Selecting the donor liver: risk factors for poor function after orthotopic liver transplantation

Initial poor function and primary nonfunction are important problems in clinical transplantation. The incidence of primary nonfunction is about 6% and that of initial poor function is about 15%. Grafts with initial poor function have a higher graft failure rate in the first 3 mo after transplantation. Severe steatosis and cold preservation in University of Wisconsin solution for over 30 hr will alone cause primary nonfunction. However, primary nonfunction is probably most often caused by the presence of multiple relative risk factors. The major donor-relative risk factors are moderate steatosis, cold preservation over 12 hr and donor age over 50 yr, whereas retransplantation, high (United Network of Organ Sharing class 4) medical status and kidney failure are recipient relative risk factors. The most important perioperative risk factor is warm ischemia time. Rates of primary nonfunction and initial poor function might be reduced by avoidance of combinations of risk factors. Several tests have been developed to predict primary nonfunction and initial poor function, but none is yet clinically efficient.

Primary adenocarcinoma of the duodenum with choledochoduodenal fistula

BACKGROUND

Primary adenocarcinoma of the duodenum is an uncommon clinical entity. It has been associated with a dismal prognosis because it is rare and produces no distinctive symptoms until late in its course.

CASE SUMMARY

A 68-year-old man presented with a 6-month history of epigastralgia, anorexia, and progressive weight loss. Esophagogastroduodenoscopy showed a tumor mass in the deformed duodenal bulb with a fistula into the biliary tract. Upper gastrointestinal (UGI) barium studies and cholangiography confirmed a fistulous communication between the duodenum and biliary tree.

CONCLUSIONS

Aggressive evaluation of minor, yet refractory, UGI symptoms and a high index of suspicion offer the best hope for early diagnosis. Esophagogastroduodenoscopy and barium UGI study are the principal methods of diagnosis of these tumors. Early diagnosis would thus prevent metastasis and complications.

Liver transplantation: newer surgical approaches

The standard procedure for orthotopic liver transplantation remains transplantation of the whole organ together with resection of the vena cava and the use of venovenous bypass. In cases of severe mismatch of the donor and recipient vena cava, the piggyback technique, if necessary with vena cava plasty, is preferable. Furthermore, in all cases where venovenous bypass cannot be performed, the piggyback or other technique preserving the vena cava should be performed. In paediatric patients, reduced/size liver transplantation may be indicated because of the shortage of small livers. In the hands of experienced surgeons, the results of reduced-size liver transplantation in paediatric patients are similar to those of whole organ transplantation. Further innovative procedures to overcome the problem of organ shortage include split-liver and living related transplantation in children. Distinct advantages of living related transplantation can be seen in a well-functioning graft, lack of preservation injury, elective operation and optimal graft-size matching. The immunological advantage that has been claimed could not be demonstrated so far, and will need to be examined in the long-term follow-up. However, there remains a distinct disadvantage for living related transplantation with regard to the surgical technique. Preoperative portal venous thrombosis should be carefully assessed, but is not a contraindication to liver transplantation if the confluence of the superior mesenteric vein and splenic vein is patent. Arterial reconstruction at the confluence of two arteries (hepatic and gastroduodenal or splenic artery) seems to be preferable to an end-to-end anastomosis because of improved inflow into the graft and a reduced risk of arterial stenosis and thrombosis. Where the common hepatic arteries are small, with reduced or reversed flow, and in patients with coeliac trunk stenosis, we recommend a direct approach to the suprarenal or infrarenal aorta. Bile duct anastomosis may preferably be performed with a side-to-side technique, to reduce early and late biliary complications.

The influence of cold ischemia time on biliary complications following liver transplantation

Biliary complications are a continuing source of morbidity and mortality following orthotopic liver transplantation. The results of 100 whole-liver allografts performed in 92 adult patients were reviewed to determine whether cold ischemia time and preservation injury influenced both the incidence and type of biliary complications. Mean cold ischemia time was 10.2 +/- 0.5 h (range 3.6-19). Eighteen patients (19.6%) developed 25 biliary complications: there were eight anastomotic leaks, eight anastomotic strictures, six non-anastomotic strictures, two cystic duct mucoceles, and one biliary fistula following T-tube removal. Despite the high rate of reoperative surgery (68%), no death was attributable to biliary complications. Neither cold ischemia time nor early graft function influenced the rate of biliary complications or strictures of either type. Furthermore, an analysis of different factors revealed no predisposing effect of the pre-operative status of the recipient, type of biliary reconstruction, blood requirement, vascular complications, rejection or cytomegalovirus infection on the incidence of biliary complications or strictures. Only chronic rejection could be singled out as a risk factor for non-anastomotic strictures (p = 0.05). These results suggest that prolonged cold ischemia time does not seem to affect the rate or type of biliary complications following orthotopic liver transplantation. In view of these data, there is no clear reason to reconsider prolonged cold ischemia up to 15 h in University of Wisconsin solution, as it has transformed liver transplantation from an emergency operation to a semi-elective procedure and allows longer back-table preparation for graft reduction of splitting.

