Liver Re-transplantation in Adults: Indications and Outcomes Analysis of a 23-year Experience in a Single Center in Argentina.

Background: Liver re-transplantation (re-LT) represents the only treatment for patients with irreversible graft failure. Objective: The aim of the current study was to describe the outcomes of both, patient and graft, after re- LT, at a high-volume referral center. Methods: Our population consisted of patients, with liver disease, who underwent re-LT in our institution between January 1996 and December 2019. Results: 49 patients met the inclusion criteria. The patient's overall survival (OS) for the first year was 85% (Confidence Intervals (CI) 71-92) and 70% at five years (CI 53-82). In our population, three (6.12%) patients presented loss of graft and were included again in the transplant list; of these, one agreed to a new transplant while the remaining two died. This gave us graft survival results similar to those obtained for the re-LT patient; 85% at one year (CI 71-92) and 70% at 5 years (CI 53-82). Conclusion: Our study shows that re-LT is a valid and safe treatment for both early graft dysfunction and for transplanted patients who again present end-stage liver disease, showing a satisfactory long-term evolution, with parameters comparable to primary transplantation.

Conversion and pharmacokinetic studies of a microemulsion formulation of cyclosporine in pediatric liver transplant patients.

A study of conversion from the standard cyclosporine treatment to a microemulsion formulation was performed in 29 stable pediatric liver transplant patients. The study was divided into conversion and in follow-up phases. While on therapy with the standard formulation at a mean daily dose+/-SD of 231+/-101.8 mg patients had a mean cyclosporine trough level of 188.7+/-51.4 ng/ml. Following a 1:1 conversion from the standard to the microemulsion formulation an increase in the cyclosporine trough level was observed in 75% of the patients. The mean cyclosporine trough level at this point was 221.5+/-69.7 ng/ml. On follow-up, the dose had to be reduced an average of 21.7% in 49% of the patients, whereas the rest remained stable. The incidence of adverse events was not significant and no differences were observed between the two formulations. The pharmacokinetic study of the microemulsion in 11 patients showed a monophasic curve, with an early absorption at 30 min and maximum concentration+/-SD of 880.8+/-72.8 ng/ml and time to maximum concentration of 1.5+/-0.12 hr. Basal time showed the least correlation with the area under the curve and T4 the most statistically significant. The microemulsion showed better bioavailability and pharmacokinetic characteristics than the standard formulation.

Liver transplantation as treatment for arterioportal fistulae.

The authors present the case of a 14-year-old boy with secondary portal hypertension caused by arterio-portal fistulae. Ascites, edema, severe abdominal pain, and steatorrhea developed in the patient. In an attempt to decrease arterioportal flow the authors carried out vascular embolization that was partially successful. A liver transplant was performed as a last therapeutic resource in view of the fact that it constitutes an accepted therapy for patients with severe liver disease. Orthotopic liver transplantation may be considered as another possible treatment of arterio-portal fistulae.

[Multifocal biliary papillomatosis: an indication for liver transplantation]. / Papillomatose multifocale des voies biliaires: une indication de transplantation hépatique.

Biliary papillomatosis is a uncommon disease. Because of the high rate of recurrence and the possibility of malignant transformation, liver resection or transplantation was recommended. A case of diffuse bilobar biliary papillomatosis, in a 60 years old patient, responsible for cholangitis, cholestasis and for high portal pressure (esophageal varices grade I and II and hypersplenisme) is reported. The patient had had an external biliary drainage leading to an great loss of hydroelectrolytic component important. Opacification and biopsies under endoscopic control assert the right diagnosis. He was treated by a orthotopic liver transplantation. Post operative course was simple. In the 9th month, it was asymptomatic with a completely satisfactory evolution. The other therapeutic modalities was discussed, as well as the review of the literature.

[Renal failure in patients with liver transplant: incidence and predisposing factors]. / Insuficiencia renal en pacientes con trasplante hepático: incidencia y factores predisponentes.

