[Show abstract][Hide abstract] ABSTRACT: Background Preoperative locoregional treatments (PLT) are performed to avoid progression before liver transplantation for hepatocellular carcinoma (HCC). The objective of this study was to analyze the prognostic factors affecting the outcome in patients who received PLT. Material and Methods A retrospective analysis of patients who underwent liver transplantation (LT) was performed. All patients who underwent PLT with confirmed pathological diagnosis of HCC were included. The rate of tumor necrosis (TN) was assessed by microscopic histological examination. Results From January 1997 to December 2010, PLT was performed in 154 patients ROC analysis individuated a TN cut-off value at 40%. Ninety-one patients (59.1%) of the patients presented TN>40%. At multivariate analysis, TN<40% (HR=1.76; p=0.04) and vascular invasion (VI) (HR=2.16; p<0.01) were associated with lower Overall Survival (OS). At multivariate analysis, TN<40% (HR=1.59; p=0.001) and VI (HR=2.51; p=0.001) were significant associated with lower Disease Free Survival (DFS). One, 3 and 5 years OS was 87.9%, 82.0% and 69.1% for patients with TN>40% and 82.5%, 64.2% and 53.2% for those with TN<40% (p=0.02). Tumour size <5 cm (p=0.02); age <55 years (p=0.02); absence of VI (p=0.02) and multiple procedures (p=0.04) were predictive factors for TN>40%. Conclusions Response to preoperative locoregional treatment can be used as potential selection criteria for LT.
Annals of transplantation : quarterly of the Polish Transplantation Society. 01/2013; 18:273-84.
[Show abstract][Hide abstract] ABSTRACT: Hepatocellular carcinoma (HCC) is an indication for liver resection or transplantation (LT). In most centers, patients whose HCC meets the Milan criteria are considered for LT. The first objective of this study was to analyze whether there is a correlation between the pathologic characteristics of the tumor, survival and recurrence rate. Second, we focused our attention on vascular invasion (VI).
From January 1997 to December 2007, a total of 196 patients who had a preoperative diagnosis of HCC were included. The selection criteria for LT satisfied both the Milan and the San Francisco criteria (UCSF). Demographic, clinical, and pathologic information were recorded.
HCC was confirmed in 168 patients (85.7%). The median follow-up was 74 months. The pathologic findings showed that 106 patients (54.1%) satisfied the Milan criteria, 134 (68.4%) the UCSF criteria of whom 28 (14.3%) were beyond the Milan criteria but within the UCSF criteria, and 34 (17.3%) beyond the UCSF criteria. VI was detected in 41 patients (24%). The 1-, 3-, and 5-year overall survival rates were 90%, 85%, and 77%, respectively, according to the Milan criteria and 90%, 83%, and 76%, respectively, according to the UCSF criteria (P = NS). In univariate and multivariate analyses, tumor size and VI were significant prognostic factors affecting survival (P < 0.001). Two factors were significantly associated with VI: alfa-fetoprotein level of >400 ng/ml and tumor grade G3.
Tumor size and VI were the only significant prognostic factors affecting survival of HCC patients. Primary liver resection could be a potential selection treatment before LT.
Annals of Surgical Oncology 12/2011; 19(6):2020-6. · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this 11-year cohort retrospective study conducted in adult patients with chronic hepatitis C virus (HCV) who underwent liver transplantation (LT) was to identify whether human leukocyte antigen (HLA) mismatching is associated with the recurrence of HCV and with the time to recurrence of HCV.
Among the 181 patients (74% men; mean age: 54 years, range 25-71) who underwent a LT between 1995 and 2006 in the study center, 163 had relevant data in their medical chart documenting HCV recurrence, and 107 (65.64%) reported a histological evidence of HCV recurrence.
Survival was 78% at 5 years. There was no significant relationship between the total score of HLA-mismatches and the recurrence of HCV. Similarly, there was no significant relationship between the total score of HLA mismatches and the time to recurrence of HCV. For the analyses at each individual locus, a significant relationship between the individual scores of HLA-mismatches and the recurrence of HCV were observed. Out of the 40 patients who experienced a rejection, the rate of recurrence was not different according to the severity of the rejection (75% mild, 64% moderate and 64% for severe rejection).
