Eric T. Castaldo

Continuous versus interrupted suture for end-to-end biliary anastomosis during liver transplantation gives equal results†

Biliary complications following orthotopic liver transplantation have been reported in 10% to 30% of patients. Most surgeons perform an end‐to‐end choledochocholedochostomy with interrupted sutures for biliary reconstruction. The goal of this study was to compare biliary complications between interrupted suture (IS) and continuous suture (CS) techniques during liver transplantation in which an end‐to‐end choledochocholedochostomy over an internal biliary stent was performed. A retrospective cohort study of 100 consecutive liver transplants occurring between December 2003 and July 2005 was conducted. An end‐to‐end choledochocholedochostomy over an internal biliary stent was performed during liver transplantation. Data were analyzed using Kaplan‐Meier methods, t tests, and chi‐square tests of proportions. IS and CS techniques were used in 59 and 41 patients, respectively, for biliary reconstruction during liver transplantation. Mean follow‐up time for the CS group was 17 ± 8 months and 15 ± 7 months for the IS group (P = .21). The overall biliary complication rate was 15%. There was no difference in the proportion of leaks (CS = 7.3%, IS = 8.5%; P = .83) or strictures (CS = 9.8%, IS = 5.1%; P = .37) between groups. Kaplan‐Meier event rates show no difference in leaks (P = .79), strictures (P = .41), graft survival (P = .52), and patient survival (P = .32) by anastomosis type. In conclusion, there was no difference in biliary complications, graft survival, or patient survival between the 2 groups. CS and IS techniques for biliary reconstruction during liver transplantation yield comparable outcomes. Liver Transpl 13:234–238, 2007.

A clinical comparative analysis of crush/clamp, stapler, and dissecting sealer hepatic transection methods

INTRODUCTION Several methods for hepatic parenchymal division exist. The primary aim was to assess differences in postoperative bile leaks, operative blood loss, and margin status between three transection methods: crush/clamp (CC), stapler (SP), or dissecting sealer (DS). METHODS A single institution, retrospective cohort study was performed on data collected over a three-year period in patients undergoing elective liver resection using the CC, SP, or DS. Patients were excluded if multiple methods of transection were used or for intraoperative death. The association of bile leak with transection type was assessed. A logistic regression model was tested to assess if blood loss was associated with the covariates of transection method, use of portal inflow occlusion, extent of liver resection, and other concurrent major operations. RESULTS Analyses included 141 patients. The stapler method was quicker than the other methods (p=0.01). The risk of postoperative bile leak was no different between CC, SP, and DS transection methods (p=0.23). There was no difference in mean blood loss or transfusions; however, hepatectomies performed with DS were associated with an increased risk of blood loss > or = 1000 mL compared to CC (p=0.04). There were no differences in mean surgical margin between the three methods. CONCLUSION The risk of bile leaks was not different between the three methods. While mean blood loss was similar, hepatectomy performed with the DS was associated with an increased risk of having operative blood loss > or = 1000 mL compared to CC. Margins were equal by all methods. The stapler method was quicker.

Correlation of Health-Related Quality of Life After Liver Transplant With the Model for End-Stage Liver Disease Score

OBJECTIVE To determine whether a correlation exists between the Model for End-Stage Liver Disease (MELD) score and health-related quality of life (HRQOL) after liver transplant (LT). DESIGN Prospective cohort. SETTING University hospital. PATIENTS Adult LT recipients (N = 209). MAIN OUTCOME MEASURES Postoperative HRQOL over a 1-year period after LT as measured via multiple regression-based path analysis testing the effects of the MELD score, preoperative variables, and postoperative variables on scores on the physical component summary and mental component summary scales of the 36-Item Short Form Health Survey and on composite physical and mental HRQOL scores derived from multiple scales. RESULTS The MELD score (beta = .16), cholestatic cirrhosis (beta = .12), autoimmune/metabolic disease (beta = .18), neoplasm (beta = .23), time after LT (beta = .16), and the Karnofsky score (beta = .49) had significant effects on the physical component summary scale score. Autoimmune/metabolic disease (beta = .16) and the Karnofsky score (beta = .25) had significant effects on the mental component summary scale score. The MELD score (beta = .15), high school education (beta = .15), college education (beta = .17), autoimmune/metabolic disease (beta = .15), neoplasm (beta = .23), time after LT (beta = .11), and the Karnofsky score (beta = .51) had significant effects on the composite physical HRQOL score. Autoimmune/metabolic disease (beta = .23), neoplasm (beta = .15), and the Karnofsky score (beta = .42) had significant effects on the composite mental HRQOL score. CONCLUSIONS An increasing MELD score, when computed without any diagnosis-based exception points, was associated with improved physical HRQOL in the first year after LT. The MELD score did not affect mental HRQOL.

