Herwig Pokorny

Combination of extended donor criteria and changes in the Model for End-Stage Liver Disease score predict patient survival and primary dysfunction in liver transplantation: a retrospective analysis.

Background. The purpose of this study was to analyze the impact of extended donor criteria (EDC) and of changes in the Model for End-Stage Liver Disease (MELD) score while waiting for liver-transplantation (&Dgr;-MELD) on patient survival and initial graft function. Methods. We included 386 consecutive patients with end-stage liver disease who underwent orthotopic liver transplantation at the Medical University Vienna between 1997 and 2003. Primary outcome was patient survival and secondary outcome was initial graft function. EDC included: age >60 years, >4 days intensive medical care, cold ischemia time >10 hr, need for noradrenalin >0.2 &mgr;g/kg/min or doputamin >6 &mgr;g/kg/min, a donor peak serum sodium >155 mEq/L, a donor serum creatinine >1.2 mg/100 mL, and a body mass index >30. Results. &Dgr;-MELD was significantly higher in the nonsurvivor population (P=0.01) and EDC showed a significant influence on initial graft function (P=0.01). Worsening in either &Dgr;-MELD or the presence of at least two EDC was not associated with an increased risk of primary graft dysfunction and death. Worsening in &Dgr;-MELD and the presence of at least two EDC was significantly associated with primary graft dysfunction (P=0.01) and death (P=0.008). Conclusion. The combination of a liver recipient with worsening &Dgr;-MELD and a potential donor with at least two EDC should be avoided.

Organ survival after primary dysfunction of liver grafts in clinical orthotopic liver transplantation

Abstract In a retrospective analysis of 632 orthototopic liver transplant procedures performed between 1982 and 1997, the incidence of primary dysfunction (PDF) of the liver and its influence on organ survival were studied. Graft function during the first 3 postoperative days was categorized into four groups: (1) good (GOT max < 1000 U/l, spontaneous PT > 50 %, bile production > 100 ml/day); (2) fair (GOT 1000‐2500 U/l, clotting factor support < 2 days, bile < 100 ml/day); (3) poor (GOT > 2500 U/l, clotting factor support > 2 days, bile < 20 ml/day); (4) primary non‐function (PNF; retransplantation required within 7 days). The aim of this study was to evaluate graft survival comparing organs with PDF (poor function) and PNF vs organs with initial good or fair function. After a median follow‐ up of 45 months, initially good and fair function of liver grafts resulted in a significantly better long‐term graft survival compared with grafts with initially poor function or primary non‐function (if re‐transplanted) (P < 0.01). The Cox model revealed primary function as a highly significant factor in the prediction of long‐term graft survival (P < 0.0001). We conclude that these results confirm the hypothesis that primary graft function is of major importance for the long‐term survival of liver transplants. Patients with a poor primary function have the worst survival prognosis, which leads to the interpretation that these patients may be candidates for early retransplantation.

Does Additional Doxorubicin Chemotherapy Improve Outcome in Patients with Hepatocellular Carcinoma Treated by Liver Transplantation

The aim of this prospective randomized study was to determine whether additional doxorubicin chemotherapy improves outcome in patients with hepatocellular carcinoma (HCCA) treated by liver transplantation. Stratification parameters were tumor stage (UICC I‐IVa), gender, age 50 years, α‐fetoprotein 20 ng/mL, cirrhosis and HbsAg status. For pre‐operative chemotherapy doxorubicin (15 mg/m2) was given biweekly, intra‐operative chemotherapy was a single dose administered before surgical manipulation. Post‐operative chemotherapy from day 10 was as given preoperatively for a total dosage of 300 mg/m2. Outcome parameters were overall survival (OS) and disease‐free survival. Of the 75 consecutive patients who received liver transplantation for treatment of HCCA, 62 patients were enrolled. Thirty‐four patients were randomized in the chemotherapy group; 28 patients were in the control group and transplanted only. OS rates at 5 years were 38% in the chemotherapy group and 40% in the control group, disease‐free survival rates at 5 years 43% and 53%, respectively. Tumor stage and vascular invasion were identified as independent risk factors for recurrence of disease. Doxorubicin chemotherapy did not improve organ survival and disease‐free survival in patients undergoing liver transplantation for HCCA.

