W.O Bechstein

Venous complications after orthotopic liver transplantation

Complications involving the portal vein or the vena cava, are rare after orthotopic liver transplantation. We report on the incidence and treatment of venous complications following 1000 orthotopic liver transplantations in 911 patients. Twenty‐six of the adult patients (2.7%) suffered from portal complications after transplantation, whereas complications of the vena cava were observed in only 17 patients (1.8%). Technical problems or recurrence of the underlying disease (e.g. Budd–Chiari syndrome) accounted for the majority of complications of the vena cava, whereas alteration of the vessel wall or splenectomy during transplantation could be identified as important risk factors for portal vein complications. In patients undergoing modification of the standard end‐to‐end veno‐venous anastomosis of the portal vein due to pathological changes of the vessel wall, complications occurred in 8.3%, whereas only 2.4% of patients who received a standard anastomosis of the portal vein experienced complications of the portal vein. Furthermore, splenectomy during transplantation was also associated with an increased incidence of portal vein complications (10.5 vs. 2.2% in patients without splenectomy). Treatment was dependent on the signs and symptoms of the patients, and varied considerably between patients with portal vein complications and patients suffering from complications of the vena cava. Complications of the vena cava led to retransplantation in about one‐third of the patients, whereas in patients with occlusion of the portal vein, retransplantation was necessary in only 15%, and more than half of the patients suffering from portal vein complications did not require any treatment at all. Usually, treatment of patients with portal vein complications only became necessary when additional complications such as arterial occlusion or bile duct injuries occurred.

Einteilung und Behandlung von Gallengangverletzungen nach laparoskopischer Cholecystektomie

Abstract. Iatrogenic bile duct lesions are serious complications during laparoscopic cholecystectomy and include biliary leakage and major bile duct injury. The incidence of biliary lesions following laparoscopic cholecystectomy is up to threefold higher than that of the open procedure. A total of 108 patients with bile duct lesions after laparoscopic cholecystectomy were treated at our institution. Endoscopic treatment was successful in 68 cases, 6 patients were treated by external drainage, and 34 patients required surgical therapy. Selection criteria for the type of treatment included the etiology, anatomical situation, and diagnostic interval of the biliary lesion. We suggest a classification of bile duct injury and a proposal for diagnosis and treatment of these complications.Zusammenfassung. Die iatrogene Gallengangverletzung stellt eine schwerwiegende Komplikation der laparoskopischen Cholecystektomie dar. Sie umfaßt periphere Galleleckagen und Verletzungen des extrahepatischen Gallengangsystems. Ihre Incidenz ist im Vergleich zur konventionellen Cholecystektomie um das 2–3 fache erhöht. In unserem Zentrum wurden 108 Patienten wegen einer iatrogenen Gallengangläsion nach laparoskopischer Cholecystektomie behandelt. Während 68 Patienten erfolgreich endoskopisch therapiert werden konnten, war bei 34 Patienten eine chirurgische Intervention erforderlich. Bei 6 Patienten mit einem peripheren Galleleck war die alleinige percutane äußere Drainage ausreichend. Für die Gallengangverletzungen wird unter Berücksichtigung der Ätiologie, der Lokalisation und des diagnostischen Intervalls eine neue Klassifikation vorgeschlagen, aus der sich diagnostische und therapeutische Konsequenzen ableiten lassen.

Postoperative tracheal extubation after orthotopic liver transplantation

Background: The duration of postoperative mechanical ventilation and its influence on pulmonary function in liver transplant recipients is still debated controversially.

Liver transplantation for alcoholic cirrhosis.

