Liver transplantation in recipients receiving renal replacement therapy: outcomes analysis and the role of intraoperative hemodialysis.

The Model for End-Stage Liver Disease (MELD) system has dramatically increased the number of recipients requiring pretransplant renal replacement therapy (RRT) prior to liver transplantation (LT). Factors affecting post-LT outcomes and the need for intraoperative RRT (IORRT) were analyzed in 500 consecutive recipients receiving pretransplant RRT, including comparisons among recipients not receiving IORRT (No-IORRT, n = 401), receiving planned IORRT (Pl-IORRT, n = 70), and receiving emergent, unplanned RRT after LT initiation (Em-IORRT, n = 29). Despite a median MELD of 39, overall 30-day, 1-, 3- and 5-year survivals were 93%, 75%, 68% and 65%, respectively. Em-IORRT recipients had significantly more intraoperative complications (arrhythmias, postreperfusion syndrome, coagulopathy) compared with both No-IORRT and Pl-IORRT and greater 30-day graft loss (28% vs. 10%, p = 0.004) and need for retransplantation (24% vs. 10%, p = 0.099) compared with No-IORRT. A risk score based on multivariate predictors of IORRT accurately identified recipients with chronic (sensitivity 84%, specificity 72%, concordance-statistic [c-statistic] 0.829) and acute (sensitivity 93%, specificity 61%, c-statistic 0.776) liver failure requiring IORRT. In this largest experience of LT in recipients receiving RRT, we report excellent survival and propose a practical model that accurately identifies recipients who may benefit from IORRT. For this select group, timely initiation of IORRT reduces intraoperative complications and improves posttransplant outcomes.

Antiviral prophylaxis and recurrence of hepatocellular carcinoma following liver transplantation in patients with hepatitis B.

BACKGROUND: Orthotopic liver transplantation (OLT) is a viable treatment option for patients with hepatitis B (HBV) and concomitant hepatocellular carcinoma (HCC). However, cancer recurrence following transplantation approaches 20%. This study sought to identify the clinical and pathological factors associated with post-OLT survival. METHODS: Univariate and multivariate analyses considered the following variables: combination viral prophylaxis, HBV recurrence, tumor stage, vascular invasion, distribution, nodularity, pre- and post-OLT tumor size, pre-OLT alpha-fetoprotein (AFP), Milan and UCSF criteria, and Asian race. RESULTS: Cumulatively, HCC recurrence-free survival was 77%, 62%, and 53% at 1, 3, and 5 years, respectively, and was significantly better in patients who were free of viral recurrence post-OLT. Similarly, patients treated with combination prophylaxis had a significantly lower mortality than those who were not. CONCLUSIONS: Multivariate analysis revealed that AFP>500 ng/mL, presence of vascular invasion by explant, HBV recurrence, and combination prophylaxis were independent predictors of HCC recurrence-free survival.

Randomized prospective trial of OKT3 for early prophylaxis of rejection after liver transplantation.

A group of 52 liver transplant patients was prospectively randomized to receive prophylactic immunosuppressive therapy consisting of either Orthoclone OKT3 for 14 days, azathioprine, and steroids (25 patients); or cyclosporine, azathioprine, and steroids (27 patients). The groups were similarly matched for age, diagnosis, and Child's classification. The patients were studied to determine the effect of these two regimens on the incidence of rejection, infection, renal dysfunction, and mortality. Seven rejection episodes, as determined by clinical and histological criteria, occurred in seven of 25 patients (28%) receiving OKT3 compared with 18 episodes in 27 patients (67%) receiving cyclosporine during the first 14 days after transplantation (P less than 0.02). In 20% of the OKT3 patients, CD3+ levels of greater than 10% developed during therapy, and 16% of the patients developed anti-OKT3 antibodies during OKT3 treatment. Five patients were retreated with OKT3 for steroid-resistant acute rejection episodes; all had resolution of the rejection episode. Infectious complications were similar in each group. Renal function, as measured by serum creatinine, was significantly better with OKT3 than with cyclosporine (P less than 0.003) at 14 days. We conclude that prophylactic OKT3 is effective in reducing the number of early rejection episodes after liver transplantation; after 14 days the incidence of rejection is similar; reuse of OKT3 has been successful in liver transplant patients; infectious complications are similar between OKT3 and cyclosporine; and OKT3 preserves renal function better than cyclosporine and is thus indicated in patients with compromised preoperative renal function.

A method for vascular access in small children.

A new method is described to achieve vascular access for either hemodialysis or plasmapheresis in small children. This technique provides reliable arterial inflow and venous outflow with minimal complications.

