Incidence of de novo nonmelanoma skin tumors after liver transplantation for alcoholic and nonalcoholic liver diseases.

INTRODUCTION: Skin tumors are the most common malignancies after orthotopic liver transplantation (OLT). They have been related to sunlight exposure, tobacco consumption, and immunosuppression. The aim of this study was to compare the incidence of de novo skin tumors (nonmelanoma) in patients who underwent liver transplantation for alcoholic cirrhosis versus nonalcoholic diseases. PATIENTS AND METHODS: Between April 1986 and July 2004, we performed 1000 OLT in a population of 888 recipients. This study was performed in a sample of 701 adult recipients who survived >2 months after transplantation: 276 patients (39.4%) underwent OLT for alcoholic cirrhosis (AC-group), and 425 (60.6%) for nonalcoholic disease (N-AC). The overall incidence of de novo skin tumors was 3.5% (25 tumors): 5.4% (15 tumors) in the AC-group and 2.4% (10 tumors) in the N-AC group (P = .027). Two patients developed two tumors. There were 19 men and 4 women, mean age at OLT of 54.4 +/- 6.8 years (range, 40 to 66 years). The mean time from OLT to tumor diagnosis was 66.1 +/- 51.4 months (range, 3 to 165 months): 56.4 +/- 44.4 months in the AC-group versus 80.6 +/- 59.8 months in the N-AC group (P = NS). Histologically, 17 tumors (68%) were basal cell carcinomas and eight tumors (32%) were squamous cell carcinomas (P = .128). Fourteen patients (60.8%) were smokers: 11 patients (84.6%) in the AC-group versus 3 patients (30%) in the N-AC group (P = .012). All the patients underwent tumor resection, with only one patient dying, because of lymph node invasion of the neck. CONCLUSION: There was a higher incidence of de novo skin tumors among patients who smoked who underwent OLT for alcoholic cirrhosis.

Hepatic allograft arterialization by means of the gastroduodenal bifurcation (branch patch) as a prognostic factor.

INTRODUCTION: Because of the current shortage of cadaveric organs, it is important to determine preoperatively those variables that are readily available, inexpensive, and noninvasive that can predict a higher incidence of hepatic artery thrombosis (HAT). MATERIAL AND METHODS: From April 1986 to October 2001, 717 patients underwent 804 liver transplants. All the arterial reconstructions were performed with fine (7-0) monofilament sutures in an interrupted fashion. Two methods were used: group I, end-to-end arterial anastomosis, and group II, the gastroduodenal branch patch. RESULTS: After a mean follow-up of 72 (range 3-174) months, HAT was observed in 19 patients (overall incidence 2.4%). End-to-end anastomosis (group I) was performed in 39.50% (316) of cases, and HAT developed in 14 (4.4%) cases. Branch-patch anastomoses (group II) were carried out in 60.5% (488) of the patients; the presence of HAT was detected in five cases (1.03%) (P = 0.03, P < 0.05). A total of 21 variables were selected in the univariate analysis; however, after the multivariate analysis, all but two of the factors lost statistical significance, and these corresponded to the type of arterial reconstruction (gastroduodenal branch patch vs. end-to-end) and the ABO compatibility. CONCLUSIONS: Liver transplantation with compatible grafts using branch-patch anastomosis for the arterialization (both manipulative by the transplant team) reduces HAT-derived loss of grafts, with the consequent increase in graft availability and reduced mortality rate on the waiting list.

Liver transplantation for Echinococcus granulosus hydatid disease.

The authors report their experience with 6 patients requiring liver transplantation who suffered with liver infestation by Echinococcus granulosus. One patient presented with acute Budd-Chiari syndrome because obstruction of hepatic veins was produced during the first operation; the other 5 patients received liver transplants for terminal chronic liver disease (2 secondary sclerosing cholangitis, 2 secondary biliary cirrhosis, and 1 postnecrotic cirrhosis of the liver). All the patients had been operated previously on for hydatidosis and were at the end of liver functional disorder. Some of the patients had undergone many operations, making the transplantation procedure even more difficult. One patient required a second transplant for primary graft failure; he died 40 days later from cerebrovascular accident. Another patient died 7 months after transplant from pulmonary embolism. The other 4 patients are alive and in optimal condition 37-65 months after transplantation. Hepatic hydatidosis--in principle, a benign disease--can cause hepatic complications that eventually require liver transplantation. The transplantation procedure is more difficult than usual in these cases. Although postoperative complications are frequent, most patients achieve prolonged survival and a good quality of life.