Profile of health-related quality of life outcomes after liver transplantation: univariate effects and multivariate models

AIM To test the effects of pre- and post-transplant clinical covariates on post-transplant health-related quality of life (HRQOL) score profiles in liver transplant recipients. MATERIAL AND METHODS HRQOL was measured before and after transplantation using the SF-36 Health Survey. Clinical data [diagnosis, model of end-stage liver disease (MELD) score, post-transplant rejection and infection episodes], pre-transplant functional performance (FP), and demographics were collected. Multivariate models for the eight SF-36 scales and two summary components were developed using multiple regression. Discriminant analysis was used to test whether the score profiles differentiated among recipients with and without hepatitis C virus (HCV) infection. RESULTS 104 adults reported pre- and post-transplant HRQOL. Time post-transplant averaged 9+/-8 months (range 1-39). Scores on all SF-36 measures improved from pre- to post-transplant (p<0.001), and 7 of 10 models were significant (p<0.05). After controlling for pre-transplant HRQOL and time post-transplant, HCV infection had a negative effect on the role physical, bodily pain, and role emotional scales. History of a rejection episode had a negative effect on the bodily pain and vitality scales. MELD scores > or = 18 had a positive effect on the role physical scale. Pre-transplant FP and post-transplant infection episodes did not affect post-transplant HRQOL. HCV infection had a significant effect on the SF-36 score profile (canonical correlation=0.50; p<0.001). CONCLUSIONS Pre-transplant HCV infection, MELD score, and post-transplant rejection episodes have significant independent effects on HRQOL after liver transplantation. Their specific effects vary among the individual SF-36 scales, and HRQOL score profiles differ among HCV+ and HCV- recipients.

Liver transplantation for acute hepatic failure

There are numerous causes of acute hepatic failure (AHF). Cerebral edema, coagulopathy, renal failure, metabolic disturbances and infection are the main clinical sequelae. Patients with AHF should be stabilized when first encountered and transferred to the nearest liver transplant center, as AHF progresses quickly and is often fatal. There are few adequate medical interventions and care of patients with AHF is supportive until spontaneous recovery ensues. If recovery does not appear to occur, most causes of AHF are well accepted indications for liver transplantation.

Liver transplantation for non-hepatocellular carcinoma malignancy

Liver transplantation (LT) for hepatocellular carcinoma is effective for selected patients. LT for other malignancies like cholangiocarcinoma (CCA), hepatoblastoma (HB), hepatic epithelioid hemangioepithelioma (HEHE), angiosarcoma (AS), and neuroendocrine tumors (NET) is being defined. For CCA, series that did not emphasize highly selected early stage disease and neoadjuvant or adjuvant chemoradiation had an average 5-year survival of 10%. However, emphasizing neoadjuvant radiation and chemosensitization in operatively confirmed stage I or II hilar CCA has led to improved 5-year survival, up to 82%. LT is indicated under strict research protocols at selected centers, for patients with early stage CCA and anatomically unresectable (Bismuth type IV) lesions. HB is typically sensitive to cisplatin-based chemotherapy. LT plays a role as primary surgical therapy for those individuals in whom tumors remain unresectable after chemotherapy or as rescue therapy for those who are incompletely resected, recur after resection, or develop hepatic insufficiency after chemotherapy and/or resection. Long-term survival is reported at 58-88%. HEHE is a multifocal tumor that lies somewhere between benign hemangiomas and malignant AS. The extensive multifocal nature makes resection difficult and LT an attractive option. Series on LT for HEHE report overall survival of 71-78% at 5 years. However, AS is an aggressive tumor and LT is contraindicated. For NET, resection of the primary tumor and all gross metastatic disease is reported to provide 5-year survival of 70-85%. LT has been employed for some patients for unresectable tumors or for palliation of medically uncontrollable symptoms with 5-year survival reported between 36% and 80%.

Improvement of Survival With Response to Neoadjuvant Radiation Therapy for Rectal Cancer

OBJECTIVES To determine whether patients with a complete or near-complete response to neoadjuvant radiation therapy (XRT) have improved survival compared with those with less of a response and to compare survival between patients with disease downstaged after neoadjuvant XRT and patients with stage I disease undergoing resection alone. DESIGN, SETTING, AND PATIENTS Retrospective cohort of 10,971 patients (3760 patients with neoadjuvant XRT; 7211 with stage I disease with resection alone) from the Surveillance, Epidemiology, and End Results registry using data from January 1, 1994, through December 31, 2003. MAIN OUTCOME MEASURES Overall survival and disease-specific survival (DSS) of patients undergoing resection for nonmetastatic rectal adenocarcinoma receiving neoadjuvant XRT and patients with stage I disease undergoing surgical resection alone. RESULTS The 5-year DSS and overall survival were 94% and 82%, respectively, for responders to neoadjuvant XRT, 78% and 60%, respectively, for nonresponders, and 97% and 79%, respectively, for patients with stage I disease undergoing resection alone. Responders had improved DSS (P < .001) and overall survival (P < .001) compared with nonresponders by Cox regression. Patients with stage I disease undergoing resection alone had improved DSS (P = .01) but not overall survival (P = .89) compared with XRT responders. CONCLUSIONS Patients with rectal adenocarcinoma downstaged after neoadjuvant XRT have improved survival compared with nonresponders. While DSS is excellent for responders to neoadjuvant XRT, it did not equal the DSS of patients with stage I disease undergoing resection alone.