Elizabeth Balbi

Liver transplantation with monosegments. Technical aspects and outcome: A meta-analysis

The shortage of organ donors for low‐weight liver transplant recipients, especially small children, has led to the development of new surgical techniques to increase the donor pool. Almost all of these techniques use the left lateral segment (Couinauds segments II and III), but even this graft could be too large for children under 10 kg, and further reduction could be necessary. Few articles address the issue of monosegmental liver transplantation. Available articles are with small sample sizes or even case reports, which makes it difficult to draw conclusions about indication and outcome for monosegmental grafts. A search of the MEDLINE databases using the terms “Liver Transplantation” and “Monosegmental” or “Monosegments” limited to title or abstract with publication in the English language was conducted. The data from each study were selected and analyzed, regarding donor status (living or cadaveric), donor weight, surgical techniques used in left lateral further reduction, recipient indication for liver transplantation, age and recipient weight, graft‐to‐recipient body weight ratio, segment utilized, type of abdominal closure, postoperative complications, and survival. Seven publications were identified from 1995 to 2004 and fulfilled the criteria. A total of 27 pediatric patients who received a monosegment transplant were identified, median age 211 days (range, 27 to 454 days) and median weight 4.6 kg (range, 2.45 to 7.4 kg). Segment III was utilized in 21 (78%) and segment II in 6 (22%). Patient survival was 85.2%. In conclusion, monosegment liver transplantation appears to be a satisfactory option for infants weighing less than 10 kg who require a liver transplant. (Liver Transpl 2005;11:564–569.)

Vascular Complications After Living Donor Liver Transplantation: A Brazilian, Single-Center Experience

BACKGROUND In living donor liver transplantation (LDLT), vascular complications are more frequently seen than in deceased donor transplantation. Early arterial, portal vein, or hepatic vein thromboses are complications that can lead to graft loss and patient death. The aim of this study was to assess the incidence, treatment, and outcome of vascular complications after LDLT in a single Brazilian center. METHODS Between December 2001 and December 2010, we performed 130 LDLT. Sixty-four recipients were children (27 weighing <10 kg). RESULTS Nine recipients had vascular complications. Hepatic artery thrombosis (HAT) occurred in 4 (3.1%), portal vein thrombosis (PVT) in 3 (2.3%), and hepatic vein thrombosis (HVT) and hepatic arterial stenosis (HAS) in 1 (0.8%) patient each. Complications were identified by Doppler and confirmed by angiography or angiotomography. Patients with HAT were listed for retransplantation. One died before retransplant. Two children were submitted to retransplantation; one is still alive, with neurologic sequelae. One adult with HAT was retransplanted with a deceased donor graft and is doing well 58 months after surgery. Two patients with PVT died as a consequence of graft malfunction. In the other case, portal vein arterialization was performed, but patient died 11 months posttransplant. HVT was detected after cardiac reanimation and was treated with an endovascular stent. This patient died 3 months after LDLT. HAS was diagnosed after liver abscess development and was successfully treated by endovascular angioplasty. No recurrence was observed after 22 months. Follow-up ranged from 9 to 117 months. CONCLUSION Pediatric patients are more prone to develop vascular complications after LDLT. Long-term survival was statistically lower for recipients with vascular complications (33.3% vs 77.7%; P = .008).

Methylene Blue Used as a Bridge to Liver Transplantation Postoperative Recovery: A Case Report

Hepatopulmonary syndrome is defined as a triad of liver disease, arterial hypoxemia, and intrapulmonary vascular dilatation. The clinical hallmark of this disorder is the impairment of pulmonary gas exchange, not necessarily correlated with the severity of the underlying liver disease. Liver transplantation (OLT) is the only definitive treatment for this syndrome. However, patients with preoperative partial pressure of arterial oxygen (PaO(2)) under 50 mm Hg are exposed to an unacceptably high postoperative mortality and morbidity. Herein we have described a case of a 15-year-old female patient who underwent OLT and was treated with methylene blue in the early postoperative period to improve hypoxemia. We suggest that the use of methylene blue after liver transplantation can decrease postoperative complications and mortality rates in these patients.

