Settimo Caruso

Successful treatment of small‐for‐size syndrome in adult‐to‐adult living‐related liver transplantation: single center series

Abstract:  The portal hyperperfusion, or small‐for‐size syndrome (SFSS), is a widely recognized clinical complication that may occur after segmental liver transplantation. Several surgical strategies have been proposed to reduce portal blood inflow and portal pressure after partial liver transplantation. In particular, splenic artery ligation and splenectomy have been used without a firm hemodynamic basis for these procedures. Our group recently demonstrated that, in patients with cirrhosis and portal hypertension, the occlusion of the splenic artery causes a significant reduction in the portal pressure gradient, which is directly related to the spleen volume and indirectly related to the liver volume. This concept is at the center of our strategy for performing early splenic artery embolization (SAE) for the treatment of SFSS after living‐related liver transplantation (LRLT). Six patients developed small‐for‐size syndrome, defined as: onset within the first week after LRLT of progressive hyperbilirubinemia without mechanical cause; marked cholestasis; centrilobular sinusoidal dilatation and hepatocyte atrophy at liver biopsy; and refractory ascites in the absence of vascular complications. All six patients who underwent SAE rapidly improved their clinical condition, with an evident decrease in the value of bilirubin in the serum, in the production of ascites, and improvement in condition of pancytopenia. Coagulopathy expressed by the international normalized ratio value (INR) was not a reliable early marker of SFSS in this series; in fact a slight improvement in the result of this test was already present immediately after LRLT and before SAE. Because splenic flow clearly contributes to portal hyperperfsion, an early SAE can relieve the partial graft from the deleterious effect of this portal overflow.

Effects of splenic artery occlusion on portal pressure in patients with cirrhosis and portal hypertension

The specific contribution of splenic blood inflow to portal hypertension in patients with cirrhosis is still unclear. In this study, we investigated this contribution by assessing the hemodynamic effects of transient splenic artery occlusion. In 15 cirrhotic patients, portal pressure gradient (PPG) was measured just before inserting a transjugular intrahepatic portosystemic shunt (TIPS), in baseline conditions, for 15 minutes after splenic artery occlusion and 5 minutes after recovery. Splenic artery occlusion caused a significant decrease in PPG (range, −4% to −38%, median −20%, P < 0.001) which promptly returned to baseline values after recovery of the splenic inflow. The decrease in PPG showed a significant correlation with spleen volume (r = 0.70, P < 0.005), liver volume (r = −0.63; P < 0.01), and spleen/liver volume ratio (r = 0.82, P < 0.001). Seven out of eight patients with a spleen/liver volume ratio greater than 0.5 had a marked decrease in PPG (>20%), whereas none of patients with a ratio lesser than 0.5 had a marked PPG response. In conclusion, in cirrhotic patients with portal hypertension, splenic artery occlusion causes a significant reduction in portal pressure (PPG). The drop in PPG is directly related to spleen volume and indirectly related to liver volume. The spleen/liver volume ratio accurately predicts the drop in PPG and may be used to identify patients who could obtain a significant advantage from surgical and nonsurgical procedures decreasing splenic inflow. Liver Transpl 12:1237‐1243, 2006.

Measurement of hepatic vein pressure gradient in children with chronic liver diseases

BACKGROUND & AIMS The aim of this study is to present our preliminary experience with Hepatic Vein Pressure Gradient (HVPG) measurements in pediatric patients with chronic liver disease. METHODS Institutional review board approval was obtained. HVPG was measured in 20 pediatric patients, mean age 82+/-54 months, with chronic liver disease, without extrahepatic portal vein obstruction. In nine patients the end-stage liver disease was secondary to biliary atresia; in the remaining 11, to various causes. Eleven patients had esophageal varices at endoscopy, 14 had perigastric and periesophageal collaterals at imaging scan, three had ascites, 12 had low platelet count, and all had splenomegaly. RESULTS Hepatic vein catheterization was technically possible in all patients without complications. HVPG values were elevated in all but three patients, ranging between 2 and 33 mmHg (mean 11.3+/-7.2 mmHg), thus indicating a sinusoidal component in portal hypertension. A salient finding was the presence of hepatic venovenous shunts in 7 out of 9 patients with biliary atresia; however, the HVPG could still be measured distal to the shunts, but in three patients (with an HVPG of 8 mmHg) it was determined in an area with a small venovenous communication still visible, therefore underestimating the actual portal pressure gradient. No venovenous shunts were detected in the non-biliary atresia patients. CONCLUSIONS HVPG is a feasible procedure in pediatric patients. Patients with biliary atresia very frequently have communicating vessels between hepatic veins. This hitherto unacknowledged finding can lead to the underestimation of portal pressure by HVPG measurement.

Percutaneous transhepatic venous angioplasty in a two-yr-old patient with hepatic vein stenosis after partial liver transplantation.

Abstract:  We report one case of severe hepatic vein stenosis, in a two‐yr‐old pediatric patient with a left lateral split liver transplantation (S2–S3) and severe ascites, in whom color Doppler ultrasound failed to make the diagnosis and transhepatic balloon angioplasty was successfully performed.

Percutaneous recanalization of an occluded hepatico-jejunostomy, using Colapinto needle, in a two-yr-old patient after partial liver transplantation

Abstract:  We report one case of percutaneous recanalization of an hepatico‐jejunostomy, using Colapinto needle, in a two‐yr‐old patient after partial liver transplantation and occlusive anastomotic biliary stricture non‐crossable with conventional interventional radiology techniques. The procedure was successfully performed and followed by biliary trans‐anastomotic catheter placement. Later, the patient underwent multiple session of conventional percutaneous balloon dilatation of the anastomosis as a good flow of contrast from bile ducts to bowel loops was achieved. The patient is now without percutaneous biliary catheter since 10 months in good general conditions and with good liver function tests.

Evolution of surgical technique in conventional open hepatectomy for living liver donation over a 12-year period in a single center.

We report details of the experience from the largest Italian program with hepatic living donation, focusing particularly on the use of intraoperative ultrasound in liver transplantation and living donation. During a 12-year period we changed our surgical technique in the conventional open procedures thanks to the experience gained into the laparoscopic setting. Intraoperative ultrasound has been implemented during these delicate procedures for ensuring a fast and safer detection of the accessory veins and final severing of the vascular stumps during liver transection.

Transjugular biopsy of an atypical focal nodular hyperplasia in a patient with acute liver failure clinical presentation

The following is a report on one case of successful biopsy of a hepatic focal lesion incidentally found in an emergency computed tomography scan performed in a patient with acute liver failure clinical presentation. The presence of peri-hepatic ascites and severe coagulopathy contraindicated the percutaneous biopsy. The transjugular approach was used to perform a random liver biopsy to assess the amount of hepatic necrosis and to perform the focal lesion biopsy orienting the needle with sonography guidance. The specimen acquired was satisfactory to exclude the presence of malignant cells in the lesion; the diagnosis of atypical focal nodular hyperplasia was performed. The patient underwent successful liver transplantation the day after.

Percutaneous retrograde colangiography of segment III bile duct, through the previously catheterized segment II bile duct, in 15‐month‐old patient after partial liver transplantation with two separate bilio‐enteric anastomoses

Abstract:  We report one case of percutaneous retrograde colangiography of segment III bile duct, through the previously catheterized segment II bile duct, in 15‐month‐old patient after partial liver transplantation and two separate biliary anastomoses. The retrograde diagnostic cholangiogram confirmed the suspicion of anastomotic stricture and distended the bile ducts, which were easily punctured with percutaneous approach with a 20 Ga Chiba needle.