Right-sided diaphragmatic hernia after orthotopic liver transplantation: report of two cases.

Diaphragmatic hernia after OLT is a rare surgical complication. We here report successful diagnosis and treatment of two cases with right-sided diaphragmatic hernia developed after OLT both utilizing left-sided allografts. Combination of factors related to the surgical techniques and patient characteristics might explain the pathophysiology behind the diaphragmatic hernias following liver transplantation. Respiratory as well as non-specific gastrointestinal symptoms may be hints for an overlooked diaphragmatic hernia after liver transplantation. Diaphragmatic hernia should be added to the list of potential complications of liver transplantation for prompt diagnosis and appropriate treatment.

Intrahepatic cholangiocarcinoma arising in chronic viral hepatitis-associated cirrhosis: two transplant cases.

Hepatitis C virus (HCV) or hepatitis B virus (HBV)-related cirrhosis is known to be a risk factor for hepatocellular carcinoma (HCC). Recently, these viruses have been reported to have an etiologic role in the development of intrahepatic cholangiocarcinoma (ICC). Herein we have reported two cases of HCV- and HBV-related cirrhosis with ICC in whom the pretransplant diagnosis was HCC. The patient with HCV cirrhosis, was a 47-year-old woman with a large nodule in the right lobe. The patient with HBV cirrhosis was a 45-year-old man with two nodules. Serum tumor marker levels, carcinoembryonic antigen (CEA), alphafetoprotein (AFP), and carbohydrate antigen 19-9 (CA 19-9) were determined before live donor liver transplantation (LDLT). The patient with HCV cirrhosis showed mildly elevated serum levels of AFP. The patient with HBV cirrhosis showed an elevated CA 19-9 level. On microscopic examination, all nodules exhibited typical morphological findings of adenocarcinoma. The patient with HCV cirrhosis developed brain metastases 4 years after LDLT. The patient with HBV cirrhosis is disease-free at 18 months after transplantation. In cirrhotic patients with active malignancy who are candidates for LDLT, ICC should be considered in the differential diagnosis. Although the literature is limited, selected patients with ICC may benefit from LDLT.

Simultaneous air transportation of the harvested heart and visceral organs for transplantation.

BACKGROUND: The purpose of this study was to evaluate the duration for organ procurement including both heart and visceral organs and outcomes of the simultaneous transportation of the teams back to the recipient hospitals. PATIENTS AND METHODS: Between March 2005 and March 2007, 37/82 organ procurement was performed in the district hospitals and transported to our institution for organ transplantation. Combined heart and visceral organ procurement which was simultaneously transported to the recipient hospitals by one air vehicle was reviewed. After both the thoracic and abdominal cavities were entered, all intra-abdominal organs were mobilized allowing exposure of the inferior mesenteric vein and aorta. The supraceliac abdominal aorta was elevated. The attachments of the liver in the hilar region were incised and both kidneys and pancreas prepared for removal. After the inferior mesenteric vein and aorta were cannulated, simultaneous aortic cross-clamping was performed and cold preservation solution infused. Harvested organs were packed with ice and removed to the back table for initial preparation and packaging for air transport. RESULTS: The mean duration of 6 procurement procedures was 63 minutes (range 50-75 minutes) to aortic clamping, and 27.5 minutes (range, 20-40 minutes) between clamping and harvesting. Mean cold ischemia times for 6 hearts, 6 livers, 12 kidneys, 2 pancreas, and 1 small intestine were 2.4 hours (range, 2-3.5 hours), 5 hours (range, 3-8 hours), 10.3 hours (range, 8-15 hours), 6.7 hours, and 9.5 hours, respectively. No graft complication was observed to be associated with the procurement procedure. CONCLUSION: Better collaborations between surgical teams and rapid procurement techniques provide simultaneous air transportation back to the recipient hospital with reduced cold ischemia times of the visceral organs.

Preoperative helical computerized tomography estimation of donor liver volume.

