Invasive gastrointestinal zygomycosis in a liver transplant recipient: case report.

BACKGROUND: Gastric zygomycosis is a rare but potentially lethal complication in transplant patients. Forty-two cases of gastric mucormycosis have been described in the literature, with a mortality of 98%. METHODS: We report of a case of gastric mucormycosis in a 45-year-old male undergoing liver transplantation for alcohol-induced cirrhosis. The diagnosis was made 20 days after transplantation in a biopsy of a bleeding gastric ulcer identified during a reoperation for a common bile duct stricture. RESULTS: After the surgical procedure and therapy with amphotericin B, the patient made a good recovery and is alive and well 2 years after transplantation. CONCLUSIONS: Gastric mucormycosis should be suspected in those patients in whom gastrointestinal symptoms such a pain or bleeding are present. Because the diagnosis is dependent on histology, the importance of biopsy cannot be underestimated. Once diagnosed, a successful outcome depends on effective treatment with amphotericin.

Ex situ preparation of left split-liver grafts with left vascular pedicle only: is it safe? A comparative single-center study.

The procurement of left-lateral-segment grafts from living donors for transplantation in children is performed by retaining only the left branches of the artery and veins. New techniques and the implementation of microsurgery in the transplant operation made this procedure a successful approach. However, controversy persists about using such an approach for division of liver grafts from cadaveric donors, and many teams prefer retaining the main arterial trunk with the left split graft, with or without the main portal vein trunk. Since 1998, in our center, when a donor-liver graft is divided we prefer retaining the main vessels with the right split graft if graft vascular anatomy is favorable. After 1998, 40 liver grafts from cadaveric donors were divided, and all divisions were performed ex situ. This experience was retrospectively reviewed to compare the outcome of left split grafts prepared for implantation with the left vasculature only (group A), or with the main arterial supply (group B). A single vascular complication occurred (one hepatic artery thrombosis in group B). Three patients died (one in group A and two in group B) and three other grafts were lost (one in group A and two in group B). One-year and 3-year graft survival rates were 94% and 86% in group A, and 83% and 83% in group B, respectively (not significantly [NS] different). We conclude that left split grafts can be safely transplanted with the left vascular supply only, provided that division is guided by careful anatomical evaluation and that vascular reconstructions are adequate.

A simple scoring system to evaluate the effects of cold ischemia on marginal liver donors.

BACKGROUND: Exactly what constitutes a marginal donor remains ill defined. The authors set out to create a scoring system that objectively classifies a donor as marginal or nonmarginal and to define what the maximum acceptable preservation period is for the marginal liver to minimize early graft dysfunction. METHODS: The authors performed an analysis on data collected prospectively of 397 cadaveric liver transplants. Both univariate and multivariate analyses were performed on donor, recipient, and perioperative factors with relation to early allograft dysfunction. A score was developed that classified donors into marginal and nonmarginal populations, and the influence of cold ischemia was determined for each group. RESULTS: Multivariate analysis-determined donor age and steatosis (moderate to severe) were independent predictors of deranged function. This enabled the authors to produce a scoring system to differentiate marginal donors with respect to risk of early allograft dysfunction as follows: Formula=(20.06xsteatosis)+(0.44xdonor age), cutoff 23.1. In the marginal group, the cutoff value of cold ischemia time was 12.6 hr. CONCLUSIONS: The authors developed a scoring system that classified an organ as marginal or nonmarginal depending on the donor age and degree of steatosis. Marginal livers have a strong risk of developing early allograft dysfunction with increasing cold ischemia times and should be transplanted within 12 hr. Cold ischemia time was not found to be an important factor in the development of early allograft dysfunction in nonmarginal donors.

Colorectal cancer in patients with inflammatory bowel disease after liver transplantation for primary sclerosing cholangitis.

BACKGROUND: Patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) may have an increased risk of developing colorectal cancer (CRC) after liver transplantation (LT). We evaluated our patients with PSC after LT to identify risk factors for CRC and its impact on survival. PATIENTS AND METHODS: A total of 152 patients (108 men, 100 with IBD) with PSC who underwent 173 LTs between 1986 and May 2000 were analyzed in three groups: (1) PSC without IBD (n=52); (2) PSC with colectomy (pre-LT and at LT) (n=17, colectomy pre-LT in 13 and simultaneous colectomy at LT in four); and (3) PSC with IBD and an intact colon (n=83). The following factors were studied: age, gender, liver, and renal biochemistry, international normalized ratio, Child-Pugh stage, operative time, blood use, hospital stay, immunosuppression, risk of CRC, retransplantation rate, and mortality. RESULTS: The incidence of CRC after LT was 5.3% (8/152) compared with 0.6% (7/1,184) in non-PSC cases (P<0.001). All CRCs in the PSC group were in patients with IBD and an intact colon. The cumulative risk of developing CRC in the 83 patients with an intact colon and IBD was 14% and 17% after 5 and 10 years, respectively (PSC non-IBD group 0% risk after 10 years, P<0.06). The multivariate analysis showed three significant variables related to the risk of developing CRC: colonic dysplasia after LT (P<0.0003), duration of colitis more than 10 years (P<0.002), and pancolitis (P<0.004). The cause of death in patients with CRC was cancer related in 75% of cases with a reduced 5-year survival of 55% versus 75% without CRC (not significant). CONCLUSION: Patients with PSC undergoing LT with a long history of ulcerative colitis and pancolitis have an increased risk of developing CRC with reduced survival. We advocate long-term aggressive colonic surveillance and colectomy in selected high-risk patients with longstanding severe colitis.