Percutaneous aspiration of peripancreatic fluid collections: a safe method to detect infection.

During the past 5 years, we have used percutaneous aspiration of peripancreatic fluid collections guided by computed tomography (CT) or ultrasonography (US) to facilitate diagnosis of infection in selected cases. Fifteen of 18 patients undergoing guided needle aspiration had persistent fevers (greater than 38.3 degrees C). The three afebrile patients all had abdominal pain and leukocytosis, and two of the three also had elevated serum amylase levels. Percutaneous aspiration was guided by CT in 14 patients and by US in four. On the basis of aspirate Gram stains and cultures, as well as surgical (15) and percutaneous drainage (1) findings, the final diagnosis was pancreatic abscess in nine patients, infected pseudocyst in four, uninfected pseudocyst in four, and cystadenoma in one. Diagnosis based on percutaneous aspiration was correct in 17 of 18 patients (94%), and no complications could be directly attributed to the procedure. We conclude that CT- or US-guided percutaneous aspiration is a safe and accurate diagnostic procedure for patients with peripancreatic fluid collections in whom secondary infection is suspected.

Perineal gangrene in the patient with granulocytopenia: the importance of early diverting colostomy.

Perirectal and perineal infections represent a life-threatening complication of hematologic diseases associated with granulocytopenia. Early and aggressive surgical management is essential. This should include hemodynamic support and monitoring, broad-spectrum antibiotics, wide surgical debridement, and a totally diverting colostomy. The prognosis of these infections parallels that of the underlying hematologic disease. Three patients seen on a university surgical service whose clinical management and course underscore these principles are presented.

The value of open lung biopsy in the immunosuppressed patient.

To evaluate the impact of the open lung biopsy on diagnosis and therapy in the immunosuppressed patient, 68 such patients managed at UCLA from 1975 to 1980 were reviewed. Most had hematologic malignancies, and all were severely immunosuppressed. The rates of surgical mortality (1 operative death) and morbidity were minimal. There were 10 diagnostic differences apparent when biopsy results were compared with autopsy findings in 28 autopsied patients. Therapy was initiated or modified in 19 patients on the basis of open lung biopsy. Forty-four patients lived 1 year or less, 14 for more than 1 year, and 10 were lost to follow-up. Of 42 patients with an untreatable disease on the basis of lung biopsy, 67% died and 33% lived to leave the hospital. Of 25 patients with a treatable disease, 56% died and 44% left the hospital. Of 28 autopsied patients, only 12 were receiving appropriate medication at time of death despite biopsy. The patient whose disease is generally characterized by brief survival like acute leukemia, and whose situation is most desperate, unfortunately benefits least from open lung biopsy. We conclude that this procedure has only a modest impact in the management of these critically ill patients and should be used conservatively.

Massive splenomegaly. Superior results with a combined endovascular and operative approach.

Splenectomy for massive splenomegaly (drained splenic weight, greater than 1000 g) has an uncommonly high morbidity and mortality because of technical challenges and problems of hemostasis. In a group of 10 patients with massive splenomegaly due to myeloproliferative disorders (average splenic weight, 4193 g), we developed a management algorithm based on preoperative angiographic embolization of the splenic artery. Average operating time was 1.7 hours (range, 1 to 2.5 hours). Average blood loss was 528 mL; six of the 10 patients had blood loss less than 250 mL. There were four minor complications and one major complication (gastric ulcer requiring reoperation). There were no deaths in the perioperative period, and no patients required reoperation for hemorrhage.

Telesurgery. Acceptability of compressed video for remote surgical proctoring.

OBJECTIVE: To determine the clinical acceptability of various levels of video compression for remote proctoring of laparoscopic surgical procedures. DESIGN: Observational, controlled study. SETTING: Community-based teaching hospital. PARTICIPANTS: Physician and nurse observers. INTERVENTIONS: Controlled surgical video scenes were subjected to various levels of data compression for digital transmission and display and shown to participant observers. MAIN OUTCOME MEASURES: Clinical acceptability of video scenes after application of video compression. RESULTS: Clinically acceptable video compression was achieved with a 1.25-megabit/second data rate, with the use of odd-screen 43.3:1 Joint Photographic Expert Group compression and a small screen for remote viewing. CONCLUSION: With proper video compression, remote proctoring of laparoscopic procedures may be performed with standard 1.5-megabit/second telecommunication data lines and services.

Effect of endarterectomy on arterial fibrinolytic activator activity.