BACKGROUND: The purpose of this study was to evaluate the accuracy of spiral computed tomography (CT) and 3-D imaging models in measuring total and segmental liver volume in potential living donors. METHODS: A prospective study was undertaken to assess the correlation between the volumes of potential donor livers determined via helical CT and the actual volumes measured during operation in 150 donor candidates. Left-lateral segment (S2,3) or left-lobe (S2,3,4) transplantation was performed in 36 cases with 96 right-lobe liver transplants (S5,6,7,8). Ten donor candidates were refused owing to inadequate liver volumes, and 8 for other reasons. RESULTS: The regression analysis model showed a significant correlation between the preoperative CT estimates of graft volume and intraoperative weight measurement of harvested grafts in living liver donors (F: 5525.37; P < .05); 97.7% of changes in CT volume were explained by differences in graft mass (R2: 0.977). CONCLUSION: Preoperative estimation of segmental volumes of the donor liver is necessary to avoid donor-recipient size disparity, thereby preventing hepatic failure of donors after harvesting. It has a major impact on donor selection and type of surgical management. The accuracy of helical CT was high to determine total and segmental liver volumes.

The incidence and management of acute and chronic rejection after living donor liver transplantation.

Living donor liver transplantation (LDLT) is a good alternative to cadaveric liver transplantation for end-stage liver disease. Herein we report the outcome of 132 LDLTs performed between 1999 and 2005, with special emphasis on the incidence and management of acute and chronic rejection. Among the LDLT population a first acute rejection episode (ARE) was clinically suspected in 24% and proven by liver biopsy in 11%. According to the Banff classification, 50% of AREs were grade 1, and 50%, grade 2. There was no grade 3 AREs. The first ARE occurred between 7 days and 23 months posttransplantation (mean 97 days, median 70 days). Ninety-seven percent (31/32) of the AREs occurred within the first year after transplantation and 3% (1/32) in the second year. Among the patients with ARE, 23% developed a second ARE between 4 and 11 months. A third ARE was detected in 8% of patients after month 18. All AREs responded to adjustment of immunosuppressive doses or steroid boluses. Chronic rejection (CR) was detected in 2%. In conclusion, the incidences of ARE and CR are consistent with the previously reported data. Acute and chronic rejections seem to be mild and easily manageable clinical conditions. Our results also showed a significant difference between clinically suspected and biopsy-proven ARE emphasizing the importance of indicated liver biopsies in the management of the LDLT population.

Primary hepatic marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type in a liver transplant patient with hepatitis B cirrhosis.

We describe the clinical, histological, and immunohistochemical features of primary hepatic low grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) in a liver transplant recipient with hepatitis B cirrhosis. MALT lymphomas arise in organs normally devoid of lymphoid tissue, which accumulates as a consequence of chronic antigenic stimulation associated with chronic infection or autoimmune disease. Primary hepatic MALT lymphoma is extremely rare; 13 cases have been reported worldwide to date. Our patient is the first case of primary hepatic MALT lymphoma associated with hepatitis B cirrhosis who was treated with orthotopic liver transplantation.

Roux-en-Y bleeding after living donor liver transplantation: a novel technique for surgical treatment.

Upper gastrointestinal bleeding (GIB) is one of the most common gastroenterologic complications following liver transplantation. The aim of this study is to define the prevalence of GIB due to Roux- en Y (R-Y) enteral anastomoses after living donor liver transplantation (LDLT) and recommend an anastomotic technique for easy surgical intervention. Ninety-five patients underwent 96 LDLT from June 1999 through January 2003. R-Y biliary reconstruction was employed in 43 patients. Anastomoses were end-to-side (ES) in the first 25 patients and side-to-side (SS) type in the last 18 patients. GIB occurred in 13 patients (30%). The R-Y anastomotic line was shown to be the bleeding site in 10 patients. Anastomoses were in ES fashion in 7 of 10 patients (70%). In other words 28% of ES and 17% of SS anastomoses displayed a bleeding episode after LDLT. Four patients required surgical intervention (Three ES, one SS), namely an operative rate of 9%. The type of the jejunojejunostomy, the UNOS or Child-Pugh scores, the presence of preexisting portal hypertension, the duration of portal vein clamping, the GRWR of patients, revealed no statistical significant difference between bleeding and non- bleeding patients. Although statistical analyses did not reveal any significant difference (P =.47), GIB was higher among patients with an ES type of anastomoses. As a result we recommend a jejunojejunostomy in SS fashion on the antimesenteric borders of the jejunal segments with a 3-4 cm blind intestinal segment. The surgical procedure for R-Y bleeding may then be performed without disrupting the jejunojejunostomy.

Hepatocellular carcinoma in liver transplant era: a clinicopathologic analysis.

