Murat Zeytunlu

Vascular complications after liver transplantation: evaluation with Doppler US

PurposeTo demonstrate the spectral and color Doppler ultrasonography (US) findings that would indicate vascular complications after liver transplantation and to report our single center results of vascular complications detected in liver transplant recipients.Materials and methodsOur study was consisted of 326 patients who underwent liver transplantation procedures between November 1997 and May 2004. The records of all patients were reviewed retrospectively for the details of each patient’s post-transplant Doppler US examinations, visceral angiographic examinations, and/or surgical procedures. Doppler US findings were correlated with angiographic results or surgery. Sensitivity and specificity of Doppler US parameters for the diagnosis of vascular complications of the hepatic artery, portal vein, and hepatic veins were calculated.ResultsVascular complications occurred in 47 patients (14%). Eight instances of vascular complications were detected intraoperatively by Doppler US at the time of transplantation. For hepatic artery complications, use of a Doppler US criteria resulted in a sensitivity and a specificity of 92% and 97%, respectively. Doppler US parameters also resulted in a sensitivity and a specificity of 100% in detecting portal vein complications, and resulted in a sensitivity of 99% and a specificity of 100% in detecting hepatic vein complications.ConclusionAlthough it is clear that Doppler US evaluation is an effective choice for diagnosing vascular complications after liver transplantation, we also observed that Doppler US examination plays an important role in detecting vascular complications intraoperatively and improving the patient’s chance for a successful outcome.

Adefovir dipivoxil therapy in liver transplant recipients for recurrence of hepatitis B virus infection despite lamivudine plus hepatitis B immunoglobulin prophylaxis

Background:  Treatment of post‐transplantation recurrence of hepatitis B virus (HBV) infection despite prophylaxis with hepatitis B immunoglobulin (HBIG) and lamivudine combination therapy is not easy. Because HBV reinfection has a severe course and could result in graft failure in liver transplant recipients, prompt medication is essential. Herein is reported the authors’ experience with adefovir dipivoxil (AD) therapy in 11 liver transplant recipients who had HBV reinfection despite the administration of lamivudine and HBIG.

Expression of matrix metalloproteinase‐9 in predicting prognosis of hepatocellular carcinoma after liver transplantation

Matrix metalloproteinases (MMPs) are known to play an important role in cell migration during cancer invasion by degrading extracellular matrix proteins. This study aimed to determine the role of MMP‐9 in hepatocellular carcinoma (HCC) carcinogenesis. Eighty‐nine cases who underwent liver transplantation for HCC in cirrhotic liver were selected for this study. The tumor characteristics such as nodule number, maximal diameter, portal vein invasion, and the preoperative alpha‐fetoprotein levels were reviewed. The intensity of immunostaining and the percentage of immunoreactive cells with MMP‐9 were evaluated. All patients were evaluated for HCC recurrence and/or death, and cause of death was noted. There was a lower survival and more recurrence risk among participants with 4 or more nodules exceeding 3 cm in diameter, with poorly differentiated tumor, and with large‐vessel involvement. Eleven patients developed recurrent HCC (12.4%). Twelve patients died as a result of HCC (13.5%). Among 89 HCCs, the incidences of a weak (+) and moderate (++) expression of MMP‐9 in carcinoma cells were 30.3% (23/89) and 43.8% (39/89), respectively. Increased expression and intensity of MMP‐9 were found to be inversely associated with poor tumor differentiation (P = 0.016, P = 0.009, respectively). A significant correlation between expression and intensity of MMP‐9 and large vascular invasion (P = 0.01, and P = 0.03) was also observed. As far as prognosis is concerned, increased immunoreactivity and intensity of MMP‐9 were found to exert an unfavorable impact on overall survival rates (P < 0.01, P = 0.01, respectively) and recurrences (P = 0.001, P = 0.02). Multivariate analyses revealed that MMP‐9 staining percentage (P = 0.007) and portal vein invasion (P = 0.002) were independent predictors of survival, whereas the only independent predictor of recurrences was portal vein invasion (P = 0.007). In this study, our results indicate a positive association between MMP‐9 expression and histopathologic parameters that indicate poor prognosis. We conclude that together, MMP‐9 staining percentage and portal vein invasion in HCC may aid to predict poor outcome. Nevertheless MMP‐9 staining percentage is expected to be a potential predictive marker on survival and needs to be studied more in detail. Liver Transpl 16:621‐630, 2010.

Live donor liver transplantation for acute liver failure.

