Successful liver transplantation in a patient with a thrombosed portomesenteric system after multiple failed shunts

Combined portal and mesenteric vein thrombosis preventing restoration of adequate portal venous flow has been considered a contraindication to liver transplantation. We report a patient with failed splenorenal (SR), portocaval (PC), and mesocaval (MC) shunts, who despite the absence of any obvious means for supplying portal venous inflow to a hepatic graft, successfully underwent orthotopic liver transplantation. A method of reconstruction of the portal vein with the use of vein grafts anastomosed to a large splanchnic venous collateral is described. This technique can be used in selected patients in whom orthotopic liver transplantation might otherwise be considered technically impossible.

Liver transplantation for hepatoblastoma. The American experience

The current role of liver transplantation in treating malignant tumors of the liver is uncertain, except for select histologic types. Pooled data on the results of liver transplantation in 12 children with hepatoblastoma is presented here. One half of the children are alive 24 to 70 (44 +/- 19) months after transplantation with no evidence of recurrence. Three patients (25%) died of tumor recurrence and three (25%) died of other causes. Unifocal and intrahepatic tumors were associated with better prognosis compared to the multifocal tumors and tumors with extrahepatic spread (p = 0.04 and 0.13). Microscopically vascular invasion and the predominance of embryonal and/or anaplastic epithelium were associated with a poor prognosis compared to the tumors with no vascular invasion and with predominantly fetal epithelium (p = 0.08 and 0.1). It is concluded that continued efforts to treat unresectable hepatoblastomas by liver transplantation is justified and the role of adjuvant chemotherapy in improving the results needs to be better defined.

Vascular complications after orthotopic liver transplantation

Over a 57-month period, we performed 430 orthotopic liver transplants in 372 patients. A total of 38 vascular complications were identified including hepatic artery thrombosis (n = 24), portal vein thrombosis (n = 6), combined hepatic artery thrombosis/portal vein thrombosis (n = 3), and hepatic artery rupture (n = 5). A number of potential risk factors for the development of vascular thrombosis were evaluated with only children, weight less than 10 kg, and cold ischemia time found to be significant. The clinical presentation included fulminant hepatic failure, allograft dysfunction, biliary sepsis, and screening ultrasound. Duplex ultrasonography was diagnostic in nearly all cases. Therapeutic modalities included revascularization, revascularization followed by retransplantation, retransplantation alone, and observation. Five cases of hepatic artery rupture occurred in four patients. Infectious arteritis was present in four patients. The 6-month actuarial survival in patients with vascular complications was 70%. Early diagnosis is critical for graft salvage, with surgical intervention the mainstay of therapy.

Orthotopic liver transplantation for graft-versus-host disease following bone marrow transplantation

Chronic graft-vs.-host disease occurs in 30%-50% of long-term survivors of allogeneic bone marrow grafts, and may eventuate in cirrhosis. In this study, a young woman, originally diagnosed as having acute myelogenous leukemia, underwent successful bone marrow transplantation but later developed graft-vs.-host disease-induced cirrhosis and recurrent variceal hemorrhage. She underwent successful orthotopic liver transplant. Her postoperative course was uncomplicated, with no evidence of rejection or recurrence of graft-vs.-host disease. As bone marrow transplantation is more widely used and survival improves, the number of patients with graft-vs.-host disease or venoocclusive disease resulting in cirrhosis is likely to increase. Hepatic transplantation should be considered for bone marrow transplant patients who develop end-stage liver disease.

Immunohistologic identification of Epstein-Barr virus-induced hepatitis reactivation after OKT-3 therapy following orthotopic liver transplant

Reactivated Epstein-Barr virus infection associated with hepatitis appeared in a liver transplant patient receiving monoclonal OKT-3 antibody for rejection. The histologic findings in liver biopsy specimens characteristic of allograft rejection were observed prior to and during the initial phase of antirejection therapy. However, failure of a complete response to antirejection therapy promoted rebiopsy. The specimen showed portal infiltrates composed predominantly of plasma cells and immunoblasts. The presumptive diagnosis of Epstein-Barr virus hepatitis was confirmed by staining frozen liver tissue for Epstein-Barr virus nuclear-associated antigen. OKT-3 therapy was discontinued, and cyclosporine and steroid doses were reduced. Gradually, clinical features, serum aminotransferase and bilirubin levels, and the portal lymphoid infiltrate resolved. Epstein-Barr virus serology showed an increase in convalescent titers IgG-antiviral capsid antigen, and Epstein-Barr virus nuclear-associated antigen. The histologic, clinical, and laboratory features supporting the diagnosis of Epstein-Barr virus hepatitis in a liver transplant patient are presented and discussed. This diagnosis guided appropriate therapy.

