Ernest Hidalgo

Liver Transplantation for Malignant Diseases: Selection andPattern of Recurrence

Liver transplantation (LT) for malignant tumors should be accepted if, with adequate case selection, long-term results are similar to those in patients transplanted for benign diseases. The aim of the present study was to reexamine selection criteria for LT in malignant diseases with particular emphasis on hepatocellular carcinoma (HCC) in cirrhosis. One hundred-three of 369 patients transplanted in our unit had HCC in cirrhosis (28%), 15 of which were incidental tumors, and 234 patients underwent LT for non-cholestatic cirrhosis. Pretransplant arterial chemoembolization(TACE) was performed in 36 cases (41%) of known HCC. Only early,well-delimited tumors in advanced cirrhosis with no extrahepatic disease were accepted for LT. Hepatocellular carcinoma characteristics included mean tumor size (3.1 cm), multiple (59%), bilobular involvement (31%), and vascular invasion (9.2%). Postoperative mortality was 4%. Median follow-up was 67.5 months. Tumor recurrence rate was 14.5%, 33% (5/15) in incidental tumors and 11.4% (10/88) in known HCC and by tumor stage (pTNM): 7.7% (1/13) in stage I, 16.7%(5/30) in stage II, 15% (3/20) in stage III, and 17% (6/35) in stage IV. Mean time for recurrence was 20.6 months. Tumoral vascular invasion, tumor differentiation, and satellite tumors were significant factors for tumor recurrence in univariate analysis, whereas tumor vascular invasion was the only significant factor for tumor recurrence in multivariate analysis. Actuarial survival rates at 1, 3, and 5 years were 81%, 66%, 58%, respectively, in patients with HCC and were similar to those of cirrhotic patients 76%, 67%, 63%, respectively. In conclusion, patients with early HCC in cirrhosis are good candidates for LT; results are similar when compared with those of cirrhotic patients without tumor. Liver transplantation for other malignancies is admitted only in fibrolamellar hepatoma, hepatoblastoma, epithelioid hemangioendothelioma without extrahepatic disease, and in metastases from carcinoid tumors.

Predictive factors for early mortality following liver transplantation

Abstract: Aims: To retrospectively review our liver transplant performance to identify factors that influenced early outcomes and to prospectively test their validity in predicting outcomes.

Outcome and hepatic hemodynamics in liver transplant patients with portal vein arterialization.

Few cases of successful portal vein arterialization in orthotopic and auxiliary liver transplantation have been reported.

Hemodynamic consequences of spontaneous splenorenal shunts in deceased donor liver transplantation

The presence of large spontaneous splenorenal shunts (SSRSs) is a risk factor for poor portal vein flow and liver dysfunction. The disconnection of splenorenal shunts by left renal vein (LRV) ligation has been suggested as a potential solution for improving portal flow. We reviewed the hemodynamic consequences of splenorenal shunts in deceased donor liver transplantation and investigated the role of LRV ligation. In 10 patients who underwent liver transplantation at our institution between January 2006 and April 2010, an SSRS was diagnosed preoperatively. Intraoperative portal and hepatic artery flows were measured with a transit time flowmeter. The shunt was disconnected in 6 patients for whom the portal flow after reperfusion was less than or equal to 1200 mL/minute. LRV ligation resulted in significant increases in the portal flow. There were no differences in renal function for the patients who underwent renal vein ligation and the patients who did not undergo ligation. In conclusion, LRV ligation disconnects splenorenal shunts and modulates the portal inflow without any detrimental effects on renal function. Liver Transpl 17:891–895, 2011.

Hemodynamics in human liver transplantation with inferior vena cava preservation

S OME patients do not tolerate inferior vena cava (NC) and portal clamping during the anhepatic phase of orthotopic liver transplantation (OLT), and veno-venous bypass (VVBP) is usually required in order to maintain hemodynamics during this phase.’ Recipient hepatectomy with IVC preservation’ was introduced into our program in 1991 to avoid WBP and complications due to its use. This technique became routine in the majority of cases.3 The aim of this study was to ratify our results by measuring I?C flow and pressure and correlating them with data on patient hemodynamics.

