José Manoel Martinho

Liver transplantation with monosegments. Technical aspects and outcome: A meta-analysis

The shortage of organ donors for low‐weight liver transplant recipients, especially small children, has led to the development of new surgical techniques to increase the donor pool. Almost all of these techniques use the left lateral segment (Couinauds segments II and III), but even this graft could be too large for children under 10 kg, and further reduction could be necessary. Few articles address the issue of monosegmental liver transplantation. Available articles are with small sample sizes or even case reports, which makes it difficult to draw conclusions about indication and outcome for monosegmental grafts. A search of the MEDLINE databases using the terms “Liver Transplantation” and “Monosegmental” or “Monosegments” limited to title or abstract with publication in the English language was conducted. The data from each study were selected and analyzed, regarding donor status (living or cadaveric), donor weight, surgical techniques used in left lateral further reduction, recipient indication for liver transplantation, age and recipient weight, graft‐to‐recipient body weight ratio, segment utilized, type of abdominal closure, postoperative complications, and survival. Seven publications were identified from 1995 to 2004 and fulfilled the criteria. A total of 27 pediatric patients who received a monosegment transplant were identified, median age 211 days (range, 27 to 454 days) and median weight 4.6 kg (range, 2.45 to 7.4 kg). Segment III was utilized in 21 (78%) and segment II in 6 (22%). Patient survival was 85.2%. In conclusion, monosegment liver transplantation appears to be a satisfactory option for infants weighing less than 10 kg who require a liver transplant. (Liver Transpl 2005;11:564–569.)

Vascular Complications After Living Donor Liver Transplantation: A Brazilian, Single-Center Experience

BACKGROUND In living donor liver transplantation (LDLT), vascular complications are more frequently seen than in deceased donor transplantation. Early arterial, portal vein, or hepatic vein thromboses are complications that can lead to graft loss and patient death. The aim of this study was to assess the incidence, treatment, and outcome of vascular complications after LDLT in a single Brazilian center. METHODS Between December 2001 and December 2010, we performed 130 LDLT. Sixty-four recipients were children (27 weighing <10 kg). RESULTS Nine recipients had vascular complications. Hepatic artery thrombosis (HAT) occurred in 4 (3.1%), portal vein thrombosis (PVT) in 3 (2.3%), and hepatic vein thrombosis (HVT) and hepatic arterial stenosis (HAS) in 1 (0.8%) patient each. Complications were identified by Doppler and confirmed by angiography or angiotomography. Patients with HAT were listed for retransplantation. One died before retransplant. Two children were submitted to retransplantation; one is still alive, with neurologic sequelae. One adult with HAT was retransplanted with a deceased donor graft and is doing well 58 months after surgery. Two patients with PVT died as a consequence of graft malfunction. In the other case, portal vein arterialization was performed, but patient died 11 months posttransplant. HVT was detected after cardiac reanimation and was treated with an endovascular stent. This patient died 3 months after LDLT. HAS was diagnosed after liver abscess development and was successfully treated by endovascular angioplasty. No recurrence was observed after 22 months. Follow-up ranged from 9 to 117 months. CONCLUSION Pediatric patients are more prone to develop vascular complications after LDLT. Long-term survival was statistically lower for recipients with vascular complications (33.3% vs 77.7%; P = .008).

Fulminant hepatitis failure in adults and children from a Public Hospital in Rio de Janeiro, Brazil.

Fulminant hepatic failure (FHF) is characterized by massive hepatocellular injury, whose physiopathology is still unclear. Hepatitis B (HBV) is probably the most common viral cause of FHF, while hepatitis A (HAV) virus seem occurs less frequently. However, the host and viral factors that determine the outcome of these infections are poorly understood. In the present study, viral load and genotyping determining regions of HAV and HBV genomes were sequenced. Eight FHF patients and one patient with severe acute hepatitis (SAH) were included. Liver and blood samples were collected during liver transplantation or necropsy procedures. HAV-RNA and HBV-DNA were extracted from serum, biopsy and paraffin liver. Nucleotide sequencing of HAV-RNA was performed from VP1/2A and HBV-DNA from PreS/S region. The amplified samples were quantified by Real-Time PCR. The cases of HAV infection were due to subgenotype IA. The cases of HBV infection were due to genotype A2 and D4. The case of HAV/HBV coinfection was infected by genotype IA and D3. Hepatitis A and B infection were associated with genotypes most prevalent in Brazil. In hepatitis A infection the mean of period evolution was 13 days. In hepatitis B, FHF patients infected by genotype D have a shorter period of evolution than FHF patients infected by genotype A (mean 15 v. 53 days). There was no association with genotype-determining region with the severity of hepatitis, however nucleotide differences and high viral load could be observed among FHF.