Outflow reconstruction in domino liver transplantation with interposition of autologous portal vein graft. A new technical option in living donor domino liver transplant scenario

In 1997, a new modality of liver transplantation was introduced: the sequential, or domino, liver transplantation. 1 The Achilles heel of domino transplantation remains the inferior vena cava length of both the familial amyloidotic polyneuropathy (FAP) patient and the domino recipient. Some investigators have reported that the pericardium may be sectioned to lengthen the vena cava stumps, and serious complications of inferior vena cava anastomosis in domino liver transplantation have been reported. Recently, Pena et al. and Pacheco-Moreira et al. described the new technique for domino liver transplantation in which vascular outflow anastomosis in the domino recipient were performed with an iliac/caval vein graft from cadaveric donor. For this reason, some technical difficulties such as short vena cava stump, pericardial effusion, and bad outflow in both patients are avoided. This technique also avoids the necessity of the venovenous bypass or the hemodynamic changes after caval clamping in FAP patients. In this case we describe the success of using a recipient’s inverted portal vein bifurcation as an interposition graft to drain the outflow in the domino recipient also in a living donor liver transplantation scenario. Lately, techniques for reconstruction of hepatic vessels including the portal vein have been reported in living donor liver transplantation. A 37-year-old man (a FAP patient’s husband) donated a right liver. The living donor liver transplantation recipient, a 36-year-old woman with FAP, agreed to also be a domino donor. The native hepatectomy in the FAP patient was performed with inferior vena cava preservation, and venovenous bypass was not required. The living donor right graft was implanted in the FAP patient as usual. The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day. The FAP liver as a domino graft was harvested without the vena cava (Fig. 1) and perfused on the backtable with Belzer solution (Viaspan, DuPont Pharma, Wilmington, DE). The middle and left hepatic veins were joined together (Fig. 2). The autologous portal vein bifurcation (domino recipient) was used as vascular graft according to inverted Y-graft technique (Fig. 3). The venous graft of the right portal vein was anastomosed with right hepatic vein, and the left portal vein was anastomosed with the new common trunk of the middle and left hepatic veins using a 5-0 polypropylene running suture. A 49-year-old man with end-stage liver disease secondary to hepatitis C agreed to accept the FAP liver. The recipient’s hepatectomy was performed with preservation of the inferior vena cava, and the liver was implanted in the standard piggyback fashion using the portal stump of the venous graft as the outflow from the

Tuberculosis in Liver Transplant Recipients: Prophylaxis in an Endemic Area

BACKGROUND Tuberculosis (TB) has a high prevalence in Brazil. The scenario of liver transplantation (LT) creates challenges: atypical presentation, treatment hepatotoxicity, and increased mortality. The majority of TB cases after transplantation represent reactivation of latent infections; therefore, prophylaxis (PX) plays a major role. The aim of this study was to evaluate the benefits of PX after LT based on a pretransplantation tuberculin test (TT) in an endemic area. METHODS Retrospective analysis of medical data from 376 adult cirrhotic patients undergoing OLT from 2001 to 2009. RESULTS Among 191 selected patients, 137 (71%) showed a pretransplant TT including 41 (30%) with a TT ≥5 mm. The 17 (40%) of these patients who were prescribed PX did not experience TB. Prophylaxis was discontinued in 5 patients (20%) owing to suspicion of hepatotoxicity (medium serum alanine transaminase 175 U/L). In the group without PX, we diagnosed 1 case of pulmonary TB. The overall prevalence of anergic patients in the cirrhotic phase was 65% and prevalence of TB 1%. CONCLUSIONS The prevalence of TB was similar to that reported in the literature, but positivity to TT was higher (34% vs 25%), possibly because of the endemicity of the area. There was a lower prevalence of extrapulmonary disease and no mortality. No patient undergoing PX with isoniazid, although incomplete due to suspicion of hepatotoxicity displayed TB. One patient without PX was affected by TB. The drug was effective but not always safe.

Selection of donors for living donor liver transplantation in a single center of a developing country: lessons learned from the first 100 cases.

Abstract: The selection of donors for living donor liver transplantation (LDLT) is one of the most important features in this kind of surgery. The aim of this study is to describe our initial experience in the donor evaluation process. From December 2001 to January 2005, 104 donors were evaluated for 70 recipients (65 potential donors were evaluated for 39 adult recipients, and 39 donors for 31 pediatric recipients). Only 30 donors were able to donate: 13 for the adult group, and 17 for the pediatric one. In general, the utilization rate of potential donors was 28.8% (30/104). For the adult patients, 65 potential donors were seen to perform 13 LDLT, which represents a utilization rate of potential donors of 20%. For the pediatric patients, this rate was 43.6%. The exclusion criteria were clinical in 22 cases (21%), anatomical in 13 cases (13%), psychosocial in nine cases (9%), and others in 12 (12%). Death of recipients led to excludsion 18 of donors (17%). Thirty‐three percent of adults and 55% of pediatric recipients who had at least one potential donor to start the evaluation process were able to identify a living donor. In conclusion, the first limit for LDLT is the rigorous donor evaluation.

