Dean Y. Kim

Recurrence of non-alcoholic steatohepatitis and cryptogenic cirrhosis following orthotopic liver transplantation in the context of the metabolic syndrome.

Non‐alcoholic steatohepatitis (NASH) and cryptogenic cirrhosis (CC) are increasing indications for orthotopic liver transplantation (OLT). The aim of this study is to describe our outcomes and delineate predictors of recurrence of NASH and CC after OLT.

Successful embolization of hepatocelluar carcinoma with yttrium-90 glass microspheres prior to liver transplantation

We report a case of a patient with end-stage liver disease secondary to hepatitis C, complicated by a large hepatocellular carcinoma. Because of the size of the tumor exceeded the Milan criteria, he was not a can-didate for liver transplantation. However, after two treatments with yttrium-90 glass microsphere infu-sions, the tumor became smaller and the patient’s α-fetoprotein level dropped to normal range. He was listed for transplantation and subsequently received a deceased donor liver transplant. Two years after his transplantation, he remains tumor free and has normal α-fetoprotein levels. This is the first reported case in the literature of using yttrium-90 microspheres as a bridge to liver transplantation in a patient with a large hepatocellular carcinoma. This therapy should be considered in patients with cirrhosis and large hepatocellular carcinomas exceeding current size criterion, who would otherwise be good candidates for transplantation.

Impact of aberrant arterial anatomy and location of anastomosis on technical outcomes after liver transplantation.

Variations in donor and recipient arterial anatomy frequently present challenges for surgeons when attempting to establishproper arterialinfiowduring liver transplantation. Wereviewed our dataon233 adult primary liver transplants, conducted from January 1996 through December 2001, to determine the impact of these variations on the outcomes after liver transplantation. Twenty-four (10.3%) arterial complications were encountered at a mean of 2.27 months after transplant. Carrel patches for the anastomoses were not used in 33 patients (14%), which had no relation to arterial complications (P = 0.7). Sixty-one donors (26.2%) had at least one aberrant artery, which had no relation to arterial complications. However, use of donor celiac artery for anastomosis was significantly associated with higher arterial complications (16% versus other choices, P = 0.03). Furthermore, use of common hepatic recipient artery was associated with higher arterial complications (16%, P = 0.03).There were 58 total biliary complications (24.8%). Biliary complications were associated with the presence of arterial complications (P = 0.01). In conclusion, aberrant donor arterial anatomy was not associated with an increased rate of arterial complications; however, choice of location of arterial anastomosis may be a significant factor. Biliary complications were associated with arterial complications.

New application of the bipolar vapor plasma coagulation system for laparoscopic major liver resections

BackgroundIn recent years, laparascopic techniques have become a more widely used and accepted means for performing various types of liver resections. In this report, the authors describe the use and initial applications of a new approach to laparoscopic liver resection using vapor pulse coagulation.MethodsLiver resections using vapor plasma coagulation technology were performed for 11 patients at the authors’ center. Candidates were initially selected because they had benign disease and lesions amenable to standard resections along anatomic planes. Four resections were performed with a hand-assist technique and seven without it.ResultsAll the patients faired well. The length of the hospital stay was 3.4 ± 0.7 days. There were no major surgical complications, bile leaks, or reoperations. None of the patients required blood transfusions. One patient was readmitted for fever and urinary tract infection, and one patient had 1 week of right leg swelling attributable to the use of stirrups.ConclusionsVapor plasma coagulation using a laparoscopic approach for hepatic resection is a promising new technology that deserves further exploration.

Experience with recipient splenic artery inflow in adult liver transplantation: a case series

IntroductionHepatic artery thrombosis following orthotopic liver transplant is one of the most common reasons for early graft failure. Meticulous reconstitution of hepatic artery flow remains essential for good outcomes. Prior surgery, body habitus, hepatic artery inadequacy and anatomic differences can complicate hepatic artery revascularization.Case presentationWe report a single institutions experience, from January 1996 to January 2007, using splenic artery inflow in seven patients with inadequate native hepatic arteries.ConclusionEnd-to-side anastomosis was associated with postanastomotic intimal hyperplasia. End-to-end anastomosis provided effective hepatic inflow, demonstrated splenic and pancreatic safety, and was not associated with the intimal hyperplasia experienced with end-to-side anastomosis.

