Paulo Sérgio Vieira de Melo

Impact of MELD allocation policy on survival outcomes after liver transplantation: a single-center study in northeast Brazil

OBJECTIVE: To analyze the impact of model for end‐stage liver disease (MELD) allocation policy on survival outcomes after liver transplantation (LT). INTRODUCTION: Considering that an ideal system of grafts allocation should also ensure improved survival after transplantation, changes in allocation policies need to be evaluated in different contexts as an evolutionary process. METHODS: A retrospective cohort study was carried out among patients who underwent LT at the University of Pernambuco. Two groups of patients transplanted before and after the MELD allocation policy implementation were identified and compared using early postoperative mortality and post‐LT survival as end‐points. RESULTS: Overall, early postoperative mortality did not significantly differ between cohorts (16.43% vs. 8.14%; p = 0.112). Although at 6 and 36‐months the difference between pre‐ vs. post‐MELD survival was only marginally significant (p = 0.066 and p = 0.063; respectively), better short, medium and long‐term post‐LT survival were observed in the post‐MELD period. Subgroups analysis showed special benefits to patients categorized as non‐hepatocellular carcinoma (non‐HCC) and moderate risk, as determined by MELD score (15‐20). DISCUSSION: This study ensured a more robust estimate of how the MELD policy affected post‐LT survival outcomes in Brazil and was the first to show significantly better survival after this new policy was implemented. Additionally, we explored some potential reasons for our divergent survival outcomes. CONCLUSION: Better survival outcomes were observed in this study after implementation of the MELD criterion, particularly amongst patients categorized as non‐HCC and moderate risk by MELD scoring. Governmental involvement in organ transplantation was possibly the main reason for improved survival.

Emprego do escore MELD para a predição da sobrevivência pós-transplante hepático

OBJECTIVE To assess the overall accuracy of the preoperative MELD score for predicting survival after liver transplantation (LT) and appraise medium-term (24 months) predictors of survival. METHODS We conducted a cross-sectional study including patients transplanted by the Department of General Surgery and Liver Transplantation of the Oswaldo Cruz University Hospital, University of Pernambuco, between July 15th, 2003 and July 14th, 2009. We used analysis of area under ROC (receiver operating characteristic) as a summary measure of the performance of the MELD score and assessed predictors of medium-term survival using univariate and multivariate analysis. RESULTS The cumulative survival of three, six, 12 and 24 months of the 208 patients studied was 85.1%, 79.3%, 74.5% and 71.1%, respectively. The preoperative MELD score showed a low discriminatory power for predicting survival after TH. By univariate analysis, we identified intraoperative transfusion of red blood cells (p <0.001) and platelets (p = 0.004) and type of venous hepatocaval anastomosis (p = 0.008) as significantly related to medium-term survival of the patients studied. However, by multivariate analysis only red blood cell transfusion was a significant independent predictor of outcome. CONCLUSION The MELD score showed low overall accuracy for predicting post-transplant survival of patients studied, among which only intraoperative transfusion of red blood cells was identified as an independent predictor of survival in the medium term after TH.

Postoperative kidney injury does not decrease survival after liver transplantation

PURPOSE To explore the effect of acute kidney injury (AKI) on long-term survival after conventional orthotopic liver transplantation (OLT) without venovenous bypass (VVB). METHODS A retrospective cohort study was carried out on 153 patients with end-stage liver diseases transplanted by the Department of General Surgery and Liver Transplantation of the University of Pernambuco, from August, 1999 to December, 2009. The Kaplan-Meier survival estimates and log-rank test were applied to explore the association between AKI and long-term patient survival, and multivariate analyses were applied to control the effect of other variables. RESULTS Over the 12.8-year follow-up, 58.8% patients were alive with a median follow-up of 4.5-year. Patient 1-, 2-, 3- and 5-year survival were 74.5%, 70.6%, 67.9% and 60.1%; respectively. Early postoperative mortality was poorer amongst patients who developed AKI (5.4% vs. 20%, p=0.010), but long-term 5-year survival did not significantly differed between groups (51.4% vs. 65.3%; p=0.077). After multivariate analyses, AKI was not significantly related to long-term survival and only the intraoperative transfusion of red blood cells was significantly related to this outcome (non-adjusted Exp[b]=1.072; p=0.045). CONCLUSION The occurrence of postoperative acute kidney injury did not independently decrease patient survival after orthotopic liver transplantation without venovenous bypass in this data from northeast Brazil.