Renal failure is a common finding in patients undergoing orthotopic liver transplantation. The aim of the present study was to evaluate the incidence, prognostic value of pre, intra and postoperative factors and severity of renal dysfunction in patients who undergo liver transplantation. Therefore, the records of 38 consecutive adult patients were reviewed. Renal failure was defined arbitrarily as an increase in creatinine (> 1.5 mg/dl) and/or blood urea (> 80 mg/dl). Three patients were excluded of the final analysis (1 acute liver failure and 2 with a survival lower than 72 hs.) Twenty one of the 35 patients has renal failure after orthotopic liver transplantation. Six of these episodes developed early, having occurred within the first 6 days. Late renal impairment occurred in 15 patients within the hospitalization (40 +/- 10 days) (Mean +/- SD). In he overall series, liver function, evaluated by Child-Pugh classification, a higher blood-related requirements and cyclosporine levels were observed more in those who experienced renal failure than those who did not (p < 0.05). Early renal failure was related with preoperative (liver function) and intraoperative (blood requirements) factors and several causes (nephrotoxic drugs and graft failure) other than cyclosporine were present in patients who developed late renal impairment. No mortality. No mortality was associated with renal failure. We conclude that renal failure a) is a common finding after liver transplantation, b) the pathogenesis of this complication is multifactorial and, c) in not related with a poor outcome.

[Multimodal treatment of hepatocellular carcinoma]. / Tratamiento multimodal del hepatocarcinoma.

BACKGROUND: Several options now available create the need for a multidisciplinary approach to the treatment of patients with hepatocellular carcinoma (HCC). OBJECTIVE: To describe the experience with a group of patients with HCC diagnosed and treated with the current modalities for control of this entity. POPULATION AND METHOD: A total of 169 consecutive patients with HCC treated between January 1990 and February 1998; 41 liver resections, 14 liver transplants, 87 chemoembolizations and 8 alcoholizations were performed. The median follow-up time was 23.6 months (range: 0.2-94). In the other 29 patients, only support treatment was administered. RESULTS: Resected patients had a lower median hospitalization rate, blood transfusions, and hospitalization mortality. Recurrence was 42.1% in the resected group but 0% in transplanted patients. The overall survival at 36 months was better for transplanted than for resected patients (100% vs. 62.3%; p < 0.02). The median survival time was 13 months (IC: 95%: 11-15 months) in chemoembolizated patients. CONCLUSIONS: 1. The outcome of patients with HCC is influenced by several factors, therefore calling for multimodal approach. 2. Surgical procedures should be indicated with low morbimortality rates. 3. The overall survival and disease free survival time is better in transplanted patients than in the resected group. 4. The survival time of patients with unresectable HCC without extra-liver disease could be improved with chemoembolization.

Bronchobiliary fistulas in adults.

Reported herein are 16 cases of nontraumatic bronchobiliary fistula in adults observed over 32 years. The fistulas were due to either biliary obstruction or infectious diseases involving the liver. All patients had biloptysis and other respiratory symptoms, and most had cholangitis, jaundice, and/or sepsis. The diagnosis was established by fistulography or cholangiography. All patients except one were treated surgically by relief of biliary obstruction and drainage of intra-abdominal abscesses. All 15 surgically treated patients had a successful outcome. Rapid diagnosis and early treatment of septic complications are necessary, but careful assessment and surgical relief of the biliary obstruction are essential in successfully treating this condition.

Splanchnic hyperemia after liver transplantation in patients with end-stage liver disease.