Extrahepatic metastasis of hepatocellular carcinoma to the paravertebral muscle: A case report

Identification of extrahepatic metastases (EHM) of hepatocellular carcinoma (HCC) has been paradoxically increasing due to an increase in the survival of HCC patients. However, metastasis of HCC to the skeletal muscle tissue is extremely rare. We describe a unique case of HCC metastasizing to the paravertebral muscle. A 55-year-old man with a history of hepatitis B cirrhosis underwent partial liver resection with complete removal of HCC. Three months later, a computed tomography (CT) scan showed intrahepatic recurrence. The tumors were treated with yttrium-90 microspheres, trans-catheter arterial chemoembolization, and sorafenib. Six months later, a CT scan showed an enhancing lesion of the left paravertebral muscle that on biopsy were consistent with metastatic HCC. The tumor was treated with stereotactic hypo-fractionated image-guided radiation therapy (SHFRT). A follow-up scan 3 mo post-radiotherapy revealed a stable appearance of the paravertebral muscle metastasis. Because of the progression in the intrahepatic tumors, the patient was treated with capecitabine, which was changed to dasatinib 6 mo later. The patient passed away three years after the primary surgical resection. Management of EHM poses an extreme challenge. This is the first case of HCC with EHM to the paravertebral muscle in which stability of disease was achieved using SHFRT. This case highlights the importance of early detection of hepatitis B viral infection and initiation of anti-viral therapy to decrease recurrence of HCC and prevent EHM.

Allograft loss from acute Page kidney secondary to trauma after kidney transplantation

We report a rare case of allograft loss from acute Page kidney secondary to trauma that occurred 12 years after kidney transplantation. A 67-year-old Caucasian male with a past surgical history of kidney transplant presented to the emergency department at a local hospital with left lower abdominal tenderness. He recalled that his cat, which weighs 15 lbs, jumped on his abdomen 7 d prior. On physical examination, a small tender mass was noticed at the incisional site of the kidney transplant. He was producing a normal amount of urine without hematuria. His serum creatinine level was slightly elevated from his baseline. Computer tomography revealed a large subscapular hematoma around the transplant kidney. The patient was observed to have renal trauma grade II at the hospital over a period of three days, and he was finally transferred to a transplant center after his urine output significantly decreased. Doppler ultrasound demonstrated an extensive peri-allograft hypoechoic area and abnormal waveforms with absent arterial diastolic flow and a patent renal vein. Despite surgical decompression, the allograft failed to respond appropriately due to the delay in surgical intervention. This is the third reported case of allograft loss from acute Page kidney following kidney transplantation. This case reinforces that kidney care differs if the kidney is solitary or a transplant. Early recognition and aggressive treatments are mandatory, especially in a case with Doppler signs that are suggestive of compression.

Mycophenolate Mofetil and Pulmonary Fibrosis After Kidney Transplantation: A Case Report

Patient: Male, 50 Final Diagnosis: Pulmonary fibrosis Symptoms: Short of breath Medication: — Clinical Procedure: — Specialty: Transplantology Objective: Adverse events of drug therapy Background: Mycophenolate mofetil (MMF) induced lung disease has been described in only a few isolated reports. We report a case of fatal respiratory failure associated with MMF after kidney transplantation. Case Report: A 50-year-old Hispanic male with a history of end-stage renal disease secondary to hypertension underwent deceased donor kidney transplantation. His preoperative evaluations were normal except for a chest x-ray which showed bilateral interstitial opacities. Tacrolimus and MMF were started on the day of surgery. His postoperative course was uneventful and he was discharged on postoperative day 5. One month later, he presented with shortness of breath and a cough with blood-tinged sputum. His respiratory condition deteriorated rapidly, requiring intubation. Chest computer tomography (CT) demonstrated patchy ground-glass opacities with interlobular septal thickening. Comprehensive pulmonary, cardiac, infectious, and immunological evaluations were all negative. Open lung biopsy revealed extensive pulmonary fibrosis with no evidence of infection. He temporarily improved after discontinuation of tacrolimus and MMF, however, on resuming MMF his respiratory status deteriorated again and he subsequently died from hypoxic respiratory failure. Conclusions: An awareness of pulmonary lung disease due to MMF is important to prevent adverse outcomes after organ transplantation. MMF must be used with utmost care in recipients with underlying lung disease as their pulmonary condition might make them more susceptible to any harmful effects of MMF.

PATIENT SURVIVAL AFTER LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA: SINGLE CENTER EXPERIENCE WITH THE MILAN AND UP-TO-SEVEN CRITERIA: 2821

M.S. Abouljoud1, M.M. Elatrache2, A. Yoshida3, D.Y. Kim1, M.M. Kazimi1, R. Slater1, K. Brown4, D. Moonka4 1Henry Ford Hospital, Transplant Institute, Detroit/MI/UNITED STATES OF AMERICA, 2Henry Ford Hospital, Transplant Institute , Detroit/MI/UNITED STATES OF AMERICA, 3Henry Ford Hospital, Transplant Institute, Detroit/UNITED STATES OF AMERICA, 4Henry Ford Hospital, Gastroenterology and Hepatology, Detroit/MI/UNITED STATES OF AMERICA