In conclusion, this large study did not demonstrate any relationship between the total score of HLA mismatches and HCV-recurrence. Contrarily a significant relationship between the individual scores of HLA mismatches (HLA-A3, HLA-B35, HLA-DR3, HLA-DR7, HLA-DQ2, HLA-DQ2-0) and the recurrence of HCV were observed.
Journal of Gastroenterology and Hepatology 12/2011; 26(12):1772-8. · 3.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Liver transplantation (LT) is indicated for patients (pts) with autoimmune hepatitis (AIH) presenting with acute liver failure, and is the treatment of choice for pts with decompensated cirrhosis and a MELD score ≧15. The efficacy of steroids in severe forms remains debated. Patients and Methods: We retrospectively evaluated, the predictive factors of LT and the role of steroids, in pts with acute severe or fulminant type 1 AIH. Results: Between 1995 and 2010, 17 pts (12 females, 4 males; mean age 56.4 ± 13.4 years) were hospitalized for acute severe or fulminant type 1 AIH. At admission 8 out of 17 (47%) presented with encephalopathy. Median INR, bilirubin, AST, and creatinine values were 2.5 (range 1.4-5.4), 396 μmol/L (range 83-797), 792 IU/L (range 90-2708), respectively. A total of 15 pts received steroids with a mean delay of 15±9.1 days from admission. In two pts steroids were avoided due to ongoing sepsis and were transplanted 2 and 13 days later. Totally, 9 out of 17 pts underwent LT with a median delay of 15 days (range 2-61). Predictive factors of LT at admission were a higher median MELD score (38, range 25-47 versus 24, range 20-29, p=0.002), a higher median INR (3.4, range 2.3-5.4, versus 1.7, range 1.4-2.5, p<0.001), and a lower median AST values (581, range 90-1913 versus 1369, range 615-2708, p=0.046). 8 out of 15 pts responded to steroids within a week, with a decrease of INR and bilirubin, at a median delay of 4.5 days (range 2-8) and 2.5 days (range 1-5), respectively. Treatment delay with steroids, bilirubin levels at admission and presence of cirrhosis did not differ significantly between non-transplanted and transplanted pts. 16 out 17 pts are still alive; 1 died 1 year later of unrelated causes. Conclusion: This study outlines the predictive value of MELD score at admission in the management of patients with severe or fulminant AIH. Patients with a lower MELD score and within the first week improvement of serum bilirubin and INR may respond to steroid therapy and avoid LT.
[Show abstract][Hide abstract] ABSTRACT: Sirolimus is a potent immunosuppressant with a mechanism of action different from calcineurin inhibitors (CNIs). It has increasing importance for liver transplant (OLT) patients, in particular if when there is decreased renal function. We evaluated the efficacy and the causes for discontinuation of sirolimus-based immunosuppression among OLT recipients.
We retrospectively analyzed 97 liver transplanted patients who were prescribed sirolimus as the principal immunosuppressant. Of these, 61 patients discontinued treatment. Herein we have reported the causes, the timing, and the effects of sirolimus discontinuation.
The overall patient survival at 3 years follow-up was 89%. Hepatotoxicity and blood disorders were the most frequent, severe reported side effects. Acute cellular rejection episodes appeared in seven patients and was relieved in 1 to 2 weeks after the sirolimus administration. In 10 patients, the cholestasis associated with chronic rejection was sharply reduced after the introduction of sirolimus. No increase in vascular thrombosis and/or poor wound healing were reported.
Sirolimus given alone or in combination with CNIs appears to be an effective primary immunosuppressant regimen for OLT patients. However, in the late postoperative period (>3 months) the drug is associated with a relatively high rate of side effects.
[Show abstract][Hide abstract] ABSTRACT: Today local anesthetic wound infiltration is widely recognized as a useful adjunct in a multimodality approach to postoperative pain management. The effectiveness of continuous wound infusion of ropivacaine for postoperative pain relief after laparoscopic living donor nephrectomy was analyzed in this retrospective, comparative analysis.