Hepatocellular carcinoma (HCC) is one of the most common tumors in the world, and the prognosis is usually poor. Today, liver transplantation (LT) is a radical but frequently curative treatment modality for HCC. In selected patients, it cures HCC and the underlying cirrhosis at the same time. The present clinicopathological study examined the importance of tumor characteristics for their effects on recurrence and survival rates after LT for HCC. Forty-two native hepatectomy specimens among 250 consecutive orthotopic liver transplantations contained HCC. Patients were predominantly men (30 men, 12 women), ranging in age from 1 to 61 years (median 51). While 20 patients received cadaveric organs, 22 were transplanted from living donors. In 14 patients (33%) HCC presented as a solitary nodule, 5 (12%) as two nodules; 2 (5%) as three nodules; and 21 patients (50%) as more than three nodules. The maximal diameter of the largest tumor not larger than 3 cm in 28 patients (66%), exceeding this size in 14 patients (34%). There was a significant correlation between nodule number and tumor size (r = 0.36, P = 0.05). While 23 patients had no sign of vascular involvement, 17 tumors showed microscopic invasion and two large vessel involvement. There was a positive correlation between vascular invasion and nodule number (r = 0.41, P = 0.05). The histopathological grade of differentiation of the tumors was assessed as "well" in seven patients (14%), moderate in 28 (72%), and poor in 7 (14%). The differentiation was significantly poorer when vascular invasion was observed (r = 0.43, P =.01). According to the TNM classification, 11 patients (26%) were stage I, 6 (14%) stage II, 13 (31%) stage III, and 12 (29%) stage IV. After a median follow-up of 10 months (1-50 months), the overall mortality was 18% (n = 8). Patient survival at 6 month, 1, and 4 years was 88%, 80%, and 60%, respectively. The outcome was significantly poorer for TNM stage IV versus stage I,II, and III tumors to (P =.02). Tumor recurred in three patients at 4,6, and 50 months after liver transplantation. The sites of recurrence were bone, lung, and adrenal glands. In conclusion, liver transplantation represents a safe and feasible treatment for hepatocellular carcinoma with excellent outcomes compared with other treatment modalities. Liver transplantation offers excellent survival rates and chance for cure in stages I, II, and III hepatocellular carcinoma in cirrhotic patients.

Impact of pretransplant MELD score on posttransplant outcome in living donor liver transplantation.

It is not clear whether pretransplantation MELD (model for End-Stage Liver Disease) score can foresee posttransplant outcome. We retrospectively evaluated 80 adult patients (55 men, 25 women) who underwent living donor liver transplantation between September 1998 and March 2003. Five other patients with fulminant hepatitis were excluded. The UNOS-modified MELD scores were calculated to stratify patients into three groups: group 1) MELD score less than 15 (n = 13); group 2) MELD score 15 to 24 (n = 36); and group 3) MELD score 25 and higher (n = 26). The patients were predominantly men (n = 52, 69.3%) with overall mean age of 43.9 years (range, 17-62 years). The mean follow-up was 15.7 months (range, 1-47; median = 14 months). The mean MELD score was 22.7 (range, 9-50; median = 21). The overall 1- and 2-year patient survivals were 87% and 78.7%, respectively. The 1-year patient survivals for groups 1, 2, and 3 were 100%, 87%, and 79%; respectively. 2-year survivals, 100%, 79%, and 61%, respectively. Survivals stratified by MELD showed no statistically remarkable differences in 1-year and 2-year patient survival (P = .08). In contrast, 1-year and 2-year patient survival rates for UNOS status 2A, 2B, and 3 were 73%-50%, 95%-91%, and 91%-91%, statistically significant difference (P = .002). Finally, to date preoperative MELD score showed no significant impact on 1- and 2-year posttransplant outcomes in adult-to-adult living donor liver transplantation recipients, but we await longer-term follow-up with greater numbers of patients.

Variations of hepatic veins: helical computerized tomography experience in 100 consecutive living liver donors with emphasis on right lobe.