Predictive value of intraoperative liver biopsies of donor organs in patients undergoing orthotopic liver transplantation

The evaluation of prerevascularization and postrevascularization biopsies in comparison with clinical and laboratory data has revealed a direct correlation between elevated PT and AST levels and pericentral and panlobular individual hepatocyte necrosis. No other significant correlations were determined when comparing selected histologic features to selected clinical laboratory values. In conclusion, these biopsies are of limited use in predicting subsequent allograft function in the absence of prominent individual hepatocyte or pericentral necrosis.

Primary nonfunction. Is there a contribution from the back table bath?

A persistent problem in orthotopic liver transplantation (OLT) is primary nonfunction (PNF) of the hepatic allograft. In most instances the cause of the failure is unknown. In an attempt to minimize these graft failure, modifications in the procurement and operative procedure have been investigated. One change in the procedure at the University of Nebraska Medical Center has been the monitoring of the temperature of the fluid in the back table bath during preparation of the donor liver. Our initial procedure involved creating an ice slurry of lactated Ringer's solution and ice slush in which the donor liver was then prepared. The temperature of this ice slurry was retrospectively found to be from -3 degrees C to -1 degrees C (group I). In this group there was a higher-than-expected incidence of PNF. To investigate whether the temperature of the back table bath influenced the incidence of PNF, beginning with transplant No. 42 the preparation of the back table bath was modified. The bath was created by adding a small amount of PlasmaLyte slush to 2 L of PlasmaLyte (group II). The temperature of the bath was maintained at 2-4 degrees C. Data were collected on 100 consecutive liver transplants. All transplants were performed using standard techniques, the operation for the two groups differing only as described above. Transaminase levels were followed as an index of the allograft function and were expected to begin to normalize within 2-3 days after transplantation. While both groups display this trend, transaminase levels in group II were significantly lower postoperatively than group I levels (P less than 0.05). Preoperative values were similar. There were 7 PNFs in group I; 0 in group II (P less than 0.005). We feel that the change in the back table procedure has positively influenced the function of the hepatic allografts, and we conclude that transplant centers need to monitor the temperature at which all allografts are stored and prepared, and the cognizant that this may influence the postoperative function of the transplanted liver.

Liver transplantation for variceal hemorrhage

At the present time, liver transplantation must be considered among the treatment options for patients with variceal hemorrhage. For a significant percentage of variceal bleeders throughout the world, however, transplantation is not a viable option either because the patient is not an appropriate transplant candidate or because of the etiology of the patient's portal hypertension. Sclerotherapy and portosystemic shunts remain the mainstay of therapy for these patients. The survival rates with liver transplantation are superior to those reported for other therapies for variceal hemorrhage in patients who have moderate or severe liver disease in addition to variceal hemorrhage. Child's C patients whose variceal hemorrhage is controlled medically should be evaluated for transplantation and receive chronic sclerotherapy while they wait on the transplant list. If the variceal hemorrhage cannot be controlled medically in a transplant candidate, then the patient should undergo an emergency shunt procedure. The shunt of choice is a large-bore H-graft mesocaval or mesorenal shunt. This shunt effectively controls the acute hemorrhage, is relatively simple to perform, does not adversely impact on the subsequent liver transplant, and can simply be ligated after the transplant is completed. Patients who experience variceal hemorrhage as the only manifestation of their liver disease should be treated initially with endoscopic sclerotherapy. For that small group of patients who are either not candidates for sclerotherapy or who rebleed despite sclerotherapy, the choice of shunt or transplantation is presently a difficult one, because both therapies provide excellent results in this group of patients. The choice of therapy should be made on an individual basis and only after consultation with both transplant and shunt surgeons. If a shunt is chosen, we prefer the DSRS because it maintains hepatic portal perfusion in many patients and does not require dissection of the porta hepatis. The management of patients with a prior portosystemic shunt at the time of transplantation depends on the type of shunt and the duration of time between the shunt and the transplant. Shunts not involving the hepatic hilum have little adverse impact on the performance of the transplant. There are insufficient data to assess accurately the effect of a prior portacaval shunt on the transplant. However, our clinical experience and that of other transplant groups indicate that the transplantation of these patients is technically more difficult than that of patients with shunts not involving the hilum. With the availability of other shunting procedures that do not involve extensive dissection of the hepatic hilum, there is little role for either end-to-side or side-to-side portacaval shunts in patients who are potential liver transplant candidates.(ABSTRACT TRUNCATED AT 400 WORDS)

Drug-induced hypertrichosis: case report and review of the literature

Hypertrichosis is a well-recognized adverse effect of therapy with either cyclosporine or minoxidil. We present a case of extreme hypertrichosis in an eight-year-old male liver transplant recipient who received concurrent cyclosporine and minoxidil therapy. A review of drug-induced hypertrichosis is presented.