Sequential treatment of biliary atresia with Kasai portoenterostomy and liver transplantation: a review

Biliary atresia is the most frequent cause of chronic cholestasis in infants. When left untreated, this condition leads to death from liver insufficiency within the first 2 yr of life. The modern therapeutic approach consists of a sequential strategy with Kasai portoenterostomy as a first step and, in case of failure, liver transplantation. After portoenterostomy, no more than 20% to 30% of patients will live jaundice-free into adulthood. Illness in another third will be palliated, and these patients have extended survival, delaying liver transplantation to later childhood (2 to 15 yr). The remaining 30% to 40% will not benefit from the Kasai operation and will die of liver failure in infancy. The annual need of liver transplantation for biliary atresia is one case per million people. This indication represents 35% to 67% of the reported series of pediatric liver transplantation and between 5% and 10% of the indications for liver transplantation, all ages included. Approximately four of five children transplanted for biliary atresia will become long-term survivors with good physical and mental development; recurrence of the disease after transplantation has not been observed. Because most candidates are young children (< 3 yr) of small size (< 10 kg), there is a shortage of size-matched donors (which has been alleviated by the use of innovative techniques such as reduced and split livers). The resulting redistribution of the adult donor liver pool is ethically justified by the equal quality of the results after transplantation of a full-size or partial graft.

Raised pressure in the bile ducts after orthotopic liver transplantation

Biliary complications are common after orthotopic liver transplantation. Bile leakage in the immediate postoperative period and on removal of the T-tube could possibly be caused by a raised bile duct pressure. In order to test this hypothesis, bile duct pressure was studied in seven consecutive liver transplant patients. During the operation, the common bile duct was anastomosed end-to-end over a T-tube. The initial bile duct pressure measurement was performed a median of 12 days (range 10-17 days) after the transplantation and on one or two more occasions during the following 3 months. Seven cholecystectomized gallstone patients with indwelling T-tubes were used as controls. The bile duct pressure at the level of the xiphoid process in the transplanted group was 7.7 +/- 1.4 cm H2O and in the control group 0.5 +/- 0.8 cm H2O (P < 0.001). The initially increased bile duct pressure after liver transplantation decreased with time (P < 0.05) towards normal during the following 3 months. The raised pressure may increase the risk of bile leakage in the postoperative period.

Safety and function of isolated Roux loop pancreaticojejunostomy after Whipple's pancreaticoduodenectomy

A novel method of pancreatic anastomosis after proximal Whipple-type resection: classical pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD), has been evaluated over a 5-year period from 1987 to 1992 in 52 patients. Indications for resection included chronic pancreatitis (n = 9) and neoplasms (n = 43). Reconstruction involved a cephalad end-to-end duodeno-/gastro-jejunal anastomosis with a biliary anastomosis 6-8 cm downstream. A separate isolated defunctioned Roux loop was used to construct a duct-to-mucosa (Wirsung-jejunal) pancreaticojejunostomy. Median postoperative stay was 18.0 days (range 11-32 days); three deaths (operative mortality 5.8%) occurred due to sepsis (subhepatic abscess), profound hypoglycaemia and necrotising pancreatitis respectively. These deaths were not related to pancreatic fistula. There were no pancreatic leaks (defined as greater than 50 ml of amylase-rich fluid for more than 7 days). Postoperative exocrine pancreatic function was good as assessed by re-establishment of preoperative weight (achieved in 35 of 40, ie 88% of surviving PPPD patients), clinical steatorrhoea (present in 10 of 41, ie 24% of surviving patients resected for neoplasm), and the need for pancreatic exocrine supplements (required in only 4 of 41, ie 9.8% of surviving patients resected for neoplasm). Twenty patients considered to have normal pancreatic remnants underwent a p-aminobenzoic acid (PABA) excretion test at 3 to 18 months after operation. Median PABA excretion index was 48% (range 24-100%). Isolated defunctioned duct-to-mucosa pancreaticojejunostomy is a safe procedure offering good functional results after Whipple's PD or PPPD resection.