Resection of Hilar Cholangiocarcinomas: Pivotal Prognostic Factors and Impact of Tumor Sclerosis

The well-known poor prognosis of proximal bile duct cancer is due to its unfortunate anatomical location and its late diagnosis. Successful tumor resection, which is considered to be optimal treatment, depends on many factors. Eighty-eight patients suffering from proximal bile duct cancer underwent surgical exploration at our institution between 1977 and 1998. In 37 patients the tumor was resectable; in the remaining 51 patients exploratory laparotomy or a palliative operation was performed. The median survival after tumor resection was 18.6 months, but median survival after a palliative procedure or an exploratory laparotomy was only 3.4 months (p < 0.001). A curative R0 resection was possible in 11 patients, an R1 resection was performed in 22 patients, and 4 patients had an R2 resection. The median survival rate after R0 resection was 83.6 months, 12.3 months after R1 resection, and 2.7 months after R2 resection (p < 0.001). Survival after resection in patients with negative lymph nodes (n = 30) was significantly longer than in those with positive lymph nodes (n = 7) (p = 0.022). Grade of tumor sclerosis tended to have an influence on resectability rate (p = 0.076). The pattern of tumor growth was without statistical influence. Multivariate analysis revealed resection (p < 0.001) as the only significant prognostic marker for patient survival. Radical resection is the only therapy that provides a chance for long-term survival, with sclerosis of the cancer tending to have an influence on univariate analysis.

Predictors for Complications after Loop Stoma Closure in Patients with Rectal Cancer

PurposeThis unmatched case control study was undertaken to evaluate factors contributing to surgery-related complications of loop stoma closure in patients with rectal cancer.MethodsCases were consecutive patients with complications identified from a local registry. Complications were defined as surgery-related and included 30 days overall mortality. Controls were all other patients with stoma closure from the same population of the registry without the endpoint.ResultsOf the 243 patients, 47 (19%) patients experienced a surgery-related complication, including 5 patients who died within 30 days after surgery. Significant risk factors in the univariate analysis were supervised operation (odds ratio 0.50; 95% confidence interval 0.27–0.95; P = 0.04), stapled anastomosis (odds ratio 0.40; 95% confidence interval 0.17–0.91; P = 0.04) and using a soft silicone drain (odds ratio 2.03; 95% confidence interval 1.07–3.85; P = 0.04). Using a soft silicone drain (odds ratio 2.17; 95% confidence interval 1.10–4.26; P = 0.03) and stapled anastomosis (odds ratio 0.38; 95% confidence interval 0.15–0.98; P = 0.04) were the only significant predictors in the multivariate analysis.ConclusionsThe present study in a homogeneous group of patients with rectal cancer as elective indication for temporary loop stoma construction confirms the high complications rate and mortality rate associated with stoma closure. Intraperitoneal drains should be omitted after loop stoma closure.

Parenchymal liver injury in orthotopic liver transplantation.

BACKGROUND A 35-year period of clinical development resulted in orthotopic liver transplantation (OLT) becoming a standardized surgical procedure. Despite this progress, the rate of technical complications is still high. Although the main problem in most analyses is vascular or bile duct failure, we observed a remarkable number of parenchymal liver injuries that led to intraoperative problems. Our aim, therefore, is to present an overall report on the incidence, treatment, and clinical course of parenchymal liver injuries in OLT. METHODS Five hundred seventy-two consecutive OLT procedures performed between 1988 and 1998 were analyzed in a retrospective study. Parenchymal liver injury was diagnosed by means of examination of the surgical reports. Donor- and recipient-related data followed the medical report. The lesions were classified according to the Organ Injury Scale. RESULTS Parenchymal liver injury was diagnosed in 23 patients (4%). The lesions were classified as grade Ia (13.1%), grade Ib (13.1%), grade IIb (52.1%), grade IIIa (17.1%), and grade IIIb (4.3%). In 19 patients (82.6%), the lesion was detected during OLT, and in four patients (17.4%), during relaparotomy. The latter group showed significantly higher-grade injuries. Treatment was suture or fibringlue alone, 17.4%; fibringlue and hemostyptics, 26.1%, mesh wrapping 30.4%, and mesh packing 26.1%. Seven patients (30.4%) underwent relaparotomy. Further active bleeding was not found in any of them. Statistical analysis found a correlation between injury grade and relaparotomy rate. No patients died as a result of parenchymal liver injury. CONCLUSIONS Parenchymal liver injuries can be treated well, with no adverse effect on patient or graft survival. An early decision concerning the surgical procedure for controlling hemorrhage is required. A basically aggressive therapeutic approach might avoid further complications relating to reperfusion edema.

The use of the antioxidant tirilazad mesylate in human liver transplantation: is there a therapeutic benefit?

Objectives: To test the hypothesis whether in patients undergoing liver transplantation the antioxidant tirilazad mesylate can reduce hepatic ischaemia-reperfusion injury and improve postoperative outcome. Design: Prospective, randomised, placebo controlled trial. Setting: University hospital. Patients: 20 patients were randomised to receive either tirilazad mesylate or placebo (saline). Interventions: Patients in the tirilazad group (n = 10) received four intravenous infusions of tirilazad at 6-h intervals (men 3 mg/kg, women 3.75 mg/kg) after the induction of anaesthesia. The other patients (n = 10) served as controls. Measurements and results: Plasma levels of malonaldehyde (MDA) were determined after the induction of anaesthesia prior to the infusion of tirilazad (baseline), during the anhepatic period, and 5 min and 24 h after reperfusion. Postoperatively, alanine aminotransferase, aspartate aminotransferase, prothrombin time, and serum cholinesterase were determined daily for 1 week. Compared to baseline, plasma MDA levels did not significantly change during the anhepatic period and after reperfusion and they did not differ between groups. Postoperative liver enzymes and prothrombin time did not differ between groups, but on the first (p = 0.03) and second (p = 0.01) postoperative day cholinesterase levels were significantly higher in tirilazad-treated patients than in control patients. For neither length of stay in the intensive care unit nor hospital stay were any differences observed between groups. Conclusions: In patients undergoing liver transplantation, tirilazad does not improve overall outcome. Whether the higher cholinesterase levels on the first 2 postoperative days in tirilazad treated patients indicates an earlier recovery of liver function remains to be tested.

