Richard R. Lopez

Management of biliary complications after liver transplantation

Biliary tract complications after liver transplantation are common, and the evaluation of newer treatment options compared with standard surgical treatment is important. In 62 liver transplants performed in 55 adult patients, the biliary tract was reconstructed with choledochocholedochostomy (CC) in 52 (84%) and Roux-en-Y choledochojejunostomy (RYCJ) in 10 (16%). Seventeen biliary tract complications occurred in 16 patients (29%). The incidence of complications was the same after CC and RYCJ. Eight complications (47%) occurred within the first month and nine (53%) thereafter. Only 6 of 17 (35%) biliary tract complications required operation. One patient died of a biliary tract complication. No other allografts were lost due to biliary tract complications. Four patients transplanted at other centers were also treated, for a total of 21 biliary tract complications. Overall, there were nine bile leaks, eight bile duct strictures, two Roux loop hemorrhages, one choledocholithiasis, and one ampullary dyskinesia. Temporary or permanent stents were used successfully in seven of eight strictures. Five bile leaks were managed without operation. Nonsurgical management is appropriate for a selected majority of patients with late bile leaks, biliary tract strictures, or choledocholithiasis after liver transplantation.

Problems in diagnosis and management of desmoid tumors

Thirty-two primary desmoid tumors occurred in 29 patients. The median patient age was 32 years, and 55% of the patients were females. An antecedent history of trauma at the tumor site was elicited from 28% of patients. Thirty-one of 32 primary tumors were completely excised at initial presentation. Five tumors were treated with adjuvant radiotherapy. The overall recurrence rate for primary and recurrent lesions was 60%. The recurrence rate in children (88%) was more than twice that found in adults (38%). A single recurrence did not significantly increase the likelihood of a subsequent recurrence. Greater than 90% of all recurrences took place within 3 years of treatment. The rate of recurrence was not clearly influenced by the status of histologic margins, although this was examined in less than half the tumors. Desmoid tumors are aggressive neoplasms that exhibit a strong propensity for local recurrence. They should be treated as low-grade malignancies with documentation of histologic margins and close clinical follow-up within the framework of a tumor registry.

Role of computed tomographic scans in the staging of esophageal and proximal gastric malignancies

In order to determine the accuracy of computed tomographic (CT) scanning, CT scan results were compared with operative and pathologic findings in 45 patients with esophageal and proximal gastric malignancies. CT scans were evaluated with respect to nodal metastases, hepatic metastases, and adjacent spread. Eight patients did not undergo surgery because of advanced disease noted on the CT scan. Of the remaining 37 patients, sensitivity of CT for all 3 parameters was less than 60%, whereas the specificity was greater than 90%. The positive predictive value was greater than 90% for nodal metastases and adjacent spread and 67% for hepatic metastases. The negative predictive value was less than 40% for nodal metastases and adjacent spread and 90% for hepatic metastases. For esophageal and proximal gastric malignancies, CT is useful in identifying advanced disease and in predicting resectability. In less advanced cases, CT is not sensitive, and its negative predictive value is poor with regard to local and lymphatic spread. CT scanning is useful to stage the most advanced cases but because of limited accuracy should be combined with other diagnostic studies when accurate staging is required.

Initial two-year results of the oregon liver transplantation program

During the first 24 months of the Oregon Liver Transplantation Program, which began in October 1988, 94 patients were formally evaluated and 47 adults underwent 54 liver transplantations. Thirty-four percent of patients were veterans. The recipient operation lasted a mean of 7.4 hours (range: 4 to 16 hours). Veno-venous bypass was used routinely at first but selectively later (7 of the last 26 cases), resulting in reduced operating time. Hepatic artery reconstruction was end-to-end anastomosis in 52 cases and iliac conduit in 2. No arterial thrombosis occurred. Biliary reconstruction was choledochocholedochostomy in 83% and choledochojejunostomy in 17%. Biliary complications occurred in 28%. Operative mortality was 2%, and 1-year actual survival was 80%. Patients with hepatitis B fared worse, with four of six dying at a mean of 7.6 months. Overall, the median hospital stay was 30 days. Patients surviving more than 3 months had a mean Karnofsky score of 82%. No significant difference in outcome was noted in patients receiving prophylactic OKT3 monoclonal antibody (used in 45%) versus conventional immunosuppressive therapy. Overall, allograft rejection occurred in 55% of patients. Retransplantation was required in seven patients, three for primary graft nonfunction, two for uncontrolled rejection during induction therapy with OKT3, and two for graft failure secondary to recurrent hepatitis B.