Three synchronous carcinomas of the papilla of Vater, common bile duct and pancreas

Multiple carcinomas of the pancreatico-biliary tree are rare. A 53 year old Japanese man was diagnosed as having an adenocarcinoma in the papilla of Vater. During the operation, he was also found to have a polypoid mass in the common bile duct. While cutting the operative specimen into stepwise sections, a small tumor was also detected incidentally in the main pancreatic duct of the pancreatic head. Histologically, all three tumors proved to be papillary adenocarcinomas and were restricted to the mucosa. Immunohistochemically, all three tumors were positive for carcinoembryonic antigen, carbohydrate antigen 19-9, chromogranin A and serotonin, while they were negative for somatostatin. Immunoreactivity to the tumor suppressor gene p53 protein (PAb 1801) was found in all three tumors. A flow cytometric analysis of the cellular DNA content revealed all three tumors to be aneuploid. The above results suggested that these three tumors from different sites all had the same histological, immunohistochemical and flow cytometrical characteristics.

Technique and results of biliary reconstruction using side-to-side choledochocholedochostomy in 300 orthotopic liver transplants

OBJECTIVE

The authors evaluated the complication rate and outcome of side-to-side common bile duct anastomosis after human orthotopic liver transplantation.

SUMMARY BACKGROUND DATA

Early and late biliary tract complications after orthotopic liver transplantation remain a serious problem, leading to increased morbidity and mortality. Commonly performed techniques are the end-to-end choledochocholedochostomy and the choledochojejunostomy. Both techniques are known to coincide with a high incidence of leakage and stenosis of the bile duct anastomosis. The side-to-side bile duct anastomosis has been shown experimentally to be superior to the end-to-end anastomosis. The authors present the results of 316 human liver transplants, in which a side-to-side choledochocholedochostomy was performed.

METHODS

Biliary tract complications of 370 transplants in 340 patients were evaluated. Three hundred patients received primary liver transplants with side-to-side anastomosis of donor and recipient common bile duct. Thirty-two patients with biliary tract pathology received a bilioenteric anastomosis, and in eight patients, side-to-side anastomosis was not performed for various reasons. Clinical and laboratory investigations were carried out at prospectively fixed time points. X-ray cholangiography was performed routinely in all patients on postoperative days (PODs) 5 and 42. In patients with suspected papillary stenosis, endoscopic retrograde cholangioscopy and papillotomy were performed.

RESULTS

One biliary leakage (0.3%) was observed within the early postoperative period (PODs 0 through 30) after liver transplantation. No stenosis of the common bile duct anastomosis was observed during this time. Late biliary stenosis occurred in two patients (0.6%). T tube-related complications were observed in 4 of 300 primary transplants (1.3%). Complications unrelated to the surgical technique, including papillary stenosis (5.7%) and ischemic-type biliary lesion (3.0%), which must be considered more serious in nature than complications of the anastomosis or T tube-related complications, were observed. Papillary stenosis led to frequent endoscopic interventions and retransplantations in 1.3%.

CONCLUSIONS

Side-to-side common bile duct anastomosis represents a safe technique of bile duct reconstruction and leads to a low technical complication rate after human orthotopic liver transplantation. Ischemic-type biliary lesion evoked by preservation injury, arterial ischemia, cholestasis, and cholangitis may represent a new entity of biliary complication, which markedly increases the morbidity after human liver transplantation. Therefore, this complication should be the subject of further research.

Pancreatic resection for periampullary carcinoma in the elderly

The effect of pancreatic resection for periampullary carcinoma in the elderly was studied by comparing the pre- and perioperative factors affecting survival in 102 patients less than 70 years of age (group A) with those in 28 patients 70 years and older (group B). Concomitant cardiac and pulmonary diseases were significantly more frequent in group B (P < 0.05), but the difference in routine laboratory data was not significant. The overall operative mortality was 7% (7/102) in group A and 18% (5/28) in group B, while the actuarial 5-year survival rates were 31% in group A and 23% in group B, these differences not being significant. A multivariate analysis using a logistic model showed that blood loss was the greatest risk factor for early postoperative death in the elderly patients, whereas anastomotic dehiscence and postoperative bleeding were significant factors in the younger patients. Thus, we conclude that age is not a contraindication to pancreaticoduodenectomy which offers the only hope for long-term survival in patients with periampullary carcinoma; however, meticulous dissection to minimize blood loss is especially important in elderly patients.

