaciones mas frecuentes fueron la trombosis arterial (13 pacientes) y el fallo primario del injerto (10 pacientes). En 19 enfermos se realizo un trasplante combinado hepatorrenal. La causa mas frecuente de muerte del donante en el grupo I fueron los traumatismos craneales (80%), mientras que en el grupo V fue la enfermedad vascular (52%). Otras diferencias significativas entre estos grupos se observan en la proporcion de pacientes en estadio 2 y 3 de la clasificacion UNOS (el 45 frente al 19%), en el consumo de hemoderivados (29,6 [26] frente a 4,6 [5,3] concentrados de hematies), en la frecuencia de reintervenciones por hemoperitoneo (el 22 frente al 5%), en la estancia en UCI (13 [13] frente a 7,4 [11] dias) y en el hospital 40 [52] frente a 23,7 [17] dias), y en la incidencia de rechazo (el 46 frente al 20%) y de fallo primario del injerto (el 9 frente al 3%). Sin embargo, la prevalencia de infeccion (el 48 frente al 54,5%) y la incidencia de complicaciones biliares (el 26 frente al 20%) no han presentado variaciones significativas. La supervivencia actuarial de los pacientes trasplantados desde 1990 es del 83 y del 70% al ano y a los 5 anos, respectivamente. Conclusiones Se observa una mejoria notable y progresiva de los resultados del trasplante hepatico. Sin embargo, los tumores de novo, la recidiva de la hepatitis por virus C y el rechazo cronico pueden limitar los resultados a largo plazo.

Comparative Study of Celsior and Belzer Solutions for Hepatic Graft Preservation: Preliminary Results

HE SCARCITY OF donors and the increase in the number of transplant candidates have stimulated research to minimize the loss of donated organs. Preservation solutions are available to conserve the organs for a determinate period. In liver transplant (LT) Belzer and Brettschneider solutions give satisfactory results. However, graft malfunction remains a problem and other solutions are being examined. This randomized comparative study aims to examine the hepatic function of grafts perfused with Celsior solution (CS) and Belzer solution (BS) following liver transplant in adults.

Postreperfusion biopsy changes predict biliary complications after liver transplantation.

PRESERVATION injury (PI) is a major contributor to primary allograft failure after liver transplantation (LT). However, few studies have analyzed the predictive value of postreperfusion liver biopsies for the development of graft dysfunction and late complications. Extended cold preservation has been associated with biliary strictures. Consequently, it has been postulated that the ischemiareperfusion injury may play a role in the pathogenesis of some biliary complications. This study was performed to assess whether the presence of histologic lesions on postreperfusion (0Post) allograft biopsy is a predictive factor of postoperative biliary complications. Other secondary objectives were to examine the possible relationship between 0Post biopsy features and donor data, and to correlate postreperfusion histologic findings with graft and patient outcome.

Resección de metástasis hepáticas de carcinoma colorrectal. Índice de resecabilidad y supervivencia a largo plazo

Resumen Introduccion Para obtener los mejores resultados posibles, el tratamiento de las metastasis hepaticas de carcinoma colorrectal debe ser multidisciplinario. Sin embargo, las posibilidades de curacion o supervivencia a largo plazo se basan en la reseccion completa de toda la enfermedad tumoral detectable en el estudio de extension, que debe ser lo mas preciso posible para evitar laparotomias innecesarias. Objetivos Establecer la eficacia de nuestro estudio de extension a traves del indice de resecabilidad y conocer cuales son nuestros resultados en cuanto a supervivencia a largo plazo. Pacientes y metodos. Desde enero de 1991 hasta diciembre de 2000 practicamos 273 hepatectomias por metastasis de carcinoma colorrectal en 250 pacientes. Ni el numero, ni el tamano de las metastasis, ni la invasion locorregional fueron considerados criterios de exclusion. El unico criterio utilizado para indicar la intervencion fue la presuncion preoperatoria de que la exeresis seria completa y macroscopicamente curativa. Resultados. El indice de resecabilidad fue del 91,3% (273 de 299 casos) y la mortalidad postoperatoria del 3,3%. En 37 casos se practico cirugia simultanea del tumor primario, en 23 se llevo a cabo una segunda reseccion hepatica y en 18 pacientes se realizo una reseccion pulmonar por metastasis pulmonares. En 106 pacientes (55%) se instauro quimioterapia adyuvante. La supervivencia actuarial a los 1, 3 y 5 anos fue del 87, 57 y 36%, respectivamente. En el analisis multivariante, la presencia de cuatro o mas metastasis y el margen de reseccion invadido fueron los unicos factores predictivos de mala evolucion. La quimioterapia adyuvante mejoro significativamente la supervivencia. Conclusiones. La reseccion de las metastasis hepaticas puede realizarse con una baja mortalidad operatoria y obtiene buenos resultados en cuanto a supervivencia. Con el metodo de estudio preoperatorio que aplicamos, es posible obtener un alto indice de resecabilidad. La indicacion quirurgica agresiva, el seguimiento sistematico, el rescate quirurgico con intencion curativa de recidivas y la quimioterapia adyuvante comportan una supervivencia a largo plazo del 36%.

Experience with domino or sequential liver transplantation in familial patients with amyloid polyneuropathy.

THE SHORTAGE of organ donors and the increased demand for orthotopic liver transplantation (LTX) has led to new strategies to increase the availability of grafts for transplantation. In LTX because of familial amyloid polyneuropathy (FAP), the reuse of the liver for a patient aged more than 60 years was suggested by our group in 1993. The first was performed in Portugal and it is called domino liver transplantation (DLTX) or sequential LTX. We describe our experience in six cases of DLTX for FAP performed in our unit between February 1999 and September 2000.

Trasplante hepático dominó o secuencial: descripción de los tres primeros pacientes en España

Fundamento El trasplante hepatico domino o secuencial (DTXH) es un tipo de injerto de donante vivo propuesto en 1993 y realizado por primera vez en 1995; posteriormente se han publicadomas de 45. El higado de un paciente con polineuropatia amiloidotica familiar (PAF) se implanta a un enfermo mayor de 60 anos afectado de un proceso hepatico generalmente neoplasico, porque el higado de esos donantes es normal desde el punto de vista anatomico y funcional, salvo la sintesis de la variante sistemica de la transtirretina (TTR), que solo podria originar la PAF en el receptor al cabo de un periodo mayor de 8 anos. Pacientes y metodo Se presentan los tres primeros casos de DTXH realizados en Espana. Los donantes eran pacientes con PAF con variante TTRMet30 procedentes del foco mallorquin. El primero de los receptores presentaba un gravisimo hiperinsulismo debido a metastasis hepaticas de insulinoma maligno; los otros dos tenian hepatocarcinoma implantado sobre higado cirrotico. Resultados En el postoperatorio de los receptores, la funcion del higado fue perfecta, y desaparecio inmediatamente el hiperinsulinismo en el primero; este fallecio a los 10 dias por sepsis, mientras que los otros siguen con funcion hepatica normal, sin recidiva neoplasica ni inicio de PAF. En los donantes, la evolucion fue normal, con perfecta funcion hepatica. Conclusiones Nuestros datos, coincidentes con los publicados, permiten concluir que el DTXH es un metodo valido para un determinado grupo de pacientes. Ademas, aumenta el contingente de donantes hepaticos y, por consiguiente, disminuyen las sobrecargadas listas de espera.