F Acosta

Eversion thromboendovenectomy in organized portal vein thrombosis during liver transplantation

Portal thrombosis is no longer considered a contraindication for transplantation because of the technical experience acquired in the field of liver transplantation and the development of various surgical techniques. All the same, the results obtained in portal thrombosis patients are at times suboptimal, and the surgical technique used (thromboendovenectomy or veno‐venous bypass) is also controversial.

Does the standard vs piggyback surgical technique affect the development of early acute renal failure after orthotopic liver transplantation

The objective of this study was to evaluate the effect of the surgical technique on postoperative renal function during the first week after liver transplantation (OLT). We performed a retrospective study of 184 consecutive OLT. Criteria for acute renal failure were: serum creatinine >1.5 mg/dL, an increase by 50% in the baseline serum creatinine, or oliguria requiring renal replacement therapy. The distribution of patients according to the surgical technique was: standard (n=84), venovenous bypass (n=20), and piggyback (n=80). Other variables analyzed were: intraoperative requirement for blood products, treatment with adrenergic agonists, intraoperative complications, and postreperfusion syndrome. Univariate analysis showed the following parameters to be significantly related to postoperative renal failure: intraoperative fresh frozen plasma and cryoprecipitate requirements, intraoperative complications, postreperfusion syndrome, need for noradrenaline or dobutamine, standard surgical technique versus piggyback (39% vs 18%, P<.01) and venovenous vs piggyback (50% vs 18%, P<.01). Logistic regression analysis identified the following variables as having independent prognostic value: (1) Standard surgical technique vs piggyback (OR=3.3, P=.01); (2) venovenous vs piggyback (OR=4.7, P=.02); and (3) >20 U cryoprecipitate requirement (OR=1.04, P=.01). In conclusion, compared with the piggyback technique, the standard surgical technique appears to be an independent risk factor for postoperative acute renal failure. When venovenous bypass is used in patients who do not tolerate trial clamping of inferior vena cava, it does not reduce the incidence of postoperative renal failure. Finally, the piggyback technique significantly reduces the probability of acute renal failure after liver transplantation.

Serum ionized magnesium monitoring during orthotopic liver transplantation

During orthotopic liver transplantation (OLT) citrate accumulates and magnesium can be chelated, which can lead to ionized hypomagnesemia and cardiovascular dysfunction. Our aim was to study the serum ionized magnesium (Me2+) evolution and establish its relation to serum total Mg and citrate levels during OLT. We studied 58 adult patients undergoing OLT. The serum Me2+ level dropped significantly at the end of the preanhepatic phase, and remained low until the end of the procedure. Furthermore, the Me2+ levels remained below the range of reference from the beginning of the anhepatic phase onward. There was an inverse correlation between Me2+ and citrate for all patients. Me2+, like ionized calcium (Ca2+), is chelated by citrate and its evolution is a mirror image of that of citrate. In our patients, we did not observe any significant dysrhythmias that could be directly attributed to ionized hypomagnesemia. In conclusion, low preoperative levels, together with the massive transfusion of blood products and the increase in renal losses, cause progressive ionized hypomagnesemia in OLT patients. We propose that it he routinely monitored and treated accordingly, as is already done with Ca2+.

Ventricular function during liver reperfusion in hepatic transplantation. A transesophageal echocardiographic study.

Postreperfusion syndrome (PRS) is the most dramatic and acute hemodynamic alteration that occurs in OLT. Our aim was to determine heart function by hemodynamic monitoring and transesophageal echocardiography during PRS. We studied 24 nonconsecutive patients allocated to 2 groups: group A (n = 8), patients with PRS, and group B (n = 16), patients without PRS. Usual hemodynamic data were obtained simultaneously with transesophageal echocardiography recording of the left ventricular imaging in 4 different stages: after induction of anesthesia, 5 min before the end of the anhepatic phase, between 2 and 5 min after reperfusion, and 5 min after graft reperfusion. The hemodynamic and echocardiographic findings during reperfusion were (group A vs. group B patients): mean arterial pressure, 50.0 +/- 15.2 vs. 74.7 +/- 13.9 mmHg (P < 0.01); pulmonary capillary wedge pressure, 12.7 +/- 6.1 vs. 13.9 +/- 5.7 mmHg (NS); left ventricular ejection fraction, 79.6 +/- 9.3 vs. 83.4 +/- 9.4% (NS); left ventricular end diastolic volume index, 35.5 +/- 12.7 vs. 54.7 +/- 21.3 ml/m2 (P < 0.05); and stroke volume index, 27.9 +/- 8.9 vs. 45.5 +/- 15.9 ml/m2 (P < 0.01). There was a mild decrease in left ventricular compliance in group A. We found no alteration in left ventricular function that can justify PRS. The hemodynamic changes during PRS seemed to be caused by an insufficient increase in preload after unclamping.