Primary care management of the liver transplant patient

The patient referred for liver transplantation typically has complications from a progressive, irreversible liver injury. Less traditional complications of end-stage liver disease, such as bone disease and some hepatobiliary malignancies, may also prompt referral. However, there are contraindications to liver transplantation, such as metastatic malignancy and persistent substance abuse. Each patient should be referred as early as possible. The evaluation process includes a complete physical examination and social and psychologic evaluations. If transplantation is agreed upon, the patient is listed by clinical status and enters a waiting period for a donor liver. Following transplantation, the patient is maintained on a regimen of immunosuppressive drugs to prevent allograft rejection. Each patient is also maintained on prophylactic medications, to decrease the risk of opportunistic infection. Many of the postoperative problems in liver transplantation are a result of immunosuppression, either as side effects of the medications used to prevent and control rejection or from the intensity of the resulting immunosuppression. These problems include headaches, systemic hypertension, acute and chronic allograft rejection, renal dysfunction, opportunistic infection with cytomegalovirus or Pneumocystis carinii, disease recurrence, and neoplasia. Routine, long-term care includes systematic clinical follow-up and repetitive blood tests. Communication among the transplant center, the patient, and the referring physician are essential to a successful outcome over the long term.

[Mesentric venous thrombosis. Risk factors, treatment and outcome. An analysis of 18 cases]

Eighteen patients with an acute thrombosis of the splanchnic veins were reviewed. Most of apparently idiopathic cases of splanchnic vein thrombosis are related to an increased coagulation related to a congenital or acquired defect of haemostasis. The aim of this study was to assess the effects of a new and effective treatment. Nine male and 9 female patients (range of age: 19 to 81 years) experienced a mesenteric venous thrombosis. There were 14 mesenteric vein thromboses with infarction, two transient mesenteric venous ischaemias without bowel infarction and two acute thromboses of the splanchnic veins without bowel ischaemia. A coagulopathy was detected in seven patients: oral contraception, protein C (PC) or antithrombin III (AT III) congenital deficiencies, acquired deficiency of AT III, PC and protein S (PS), polycythaemia in the post-partum period and primary myeloproliferative disorder. No coagulopathy was associated with thrombosis in eight cases: mesenteric haematoma, splenomegaly, cirrhosis, appendicectomy, cholescytectomy, chronic heart failure, treatment with beta-adrenergic receptor antagonist and digitalis, stenosis of the portal anastomosis after liver transplantation. Twelve patients required surgery: eight intestinal bowel resections with immediate anastomosis, four resections without immediate anastomosis. Only one patient underwent a second look for a repeat bowel resection. No death occurred in the early postoperative period and 17 out of 18 patients were alive after 12 years. An oral anticoagulant therapy was undertaken from two months to seven years. However, three patients suffered a recurrent thrombosis. Two of them required a long-term anticoagulation. Six patients experienced a portal hypertension and oral anticoagulants were discontinued in three of them because of bleeding oesophageal varices. Six patients were treated only by unfractionated heparin (UFH) or low molecular weight heparin (LMWH) followed by oral anticoagulants. After laparotomy, two were only treated with UFH without any bowel resection, as mesenteric venous ischaemia was too extensive. These observations suggest that the choice between an appropriate medical or surgical treatment is important and must be discussed. Since 1989, the therapeutic choice has been modified by ultrasonography and contrast enhanced computed tomographic scan which confirms diagnosis, allows to follow up and check the effects of anticoagulation and to choose the time for surgery. When the diagnosis is established and the patient's risk is low, the IU . kg(-1) . d(-1) to obtain an antifactor Xa activity between 0.3 and 0.6 antiXa IU mL(-1). When the diagnosis is uncertain and the patient's risk if high a laparotomy is required.(ABSTRACT TRUNCATED AT 400 WORDS)

Adenocarcinoma of the duodenum: factors influencing survival. French Association for Surgical Research

The records of 66 patients with histologically proven adenocarcinoma of the duodenum were reviewed retrospectively to determine factors influencing survival. The parameters studied were age, sex, weight loss, jaundice, anaemia, duodenal stenosis, type of surgical procedure, tumour size and location, depth of parietal invasion, presence and location of lymph node metastases, and pancreatic invasion. These factors were assessed in a group of 46 patients who underwent curative resection of the tumour; 20 patients who received palliative procedures were excluded from statistical analysis. Survival curves were established by the Kaplan-Meier method and compared by the Mantel-Haentszel test. The actuarial 3- and 5-year survival rates of patients undergoing curative resection were 59 and 45 per cent respectively. None of the prognostic factors studied influenced survival. These results indicate that resection of adenocarcinoma of the duodenum should be performed whenever possible, even in the presence of lymph node metastasis and pancreatic spread.

Percutaneous transluminal angioplasty of venous anastomotic stenoses complicating liver transplantation: intermediate-term results

PURPOSE

The authors evaluated the safety and efficacy of percutaneous transluminal angioplasty (PTA) for the treatment of venous stenoses in liver transplant recipients.