Twenty patients undergoing living donor nephrectomy were divided into two groups: standard analgesic therapy (n=10) and ropivacaine continuous infusion group (n = 10).
We observed a significant difference in term of visual analogue scale scores, use of morphine, hospital stay, and bowel recovery in favor of the ropivacaine group. The cost analysis demonstrated an overall savings of 985 Euros/patient.
Surgical wound infusion with ropivacaine was safe and seemed to improve pain relief and accelerate recovery and discharge, reducing the overall costs of care. Postoperative pain control in the donor is of primary importance for better patient compliance and greater perceived quality of health care service.
[Show abstract][Hide abstract] ABSTRACT: BACKROUNDS/PURPOSE: Hereditary hemorrhagic telangiectasia or Rendu-Weber-Osler is an autosomal dominant inherited disorder characterized by arteriovenous malformations and telangiectasia that may affect the nose, skin, lungs, brain and gastrointestinal tract. Liver involvement of the disease has been described to be responsible of biliary tract necrosis, high cardiac output and portal hypertension, due to intra-hepatic vascular shunts. We aimed to present four cases of successful orthotopic liver transplantations in this indication performing our modified Piggy-back technique.
Between 2002 and 2008, four patients have been diagnosed for Rendu-Weber-Osler disease and underwent liver transplantation. Three of them suffered from high cardiac output with heart failure, two presented HBV infection and one patient suffered from renal failure requiring a liver-kidney transplantation. We performed our modified Piggy-back technique for liver implantation, which consists to clamp selectively the hepatic veins during the hepatectomy, without venous bypass, the retro-hepatic vena cava is preserved.
No hemodynamic concerns disturbed the surgery and no massive transfusions were needed. The liver replacement corrected the cardiac insufficiency due to high cardiac output for the three patients. At present, the four patients are getting well.
Despite new advances in immunotherapy for the medical treatment of Rendu-Weber-Osler disease, liver transplantation remains the curative option for hepatic based-hereditary hemorrhagic telangiectasia.
Hepatology International 02/2011; 5(3):834-40. · 2.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A perfusion fluid used in the preservation of the grafted liver represents a medium suitable for microorganism growth. In this observational study, a sample of 232 transplanted livers was collected. Perfusion fluid samples were stored for microbiological analysis from harvested donors. Bacteria were isolated in 91 out of 232 samples, post-operative infections related to contaminated perfusion solution occurred in 13 cases. The contamination rate of the preservation medium appears to be high, but postoperative infections occurs rarely. We suggest periodic detection and a protocol in place designed for antibiotic use for transplanted patients exposed to contaminated perfusion solution.
[Show abstract][Hide abstract] ABSTRACT: The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentation. Robotic surgery for hepatic resection has not yet been extensively reported. The aim of this article is to report the first known case of liver resection with the use of a robot in France.
A 61-year-old male with hepatitis C liver cirrhosis and hepatocellular carcinoma was referred for surgical treatment. Preoperative clinical evaluation and laboratory data disclosed a Child-Pugh class A5 patient. Magnetic resonance imaging showed a 3.4-cm tumor in segment III. Liver size was normal, and there were not signs of portal hypertension. Five trocars were used.
Liver transection was achieved with Harmonic scalpel and bipolar forceps without pedicle clamping. Hemostasis of raw surface areas was accomplished with interrupted stitches. Operative time was 180 minutes. Blood loss was minimal, and the patient did not receive transfusion. The recovery was uneventful, and the patient was discharged on the fifth postoperative day without ascites formation.
The robotic approach may enable liver resection in patients with cirrhosis. The da Vinci robotic system allowed for technical refinements of laparoscopic liver resection due to 3-dimensional visualization of the operative field and instruments with wrist-type end-effectors.
JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 01/2011; 15(1):86-9. · 0.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the cardiac death donor era, many reports deal with biliary tract complications and concerns about ischemic reperfusion injury owing to the exclusive arterial vascularization of the biliary tree, the warm ischemia time has been implicated as responsible for biliary lesions during organ procurement. We defined the arterialization time as the second warm ischemia time. Our purpose was to study the correlation between the arterialization time during liver implantation and the appearance of biliary lesions.
