Hepatic artery reconstruction prior to orthotopic liver transplantation

BACKGROUND

This study examines the types of arterial reconstruction for grafts prepared for orthotopic transplantation procedures.

METHODS

Between 1993 and February 2003, 200 organs were harvested for orthotopic liver transplantation. Arterial variations were found in 28 cases (14%), among which 16 cases (8%) required vascular reconstruction with 4 cases due to accidentally damaged during liver harvesting.

RESULTS

Among the 200 organs harvested for liver transplantation, arterial variations requiring reconstruction were found in 12 cases (6%); these included: replacing an accessory left hepatic artery from the left gastric artery (9/1 reconstruction); replacing an accessory left hepatic artery from the upper mesenteric artery (2/1 reconstruction), and replacing an accessory right hepatic artery from the upper mesenteric artery (10/10 reconstructions). The splenic artery was typically used for anastomosis (seven cases, 58.3%) as well as the gastroduodenal artery (two cases, 16.7%) or the right gastric artery (one case, 8.3%). In the remaining two cases, a more complex technique was required.

CONCLUSIONS

Reconstruction of graft vessels before an orthotopic liver transplantation procedure does not increase the risk of vascular complications.

Comparison of the results of liver transplantation for elective versus urgent indications

The authors present an analysis of early and remote liver transplantation outcomes related to the presence of emergent indications among 196 of the 209 operations performed from 1989 to April 2003; namely 178 elective and 18 emergent transplantations. Perioperative mortality was 15%. The survival rate during the first 12 months was 79.8% and within 3 years 73.5% among patients operated on an elective basis (UNOS 3 and 2B). In contrast, patients with acute liver failure (UNOS 1 and 2A) showed rates of 45%, 50%, and 47%, respectively. Liver transplant outcomes depend primarily on the urgency of an operation. Longterm results are much better among patients operated on electively. Liver transplantation in patients with acute hepatic insufficiency is burdened with a high 45% mortality.

Assessment of early biliary complications after orthotopic liver transplantation and their relationship to the technique of biliary reconstruction

INTRODUCTION

Biliary complications are known as the weak point of liver transplantation. Their occurrence can be related to the practice of drainage of the biliary anastomosis, the routine use of which was abandoned in June 2004. The aim of the study was to assess the incidence and type of biliary complications following orthotopic liver transplantation in relation to the technique of biliary anastomosis.

MATERIAL AND METHODS

We compared the results of two groups of adult liver transplant recipients: group I, recent 50 transplantations with biliary drainage (25 women: 25 men of age range: 17 to 63 years), and group II, first 50 transplantations without drainage (19 women and 31 men of age range, 20 to 65 years). We examined the problem of biliary complications and their influence on the further management of the patients. In both groups the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In the majority of cases (n = 86) an end-to-end common bile duct anastomosis was performed and in 14 cases, hepaticojejunal anastomosis.

RESULTS

In group I, biliary complications requiring surgical or endoscopic intervention occurred in 10 (20%) recipients. In one case, biliary complications resulted in the need for retransplantation. In group II, biliary complications occurred in only four (8%) patients, none of which caused organ loss.

CONCLUSION

Cessation of biliary anastomosis drainage has reduced the occurrence of early biliary complications following orthotopic liver transplantation.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

Biochemical assessment of the early liver graft function in relation to selected donor parameters

The aim of this study was to assess the usefulness of liver grafts procured from "marginal donors." Among 62 liver transplants in 2002, almost half were harvested from donors who were not deemed acceptable by other transplant units. The authors compared the data concerning the donor's status with the function of the transplanted liver. The relations between individual parameters were estimated, as well as the differences between two groups of recipients: those who received a graft from the "poorer" donors versus those who received "better" grafts. Regardless of the relations between particular parameters a statistical analysis revealed that differences of liver function that were detected during the first 5 days after transplantation disappeared thereafter.

