[Show abstract][Hide abstract] ABSTRACT: A 57-year-old male with a history of hypercholesterolemia and anxiety but otherwise in good health volunteered to donate the right lobe of his liver to his brother. The operation was performed uneventfully, without transfusion. Postoperatively he did well, until he developed tachycardia, profound hypotension, and coffee ground emesis on postoperative day 3. Despite resuscitative measures, he arrested and expired. Autopsy demonstrated gas gangrene of the stomach as the underlying cause of the hemorrhage and numerous colonies of Gram-positive bacilli were identified. Subsequent polymerase chain reaction (PCR) analysis identified these bacteria to be Clostridium perfringens (C. perfringens) type D. This patient's death was devastating, both to his family and his medical team. The impact of his death has transcended that of an individual occurrence. In conclusion, herein we present the facts and discuss this extraordinary example of florid clostridial infection and toxin-mediated shock. It was completely unexpected and probably unpreventable, and its cause was almost inconceivable.
[Show abstract][Hide abstract] ABSTRACT: Biliary reconstruction represents one of the most challenging parts of right lobe (RL) living donor liver transplantations (LDLTs). Different causes, surgical techniques, and treatments have been suggested but are incompletely defined.
Between June 1999 and January 2002, 96 RL LDLTs were performed in our center. We reviewed the incidence of biliary complications in all the recipients.
Roux-en-Y reconstruction was performed in 53 cases (55.2%) and duct-to-duct was performed in 39 cases (40.6%). Both procedures were performed in 4 cases (4.2%). Multiple ducts (> or =2) were found in 58 grafts (60.4%). Thirty-nine recipients (40.6%) had 43 biliary complications: 21 had bile leaks, 22 had biliary strictures, and 4 had both complications. Patients with multiple ducts had a higher incidence of bile leaks than those patients with a single duct (P=0.049). No significant differences in complications were found between Roux-en-Y or duct-to-duct reconstructions. Freedom from biliary complications was 59% at 1 year and 55% at 2 years. The overall 1-year and 2-year survival rates for patients were 86% and 81%, respectively. The overall 1-year and 2-year survival rates for grafts were 80% and 77%, respectively. Occurrence of bile leaks affected patient and graft survival (76% and 65% 2-year patient and graft survival, respectively, vs. 89% and 85% for those without biliary leaks, P=0.07).
Despite technical modifications and application of various surgical techniques, biliary complications remain frequent after RL LDLT. Patients with multiple biliary reconstructions had a higher incidence of bile leaks. Patients who developed leaks had lower patient and graft survival rates.
[Show abstract][Hide abstract] ABSTRACT: Acute cellular rejection (ACR) after liver transplantation occurs in as much as 70% of patients within the first year. There is very little known about ACR that occurs more than 1 yr after transplant, and it is generally believed that late occurring ACR may be more resistant to medical treatment and is associated with a higher rate of chronic ductopenic rejection and graft loss. A total of 532 recipients with more than 1000 d follow-up and who did not have hepatitis C were identified. Forty-three (8.1%) had biopsy proven late ACR at a mean of 1545 +/- 441 d post-transplant. Additionally, 38 of the 43 (88.4%) patients with late ACR had earlier episodes of ACR before 1000 d post-transplant vs. only 295 of the 488 patients (60.5%) that did not have late ACR (p < 0.01). The incidence of primary sclerosing cholangitis (PSC) was 32.6% among patients with late ACR and 11.1% among patients without late ACR (p < 0.01). The overall patient survival for patients who had late ACR (n = 43) is 81.4% while for patients without late ACR (n = 488) it is 82.0% (p = ns). Patients remain at risk for ACR even after 1000 d post-transplant, particularly those with PSC.
[Show abstract][Hide abstract] ABSTRACT: Posttransplantation allograft malignancy of donor origin is a rare complication after liver transplantation. In the case described, subjective fevers and nonspecific abdominal complaints nearly 6 months following cadaveric liver transplantation in a young woman prompted an evaluation which was remarkable for a large central liver mass. A poorly differentiated squamous cell carcinoma was diagnosed, but was unresectable at exploration. The tumor was confined to the liver. Histocompatibility testing using polymerase chain reaction (PCR) amplification techniques identified both donor and recipient HLA alleles. The patient was treated with chemoembolization, systemic chemotherapy and cessation of immunosuppression. Repeat biopsy 2 months later showed the tumor to be completely necrotic. With decompensated liver disease, she was relisted and retransplanted. More than 2 years later she remains disease-free with complete pathological remission. This is the only reported case of squamous cell carcinoma of donor origin arising in a transplanted liver.