Changes in serum potassium during reperfusion in liver transplantation

We studied 106 cirrhotic patients treated with OLT using the piggy-back technique. Before reperfusion they were administered a prophylactic treatment consisting of atropine (0.2 mg/kg), sodium bicarbonate (1 mEq/kg), calcium chloride (0.5 g), and hyperventilation. We recorded patients who presented with postreperfusion syndrome (PRS) according to the established definition. Blood samples were obtained from the radial artery before reperfusion (baseline) and at 30 and 90 seconds and at 5 minutes after the start of reperfusion.

Eversion thromboendovenectomy for organized portal vein thrombosis encountered during liver transplantation

INTRODUCTION Due to the technical experience acquired in the field of liver transplantation portal vein thrombosis is no longer considered a contraindication for transplantation. Nevertheless, the results obtained in patients with portal vein thrombosis are at times suboptimal, and there is no consensus on the appropriate surgical technique. PATIENTS AND METHODS Among the 455 liver transplants performed between May 1988 and December 2001, 32 (7%) presented with portal vein thrombosis. Twenty (62%) were type Ib, seven (22%) type II/III, and five (16%) type IV. Twenty-two were men (69%), with a mean age of 50 years (range: 30-70 years); the thrombosis in all cases developed in a cirrhotic liver. The surgical method in all cases consisted of an eversion thromboendovenectomy under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. RESULTS Among the 32 cases undergoing thrombectomy, 31 (96%) were successful with a failure in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis rethrombosed. The 5-year survival rate of the patients in the series was 69%. Only two patients died from causes related to the thrombosis, both showing type IV thrombosis. CONCLUSION The ideal treatment for portal thrombosis during liver transplantation depends on its extension and on the experience of the surgeon. In our experience, eversion thromboendovenectomy resolves most thromboses (types I, II, and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal hemitransposition.

Trasplante hepático split para 2 adultos

El trasplante hepático split es un procedimiento quirúrgico por el cual un hígado donante se divide en 2 partes a fin de obtener 2 injertos para 2 receptores. Conceptualmente procede de las técnicas de reducción hepática y se desarrolló inicialmente como un método para incrementar el número de injertos hepáticos disponibles, en especial para la población pediátrica. En el caso del trasplante pediátrico su utilización ha ayudado claramente a resolver los problemas de la escasez de donantes. Sin embargo, la utilización del split para 2 adultos, realizado por primera vez por Bismuth en 1989, tiene aún poco desarrollo. Recientemente, de la mano de los avances técnicos, sobre todo por la experiencia acumulada del trasplante hepático de donante vivo, y sobre la base de la consideración anatómica de que el hígado es un órgano doble (2 hemihígados con 2 sistemas vasculobiliares), se ha potenciado la idea de utilizarlo para aumentar el número de órganos para adultos mediante la obtención de 2 injertos de un solo hígado. España es el país del mundo con la tasa de trasplante hepático por 1.000.000 de habitantes más elevada del mundo. Probablemente por este motivo la bipartición del hígado se encuentra actualmente poco desarrollada. Sin embargo, esta técnica en España también estaría justificada por la escasez relativa de donantes –parece que hemos llegado al techo de donantes que podríamos obtener– y por el aumento progresivo de la mortalidad en lista de espera (8-15%). Así, en los últimos años se están alcanzando tasas de donación por 1.000.000 de habitantes en torno al 30-34%, mientras que las indicaciones del trasplante hepático están en continuo aumento. Por ello, se van buscando nuevas fuentes de órganos para trasplante, entre las que destacan el donante subóptimo, el donante vivo, el donante dominó y el donante en asistolia, independientemente de las líneas de investigación en xenotrasplante y células madre. La implantación extendida del split supondría, al menos en teoría, poder incrementar el número de hígados para trasplantar, pues de cada donante podríamos sacar 2 hemihígados y trasplantar a 2 receptores. Según las estimaciones, se podría conseguir un aumento teórico de un 8 a un 20% de injertos, lo que reduciría la mortalidad actual en lista de espera.

Fulminant hepatic failure and liver transplantation: Experience of Virgen de la Arrixaca Hospital

INTRODUCTION For patients with fulminant hepatic failure who show a poor evolution despite medical treatment, liver transplantation is an option, with survival rates of greater than 50%. The ideal time to perform the transplant is controversial, as it must not be done too soon (when the liver disease is still reversible) or too late (when the patient is in an irreversible clinical situation). PATIENTS AND METHODS Retrospective review of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure included 26 who underwent transplantation. The most frequent cause was viral (n=10, 38%); with no etiology established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of AB0/DR compatibility, 13 cases were identical (40%), 17 compatible (51%), and the other three incompatible (9%). RESULTS Thirty-three transplants were performed in 26 patients: four were retransplants due to chronic rejection, two for primary graft failure, and one for hyperacute rejection. The overall mortality rate was 46% (12 patients). The most frequent cause of death was infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years, and 59% at 5 years. The factors associated with a poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the last being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the last being the only prognostic factor identified in the multivariate analysis. CONCLUSION Good results of transplantation for the management of fulminant hepatic failure depends on optimal selection of transplant candidates, which means identifying them early, reducing the waiting time, and excluding factors associated with a poor prognosis.