Bile duct variations in partial liver transplantations from living-related donors

The aim of this paper was to present anatomic variations of bile ducts and their effect on the perioperative course of living-related donors in partial liver transplantations in children. Liver fragments for partial transplantation were harvested from 41 related donors. Segments II and III were harvested from 35 and segments II, III, and IV from 6 donors. During the procedure, cholangiography through cystic duct was performed revealing a normal anatomy of the bile ducts in 33 (80.5%) cases. The rest of the donors showed anatomic variations. There was only one case of complications related to the bile duct. The intraoperative diagnosis of anatomic variations allowed for safe partial liver harvesting.

Evaluation of Donor’s Liver Regeneration After Left Lobe Harvesting for Living-Related Liver Transplantation

BACKGROUND

Computerized tomography-assisted volumetry permits one to estimate the volume of the liver graft as well as to monitor the regeneration in the donor for living- related liver transplantation (LRLT).

METHODS

The size of the whole liver and of the segments II, III, and IV was assessed in 64 living-related liver donors by preoperative computerized tomography (CT) volumetry. Segments II and III were harvested in 56 cases; segments II, III, and IV in 8 cases. The remnant liver was assessed by CT volumetry on postoperative days 7 and 30.

RESULTS

There was a linear correlation between the calculated volume of the graft and its weight (R = 0.61, P < .04). Postoperative CT volumetry of the liver from a living-related donor showed a different pattern of volume restoration (regeneration index) both at 7 and 30 days among donors who sacrificed segments II and III versus segments II, III, and IV. The mean regeneration indices were significantly higher among donors of segments II, III, and IV compared with donors of segments II and III after 7 and 30 days (P < .05).

DISCUSSION

It is possible that the donor liver displays a different pattern of growth due to the alteration in the blood supply to segment IV.

The gentamicin-collagen implant and the risk of distant metastases of rectal cancer following short-course radiotherapy and curative resection: the long-term outcomes of a randomized study

PURPOSE

A previous randomized study conducted by our group showed that application of gentamicin-collagen implant (GCI) into the pelvic cavity after total mesorectal excision (TME) reduced the incidence of distant metastases. Therefore, we decided to conduct a confirmatory study.

METHODS

Patients with rectal cancer were included in the study if they met the following criteria: adenocarcinoma of the rectum, preoperative short-term radiotherapy (5 × 5 Gy), and WHO performance score 0-1.

RESULTS

One hundred seventy-six patients were randomly assigned either to an experimental group in which GCI was applied (n = 81) or to a control group without GCI (n = 81). Median follow-up was 80 months. Cumulative incidence of distant metastases at 5 years was higher in the control group compared to the experimental group: 23.5 vs 8.6% (HR 2.4 [95% CI 1.1-5.5], P = 0.005). Overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) did not differ between the experimental group and the control group: HR 0.95 [95% CI 0.55-1.70], P = 0.864; HR 0.85 [95% CI 0.50-1.45], P = 0.548, and HR 0.5 [95%CI 0.22-1.22], P = 0.093, respectively. The predefined by the protocol subgroup analysis for yp stage III disease showed better DFS in the experimental group compared to the control group; HR 0.47 [95%CI 0.23-0.97], P = 0.042).

CONCLUSIONS

The results confirmed our previous finding that GCI applied in the pelvis significantly reduced the rate of distant metastases in patients after radical rectal cancer resection.

