Gerrit Krupski

Portal Vein Embolization vs. Portal Vein Ligation for Induction of Hypertrophy of the Future Liver Remnant

The objective of this study was to assess the efficacy of right portal vein embolization (PVE) vs. right portal vein ligation (PVL) for induction of hypertrophy of the left lateral liver lobe before extended right hepatectomy. Thirty-four patients with primary or secondary liver tumors and estimated remnant functional liver parenchyma of less than 0.5% of body weight underwent either right PVE (transcutaneous, n= 10; transileocolic, n =7) or right PVL (n=17). Liver volume was assessed by CT scan before occlusion of the right portal vein and prior to resection. There were no deaths. The morbidity rate in each group was 5.8% (PVE, 1 abscess; PVL, 1 bile leak). The increase in liver volume was significantly higher after PVE compared with PVL (188±81 ml vs. 123±58 ml) (P= 0.012). Postoperative hospital stay was significantly shorter after PVE in comparison to PVL (4±2.9 days vs. 8.1±5.1 days;P<0.01). Curative liver resection was performed in 10 of 17 patients after PVE and 11 of 17 patients after PVL. PVE and PVL were found to be feasible and safe methods of increasing the remnant functional liver volume and achieving resectability for extended liver tumors. PVE results in a significantly more efficient increase in liver volume and a shorter hospital stay.

Evolution of Donor Morbidity in Living Related Liver Transplantation: A Single-Center Analysis of 165 Cases

Objective:During the last 14 years, living donor liver transplantation (LDLT) has evolved to an indispensable surgical strategy to minimize mortality of adult and pediatric patients awaiting transplantation. The crucial prerequisite to performing this procedure is a minimal morbidity and mortality risk to the healthy living donor. Little is known about the learning curve involved with this type of surgery. Patients and Methods:From January 1991 to August 2003, a total of 165 LDLTs were performed in our center. Of these, 135 were donations of the left-lateral lobe (LL, segments II and III), 3 were of the left lobe (L, segments II–IV), 3 were full-left lobes (FL, segments I–IV), and 24 were of the full-right lobe (FR, segments V–VIII). We divided the procedures into 3 periods: period 1 included the years 1991 to 1995 (LL, n = 49; L, n = 2; FR, n = 1), period 2 covered 1996 to 2000 (LL, n = 47), and period 3 covered 2001 to August 2003 (LL, n = 39; FR, n = 23; FL, n = 3; L, n = 1). Perioperative mortality and morbidity were assessed using a standardized classification. Length of stay in intensive care unit, postoperative hospital stay, laboratory results (bilirubin, INR, and LFTs), morbidity, and the different types of grafts in the 3 different periods were compared. Results:One early donor death was observed in period 1 (03/07/93, case 30; total mortality, 0.61.%). Since 1991, the perioperative morbidity has continually declined (53.8% vs. 23.4% vs. 9.2%). In period 1, 28 patients had 40 complications. In period 2, 11 patients had 12 complications, and in period 3, 6 patients had 9 complications. Within the first period, 1 donor underwent relaparotomy because of bile leakage. Postoperative hospital stay was 10 days, 7 days, and 6 days, respectively. Donation of the full right lobe, in comparison with that of the left lateral lobe, resulted in a significantly diminished liver function (bilirubin and INR) during the first 5 days after donation but did not increase morbidity. One donor from period 1 experienced late death caused by amyotrophic lateral sclerosis. Conclusions:In a single center, morbidity after living liver donation strongly correlates to center experience. Despite the additional risks associated with temporary reduction of liver function, this experience enabled the team to bypass part of the learning curve when starting right lobe donation. Specific training of the surgical team and coaching by an experienced center should be implemented for centers offering this procedure to avoid the learning curve.

Living donor for liver transplantation

Since living related liver transplantation was first performed in 1989, more than 150 cases have been performed worldwide, mostly in the United States and Japan. This paper reports the first series of living related liver transplantation in Europe. Twenty living related liver transplantation surgeries were performed over a 13‐mo period, with an overall patient survival of 85%. For patients who underwent elective transplantation (n=13), the survival rate was 100%. Technical complications included one arterial thrombosis necessitating retransplantation and five bile leaks requiring surgical revision. The technical improvements that permit avoidance of these complications are discussed. A detailed description of the living related liver procurement is given. All procurements yielded grafts of excellent quality. No intraoperative complications occurred, and no reoperations were necessary. No heterologous blood transfusion was needed. In two patients, incisional hernias developed after wound infection. Living related liver transplantation does not absolve the transplant community of efforts to promote cadaveric organ procurement. Nevertheless, living related liver transplantation does have the advantage of a readily available graft of excellent quality, permitting transplantation with optimal timing under elective conditions. Several centers are now preparing living related segmental liver transplants, following the model of our protocol, for three reasons: (a) to obtain superior results compared with cadaveric liver transplantation; (b) to overcome cadaveric organ shortage and further reduce pretransplantation mortality and (c) to provide viable organs in countries where cadaveric organ procurement is not established. When performed by a team experienced in pediatric liver transplantation and in adult liver resection, living related liver transplantation is an excellent modality for the treatment of end‐stage liver disease in children. (Hepatology 1994;20:49S‐55S.)