Systemic and splanchnic hemodynamic parameters were evaluated in 12 patients with cirrhosis before and 3 and 6 months after liver transplantation. Results were compared with those obtained in 8 healthy subjects. Three months after liver transplantation recipients had an increase in mean arterial pressure (98 +/- 7 v 78 +/- 9 mmHg; P < .05), an insignificant decrease in cardiac index (3. 4 +/- 0.6 v 4.0 +/- 1.0 L . min-1 . m-2), and a marked increase in peripheral vascular resistance (1,563 +/- 308 v 800 +/- 205 dyne . s . cm-5; P < .05) compared with pretransplantation values. Portal blood flow was also significantly increased (1,494 +/- 200 v 829 +/- 130 mL/min; P < .05). These hemodynamic changes were more pronounced 6 months after transplantation (mean arterial pressure, 100 +/- 8 mmHg; cardiac index, 3.0 +/- 1.0 L . min-1 . m-2; P < .01; peripheral vascular resistance, 1,680 +/- 405 dyne . s . cm-5; portal blood flow, 1,520 +/- 180 mL/min). Systemic hemodynamics 6 months after liver transplantation were similar to those observed in the healthy control group (mean arterial pressure, 95 +/- 6 mmHg; cardiac index, 2.9 +/- 0.9 L . min-1 . m-2; peripheral vascular resistance, 1,480 +/- 380 dyne . s . cm-5). However, portal blood flow was still significantly higher than in healthy controls at 6 months (1,520 +/- 180 v 910 +/- 140 mL/min; P < .05). This study shows that systemic hemodynamics are normalized after liver transplantation. However, an increase in portal blood flow occurs and persists for at least 6 months after liver transplantation. Further studies are needed to clarify the cause of the abnormally high portal flows.

Partial left lateral segment transplant from a living donor.

A shortage of liver donors for low-weight transplant recipients has prompted the development of procedures for liver-reduction, split-liver, and living related donor transplantations. For pediatric recipients weighing less than 10 kg, the left lateral segment is often still too large. We describe the procedure of monosegmental transplantation using segment II after segment III was resected in situ from a living related donor. Successful monosegmental transplantation is technically feasible and is a valid alternative to be considered for cases of size discrepancy between the recipient's volume and the donor's left lateral segment.

Catastrophic antiphospholipid syndrome complicating orthotopic liver transplantation.

Catastrophic antiphospholipid syndrome (CAPS) is an acutely devastating situation characterized by widespread thrombotic microangiopathy in the presence of elevated titers of antiphospholipid antibodies. We describe a 57-year old woman who underwent liver transplantation for primary sclerosing cholangitis and developed this malignant variant of the antiphospholipid syndrome.

Liver transplantation for the sequelae of intra-operative bile duct injury.

BACKGROUND: Intra-operative bile duct injuries (IBDI) are potentially severe complications of the treatment of benign conditions, with unpredictable long-term results. Multiple procedures are frequently needed to correct these complications. In spite of the application of these procedures, patients with severe injuries can develop irreversible liver disease. Liver transplantation (LT) is currently the only treatment available for such patients, but little information has been published concerning the results of LT. METHODS: Eight patients with LT for end-stage liver disease for IBDI were studied retrospectively. They had failure of multiple previous treatments and experienced recurrent episodes of cholangitis, oesophageal variceal bleeding, severe pruritus, refractory ascites and spontaneous peritonitis. RESULTS: Mean recipient hepatectomy time was of 243 minutes (range 140-295 min), the complete procedure averages 545 minutes (260-720) and intraoperative red-blood-cells consumption was 6.5 units (1-7). One patient required reoperation due to perforation of a Roux-en-Y loop, and three developed minor complications (2 wound infections, I inguinal lymphocele). One patient died due to nosocomial pneumonia (mortality rate 12.5%). One patient required retransplantation due to delayed hepatic artery thrombosis. At follow-up 75% of patients are alive with normal graft function and an excellent quality of life. CONCLUSIONS: LT represents a safe curative treatment for end-stage liver disease after IBDI, albeit a major undertaking in the context of a surgical complication in the treatment of benign disease. The complications of the surgical procedure and the long-standing immunosuppression impart a high cost for resolutions of these sequelae but LT represents the only long-term effective treatment for these selected patients.