Severe preprocurement blunt trauma to the liver: Is there a need for back-table cutdown?

We read with great interest the recent article by Geenen et al., who described the utilization and outcomes of deceased donor liver allografts with preprocurement injury from blunt trauma. Marginal grafts are increasingly being used to reduce waiting list mortality and minimize the gap between the demand for liver transplantation and the number of available organs. However, blunt trauma to the liver remains a concern for transplantation, with no consensus on the utilization of such grafts and, in particular, the optimal surgical approach. There are very few reports on the use of livers with blunt trauma, and this series is a significant addition, describing the largest experience to date with all grades of liver trauma. The authors identified a 4.8% contribution to the donor pool from livers that had sustained blunt trauma. Most injuries were minor (grades I and II), whereas 30% were major (grades III-V). However, it is unclear from the article whether the 2 additional cases with intimal injuries to the cava and celiac axis had associated liver parenchyma injuries, which would make them suitable for this series. The first important message of this article is the excellent outcome achieved in all patients. This appears to be a recurring theme in all published reports and supports a revision of the discarding policy for traumatized livers. In addition to the 15 cases in their report, the authors identified another 42 potentially suitable livers that were discarded. These findings suggest that such a revision could provide an increase in the number of available livers, particularly in countries in which trauma remains a significant cause of death for potential donors. A second key but controversial message concerns the surgical strategy for severe injuries ( grade II) that are known pre-procurement. Geenen et al. suggested that these livers should undergo resection of the injured area of the graft, either on the back-table or as an in situ split. Although the former option could be indicated in severe injuries with significant capsular damage, the latter is likely to be the exception rather than the norm in the setting of an unstable donor, who would require packing and an expedited procedure. Although the proposed surgical strategy of cutdown would be suitable for lacerations with parenchymal damage, it may not be necessary for grade III-IV injuries (hematoma, lacerations, or a combination of both) within the liver and with no capsular damage. Back-table resection could in fact expose the recipient to the additional risks and complications of a reduced graft. Recently, we were offered a liver from a 22-year-old donor that was turned down by another center because of significant trauma. A computed tomography scan of the abdomen at the time of admission revealed a grade III injury with a 7-cm diffuse intrahepatic hematoma involving segments 7 and 8 adjacent to the right hepatic vein and a 3-cm deep parenchymal laceration extending towards the surface of the liver. The alanine aminotransferase level was elevated (220 IU/L) with otherwise normal liver function tests. The liver perfused well during the procurement and was further assessed at the time of back-table preparation. There was no evidence of capsular damage or hilar injuries (no cholangiogram was performed). The confluence of the right hepatic vein with the inferior vena cava was explored to rule out a major vascular injury. The liver was implanted into a 50-year-old female with hepatitis C cirrhosis (genotype 3) and a Model for End-Stage Liver Disease score of 18 by a piggyback technique (side-to-side cavocavostomy and temporary portocaval shunt) with no immediate complications and a cold ischemic time of 11 hours. Reperfusion was carried out with portal vein revascularization initially and was well tolerated, with no evidence of bleeding or expansile hematoma. The recipient’s alanine aminotransferase level rose to a peak of 578 IU/L on day 1 postoperatively, returning to normal by day 10. A computed tomography scan on day 7 demonstrated an unchanged hematoma and good perfusion of the liver, whereas a computed tomography scan at 5 months revealed complete resolution of the injury. It is unclear from the study by Geenen et al. why so few donor livers had evidence of contusion/hematoma. A likely explanation is that such injuries may go unno-

