Treatment of portal vein thrombosis by thrombectomy and regional thrombolysis

BACKGROUND

Portal vein thrombosis is a rare disorder. The prognosis of both the acute and the chronic forms is determined by the resulting acute or chronic portal hypertension. The therapeutic approach of choice is controversial.

METHODS

A case of etiologically unclear thrombosis of the portal vein system in a young man is reported, which was treated successfully by means of portal vein thrombectomy combined with intraoperative and postoperative thrombolysis with recombinant tissue plasminogen activator (rTPA).

RESULTS

Initial thrombectomy established sufficient venous return. However, rethrombosis of the portal vein occurred 2 days later. In a second operation rethrombectomy was followed by intraoperative regional application of rTPA, which was continued after operation during a period of 48 hours through a catheter inserted in a mesenteric vein. Patency of the portal system was confirmed 1 week after the procedure. The 1-year follow-up reconfirmed this result (through indirect portography and Doppler sonography). The patient received the anticoagulant phenprocoumon.

CONCLUSIONS

The combination of surgical thrombectomy and regional thrombolysis with rTPA could offer a feasible therapeutic option for selected patients with acute prehepatic portal vein thrombosis.

Role of liver transplantation in management of esophageal variceal hemorrhage

The management of esophageal variceal hemorrhage ranges from conservative to surgical modalities. Before introduction of liver transplantation as a potentially curative therapy of the underlying etiology, decompressive portosystemic shunt operations have been the mainstay of mostly palliative procedures. Our own experience with surgery for advanced hepatic disease and portal hypertension over 20 years includes 803 liver transplantations and 201 portosystemic shunts, emphasizing our primary objective of treatment. The results after shunt surgery were favorable in Child class A candidates when performed electively and with selective decompression. After liver replacement the clinical status of the patient, including hepatic function and extrahepatic complications, had a strong influence on postoperative outcome, with the chance of excellent long-term survival. The additional risk of previous shunt surgery for subsequent transplantation could be reduced over time. Based on this experience and reports from others there are enough reasonable arguments for shunt and transplantation. Instead of the choice being controversial, the two forms of therapy should supplement each other and be available in the same center that specializes in the treatment of patients with diseases that eventually lead to liver failure and portal hypertension. Selection of either approach must depend on etiology, stage of the disease, and proper timing. Shunt procedures may be indicated in stable patients with the risk of bleeding after sclerotherapy failure, in those with contraindications to transplantation, or as a bridge to transplantation. The role of liver transplantation has been clearly established in patients with progressive or endstage (otherwise intractable) hepatobiliary disease.

Liver transplantation for Budd-Chiari syndrome--palliation or cure?

This report documents two cases of Budd-Chiari syndrome (BCS) with essential thrombocytosis and antithrombin (AT) III deficiency as underlying etiological factors. Orthotopic liver transplantation was successfully performed in both patients but with different therapeutic intention. In the patient with essential thrombocytosis, hepatic transplantation only relieved the symptoms of the predisposing thrombogenic condition; it did not cure the underlying disorder. Prophylactic long-term anticoagulation, as well as adjuvant therapy for the causative disease, remained necessary. On the other hand, in the patient with AT III deficiency, liver transplantation was curative, resulting in complete reconstitution of serum AT III activity with resolution of the hypercoagulable state postoperatively. Thus, depending on the underlying etiology, liver transplantation for BCS can be considered as palliative, necessitating long-term adjuvant therapy, or as curative, with correction of a metabolic defect.

Vascular complications in adult patients after orthotopic liver transplantation: role of color duplex sonography in the diagnosis and management of vascular complications