Liver transplantation with monosegment from a living donor

Abstract:  The shortage of organ donors for low‐weight liver transplant recipients, especially for small children, has led to the development of new surgical techniques to increase the donor pool. Almost all of these techniques use the left lateral segment (Couinauds segments II and III), but even this graft could be too large for children under 10 kg. We report here the case of an 8‐month‐old boy, weighing 6.1 kg, who received a monosegmental graft (segment III) from his grandmother weighing 68 kg. The graft was reduced at the donor surgery, before clamping of the vessels. The donor was discharged on the fourth post‐operative day; the recipient had an uneventful post‐operative period and was discharged after 22 days.

Hepatic artery reconstruction in pediatric living donor liver transplantation under 10 kg, without microscope use

Enne M, Pacheco‐Moreira L, Balbi E, Cerqueira A, Alves J, Valladares MA, Santalucia G, Martinho J‐M. Hepatic artery reconstruction in pediatric living donor liver transplantation under 10 kg, without microscope use.
Pediatr Transplantation 2010: 14: 48–51.

The safest way to play domino

In their article, Jabbour et al. describe a technical option to perform a domino liver transplantation. Inferior vena cava length is considered the Achilles heel of domino liver transplantation, and this technique may be considered as a strategy for circumvent problems related to inferior vena cava length for both patients: the patient with familial amyloid polyneuropathy (FAP), and the domino recipient. Portuguese and Brazilian liver transplantation surgeons have much experience in domino liver transplantation because FAP is not a rare disease in these countries. Our team is pleased when good results in domino liver transplantation are published. It is an incentive to perform this type of liver transplantation. Although the technique described by Jabbour et al. is interesting, they cannot say that “this is a first time it has been described for a domino liver transplantation.” A Portuguese team presented this idea during the ILTS Chicago Congress in 2002, and we published exactly the same technique in Liver Transplantation in 2003. From 2002 to the present day, we have performed 6 cases of domino liver transplantations. In 4 of them, an inferior vena cava with the iliac veins graft harvested from a deceased donor was used as described. In these 4 transplantations, the outflow anastomosis was performed without any difficulty. Finally, because the deceased donor organ pool is not sufficient in every country, the allocation policy in many countries is to transplant the sickest patients first, which means that patients with FAP often spend a longer time on waiting lists. However, if good results are seen in domino liver transplantation, and if the domino technique is more secure and easy to perform, patients with FAP could be transplanted first, before the sickest patients. If the domino transplantation becomes routine, a FAP liver can be used in elderly patients with cirrhosis without problems and without additional technical difficulty. In general, livers from patients with FAP are good grafts because the donor is young, is hemodynamically stable, and does not have steatosis, and because the ischemia time is short. Placing the patient with FAP first will not adversely effect the liver waiting list. As Tzakis says, “Let’s play dominos.”

Normalização dos ciclos menstruais e gravidez após transplante de fígado

The objective of the present study is to evaluate the effects of successful liver transplantation on menstrual cycles abnormalities and on reproductive function of women with chronic liver disease. Twelve women with age between 17 and 54 years who underwent liver transplantation were evaluated. The following variables were analyzed: age, etiology of chronic liver disease, pattern of menstrual function and period of amenorrhea before and after transplantation, and occurrence of pregnancy after transplantation. The mean age of patients was 36 +/- 12.6 years. Patients with primary biliary cirrhosis did not have menstrual abnormalities before transplantation. The other patients presented amenorrhea for 3 months to 11 years before the transplantation. Rapid recovery of menstrual function was observed in all patients after the transplantation (3.1 +/- 1.2 months). Two patients became pregnant one and three years after the transplantation. It is concluded from this study that most women who present amenorrhea secondary to chronic liver disease have normal menstrual cycles in approximately three months following liver transplantation and they may become pregnant.O objetivo do presente estudo e avaliar os efeitos do transplante hepatico bem sucedido nas alteracoes dos ciclos menstruais e da fertilidade observadas em mulheres com hepatopatia cronica. Doze mulheres com idade de 17 a 54 anos submetidas a transplante hepatico foram avaliadas. As seguintes variaveis foram analisadas: idade, etiologia da hepatopatia, padrao da menstruacao, periodo de amenorreia, antes e apos o transplante, e ocorrencia de gravidez apos o transplante. A idade media das pacientes foi de 36 ± 12,6 anos. Pacientes com cirrose biliar primaria nao apresentavam amenorreia antes do transplante. Os demais pacientes apresentavam amenorreia por 3 meses a 11 anos antes do transplante. Recuperacao rapida da menstruacao ocorreu em todos pacientes apos o transplante (3,1 ± 1,2 meses). Duas pacientes engravidaram um e tres anos apos o transplante. Conclui-se deste estudo que a maioria das mulheres que apresenta amenorreia secundaria a doenca hepatica avancada, volta a ter ciclos menstruais normais aproximadamente tres meses apos o transplante hepatico e podem engravidar.