Background. Acute liver failure (ALF) carries a high mortality unless urgent orthotopic liver transplantation (OLT) is performed on time. Live donors are utilized to treat this irreversible condition first in pediatric cases and then in adults. Herein, we aimed to report our experience with live donors for ALF in a country of a deceased donor organ donation rate is only 1.5 per million people. Methods. Among the 245 live donor liver transplantations (LDLT) performed from June 1999 to December 2005, 14 of them (6%) were performed for ALF in 8 pediatric and 6 adult cases. Right lobes were harvested for the adult cases whereas left lateral segments were harvested for pediatric cases, except one child transplanted with a right lobe graft. The etiology of the disease was; acute hepatitis B in four cases, hepatitis A in three cases, Wilson disease two cases, autoimmune hepatitis in two cases, and was unknown in three cases. Results. Three-year graft and patient survival is 79% for these series. Five of the six adult patients and six of the eight pediatric cases survived after transplantation. There was not any donor mortality or major morbidity. Conclusions. LDLT offers a safe and effective modality of treatment for ALF for both pediatric and adult patients to overcome the problem of organ shortage especially in countries where the chance of receiving an organ from a deceased donor is low.

Is it more dangerous to perform inadequate packing

Peri-hepatic packing procedure, which is the basic damage control technique for the treatment of hepatic hemorrhage, is one of the cornerstones of the surgical strategy for abdominal trauma. The purpose of this study was to evaluate the efficacy of the perihepatic packing procedure by comparing the outcomes of appropriately and inappropriately performed interventions. Trauma patients with liver injury were retrospectively evaluated. The patients who had undergone adequate packing were classified as Group A, and the patients who had undergone inappropriate packing, as Group B. Over a five-year period, nineteen patients underwent perihepatic packing. Thirteen of these patients were referred by other hospitals. Of 13 patients, 9 with inappropriate packing procedure due to insertion of intraabdominal drainage catheter (n=4) and underpacking (n=5) were evaluated in Group B, and the others (n=10) with adequate packing were assessed in Group A. Mean 3 units of blood were transfused in Group A and unpacking procedure was performed in the 24th hour. Only 3 (30%) patients required segment resection with homeostasis, and the mortality rate was 20% (2/10 patients). In Group B, 4 patients required repacking in the first 6 hrs. Mean 8 units of blood were transfused until unpacking procedure. The mortality rate was 44% (4/9 patients). The length of intensive care unit stay and requirement of blood transfusion were statistically significantly lower in Group A (p < 0.05). The mortality rate of this group was also lower. However, the difference between the groups for mortality rates was not statistically significant. This study emphasizes that efficacy of the procedure is one of the determinants that affects the results, and inadequate or inappropriate packing may easily result in poor outcome.

Comparison between allogenic and autologous vascular conduits in the drainage of anterior sector in right living donor liver transplantation

Congestion of the anterior sector may lead to graft failure in right lobe grafts. Selective drainage of the prominent segment 5 and/or 8 veins is proposed to overcome this problem. Different vascular conduits may be used during drainage of the anterior sector. In this study, we evaluated the efficiency of the vascular conduits. Between June 1999 and December 2005, 190 patients underwent living donor right lobe liver transplantation and reconstruction of segment 5 and/or 8 veins was performed in 48 patients (25.2%). Two groups were formed according to the types of vascular conduits. Cryopreserved cadaveric iliac artery (n = 28) and cryopreserved cadaveric iliac vein (n = 8) were used in group A. In group B, recipient saphenous vein (n = 6), recipient umbilical vein (n = 5) and recipient collateral omental vein (n = 1) were used for reconstruction. The graft‐recipient weight ratio, mean duration of anhepatic phase and MELD scores between two groups were not significantly different. All of the conduits were found to be patent just after reperfusion and in the early postoperative period by Doppler ultrasonography. In follow‐up period of 1 year, four (11%) patients died in group A, two patients (16%) in group B. One of these patients died because of sepsis started from the saphenous vein incision site. None of the patients dying in the two groups were lost due to venous outflow problems. This study proves the efficacy of drainage of segment 5 and/or 8 veins using cryopreserved cadaveric vascular conduits. Every effort should be employed to store cadaveric iliac vessels, otherwise, whole other additive surgical intervention to ensure vascular conduit may lead uninvited serious complication.

Leiomyosarcoma of the inferior vena cava: report of a case.