Vascular complications after orthotopic liver transplantation are one of the most serious problems in liver-grafted patients, and if undetected they may result in graft failure and death unless prompt revascularization or retransplantation is performed. As the outcome of treatment of vascular complications depends on an early diagnosis, the role of color-coded duplex sonography (CCD) for diagnosis and treatment was analyzed during a 17-month observation period. Altogether, 88 consecutive liver allografts in 77 adult patients were studied by serial CCD. Vascular complications occurred with an incidence of 12.9%. Hepatic artery complications represented the most frequent event with an incidence of 11.6%. CCD showed a sensitivity of 100%, a specificity of 97% and a positive predictive value of 0.84. With the use of CCD, vasculature and localization of the site of arterial complications can be directly visualized and the various types of complications can be differentiated, thus reducing the time needed for diagnosis. Early hepatic artery complications, occurring during the first 3 days after transplantation, which were immediately diagnosed by CCD examination and rapidly treated by revascularization had a good clinical outcome. In contrast, the outcome of vascular complications requiring retransplantation was found to be poor. As radiologic intervention offers an alternative to the treatment strategy of vascular complications in liver-grafted patients, CCD is the method of choice to noninvasively monitor the initial and follow-up examinations after intervention.

A new procedure for abdominal wound closure after pediatric liver transplantation: the "sandwich" technique

Primary wound closure cannot always be achieved after pediatric liver transplantation (LTx). This may be due to lack of intraabdominal space from postanhepatic small bowel edema or oversized grafts despite partial LTx. For those instances we developed the "sandwich" technique. This procedure incorporates advantages of previous techniques with some additional advantages described herein. Use of polyglactin 910/silicone meshs in a sandwich fashion allows for one-stage permanent abdominal closure without major loss of body plasma fluids after pediatric LTx. So far our clinical experience with this technique has been very satisfying.

Conversion from cyclosporin to FK 506 after liver transplantation

Thirty-seven liver-grafted patients with steroid-resistant acute or chronic graft rejection or with cyclosporin-related complications were converted from CyA to FK 506. The clinical outcome of the patients primarily depended on the degree of liver dysfunction present at initiation of FK 506 treatment. In patients switched to FK 506 for treatment of acute or early chronic graft rejection, CyA nephrotoxicity, or CyA malabsorption, the FK 506 therapy was associated with a clear improvement in the clinical course. In contrast, in patients with advanced chronic graft rejection, a lower response rate to the conversion in immunosuppression was observed. The lower response rate was associated with a higher patient mortality. These studies demonstrate that FK 506 represents a valuable alternative immunosuppressant for liver-grafted patients. The conversion from CyA to FK 506 should take place before serious--and potentially irreversible--disturbances in liver function are observed.

Persistence of donor lymphocytes in liver allograft recipients

Occasional cases of graft-versus-host disease after liver transplantation indicate a transfer of donor lymphocytes by human liver grafts. However, little is known about the usual fate and potential function of passenger lymphocytes in clinical liver transplantation. In this study, we have analyzed liver graft recipients for the presence of donor lymphocytes in the early course after transplantation. The presence of such cells in blood, the graft, and, occasionally, the skin was studied by the use of mAb to polymorphic HLA class I determinants and double-staining techniques in flow cytometry and immunocytology. The findings were compared with the clinical courses and with the results of routine graft biopsies. Within the first week after transplantation, in all 16 patients, between 1% and 24% donor lymphocytes (T, NK, and B cells) were detectable in blood, and in 14 of 22 patients (64%), between 2% and 23% donor T cells were found in the graft. After more than 2 weeks, donor cells were still present in blood in 2 of 14 patients at very low numbers. The presence of donor lymphocytes in the graft was associated with intragraft immune activation in 5 of 15 patients, but no clinical rejection occurred in these cases; mild graft-versus-host disease was observed in one patient. These findings demonstrate that donor lymphocytes regularly persist in liver-grafted patients for some time; this transient mixed lymphoid chimerism is only rarely associated with clinical graft-versus-host disease and some evidence even suggests that these donor-derived lymphocytes may exert beneficial immunomodulatory properties.