PATIENTS AND METHODS

Over a 5-year period, 15 venous stenoses were treated with PTA in 12 patients with liver transplants (seven children and five adults). PTA was performed for portal vein stenoses in five patients, inferior vena cava (IVC) stenoses (n = 6) in five patients, combined superior mesenteric vein-portal vein graft anastomosis and hepatic vein-IVC anastomosis in one patient, and combined IVC and hepatic vein-IVC anastomosis in one patient. PTA was repeated in three patients (five procedures) for recurrent IVC stenoses.

RESULTS

Initial technical and clinical success of PTA was achieved in 11 patients (92%); failure occurred in one patient (8%) with a portal vein anastomotic stenosis. No complications occurred in the immediate post-procedure period (up to 7 days). Nine patients (75%) are clinically well, with follow-up ranging from 7 to 33 months (mean, 18 months). Two of them required one or more repeated PTA procedures to maintain vessel patency. One patient required retransplantation for chronic rejection at 3 months, and another died of gastrointestinal tract bleeding from a gastric ulcer at 2 months after initially successful IVC PTA.

CONCLUSIONS

PTA is a safe procedure for the treatment of venous anastomotic stenoses in liver transplant recipients. PTA of portal vein anastomotic stenosis has favorable intermediate-term results. Repeat PTA may be necessary in some cases of IVC anastomotic stenoses to maintain vessel patency and avoid surgical revision or retransplantation.

Indwelling mesenteric venous catheterization for early detection of portal vein thrombosis: possible application to pediatric liver transplantation

Portal vein thrombosis (PVT) is a well-recognized complication after liver transplantation, particularly in children. When it occurs early in the postoperative period, it has serious consequences, and rapid detection is essential. The purposes of this study were (1) to ascertain whether continuous monitoring of mesenteric venous pressure (MVP), via an indwelling mesenteric venous catheter, could assist in early detection of PVT and (2) to investigate the role of portography, via the catheter, in confirming this complication. An animal model of PVT was developed in pigs. At laparotomy, a heparin-coated catheter was inserted into a jejunal mesenteric vein, delivered percutaneously and connected to a pressure transducer. Conditions of PVT were simulated by progressive occlusion of the portal vein (PV) using a silastic tourniquet, and the degree of PV stenosis was assessed by Doppler ultrasound flow-velocity measurement. MVP was recorded 1 and 3 minutes after PV occlusion, and portography was performed via the indwelling catheter. There were significant increases in MVPs with all degrees of PV stenosis (P < .01, Student's t test). No significant changes in MVP were noted between 1 and 3 minutes postocclusion. Portography clearly demonstrated PV stenosis. There were no instances of PVT, despite repeated and prolonged occlusion of the PV. Progressive degrees of PV stenosis have been clearly detected by an indwelling mesenteric venous catheter in an animal model. This method may be useful for the diagnosis and treatment of PVT after pediatric liver transplantation.

Primary common bile duct anastomosis in the rat using microsurgical techniques

In a rat model, we attempted to describe the natural healing course of the common bile duct (CBD) after primary microsurgical repair. Fifty-three rats were divided into experimental groups with CBD microsurgical anastomoses and control groups with CBD mobilization and ligation. Examination of three experimental groups at 1 week, 1 month, and 3 months showed evolving inflammation and stricture changes with eventual patent, healed ducts in 92% of animals at the end of 3 months following transection and repair. There were no histologic abnormalities in the livers. There were fibrotic ducts and hepatic stasis and cirrhosis changes in the control group with CBD ligation. This study demonstrates that microsurgical techniques can achieve successful primary biliary repair in the rat.

Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery

A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12.3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0.001). The operative mortality rate was higher after total pancreatectomy than pancreatoduodenectomy (17 versus 8 per cent, P = 0.015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.

Biliary tract reconstruction: comparison of different techniques after 187 paediatric liver transplantations

Biliary complications after liver transplantation are common and cause significant morbidity and mortality. In order to evaluate the complications related to different sorts of biliary reconstruction, from January 1984 to July 1992 we retrospectively analysed 187 consecutive liver transplants in 136 paediatric patients at Addenbrooke's Hospital, Cambridge. There were 51 (27.2%) retransplantations. Biliary reconstruction consisted of: type 1-common bile duct-Roux loop (CBD-RL); n = 90 (48.1%); type 2-gallbladder conduit-Roux loop (GC-RL), n = 51 (27.2%); type 3-gallbladder conduit-common bile duct (GC-CBD), n = 20 (10.6%); type 4-common bile duct-common bile duct (CBD-CBD), n = 18 (9.6%); and type 5-common bile duct-common bile duct+gallbladder drainage (CBD-CBD+GB), n = 8 (4.2%). There were, in all 26 biliary complications (14%). Of these 26 complications, biliary stricture was the most common (17/26; 65.3%) and 6 out of these 17 (35.2%) were associated with chronic rejection. Hepatic artery thrombosis was directly related to biliary leakage in 6 out of 26 (23.1%) biliary tract complications. This series demonstrated that type 1 and type 4 reconstructions were related to fewer biliary complications (9/90, 10% and 2/18; 11%, respectively) than the other techniques: 8/51 (16%) for GC-RL 5/20 (25%) for GC-CBD and 2/8 (25%) for CBD-CBD+GB (P = 0.09).

