I. García

LIVER TRANSPLANTATION FOR ECHINOCOCCUS GRANULOSUS HYDATID DISEASE

The authors report their experience with 6 patients requiring liver transplantation who suffered with liver infestation by Echinococcus granulosus. One patient presented with acute Budd-Chiari syndrome because obstruction of hepatic veins was produced during the first operation; the other 5 patients received liver transplants for terminal chronic liver disease (2 secondary sclerosing cholangitis, 2 secondary biliary cirrhosis, and 1 postnecrotic cirrhosis of the liver). All the patients had been operated previously on for hydatidosis and were at the end of liver functional disorder. Some of the patients had undergone many operations, making the transplantation procedure even more difficult. One patient required a second transplant for primary graft failure; he died 40 days later from cerebrovascular accident. Another patient died 7 months after transplant from pulmonary embolism. The other 4 patients are alive and in optimal condition 37–65 months after transplantation. Hepatic hydatidosis—in principle, a benign disease—can cause hepatic complications that eventually require liver transplantation. The transplantation procedure is more difficult than usual in these cases. Although postoperative complications are frequent, most patients achieve prolonged survival and a good quality of life.

Advantages of the piggy back technique on intraoperative transfusion, fluid compsumption, and vasoactive drugs requirements in liver transplantation: a comparative study

INTRODUCTION The piggyback technique was first described in adult liver transplantation in 1989, although it has been used in conjunction with venous bypass, with cross-clamping the vena cava, or both. In this study, the inferior vena cava was not occluded at any time during the liver transplant. OBJECTIVE We compared the use of intraoperative blood products, fluid requirements, and vasoactive drugs among patients managed with bypass, without bypass, and with the piggyback technique. MATERIAL AND METHODS Between May 1986 and October 2002, 875 liver transplants included 50 patients divided into three groups (cases considered to be the preliminary series on each group): group A/piggyback (17 patients:34%), group B/ bypass (16 patients: 32%), and group C/no bypass (17 patients:34%). There were no differences in mean age, gender, UNOS or Child-Pugh score, and indications for liver transplantation. RESULTS Mean follow up was 134.63+/-32.19 months. At the end of the study, 91.3% of the patients are alive with no operative mortality. There were no differences in postoperative complications, postreperfusion syndrome rate, and postoperative renal failure. However, the number of packed red blood cell units consumed intraoperatively (12+/-7.43 vs 18.03+/-11.46 vs 17.59 +/- 23.8; P =.043), the need for intraoperative crystaloids (3.1 L+/-1.6 vs 6.8+/-4.8 vs 9.1 L+/-3.6; P=.001) and the requirement for vasoactive drugs (18% vs 38% vs 24%; P=.043) was notably lower in group A vs group B vs group C. Operative time was longer in group A (121.54+/-37.77 vs 78.73+/-11.89 vs 87.07+/-14.33 minutes). CONCLUSIONS The piggyback technique requires a longer operative time but offers the advantages of reducing the red blood cell requirements and preventing severe hemodynamic instability by virtue of reducing the need for vasoactive drugs and for a larger volume of intraoperative fluids.

Liver transplantation for hepatocellular carcinoma: our experience from 1986.

Abstract Currently liver transplantation is the treatment of choice for early hepatocellular carcinoma and end-stage liver disease. We analyzed our experience to identify factors that could be used to select patients who will benefit from liver transplantation. Patients and methods From April 1986 to December 2001, 71 (8.7%) of 816 LT performed in our institution, were for patients with hepatocellular carcinoma. In 25 patients the tumor was observed incidental by (35.2%). All patients had liver cirrhosis, most due to hepatitis C related (35) or alcoholic (14) diseases. Before liver transplantation, chemoembolization was performed in 18 patients (25.4%). Results Bilateral involvement was present in seven patients. Eight patients showed macroscopic vascular invasion, and eight others showed satellite nodules. Most patients were stage TNM II (29) and IVa (16). Overall 1-, 3-, and 5-year survival were 79.3%, 61%, and 50.3% with recurrence-free survivals of 74.6%, 57.5%, and 49%, respectively. With a mean follow-up of 42 months, 12 patients (19%) developed recurrence and 29 patients died (only 11 due to recurrence). Stage TNM IVa, macrocopic vascular invasion, and the presence of satellite nodules significantly affected overall survival and recurrence-free survival rates and histologic differentiation and bilateral involvement only recurrence-free survival. Patients with solitary tumors less than 5 cm or no more than three nodules smaller than 3 cm showed better recurrence-free survival and lower recurrence rates. Discussion In our experience, liver transplantation proffers good recurrence-free survival and low recurrence rates among patients with limited tumor extension. The most important prognostic factor was macroscopic vascular invasion.

