F.S Bueno

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.

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.

Fulminant hepatic failure after Lepiota mushroom poisoning

We present ten patients who suffered from a cyclopeptide syndrome from two different foci, one caused by Lepiota helveola (seven cases) and the other by Lepiota brunneoincarnata (three cases). Of the ten victims, five recovered completely after the intestinal stage and the other five developed a phase of visceral involvement with alterations of liver function. In two patients, hepatic function became normal after the 7th day after ingestion. Three patients developed fulminant hepatitis and two of these died of adult respiratory distress syndrome. The fulminant hepatitis patient who later improved developed active chronic hepatitis 1 year later. Finally, five patients developed mixed polyneuropathy. In this paper the indications for orthotopic liver transplant (OLTx) are discussed and the development of late complications such as active chronic hepatitis and mixed polyneuropathy are considered.

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.

Improving the Waiting List by Using 75-Year-Old Donors for Recipients With Hepatocellular Carcinoma

The best treatment for hepatocellular carcinoma (HCC) associated with liver cirrhosis is liver transplantation and the best results are obtained when the tumors fulfill the Milan criteria. However, although the number of transplants is increasing, the organ deficit is growing, which lengthens time on the waiting list, increasing the risk of tumor progression of and exclusion from the list. The use of elderly donors is a valid option for patients on the transplant waiting list with HCC, reducing time on the waiting list. We report our experience with patients transplanted for HCC associated with hepatic cirrhosis using livers from donors >75 years of age. Our preliminary results supported the use of elderly suboptimal donors making it possible to give priority to these patients. All patients in the series achieved good graft function after a follow-up of 2 years with a 100% disease-free survival rate. More extensive long-term studies are needed to confirm these findings.

Hemorragia diferida de la arteria hepática derecha tras iatrogenia biliar por colecistectomía laparoscópica que precisó trasplante hepático por insuficiencia hepática aguda: caso clínico y revisión de la literatura

INTRODUCTION Right hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required. PATIENTS AND METHOD We provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury. RESULTS LT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury. CONCLUSIONS RHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion.INTRODUCTION Right hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required. PATIENTS AND METHOD We provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury. RESULTS LT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury. CONCLUSIONS RHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion.

Successful embolization of a cytomegalovirus-related duodenal ulcer in a kidney-pancreas transplant recipient

One of the complications that can occur in pancreas transplant is a massive intestinal hemorrhage, although such a hemorrhage is very rarely caused by ulcers due to cytomegalovirus infection. Treatment is fundamentally based on relaparatomy, although in some cases interventional radiology can be an efficient alternative because it allows the exact bleeding point to be located and therapeutic embolization to be performed. In this case, a man with diabetes type 1 who was given a simultaneous kidney-pancreas transplant had an ulcer due to cytomegalovirus infection develop in the duodenal graft (in the early postoperative period), causing a severe hemorrhage in the lower part of the gastrointestinal tract that was controlled via selective embolization of a branch of the pancreaticoduodenal artery.

Liver Transplantation for Fulminant Hepatic Failure due to Heat Stroke. Case Report

Heat stroke is a condition caused by an excessive increase in body temperature in a relatively short period of time, and is clinically characterized by central nervous system dysfunction, including delirium, seizures, coma, and severe hyperthermia. In this context, the resulting fulminant hepatic failure makes liver transplant the best choice when there are no guarantees of better results with conservative treatment. We present our experience in this case, possible alternative choices, and the current role of liver transplantation in the resolution of fulminant liver failure due to heat stroke. CASE REPORT: We report the case of a 32-year-old man with a history of malabsorption syndrome and unconfirmed celiac disease controlled with a gluten-free diet, who, while working on a typical summer midday in southern Spain (approximately 40°C), abruptly presented with loss of consciousness, coma, and a temperature of 42°C, as well as seizures at the initial medical assessment that subsided after the administration of diazepam. On the third day, the patient presented with multiple organ dysfunction syndrome, requiring mechanical ventilation, hemodialysis, and inotropic support. He did not improve with the support of conservative treatment, therefore it was decided to perform an urgent liver transplant, after which he recovered completely. CONCLUSIONS: Liver transplantation should be a main choice of treatment for cases in which, despite intensive medical treatment, there is still clinical and analytical evidence of massive and/or irreversible hepatocellular damage.

Liver Transplantation Due to Fulminant Liver Failure Secondary to Acute Submassive Necrosis in a Patient Treated with Orlistat

Introduction and Objective: Orlistat is an intestinal lipase inhibitor drug, approved by the Food and Drug Administration in 1998, which has been shown to be superior to placebo in weight loss and is currently recommended in obese patients along with a hypocaloric diet, assuming a weight loss of approximately 30%. Although the most frequent secondary effect is the steatorrhea, Fulminant Liver Failure has been associated with this drug, even reaching liver transplantation in 3 patients. We present a case of urgent liver transplantation due to acute liver failure associated with drug treatment. Clinical case A 42 year old man with hypertension under medical treatment. Obese, with a height of 183 cms and 131 Kg, with a body mass index of 39.12. Diagnosed of liver steatosis, in treatment with hypocaloric diet and Orlistat 240 mg / day. 3 months after starting treatment, he suffered a Fulminant Liver Failure with coagulopathy, oliguria and grade II-III encephalopathy. Despite conservative treatment, he clinically worsens substantially, being submitted for an urgent liver transplant. In the postoperative period, a reintervention is done because a severe hypovolemic shock finding an important hemoperitoneum secondary to a bleeding of a little branch dependent of the hepatic artery of the donor. After a favorable postoperative, on the 26th day post-transplant the patient is discharged in good conditions. One year later, a Roux-en-Y Hepaticojejunostomy is performed because an important cholestasis due to a stenosis of the bile duct at the level of the choledochal-choledochal anastomosis, after a failed attempt of endoscopic resolution. Currently uncomplicated with a standard of living acceptable 8 years after the transplant. Conclusion Obesity has become a major health problem and Orlistat is currently an available drug of proven effectiveness. Although the direct cause of this drug with the development of a Fulminant Liver Failure is not demonstrated, it is assumed that they would be involved in idiosyncrasy mechanisms. Therefore, we believe that we should be aware of this possibility and closely monitor patients who have steatosis with signs of hepatic dysfunction. Figure. No caption available. Figure. No caption available. Figure. No caption available.