American Journal of Transplantation 03/2004; 4(2):278-82. DOI:10.1046/j.1600-6143.2003.00322.x · 5.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Liver transplantation for the treatment of metastatic neuroendocrine tumors (NETs) is radical. Although cure is not impossible, it is improbable. The reported experience with transplantation for NETs is limited to less than 150 cases with widely varying results and few 5-year disease-free survivors. We reviewed our experience with transplantation for patients with NETs. Fourteen symptomatic patients with unresectable NET liver metastases who had failed medical management were listed for transplantation. Two patients listed for transplantation underwent prior right lobectomies. Three patients were listed but did not undergo transplantation: one was lost to follow-up, one died 14 months after listing, and one remains waiting over 4 years. Eleven patients underwent liver transplantation, three with living donor grafts. There were four men (36.4%) and seven women (63.6%) who had a mean age of 51.2+/-6.3 years. Three patients had distal pancreatectomies and one patient had a Whipple procedure at the time of transplantation. There were six nonfunctioning tumors (54.6%), three carcinoid tumors (27.3%), and two (18.2%) Vipomas. In one patient, with fulminant hepatic failure, the NET was an incidental finding in the explant. The 1- and 5-year survival among transplanted patients is 73% and 36%, respectively, with a mean follow-up of 34+/-40 months (range 0 to 119 months). Of the three patients surviving more than 5 years, only one was disease free. In carefully selected patients with metastatic NETs, liver transplantation may be an appropriate option.
Journal of Gastrointestinal Surgery 03/2004; 8(2):208-12. DOI:10.1016/j.gassur.2003.11.010 · 2.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Liver transplantation is the best therapeutic option for patients with end-stage liver disease from primary sclerosing cholangitis. Primary sclerosing cholangitis is associated with a markedly increased risk of cholangiocarcinoma, which adversely affects survival. Approximately 20% to 30% of cholangiocarcinomas are localized in the distal bile duct. Pancreatoduodenectomy is the curative therapy for cholangiocarcinomas in this location.
We reviewed our data on a patient with primary sclerosing cholangitis-related end-stage liver disease and a simultaneous distal bile duct tumor, which was treated with a combined right-lobe, living-donor liver transplantation and pancreatoduodenectomy.
The patient was discharged 32 days post-transplantation. He is currently alive 1 year after the procedure with no evidence of recurrent cancer.
Combined living-donor liver transplantation and pancreatoduodenectomy is feasible and allows timely and elective surgical control of carefully selected distal bile duct tumors in the setting of end-stage liver disease.
Journal of the American College of Surgeons 12/2003; 197(5):765-9. DOI:10.1016/j.jamcollsurg.2003.06.001 · 5.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Resection offers the only potential cure of hilar cholangiocarcinoma. Portal bifurcation involvement is often thought to contraindicate resection. We reviewed our experience with aggressive surgical management in 28 patients with hilar cholangiocarcinoma.
All patients underwent hepatectomy and bile duct resection with hepaticojejunostomy. In 10 cases (group 1) the portal bifurcation was involved, necessitating portal resection and reconstruction; 18 (group 2) had no portal involvement. Frozen section of duct margins was routine. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test.
Portal reconstruction in group 1 was by graft interposition (1), venoplasty using the posterior wall of the right portal vein (2), or end-end anastomosis (7). Hepatectomies included right trisegmentectomy (8), right lobectomy (4), and left lobectomy (16); 20 (71%) had concomitant caudate resection. Median survival was 18 months in group 1 and 32 months in group 2 ( P, not significant [NS]). One-, 3-, and 5-year survivals were 60%, 22%, and 22%, respectively, in group 1 and 70%, 47%, and 38%, respectively, in group 2 ( P= 0.319).
Portal involvement by hilar cholangiocarcinoma does not contraindicate resection.