Nitric oxide synthase activity in the splanchnic vasculature of patients with cirrhosis: relationship with hemodynamic disturbances.

BACKGROUND/AIMS: It has been demonstrated that an overproduction of nitric oxide plays an important role in the pathogenesis of the hyperdynamic circulation exhibited by cirrhotic patients. Nevertheless, evidence is supported by studies performed in experimental models or by indirect measurements in humans. The purpose of this study has been to evaluate nitric oxide production in splanchnic vasculature of patients with cirrhosis and to investigate its possible relationship with systemic and splanchnic hemodynamics. METHODS: Nitric oxide synthase (NOS) activity was measured in hepatic artery and portal vein tissues of nine cirrhotic patients. Samples were obtained during liver transplantation. Control samples were obtained simultaneously from the corresponding tissues of the liver donors. Hemodynamic parameters were determined with Doppler ultrasonography. RESULTS: NOS activity was significantly higher in hepatic artery of cirrhotic patients than in controls (8.17 +/- 1.30 vs 4.57 +/- 0.61 pmoles/g of tissue/min, P < 0.05). Patients with ascites showed a higher hepatic artery NOS activity than patients without ascites. Highly significant correlation was observed between cardiac output and hepatic artery NOS activity as well as between portal blood flow and hepatic artery NOS activity. CONCLUSIONS: The present study demonstrates an enhanced production of nitric oxide in the splanchnic vasculature of patients with cirrhosis.

Doce años de experiencia en trasplante hepático con donante vivo relacionado en el Hospital Italiano de Buenos Aires: evolución y resultados / Twelve years experience with living donor transplantation: follow-up and results

Antecedentes: El trasplante hepático es el tratamiento de elección para pacientes con enfermedad hepática terminal. La disponibilidad de órganos es el factor limitante para su empleo. El empleo de injertos provenientes de donantes vivos desde hace años se aplica a la población pediátrica y en los últimos años se ha generalizado su uso en receptores adultos. Objetivo: Analizar la experiencia con el empleo de esta técnica en nuestro programa de trasplante. Lugar de aplicación: Hospital Privado de la comunidad. Diseño: Estudio retrospectivo y descriptivo. Población: 458 pacientes a los que se le realizaron 492 trasplantes hepáticos ortotópicos (TOH). 79 (TOH) con donante vivo (50 niños y 29 adultos). Método: Se realizó la evaluación de los donantes con exámenes de laboratorio. Ecodoppler y tac abdominal, posteriormente arteriografía y biopsia hepática en caso de sospechar hepatopatía. Los niños fueron trasplantados con segmentos II y III (n = 45) o con monosegmento (n = 5). 28 adultos recibieron hígado derecho (LD) y uno hígado izquierdo (LI). Resultados: De 120 potenciales donantes pediátricos 60 fueron rechazados (50 por ciento). Presentaron complicaciones 6 de los 50 (12 por ciento). Se evaluaron 71 potenciales donantes para adultos, fueron rechazados 25 (35,2 por ciento). Cinco de los 29 (17,2 por ciento) donantes presentaron complicaciones. La indicación más frecuente fue la atresia de vías biliares en la población pediátrica (65,9 por ciento) y cirrosis por Virus C en los adultos (44 por ciento). Las complicaciones vasculares en la población pediátrica ocurrieron en 8 pacientes (16 por ciento) y las biliares en 14 (28 por ciento). La supervivencia actuarial de pacientes e injertos a 10 años fue de 94 por ciento y 90 por ciento respectivamente. Los adultos presentaron complicaciones vasculares en el 6,89 por ciento y biliares en el 37 por ciento. La supervivencia actuarial de pacientes e injertos fue de 89,8 por ciento y 89,3 por ciento al año y de 83,7 por...