We retrospectively collected data from the last 5-years of orthotopic liver transplantation: namely, indications, cold perfusion fluid, cold ischemia time, operative procedure times, and acute rejection events. We excluded split-liver transplantations, retransplantations, pediatric patients, transplantations for cholestatic disease, cases where hepatic artery thrombosis happened before biliary complications, or patients with posttransplant cytomegalovirus infection. We defined 2 groups: A) without biliary complications; and B) with biliary complications. We compared the mean arterialization time using Student t test to define whether the warm ischemic time during implantation was responsible for biliary tract complications. A P value of <.05 was considered to be significant.
Between 2004 and the end of 2008, we grafted 402 patients among whom 243 met the inclusion criteria: 198 in group A and 45 in group B. Only the cold ischemia time was significantly different between the 2 groups (P = .039).
After the anhepatic time, the surgeon may take time for the arterial anastomosis without fearing increased biliary damage.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to assess the impact of laparoscopic thermoablation (LTA) as a neoadjuvant therapy prior to orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC).
Between January 2008 and January 2009, 12 consecutive patients, including 10 males and 2 females with unresectable HCC within liver cirrhosis, were treated with LTA under ultrasound (US) guidance. Most patients were in Child-Pugh class B (54.1%) with a mean age of 60.7 +/- 7.74 years (range, 45-69; median, 60).
The LTA procedure was completed in all patients with thermoablation of 23 HCC nodules. LTA identified 4 new malignant lesions (20%) undetected by preoperative imaging (<0.5 cm). The mean length of surgery was 96 minutes (range, 45-118). Six procedures were performed in 4 patients. No postoperative hepatic insufficiency was reported. The mean hospital stay was 4.5 days; no postoperative morbidity was reported. Complete tumor necrosis was achieved in 19/23 thermoablated nodules (82.6%) as evidenced computed tomography (CT) scan by at 3 weeks after the treatment. All patients underwent OLT without complications. The histology of the native liver showed complete necrosis in 17/23 (74%) treated nodules.
There is currently no convincing evidence that LTA allows one to expand the current selection criteria for OLT, nor that LTA decreases dropout rates on the waiting list. However, LTA does not increase the risk of postoperative complications. There is insufficient evidence that LTA offers any benefit when used prior to OLT either for early or for advanced HCC.
[Show abstract][Hide abstract] ABSTRACT: Patients undergoing orthotopic liver transplantation (OLT) show a high risk of developing an incisional hernia. The aim of this retrospective study was to establish the incidence and the factors influencing the outcomes of this complication.
We reviewed 450 consecutive OLT performed in 422 adult recipient between January 2000 and December 2005. Herniae were analysed with aspect to localization, classification, repair technique, and recurrence. All treated herniae were followed for a median of 50.5 months.
Incisional herniae occurred in 36 patients (8.5%, Group 1). Their mean age OLT was 51.4 years with 94.4% male subjects. No significant difference was observed between affects and unaffected individuals for age, OLT indication, Child-Pugh score, albumin, comorbidities, operative time, transfusions, immunosuppressant regimen, and graft rejection episodes as well as for the incisional approach and hospital stay. Gender, body mass index (BMI), preoperative ascites, and pulmonary complications after OLT were significantly different (P < .01). Herniae were small (<5 cm; n = 12), medium (5-10 cm; n = 28), or large (> 10 cm; n = 2). Herniorrhaphy techniques included primary suture repair in 5 (13.9%) and mesh repair in 31 (86.1%) cases. In 3 patients with a primary repair and 1 patient with a mesh repair there were recurrences.
Preoperative ascites, gender, BMI, and pulmonary complications after OLT seemed to have significant influences on the formation of incisional herniae. Polypropylene mesh may be a first choice for the surgical treatment of there transplant recipients.
[Show abstract][Hide abstract] ABSTRACT: Introduction
L’hépatocarcinome (CHC) est une indication de résection hépatique ou de transplantation hépatique (TH). Dans la plupart des centres, seuls les patients dont le CHC répond aux critères de Milan sont éligibles pour la TH. L’objectif de l’étude est d’analyser la corrélation entre les caractéristiques pathologiques de la tumeur, la survie et le taux de récidive.
