Paolo Aseni

Portal thrombosis in cirrhotics. A retrospective analysis.

The development of thrombotic obstruction in the portal bed of cirrhotic patients presents special problems in diagnosis and treatment. In the cirrhotic population treated for portal hypertension at our Surgical Department during the period 1967-1983 (512 patients), the incidence of thrombosis in the portal bed was 16.6% (85 patients). Bleeding was the main presenting symptom (70/85), with a mean of four episodes prior to treatment. Careful angiographic studies and intraoperative evaluation are fundamental steps to determine the exact anatomical involvement, the presence of recanalized veins or fresh occluding clots, and the applicability of shunt procedures. A massive portosplenomesenteric involvement often associated with poor surgical possibilities was found in 19 patients (22.3%). The presence of partially recanalized veins and fresh occluding clot suitable for disobliterative techniques prior to shunt was found in 16 patients, and out of 73 operated patients a total of 55 shunt procedures could be performed. Fifty-three patients who bled from varices could be followed up to 5 years: 39 underwent a shunt procedure with a 51.2% 5-year survival rate, while only one of 14 nonshunted or nonoperated survived up to 3 years, and a lethal bleeding was the cause of death in all but one. Disobliterative techniques (Fogarty thrombectomy and endovenectomy of intimal fibrotic thickenings) prior to shunting provided a good long-term patency rate with a 50% protection from lethal bleeding recurrences. Nonshunt procedures and the extensive involvement of the portal bed are associated with bad prognosis. Also, endoscopic sclerotherapy, attempted in patients with massive thrombosis, could not prevent recurrences and death from bleeding. Despite a 30% failure rate in our study, shunting surgery should be considered the only therapeutical possibility of preventing further thrombotic recurrences and consequent life threatening bleeding episodes.

Liver transplantation for hepatocellular carcinoma: prognostic factors associated long-term survival

Abstract  Between December 1985 and February 1995, 260 orthotopic liver transplantations (OLTX) were performed on 238 patients at Niguarda Hospital. Sixty‐three patients had hepatocellular carcinoma (HCC); in 13 of the patients HCC was incidental. All patients had negative lymph nodes. According to the Child classification, 13 patients were Child A, 30 Child B, and 18 Child C. According to the TNM classification, 11 patients were stage I, 22 stage II, 15 stage III, and 15 stage IVa. Pre‐OLTX chemoem‐bolization was performed on 25 patients. The perioperative mortality rate was 27 % (17 patients). Overall survival and disease‐free actuarial survival rates at 1, 3, and 5 years were 94 %, 76 %, 76 %, and 83 %, 75 %, 75 %, respectively. Survival curves were compared for 16 different variables. No difference was observed for all parameters analyzed except tumor site, TNM stage, pre‐OLTX AFP levels and vascular infiltration. These results seem to demonstrate that the OLTX for un‐resectable HCC can be considered in specifically selected cases as the treatment of choice. An adequate tumor staging is also necessary for a better patient selection in order to increase survival.

A prospective policy development to increase split-liver transplantation for 2 adult recipients: Results of a 12-year multicenter collaborative study

Objective:To analyze in a multicenter study the potential benefit of a new prospective policy development to increase split-liver procedures for 2 adult recipients. Background:Split-liver transplantation is an important means of overcoming organ shortages. Division of the donor liver for 1 adult and 1 pediatric recipient has reduced the mortality of children waiting for liver transplantation but the benefits or disadvantages to survival when the liver is divided for 2 adults (adult-to-adult split-liver transplant, AASLT) compared with recipients of a whole graft have not been fully investigated. Methods:We developed a computerized algorithm in selected donors for 2 adult recipients and applied it prospectively over a 12-year period among 7 collaborative centers. Patient and graft outcomes of this cohort receiving AASLT either as full right grafts or full left grafts were analyzed and retrospectively compared with a matched cohort of adults who received a conventional whole-liver transplant (WLT). Univariate and multivariate analysis was done for selected clinical variables in the AASLT group to assess the impact on the patient outcome. Results:Sixty-four patients who received the AASLT had a high postoperative complication rate (64.1% grade III and IV) and a lower 5-year survival rate than recipients of a WLT (63.3% and 83.1%) Conclusions:AASLT should be considered a surgical option for selected smaller-sized adults only in experimental clinical studies in experienced centers.