Aplicación de la termoablación por radiofrecuencia en el tratamiento de los tumores de hígado: resultados preliminares / Radiofrequency thermoablation in the treatment for liver tumors: initial results

Antecedentes: La termoablación por radiofrecuencia ocupa un lugar importante actualmente en el tratamiento de los tumores malignos de hígado. Objetivo: Comunicar nuestra experiencia con el uso de la radiofrecuencia en el tratamiento de los tumores de hígado. Lugar de aplicación: Hospital privado de comunidad. Diseño: Serie de casos, retrospectivo. Material y método: 44 pacientes tratados con radiofrecuencia entre enero de 1999 y diciembre de 2002. Población: Fue dividida según el origen tumoral en: 1. primario, 2. metástasis colorrectal, 3. metástasis neuroendocrina y 4. metástasis no colorrectal no neuroendocrina. La radiofrecuencia fue utilizada: 1. como única modalidad, 2. asociada a cirugía y 3. combinada con otro procedimiento. Se evaluaron la vía de abordaje, la morbilidad, mortalidad, control local, recurrencia local y supervivencia. Resultados: Media de edad 64 años. Masculinos 65 por ciento. Origen del tumor: colorrectal 50 por ciento, hepatocarcinoma 32 por ciento y no colorrectal no neuroendocrino 18 por ciento. Vía de abordaje: Laparotómica 82 por ciento, percutánea 13,5 por ciento y laparoscópica en 4,5 por ciento. Estadía hospitalaria promedio: 4 días. Complicaciones: 8 pacientes (18 por ciento). No hubo mortalidad, ni necesidad de reoperación. Se observó una recidiva parietal luego del abordaje percutáneo. En 8 pacientes (18 por ciento) se indicó radiofrecuencia por segunda vez. Supervivencia actuarial global: 28 por ciento a los 4 años. Conclusiones: La radiofrecuencia es un procedimiento válido y seguro en pacientes seleccionados. Puede ser considerada un tratamiento alternativo en pacientes con imposibilidad o rechazo al tratamiento quirúrgico. En pacientes seleccionados la radiofrecuencia se puede indicar asociada a tratamiento quirúrgico resectivo

Resecciones hepáticas: análisis de los cambios en las técnicas quirúrgicas, anestésicas y transfusionales / Hepatic resection: analysis of changes in transfusional, surgical and anesthesic techniques

Introducción: La cirugía de resección hepática se ha caracterizado desde sus inicios por una alta tasa de morbimortalidad, relacionada esencialmente con el riesgo de hemorragias y con la necesidad de transfusiones masivas. La experiencia acumulada en 900 intervenciones permitió el desarrollo de una conducta quirúrgico-anestésica que incorpora métodos más modernos y elementos propios, con el objetivo de disminuir el consumo de sangre. Objetivo: Conocer el impacto de las modificaciones en la técnica anestésica, quirúrgica y en las indicaciones de transfusión de hemocomponentes, en enfermos sometidos a resecciones hepáticas, practicadas por el mismo equipo anestésico, quirúrgico y transfusional, en 18 años de experiencia. Material y método: Dos grupos de enfermos sometidos a resecciones hepáticas comparables. Grupo 1: 45 enfermos consecutivos intervenidos entre 1983 y 1987. Técnica anestésica, neuroleptoanestesia y anestesia inhalatoria. Transfusión de hemocomponentes a demanda. El parámetro intraoperatorio más importante fue la tensión arterial. Grupo 2: 45 enfermos consecutivos intervenidos en el año 2000. Técnica anestésica endovenosa. Transfusión de sangre separada en hemocomponentes y sangre autóloga, de acuerdo con las guías de la Asociación Americana de Anestesia (ASA) y de los Servicios de Anestesia y Medicina Transfusional. Parámetros intraoperatorios más importantes: tensión arterial media y presión venosa central. La última variable debe permanecer por debajo de 5 cm de H2O. Se utilizaron además drogas vasoactivas. Resultados: Grupo 1: transfundidos 778 por ciento; grupo 2: 53,3 por ciento (p=0,027). Promedio de horas en respirador: grupo 1: 19 horas; grupo 2: 4 horas (p=0,0001). Promedio de horas en la unidad de cuidados intensivos: grupo 1: 36 horas; grupo 2: 2:30 horas (p=0,06). Promedio de días de internación: grupo 1: 12; grupo 2: 7 (p=0,006). Morbilidad del grupo 1: 71 por ciento; grupo 2: 26,7 por ciento (p=0,0001). Mortalidad: grupo 1: 6,7 por ciento; grupo 2: 0 por ciento (p=0,24). Conclusiones: Las modificaciones en la técnica quirúrgica, anestésica y transfusional permitieron disminuir el consumo de hemocomponentes, una desconexión precoz del respirador, menor cantidad de tiempo en la unidad de cuidados intensivos, menor estadía hospitalaria y una disminución en la morbimortalidad.

