Early Outcomes of Liver Transplantation Using Donors After Circulatory Death in Patients With Hepatocellular Carcinoma: A Comparative Study

INTRODUCTION

Donation after circulatory death (DCD) has increased in the last decade, although a slight increase in surgical complications has been reported in liver transplantation (LT). Therefore, DCD is not overall recommended because it entails an added risk. However, DCD in selected patients shows acceptable results.

OBJECTIVE

The objective was to analyze the characteristics, early outcomes, and survival at 1 year post-LT from a single institute (January 2015 to May 2017).

MATERIALS AND METHODS

We included 18 DCD-LTs and compared them with a control group of 18 donation after brain death (DBD) LTs. We analyzed pre- and posttransplant variables related to donors, recipients, and intraoperative early outcomes within patients transplanted due to hepatocellular carcinoma (HCC). A descriptive analysis, Mann-Whitney U test, χ², or Fisher test was performed when appropriate, as well as multivariate analysis in case of statistical significance. A variable is considered as statistically significant when it reaches a value of P < .05.

RESULTS

In DBD, we found a lower length of stay in the intensive care unit before retrieval and a higher rate of alcoholism and diabetes mellitus, Model for End-Stage Liver Disease score, and Child B and C score (P < .05). Most of the DCD were originally from the same LT recipient center, and a higher donor mean post-LT alanine aminotransferase level was found (P < .05). Survival for the DBD group was 88% and 75% in the DCD group at 1 year post-LT, being not significant (NS).

CONCLUSION

HCC recipients who are transplanted with good quality DCD livers do no worse than those transplanted with livers from DBD donors, although a good selection of them is crucial.

Molecular Adsorbent Recirculating System Treatment Can Reduce Blood Levels of N-Acetylcysteine in Patients With Acetaminophen Overdose: Case Reports

BACKGROUND

Acetaminophen poisoning continues to be a major cause of liver failure that can lead to liver transplantation. N-acetylcysteine (NAC) is the cornerstone of treatment. Some authors use a Molecular Adsorbent Recirculating System (MARS) system in acetaminophen poisoning. It is reported that the MARS system eliminates acetaminophen more efficiently than conventional dialysis. It is theoretically possible that treatment with MARS administered after NAC will increase the effectiveness of treatment.

CASE REPORTS

The first patient, a woman of 14 years old, presented blood levels of 112 mg/dL 12 hours after ingestion of 15 g of acetaminophen. Treatment with NAC was initiated. At 17 and 23 hours after ingestion, blood levels were 23.5 μg/mL and 5.9 μg/mL, respectively. The second patient, a woman of 28 years old, presented blood levels of 115 mg/dL 4 hours after ingestion of 40 g of acetaminophen. Treatment with NAC was initiated. At 14 and 23 hours after ingestion, blood levels were 15.8 μg/mL and <2 μg/mL, respectively. In both patients, we performed MARS after completing treatment with NAC, and after the first session, blood levels were below the lower limit of detection (≤2 μg/mL).

DISCUSSION

The correct timing of MARS to avoid interactions with the administered dose of NAC in acetaminophen overdose is essential so as to not impair the effectiveness of this treatment. These considerations in the management of this entity help in the resolution of liver failure, thus avoiding the need for a liver transplant.

Liver transplantation for Klatskin's tumor: contraindicated, palliative, or indicated?

OBJECTIVE

Surgical resection is the only potential curative treatment for Klatskin's tumor. In the cases of Bismuth type IV, some authors have suggested performing liver transplantation (OLT). Our aim was to present our experience in the management of Klatskin's tumor, with special reference to patients undergoing OLT.

PATIENTS AND METHODS

Between May 1988 and December 2006, 66 patients were treated in our department for Klatskin's tumor, including 43 men and 23 women of overall mean age 66 years (range = 38 to 88). Twenty patients (group 1) were in operable and 46 patients underwent resection surgery (group 2), including 13 tumors considered unresectable (group 2a), with OLT contraindicated for disseminated tumor; tumor resection was possible in 23 cases (group 2b) and the remaining 10 patients who were surgically unresectable but with nondisseminated neoplasm (by staging laparotomy) underwent OLT (group 2c). The mean waiting time for OLT was 2 months (range = 1 to 4 months).

RESULTS

The mean survival rates of the group 1 and 2a patients was 6 +/- 2 months and 8 +/- 2 months, respectively. Of the 23 resected patients, the 1-, 3-, and 5-year survivals were 84%, 59%, and 40%. The 1-, 3-, and 5-year survival of OLT was 80%, 60%, and 37%, respectively. Among the 10 transplanted patients, six died due to tumor recurrence at 46, 43, 19, 16, 12, and 12 months. The remaining four patients are alive and tumor-free at 120, 89, 68, and 29 months, respectively.