Journal of Hepato-Biliary-Pancreatic Surgery 02/2002; 9(2):237-41. DOI:10.1007/s005340200025 · 1.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cadaveric liver transplantation for hepatocellular carcinoma (HCC) is limited by donor organ availability. This report reviews our initial experience with living donor liver transplantation (LDLT) for HCC. Since August 1998, a total of 71 adults have undergone LDLT; 27 (38%) for HCC. Underlying diagnoses included hepatitis C in 17, hepatitis B in eight, cryptogenic cirrhosis in one, and primary biliary cirrhosis in one. Four patients had recurrent HCC after resection. Patients with tumors measuring 5 cm or larger received a single dose of intravenous doxorubicin intraoperatively and six cycles of doxorubicin at 3-week intervals beginning 6 weeks postoperatively. All HCC patients are followed with CT scans and alpha-fetoprotein measurements every 3 months during the first 2 years after transplant. Mean waiting time to transplant for patients with HCC was 83 days, compared to 414 (P = 0.001) days for 50 patients with HCC who were transplanted with cadaveric organs during this period. At median follow-up of 236 days, there have been four deaths due to non-tumor-related causes and one death from recurrence; recurrence has been observed in one other patient. LDLT permits expeditious transplantation in patients with early HCC, and provides access to transplantation for patients with HCC exceeding the United Network of Organ Sharing criteria for prioritization who are, in effect, barred from receiving cadaveric organs.
Journal of Gastrointestinal Surgery 01/2002; 6(1):102-7. DOI:10.1016/S1091-255X(01)00024-5 · 2.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Because increased hepatotoxicity was observed with first line antituberculous agents using four drug standard induction therapy in orthotopic liver transplant patients, we evaluated the efficacy and adverse effects of a novel continuation regimen for the treatment of tuberculosis in orthotopic liver transplant patients at a University Hospital in New York City.
The hospital records of all patients who were referred to Mount Sinai Hospital (n=924) and who underwent orthotopic liver transplant between September 1988 and May 1998 were reviewed. Data were collected from patient records. Nine orthotopic liver transplant patients (0.97%) developed tuberculosis over a 9.5-year period. A total of seven of nine (78%) patients had disseminated tuberculosis including two patients with meningitis. All mycobacterial isolates were sensitive to isoniazid, rifampin, pyrazinamide, and ethambutol. Standard induction therapy with three or four drugs was given for 2 months (mean). Hepatotoxicity related to the standard induction regimen developed in five of six (83.3%) patients. Liver biopsy during induction therapy revealed drug induced hepatitis in five of six (88%) patients and rejection in three of six (50%) patients. Continuation regimens consisted mainly of ethambutol and ofloxacin; mean length of therapy 9 months.
Overall mortality was 33.3% (three of nine patients) over a 4.5-year follow-up period. Tuberculosis associated mortality was 22.2%. One patient died before therapy, another died with concomitant bacterial sepsis during induction therapy. Six of seven patients are alive and disease free. One patient died of recurrent hepatitis C and graft failure without evidence of tuberculous infection at death. Another patient retransplanted for chronic rejection, remains disease free at 1 year. The mean follow-up for six patients that completed treatment was 3.75 years (2.5-5.3 years). Six patients are free of tuberculosis.
Our experience reveals that orthotopic liver transplant patients have poor tolerance for conventional therapy due to inherent toxicity of these agents and their concomitant bouts of organ rejection. Our nonconventional therapy yielded remarkably good results in that six patients, all with disseminated disease, were well after mean 3.5 years of follow-up. Consideration should be given to this novel follow-up therapy in patients without cavitary pulmonary disease who develop hepatotoxicity during induction.
[Show abstract][Hide abstract] ABSTRACT: We report the frequency and type of infectious ocular complications following orthotopic liver transplantation (OLT) and review diagnostic and therapeutic strategies. During the period September 1988 through November 1994, 684 patients underwent OLT at Mount Sinai Hospital (New York). Nine orthotopic liver transplant patients (1.3%) developed ocular infections: Candida albicans endophthalmitis (2), Aspergillus fumigatus endophthalmitis (1), cytomegalovirus retinitis (4), herpes simplex virus keratitis (1), and varicella-zoster virus panophthalmitis (1). The mean time from OLT to ocular symptoms was 42 days for patients with fungal infections and 128 days for patients with viral infections. Blurred vision was the commonest symptom (five of nine cases). The mean duration of follow-up was 2 years (range, 33 days to 5 years). Permanent loss of vision occurred in three patients, five had improvement in visual acuity, and one died of disseminated aspergillosis 33 days after OLT. Infectious ocular complications following OLT may occur as isolated events or with disseminated disease. Fungal infections occur earlier (mean, 42 days after OLT) than viral infections (mean, 4 months after OLT). The clinical presentation may be atypical; aggressive vitreoretinal procedures and serial examinations may be required to establish the diagnosis. Cytomegalovirus retinitis in orthotopic liver transplant patients may not require life-long maintenance therapy with antiviral agents.