Abstract Because of the donor shortage, there are concerns for liver transplantation in patients with alcoholic cirrhosis. We therefore analyzed patients transplanted for alcoholic cirrhosis at our center with respect to patient and graft survival, recurrence of disease, and postoperative complications. Out of 1000 liver transplantations performed in 911 patients, 167 patients were transplanted for alcoholic cirrhosis; 91 patients received CsA‐ and 76 patients FK506‐based immunosuppression. Recurrence was diagnosed by patients or relatives declaration, blood alcohol determination, and delirium. Diagnosis and treatment of acute and chronic rejection was performed as previously described. One‐ (96.8 % versus 91.3 %) and 9‐year patient survival (83.3 % versus 80%) compared well with other indications. Five of 15 patients died due to disease recurrence. Recurrence of disease was significantly related to the duration of alcohol abstinence prior to transplantation. In patients who were abstinent for less than 6 months (17.1 %), recurrence rate was 65 %, including four of the five patients who died of recurrence. Recurrence rate decreased to 11.8%, when abstinence time was 6‐12 months and to 5.5%, when the abstinence times was > 2 years. Next to duration of abstinence, alcohol relapse was significantly related to sex, social environment, and psychological stability. The incidence of acute rejection compared well with other indications (38.1%); CsA: 40.1% versus 33.3% in FK506 patients. In all, 18.2% of CsA patients experienced steroid‐resistant rejection compared with 2.6 % of FK506 patients. Seven patients (7.6%) in the CsA group and one patient (1.3%) in the FK506 group developed chronic rejection. A total of 57.1% developed infections; 5.7% were life‐threatening. CMV infections were observed in 14.3% (versus 25% for other indications). New onset of insulin‐dependent diabetes was observed in 8.6% and hypertension in 32.4%. In conclusion, alcoholic cirrhosis is a good indication for liver transplantation with respect to graft and patient survival and development of postoperative complications. FK506 therapy was favourable to CsA treatment. Patient selection is a major issue and established criteria should be strictly adhered to. Patients with alcohol abstinence times shorter than 6 months should be excluded, since recurrence and death due to recurrence was markedly increased in this group of patients.

Mycophenolate mofetil in combination with tacrolimus versus neoral after liver transplantation

MYCOPHENOLATE mofetil (MMF) is an accepted immunosuppressive agent after kidney transplantation. Possible indications for MMF after liver transplantation include: (1) rejection therapy; (2) reduction of cyclosporine or tacrolimus dosage in patients with nephro-, neuro-, or hepatotoxicity; and (3) early steroid withdrawal. The potential role of additive MMF therapy in patients with HCV cirrhosis has been explored; however, data concerning MMF induction or maintenance therapy are limited.

Perioperative parenteral and enteral nutrition for patients undergoing orthotopic liver transplantation. Results of a questionnaire from 16 European transplant units

Abstract The present clinical experience in perioperative nutrition for patients undergoing orthotopic liver transplantation was evaluated by a questionnaire, answered by 16/21 European transplant units (76.1%). There is agreement, that malnutrition reflects per se the severity of chronic liver disease and should be not considered, in general, to exclude patients from the transplant waiting list. Most centers administer postoperative nutrition without difference to other patients after gastrointestinal major surgery. A combination of parenteral and enteral nutrition is preferred. Experience with preoperative nutritional support and use of new immunomodulating substances is rather limited.

Recurrence-free survival after liver transplantation for small hepatocellular carcinoma

Abstract Recurrence‐free survival (RFS) in patients with small hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT) was analyzed. From 1988 until 1996, 725 OLTs were performed in 669 patients. In 52 adults, HCC was confirmed histologically. OLT was limited to patients with small (<5 cm) HCC with a maximum number of three nodules. Actuarial survival for these 52 patients at 1 and 5 years is 88% and 71%. RFS was defined as time until death without recurrence, time until follow up with a diagnosis of recurrence, or, in patients without recurrence, time of last follow up. Overall, the 5‐year RFS was 60%. Five‐year RFS was less for bilobar compared to unilobar tumors (36% vs 70%), less for stage IVa tumors (UICC) compared to stage I‐III tumors (17% vs 71%), and less for multiple compared to solitary tumors (54% vs 67%). In conclusion, potential cure may be achieved in more than 50% of all transplanted patients.

Perioperative factors influencing patient outcome after liver transplantation

Abstract We have previously shown that the development of multiple organ dysfunction syndrome (MODS) after liver transplantation significantly reduced patient survival. Therefore, the question arises of which are the most prominent perioperative donor and recipient factors leading to MODS after transplantation. In total, 634 patients with 700 liver transplants were analyzed. Donor factors included age, increase in transaminases, sex mismatch, requirement for catecholamines, intensive care time, histology, and macroscopic graft appearence. Recipient factors included Child classification, preoperative gastrointestinal (GI) bleeding, mechanical ventilation, hemodialysis, and requirement for catecholamines. MODS was defined by more than two severe organ dysfunctions. The cumulative 2 to 9‐year patient survival was 90.9 % in patients developing less than 3 severe organ dysfunctions following transplantation. Survival decreased to 60.3 % in patients with MODS. Neither any of the donor factors nor the duration of cold ischemia (CIT) was associated with an increase in MODS or decrease in survival. On the other hand, duration of warm ischemia, amount of blood loss, requirement for red packed blood cells, and reoperation had an influence on the development of MODS (40%‐56%) and decreased patient survival to 58%‐69%. Preoperative therapy with catecholamines, GI bleeding, mechanical ventilation, and hemodialysis were associated with the development of MODS in 54 %‐88 %. Patient survival following MODS decreased to 50%‐74%. Initial graft function had a slight influence on the development of MODS, but no influence on the long‐term patient survival. In conclusion, patient survival was significantly influenced by the development of postoperative MODS. The most prominent factors in this were recipient and intraoperative ones. No major influence was observed for donor factors, CIT, and initial graft function. Prevention of MODS will further improve the outcome after liver transplantation.