Diagnostic value of color Doppler sonography in primary liver tumors--a trend study

In order to investigate the diagnostic value in differential diagnosis of primary liver tumors, color Doppler sonography was used preoperatively in 30 patients. Without difference, tumor hypervascularization was found in patients with hepatocellular carcinoma (2 of 4), cholangiocellular carcinoma (4 of 4), hemangioma (3 of 8), focal nodular hyperplasia (8 of 8), adenoma (3 of 4), and neuroendocrine tumor (n = 1). No vascular signal could be detected in 1 case of adenomatous hyperplasia and 2 cases of hepatocellular carcinoma, one after previous chemoembolization. Hemangioma appeared hypo- or even avascular in 5 of 8 patients. Therefore, according to our experience, the yield of color Doppler sonography is rather low for differential diagnosis and prediction of the tumor dignity. With regard to the surgical procedure, valuable information about tumor extension can be obtained particularly in central lesions close to hilar structures or liver vein confluence. Further indications result from follow-up of tumor vascularization after chemoembolization and chemotherapy.

[Therapy of severe liver trauma--is there an indication for liver transplantation?]

The therapy of severe hepatic trauma requires complex surgical procedures. Our current surgical management of these injuries is described, including liver transplantation for the treatment of potentially lethal hepatic trauma.

Cystic enlargement of extrahepatic bile ducts

BACKGROUND

Cystic enlargement of the extrahepatic bile duct system is a rare abnormal finding. A congenital origin is usually supposed; however, the pathogenesis is unknown. We report on our experience with extrahepatic bile duct cysts with special regard to cause, treatment, and recurrent disease.

METHODS

From 1976 to 1991, 13 patients, 35 to 74 years of age, were treated for extrahepatic bile duct cysts. Seven patients had previously undergone cholecystectomy. Two patients were admitted because of recurrent disease; neither had undergone curative resection.

RESULTS

In 11 patients a biliojejunal anastomosis with a Roux-en-Y was created after cyst resection; one patient underwent a diverticular stalk resection with end-to-end anastomosis of the choledochal duct. After a mean follow-up of 68 months eight of 10 patients were alive, two of whom complained about cholangitis. Recurrent diffuse dilatation of the remaining choledochus developed in one patient; one other patient died of cholangiocellular carcinoma 2 years after operation.

CONCLUSIONS

In patients who had undergone previous cholecystectomy or with recurrent disease an acquired malformation cannot be excluded. Surgical treatment is always indicated because of imminent complications and should aim at complete resection of cystic tissue. Periodic postoperative evaluation is necessary to detect recurrent disease and malignant transformation.

Total hepatectomy and liver transplantation as two-stage procedure

OBJECTIVE

This article describes the experience with a bridging procedure for a prolonged anhepatic period during clinical liver transplantation in case of special emergency situations.

SUMMARY BACKGROUND DATA

Hepatic necrosis due to fulminant hepatitis or acute graft failure, as well as severe liver trauma are well-known and accepted indications for urgent liver transplantation. Prerequisite is the allocation of a suitable donor organ. If no allograft is available in time, patients with "toxic liver syndrome" or exsanguinating hemorrhage have been shown to benefit from advanced total hepatectomy.

METHODS

As a modification of the standard one-stage procedure, recipient hepatectomy and subsequent liver transplantation are performed in two separate operations. To bridge the prolonged anhepatic period and to allow decompression and return of venous blood, an end-to-side portocaval shunt is constructed temporarily.

RESULTS

Thirteen of thirty-two patients underwent hepatectomy but not transplantation subsequently, and died within 34 hours after progressive deterioration. In 19 of 32 patients, transplantation was realized 6-41 hours after hepatectomy; 9 of 19 patients died, mostly from sepsis. Ten of nineteen liver recipients survived the procedure including three unrelated late deaths; presently, seven patients are alive with a follow-up of 3 to 46 months.

CONCLUSIONS

Two-stage total hepatectomy with temporary portocaval shunt, and subsequent liver transplantation can be a life-saving approach in patients most likely to die of the sequelae of advanced liver or graft necrosis or exsanguination that cannot be controlled by conventional treatment or immediate liver transplantation.

Changes in energy substrates in relation to arterial ketone body ratio after human orthotopic liver transplantation

BACKGROUND

Changes in energy substrate metabolism, as well as those in arterial ketone body ratio (KBR; acetoacetate/3-hydroxybutyrate), were investigated to follow energy status of hepatic allograft.

METHODS

Plasma concentrations of energy substrates were measured immediately after 35 orthotopic liver transplantations in 32 adult patients.

