C. Loinaz Segurola

Liver transplantation for hepatocellular carcinoma: our experience from 1986.

Abstract Currently liver transplantation is the treatment of choice for early hepatocellular carcinoma and end-stage liver disease. We analyzed our experience to identify factors that could be used to select patients who will benefit from liver transplantation. Patients and methods From April 1986 to December 2001, 71 (8.7%) of 816 LT performed in our institution, were for patients with hepatocellular carcinoma. In 25 patients the tumor was observed incidental by (35.2%). All patients had liver cirrhosis, most due to hepatitis C related (35) or alcoholic (14) diseases. Before liver transplantation, chemoembolization was performed in 18 patients (25.4%). Results Bilateral involvement was present in seven patients. Eight patients showed macroscopic vascular invasion, and eight others showed satellite nodules. Most patients were stage TNM II (29) and IVa (16). Overall 1-, 3-, and 5-year survival were 79.3%, 61%, and 50.3% with recurrence-free survivals of 74.6%, 57.5%, and 49%, respectively. With a mean follow-up of 42 months, 12 patients (19%) developed recurrence and 29 patients died (only 11 due to recurrence). Stage TNM IVa, macrocopic vascular invasion, and the presence of satellite nodules significantly affected overall survival and recurrence-free survival rates and histologic differentiation and bilateral involvement only recurrence-free survival. Patients with solitary tumors less than 5 cm or no more than three nodules smaller than 3 cm showed better recurrence-free survival and lower recurrence rates. Discussion In our experience, liver transplantation proffers good recurrence-free survival and low recurrence rates among patients with limited tumor extension. The most important prognostic factor was macroscopic vascular invasion.

Porcine acellular dermal matrix for delayed abdominal wall closure after pediatric liver transplantation

Children are one of the groups with the highest mortality rate on the waiting list for LT. Primary closure of the abdominal wall is often impossible in the pediatric population, due to a size mismatch between a large graft and a small recipient. We present a retrospective cohort study of six pediatric patients, who underwent delayed abdominal wall closure with a biological mesh after LT, and in whom early closure was impossible. A non‐cross‐linked porcine‐derived acellular dermal matrix (Strattice™ Reconstructive Tissue Matrix; LifeCell Corp, Bridgewater, NJ, USA) was used in all of the cases of the series. After a mean follow‐up of 26 months (21–32 months), all patients were asymptomatic, with a functional abdominal wall after physical examination. Non‐cross‐linked porcine‐derived acellular dermal matrix (Strattice™) is a good alternative for delayed abdominal wall closure after pediatric LT. Randomized controlled trials are necessary to determine the best moment and the best technique for abdominal wall closure.

Simultaneous liver-kidney transplant for combined renal and hepatic end-stage disease.

INTRODUCTION After the first combined liver-kidney transplantation (CLKT) reported by Margreiter in 1984, it became clear that renal failure was no longer an absolute contraindication. OBJECTIVE Our goal was to assess our results with combined liver-kidney transplant. Among 875 liver transplants performed between May 1986 and October 2002, there were 17 cases (1.96%) of combined liver-kidney transplant. RESULTS With a mean follow-up of 42.2+/-29 months (range, 1-90), six patients had died (mortality: 37.5%). There were four (25%) operative in-hospital deaths, and two late mortality cases (beyond the month 6 after hospital discharge). The causes were sepsis (four cases, three postoperative and one in later follow-up), refractory heart failure (one postoperative), and recurrent liver disease (HCV-induced severe recurrence) during follow-up one). Actuarial survival (calculated for those who survived the postoperative period) was 80%, 71%, and 60% at 12, 36, and 60 months. Actuarial mean survival time was 60 months (95%IC:47-78). Neither the sex, the UNOS status, the etiology of liver disease, the etiology of renal failure, the type of hepatectomy (piggy back vs others) or the type of immunosuppression (P=.83) were related to long-term survival according to the log-rank test. A control group of 48 patients was constructed with subjects who underwent liver transplantation immediately before or after the combined transplant. A total (two cases after the CLKT and one case prior to). There were no differences in survival. CONCLUSION Combined liver-kidney transplant represents a proper therapeutic option for patients with simultaneously failing organs based on long- and short-term outcomes.