Percutaneous Transhepatic Bile Duct Ablation with n-Butyl Cyanoacrylate in the Treatment of a Biliary Complication after Split Liver Transplantation

Biliary complications continue to be a major cause of morbidity after split-liver transplantation (SLT). In this report we describe an uncommon late biliary complication. One year after SLT the patient showed an intrahepatic bile dicy dilatation with severe cholangitis episodes. The segmentary bile duct of hepatic segment VI-VII draining in the left duct was unidentified and tied at the time of the in situ split-liver procedure. We perform a permanent obliteration of the dilated intrahepatic ducts by a percutaneous embolization using an n-butyl cyanoacrylate (NABC). The management of biliary complications after SLT requires a multidisciplinary approach. The use of NBCA in obliteration of a dilated bile duct seems to be a safe procedure with good results providing a less invasive option than hepatic resection and decreasing the morbidity associated with chronic external biliary drainage. Further studies are needed to determine whether this approach is effective and safe and whether it could reduce hospital stay and cost.

Endoscopic ultrasound-guided fine-needle aspiration for suspected malignancies adjacent to the gastrointestinal tract.

AIM To investigate the impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in association with a multidisciplinary team evaluation for the detection of gastrointestinal malignancies. METHODS A cohort of 1019 patients with suspected malignant lesions adjacent to the gastrointestinal tract received EUS-FNA after a standardized multidisciplinary team evaluation (MTE) and were divided into 4 groups according to their specific malignant risk score (MRS). Patients with a MRS of 0 (without detectable risk of malignancy) received only EUS without FNA. For patients with a MRS score ranging from 1 (low risk) - through 2 (intermediate risk) - to 3 (high risk), EUS-FNA cytology of the lesion was planned for a different time and was prioritized for those patients at higher risk for cancer. The accuracy, efficiency and quality assessment for the early detection of patients with potentially curable malignant lesions were evaluated for the whole cohort and in the different classes of MRSs. The time to definitive cytological diagnosis (TDCD), accuracy, sensitivity, specificity, positive and negative predictive values, and the rate of inconclusive tests were calculated for all patients and for each MRS group. RESULTS A total of 1019 patients with suspected malignant lesions were evaluated by EUS-FNA. In 515 patients of 616 with true malignant lesions the tumor was diagnosed by EUS-FNA; 421 patients with resectable lesions received early surgical treatment, and 94 patients received chemo-radiotherapy. The overall diagnostic accuracy for the 1019 lesions in which a final diagnosis was obtained by EUS-FNA was 0.95. When patients were stratified by MTE into 4 classes of MRSs, a higher rate of patients in the group with higher cancer risk (MRS-3) received early treatment and EUS-FNA showed the highest level of accuracy (1.0). TDCD was also shorter in the MRS-3 group. The number of patients who received surgical treatment or chemo-radiotherapy was significantly higher in the MRS-3 patient group (36.3% in MRS-3, 10.7% in MRS-2, and 3.5% in MRS-1). CONCLUSION EUS-FNA can effectively detect a curable malignant lesions at an earlier time and at a higher rate in patients with a higher cancer risk that were evaluated using MTE.

Multiorgan procurement for transplantation

Multiorgan procurement for transplantation : , Multiorgan procurement for transplantation : , کتابخانه دیجیتال جندی شاپور اهواز

Life-Saving Super-Urgent Liver Transplantation with Replacement of Retrohepatic Vena Cava by Dacron Graft

We describe a modified technique of side-to-side cavo-cavostomy by Dacron interposition prosthesis during a super urgent liver transplantation. A liver graft from a deceased donor was immediately requested on a top priority basis as a consequence of massive bleeding during extended left hepatectomy for a huge hepatic haemangioma arising from the caudate lobe. Veno-venous bypass was employed during anhepatic phase but it was disconnected due to severe fibrinolysis and hypothermia. A porto-caval shunt was performed and the inferior vena cava outflow was restored by a Dacron interposition prosthesis. A liver graft from a deceased donor was available 16 hours later. Due to the shortness of the vena cava of the donor liver graft, the removal of the Dacron graft was impossible and a modified side-to-side cavo-cavostomy between the Dacron interposition graft and the vena cava of the donor liver was than performed. Liver transplantation was uneventful and the patient is doing well 25 months after the surgical procedure. Although the use of synthetic vascular prosthesis should usually be discouraged during organ transplantation, its exceptional use during liver transplantation is possible with long-term good results.