RESULTS

Twenty-three patients left the intensive care unit within 1 month (group A), six patients were forced to stay in the intensive care unit longer than 1 month (group B), and the other six grafts failed within 1 month (group C). In group B the KBR was significantly lower than in group A 6 hours after reperfusion of the grafts (0.70 +/- 0.09 vs 1.21 +/- 0.10, mean +/- SEM; p < 0.05). In group C the KBR remained significantly lower than in group A at 6 hours (0.65 +/- 0.04 vs 1.21 +/- 0.10; p < 0.01), on the first postoperative day (0.64 +/- 0.03 vs 1.36 +/- 0.10; p < 0.001), and on the second postoperative day (0.65 +/- 0.02 vs 1.58 +/- 0.11; p < 0.01). Total ketone body concentration (TKB) was significantly higher in group B than in group A at 4 hours (462.9 +/- 105.0 mumol/L vs 201.6 +/- 32.6 mumol/L; p < 0.01), 6 hours (483.4 +/- 102.1 mumol/L vs 125.5 +/- 25.9 mumol/L; p < 0.001), and the first postoperative day (481.1 +/- 196.6 mumol/L vs 123.9 +/- 24.1 mumol/L; p < 0.001). No increase in TKB was observed in group C.

CONCLUSIONS

It is suggested that low values in KBR accompanied with low levels of TKB should be regarded as a strong indicator of graft failure and fatty acid oxidation and ketogenic pathways are accelerated to compensate for energy deficits in patients with low values in KBR and high levels of TKB until KBR recovers immediately after orthotopic liver transplantation.

Serum bile acids and esterified bilirubin in early detection and differential diagnosis of hepatic dysfunction following orthotopic liver transplantation

Routine laboratory tests are of little help for early detection and differential diagnosis of hepatic dysfunction following orthotopic liver transplantation (OLT). In the present study, serum levels of esterified bilirubin, total bilirubin and bile acids were investigated in 20 patients after OLT. Twenty episodes of liver dysfunction were observed: 10 rejection episodes, 3 cases of thrombosis of the hepatic artery, 3 cases of septic shock, and 4 episodes of cyclosporin toxicity. During rejection, the median increase in esterified bilirubin was 3.2-fold (range 1.6-24.9), while total bilirubin increased 1.5-fold (range 0.7-3.4). Bile acids increased 3.6-fold (range 2.5-6.6; peak levels 25-87 microM). Both bile acids and esterified bilirubin increased 1-3 days earlier than serum transaminases and decreased only after successful anti-rejection treatment. The response of bile acids to successful treatment was usually more rapid than the response of esterified bilirubin. Hepatic artery thrombosis and septic shock were associated with a sharp increase in esterified bilirubin and very high bile acid levels (peak levels 80-185 microM). During cyclosporin toxicity, a characteristic pattern of progressively increasing bilirubin with no change in the bile acid levels was observed. Both esterified bilirubin and bile acids are very sensitive indicators of hepatic graft dysfunction. In particular, serum bile acids are useful for identifying cyclosporin toxicity and monitoring the response to anti-rejection treatment.

Arterial ketone body ratio as a predictor of donor liver viability in human liver transplantation

The viability of the donor liver was assessed with regard to early postoperative survival in human liver transplantations from 40 brain-dead donors at Hannover Medical College and 13 living donors at Kyoto University by measuring the arterial ketone body ratio (AKBR). Of 40 grafts harvested from brain-dead patients in Hannover, 35 survived the first week after operation, but 5 developed initial nonfunction of the transplanted graft within the first week. The mean AKBR values were 1.11 +/- 0.11 for grafts that survived and 0.44 +/- 0.10 for grafts that failed (P < 0.01). The AKBR values of the 5 initially nonfunctioning cases were all below 0.7. Of 13 grafts harvested from the living donors in Kyoto, all survived the first week. The AKBR values of the donors were all above 1.0, with a mean value of 1.87 +/- 0.23. Among all 53 cases, the survival rate of the grafts with AKBR above 0.7 was significantly higher than that of the grafts with AKBR below 0.7 (100% vs. 62%, P < 0.01). No other donor parameters, including age, dose of dopamine administered, and clinical laboratory findings, were significantly related to differences in graft survival rates. AKBR is a useful index for the evaluation of donor liver viability. Grafts used from donors with AKBR of less than 0.7 have a significantly increased risk of early nonfunction. Grafts from donors with AKBR of greater than 1.0 have, in our experience, always been viable after transplantation.