Insuficiencia renal en pacientes con trasplante hepatico: incidencia y factores predisponentes / Renal failure in patients with liver transplat: incidence and predisposing factors

En los pacientes que son sometidos a un trasplante hepático se desarrolla con frecuencia insuficiencia renal. Sin embargo, su incidencia y los factores predisponentes al desarrollo de esta complicación no han sido bien establecidos. Por tanto, nuestro estudio ha sido dirigido a clarificar ambos aspectos en pacientes que han sido sometidos a un trasplante hepático en el Hospital Italiano de Buenos Aires. Para ello, se evaluaron em forma retrospectiva 38 pacientes adulltos receptores de un trasplante hepático durante su estadía en el hospital (40 + 10 días) (media + DS). En el an lisis final se excluyeron 3 pacientes (1 hepatitis fulminante y 2 con sobrevida menor a 72 hs). El tratamiento inmunosupresor se basó en el triple esquema: ciclosporina, corticoides y azatioprina. La presencia de insuficiencia renal se definió como la existencia de una creatinina sérica > 1.5 mg/dl y/o urea > 80 mg/dl. La insuficiencia renal se clasificó cronológicamente como precoz (días 0-6) y tardia (luego del día 6). Los siguientes par metros fueron evaluados en relación a la insuficiencia hepática: preoperatoria (función hepatocelular mediante la clasificación de Chil-Pugh y renal), intraoperatorios (cantidad de hemoderivados transfundidos, episodios de hipotensión, "by-pass" venovenoso, duración de la cirugía y de la fase anhepática) y postoperatorios (sepsis, rechazo, niveles plasm ticos de ciclosporina y uso de drogas nefrotóxicas). En veintiuno de los 35 pacientes (60 por ciento) con trasplante hepático se desarrolló insuficiencia renal. En 6 pacientes fue precoz y en 15 tardía. En la serie global, los pacientes con insuficiencia renal presentaron un mayor deterioro de la función hepática en el preoperatorio (8.6 + 0.3 vs 7.8 + 0.4, p<0.05), en el intraoperatorio un mayor requerimiento de hemoderivados (13.1 + 4.3 vs 10.1 + 3.8 unidades, p<0.05) y en el postoperatorio in nivel más elevado de ciclosporina (624 + 60 vs 430 + 30 ng/ml, p<0.05) que aquellos pacientes en quienes no se desarrolló complicación. Asimismo, en los pacientes que presentaron la insuficiencia renal en forma precoz se observó un mayor deterioro de la función hepatocelular y un mayor requerimiento de hemoderivados durante la cirugía. De otra parte, en los pacientes que la desarrollaron en forma tardía, la etiopatogenia de esta complicación fue multifactorial (falla del injerto, uso de drogas nefrotóxicas y ciclosporina). En 1 paciente hubo necesidad de realizar hemodiálisis y en otro hemofiltración...