Esplenectomia e ligadura da veia gástrica esquerda na esquistossomose mansônica: efeito sobre a pressão das varizes de esôfago aferida por tecnica não-invasiva

Em ambos os hospitais universitarios de Pernambuco, o tratamento de escolha para portadores de esquistossomose hepatoesplenica (EHE) com antecedente de hemorragia digestiva alta (HDA) por rotura de varizes de esofago (VE) e a esplenectomia associada a ligadura da veia gastrica esquerda (ELGE); porem, o impacto desta cirurgia sobre a pressao das VE, provavelmente, o parâmetro que melhor se correlaciona com o risco de recidiva hemorragica, ainda nao foi estudado. Com a introducao, em nosso meio, de tecnica nao-invasiva de medicao da pressao das VE, isto tornou-se possivel, com minimos riscos, tomando-se o objetivo do presente estudo. A ELGE foi empregada em vinte portadores de EHE com antecedentes de HDA. A pressao das VE foi medida atraves do metodo endoscopico nao-invasivo do balao pneumatico, antes da cirurgia, e estes valores comparados com novas medicoes realizadas cinco a oito dias apos. A pressao nas VE no pre-operatorio variou entre 20,0 e 28,7mmHg (media de 24,35± 2,36 mmHg). Nao houve correlacao da pressao com o calibre das VE. No pos-operatorio (PO), observou-se uma queda significante na pressao das VE, que variou entre 14,6 e 21,5 mmHg (media 17,29± 1,75 mmHg, p<0,001). Os resultados do presente trabalho confirmam as ideias que fundamentam a indicacao da ELGE em portadores de EHE com antecedente de HDA. Esta cirurgia determina, pelo menos a curto prazo e na ampla maioria dos casos, uma reducao na pressao das VE reduzindo o risco de recidiva de HDA.

O doador marginal: experiência de um centro de transplante de fígado

RACIONAL: Desde que o uso de enxertos marginais e solucao aceita para escassez de orgaos para transplante, ele tornou-se muito comum em todo mundo e a literatura vem mostrando efetividade desses enxertos no transplante de figado. OBJETIVO: Apresentar a experiencia do Servico de Transplante Hepatico do Hospital Universitario Oswaldo Cruz, em transplante de figado com o uso de doadores marginais. METODOS: Estudo retrospectivo em 137 transplantes ortotopicos de figado, usando enxertos marginais entre 1999 e 2006, com acompanhamento minimo de 180 dias. Os receptores foram classificados de acordo com a funcao inicial do enxerto no pos-operatorio como normal (FN) e disfuncao primaria (DP). RESULTADOS: Nao foi observada diferenca estatisticamente significante entre os grupos FN e DP com os seguintes parâmetros dos doadores: idade, sodio serico, tempo de protrombina, esteatose hepatica, transaminases serica, pressao sanguinea, drogas vasoativas, indice de massa corporea, parada cardiaca antes da doacao de orgao, doador em assistolia e tempo de isquemia quente. Analise da curva de sobrevida (Kaplan-Meier) de pacientes e de enxertos de figado de pacientes que receberam figado de doadores ideais versus doadores marginais nao mostrou diferenca com significância estatistica. CONCLUSAO: Pode ser recomendado o uso de enxertos marginais para transplantes hepaticos, inclusive os provenientes de doadores com o coracao parado.

A veia gástrica esquerda como alternativa de revascularização portal no transplante hepático

Trombose ou hipoplasia da veia porta nao tem sido, ainda, considerados contra-indicacoes para o transplante ortotopico de figado. Contudo, permanecem com obstaculos associados com aumento da frequencia de falha primaria e a longo prazo do transplante de figado. Existem alguns fatores de risco tais como: sexo masculino, cirrose avancada, doenca hepatica alcoolica e cirurgia previa para hipertensao portal. Os autores relatam o caso de uma crianca de 4 anos, do sexo feminino, que sofria de doenca terminal do figado resultante de atresia de vias biliares e que tinha submetido, sem sucesso, a uma operacao de Kasai. Ela se submeteu a um transplante ortotopico de figado por cirrose biliar secundaria. Durante a cirurgia uma hipoplasia portal severa do receptor foi encontrada. Uma anastomose entre a veia gastrica esquerda do receptor e a veia porta do doador foi feita. Reperfusao hepatica e subsequente funcao do figado foram excelentes. A paciente recebeu alta hospitalar no trigesimo dia. A veia gastrica esquerda pode ser uma alternativa para revascularizacao portal no transplante hepatico.

UPPER MIDLINE INCISION IN RECIPIENTS OF DECEASED-DONORS LIVER TRANSPLANTATION

ABSTRACT Background: Liver transplant (LT) is the only effective and long-lasting option for patients with end-stage liver disease. Innovations and refinements in surgical techniques occurred with the advent of transplants with partial grafts and laparoscopy. Despite these modifications, the abdominal incision remains with only few changes. Aim: Demonstrate the experience with the upper midline incision in LT recipients with whole liver grafts from deceased donors. Methods: Retrospective study with patients submitted to LT. Data were collected from the recipients who performed the surgical procedure through the upper midline incision. Results: The upper midline incision was used in 20 LT, 19 of which were performed in adult recipients. The main cause was liver disease secondary to alcohol. Male, BMI>25 kg/m² and MELD greater than 20 were prevalent in the study. Biliary complications occurred in two patients. Hemoperitoneum was an indication for reoperation at one of the receptors. Complication of the surgical wound occurred in two patients, who presented superficial surgical site infection and evisceration (omental). Two re-transplant occurred in the first postoperative week due to severe graft dysfunction and hepatic artery thrombosis, which were performed with the same incision, without the need to increase surgical access. There were two deaths due to severe graft dysfunction after re-transplant in 72 h and respiratory sepsis with multiple organ dysfunction in the third week. Conclusion: The upper midline incision can be safely used in LT recipients with whole grafts from deceased donors. However, receptor characteristics and hepatic graft size should be considered in the option of abdominal surgical access.