The incidence, timing, and management of biliary tract complications after orthotopic liver transplantation

OBJECTIVE

This study analyzed the incidence and timing of biliary tract complications after orthotopic liver transplantation (OLTx) in 1792 consecutive patients. These results were then compared with those of previously reported series. Finally, recommendations were made on appropriate management strategies.

SUMMARY BACKGROUND DATA

Technical complications after OLTx have a significant impact on patient and graft survival. One of the principal technical advances has been the standardization of techniques for biliary reconstruction. Nonetheless, biliary complications still occur. A 1983 report from the University of Pittsburgh reported biliary complications in 19% of all transplants, and an update in 1987 reported biliary complications in 13.2% of transplants.

METHODS

The medical records of all patients who underwent liver transplantation and were hospitalized between January 1, 1988 and July 31, 1991 were reviewed. The case material consisted of the medical records of 217 patients treated for 245 biliary complications.

RESULTS

Primary biliary continuity was established by either choledochocholedochostomy over a T-tube (C-C, n = 129) or a Roux-en-Y choledochojejunostomy with an internal stent (C-RY, n = 85). The overall incidence for biliary complication in this large series was 11.5%. Strictures (n = 93) and bile leak (n = 58) were the most common complications (69.6%). Most biliary complications (n = 143, 66%) occurred within the first 3 months after surgery. In general, leaks occurred early, and strictures developed later. Bile leaks were equally frequent in both C-C and C-RY (27.1% and 25.9%, respectively); strictures were more common after a C-RY type of reconstruction (36.4% and 52.9%, respectively). Twenty-one patients died, an incidence of 9.6%. Fifteen of the 21 biliary-related deaths were among patients treated for rejection before the recognition of biliary tract pathologic findings.

CONCLUSIONS

Progress has been made on improving the results of biliary reconstruction after OLTx. Nonetheless, patients continue to experience biliary complications after OLTx, and these complications cause considerable loss of grafts and life. If significant additional improvement in patient and graft survival are to be obtained, the technical performance of OLTx must continue to improve.

Reoperation for biliary tract complications following orthotopic liver transplantation

Biliary tract complications were analysed after 54 orthotopic liver transplantations performed in 49 patients over a 2-year period. Reconstruction of the bile duct consisted of end-to-end choledochocholedochostomy over a T tube in 47 cases and Roux-en-Y choledochojejunostomy in seven (two for sclerosing cholangitis, one for secondary biliary cirrhosis, four retransplants). The T tube was withdrawn 12-16 weeks after operation in all but two patients (2-3 weeks). There was no intraoperative mortality. Eight patients (16 per cent) died during the first month and the 1-year actuarial survival rate was 75 per cent. Early biliary complications (up to 3 months after operation) consisted of five bilomas, for which ultrasonographically guided drainage was effective in three and surgical drainage necessary in two. Late biliary complications (3 months onwards) consisted of biliary peritonitis following T tube removal (four patients; reoperation was required in all four) and necrosis of the bile duct secondary to a late arterial thrombosis (one). The incidence of reoperation as a result of early biliary complications was low (two patients), but higher for biliary peritonitis following T tube removal.

A follow up of 53 adult patients alive beyond 2 years following liver transplantation

Although hepatic transplantation is now a well-accepted treatment modality for end-stage liver diseases there are little detailed data on the clinical profile of patients who survive beyond 1 year following transplantation. The aim of this study was to develop a cross-sectional profile on 53 adults who have survived beyond 2 years following liver transplantation. These patients have been followed for a mean of 43.5 months (range 24-84) since the time of transplant. Nineteen patients had persisting liver enzyme abnormalities, 11 due to chronic viral hepatitis (seven hepatitis C virus, three hepatitis B virus), four due to biliary disease. Two had post severe rejection, one steatosis secondary to obesity while in one the aetiology was unclear. Nineteen (36%) of patients required anti-hypertensive medications. The median doses of Prednisone, Cyclosporin and Imuran were 7.5, 300 and 50 mg daily, respectively. The mean serum creatinine was 117 +/- 27 mumol/L. However 22 (41%) had an elevated serum creatinine (> 120 mumol/L) but in only seven was the serum creatinine > 150 mumol/L. Fourteen (26%) of patients were obese (body mass index > 30) whilst 46% had a higher than recommended serum cholesterol (mean level 5.6 +/- 1.5 mumol/L). There has only been one case of internal malignancy (lymphoma) although 19 patients attend regular dermatological review for skin cancer surveillance. Forty-eight patients had a Karnofsky Score > 80. In conclusion, the vast majority of these patients have excellent clinical function but some caution is required with respect to renal function, hypertension, obesity and mild hypercholesterolaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Concomitant adenosquamous carcinoma of the common bile duct and early adenocarcinoma of the gall-bladder