Long noncoding RNA CCAT1 rs67085638 SNP contribution to the progression of gastric cancer in a Polish population

The role of the long noncoding RNA CCAT1 NC_000008.10:g.128220661C > T (rs67085638) in the development of colon cancer has been reported. Therefore, we assessed the prevalence of rs67085638 in patients with gastric cancer (GC). We also evaluated the effect of rs67085638 on B-cell-specific Moloney leukaemia virus insertion site 1 (BMI1) transcripts in primary GC and counterpart histopathologically confirmed disease-free margin tissue. Using high-resolution melting analysis, we evaluated rs67085638 frequency in patients with the GC genotype (n = 214) and controls (n = 502) in a Polish Caucasian population. qRT-PCR was used to determine BMI1 transcripts. We observed the trend of rs67085638 association in all patients with GC (p_trend = 0.028), a strong risk of the GC genotype in male (p_trend = 0.035) but not female (p_trend = 0.747) patients, and the association with non-cardia GC (p_trend = 0.041), tumour stages T3 (p_trend = 0.014) and T4 (p_trend = 0.032), differentiation grading G3 (p_trend = 0.009), lymph node metastasis stage N3 (p_trend = 0.0005) and metastasis stage M0 (p_trend = 0.027). We found that significantly increased BMI1 transcripts were associated with the primary GC genotype classified as grade G3 (p = 0.011) and as lymph node metastasis N3 (p = 0.010) and counterpart marginal tissues (p = 0.026, p = 0.040, respectively) from carriers of the T/T versus C/C genotypes. rs67085638 may contribute to increased BMI1 transcripts and the progression and rapid growth of GC.

Liver transplantation in hepatitis C virus–related cirrhosis

End-stage liver disease associated with HCV infection has become one of the leading indications for liver transplantation and it is the most common disease recurring after liver transplantation. The aim of this retrospective study was to asses factors potentially affecting outcome in patients transplanted for HCV-related liver disease. Among 164 adult patients who underwent orthotopic liver transplantation from December 1994 to December 2002, 134 survived >2 months, including 25 with HCV-related liver disease. Mean follow-up after LTx was 24.8 months (range, 2.1-99.4). Anti-HCV was negative in all donors. The parameters considered in our analysis were: the course, outcome, and liver function tests at 1-year follow-up after HCV reinfection: the potential impact of maintenance and induction immunosuppressive regimens; and episodes of acute rejection. Deterioration of graft function because of HCV reinfection occurred in 16 patients (64%). Mean time for deterioration of liver function related to reinfection was 4.5 months (range, 0.83-23). Induction and maintenance immunosuppression did not affect outcome of HCV-infected liver transplant recipients. Aminotransferases were significantly higher among HCV-infected recipients than among the other patients in our series. There was a slight tendency for earlier recurrence of HCV hepatitis among patients treated with high-dose steroids because of acute rejection.

Anatomical alteration of the vascular tree observed during living related liver transplantation

INTRODUCTION

The number of available cadaveric donor organs has reached a plateau. One current solution has been to increase number of living related liver transplantations.

MATERIAL AND METHODS

Since October 1999 in the Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 40 living related liver transplantation have been carried out.

RESULTS

In 31 (77.5%) cases, a normal arterial supply was observed: the common hepatic artery arose from a celiac trunk. In two cases (5.0%), there was a partial arterial blood supply by the right accessory hepatic artery originating from the superior mesenteric artery. In two cases (5.0%), a right hepatic artery arose completely from the superior mesenteric artery (replaced artery). In one case (2.5%), a common hepatic artery originated from the superior mesenteric artery. In two cases (5.0%), an accessory left segmental artery originated from the left gastric artery. In two cases (5.0%), the function of an absent left hepatic artery was assumed by a replaced left hepatic artery originating from the left gastric artery. In two (5.0%) cases, there were two separate ducts draining the right hemiliver. There were two (5.0%) cases of an accessory duct draining segment IV, originating within the confluence of the right and left hepatic ducts. In one (2.5%) case, the common hepatic duct showed a trifurcation.

CONCLUSION

During harvesting from a living donor knowledge of anatomical variants must be used to optomize the liver graft.

Liver regeneration in living-related donors after harvesting of liver segments II and III or II, III and IV

BACKGROUND

CT-assisted volumetry permits an estimation of the volume of the graft in liver transplantation, as well as monitoring the donor's liver regeneration. The aim of the study was to observe the restitution of liver tissue in donors after harvesting of the liver fragment for living-related liver transplantation (LRLT).