[Show abstract][Hide abstract] ABSTRACT: The risk factors for acquisition of and mortality due to nosocomial infection with vancomycin-resistant Enterococcus faecium (VREF) in orthotopic liver transplant (OLT) recipients were studied at a tertiary care hospital; 32 VREF-infected OLT patients (cases) were compared with 33 randomly selected OLT recipients (controls). More antibiotics were administered preoperatively to cases (mean, 4 antibiotics per patient for 474 antibiotic-days) than to controls (mean, 1.8 antibiotics per patient for 131 antibiotic-days). Cases were more likely than controls to have received vancomycin therapy preoperatively and to have been hospitalized in the intensive care unit (ICU) preoperatively. Logistic regression revealed that the risk factors for acquisition of VREF infection were surgical reexploration and a prolonged stay in the surgical ICU postoperatively. In the cases, the risk factors for mortality were admission to the ICU preoperatively and hemodialysis. The mortality rate associated with polymicrobial bloodstream infections was 100% despite appropriate therapy. Sixteen and 18 cases received parenteral chloramphenicol and doxycycline, respectively, for treatment of VREF infection. There were no hematologic adverse effects attributed to chloramphenicol treatment. DNA analysis of selected E. faecium isolates suggested that infections were due to multiple clones. In summary, the source of VREF infection in OLT patients is the gastrointestinal tract. Antibiotic selective pressure may contribute to colonization. Infection with VREF is a predictor of morbidity and mortality in OLT patients.
[Show abstract][Hide abstract] ABSTRACT: Macroregenerative nodules (MRNs), probably representing a pathway for human hepatocarcinogenesis, are generally classified into type I MRNs (or ordinary adenomatous hyperplasia) and type II MRNs (or atypical adenomatous hyperplasia), on the basis of imprecise definitions of cytological and architectural atypia. It is currently believed that type II MRNs are probably true precursors of hepatocellular carcinoma (HCC), whereas type I lesions may simply represent large regenerative nodules. A series of 155 consecutive adult cirrhotic liver explants were examined for evidence of MRNs, HCC, and liver cell dysplasia (LCD) of large and small cell types, and their appearance, in terms of proposed classification schemes, was reviewed. There was evidence indicating that the presence of either type of MRN was associated with an increased incidence of HCC (all MRNs, P < .00019; type I MRNs, P < .067; type II MRNs, P < .012) compared with cirrhotic livers without MRNs. A subset of younger patients with a large (uncountable) number of MRNs in their livers, who did not show any increased incidence of carcinoma, was identified. Excluding these cases from statistical analysis, all associations were strengthened, implying either that malignant progression had not had time to occur in this younger population or that these nodules were simply large regenerative nodules without malignant potential. MRNs from these livers were histologically indistinguishable from MRNs occurring in more limited numbers, although atypical changes other than large cell type LCD were less frequent. No independent association between LCD of large cell type and HCC was found in the entire series. Deleting this feature from the criteria for cytological atypia resulted in a stronger association of both types of MRNs with HCC (redefined type II MRNs/HCC, P < .0001; redefined type I MRNs/HCC, P < .0306). Some of the type II MRNs remaining after exclusion of large cell type LCD showed “borderline” changes insufficient for a diagnosis of HCC, but most type II MRNs (82%) contained expansile “nodule-in-nodule” growth patterns. The conclusions of this report are that (1) histological examination of type I MRNs is insufficient in many cases to distinguish large regenerative nodules from neoplastic ones; (2) LCD of large cell type should not be used as a criterion for terming an MRN atypical; and (3) expansile “nodule-in-nodule” formation in MRNs should be considered to represent evidence of architectural atypia.