Utilidad de la videotoracoscopia en el tratamiento de los derrames pericárdicos

Introduccion La tecnica de eleccion en el manejo quirurgico del derrame pericardico es todavia discutida. Se han descrito diferentes abordajes (toracotomia, via subxifoidea y toracoscopia), pero ninguno cumple los objetivos basicos del tratamiento quirurgico de esta patologia: resolucion inmediata del derrame con tasas de recurrencia nulas, alta capacidad diagnostica y bajas tasas de morbimortalidad. El objetivo de este estudio es describir la utilidad de la videotoracoscopia en el manejo de los derrames pericardicos Pacientes y metodos Un total de 32 derrames pericardicos fueron drenados mediante una pericardiectomia parcial videotoracoscopica; 9 casos fueron de origen uremico, 9 neoplasicos, 9 idiopaticos, 3 de pospericardiotomia y 2 de origen infeccioso. Se tomaron nuestras del derrame, del pericardio y de cualquier otra lesion relevante para su estudio postoperatorio Resultados No hubo mortalidad intraoperatoria. Tres pacientes murieron en el primer mes postoperatorio, uno por neumonia y otros dos por shock septico no relacionado con el procedimiento quirurgico. La morbilidad postoperatoria fue del 6% (dos casos de derrames pleurales). En los 23 restantes, y tras un periodo medio de seguimiento de 29 meses, ningun derrame recurrio. Durante el seguimiento a largo plazo de estos pacientes, 6 fallecieron por evolucion de la enfermedad neoplasica subyacente. Por otra parte, la tecnica nos permitio identificar la etiologia de dos derrames inicialmente clasificados como idiopaticos Conclusiones La viodeotoracoscopia es una tecnica adecuada en el manejo del derrame pericardico debido a su combinacion de alta capacidad diagnostica, alta efectividad y bajas tasas de recurrencia y morbimortalidad

Tromboendovenectomía de eversión en la trombosis organizada de la vena porta durante el trasplante hepático

Resumen Introduccion Gracias a la experiencia tecnica obtenida en el campo del trasplante hepatico, la trombosis portal no se considera en la actualidad una contraindicacion para el trasplante. Sin embargo, los resultados obtenidos en este grupo de enfermos son en ocasiones suboptimos y, ademas, la tecnica quirurgica a emplear es controvertida. Pacientes y metodo Entre mayo de 1988 y diciembre de 2001 se han realizado 455 trasplantes hepaticos, de los que 32 (7%) presentaban trombosis de la vena porta. De estos, ocho pertenecian a los 227 primeros trasplantes (grupo I) y 24 a los restantes 228 (grupo II). De los 32 casos con trombosis portal, 20 (62%) eran de tipo Ib, 7 (22%) de tipo II/III y 5 (16%) de tipo IV. Un total de 22 pacientes eran varones (69%), con una edad media de 50 anos (rango, 30-70 anos). En 5 casos existian antecedentes de tratamiento quirurgico de la hipertension portal. El metodo quirurgico consistio, en todos los casos, en una tromboendovenectomia de eversion bajo vision directa con oclusion del flujo portal con balon de Fogarty. Una vez lograda la recanalizacion se procedio a la heparinizacion local y anastomosis portal termino-terminal. No se efectuo en ningun caso heparinizacion postoperatoria sistemica. Resultados De los 32 casos en que se intento la trombectomia, esta se logro en 31 ocasiones (96%), fracasando solo en un caso de trombosis tipo IV que se resolvio mediante arterializacion portal. De los 31 casos realizados con exito, solo se observo retrombosis en uno con trombosis de tipo IV. La supervivencia de los enfermos de la serie a los 5 anos fue del 69%. Solo 2 pacientes fallecieron por causas relacionadas con la trombosis y su tratamiento, ambos con trombosis de tipo IV. Conclusion El tratamiento idoneo de la trombosis portal durante el trasplante hepatico es discutido y depende su extension y de la experiencia del cirujano. Segun nuestra experiencia, la tromboendovenectomia de eversion resuelve la mayoria de la trombosis (tipos I, II y III), pero el manejo de las de tipo IV, ocasionalmente tratables con esta tecnica, puede requerir el empleo de tecnicas mas complejas, como el bypass, la arterializacion portal o la hemitransposicion cavo-portal.