Endo-therapies for biliary duct-to-duct anastomotic stricture after liver transplantation: Outcomes of a nationwide survey.

BACKGROUND: The most appropriate endo-therapeutic approach to biliary anastomotic strictures is yet to be defined. AIM: To retrospectively report on the endo-therapy of duct-to-duct anastomotic strictures during 2013 in Italy. METHODS: Data were collected from 16 Endoscopy Units at the Italian Liver Transplantation Centers (BASALT study group). RESULTS: Complete endo-therapy and follow-up data are available for 181 patients: 101 treated with plastic multistenting, 26 with fully covered self-expandable metal stenting and 54 with single stenting. Radiological success was achieved for 145 patients (80%), that is, 88% of plastic multistenting, 88% of self-expandable metal stenting and 61% of single stenting (P < 0.001 vs plastic multistenting; P < 0.05 vs self-expandable metal stenting). After first-line endo-therapy failure, the patients underwent a second-line endo-therapy with plastic multistenting for 25%, fully covered self-expandable metal stenting for 53% and single stenting for 22% of cases, and radiological success was achieved for 84%, that is, 100%, 85% and 63% with plastic multistenting, self-expandable metal stenting and single stenting (P < 0.05 vs plastic multistenting or self-expandable metal stenting) respectively. Procedure-related complications occurred in 7.8% of endoscopic retrograde cholangiopancreatographies. Overall, clinical success was achieved in 87% of patients after a median follow-up of 25 months. CONCLUSION: Plastic multistenting is confirmed as the preferred first-line treatment, while fully covered self-expandable metal stenting as rescue option for biliary anastomotic strictures. Single stenting has sub-optimal results and should be abandoned.

Liver transplantation for viral hepatitis in 2015.

Liver transplantation (LT) is a life-saving treatment for patients with end-stage liver disease and for patients with liver cell cancer related to liver disease. Acute and chronic liver diseases related to hepatitis viruses are between the main indications for liver transplantation. The risk of viral reinfection after transplantation is the main limiting factor in these indications. Before the availability of antiviral prophylaxis, hepatitis B virus (HBV) recurrence was universal in patients who were HBV DNA-positive before transplantation. The natural history of recurrent HBV was accelerated by immunosuppression, and it progressed rapidly to graft failure and death. Introduction of post-transplant prophylaxis with immunoglobulin alone first, and associated to antiviral drugs later, drastically reduced HBV recurrence, resulting in excellent long-term outcomes. On the contrary, recurrence of hepatitis C is the main cause of graft loss in most transplant programs. Overall, patient and graft survival after LT for hepatitis C virus (HCV)-associated cirrhosis is inferior compared with other indications. However, successful pretransplant or post transplant antiviral therapy has been associated with increased graft and overall survival. Until recently, the combination of pegylated interferon and ribavirin was the standard of care for the treatment of patients with chronic hepatitis C. Highly active antiviral compounds have been developed over the past decade, thanks to new in vitro systems to study HCV entry, replication, assembly, and release.

Who fares worse after liver transplantation? Impact of donor and recipient variables on outcome: data from a prospective study.

BACKGROUND: Numerous donor and recipient risk factors influence survival after liver transplantation (LT). METHODS: The aim of this study was to prospectively evaluate the effect of donor and recipient variables on 12-month patient and graft survival after LT. Five hundred forty-six patients underwent LT in a single center (2000-2010). RESULTS: Bilirubin (P=0.006) and cold ischemia time (P=0.002) were predictive of graft loss at 12 months after LT. Model for End-Stage Liver Disease score ≥25 was associated with a lower 12-month graft survival than Model for End-Stage Liver Disease score <15 (P=0.02). Hepatitis C virus (HCV)-positive patients showed a lower survival than HCV-negative patients 12 months after LT (P=0.04), with serum sodium concentration (P=0.01) predictive for graft survival. Donor age demonstrated a trend of prediction (P=0.05) for HCV-positive patient survival. In hepatocellular carcinoma patients, donor age (P=0.02 and 0.02) and use of partial graft (P=0.01 and 0.02) were predictive of patient and graft survival at 12 months after LT. CONCLUSIONS: Bilirubin and cold ischemia time are crucial for graft outcome post-LT. Survival in HCV-positive patients is lower than in HCV-negative recipients. Donor age and partial graft use are predictive of patient and graft survival in hepatocellular carcinoma patients.

Management of nonneoplastic portal vein thrombosis in the setting of liver transplantation: a systematic review.

BACKGROUND: Nonneoplastic portal vein thrombosis (PVT) is frequent in patients with cirrhosis who undergo liver transplantation (LT); however, data on its impact on outcome and strategies of management are sparse. METHODS: A systematic review of the literature was performed by analyzing studies that report on PVT in LT recipients and were published between January 1986 and January 2012. RESULTS: Of 25,753 liver transplants, 2004 were performed in patients with PVT (7.78%), and approximately half presented complete thrombosis. Thrombectomy/thromboendovenectomy was employed in 75% of patients; other techniques included venous graft interposition and portocaval hemitransposition. Overall, the presence of PVT significantly increased 30-day (10.5%) and 1-year (18.8%) post-LT mortality when compared to patients without PVT (7.7% and 15.4%, respectively). However, only complete PVT accounted for this increased mortality. Rethrombosis occurred in up to 13% of patients with complete PVT and in whom no preventative strategies were used, and was associated with increased morbidity and mortality. CONCLUSIONS: PVT is common in patients with cirrhosis undergoing LT, and it affects survival when it is complete, at least in the short term after transplant. Therefore, screening for this condition is essential, alongside adequate treatment strategies to attempt repermeation of the PV and prevent thrombosis extension.

Usefulness of a hypertension education program.

BACKGROUND: Our objective was to assess knowledge about hypertension, its medical consequences in hospitalized patients with hypertension and in their relatives, and to evaluate the usefulness of a simple education program to improve such knowledge. METHOD: As part of a cohort study, six clinical physicians reviewed the medical charts of all hospitalized patients in the departments of medicine, general surgery, and orthopedic surgery. Patients with the antecedent of hypertension, patients without the antecedent of hypertension but with at least two measurements of blood pressure above normal limits during hospitalization, and the relatives or friends who were accompanying patients with known or unknown hypertension were included. Patients received an education program about hypertension. Knowledge about hypertension and its complications was assessed on the basis of three items before the education program and 4 months later. RESULTS: A total of 102 patients entered the study and 95 completed it. An association was found between higher education level and knowledge about hypertension; differences were significant with two of the three employed items (P < 0.005). Compared with baseline, knowledge about hypertension was improved 4 months after the education program; differences were significant with the three employed items (P < 0.005). CONCLUSIONS: Simple and easy-to-implement programs can be useful in improving knowledge about hypertension.