We report a case of leiomyosarcoma of the inferior vena cava, which was successfully treated by surgical en bloc resection and reconstruction of the inferior vena cava, followed by adjuvant radiation therapy. A 39-year-old man presented with nausea, vomiting, epigastric pain, and weight loss. Radiologic examinations showed a mass originating from the inferior vena cava and surgical resection was performed. Histopathological examination of the specimen revealed a moderately differentiated (grade II) leiomyosarcoma arising from the inferior vena cava. We believe that radical resection with clear surgical margins followed by adjuvant radiation therapy is a good curative strategy for achieving any chance of long-term survival.

Incidence and diagnosis of active toxoplasma infection among liver transplant recipients in Western Turkey

Toxoplasmosis is a serious and potentially life‐threatening disease in liver transplant recipients while they are immunosuppressed. We report the clinical and laboratory findings related to active toxoplasma infection associated with 40 immunosuppressed liver transplant procedures that took place over a 12‐month period at a major transplant unit in Izmir, Turkey. Twenty‐seven (67.5%) of the 40 transplant recipients were found to be seropositive for toxoplasma infection and therefore at risk of reactivated infection. From the serological status of the donors, which was ascertained in 38 of 40 cases, we identified 3 (7.9%) of 38 transplants to be from a seropositive donor to a seronegative recipient. In 10 (26.3%) of 38 transplants, both the donor and recipient were seronegative, and this excluded toxoplasma as a risk. A comparison of real‐time polymerase chain reaction (PCR) and nested PCR was undertaken in combination with a range of serological assays (the Sabin‐Feldman dye test, enzyme immunoassay immunoglobulin M, and immunosorbent agglutination assay immunoglobulin M). Ethylene diamine tetraacetic acid blood samples from 3 of the 30 recipients at risk from toxoplasma were found positive by PCR, but only 1 of these was found positive in both assays. Among the 3 PCR‐positive patients, immunoglobulin M and immunoglobulin G antibody levels increased in only 1 patient. Correlations between symptoms, laboratory findings, and clinical management (use of anti‐toxoplasma therapy) are presented. Our findings suggest that toxoplasma presents a significant risk to our liver transplant population and that PCR is a helpful addition in identifying active infections and hence in informing clinical management decisions. Liver Transpl 14:1526–1532, 2008.

Biliary intraductal papillary mucinous neoplasia: three case reports

Intrahepatic cholangiocarcinoma is subdivided as mass-forming, periductal-infiltrating, and intraductal-growing types. Intraductal-growing type is an entity described in recent years as mucin-producing intrahepatic cholangiocarcinoma or intrahepatic (biliary) intraductal papillary mucinous neoplasia (b-IPMN). b-IPMN is classified as adenoma, borderline tumor, carcinoma in situ, and carcinoma, from benign to malignant. Using a different classification, b-IPMNs are subdivided into intestinal, pancreatobiliary, gastric, or oncocytic based on morphology of the cells forming the lesion and expression of MUC1, MUC2, and MUC5 gene proteins in the mucin family. The clinical and histopathological features of b-IPMN diagnosed in three cases are presented herein. Case 1 was classified as borderline. Case 2 was diagnosed as carcinoma in situ. Case 3 had large invasive areas, and was diagnosed as carcinoma. In all three cases, immunohistochemical investigation revealed MUC1 and MUC5AC to be positive, and MUC2 to be negative. We present herein three cases diagnosed with the clinical and pathological findings of a new entity in the literature, b-IPMN, and we discuss the macroscopic, histological, and immunohistochemical features.

A new surgical technique for hepatic vein reconstruction in pediatric live donor liver transplantation.

Abstract:  The hepatic venous reconstruction is one of the corner stones of pediatric LDLT. However, problems associated with hepatic venous outflow still remain to be an issue. In this study, we aimed at comparing two methods used in hepatic venous reconstruction. Between November 1999 and December 2006, 61 consecutive left lateral segment pediatric LDLT were performed at Ege University Organ Transplant Center, and two methods were used for hepatic venous reconstruction. In the former group (group 1: 32 patients) continuous anastomosis was performed between the donor LHV and common orifice of the recipient HV. In the later group (group 2: 29 patients), the posterior wall of the anastomosis was sutured continuously while the anterior wall was sutured with interrupted sutures. HV thrombosis was detected in one patient and stenosis was detected in four patients in group 1. No hepatic venous outflow obstruction was detected in group 2 (p < 0.05). In both groups, mortality was not associated with hepatic venous outflow obstruction. As our results indicate, the novel technique used in this study is a simple and safe anastomosis procedure that has contributed into overcoming hepatic venous outflow problems in pediatric LDLT.