Incidence and indications for reintubation during postoperative care following orthotopic liver transplantation

STUDY OBJECTIVEnTo analyze the incidence and indications for reintubation during postoperative care following orthotopic liver transplantation (OLT).nnnDESIGNnRetrospective chart review.nnnSETTINGnLarge metropolitan teaching hospital.nnnPATIENTSn546 adult liver transplant recipients.nnnMEASUREMENTS AND MAIN RESULTSnThe medical charts of 546 patients who underwent OLT at our institution between January 1992 and September 1996 were reviewed for the incidence and indications of reintubation throughout primary hospitalization. Eighty-one of 546 patients (14.8%) required one or more episodes of reintubation after OLT. In the majority of cases, reintubation was performed for pulmonary complications (44.6%), followed by cerebral (19.1%) and surgical (14.5%) complications. Cardiac (9.1%) and peripheral neurologic (2.7%) complications were less frequent reasons for reintubation. Overall patient survival, according to the Kaplan-Meier estimates, was 89.9%, 87.5%, 86.5%, and 82.2% after 1, 2, 3, and 5 years, respectively. In patients with one or more episodes of reintubation, overall survival decreased to 62.5% after 1, 2, and 3 years, and to 56.4% after 5 years (p < 0.001).nnnCONCLUSIONSnThe main indications for reintubation after OLT were pulmonary, cerebral, and surgical complications. These reintubation events had a considerable influence on the patients postoperative recovery, and were associated with a significantly higher rate of mortality, than for OLT patients who did not undo reintubation.

Blutungsproblematik in der Leberchirurgie und Lebertransplantation

Abstract. In liver resection, severe bleeding can be prevented by appropriate surgical techniques. These include adequate access and mobilisation, vascular occlusion, controlled dissection of the parenchyma, prevention of venous „over-filling“and secure hemostasis of the resection surface. Excessive bleeding, both in liver resection and liver transplantation, poses a major risk for the development of postoperative complications. In liver transplantation the surgeon is most often confronted with patients with chronic liver disease and portal hypertension. Coagulation disorders are the rule, and the surgery itself is more demanding because of fragile venous collaterals as a consequence of portal hypertension. With the use of extracorporeal veno-venous bypass or newer techniques with preservation of the vena cava, some of these difficulties can be overcome. Pharmacological therapies like administration of aprotinin can reduce the fibrinolysis inherent in liver transplantation. However, surgical skill and experience are probably still the most important predictors of blood loss during surgery.Zusammenfassung. Blutungen bei der Leberresektion können durch entsprechende chirurgische Techniken vermieden werden. Hierzu zählen: adäquater Zugang, vasculäre Ausklemmung, kontrollierte Parenchymdurchtrennung, Vermeidung einer venösen „Überfüllung“ und sichere Versorgung der Resektionsfläche. Exzessive Blutungen bei Leberresektion und -transplantation bedingen ein erhöhtes Risiko postoperativer Komplikationen. Bei der Lebertransplantation ist der Chirurg meist mit Patienten mit chronischen Lebererkrankungen konfrontiert. Gerinnungsstörungen sind die Regel und die Operation ist anspruchsvoller durch verletzliche venösen Collateralen als Folge der portalen Hypertension. Durch extrakorporalen veno-venösen Bypass oder neuere Techniken mit Erhalt der retrohepatischen V. cava können diese Schwierigkeiten teilweise überwunden werden. Medikamente wie Aprotinin können die Fibrinolyse bei der Lebertransplantation vermindern. Chirurgische Geschicklichkeit und Erfahrung bleiben wohl die bedeutendsten Faktoren für den intraoperativen Blutverlust.