Uwe Hesse

Modulation of Portal Graft Inflow: A Necessity in Adult Living-donor Liver Transplantation?

ObjectiveTo evaluate the clinical significance of modulating the recipient portal inflow (rPVF) through perioperative ligation of the splenic artery in adult living-donor liver transplantation (ALDLTx) by focusing on vascular complications, intractable ascites production, and the prevention of small-for-size syndrome (SFSS). Summary Background DataIn ALDLTx, portal graft flow is enhanced to at least twice the donor value, raising the total liver inflow. Recipient hepatic arterial flow (rHAF) is lower than expected. Portal hyperperfusion of small grafts in larger recipients is thought to be one of the main causes of posttransplant graft dysfunction/SFSS. MethodsSeventeen ALDLTx were reviewed for a minimum of 2 months. Patients were divided retrospectively into two groups: G1 (n = 7), without modulation of rPVF, and G2 (n = 10), with splenic artery ligation to decrease rPVF perioperatively. Donor and recipient hepatic hemodynamics were evaluated against graft function and outcome, including correlations between rPVF, graft weight, graft:recipient body weight ratio, and recipient weight. ResultsFollowing portal and arterial reperfusion, mean rPVF and rPVF/graft weight were much higher than in the donors, whereas mean rHAF and rHAF/graft weight were much lower. No differences were found between groups, except for rPVF and rHAF, which were much more higher and lower, respectively, before splenic artery ligation. In G1 patients, SFSS was seen in two patients and vascular complications occurred in two others. In G2 patients, splenic artery ligation permitted a significant decrease in rPVF, an improvement in rHAF, and the resolution of refractory ascites. Neither SFSS nor vascular complications were seen in G2 patients. ConclusionsWhen a suboptimal graft:recipient body weight ratio is accompanied by high rPVF in ALDLTx, the portal flow should be modulated perioperatively; splenic artery ligation is a simple and safe method that is sufficient to allow this modulation in most patients.

Reduced incidence of acute renal graft failure in patients treated with peritoneal dialysis compared with hemodialysis

In a case-control study performed in two centers, the incidence of delayed graft function (DGF), defined as the necessity to perform dialysis after transplantation, was analyzed according to prior treatment with continuous ambulatory peritoneal dialysis (CAPD; n = 117) or hemodialysis (HD; n = 117). The patients were matched for age, sex, HLA compatibility, and cold ischemia time. The patients were followed up for 6 months to monitor renal graft function (serum creatinine [Screa] level immediately after transplantation, at 6 weeks, at 6 months) and postoperative complications. No significant differences were found in the warm ischemia time of the graft or previous time on dialysis. DGF occurred in 27 CAPD patients (23.1%) and 59 HD patients (50.4%; P < 0.0001). The decline in Screa level after transplantation was faster in CAPD patients: the time for Screa level to decrease 50% after transplantation (T1/2Screa) was reached after 5.0 +/- 6.6 days in the CAPD group compared with 9.8 +/- 11.5 days in the HD group (P < 0.0001). A greater number of patients developed acute rejection episodes in the CAPD group (P < 0. 05), but Screa level was not different in the two groups 6 weeks and 6 months after transplantation. No differences were observed in infectious or surgical complications. This study shows that immediate renal function after transplantation is better in CAPD patients and that peritoneal dialysis should be considered as a first choice for pretransplantation therapeutic modality.

Role of somatostatin-14 and its analogues in the management of gastrointestinal fistulae: clinical data.

Summary: Somatostatin-14 and its analogue octreotide both exert inhibitory effects on gastrointestinal secretions and may therefore be beneficial in the treatment of gastrointestinal fistulae. There are no studies that have compared these two drugs directly and hence this paper aims to review studies that are available for each drug. There are only six controlled studies that have examined the effects of somatostatin-14 and octreotide on fistula output reduction, three for each drug. All studies compared conservative therapy and the drug in combination with conservative therapy. Of the somatostatin-14 studies, two showed a significant effect on output (p<0.05) and the other demonstrated an output reduction on day 1 that was twice that in the control group (NS). Of the octreotide studies, one showed a significant effect (p<0.01) and the other two showed no effect of the drug on output. No study with either drug has demonstrated an increase in the number of patients that have achieved closure. However, a positive effect on the time to achieve closure has been found. Of the five controlled studies with somatostatin-14, all showed a significant reduction in time to closure. Of the two controlled studies with octreotide, one showed a significant reduction (p=0.002) and the other showed no difference. Due to the limited number of trials, a definitive evaluation of the efficacies of somatostatin-14 and octreotide in the treatment of gastrointestinal fistulae is not possible. However, currently available information seems to suggest a considerable benefit of somatostatin-14 when administered in association with standard conservative treatment, but this needs to be confirmed in a large prospective controlled study.

Functional, life-threatening disorders and splenectomy following liver transplantation

Splenectomy (SPL) in cirrhotic patients undergoing liver transplantation (LTx) may resolve specific problems related to the procedure itself, in case of functional and life‐threatening clinical situations often occurring as a result of liver cirrhosis and portal hypertension.