Patients et Méthodes
Dans la période 1997-2007, un diagnostic de CHC a été porté chez 196 patients. Ont été analysés dans cette série l’âge, le sexe, la nature de la cirrhose, les examens biologiques, l’alphafœtoprotéine. Pour tous les patients, les score MELD (Model for End-stage liver disease) et Child-Pugh ont été calculés. S’agissant du CHC, ont été précisés la localisation tumorale, la taille, le nombre de nodules, l’atteinte de la capsule, la différenciation histologique et la présence de micro ou macro-envahissement vasculaires (EV).
L’examen histologique a confirmé le diagnostic de CHC chez 168 (85,7 %) patients dont la médiane de survie était de 74 mois (23-154 mois). La mortalité à un mois était de 5,6 %. À l’examen anatomo pathologique des foies explantés, 106 (63 %) patients respectaient les critères de Milan, 28 (16,7 %) ceux de San Fancisco (UCSF), 34 (20,3 %) étaient audelà de ces critères. L’envahissement vasculaires (EV) a été mis en évidence chez 41 patients (24,4 %) : macroscopiques dans 10,7 % des cas (n = 18) et microscopiques dans 13,6 % (n = 23). La survie globale et sans récidive à 5 ans était respectivement de 66,1 % et 64,1 %. Les survies globales à 1, 3 et 5 ans selon les critères de Milan étaient respectivement de 90 %, 85 % et 77 % et selon les critères de UCSF de 88 %, 81 % et 74 % (NS). On a noté une différence de taux de survie entre les patients avec EV et ceux sans EV (p ≤ 0,001). L’analyse univariée et multivariée des facteurs prédictifs de la survie seule l’EV était statistiquement significatif (p < 0,001). Deux facteurs étaient associés à l’EV, l’AFP 400 ng/ml (HR = 13,167, p < 0,002) et la classification histologique G3 (HR = 12,6, p < 0,0003).
Dans cette série, le seul facteur pronostique significatif est l’EV. Dans la mesure où on ne dispose pas de marqueurs prédictifs de l’EV fiables, la résection hépatique, lorsque la fonction hépatique le permet, représente non seulement un traitement de première intention, mais une étape décisionnelle avant la TH.
Ultrasound in Medicine and Biology - ULTRASOUND MED BIOL. 01/2010; 147(4):31-31.
[Show abstract][Hide abstract] ABSTRACT: Treatment of a recurrence of hepatocellular carcinoma (HCC) after liver transplantation. Surgery has seldom been considered in such a situation because HCC recurrences are generally considered as a systemic disease.
We describe a 47-year-old male patient who underwent liver transplantation in October 1999 for HCC exceeding the Milan and University of California, San Francisco (UCSF), criteria.
In 2007 (8 years after liver transplantation), the patient developed a cervical bone metastasis treated by surgery. In April 2008, HCC had disseminated to hepatic pedicle lymph nodes. An extended hepatic pedicle lymphadenectomy was then performed. Today, our patient is doing well, without signs of recurrence.
The risk of developing a tumor recurrence is the main argument against expanding the UCSF criteria. In case of an HCC recurrence, various treatments ranging from a change in the immunosuppression regimen to chemotherapy have been proposed. Surgical treatment has rarely been envisaged in the treatment of HCC recurrences because of the technical difficulties and the frequent dissemination of cancer.
European Surgical Research 12/2009; 44(1):52-5. · 0.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to analyze a single-center experience in orthotopic liver transplantation with the piggy-back technique (PB) realized with a cuff of three veins without temporary portacaval shunt. Outcome parameters were graft and patient survival and the surgical complications.
The records of 423 liver transplantation in 396 adult recipients were reviewed. PB was performed in all cases also in patients with transjugular intrahepatic portosystemic shunts and redo transplants without temporary portacaval shunt. No hemodynamic instability was observed during venous reconstruction.