Cholecyst-thoracic fistula. A rare complication of lithiasic cholecystitis.

A 64-year-old male patient was studied for repeated right basal pneumonia of long duration. A computed tomography scan showed a cholecystitis of concealed evolution. Surgery revealed fistulization toward the thorax, with the passage of multiple calculi of a biliary origin to the chest cavity. We report the first described case to our knowledge of cholecyst-thoracic fistula secondary to cholecystitis of long evolution.

Histological diagnosis of cytomegalovirus hepatitis in liver allografts.

AIMS--To determine the incidence of histologically documented cytomegalovirus (CMV) hepatitis following orthotopic liver transplantation (OLT) and to assess the effectiveness of immunohistochemistry and in situ hybridisation (ISH) in detecting CMV. To describe the histological pattern most frequently associated with CMV hepatitis in order to select the biopsy group in which these modern techniques are most effective. METHODS--A prospective histological study was carried out on 853 biopsy specimens, obtained from 191 liver allografts (160 patients). Specimens were stained with haematoxylin and eosin and immunohistochemically (avidin-biotin complex) using monoclonal antibodies directed against early and late CMV antigens. A retrospective selection was made of 23 specimens with viral inclusion bodies in cytomegalic cells (group A) to characterise the most frequently associated histological pattern, and of 34 other specimens without viral inclusion bodies (group B) but with the same microscopic features as group A. Re-cuts from both specimen groups were studied using immunohistochemistry and ISH with a CMV specific complementary DNA probe. RESULTS--CMV infection was confirmed in 35 specimens (29 by immunohistochemistry, 23 by presence of inclusion bodies in haematoxylin and eosin stained sections, 16 by ISH) from 27 patients (incidence 16.9%). CMV hepatitis was diagnosed within 46 +/- 19 (range 21-114) days posttransplant. Twenty on (91.3%) of the 23 biopsy specimens with inclusion bodies (group A) displayed heterogeneous inflammatory foci disseminated throughout the hepatic lobule. Nineteen specimens (82.6%) were positive by immunohistochemistry and 14 (60.9%) by ISH. In eight (23.5%) of the 34 group B specimens CMV infection was confirmed by immunohistochemistry (n = 6) or ISH (n = 2). Another 12 (35.3%) of the group B specimens negative on staining with haematoxylin and eosin, immunohistochemistry and ISH came from allografts in which previous or subsequent biopsy specimens were CMV positive. CONCLUSIONS--Demonstration of cytomegalic inclusion bodies in haematoxylin and eosin sections is sufficient for a diagnosis of CMV hepatitis. The routine use of immunohistochemistry in all allograft biopsy specimens in more sensitive than demonstration of inclusion bodies by staining with haematoxylin and eosin but may yield false negative results because of the focal distribution of positive cells. ISH was less sensitive than staining with haematoxylin and eosin and/or immunohistochemistry. A histological picture of "disseminated focal hepatitis" without viral inclusion bodies selects a group of allograft biopsy specimens in which immunohistochemistry and/or ISH may improve detection of CMV.

Effectiveness of histopathological diagnoses in dysfunction of hepatic transplantation. Review of 146 histopathological studies from 53 transplants.

In 47 patients who underwent 53 liver transplantations and immunosuppression with cyclosporine (cyclosporin A), methylprednisolone sodium succinate, and antithymocyte globulin, 146 histopathological studies were performed (138 biopsies, six hepatectomies, and two autopsies). The following microscopical diagnoses were made: 43 acute rejections (29.4%), six chronic rejections (4.1%), 18 liver blood perfusion changes (12.3%), 15 biliary changes (10.2%), 10 cases of functional cholestasis (6.8%), two drug reactions (1.3%), two hepatitis B virus recurrences (1.3%), 11 opportunistic viral infections (7.5%), 18 minimal changes (12.3%), two nonclassifiable changes (1.3%), and 19 plurietiological changes (13%). A histopathological diagnosis of acute rejection was made in 31 transplants (58.4%). In 22 (71%) of them, acute rejection was diagnosed with the protocol biopsy specimen that was obtained during the second posttransplant week. Leukocyte counts and serum bilirubin and enzyme levels were obtained on the same day that the hepatic biopsy specimens were taken. There was no significant statistical difference between the mean serum data that accompanied each histopathological diagnosis, allowing identification of a characteristic biochemical profile for the causes of graft dysfunction. We report a detailed description of the microscopical findings of each diagnosis and the following conclusions: (1) Acute rejection is the most frequent cause of hepatic dysfunction and has an early appearance during the posttransplant period. (2) Histopathological findings can identify the causes of the dysfunction. (3) There is no specific biochemical pattern to differentiate these causes. This may be due to the frequent combination of etiological factors in every dysfunction episode.