METHODS

The size of the whole liver and of segments II, III and IV was assessed by preoperative CT volumetry in 29 living-related liver donors. Segments II and III were harvested in 22 patients, segments II, III and IV in 6 patients. The remnant liver was assessed by CT volumetry on the 7th and 30th postoperative days.

RESULTS

The correlation between the calculated volume of the graft and its weight was linear (r=0.56, p<0.04). Postoperative CT volumetry of the liver of living-related donors showed a different pattern of volume restoration (regeneration index) at both 7 and 30 days between donors who sacrificed segments II and III and those who sacrificed segments II, III and IV. The mean regeneration indexes were significantly higher in donors of segments II, III and IV as compared with donors of segments II and III (7 days, p<0.02; 30 days, p<0.05).

DISCUSSION

It is possible that the donor's liver displays a different pattern of growth due to the alteration in blood supply to segment IV.

Results of liver transplantation for hepatocellular cancer

BACKGROUND

Liver transplantation (LTx) for hepatocellular carcinoma (HCC) in cirrhotic liver is nowadays generally accepted treatment modality.

AIM OF STUDY

Overview of the indications and results of the LTx in the patients with HCC, the first one performed in 2001.

MATERIAL/METHODS

Among 357 adult liver transplant recipients in the period 1994-04.2005, in 26 (7%) the indication was HCC (16 men: 10 women, age 20-65, mean 46.5 years). HCC developed in cirrhotic liver in 25 pts. 12 (48%) were Child C, 10 (30%)--Child B and 3 (12%)--Child A patients. As underlying disease in 2 patients (8%) was alcoholic cirrhosis, in 7 (28%)--HBV cirrhosis, in 12 (48%)--HCV cirrhosis and in 4 (16%)--HBV/HCV cirrhosis. Milano criteria were met in 20 patients (77%). The mean waiting list time was 2.9 months (range 1-6 months). Seven patients underwent liver resection and 1 transarterial chemoembolization prior to LTx. 11 patients (42%) were operated on with use of veno-venous bypass, in 15 patients (58%) the piggy back technique was applied. Rapamycine based immunosuppression was preferred in post-LTx treatment.

RESULTS

Operative mortality was 0.4 patients required relaparotomy for intraperitoneal bleeding. 21 patients (81%) are alive in good general condition, 19--free of the disease. 5 patients died 7-28 months after LTx (mean 16.7). The mean survival time is 20 months (range 1-38).

CONCLUSIONS

Liver transplantation is safe and effective method of treatment of the selected patients with HCC in cirrhotic liver. Further investigations concerning the precise indications, timing of the transplantation and adjuvant treatment are necessary.

[Amanita phalloides poisoning as an indication for liver transplantation in three family members]

Amanita phalloides poisoning is one of the most dramatic medical invents. The course of the illness may vary from mild to the lethal, with signs of fulminant liver insufficiency with coma and multiorgan failure. When hepatic encephalopathy (III/IV degrees) occurs the prognosis is very poor. In definite cases the liver transplantation is necessary. The authors present severe Amanita phalloides poisoning in three family members, who due to fulminant hepatic failure underwent liver transplantation. The two of them (son and father) transplanted accordingly in fifth and seventh day after poisoning, survived. Mother, in whom transplantation started in ninth day after poisoning, died intraoperativel with signs of massive hemorrhage, and cardiac arrest.

