Charles Millson

Emergency Subtotal Hepatectomy: A New Concept for Acetaminophen-Induced Acute Liver Failure : Temporary Hepatic Support by Auxiliary Orthotopic Liver Transplantation Enables Long-term Success

Introduction:Acetaminophen (paracetamol) overdose (AOD) has recently emerged as the leading cause of acute liver failure (ALF) in the United States, with an incidence approaching that seen in the United Kingdom. We describe a new way to treat AOD ALF patients fulfilling Kings College criteria for “super-urgent” liver transplantation. Methods:Beginning in June 1998, we have been piloting a clinical program of subtotal hepatectomy and auxiliary orthotopic liver transplantation (ALT) for AOD ALF. Our technique is based on the following principles: (1) subtotal hepatectomy; (2) auxiliary transplantation of a whole liver graft; (3) gradual withdrawal of immunosuppression after recovery. Results were compared with patients who had undergone an orthotopic liver transplantation (OLT) for AOD ALF in the same period. Quality of life comparisons were made using the SF36 questionnaire. Results:Thirteen patients underwent this procedure between June 1998 and March 2005. Median survival is 68 months (range, 0–102 m). Actual survival data show that 9 of 13 patients are alive (69%) compared with 7 of 13 OLT patients (54%). One ALT patient required a retransplantation with an OLT due to hepatic vein thrombosis, and immunosuppression is therefore maintained. The other 8 surviving ALT patients are off immunosuppression. These 8 ALT patients have normal liver function and have a better quality of life compared with the 7 surviving OLT patients. Conclusion:Our results with this new technique are encouraging: 69% actual survival, no long-term immunosuppression requirement, and improved quality of life in the 62% successful cases.

A combined liver-pancreas en-bloc transplant in a patient with cystic fibrosis.

We report a case of combined liver-pancreas en-bloc transplant for a patient with cystic fibrosis (CF) and insulin dependent diabetes mellitus (IDDM). A combined liver-pancreas transplant for a patient with CF has been described only once before in the literature with orthotopic liver and heterotopic pancreas and kidney transplant (1). Here we present a new and more efficient en-bloc technique for combined liver-pancreas transplant.

Caution in using a unique technique of banded revision gastric bypass: Successful endosopic and surgical management of a rare complication

INTRODUCTION Revision surgery is increasingly performed as result of the increase in primary bariatric procedures. We describe a new technique of revision Roux-en-Y gastric bypass (RYGB) acombining stapled gastroenterostomy with fixed band placement. We report two cases of unique complications and its successful endoscopic and surgical management. PRESENTATION OF CASE Two out of twenty patients undergoing this revision RYGB procedure presented with gastric outlet obstruction due to band erosion within 10 weeks. Endoscopic band retrieval was successful in the first patient but the second patient required surgical removal. DISCUSSION We report the new complication of band erosion in 10% patients using a unique revision RYGB technique combining restriction of the gastric outlet and band placement. We advise using one or the other technique but not both in combination. Surgeons need to be aware of this as erosion which occurs early due to close proximity of band with fresh staple line. We report successful endoscopic and surgical management. CONCLUSION Revision surgery using this technique predisposes to bande erosion, presenting as gastric outlet obstruction. Endoscopic management should be attempted prior to surgical removal.

Fulminant hepatic failure in a patient with advanced extragonadal germ cell tumour

Fulminant hepatic failure (FHF) in association with metastatic cancer, without evidence of liver metastases, has not been previously reported in the literature. This report concerns a case of FHF in a 36-year-old man with advanced germ cell tumour arising from an extragonadal (retroperitoneal) primary. Liver function and encephalopathy improved following chemotherapy, suggesting prompt diagnosis and treatment may have cured the patient. Following completion of chemotherapy, he developed spontaneous bacterial endocarditis, requiring aortic valve replacement, a rare complication of curative chemotherapy. At 44 months post completion of chemotherapy, he has regained his premorbid performance status and has returned to work.