CONCLUSIONS

A more accurate preoperative staging, perhaps by systematic use of pre-OLT laparotomy, and the use of adjuvant, and most importantly neoadjuvant therapy may improve the results of OLT in Klatskin's tumor.

Study of Fas (CD95) and FasL (CD178) polymorphisms in liver transplant recipients

The Fas receptor is capable of transducing apoptotic cell death upon interaction with their ligand (FasL). Recent studies suggest that the Fas/FasL system is involved both in graft rejection and in transplantation tolerance. In this study, we analyzed the effect of Fas and FasL polymorphisms in liver allograft outcome. Fas and FasL polymorphisms were analyzed in 151 primary liver graft recipients. The Fas (-670 A/G) and the FasL (IVS2nt -124 A/G and IVS3nt 169 T/delT) polymorphisms were analyzed by polymerase chain reaction-restriction fragment length polymorphism. Fas -1377 G/A polymorphism was determined by allele-specific amplification. Fas and FasL polymorphisms were not associated with acute and chronic rejection in liver transplant. In contrast, those recipients bearing the AA -670 Fas genotype showed significantly lower graft survival rate (S = 40%) than those bearing the GA genotype (S = 63.1%). These differences were detected from the first year post-transplant. Multivariate analysis confirmed that the AA genotype increased the risk of liver graft loss. This work suggests for the first time a possible harmful effect of Fas -670 AA genotype on liver graft survival, whereas the Fas and FasL polymorphisms are not associated with acute or chronic rejection in liver graft recipients.

Emergency Organ Transplantation in Spain: Liver Emergency and Outcomes

The 2 main indications for emergency liver transplantation are severe acute hepatic insufficiency and emergency retransplantation. In Spain, since the creation of the National Transplant Organisation (NTO), known as "the Spanish model," there have been high rates of donation, with a mean of 33.9 donors per million inhabitants in 2003 and 34.6 donors per million inhabitants in 2004. According to data provided by the NTO, there were 169 liver emergencies in the 2-year period 2003-2004. The time on the waiting list in an emergency situation was limited; 82.8% of cases were resolved in less than 48 hours. During this 2-year period, there were 2077 liver transplantations, including 128 emergence patients, which accounted for 6.1% of transplantations.

Long-term results of liver transplantation in four siblings from the same family with familial amyloidotic polyneuropathy type I TTR Ala-71

Familial amyloidotic polyneuropathy type I (FAP I) is a hereditary systemic amyloidosis usually involving the peripheral nervous system. In this paper we report our experience regarding the survival and the evolution of the sensory motor syndrome of the extremities and autonomic dysfunction in four siblings with the Ala-71 variant who were treated by liver transplantation (LT). The four siblings are alive 2-5 years after LT. After the operation, the seriated determinations of TTR-Ala-71 variant showed a constant decrease in serum levels in all cases. Our results support the proposal that LT should be indicated especially in forms with early clinical onset (3rd and 4th decades) and rapid progress to stop the neurological deterioration of the patients.

Use of bile cytology for early diagnosis of complications in orthotopic liver transplantation

We conducted a daily analysis of bile cellularity in 25 patients undergoing 29 orthotopic liver transplants (OLT) and correlated the cytological parameters with the clinical outcome of each patient. The 16 patients without complications only showed slides with cells during the first 4-5 postoperative days. The four patients with primary non-function (PNF) of the graft had a high cell density up to the time of the retransplant, with a preponderance of polymorphonuclear (PMN) leucocytes (59.2%) and epithelial cells (29.2%). During the episodes of sepsis (n = 3) and rejection (n = 7) we noted the sudden appearance of high cellularity, almost exclusively PMN leucocytes (96.5%), and a preponderance of PMN leucocytes (84.2%) with appreciable percentages of mononuclear cells and macrophages as well as the early appearance of lymphoblasts in the rejection episodes. Our results show that bile cytology can be a useful method for diagnosing graft complications in liver transplantation.

Laparoscopic vs. open cholecystectomy in patients aged 65 and older

Laparoscopic cholecystectomy (LC) has displaced open cholecystectomy (OC) in the management of cholelithiasis. However, there are few studies on the role of this technique in patients who run a high risk of surgical complications. We performed a prospective study in 264 patients aged >65 years undergoing surgery for symptomatic cholelithiasis. They were divided into two groups according to the surgical technique performed: OC (131 patients) and LC (133 patients). Conversion from LC to OC was necessary in 11 patients (8.3%). Mean surgery time was 70.9 min for the OC group and 75 min for the LC group. The LC group had a lower rate of postoperative complications (13.53%) than the OC group (23.6%). The incidence of mild complications was similar in both groups; however, the rate of moderate complications was significantly higher in the OC group. Hospital stay was significantly longer in the OC group (9.9 days) than in the LC group (3.71 days). These results suggest that LC should be indicated in elderly patients, as they are better than those obtained with with OC and involve a lower morbidity rate and shorter hospital stay.