Live liver donation: a prospective analysis of exclusion criteria for healthy and potential donors

INTRODUCTION Living donor liver transplantation represents a controversial option to increase the donor pool. DESIGN Prospective and descriptive clinical study. OBJECTIVE (1) To identify risk factors (exclusion criteria) for live donation; (2) to determine the rate of recipients that benefit from a living donor. METHODS Between May 1995 (first adult-to-adult living donor liver transplantation in Spain) and November 2002, we evaluated 74 healthy volunteers and performed 12 living donor liver transplants (no donor mortality). RESULTS All actual donors and volunteers are alive and healthy. After a mean time of 3.2+/-0.5 weeks, 72% of potential donors were considered unsuitable for live donation. Exclusion criteria were grouped in three categories: (primary) donor safety reasons (68%); (secondary): ABO mismatch (17%) and (tertiary): cadaveric graft transplantation (15%). Consequently, just 43.7% of the recipients presenting to us with a potential living donor, did finally benefit from these organs. The mortality rate was 8.3% for 43 recipients presenting with a living donor in comparison to 15% for those who did not (321 recipients between May 1995 and November 2001). CONCLUSIONS ALDLT can benefit a significant number of recipients on the waiting list (43.7% of those presenting with a donor). The most frequent exclusion criteria concern donor safety, namely, unsuspected chronic liver diseases and unsuspected thrombophilic disorders.

Complicaciones de las resecciones hepáticas

Resumen Aunque la morbimortalidad de las resecciones hepaticas ha disminuido, sigue siendo considerable. El porcentaje de complicaciones es del 15-50% y la mortalidad del 0-5%. Los principales factores relacionados con mayor morbimortalidad son la transfusion, el tamano de la reseccion, la ictericia previa, la cirrosis, la esteatosis y ASA mayor de uno. La edad por si sola no se debe considerar factor de riesgo. Entre las complicaciones derivadas de la propia cirugia las mas importantes son el absceso intraabdominal (3-15%), la fistula biliar (3-7%), la hemorragia postoperatoria (0-4%) y la insuficiencia hepatica (1-7%). Las dos primeras raramente condicionan la reintervencion o muerte del enfermo. Los abscesos se tratan por puncion percutanea guiada con ecografia o tomografia computarizada. La fistula biliar generalmente se resuelve con tratamiento conservador. En fistulas persistentes de alto debito la colocacion de un cateter transparietohepatico o la esfinterotomia endoscopica facilitan su resolucion al disminuir la presion en la via biliar. La transfusion de sangre, ademas de coagulopatia, hipotermia, distres respiratorio, etc., causa inmunosupresion e incluso se ha asociado a recidivas mas precoces del tumor resecado. La mayoria de resecciones hepaticas se pueden realizar con un control vascular selectivo mediante ligadura de la triada portal correspondiente o la maniobra de Pringle, y ligadura de la vena suprahepatica correspondiente, con volumenes de transfusion bajos. Sin embargo, algunos equipos abogan por el empleo de la tecnica de exclusion vascular total en tumores grandes o proximos al hilio, vena cava o suprahepaticas. En nuestra experiencia, se puede realizar con seguridad cualquier tipo de reseccion hepatica sin necesidad de una exclusion vascular total. La autotransfusion o la hemodilucion normovolemica pueden reducir el volumen de transfusion de sangre homologa en un 60%. La insuficiencia hepatica origina una mortalidad del 0,7-2,5%. En higados sanos se pueden hacer con seguridad resecciones del 75% del volumen hepatico. La esteatosis, la quimioterapia o embolizacion previa y, sobre todo, la cirrosis, comportan un mayor riesgo de insuficiencia hepatica. La seleccion de candidatos a reseccion en estos grupos es fundamental, y se debe hacer basandose en tests de reserva funcional hepatica (el test de retencion de verde de indocianina ha demostrado buenos resultados) y volumentria con tomografia computarizada. La embolizacion portal para hipertrofiar el lobulo contralateral puede permitir la reseccion de algunos casos de otro modo irresecables. Entre las complicaciones generales las mas frecuentes son: derrame pleural (5-25%), neumonia (0,5-5%), infarto (0,5-1,5%) y sepsis (1-6%). Las principales causas de mortalidad son: fallo hepatico (40-60%), hemorragia (10-20%), sepsis (20-45%), infarto (20%) y neumonia (20%).

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.