Anatomical variations in the venous system of liver are not a rarity. A prospective helical computerized tomography (CT) study was undertaken to determine the prevalence of surgically significant hepatic venous anatomic variations among 100 consecutive living liver donors. The studies evaluated the ramification pattern of hepatic veins, the presence of accessory hepatic veins, and of segment 5 or 8 veins (or both) draining into middle hepatic vein. These data obtained by CT influenced surgical planning. Sixty-four donors donated their right lobes and 24 donors, left lateral segments. Only one donor candidate was refused due to combined hepatic and portal venous variations accompanied by multiple bile ducts. Eleven donors were also refused due to reasons other than anatomical variations. Seventeen segment 5 and 17 segment 8 veins draining into middle hepatic vein were anastomosed to inferior vena cava in 23 (36%) of the right lobe liver transplantations. The middle hepatic vein was harvested in only one of the donors. Among the 100 cases, 47 had accessory right inferior hepatic veins, 13 of which were multiple. Twenty-two of the right lobe grafts required surgical anastomoses of these accessory hepatic veins (34%). An isolated hepatic vein anomaly or the presence of accessory hepatic veins are not contraindications to be a living liver donor candidate. However, preoperative knowledge of vascular variations alters surgical management. Helical CT is a valuable tool to delineate the hepatic venous anatomy for surgical planning in living liver donors.

Results of surgery-related complications in donors of right lobe liver graft: analysis of 272 cases.

BACKGROUND: Living donor liver transplantation has been a new light of hope for patients with end-stage liver failure on the cadaveric waiting list. However, living donor liver transplantation still has ethical problems which cannot be overcome. Exposure of healthy donor candidates to major surgery which can be fatal is the largest of these ethical problems. In this study, we aimed to determine our rate of complications associated with surgery in donors who underwent right lobe donor hepatectomy. MATERIALS AND METHODS: Between September 2004 and December 2009, 548 liver donor candidates were examined. The right liver lobe donor hepatectomy was performed on 272 donor candidates who passed the elimination system. Demographic data as well as intraoperative findings, complication rates, and numbers were collected retrospectively. Donor complications were categorized according to the Clavien classification. RESULTS: Two hundred seventy-two donors who underwent right lobe donor hepatectomy were included in this study. One hundred sixteen (42.6%) of 272 donors were female, whereas 156 (57.4%) were male. There was no donor mortality. Grade 1 and grade 2 complications were observed in 105 (38%) of 272 donors. The most common complications were fever of unknown origin (20.9%) and prolonged hyperbilirubinemia (3.6%). Grade 3 complications and grade 4 complications were observed in 6 donors (2%) and 3 donors (1%), respectively. Three donors were underwent re-operation due to bleeding. The re-laparatomy rate in our series was detected as 1.10%. One donor, categorized as grade 4B according to the Clavien classification, had small bowel perforation and intra-abdominal sepsis secondary to mechanical bowel obstruction. CONCLUSIONS: Donor mortality is a fact of living donor liver transplantation that cannot be ignored like donor morbidity. However, right liver lobe donor hepatectomy can be performed successfully with minimal complication rates with multidisciplinary and rigorous donor care in the preoperative and postoperative period.

Comparison of the harmonic scalpel and the ultrasonic surgical aspirator in subsegmental lung resections: an experimental study.

BACKGROUND: In this study, we evaluated the effectiveness of two devices using ultrasonic energy for dissection of lung parenchyma in an experimental animal model by comparing the two methods with each other. METHODS: Twenty New Zealand rabbits were used. One-lung ventilation was obtained under direct vision and the left lung was collapsed. The rabbits were ventilated with pressure-controlled ventilation during the experiment, beginning with a pressure level of 10 cmH(2)O. After a 1 x 1-cm pulmonary wedge resection of part of the collapsed left lung using a harmonic scalpel (group A) or an ultrasonic surgical aspirator (group B), the left lung was inflated and the pressure level was increased by 5 cmH(2)O every five minutes. The pressure level which caused an air leak from the resection surface was recorded. The morphological damage to the lung parenchyma was evaluated under light microscopy. RESULTS: The mean value of airway pressure levels that resulted in an air leak from the resection surface was 32.5 +/- 9.2 cmH(2)O for group A and 24.5 +/- 2.9 cmH(2)O for group B, and the difference between the two groups was statistically significant. The mean level of coagulation necrosis was 558.6 +/- 380.8 microns (133 - 1064 microns) for group A. No tissue damage to pulmonary parenchyma was observed in group B. CONCLUSION: The harmonic scalpel can be safely used in peripheral lung resections without needing any other method to ensure hemostasis and air tightness. The ultrasonic surgical aspirator can be used for the dissection and resection of deeper lesions and preserves more lung tissue but requires additional interventions for control of the air leak from the resection surface.