Prognostic factors in primary gastrointestinal non-Hodgkin's lymphoma: a multivariate analysis of 76 cases

OBJECTIVE

To present our experience with the treatment of primary gastrointestinal (GI) non-Hodgkin's lymphoma, evaluate prognostic factors, and give our recommendations for treatment.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Spain.

SUBJECTS

76 patients (47 men and 29 women, mean age 51 years) treated over the 15 years 1980-1994.

INTERVENTIONS

52 patients had radical resections, 19 palliative resections, and 5 biopsy alone. 42 (55%) also had adjuvant chemotherapy and 20 (26%) radiotherapy.

RESULTS

Patients with primary intestinal lymphoma were slightly but not significantly younger than those with gastric lymphoma (43 compared with 56 years). 43 Patients (57%) had tumours in the stomach, 26 (34%) in the small bowel, and 7 (9%) in the colon. At presentation 34 had stage I disease, 25 stage IIE1 disease, and the remaining 17 stage IIE2; 14 were classified as low grade, 41 as intermediate, and 21 as high grade. 60 (79%) had a B-cell phenotype. Overall 5-year survival was 53%. Of the 11 variables tested by univariate analysis for their prognostic effect only abdominal mass (p < 0.001), clinical stage (p < 0.001), type of operation (p < 0.001), tumour size (p < 0.05), and histological grade (p < 0.05) achieved significance, but when Cox's multivariate analysis was applied only clinical stage was significant (p < 0.01).

CONCLUSION

Operation is the treatment of choice, but chemotherapy and radiotherapy may have a role though as yet there are no standard guidelines for their use.

Effects of cold ischemia time on the graft after orthotopic liver transplantation. A bile cytological study

We conducted a daily analysis of bile cellularity in 16 orthotopic liver transplant patients fitted with a T-tube, and correlated the cytological parameters (number of cells per slide, and percentage of difference cell types) with the duration of cold ischemia time (CIT). Two groups were established: one comprised patients whose CIT was less than 7 hr (CIT averaged 345 min) and the other comprised patients with a CIT of more than 7 hr (CIT averaged 505 min). The control group consisted of 15 patients who had received cholecystectomy for biliary lithiasis and were fitted with a T-tube. All 3 groups showed the highest cell density on the 1st postoperative day (control: 53.3 +/- 15.5 cells/slide; short ischemia: 70 +/0 21.4 cells/slide; long ischemia: 158.8 +/- 53.2 cells/slide), which steadily ischemia group showed a higher cell density than did the control group for the first 2 days, although this was not significant. The long ischemia group showed the highest cell density, although only significantly for the first 2 days when compared with the controls, and basically at the expense of a increase in ductal epithelial cells. Our results show that prolonged cold ischemia causes an increase in bile cell density at the expense of ductal epithelial cells: the longer the preservation time, the greater the increase.

Laparoscopic surgery in the management of traumatic hemoperitoneum in stable patients

Unnecessary laparotomies in patients with abdominal traumatism (AT) who present hemoperitoneum with stable hemodynamics may be avoided if a diagnostic/therapeutic laparoscopy is performed. Between July 1992 and December 1994, 24 patients with AT and hemoperitoneum underwent this exploration: 5 were found to have a large retroperitoneal hematoma; 2, a tear in the intestinal mesenterium; 4, hepatic injuries; and 13, splenic lesions. Of the 24 patients, 9 needed conversion to open exploration: 8 during the laparoscopy and 1 shortly after operation. Mean hospital stay was 7 days (5-9). There was no morbidity or mortality in the series. Diagnostic/therapeutic laparoscopy is a method that is efficient and economical and can easily be undertaken by surgeons with experience in laparoscopy; it may be a valid alternative to conservative treatment or laparotomy in AT and hemoperitoneum patients who are hemodynamically stable.

Laparoscopic cholecystectomy in the treatment of acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy has several advantages over traditional cholecystectomy, which make it the treatment of choice for patients with uncomplicated biliary lithiasis. However, in patients with acute cholecystitis, the role of this technique remains controversial and some clinicians regard this condition as a contraindication to laparoscopic cholecystectomy.

STUDY DESIGN

Between June, 1991 and July, 1993, a total of 259 patients with cholelithiasis underwent laparoscopic cholecystectomy at the "Virgen de la Arrixaca" University Hospital. Of these patients, 60 underwent laparoscopic cholecystectomy for acute cholecystitis.

RESULTS

Conversion to laparotomy was necessary in eight patients (13 percent). Mean operating time was 83 minutes (range, 45 to 180 minutes). Overall mean hospital stay (laparoscopy and conversions) was 3.1 days (range, one to nine days). There was no mortality or injury to the common bile duct in our series.

CONCLUSIONS

We believe that laparoscopic cholecystectomy in patients with acute cholecystitis is a safe and effective procedure, in which the patient can benefit from the advantages of laparoscopic surgery without an increase in mortality and morbidity rates.