Optimal therapy for patients with biliary atresia: portoenterostomy ("Kasai" procedures) versus primary transplantation

As the results with liver transplantation have improved, a controversy has arisen regarding the precise role of a portoenterostomy in the treatment of infants with biliary atresia. The controversy centers around three issues: (1) the short- and long-term survival rates achieved with both procedures, (2) the influence of a portoenterostomy on a subsequent transplant, and (3) the shortage of suitable liver donors for very small infants. To address these questions, we retrospectively reviewed the charts of 48 children with biliary atresia who underwent liver transplantation and compared these results with 35 children transplanted for other liver diseases. As a group, the biliary atresia patients had significantly lower mean body weights and ages and spent a significantly longer time on the waiting list. In addition, significantly more of the biliary atresia patients had undergone prior abdominal surgery when compared with the non-biliary atresia group. There was no difference in the intraoperative variables of mean anesthesia time, mean operative time, mean anesthesia preparation time, nor the mean amount of blood transfused intraoperatively between the two groups. However, when the biliary atresia patients who had undergone a portoenterostomy with a stoma were compared with either the biliary atresia patients who did not have a stoma created as part of their portoenterostomy or the non-biliary atresia patients, significant differences were noted in mean total anesthesia time, mean operative time, and the mean amount of blood transfused intraoperatively. The survival rate of the biliary atresia patients was significantly greater than the non-biliary atresia patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Pontine and extrapontine myelinolysis following liver transplantation. Relationship to serum sodium

The relationship between central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM) and serum sodium changes in the setting of orthotopic liver transplantation (OLT) is examined. Postmortem examination of 14 patients with end-stage liver disease who underwent liver transplantation revealed CPM in four, of which three also had EPM. A retrospective review of clinical and laboratory data was performed on all patients. There were marked perioperative rises (21-32 mEq/L) in the serum sodium concentration in all four patients who developed myelinolysis. In contrast, the largest increase in sodium in patients without demyelination was 16 mEq/L. We conclude that perioperative rises in the serum sodium concentration increase the risk of myelinolysis. CPM and EPM should be considered if the patient develops mental status changes or focal neurological deficits several days after OLT.

Stratifying the causes of death in liver transplant recipients. An approach to improving survival

The causes of death in 21 adults and 23 children in a consecutive series of 180 liver transplantations were reviewed and classified into four categories. A previously described preoperative risk score was applied prospectively to estimate the relative risk of mortality following liver transplantation in adults. Categorization of the causes of death allowed for a systematic search for errors in management and technique. Comparison of the preoperative risk score with the cause of death category revealed that higher-risk adults were most likely to die of causes related to preoperative morbidity. They also accrued higher hospital costs, regardless of outcome. The data are useful for designing strategies to reduce mortality. However, the inexorable role that preoperative morbidity has on outcome was also emphasized. This has important implications in developing strategies to reduce the costs of liver transplantation and to provide optimal distribution of scarce donor organs.

Postoperative care after liver transplantation

The proliferation of liver transplant services across the country during the next 5 years will be an interesting phenomenon to observe. An enlightened approach to the process require answers to several essential questions, many of which are discussed elsewhere in this issue of Seminars. Regardless of how the future distribution of services sorts out, many physicians will face an increasing likelihood that their services will be requested in the long-term management of liver transplant recipients. In this report, the care of liver transplant patients is discussed, including that involving the immediate post-operative phase, the in-hospital recovery, and the early and long-term care of outpatients. The discussion is limited to the more common problems that these patients experience. Information from available literature is interspersed with our experience to provide a personal approach to the diagnosis and treatment of both complications and normal post-transplant clinical concerns. Part of what the reader should obtain from a general review of a complex subject is an awareness of the amount of information that the review does not contain. We have touched the surface of a large number of topics, but have come up far short of a comprehensive coverage of all aspects of the postoperative care of the liver recipient. It is hoped that we have provided enough information to serve the reader as an initial foundation for building a more complete understanding of the management of liver transplant patients.