Liver transplantation for hepatocellular carcinoma: our experience from 1986.

UNLABELLED: Currently liver transplantation is the treatment of choice for early hepatocellular carcinoma and end-stage liver disease. We analyzed our experience to identify factors that could be used to select patients who will benefit from liver transplantation. PATIENTS AND METHODS: From April 1986 to December 2001, 71 (8.7%) of 816 LT performed in our institution, were for patients with hepatocellular carcinoma. In 25 patients the tumor was observed incidental by (35.2%). All patients had liver cirrhosis, most due to hepatitis C related (35) or alcoholic (14) diseases. Before liver transplantation, chemoembolization was performed in 18 patients (25.4%). RESULTS: Bilateral involvement was present in seven patients. Eight patients showed macroscopic vascular invasion, and eight others showed satellite nodules. Most patients were stage TNM II (29) and IVa (16). Overall 1-, 3-, and 5-year survival were 79.3%, 61%, and 50.3% with recurrence-free survivals of 74.6%, 57.5%, and 49%, respectively. With a mean follow-up of 42 months, 12 patients (19%) developed recurrence and 29 patients died (only 11 due to recurrence). Stage TNM IVa, macroscopic vascular invasion, and the presence of satellite nodules significantly affected overall survival and recurrence-free survival rates and histologic differentiation and bilateral involvement only recurrence-free survival. Patients with solitary tumors less than 5 cm or no more than three nodules smaller than 3 cm showed better recurrence-free survival and lower recurrence rates. DISCUSSION: In our experience, liver transplantation proffers good recurrence-free survival and low recurrence rates among patients with limited tumor extension. The most important prognostic factor was macroscopic vascular invasion.

Advantages of the piggy back technique on intraoperative transfusion, fluid compsumption, and vasoactive drugs requirements in liver transplantation: a comparative study.

INTRODUCTION: The piggyback technique was first described in adult liver transplantation in 1989, although it has been used in conjunction with venous bypass, with cross-clamping the vena cava, or both. In this study, the inferior vena cava was not occluded at any time during the liver transplant. OBJECTIVE: We compared the use of intraoperative blood products, fluid requirements, and vasoactive drugs among patients managed with bypass, without bypass, and with the piggyback technique. MATERIAL AND METHODS: Between May 1986 and October 2002, 875 liver transplants included 50 patients divided into three groups (cases considered to be the preliminary series on each group): group A/piggyback (17 patients:34%), group B/ bypass (16 patients: 32%), and group C/no bypass (17 patients:34%). There were no differences in mean age, gender, UNOS or Child-Pugh score, and indications for liver transplantation. RESULTS: Mean follow up was 134.63+/-32.19 months. At the end of the study, 91.3% of the patients are alive with no operative mortality. There were no differences in postoperative complications, postreperfusion syndrome rate, and postoperative renal failure. However, the number of packed red blood cell units consumed intraoperatively (12+/-7.43 vs 18.03+/-11.46 vs 17.59 +/- 23.8; P =.043), the need for intraoperative crystaloids (3.1 L+/-1.6 vs 6.8+/-4.8 vs 9.1 L+/-3.6; P=.001) and the requirement for vasoactive drugs (18% vs 38% vs 24%; P=.043) was notably lower in group A vs group B vs group C. Operative time was longer in group A (121.54+/-37.77 vs 78.73+/-11.89 vs 87.07+/-14.33 minutes). CONCLUSIONS: The piggyback technique requires a longer operative time but offers the advantages of reducing the red blood cell requirements and preventing severe hemodynamic instability by virtue of reducing the need for vasoactive drugs and for a larger volume of intraoperative fluids.