Acute colonic pseudo-obstruction (Ogilvie's-syndrome) and Pneumatosis intestinalis in a kidney recipient patient

ZusammenfassungDie akute Pseudo-Obstruktion des Kolons (Ogilvie’s Syndrom) wird charakterisiert durch eine massive nicht toxische Dilatation des Kolons bei fehlender mechanischer Obstruktion und ist mit einer erhöhten Morbidität und Mortalität beim immunsupprimierten Patienten assoziiert. Wir präsentieren den Fall eines nierentransplantierten Patienten, der ein lebensbedrohliches klinisches Zustandsbild mit akuter Pseudoobstruktion des Kolons und zusätzlich radiologischem Nachweis einer linearen Pneumatosis intestinalis (PI) ausgebildet hatte.Bei der Akutlaparotomie fand sich ein massiv dilatiertes Coecum, Colon ascendens und Colon transversum mit Darmwandnekrosen und multiplen Serosadefekten weswegen eine erweiterte Hemikolektomie rechts durchgeführt wurde. In den Stuhlkulturen und intraoperativen Abstrichen konnte kein Erreger nachgewiesen, weiters fand sich kein Hinweis für eine virale Infektion oder Pilzinfektion. 31 Tage nach der Nierentransplantation konnte der Patient mit normaler Nierenfunktion entlassen werden.Über steroid-induzierten Ileus (Pseudo-Obstruktion) bei transplantierten Patienten als potentiell bedrohliche Frühform von Dysmotilität des Kolons wurde bislang selten berichtet. Die Kenntnis dieser Diagnose und ihre Früherkennung mit rascher Korrektur ursächlicher Faktoren sind für eine erfolgreiche Behandlung entscheidend. Durch eine kolonoskopische Dekompression kann in den meisten Fällen eine Rückbildung der Kolondilatation erreicht werden, jedoch in einzelnen Fällen ist eine prophylaktische Laparotomie indiziert, um die katastrophalen Konsequenzen einer Perforation zu vermeiden.SummaryAcute colonic pseudo-obstruction (Ogilvie’s syndrome) is a clinical entity characterized by massive nontoxic dilatation of the colon in the absence of mechanical obstruction and is associated with increased morbidity and mortality in the immunosuppressed patient.We present a case of a kidney transplant recipient developing a life-threatening condition with acute colonic pseudo-obstruction associated with radiologic findings of a linear pneumatosis intestinalis (PI). Urgent laparotomy and resection of the dilated cecum, colon ascendens and transversum was performed because of bowel necrosis with multiple serosal defects. Stool cultures and special stains for microorganisms were all negative, and there was no evidence for viral or fungal infection. The patient was discharged 31 days after transplantation with normal renal function.In conclusion, this steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility rarely reported in transplant recipients. Awareness and early recognition of the condition are critical for a successful outcome. Colonoscopic decompression can achieve reversal of colonic dilatation in most cases, but in some patients prophylactic laparotomy is indicated for prevention of the catastrophic consequences of perforation.

Use of absorbable mesh in the treatment of parenchymal liver injuries during orthotopic liver transplantation

OBJECTIVE To find out whether packing or wrapping with polyglactin 910 mesh was more effective in stopping bleeding in livers that had been damaged during transplantation. DESIGN Retrospective study. SETTING University hospital, Austria. SUBJECTS AND INTERVENTIONS 15 of 27 livers that had been damaged during transplantation bled sufficiently to warrant either packing (n = 6) or wrapping (n = 9). MAIN OUTCOME MEASURES Arrest of bleeding; other complications. RESULTS Both packing and wrapping succeeded in stopping the bleeding, and neither caused infections. Packing may theoretically cause an increase in intra-abdominal pressure and impair organ function. CONCLUSION It is preferable to wrap rather than pack a bleeding liver that has been damaged during transplantation.

Splanchnic circulation is maintained during passive hyperventilation in orthotopic liver recipients

Background: Mechanical hyperventilation is an established treatment to reduce brain edema and intracranial pressure in patients with encephalopathia caused by acute liver failure. Hyperventilation and ensuing hypocarbia may also affect central and systemic circulation and thereby influence graft performance in patients following orthotopic liver transplantation (OLT).