Results of hepatic resection and transplantation for fibrolamellar carcinoma

Fibrolamellar carcinoma (FLC) is a tumor of the liver that can be differentiated from common hepatocellular carcinoma (HCC). Despite the exceptional role of the clinicopathologic signs and symptoms, true appraisal of the prognosis of the tumor is not clear and remains a controversial issue. To determine the long term prognosis of FLC more precisely, a retrospective study of 20 consecutive patients was performed, with analysis of selected pathologic factors, particularly the TNM staging system. Curative tumor removal (R0) was achieved by partial hepatic resection in 14 patients and total hepatectomy with subsequent replacement of the liver in six patients, respectively. The estimated overall five year survival rate was 36.6 percent. There was an advantage of partial versus total hepatectomy, with median survival times of 44.5 versus 28.5 months. Statistically significant better survival rates at five years were observed in patients with solitary tumors and in instances of absent regional lymph node metastases. Although other factors analyzed did not show significant differences, there was a tendency indicating individual tumor stage was the most significant determinant for prognosis. For further discussion of an apparently more favorable outcome of patients with FLC as compared with common HCC, detailed specification of the tumor stages seems mandatory. From the present analysis, the fibrolamellar variant could not be confirmed to be an independent indicator of better patient survival. The treatment of choice remains radical operation. The goal can, at best, be achieved by a therapeutic concept including partial as well as total hepatectomy, depending on the stage of the tumor.

Intragraft immune events after human liver transplantation. Correlation with clinical signs of acute rejection and influence of immunosuppression

Evaluation of graft morphology is regarded as a cornerstone for diagnosis of acute liver graft rejection. Here we have studied the clinical relevance of biopsy findings obtained either by aspiration cytology or by histology in the first month after human liver transplantation, and have assessed the influence of immunosuppressive induction treatment on the incidence of morphological and clinical rejection. Results of 865 aspiration biopsies (TAC) and 155 core biopsies in 141 patients were correlated with the retrospective clinical diagnosis concerning the presence or absence of acute rejection. This analysis demonstrated that there are almost no false negative findings either in cytology or in histology (less than 0.1% of negative biopsies). In contrast, with both methods a large number of positive biopsy results were obtained that were without clinical correlate ("false positive" biopsies; 46% and 41% of positive cytologies and histologies, respectively). The rates of clinical and morphological acute rejections were differently influenced by the type of immunosuppressive induction protocol used. The incidence of clinical rejection was particularly low with a quadruple drug regimen when cyclosporine therapy was started immediately after transplantation (29% vs. 62% when introduction of cyclosporine was delayed for 2-5 days). Morphological rejections were similarly frequent with immediate and delayed introduction of cyclosporine at 2 mg/kg during quadruple therapy (65-75%) and were only reduced with initial high dose cyclosporine treatment (5 mg/kg) (35%). Antirejection treatment was not required in patients with morphological evidence of rejection but without clinical symptoms. The study demonstrates that cytology and histology are similarly reliable for exclusion and similarly unreliable for diagnosis of clinical acute rejection. The clinical relevance of positive biopsy findings is strongly influenced by the basic immunosuppressive treatment. Certain types of induction treatment can obviously alter the alloresponse in a way that no graft damage occurs despite the presence of marked intragraft immune activation. "False-positive" biopsy findings, therefore, seem to represent a qualitatively modified and self-limited type of intragraft alloresponse that is without clinical consequences ("incomplete" or "subclinical" rejection).