Surgical Complications in 100 Donor Hepatectomies for Living Donor Liver Transplantation in a Single Brazilian Center

The rising demand for liver transplantation has continued to outspace the availability of deceased donor organs, leading to the need for other treatment options including living donor liver transplantation (LDLT). A precise evaluation of surgical complications is the most important issue in this setting. There are controversies about donor morbidity with reports ranging from 13%-75%. The aim of this study was to retrospectively analyze 100 LDLTs performed in a single Brazilian center from December 2002 to August 2008, stratifying the complications according to Claviens scoring system. None of the donors experienced life-threatening complications or died. The majority of donors (n = 74) did not suffer any complication. Twenty-eight complications were observed in 26 patients. Fifty-seven hepatectomies were performed for adult and 43 for pediatric transplantations. According to the Brisbane classifications, we performed 49 right and 2 left hepatectomies as well as 49 left lateral segmentectomies. According to Clavien, the complications were as follows: grade I (n = 11; 39.2%); grade II (n = 8; 28.5%); and grade III (n = 9; 32.3%). No patient presented with grade IV or V. The most common problem a biliary tract injury, similar to other series. In this Brazilian series, hepatectomy for LDLT was a safe procedure with low morbidity, regardless of the type of liver resection. This practice will probably continue to grow to alleviate the pressure of growing waiting lists.

Outflow reconstruction in domino liver transplantation with interposition of autologous portal vein graft. A new technical option in living donor domino liver transplant scenario

In 1997, a new modality of liver transplantation was introduced: the sequential, or domino, liver transplantation. 1 The Achilles heel of domino transplantation remains the inferior vena cava length of both the familial amyloidotic polyneuropathy (FAP) patient and the domino recipient. Some investigators have reported that the pericardium may be sectioned to lengthen the vena cava stumps, and serious complications of inferior vena cava anastomosis in domino liver transplantation have been reported. Recently, Pena et al. and Pacheco-Moreira et al. described the new technique for domino liver transplantation in which vascular outflow anastomosis in the domino recipient were performed with an iliac/caval vein graft from cadaveric donor. For this reason, some technical difficulties such as short vena cava stump, pericardial effusion, and bad outflow in both patients are avoided. This technique also avoids the necessity of the venovenous bypass or the hemodynamic changes after caval clamping in FAP patients. In this case we describe the success of using a recipient’s inverted portal vein bifurcation as an interposition graft to drain the outflow in the domino recipient also in a living donor liver transplantation scenario. Lately, techniques for reconstruction of hepatic vessels including the portal vein have been reported in living donor liver transplantation. A 37-year-old man (a FAP patient’s husband) donated a right liver. The living donor liver transplantation recipient, a 36-year-old woman with FAP, agreed to also be a domino donor. The native hepatectomy in the FAP patient was performed with inferior vena cava preservation, and venovenous bypass was not required. The living donor right graft was implanted in the FAP patient as usual. The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day. The FAP liver as a domino graft was harvested without the vena cava (Fig. 1) and perfused on the backtable with Belzer solution (Viaspan, DuPont Pharma, Wilmington, DE). The middle and left hepatic veins were joined together (Fig. 2). The autologous portal vein bifurcation (domino recipient) was used as vascular graft according to inverted Y-graft technique (Fig. 3). The venous graft of the right portal vein was anastomosed with right hepatic vein, and the left portal vein was anastomosed with the new common trunk of the middle and left hepatic veins using a 5-0 polypropylene running suture. A 49-year-old man with end-stage liver disease secondary to hepatitis C agreed to accept the FAP liver. The recipient’s hepatectomy was performed with preservation of the inferior vena cava, and the liver was implanted in the standard piggyback fashion using the portal stump of the venous graft as the outflow from the

Eosinophils involved in fulminant hepatic failure are associated with high interleukin-6 expression and absence of interleukin-5 in liver and peripheral blood

Background/Aims: Although eosinophils are considered to play an important role in the pathogenesis of various parasitic, allergic and autoimmune digestive diseases, their role in fulminant hepatic failure (FHF) is unknown. Our contribution was to identify and quantify eosinophils and cytokine levels [interleukin (IL)‐6, IL‐5 and macrophage inflammatory protein (MIP)‐1α] in liver parenchyma and peripheral blood from FHF patients at pre‐ and post‐transplantation steps.