Simultaneous liver-kidney transplant for combined renal and hepatic end-stage disease.

INTRODUCTION: After the first combined liver-kidney transplantation (CLKT) reported by Margreiter in 1984, it became clear that renal failure was no longer an absolute contraindication. OBJECTIVE: Our goal was to assess our results with combined liver-kidney transplant. Among 875 liver transplants performed between May 1986 and October 2002, there were 17 cases (1.96%) of combined liver-kidney transplant. RESULTS: With a mean follow-up of 42.2+/-29 months (range, 1-90), six patients had died (mortality: 37.5%). There were four (25%) operative in-hospital deaths, and two late mortality cases (beyond the month 6 after hospital discharge). The causes were sepsis (four cases, three postoperative and one in later follow-up), refractory heart failure (one postoperative), and recurrent liver disease (HCV-induced severe recurrence) during follow-up one). Actuarial survival (calculated for those who survived the postoperative period) was 80%, 71%, and 60% at 12, 36, and 60 months. Actuarial mean survival time was 60 months (95%IC:47-78). Neither the sex, the UNOS status, the etiology of liver disease, the etiology of renal failure, the type of hepatectomy (piggy back vs others) or the type of immunosuppression (P=.83) were related to long-term survival according to the log-rank test. A control group of 48 patients was constructed with subjects who underwent liver transplantation immediately before or after the combined transplant. A total (two cases after the CLKT and one case prior to). There were no differences in survival. CONCLUSION: Combined liver-kidney transplant represents a proper therapeutic option for patients with simultaneously failing organs based on long- and short-term outcomes.

A clinopathologic review of 8 liver graft primary nonfunctions.

In a group of 276 consecutive liver transplants 8 primary graft nonfunctions were identified (2.9%). Recipients showed a progressive elevation of transferases (mean maximum value ALT: 5000 +/- 1892 U/l) and bilirubin (mean maximum value: 20 +/- 11.8 mg/dl) and a decrease in the percent prothrombin time (mean minimum value 26 +/- 13 min.) in the post-implantation survival time of the 8 grafts (range 1-5 days). No statistically significant differences were observed between mean cold and warm-ischemia times for these 8 donor organs and those of a control group of 92 consecutive grafts. All organs except one were ABO isogroup and all except another one displayed negative lymphocytotoxic crossmatch. Predominantly small-droplet hepatocytic vacuolization with no nuclear displacement was observed in plastic-embedded semithin sections of all post-primary nonfunction liver tissues (severe in 4 grafts, centri-mediozonal in 2, and centrolobular in 2). In 3 cases where fresh liver tissue was available the lipidic nature of the vacuoles was confirmed with electron microscopy and with frozen sections stained with Sudan III. Other microscopic lesions were also observed: spotty monocellular coagulative necroses, variable extension of zonal coagulative necroses and hemorrhages, cholestasis and minor mixed inflammatory infiltrate. Comparative microscopic study of these tissues with the protocol biopsy specimens obtained 2-4 hours after reperfusion demonstrated previous liver cell-vacuolization in only 3 cases. In conclusion, an acute progressive microvascular steatosis developed in this primary nonfunction series. No specific etiopathogenic factors were identified.

Diagnostic and treatment of Zenker's diverticulum: review of our series pharyngo-esophageal diverticula.