ANATOMIC VARIATIONS OF HEPATIC ARTERY: A STUDY IN 479 LIVER TRANSPLANTATIONS

ABSTRACT Background: The incidence of anatomic variations of hepatic artery ranges from 20-50% in different series. Variations are especially important in the context of liver orthotopic transplantation, since, besides being an ideal opportunity for surgical anatomical study, their precise identification is crucial to the success of the procedure. Aim: To identify the anatomical variations in the hepatic arterial system in hepatic transplantation. Methods: 479 medical records of transplanted adult patients in the 13-year period were retrospectively analyzed, and collected data on hepatic arterial anatomy of the deceased donor. Results: It was identified normal hepatic arterial anatomy in 416 donors (86.84%). The other 63 patients (13.15%) showed some variation. According to the Michels classification, the most frequently observed abnormalities were: right hepatic artery branch of superior mesenteric artery (Type III, n=27, 5.63%); left hepatic artery branch of the left gastric artery (Type II, n=13, 2.71%); right hepatic artery arising from the superior mesenteric artery associated with the left hepatic artery arising from the left gastric artery (Type IV, n=4, 0.83%). Similarly, in relation to Hiatt classification, the most prevalent changes were: right hepatic accessory artery or substitute of the superior mesenteric artery (Type III, n=28, 6.05%)), followed by liver ancillary left artery or replacement of gastric artery left (Type II, n=16, 3.34. Fourteen donors (2.92%) showed no anatomical abnormalities defined in classifications, the highest frequency being hepatomesenteric trunk identified in five (01.04%). Conclusion: Detailed knowledge of the variations of hepatic arterial anatomy is of utmost importance to surgeons who perform approaches in this area, particularly in liver transplantation, since their identification and proper management are critical to the success of the procedure.

ACUTE APENDICITIS IN LIVER TRANSPLANT RECIPIENTS

Background : Appendicitis is a common cause of emergency surgery that in the population undergoing organ transplantation presents a rare incidence due to late diagnosis and treatment. Aim : To report the occurrence of acute appendicitis in a cohort of liver transplant recipients. Methods : Retrospective analysis in a period of 12 years among 925 liver transplants, in witch five cases of acute appendicitis were encountered. Results : Appendicitis occurred between three and 46 months after liver transplantation. The age ranged between 15 and 58 years. There were three men and two women. The clinical presentations varied, but not discordant from those found in non-transplanted patients. Pain was a symptom found in all patients, in two cases well located in the right iliac fossa (40%). Two patients had symptoms characteristic of peritoneal irritation (40%) and one patient had abdominal distention (20%). All patients were submitted to laparotomies. In 20% there were no complications. In 80% was performed appendectomy complicated by suppuration (40%) or perforation (40%). Superficial infection of the surgical site occurred in two patients, requiring clinical management. The hospital stay ranged from 48 h to 45 days. Conclusion : Acute appendicitis after liver transplantation is a rare event being associated with a high rate of drilling, due to delays in diagnosis and therapy, and an increase in hospital stay.

Non-cancerous prognostic factors of hepatocellular carcinoma after liver transplantation

PURPOSE To explore non-cancerous factors that may be related with medium-term survival (24 months) after liver transplantation (LT) in this data from northeast Brazil. METHODS A cross-sectional study was carried out in patients who underwent deceased-donor orthotopic LT because hepatocellular carcinoma (HCC) at the University of Pernambuco, Brazil. Non-cancerous factors (i.e.: donor-, receptor-, surgery- and center-related variables) were explored as prognostic factors of medium-term survival using univariate and multivariate approachs. RESULTS Sixty-one patients were included for analysis. Their three, six, 12 and 24-month overall cumulative survivals were 88.5%, 80.3%, 73.8% and 65.6%, respectively. Our univariate analysis identified red blood cell transfusion (Exp[b]=1.26; p<0.01) and hepato-venous reconstruction technique (84.6% vs. 51.4%, p<0.01; respectively for piggyback and conventional approaches) as significantly related to post-LT survival. The multivariate analysis confirmed the hepato-venous reconstruction technique was an independent prognostic factor. CONCLUSION The piggyback technique was related to improved medium-term survival of hepatocellular carcinoma patients after liver transplantation in this northeast Brazilian sample.