Activated lymphocytes and high liver expression of IFN-γ are associated with fulminant hepatic failure in patients.

To study immunological mechanisms of fulminant hepatic failure (FHF) derived from extensive liver lesions, 14 patients with FHF induced by different aetiologies were investigated by observance of both lymphocyte phenotyping and cytokine levels.

Cellulitis and Nodular Skin Lesions Due to Fusarium spp in Liver Transplant: Case Report

Fusariosis is one of the emerging invasive fungal infections over the last decade. However, its recent rise has been in its ability to produce disseminated infection in severely immunosuppressed patients with neutropenia. In solid organ transplantation, fusariosis remains an uncommon picture mainly with nodules, subcutaneous abscesses, ulcers, or necrotic skin lesions resembling erthyma gangrenosum. Herein, we have reported a case of cellulitis, subcutaneous nodules, and abscesses due to Fusarium spp in a liver transplantation patient who was successfully treated with polyenes and surgical resection.

Living Donor Liver Transplantation for Acute Liver Failure: A Single Center Experience

OBJECTIVE Orthotopic liver transplantation (OLT) is the principal therapy for acute liver failure (ALF). The mortality on the waiting list for deceased donor liver transplantation (DDLT) is high, principally in countries where donation rates are low. Living donor liver transplantation (LDLT) seems an option for the treatment of ALF, although some ethical issues need to be considered. Herein we have evaluated LDLT results among patients with ALF and discussed the ethical aspects of procedures performed in emergency situations. PATIENTS AND METHODS From March 2002 to October 2008, we performed 301 liver transplantations, including 103 from living donors. ALF was responsible for 10.6% of all transplantations; LDLT was only considered for pediatric recipients among whom 7 children displayed ALF. RESULTS One patient died on postoperative day 33 due to hepatic artery thrombosis. One patient died at 2 months after transplantation due to biliary sepsis, resulting in an overall survival rate of 71%. The average time for donor discharge was 5 days. No mortality or major complications were observed. CONCLUSIONS The survival of children with ALF undergoing LDLT was comparable to published data. Furthermore, despite the fact that the available time to prepare the donors was limited, no serious complications were observed in the postoperative period. Thus, using living donors for children with ALF is an effective, safe alternative that can be extremely useful in countries with low donation rates.

Tuberculosis in Liver Transplant Recipients: Prophylaxis in an Endemic Area

BACKGROUND Tuberculosis (TB) has a high prevalence in Brazil. The scenario of liver transplantation (LT) creates challenges: atypical presentation, treatment hepatotoxicity, and increased mortality. The majority of TB cases after transplantation represent reactivation of latent infections; therefore, prophylaxis (PX) plays a major role. The aim of this study was to evaluate the benefits of PX after LT based on a pretransplantation tuberculin test (TT) in an endemic area. METHODS Retrospective analysis of medical data from 376 adult cirrhotic patients undergoing OLT from 2001 to 2009. RESULTS Among 191 selected patients, 137 (71%) showed a pretransplant TT including 41 (30%) with a TT ≥5 mm. The 17 (40%) of these patients who were prescribed PX did not experience TB. Prophylaxis was discontinued in 5 patients (20%) owing to suspicion of hepatotoxicity (medium serum alanine transaminase 175 U/L). In the group without PX, we diagnosed 1 case of pulmonary TB. The overall prevalence of anergic patients in the cirrhotic phase was 65% and prevalence of TB 1%. CONCLUSIONS The prevalence of TB was similar to that reported in the literature, but positivity to TT was higher (34% vs 25%), possibly because of the endemicity of the area. There was a lower prevalence of extrapulmonary disease and no mortality. No patient undergoing PX with isoniazid, although incomplete due to suspicion of hepatotoxicity displayed TB. One patient without PX was affected by TB. The drug was effective but not always safe.