BACKGROUND/AIMS: Clinical aspects and preneoplastic potential of Zenker's diverticulum justify its surgery. The clinical signs of the patients and the size of the diverticulum determine the surgical technique. METHODOLOGY: Between January 1974 and December 1995, 32 patients underwent surgery in our department. In order to compare the surgical technique, we divided the patients into 3 groups: group A (cricopharyngeus myotomy: 15 patients (46.9%)), group B (myotomy with diverticulectomy: 15 patients (46.9%)) and group C (myotomy with diverticulopexy: 2 patients (6.7%)). The chi-square test was used for statistical analysis, p < 0.05. RESULTS: Local or regional anaesthesia was used in 7 patients from group A (46.6%); 5 patients from group B (33.3%) and all the patients from group C (100%). General anaesthesia was used in 8 patients from group A (53.4%), 10 patients from group B (66.7%) and 0 patients from group C (0%). The overall mortality was 0%. The mean postoperative stay in group A was 6 +/- 2 days (3-10 days); in group B was 11.6 +/- 6.4 days (5-25 days) and in group C was 3.5 +/- 0.7 days (3-4 days). The mean postoperative stay in patients with local or regional anaesthesia was 5.3 +/- 1.6 days (3-9 days) and in patients with general anaesthesia, 10.9 +/- 6.1 days (4-25 days). No statistically significant difference was found between the anaesthetic technique and the surgical technique (p = 0.193), between the surgical technique and the mean postoperative stay (p = 0.596) and between the anaesthetic technique and the mean postoperative stay (p = 0.166). CONCLUSIONS: Cricopharyngeus myotomy is the main surgical technique, however, in diverticula longer than 3 cm of diameter it is mandatory to associate diverticulectomy. Diverticulopexy is indicated in patients of advanced age with a high surgical risk. Local or regional anaesthesia facilitates the identification of the diverticulum intraoperatively and reduce the mean postoperative stay, however, there is no statistical significant difference.

Tracheo-colonic fistula: an exceptional complication after total replacement of an esophagus injured by acid.

A 49-year-old woman underwent emergency gastrectomy for suicidal caustic ingestion, followed later by transhiatal esophagectomy and left colonic interposition. A fistula developed postoperatively between the trachea and interposed segment of colon. This exceptional complication was successfully treated by resection of the fistula, closure of the colonic defect and tracheal myoplasty using the sterno-cleidomastoid muscle.

Surgical treatment of congenital dilatation of the biliary system.

Six out of 1,612 patients operated on for biliary diseases between January 1974 and January 1985, had Caroli's disease. A summary of the clinical records is included. The treatment performed was: external drainage in a patient with sepsis, who did not improve and died; left hepatic lobectomy and biliary-jejunal diversion in two patients; right extended lobectomy in one patient; distal spleno-renal shunt in a patient with severe biliary cirrhosis and recurrent hemorrhage from esophageal varices. The last patient suffered from a combination of a choledochal cyst and dilatation of the left intrahepatic branches, and underwent complete resection of the choledochal cyst, and biliary jejunal anastomosis on a porta-hepatis using a Roux-en-Y jejunal loop. Currently, five patients are recovering and are free of symptoms. The authors discuss the indications for liver resection and resection of a choledochal cyst.

Graft mass and volume calculation in living related donors for liver transplantation.

Living related liver transplantation is one of the strategies currently used to increase the donor pool. A preoperative and non-invasive estimate of the donor's liver volume is needed to ensure sufficient functional liver reserve for survival after resection, and to obtain a graft of adequate volume to suit the recipient's features. A method based on a preoperative abdominal computerised axial tomography of the donor, that enables the volume and mass of the whole liver, and the graft, to be calculated is herein described. The compatibility of the estimate with real graft mass after its removal has been proved, and the accuracy of the calculi has been compared with other published methods. Moreover, progressive growth of the recipient liver remnant has been demonstrated in subsequent explorations.

Anesthetic support in synchronous liver and kidney transplantation.

BACKGROUND/AIMS: We performed a retrospective evaluation of 11 patients in the final stages of hepatic disease with chronic kidney failure, in whom simultaneous double liver-kidney transplantation was performed. METHODOLOGY: In the immediate pre-, intra- and postoperative periods, we assessed metabolic, hemodynamic and coagulation parameters; bicarbonate, calcium and inotropic drug requirements; the incidences during reperfusion of the graft; the surgical technique employed; the need for hemodialysis and/or ultrafiltration; and the survival rate of the patients. RESULTS: Of the 11 cases studied, four patients needed hemodialysis, while only one patient needed ultrafiltration; three patients required both techniques, and no dialysis or ultrafiltration was performed in three patients. The following surgical techniques were employed: Total clamping of the inferior vena cava using an external venovenous bypass in two cases; total clamping of the inferior vena cava without an external venovenous bypass in three cases; and partial clamping of the inferior vena cava with preservation of the retrohepatic cava in six cases. The results showed one death in the first postoperative month and two deaths in the course of subsequent follow-up. The survival rate was 72.7%. CONCLUSIONS: The use of conventional intraoperative hemodialysis and/or ultrafiltration is feasible, useful and achieves good results in patients undergoing double liver-kidney transplantation. Partial clamping of the inferior vena cava at the anhepatic stage appears to reduce the need for ultrafiltration. There is no increase in perioperative mortality in patients who underwent liver transplantation while conserving their renal function.