Prospectively Randomized Trial Using Perioperative Low-dose Octreotide to Prevent Organ-related and General Complications after Pancreatic Surgery and Pancreatico-jejunostomy

The aim of the present study was to evaluate the influence of low-dose perioperative octreotide on the prevention of complications (pancreatic fistula and general complications) in patients undergoing pancreatic surgery followed by pancreaticojejunostomy. A total of 105 patients were randomized to receive either octreotide 0.1 mg subcutaneously 3 times/day for a total of 7 days or no octreotide. The primary endpoints were the occurence of a pancreatic fistula and or general complications, including extended length of hospital stay. There were 25 surgical draining procedures performed and 80 duodenopancreatectomies with or without preservation of the pylorus. In all, 25 (23.8%) of the patients were treated for chronic pancreatitis, 8 (7.6%) for benign tumoral disease, and 72 (68.6%) for carcinoma. All patients underwent pancreaticojejunostomy.

A prospective randomized multicenter trial comparing histidine-tryptophane-ketoglutarate versus University of Wisconsin perfusion solution in clinical pancreas transplantation

We aimed to evaluate early pancreas transplant graft function after histidine–tryptophan–ketoglutarate (HTK) versus University of Wisconsin (UW) perfusion. Prospective randomized multicenter study including 68 pancreas transplantations stratified according to preservation fluid used (27 HTK vs. 41 UW). Primary endpoint was pancreas graft survival at 6 months. Serum α‐amylase, lipase, C‐peptide, HbA1C and exogenous insulin requirement were compared at several time points. Mean pancreas cold ischemia time was 10.8 ± 3.7 (HTK) vs. 11.8 ± 3.4 h (UW) (P = 0.247). Simultaneous pancreas–kidney transplantation was performed in 95.6% of the patients, pancreas transplantation alone in 2.9%, and pancreas after kidney transplantation in 1.5%. Six months graft survival was 85.2% (HTK) vs. 90.2% (UW) (P = 0.703). Serum amylase and lipase values did not differ between both the groups during the observation period. C‐peptide levels were elevated in both the groups without significant differences at each time point. Higher exogenous insulin requirement early after transplantation in the UW group had resolved at 3 months. Six month patient survival was 96.3% (HTK) vs. 100% (UW) (P = 0.397). With a mean cold ischemia time of 10 h in this study, HTK and UW solutions appear to be equally suitable for perfusion and organ preservation in clinical pancreas transplantation.

Hepato-venous reconstruction in orthotopic liver transplantation with preservation of the recipients' inferior vena cava and veno-venous bypass.

Abstract. Background and aims: The potential advantages of vena cava-preserving recipient hepatectomy in orthotopic liver transplantation are reduced hemorrhage, improved cardiovascular stability and preserved renal perfusion without the requirement of veno-venous bypass as compared with recipient hepatectomy including the vena cava. No detailed information is available on the use of veno-venous bypass during complicated vena cava preserving recipient hepatectomy and liver transplantation. In the present study, the peri- and postoperative courses of adult liver transplant recipients in whom the hepatovenous reconstruction was performed according to three different techniques with and without the use of veno-venous bypass were investigated. Patients/Methods: During primary orthotopic liver transplantation, an end-to-end (ETE) cavo-caval interposition of the donor vena cava to the recipient’s vena cava was performed in 75 patients (group I). In 15 patients, a termino-terminal piggyback (PB) anastomosis was constructed to the remnant of the recipient’s hepatic vein (group II), and in 72 transplantations a latero-lateral cavo-cavostomy (LLC) of donor-to-recipient’s vena cava (group III) was performed. The use of bypass, operative time and cold ischemia time, perioperative blood product requirements, incidence of relaparotomy, the evolution of postoperative renal function, technical complications and the survival were analyzed and compared using multivariate statistics and actuarial techniques for statistical evaluation. Results: No differences could be found in preoperative patient conditions, donor conditions, operating time, anastomosing time or cold ischemia time. In groups I–III, the veno-venous bypass was used in 50 (67%), 8 (53%) and 6 (8%) cases respectively (P=0.02 for group III). The mean preoperative packed cells requirements were 20.4 vs 29.6 vs 10.8 units (P=0.01 for group III), while postoperative blood product requirements (first 24 h) were 2.6 vs 5.0 vs 0.20 units of packed cells (P=0.02 for group III). Relaparotomy for diffuse retropertioneal hemorrhage was performed 14 times (19%) in group I, 3 times (20%) in group II and 7 times (8.3%) in group III (P=0.002). The incidence of posteropative early renal dysfunction (increase of ≥1.3 mg% serum creatinine) in group I vs group II vs group III was 24% vs 60% vs 16.7% (P=0.001 for group II) for patients without the use of veno-venous bypass. No significant difference was observed concerning early renal dysfunction in patients where a veno-venous bypass was used. The survival at 12 months was 81% for group I, 86% for group II and 93.0% for group III. In group III there were four complications (P=0.03) at the hepatovenous anastomosis of which two were eventually fatal. Conclusion: Preservation of the recipient’s vena cava and LLC can reduce, but not avoid, the requirement for veno-venous bypass. In orthotopic liver transplantation, postoperative hemorrhage, as measured by surgical revisions and requirement for blood products, is significantly reduced with LLC with and without bypass. Early renal dysfunction also occurs in the group of LLC as compared with the termino-terminal cavostomy independent of the bypass. A technical failure resulting in patient death can be associated with LLC.