Operation time, cold ischemia time and anhepatic phase were, respectively, 316, 606 and 82 min, respectively. The mean intraoperative transfusion of packed red blood cells was 3.2 (range 1-48). Surgical complications were observed in 25% of the orthotopic liver transplantation and 2% of these was related to caval anastomosis. No case of caval thrombosis was observed; a stenosis was noted in seven patients, always treated with an endovascular approach. A postoperative ascites was observed in seven cases. Retransplantation was required in 6.3% patients. Overall in-hospital mortality was 5.3%, but no patient died through technical problems or complications related to PB procedure. One-, 3- and 5-year grafts and patients were 94%, 83% and 75%, and 92%, 86% and 79%, respectively.
This experience indicates that our approach is feasible with a low specific risk and can be performed without portacaval shunt, with minimal outflow venous complications.
Journal of Gastroenterology and Hepatology 11/2009; 25(3):591-6. · 3.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The advanced age of the recipient is considered a "relative contraindication" to liver transplantation (LT). However, recently some studies reported a morbidity rate and an overall survival comparable with those of younger patients. Here, we reported the outcome after LT in recipients aged >65 yr.
Between January 2000 and December 2006, 565 LT was performed in 502 recipients in our institution. Of these, 34 were recipients of >65 yr old (aged group). We focused our study comparing: donor age, co-morbidities, model for end-stage liver disease (MELD) and American Society of Anesthesiologists (ASA) score, duration of operation, transfusions and outcome between the two groups (young/aged).
For the group aged >65: the mean donor age was 52.5 (range 16-75) yr and the graft weight 1339 g (890-1880 g). Co-morbidity was recorded in 25 (73.5%), coronary artery disease (CAD) in 17 (50%), diabetes mellitus (DM) and chronic renal insufficiency in four (11.7%) and chronic obstructive pulmonary disease (COPD) in three patients (8.8%). Mean MELD score was 14.9 (range 12-29) and ASA score was two in 15 (44.1%); and three in 19 (55.8%) recipients. Mean operation time was four h 45 min, three patients also received combined kidney transplantation. Twenty-five (73.5%) recipients received blood transfusions (mean 3.2). Morbidity was observed in 20 patients (58.8%); of these two had hepatic artery thrombosis requiring re-LT. Overall survival was 80% (40 months of follow-up), in particularly, at 30-d, one yr, three yr was 91%, 84%, 80%, respectively. The only two statistical differences reported (p = 0.02) are: the lower rate of CAD in the younger group of recipients (12%), compared with the aged group (50%) and the subsequently lower mortality rate secondary to cardiac causes in the younger group (1.4%) compared with aged group (8.8%).
Our results suggest that the recipient age should not be considered an absolute contraindication for LT when the graft/recipient matching is optimal and when an adequate cardiac assessment is performed.
[Show abstract][Hide abstract] ABSTRACT: The authors reviewed the passenger lymphocyte syndrome (PLS) that has appeared after transplantation. The definition, mechanism, serological, clinical features, and treatment for PLS after solid organ transplantation, especially liver transplantation, are described. The PLS refers to the clinical phenomenon of alloimmune hemolysis resulting from the adoptive transfer of viable lymphocytes from donor during solid organ or hematopoietic stem cell transplant. Sometimes, it is very severe and may cause "unexplained" hemolysis during the postoperative period. The authors reviewed literature about the PLS in liver transplantation.
Clinical and Developmental Immunology 02/2008; 2008:715769. · 3.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Despite the well-known controversies about split-liver procedures, since 1979 we have utilized an ex situ instead of an in situ technique because of its feasibility. However, we sought to prove the equality of the results of these two procedures. Herein, we have presented our experience after 27 years' follow-up.
Between March 1979 and June 2006, we transplanted 84 livers in 67 pediatric recipients including 37 ex situ split livers implanted into 28 patients.
We recorded demographic characteristics, transplantation, and retransplantation indications, age difference between donors and recipients, comorbidities, cold ischemia times, surgical times and complications, graft/recipient body weight ratios, organ recovery times, and overall survivals after 1, 5, and 15 years follow-up. We have herein reported 1, 5, and 15 years of patient versus organ survivals of 88.9.1%, 84.5%, 62.1% versus 78.6%, 74.2%, 57.4%, respectively.
We have concluded that an ex situ split liver may be a valid alternative to in situ techniques to achieve good grafts for pediatric transplantation.