We report a 59 year old male with obstructive jaundice and a clinical diagnosis of carcinoma of the midportion of the common bile duct. Examination of the surgical specimen revealed a small tumour in the neck of the gall-bladder. Histologic examination revealed the tumour in the common bile duct was an adenosquamous carcinoma whereas that in the gall-bladder was an early papillary adenocarcinoma. Thus, this is a rare case of the simultaneous development of adenosquamous carcinoma and early papillary adenocarcinoma in the biliary tree.

Synchronous carcinoma of the gall-bladder in patients with bile duct carcinoma

One hundred and twenty-four patients with bile duct carcinoma treated during 16 years were analysed retrospectively for multiple biliary tract carcinoma. Sixty-two cases had undergone a cholecystectomy either as part of a pancreaticoduodenectomy or a bile duct resection or as part of an internal drainage procedure. Three (5%) were found to have an incidental separate carcinoma of the gall-bladder. The discontinuity between the two sites of cancer was histologically confirmed. Clinical concern was that approximately 5% of patients with bile duct carcinoma had a synchronous carcinoma of the gall-bladder. Thus, careful examination of the entire biliary tract including the gall-bladder is necessary at the time of curative surgery for bile duct carcinoma.

Biliary tract complications in pediatric orthotopic liver transplantation

Biliary tract complications are reported in 15% to 30% of orthotopic liver transplantations (OLTs). Since 1986, 53 OLTs were done in 48 children with a mean age and weight of 5.3 years and 18.9 kg, respectively. Twenty-seven transplantations (51%) were reduced liver grafts (RLG) and 26 (49%) were whole liver grafts (WLG). Since 1988, 70% of transplantations have been RLG. Choledochocholedochostomy (mean weight, 25 kg) with a T-tube (CC) or choledochojejunostomy (CJ) (mean weight, 14.5 kg) were done in 24 (45%) and 29 (55%) cases, respectively. The overall mortality was 19% but none of the deaths were related to biliary problems. There were 13 biliary tract complications (24.5%) in 11 patients including 7 leaks, 5 obstructions, and 1 intrahepatic biloma. Leaks leading to bile peritonitis were managed with simple suture and drainage and were related to the T-tube (4), to the Roux-en-Y loop (2), and to the transection margin of a RLG (1). Obstruction was documented in 5 cases with none associated with hepatic artery thrombosis (HAT). Stenosis after CC reconstruction (2) required conversion to CJ. Two patients had revision of CJ because of kinking of the common bile duct after a left lateral segment graft and an anastomotic stricture 46 months after OLT. The last patient developed a vanishing bile duct syndrome 4 months posttransplant and is awaiting retransplantation. One patient had multiple episodes of cholangitis after HAT and was retransplanted. Neither the type of grafts (RLG 25.9% v WLG 23.1%) nor the type of biliary reconstruction (CC 25% v CJ 24%) influenced the rate of biliary complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Orthotopic liver transplantation in the presence of partial or total portal vein thrombosis: problems in diagnosis and management

From January 1989 to May 1992, 70 orthotopic liver transplantations (OLT) were performed in 69 patients, 53 of whom had cirrhosis (77%). Eleven patients (16%) had preoperative partial or total portal vein thrombosis (PVT). Ten of these patients had cirrhosis of various causes. PVT was total in three cases and partial in eight. Total PVT was detected preoperatively in all three cases. By contrast, partial PVT was diagnosed preoperatively in only three of the eight cases. In the five other cases of partial PVT, the obstruction was discovered intraoperatively during dissection of the portal vein. Surgical management of PVT consisted of phlebothrombectomy in ten cases followed by usual end-to-end portal anastomosis in nine cases and anastomosis of the graft's portal vein to the splenomesenteric confluence in one case. Atypical anastomosis of the graft's portal vein to a dilated choledocal vein was performed in one case of total PVT. There were no deaths or complications related to the presence of preoperative PVT or to its management. One patient died postoperatively of primary graft nonfunction at day 5. One patient had arterial thrombosis 3 months after OLT and was successfully retransplanted. Two patients died of recurrent carcinoma 3 and 7 months after OLT. Eight patients are alive 4 to 39 months after OLT. We conclude from this series that (1) the prevalence of preoperative PVT among patients transplanted for advanced cirrhosis may be high (19% of the cirrhotics in this series); (2) PVT is often partial and so difficult to diagnose preoperatively; (3) PVT, even when total, can be managed successfully during surgery and does not seem to affect survival.