Cold preservation of the porcine pancreas with histidine-tryptophan-ketoglutarate solution.

BACKGROUND Histidine-tryptophan-ketoglutarate (HTK) has been used for experimental and clinical cardiac, renal, and liver transplantation. No experience exists in either experimental or clinical pancreas transplantation. METHODS In the present study, the solution was employed to flush segmental pancreatic grafts and to autotransplant the grafts after 24, 48, and 72 hr of cold storage in a porcine model. The results were compared to those obtained from animals receiving pancreatic grafts flushed and preserved with UW (University of Wisconsin) solution. RESULTS A total of 10 landrace pigs received a graft stored with HTK solution for 24 hr, and 6 animals received a graft stored with UW solution for 24 hr. Daily blood glucose levels were normoglycemic (i.e., blood glucose < 150 mg/dl), and glucosuria was absent in all transplant animals. Intravenous glucose tolerance tests were comparable to two unoperated controls. Seven totally pancreatectomized, nontransplant diabetic controls exhibited daily hyperglycemia, glucosuria (i.e., > 1,000 mg/dl) and highly impaired intravenous glucose tolerance tests (mean K-values of -0.52+/-0.19 vs. -1.25+/-0.46 for HTK, -1.30+/-0.81 for UW, and -1.53+/-0.81 for controls, P-value vs. diabetic <0.01). The changes in wet weight between flushing and reperfusion were +2.22+/-2.84 g for HTK and -1.40+/-2.70 g for UW stored grafts (P=0.034). After 48 hr of storage with HTK, 4/17 grafts were functioning and 1/11 recipients of grafts stored with UW were normoglycemic. All grafts stored for 72 hr in either HTK (n=3) or UW (n=3) uniformly failed to render the recipients normoglycemic. CONCLUSIONS It is concluded that preservation of segmental pancreatic autografts for 24 hr with HTK solution provides reliable graft function, as does preservation with UW solution associated with an increase in wet weight after HTK preservation. Cold preservation with HTK and UW is feasible for 48 hr; however, the success rate is equally reduced with HTK and UW solution. Cold storage for 72 hr in either HTK or UW solution results in uniform graft failure in this model.

Retrospective Analysis of Laparoscopic Gastric Banding Technique: Short-term and Mid-term Follow-up

Background: Although adjustable gastric banding shows good results concerning weight loss, several complications such as excessive vomiting, total dysphagia, and slipping of the stomach through the band with pouch dilatation may occur rather frequently. Different types of adjustable bands are available to prevent these short- and mid-term complications. Methods: In this retrospective study, 120 consecutive laparoscopic adjustable gastric bandings were performed. In group I, 50 patients were treated with adjustable silicone gastric banding (ASGB) by an intragastric balloon calibration technique. Group II (n = 29) received the same band by a surgical technique with tunneling behind the esophagus toward the angle of His. Group III (n = 41) received Swedish adjustable gastric banding (SAGB) by the same technique as in Group II. Results: Weight loss was approximately 15% of the excess weight after 3 months, 30% after 6 months, and 45% after 12 months in all groups. Total dysphagia was significantly more frequent in Groups I and II. The incidence of slipping of the band and pouch dilatation was more frequent in Group II. Conclusion: The diameter of the ASGB band is rather small and can cause total dysphagia independently of surgical technique. The SAGB is easy to perform and seems less vulnerable to complications like dysphagia and slipping of the band, probably because of the individual adjustment of the stoma diameter during surgery and good fixation of both band and ventral pouch with separate posterolateral sutures.

Arterialization of the portal vein in pediatric liver transplantation - A Report of two cases.

Abstract Portal vein arterialization (PVA) is an acquired concept in shunt surgery for portal hypertension. This technique, recently described as both a temporary and permanent procedure in adult liver transplantation, is reported by the authors in two cases of pediatric transplantation. The indication was low portal blood flow after reperfusion with poor graft function due to persistence of spontaneous retroperitoneal venous shunts. In both cases described, PVA allowed for satisfactory macroscopic liver reperfusion. The increase in portal blood flow from 150 to 500 ml/min in the second patient enabled the liver to be reperfused correctly and led to successful transplantation. The graft function in both cases improved in the 1st postoperative week, but thrombosis of the PVA occurred in the 1st patient 2 months after transplantation. Signs of hepatic hyperarterialization occurred in the second patient and this necessitated a dearterialization of the portal vein 2 weeks later. Although the benefit of this procedure appears to be beyond doubt in the immediate postoperative period, we have no data on long‐term arterialization. We do think that PVA can be performed in pediatric liver transplantation, but it may need to be done only in special, individual situations when no valid alternative can be proposed, such as in the absence of a mesenteric vein and/or the presence of spontaneous retroperitoneal venous shunts.