Assessment of early graft function in relation to different preservation fluids--preliminary results

The parameters of transplanted liver functions were exposed to a retrospective analysis during the past year. A group of 51 patients out of 223 were thoroughly examined, all of them having undergone orthotopic liver transplant in Department of General, Transplant and Liver Surgery, Medical University of Warsaw until 1.09.2003. With transplants, two types of preservation fluids: UW (Viaspan) and Celsior were used alternatively. Liver function was assessed on the basis of the clinical feature and biochemical data. The results obtained were statistically verified. The way of fluid perfusion during the operation and the rinsing effectiveness were also evaluated, additionally the level of marked K during the reperfusion was checked. There were no statistically significant differences noticeable between both groups of recipients. Among all the liver and kidneys effectiveness parameters assessed with the recipients after OLTx, the considerable difference statistically, was visible only with the levels of AspAt, AlAt, INR and APTT during the first days and nights after the operations. Later the difference was gradually disappearing. However, in accordance with the harvesting teams' opinions, the usage of Celsior, owing to lower viscosity, allowed for faster and more exact blood rinsing from a vascular bed of the organ transplanted. The organ's even penetration was also possible. The lack of necessity to use additional stabilizers also simplified radically the harvesting technique. Celsior--the preservation fluid used in the authors' clinic meets all the requirements necessary to efficacious preservation and storage of a to be transplanted liver.

Results of liver transplantation in the Department of General, Transplant and Liver Surgery at the Medical University of Warsaw in patients with chronic hepatitis B and C viruses infection

INTRODUCTION

Cirrhosis related to hepatitis C virus (HCV) and hepatitis B virus (HBV) infection is the most frequent indication for liver transplantation worldwide. Progress in prophylaxis of posttransplant HBV recurrence has led to major improvements in long-term outcomes of patients after liver transplantation. Conversely, impaired posttransplant survival of patients with HCV infection was reported in several studies, mainly due to recurrence of viral infection. The purpose of this study was to compare long-term results of liver transplantation between patients with HBV monoinfection, HCV monoinfection and HBV/HCV coinfection.

MATERIAL AND METHODS

A total of 1090 liver transplantations were performed in the Department of General, Transplant and Liver Surgery in cooperation with the Department of Immunology, Internal Medicine, and Transplantology at the Transplantation Institute Medical University of Warsaw between December 1994 and May 2012. After exclusion of patients with cirrhosis of non-viral etiology, patients with malignant tumors, and patients with acute liver failure, the final study cohort comprised 209 patients with HBV (HBV+/HCV- subgroup; n = 56) or HCV (HBV-/HCV+ subgroup; n = 119) monoinfection or HBV/HCV coinfection (HBV+/HCV+; n = 34). These subgroups of patients were compared in terms of long-term results of transplantations, defined by 5-year patient and 5-year graft survival estimates.

RESULTS

Overall and graft survival rates after 5-years for the whole study cohort were 74.5% and 72.6%, respectively. Five-year overall survival was 70.4% for patients within the HBV+/HCV- subgroup, 77.8% for patients within the HBV-/HCV+ subgroup, and 68.5% for patients within the HBV+/HCV+ subgroup. The corresponding rates of graft survival were 67.0%, 76.3%, and 68.5% for patients within the HBV+/HCV-, HBV-/ HCV+, and HBV+/HCV+ subgroups, respectively. Observed differences were non-significant, both in terms of overall (p = 0.472) and graft (p = 0.461) survival rates.

CONCLUSIONS

Both overall and graft survival rates after liver transplantations performed in the Department of General, Transplant and Liver Surgery in cooperation with the Department of Immunology, Internal Medicine, and Transplantology at the Transplantation Institute Medical University of Warsaw in patients with HBV and HCV infection are comparable to those reported by other European and American centers. In contrast to other studies, obtained results do not confirm the negative impact of HCV infection on long-term outcomes of patients.