Endoscopic multiple metal stenting for the treatment of enteral leaks near the biliary orifice: A novel effective rescue procedure.

Between April 2013 and October 2015, 6 patients developed periampullary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with primary surgical repair was attempted at first but failed. A fully covered enteral metal stent was placed in all patients to seal the leak. Subsequently, we cannulated the common bile duct and, in some cases, and the main pancreatic duct inserting hydrophilic guidewires through the stent after dilating the stent mesh with a dilatation balloon or breaking the meshes with Argon Plasma Beam. Finally, we inserted a fully covered biliary metal stent to drain the bile into the lumen of the enteral stent. In cases of normal proximal upper gastrointestinal anatomy, a pancreatic plastic stent was also inserted. Oral food intake was initiated when the abdominal drain outflow stopped completely. Stent removal was scheduled four to eight weeks later after a CT scan to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. The leak resolved in five patients. One patient died two days after the procedure due to severe, pre-existing, sepsis. The stents were removed endoscopically in four weeks in four patients. In one patient we experienced stent migration causing small bowel obstruction. In this case, the stents were removed surgically. Four patients are still alive today. They are still under follow-up and doing well. Bilio-enteral fully covered metal stenting with or without pancreatic stenting was feasible, safe and effective in treating postoperative enteral leaks near the biliopancreatic orifice in our small series. This minimally invasive procedure can be implemented in selected patients as a rescue procedure to repair these challenging leaks.

Management of Hemodynamic and Metabolic Impairments in Heart-Beating Donors

Transplantation results are significantly better when organs are obtained from live donors compared with organs from brain-dead and from nonheart- beating donors. This outcome is closely related to acute and widespread physiological changes occurring during brain death that, if untreated, cause organic deterioration and cardiac arrest. Furthermore, inflammatory and hormonal changes, if not carefully diagnosed and treated, may adversely affect donor organ function after transplantation and susceptibility to rejection.

Split Liver: Surgical Techniques for Adult and Pediatric Recipients and for Two Adult Recipients

Three different standard types of liver bipartition producing six different types of grafts can be created by following a plane directed on the right or the left line of the middle hepatic vein (MHV): a) splitting for adult and pediatric recipients with left lateral graft (LLG) and right extended graft (REG), b) splitting for two adults or for adult and pediatric recipients of large size with creation of left graft (LG) and right graft (RG), c) splitting for two adult recipients with creation of full left graft (FLG) and full right graft (FRG). The absence of an extrahepatic portal vein bifurcation is an absolute contraindication to liver splitting. Division of the portal branches to Segment I optimizes the freeing/lengthening of the left portal vein for the implantation. Identifying the portal tract entering the caudate process at its lower aspect is helpful in preparing for the division of the hilar plate. Early division of the Arantius remnant allows a safe encircling and control of the left hepatic vein. During in situ splitting technique for adult and pediatric recipients, a 1–2-min. selective clamping of the left hepatic vein (LHV) may provide assurance that the hepatic venous drainage of Segment IV is not jeopardized. Recognition of independent segment II and III suprahepatic venous outflow (<5 % of cases) is crucial in the adult and pediatric splitting procedure. Segment IV hypoperfusion is a potential pitfall during adult and pediatric liver splitting. During adult and pediatric split-liver procedure, parenchyma transection can be achieved according to the transhilar (TH) approach or transumbilical (TU) approach. In the liver-splitting technique for two adults, the “hanging manoeuvre” can be helpful to define the correct plane of transection from the bifurcation of the hepatic artery and portal vein to a point between the right and middle hepatic veins. In some case of MHV dominancy during split-liver procurement for two adults, the ex situ splitting of the vena cava and/or MHV can be considered possible options to avoid complex reimplantation of multiple tributaries of the MHV and the congestion of segments IV, V, and VIII.