Side-to-side cavo-cavostomy: a useful aid in "complicated" piggy-back liver transplantation

Piggy-back liver transplantation is a useful technical variant of orthotopic liver transplantation. Its success can, however, be compromised by severe stenosis or obstruction of the recipient's inferior vena cava at the level of the anastomosis. A technique is described--side-to-side cavocavostomy--to resolve this difficult intraoperative situation.

Endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations

OBJECTIVE

This study was undertaken to prospectively evaluate the efficacy and safety of endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations.

SUMMARY BACKGROUND DATA

Surgical therapy has been the traditional approach to large or unresolving biliary fistulas complicating liver transplantation. Although endoscopic management is rapidly becoming an acceptable alternative to surgery for the treatment of biliary fistulas complicating non-liver transplant hepatobiliary operations, it has received limited attention in the liver transplant setting.

METHODS

During a 15-month period, 146 adults underwent liver transplantation with biliary reconstruction by end-to-end choledochocholedochostomy over a T-tube. Inadvertent T-tube migration or intentional T-tube removal resulted in bile peritonitis in 18 patients. The patients were treated with a nasobiliary tube (n = 13), internal stent plus endoscopic sphincterotomy (n = 3), or internal stent alone (n = 2). Thirteen patients had a biliary fistula after other hepatobiliary operations and underwent endoscopic therapy during a similar period. All 13 had an endoscopic sphincterotomy with removal of obstructing stones when present (n = 6). Twelve patients also had stents placed. All patients were prospectively followed after hospital discharge and assessed for recurrent symptoms suggestive of biliary tract disease and procedure-related complications.

RESULTS

Endoscopic retrograde cholangiopancreatography (ERCP) identified a biliary fistula at the T-tube insertion site into the bile duct in all 18 liver transplant patients. Seventeen patients had resolution of their symptoms within 12 hours of therapy. The fistula sealed in 94.4%. In the other hepatobiliary operation group, ERCP demonstrated contrast extravasation from the biliary tree in 12 of 13. The biliary fistula closure rate was 92.3%. The endoscopic complication rate for the two groups was 3.2%. During a mean follow-up of 9 months, recurrent biliary tract complications occurred in 11.1% of the liver transplant group and 0% in the other hepatobiliary operation group (p > 0.05). The 30-day mortality rate was 0%.

CONCLUSIONS

The results of this study support the application of endoscopic management of biliary fistulas complicating orthotopic liver transplantation and other hepatobiliary operations. This approach was relatively safe and obviated the need for surgical intervention.

Liver transplantation for primary sclerosing cholangitis versus primary biliary cirrhosis: a comparison of complications and outcome

Primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC) are the most common cholestatic disorders in adulthood requiring hepatic transplantation. Although they run similar courses, they may have different problems before and after transplantation. The aim of this study was to compare pre- and post-transplant complications and outcomes in these two similar but distinct patient groups. One hundred and seventeen adult patients underwent liver transplantation at our institution over a 6 year period, including 19 with PSC and 20 with PBC. Pre-transplant there were no significant differences in age, liver biochemistry, haematology or Child-Pugh scores between the two groups. The mean duration of disease before transplant was longer in PSC patients (11.7 vs 6.5 years; P < 0.05). The prevalence of septic cholangitis was greater in PSC (58 vs 5%; P < 0.01) as was the requirement for surgical or radiological interventional procedures, excluding cholecystectomy (53 vs 0%; P < 0.01). At transplantation, four patients with PSC had previously unrecognized cholangiocarcinoma. In the pre-transplant period these four patients had uncontrolled biliary sepsis at the time of transplant vs five of 15 PSC patients without cholangiocarcinoma. Postoperatively, PSC patients had a greater prevalence of intra-abdominal sepsis requiring surgical or radiological intervention (42 vs 5%; P < 0.05). In comparison, patients with PBC had a high prevalence of skeletal complications (30 vs 10%; P < 0.05) particularly avascular necrosis (15 vs 0%). The prevalence of chronic rejection was similar in both groups (15%). Overall survival was higher in PBC patients (85 vs 63%; P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)