Experiencia con el trasplante hepático split en el Hospital Vall d'Hebron

Introduccion El objetivo es exponer nuestra experiencia con la tecnica de particion del injerto hepatico o trasplante hepatico split para trasplantar a un adulto y un nino Metodos Desde octubre de 1992 a noviembre de 2001, hemos realizado 11 particiones hepaticas y se ha trasplantado a 22 pacientes, 11 adultos y 11 ninos. La particion hepatica se realizo ex situ en todos los casos menos en uno, en que se realizo una tecnica mixta. La particion se realizo en la linea media en 3 casos, y a la derecha del ligamento falciforme en 8 ocasiones, dependiendo del tamano del receptor pediatrico Resultados 1) Receptores pediatricos: la edad media fue de 3,4 anos y el peso medio de 13 kg. En 5 casos se solicito un higado en urgencia 0 por: hepatitis fulminante (n = 2), retrasplante urgente (n = 2) y enfermedad de Byler (n = 1). Seis casos presentaban atresias de las vias biliares. La mortalidad postoperatoria fue de 5 casos, 4 urgentes y uno electivo. Las causas fueron: fallo multiorganico (FMO) perioperatorio en 3 pacientes trasplantados en situacion de extrema gravedad, una hemorragia cerebral a los 2 dias de retirar un sensor de presion intracraneal y un FMO a los 5 dias secundario a una trombosis portal y hemorragia. Los 6 pacientes restantes fueron dados de alta y estan vivos en la actualidad. Las complicaciones tecnicas fueron una trombosis portal y 3 complicaciones biliares. 2) Receptores adultos: la edad media fue de 53 anos, 6 pacientes presentaban un hepatocarcinoma, 5 sobre cirrosis y uno fibrolamelar, 4 eran cirroticos de distintas etiologias y otro presentaba un retrasplante por recurrencia del virus C. Todos eran casos electivos, aunque el 45% eran Child C. La mortalidad postoperatoria fue de 2 casos, por shock irreversible despues de un retrasplante por fallo primario del injerto split y por sepsis a los 55 dias despues de presentar ascitis rebelde e insuficiencia renal. Las complicaciones tecnicas fueron una trombosis parcial de la vena porta y 4 complicaciones biliares. La supervivencia al ano fue del 83% Conclusion El trasplante hepatico split ha permitido trasplantar a 6 ninos y 5 adultos mas en nuestro programa. Los resultados en los casos electivos (6 ninos y los 11 adultos) han sido buenos, con una supervivencia al ano del 82%, mientras que en los casos urgentes en ninos los resultados han sido malos con una supervivencia del 20% debido a la situacion de extrema gravedad de los pacientes

Arterialización de la vena porta en el trasplante hepático humano

Resumen Existen pocos casos publicados de arterializacion de la vena porta en el trasplante hepatico ortotopico o heterotopico. Objetivo Evaluar el efecto de la arterializacion de la vena porta en la hemodinamica hepatica y la evolucion clinica de tres pacientes sometidos a trasplante hepatico. Metodos Dos pacientes que presentaban trombosis de todo el eje mesenterico-portal recibieron un trasplante hepatico ortotopico, y uno con hepatitis fulminante recibio un trasplante auxiliar heterotopico. En todos los casos se efectuo una arterializacion de la vena porta. Resultados Un paciente fallecio 4 meses despues de la arterializacion portal. Los otros dos permanecen vivos. El injerto auxiliar fue retirado a los tres meses por una completa regeneracion del higado nativo. La funcion hepatica inmediata fue excelente en todos los casos. Solo un paciente, a los 14 meses, desarrollo encefalopatia y hemorragia por varices esofagicas secundaria a hipertension portal causada por la fistula arterioportal. Esta se embolizo con exito a traves de radiologia intervencionista. Los datos hemodinamicos demostraron la ausencia de hipertension portal intrahepatica. Conclusion El trasplante hepatico con arterializacion de la vena porta es una alternativa quirurgica aceptable en los casos de flujo portal insuficiente. La doble circulacion arterial no condiciona cambios hemodinamicos.