Hepatic myelolipoma: new case and review of the literature.

We present a case of hepatic myelolipoma that was treated by performing a right hepatic lobectomy. These tumors are very uncommon and present great problems for the pre-operative diagnostic evaluation. Currently, the diagnosis is essentially histopathological with a definitive diagnosis being made by immunocytochemical staining. We have found no reports on this type of tumor in the Spanish literature; a review of the published cases confirms our observations and conclusions regarding hepatic myelolipoma.

Arterial reperfusion in human orthotopic liver transplantation by anastomosis of the celiac trunk to the right or left hepatic artery of the recipient.

Fifteen orthotopic liver transplants were performed from 23 April 1986 to June 1987 in 14 patients (age range 3-56 years). In 12 transplants, extracorporeal bypass was used. The installation was effected by suprahepatic and infrahepatic cava-caval and portaportal anastomoses. Arterial anastomosis was realized after reperfusing the graft through the vena porta. In 13 transplants the donor celiac trunk was anastomosed to the receptor's right hepatic artery. In one ten year-old girl, the donor celiac trunk was anastomosed to the left hepatic artery. In one patient who underwent retransplantation for rejection, the donor organ had two separate hepatic arteries and the right and left hepatic arteries were respectively anastomosed to the right and primitive hepatic arteries of the receptor. All patients were followed up periodically by Doppler echography and trimethyl-Br IDA 99 mTc scan, which, consistently confirmed the permeability of the anastomosis and dependent vessels, and the good perfusion and function of the grafts, which were free of infarcted areas. Three patients died at 30 and 31 days and postmortem studies demonstrated vascular permeability. Angiography was performed in one patient, evidencing a good vascular caliber in the hepatic arteriography.

[Intraoperative esophageal manometry in the surgical treatment of achalasia]. / Manometría esofágica intraoperatoria en el tratamiento quirúrgico de la acalasia.

Since 1985 we have done intraoperative manometry in 54 patients operated for achalasia. Manometry allows the assessment of the completeness of the division of the high pressure zone and ascertain the length of fundoplication (Nissen) as well as its pressure. In 26 patients pH and manometric controls were done postoperatively. Absence of reflux was noted in all and the pressure level after operation was 12.53 +/- 4.94 mmHg. Pressure measurements were not different from those of a group of 15 healthy subjects (15.2 +/- 2.45 mmHg). Dynamic studies of the high pressure zone revealed a post-deglutition relaxation of 72.5 +/- 16.32% over the basal tone. We believe that intraoperative manometry is essential in the surgical treatment of achalasia as it allows a precise control of myotomy as well as the fashioning of a high pressure zone to avoid reflux.

[The surgical treatment of esophageal leiomyomas: a report of 9 cases and a review of the literature]. / Tratamiento quirúrgico de los leiomiomas esofágicos: aportación de nueve casos y revisión de la literatura.

We report a series of 9 leiomyomas of the esophagus treated surgically. We review the literature, emphasizing diagnostic and therapeutic aspects, calling special attention to the good results obtained by submucosal enucleation of the tumor.

[Effects of total gastrectomy on the nutritional status]. / Efectos de la gastrectomía total sobre el estado nutricional.

In this study, we have analyzed a series of 88 patients who underwent total gastrectomy followed by two different reconstructive procedures, Roux-en-Y jejunal interposition (57%) and interposition of a jejunal limb between the oesophagus and the duodenum (38%) (Henley procedure). We examined diet, intestinal transit, symptoms of dumping syndrome and body weight curves. Patients with Roux-en-Y reconstruction presented post-prandial sweating more often (48%) than patients with the Henley procedure (21%). Forty percent patients with Roux-en-Y reconstruction suffered post-prandial nausea whereas this finding was not associated with patients after the Henley procedure. The reconstructive method has to be chosen considering the age and general condition of the patient, stage of the neoplasia and its curability. We currently favor Roux-en-Y esophagojejunostomy. However, in selected patients the Henley procedure may prove useful in order to prevent reflux and dumping symptoms.