Live liver donation: a prospective analysis of exclusion criteria for healthy and potential donors

INTRODUCTION Living donor liver transplantation represents a controversial option to increase the donor pool. DESIGN Prospective and descriptive clinical study. OBJECTIVE (1) To identify risk factors (exclusion criteria) for live donation; (2) to determine the rate of recipients that benefit from a living donor. METHODS Between May 1995 (first adult-to-adult living donor liver transplantation in Spain) and November 2002, we evaluated 74 healthy volunteers and performed 12 living donor liver transplants (no donor mortality). RESULTS All actual donors and volunteers are alive and healthy. After a mean time of 3.2+/-0.5 weeks, 72% of potential donors were considered unsuitable for live donation. Exclusion criteria were grouped in three categories: (primary) donor safety reasons (68%); (secondary): ABO mismatch (17%) and (tertiary): cadaveric graft transplantation (15%). Consequently, just 43.7% of the recipients presenting to us with a potential living donor, did finally benefit from these organs. The mortality rate was 8.3% for 43 recipients presenting with a living donor in comparison to 15% for those who did not (321 recipients between May 1995 and November 2001). CONCLUSIONS ALDLT can benefit a significant number of recipients on the waiting list (43.7% of those presenting with a donor). The most frequent exclusion criteria concern donor safety, namely, unsuspected chronic liver diseases and unsuspected thrombophilic disorders.

Treatment of splenic artery aneurysm after distal splenorenal shunt. A case report

A patient with splenic artery aneurysm which developed after creation of selective distal spleno-renal shunt for hepatic cirrhosis and portal hypertension was presented. Three months after operation, an aneurysm of the splenic artery with a diameter of about 20 mm was detected. This aneurysm reached 4 cm three months later, and a resection was carried out. An arterial continuity was established by means of end-to-end anastomosis of the sectioned arterial ends. Because the flow through the splenic artery was about 60% of the total flow of the selective distal spleno-renal shunt, it is important to maintain continuity in order to avoid thrombosis of the shunt.

Esophageal resection by cervico-abdominal approach without thoracotomy.

The authors report their experience with transhiatal esophageal resection accumulated during the period between January 1978 and March 1990. Indications for the procedure included cancer of the gastric cardia (26.3%), cancer of the hypopharynx (3.8%), cancer of the esophagus (59.2%), and benign esophageal disease (9.8%). Esophageal substitution was performed using a tubulized stomach (63.6%), ileo-cecocoloplasty (28.5%), left colon (7.6%), and jejunum (0.3%). The majority of patients with neoplastic disease were found to be in an advanced stage (67.3% of esophageal cancer patients and 69.7% of cancer of the cardia patients with stage III disease). The mean intra-operative volume of blood transfused varied between 533 and 1,220 ml. Sixteen patients required hospitalization in the intensive care unit. The mean length of post-operative hospitalization varied between 16.8 and 20.6 days. Operative complications included hemorrhage (0.3%) and tracheal injury (0.6%). Operative (30 day) mortality was 5.8%. Causes of death included respiratory insufficiency (35.2%), pulmonary sepsis (23.5%), abdominal sepsis (17.8%), and others (undefined, 23.5%). The 5 year survival was 48.5% for cancer of the gastric cardia, 57.1% for cancer of the hypopharynx and 11.8% for esophageal cancer.

Selective coronary-caval shunt using internal jugular autograft, in the treatment of portal hypertension

The selective coronary-caval shunt is considered to be one of the better procedures in the surgical treatment of portal hypertension.We have altered the previously described technique by using an internal jugular vein grafting which possesses some advantages. We have performed this shunt utilizing an internal jugular vein autograft in eight patients, who had at least one major hemorrhage from esophageal varices three to twelve months before operation.There were no postoperative deaths. All four patients are still alive three months to six years after shunting without bleeding episodes. In the X-ray and endoscopic studies the esophagogastric varices were noted to be markedly smaller in size than they were before shunting.