[Radiologic diagnosis before and after liver transplantation]

The main function of imaging procedures before liver transplantation is the exclusion of factors that may either constitute contraindications to surgery or necessitate a modification of the operation technique. Ultrasound and MRI are the modalities best suited for this purpose. After transplantation, imaging procedures are required mainly for diagnosis of and differentiation, in particular, between vascular and biliary complications, rejection, and infection, since these postoperative complications very often cannot be reliably differentiated on the basis of clinical and laboratory parameters alone. As vascular disturbances can vary widely in their presentation and can mimic other complications, duplex Doppler sonography plays a dominant role in clarification of the perfusion status of the graft. If infection is suspected, ultrasound generally has to be supplemented by other imaging procedures such as CT or MRI; if these techniques reveal suggestive lesions, a fine-needle aspiration is mandatory in most cases. Invasive procedures such as angiography or PTC are now applied only in selected cases, especially if an intervention is contemplated. Rejection cannot be reliably diagnosed by any of the imaging techniques and still requires biopsy.

Receiver operating characteristic (ROC) analysis of the ability of arterial ketone body ratio to predict graft outcome after liver transplantation--its sensitivity and specificity

To evaluate the ability of arterial ketone body ratio (AKBR; acetoacetate/3-hydroxybutyrate) to predict graft prognosis after liver transplantation, the diagnostic value as a predictive index was compared between AKBR and conventional liver function tests using receiver operating characteristic (ROC) analysis. The ROC curves were determined for AKBR, GOT, GPT, total bilirubin, serum lactate level, and prothrombin time, all of which were measured on the 1st and 2nd postoperative days in 88 cases of liver transplantation. Comparisons of the areas under the ROC curves between AKBR and other tests revealed the significant superiority of AKBR to other tests in predicting graft death within 1 month after transplantation. The present study suggests that AKBR can be used as an accurate index to predict graft prognosis after liver transplantation.

[Chemoembolization of hepatocellular carcinoma in cases of isolated liver involvement]

Chemoembolization is an effective treatment for hepatocellular carcinoma, giving results equally as good as surgical therapy for T2 tumours. Survival can be prolonged and side-effects can be reduced by combining Lipiodol and Gelfoam for chemoembolization, employing a modified technique, with repeated procedures, and using appropriate follow-up treatment. The toxicity of the procedure is acceptable, but it requires supportive therapy necessitating an intense interdisciplinary co-operation.

Liver transplantation for hepatocellular carcinoma: clinical results and future aspects

The treatment of unresectable hepatocellular carcinoma (HCC) by liver transplantation remains controversial. In our series, the 5-year survival value for 87 patients who underwent transplantations between 1972 and 1990 was 19.6%. There was no difference in the long-term survival of patients who had underlying cirrhosis and those who did not. In patients with early-stage tumors the long-term prognosis was improved, the 5-year survival in stage II disease being 55.6% according to UICC criteria. Even in some cases of more advanced tumour stage, good long-term results were obtained. In a review of the recent literature, we evaluated prognostic factors to work out criteria for a more differentiated indication for liver transplantation. Resection of increased radicality--which will keep its place as the therapy of choice--and transplantation should be performed complementarily. Further developments will reveal the value of multimodal therapeutic strategies, including chemo-embolisation, chemotherapy and immunotherapy.

Pre- and post-transplant assessment of liver function in paediatric liver transplantation

The pre-operative risk of paediatric liver transplantation candidates (n = 41) was assessed in a prospective study by means of clinical symptoms, conventional static and liver blood flow dependent dynamic liver function tests. Nine patients died during the 365-day waiting period. The data were subjected as covariates to a survival analysis in the Cox proportional hazards model. There was a significant relationship between the results of mono-ethylglycinexylidide (MEGX) formation and ICG test and the 365-day survival rate. In the stepwise analysis, none of the remaining parameters improved the predictive ability when added to the dynamic liver function test results. The assessment of post-transplantation liver function was studied in 27 patients during the first 28 postoperative-day period. In addition, liver function was studied in a cross-sectional study 1-7 years after successful liver transplantation in children with complete or partial rehabilitation. In the early postoperative period severe organ damage was indicated by both static and dynamic liver function tests. In the later course after transplantation no deterioration of liver function measured with MEGX formation was to be observed. These findings demonstrate the usefulness of dynamic liver function tests in the pre- and post-transplant assessment of liver function.