Remodeling of the immunoinflammatory network system in elderly cancer patients: implications of inflamm-aging and tumor-specific hyperinflammation.

Although it is generally accepted that aging increases postoperative morbidity and mortality rates, the underlying mechanism remains unknown. The present review evaluates the clinical implications of remodeling the immunoinflammatory status with reference to inflammaging and tumor-specific hyperinflammation. We conducted a Medline/PubMed search for articles investigating factors related to aging and their effects on postoperative outcomes. Inflamm-aging results in both decreased immunity to exogenous antigens and increased auto-reactivity, whereby the beneficial effects of inflammation devoted to the neutralization of harmful agents early in life become detrimental late in life. Cancer also represents an immunologic challenge, which upregulates the systemic immune response. Thus, tumor-related hyperinflammation and inflamm-aging synergistically lead to the systemic priming of inflammatory mediators preoperatively; then, surgical stress acts as the second hit, increasing the risk of an exaggerated postoperative inflammatory response. Age-related molecular events may place elderly patients at greater risk of postoperative complications which could result in death. For regulating uncontrolled hyperinflammation, the clinical advantages of perioperative immunonutrition or steroids have been advocated; however, double-blind, randomized, controlled trials of pharmacologic modulation therapy are needed.

Worth continuing doing ex situ liver graft splitting? A single-center analysis.

Grafts for split liver transplantation can be prepared in situ during the retrieval operation, or ex situ on the back table. The in situ technique has theoretical advantages because it minimizes the cold ischemic time and allows excellent hemostasis at the cut surface. However, in situ liver division prolongs the retrieval procedure, may precipitate hemodynamic instability in the donor, and may cause logistical difficulties for some centers. This report is a single-center analysis comparing results of ex situ liver division (group I: 1992-97; and group II: 1998-2001) before and after a new protocol for liver graft division was introduced in our center. Eighty-nine split liver transplants (SLT) were reviewed retrospectively. Vascular complications were less common in group II (3.3% vs. 20%; p = 0.04), and 1-year graft survival increased from 59% to 78% (p = 0.03). Since 1998, 1-year graft survival of SLT has been similar to that of conventional liver graft transplantation in our center (78% and 74%, respectively). In conclusion, good results can be achieved from splitting livers ex situ and this procedure should be considered when the in situ technique is not feasible.

Hepatic-artery aneurysm in adult liver transplantation.

Hepatic artery aneurysm (HAA) is a rare vascular complication, but has a high mortality rate in liver transplant recipients. This study reports the precipitating factors, clinical manifestation, pre-operative diagnosis, related micro-organism, management, and outcome, in a series of HAAs that developed after adult orthotopic liver transplantation (OLT). Data on the primary disease as well as on the above were obtained from a prospective database, and all case records were reviewed. There were eight (0.5%) HAAs in 1,575 adult cadaveric OLTs between 1982 and March 2001. All were pseudo-aneurysms around the native hepatic-artery (HA) anastomosis, and all occurred in whole-organ OLTs. There were three types of clinical presentations: sudden hypotension (n=4), gastrointestinal (GI) bleeding (n=2), and abnormal liver-function tests (LFTs) (n=2). The majority (n=7) presented within the first 2 months (median: 27.5 days, range: 12-760 days) following OLT. A pre-operative diagnosis of HAA was not determined in five cases. The sensitivity of abdominal ultrasound scan (USS), computed tomography (CT) scan and angiography for detection of HAAs was 3 of 5, 1 of 2 and 3 of 4, respectively. Micro-organisms could be identified in six patients (bacteria n=4 and fungi n=3). All patients underwent urgent operations (excision of HAA in six and ligation in two cases). Immediate reconstruction of the HA was carried out, two different methods being used: repair of native arteries (n=2) and arterial conduit (interposition n=3 and aortic conduit n=2). Two patients died peri-operatively, two died within 2 months, and the remaining four patients are alive at between 8.6 and 12.8 years after repair. HAA following OLT is unpredictable in its presentation, and the sensitivity of clinical and radiological detection is low. A high index of suspicion is required, and urgent surgery with immediate re-vascularisation and use of appropriate antibiotic/anti-fungal agents is recommended.

Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry.

The European Liver Transplant Registry (ELTR) currently allows for the analysis of 44,286 liver transplantations (LTs) performed on 39,196 patients in a 13-year period. After an exponential increase, the number of LTs is plateauing due to a lack of organs. To cope with this, alternatives to cadaveric LT, such as split LT, domino LT, or living-related LT (LRLT) are being used increasingly. They now account for 11% of all procedures. One of the most important findings in the evolution of LT is the considerable improvement of results along time with, for the mean time, a one-year survival of 83%, all indications confounded. The improvement is particularly significant for cancers. This improvement is mainly represented by hepatocellular carcinoma, with a gain of 17% for 5-year survival rate from 1990 to 2000. Increasingly, older donors are used to augment the donor pool and older recipients are transplanted due to improved results and a better selection of patients. More than two thirds of deaths and three quarters of retransplantations occurred within the first year of transplantation. Retransplantation is associated with much less optimal results than first LT. One of the prominent features of recent years is the development of LRLT. LRLT is now performed by almost half of the European centers. As with split LT or domino LT, LRLT aims to provide more patients to be transplanted. Special attention is paid to reducing the risk for the donor, which is now estimated to be 0.5% mortality and 21% postoperative morbidity.