Harvesting liver fragments from living-related donors: a single-center experience

The aim of the study was to estimate the risk of harvesting a liver fragment from a living-related adult donor. Liver fragments were harvested from 44 donors. Liver segments II and III were harvested from 36 donors. Liver segments II, III, IV were harvested from 6 donors, 2 donors gave segments V, VI, VII, and VIII. After preliminary donor selection volumetric assessment of liver segments by computed tomography and arteriography was performed to visualize the cenac trunk and superior mesenteric artery. None of the donors died. No complications were observed during the operation. Only one case, a bile collection, was observed after surgery. We treated this patient with a satisfactory result by sonography-guided drainage. We observed temporary elevation of bilirubin and transaminase levels and a decrease in prothrombin index value. Blood transfusion was not necessary during any of the procedures. Mean hospitalization time after the surgery was 9.4 days. Mean graft weight/recipient weight ratio was 2.54%. The risk of the harvesting liver fragment from a living-related adult donor seems to be minimal.

Small bowel transplantation--harvesting technique and graft preparation in pigs

BACKGROUND

In more and more frequently occurring short bowel syndrome, requiring total parenteral nutrition therapy, the complications of the latter not seldom prevent its use. The idea of treating these patients with small bowel transplantation pushed the authors to start the program aiming at development of small bowel harvesting, preservation and transplantation technique in experimental settings. Additionally, an attempt to find which, if any, and to what extent, histological changes of the preserved bowel may be of prognostic value for the early transplant failure.

MATERIAL/METHODS

The experiment was carried out on 20 pigs. Two distinct techniques, corresponding to two clinical circumstances in humans, were tested. In the first group of animals, the small bowel was harvested during a model of multivisceral operation, corresponding to the organ harvesting from a brain-dead donor. In the remaining pigs, an isolated segment of the small bowel was explanted, constituting a model of a living related donor surgery. All small bowels were preserved in hypothermia, in Celsior preserving solution for a different, predefined period. During 16 procedures, the harvested small bowel segment was replanted in the same donor, using different vascular anastomotic techniques.

RESULTS

Vascular thrombosis was significantly more frequent in grafts anastomosed by end-to-side technique, as well as in more proximal bowel segments, regardless the anastomotic technique. Following two hours of reimplantation, excised bowel segments did not demonstrate significant differences on histological examination, as compared to the hypothermia-preserved segments (from the same donor) of the same age from primary excision. In most cases, the increase of mucosal damage with preservation time was observed, although statistical significance was reached only for the presence of erosions and necrotic lesions.

CONCLUSIONS

On the basis of this experiment one may state, that an ileal graft, assuring the long vascular pedicle (derived from ileocolic vessels) and vascular end-to-end anastomoses are at lesser risk of early vascular thrombosis. While applying the presented technique of purging the graft and its preservation, the act of transplantation itself practically does not influence the histological structure of the bowel, thus is not related to the early graft failure which seems to depend, to the greatest extent, upon the technical aspects of the procedure.

Safety of living donor in pediatric liver transplantation--analysis of 100 consecutive donors

BACKGROUND/AIM

The aim of this study was to evaluate safety of donors of liver fragments of different size and regeneration of the remaining liver.

METHODOLOGY

Between October 1999 and January 2007 liver segments II and III were harvested from 90 donors and segments II, III and IV from 10 donors. Liver volumetry by computed tomography (CT) and biochemical liver function tests were performed at baseline and 7 days, 30 days and 12 months after the operation.

RESULTS

CT-assisted volumetry correlated with mass of harvested graft (r=0.779; p<0.05). Twelve months after resection mean regeneration index was 138.64% +/- 23.98% in donors of segments II, III and IV and 109.93% +/- 18.36% in donors of segments II and III (p<0.02). Transient elevation of bilirubin and trans-aminases and decreased prothrombin index were observed in the early postoperative period. Twelve months after the operation mean levels of these parameters were within normal limits. No deaths and no severe complications were observed during the follow-up.

CONCLUSIONS

CT-assisted volumetry permits an adequate estimation of liver fragments intended for harvesting. Harvesting of II and III or II, III and IV segments does not compromise donor's safety. Liver regeneration is significantly greater after harvesting of II, III and IV segments than that of II and III segments.