Vertebral osteomyelitis due to Rhodococcus equi in a liver transplant recipient

Rhodococcus equi is a rare but well-documented cause of cavitary pneumonia in immunocompromised patients. In this report the first case of R. equi infection manifesting as vertebral osteomyelitis is described. A 39-year-old liver transplant recipient presented with recurrent pneumonia and a pleura-based lung abscess and subsequently developed osteomyelitis of the lower thoracic spine. Surgical debridement and prolonged treatment with rifabutin and clarithromycin resulted in clinical cure. In the literature, 12 other cases of R. equi infection in solid-organ transplant recipients have been reported. Ten of these patients had documented pulmonary disease and seven had extrapulmonary manifestations. Prolonged antibiotic therapy and surgical drainage resulted in clinical improvement in > 90% of the reported cases.

Percutaneous Transhepatic Cholangiodrainage as Rescue Therapy for Symptomatic Biliary Leakage Without Biliary Tract Dilation After Major Surgery

Symptomatic biliary leakage following major upper abdominal surgery is a severe complication resulting in increased morbidity and mortality. Treatment options usually include either endoscopic intervention or surgical revision. These options may be burdened by a high perioperative risk for the patient (e.g., patients with severe disease) or simply may not be possible (e.g., nonpreserved gastroduodenal passage). In the past, percutaneous transhepatic cholangiodrainage did only seem to be a viable option for patients with dilated bile ducts. Here, we present our experience in a consecutive series of patients with symptomatic biliary leakage following major upper abdominal surgery and without dilation of the biliary system that underwent percutaneous transhepatic cholangiodrainage. Percutaneous transhepatic cholangiodrainage was feasible in 15 of 18 patients (83.3%). The procedure was technically not possible in three patients (16.7%). In 10 of the 15 patients (66.6%) with feasible percutaneous transhepatic cholangiodrainage, biliary leakage was definitely controlled without the need for surgical revision. Depending on the experience with the interventional procedure, percutaneous transhepatic cholangiodrainage should be considered as an alternative for treatment of symptomatic biliary leakage instead of immediate reoperation.

Bile resistance of coated transjugular intrahepatic portosystemic shunt stents in a flow-model.

Purpose:We sought to test the bile resistance of transjugular intrahepatic portosystemic shunt (TIPS) stents with 3 different coatings. Materials and Methods:Three stents with different coating materials (monolayer polyethylene terephthalate [PETP], monolayer polytetrafluoroethylene [PTFE], and double layer [PTFE]) were tested in a flow model. After testing the sealing of the system with isotonic saline solution, fresh human bile was circulated. Constant pressure was 50 cm H2O. Bile resistance of the stent membranes was analyzed. Results:Two of the 3 stents proved completely resistant to water. Only the PETP stent was resistant to bile. The PTFE-coated stents were not bile resistant. Conclusion:The bile resistance of coated TIPS stents and, thus, the dependency of TIPS shunt patency is called into question. The stent with the reported superior patency rates does not show experimental bile resistance.

Untersuchungen zur arteriellen und portalen Perfusion des IV. Lebersegmentes und deren Bedeutung für die Leber-Lebend-Spende

Bei der Leberlebendspende (LR) fur einen kindlichen Empfanger erfolgt die Teilung der Leber links des IV. Lebersegmentes und bei der Entnahme des rechten Leberlappens (Segment V - VIII) rechts des IV. Lebersegmentes. Somit kommt dem Erhalt der arteriellen und auch portalen Perfusion des IV. Segmentes eine Schlusselrolle im Rahmen der Leber-Lebend-Spende zu. Ziel der vorliegenden Untersuchung war die radiologischanatomische Klassifikation der arteriellen und portalen Perfusion dieses ambivalenten Segmentes. Methodik:Von insgesamt 105 Leberspendern, die im Zeitraum zwischen Oktober 1991 bis August 2001 evaluiert wurden, wurden retrospektiv konventionelle Angiographien, MRT-Angiographien, MRT-Leber und/oder Oberbauch-CT-Untersuchungen hinsichtlich der arteriellen und portalvenosen Gefasversorgung des Lebersegmentes IV ausgewertet. Ergebnisse:Die arterielle Versorgung des Segmentes IV erfolgte in 42,5% isoliert uber die linke Leberarterie, in 25% uber einen isolierten intermediaren Ast, in 20% sowohl uber die rechte als auch uber die linke Leberarterie, zu jeweils 5% uber die rechte Leberarterie bzw. uber die linke Leberarterie und einen zusatzlichen isolierten intermediaren Ast und in 2,5% der Falle uber die rechte Leberarterie und einem isolierten intermediaren Ast. Die portalvenose Gefasversorgung erfolgte uberwiegend isoliert uber die linke (42,5%) sowie isoliert uber die rechte (20%) Pfortader sowie uber einen isolierten intermediaren Ast (22,5%). Seltener erfolgte die Versorgung des Segmentes IV uber eine Trifurkation von rechts (5%), die linke Pfortader in Kombination mit einem isolierten intermediaren Ast (5%) oder kombiniert uber die rechte und linke Pfortader (5%). Schlusfolgerungen:Das Lebersegment IV wird nur in 42,5% uber die Gefase von links versorgt, obwohl es anatomisch dem linken Leberlappen zugeordnet wird. In den ubrigen Fallen erfolgt die Gefasversorgung uber isolierte intermediare aste (22,5% bzw. 25%), uber rechts (5% bzw. 20%) oder andere anatomische Gefasvarianten. Um eine postoperative Nekrose von Segment IV, insbesondere nach der Spende des rechten Lappens, zu verhindern, ist eine suffiziente praoperative anatomische Gefasdarstellung inklusive aller Varianten erforderlich.