Although endarterectomy leaves a raw subintimal surface, thrombotic complications are rare. This may be the result of activation of the fibrinolytic system. Fibrinolytic activator activity (FAA) was studied after intimectomy of 3-cm segments of carotid artery in dogs. Endarterectomized segments and contralateral control arteries were resected immediately following intimectomy (group 1) and after blood flow restoration of ten minutes, three hours, and 24 hours (groups 2, 3, and 4, respectively). Areas of fibrinolysis around punch biopsy specimens from each endarterectomy segment and from the control artery were measured. Fibrinolytic activator activity, the ratio of the areas in endartectomized segments to control arteries, was reduced in groups 1 through 3 (mean, 60.7%, 70.1%, and 79.7%, respectively) and was normal in group 4 (94.3%). We conclude that canine FAA is significantly depressed at the endarterectomy site initially but returns to normal at 24 hours. The source of FAA may be synthesis by subintimal structures or delivery by the circulation. During this period of increased thrombogenicity, use of antiplatelet or anticoagulant therapy would be justified.

Surgical intensive care in the nonagenarian. No basis for age discrimination.

OBJECTIVE: To investigate the effect of extreme age on outcome from surgical intensive care. DESIGN: Prospective data collection. SETTING: A 20-bed noncardiac surgical intensive care unit (SICU) that admits 2200 patients per year from a 1201-bed tertiary medical center. PATIENTS: Nonagenarians were compared with patients under 90 years of age over a 33-month period. Seven patients over age 100 years and 77 nonsurgical patients were excluded. MAIN OUTCOME MEASURES: Mortality and length of stay were determined for both the SICU and the entire hospitalization. The nonagenarian and younger groups were stratified by severity of illness using the first-day Simplified Acute Physiology Score (SAPS). RESULTS: One hundred forty nonagenarian patients (mean +/- SE age, 92.1 +/- 0.2 years) were compared with 5652 younger patients (mean age, 60.1 +/- 0.3 years). The mean SAPS of 11.1 for nonagenarian patients was significantly higher than the SAPS of 8.6 for younger patients (P < .001). Mortality in the SICU was 4.3% for nonagenarian patients vs 2.3% for younger patients (P = .13). SICU mortality rose with increasing SAPS in both groups, but there was no significant difference between nonagenarian and younger patients for any SAPS group. Hospital mortality differed significantly, with 17.1% for nonagenarian patients and 5.3% for younger patients (P < .001). Hospital and SICU length of stay did not differ significantly between the groups. CONCLUSIONS: Nonagenarians do not differ from younger SICU patients in survival from SICU care, although hospital mortality is greater in nonagenarians. Age alone should not be used to make decisions about the utility of SICU care for the elderly. Outcome correlates better with severity of illness, and the measure is valid in young and old alike.

Safe laparoendoscopic approach to biliary pancreatitis in older patients.

OBJECTIVE: To evaluate management strategies for biliary pancreatitis in different age groups. DESIGN: Retrospective review. SETTING: Large private metropolitan teaching hospital. PATIENTS: Patients seen between January 1991 and December 1994 with a diagnosis of biliary pancreatitis (N = 136) divided into 2 groups (group 1, aged < 65 years; group 2, aged > or = 65 years). INTERVENTIONS: Primary treatments included endoscopic retrograde cholangiography (n = 36) alone or with endoscopic sphincterotomy (n = 27); operative procedures, including cholecystectomy by laparoscopic (n = 54) or open (n = 16) approaches; or no definitive therapy (n = 22). Secondary treatments of common bile duct stones included laparoscopic transcystic bile duct exploration (n = 5), open common bile duct exploration (n = 4), or postoperative endoscopic retrograde cholangiography (n = 10). MAIN OUTCOME MEASURES: Success of interventions, incidence and treatment of common bile duct stones, morbidity and mortality rates, frequency of retained stones, and length of hospitalization. RESULTS: Numbers of Ranson criteria were higher for older patients (group 1, 0.83 +/- 0.12 vs group 2, 1.57 +/- 0.11 [mean +/- SEM]; P < .001). Primary endoscopic retrograde cholangiography with or without endoscopic sphincterotomy was performed earlier than operative procedures, with a significantly higher incidence of common bile duct stones (72% vs 19%; P < .001). Number of primary procedures and complication and mortality rates for endoscopic retrograde cholangiography with or without endoscopic sphincterotomy were 36, 8%, and 3%, respectively; for laparoscopic cholecystectomy, 54, 9%, and 2%, respectively; and for open cholecystectomy, 16, 6%, and 19%, respectively. For complication and mortality rates, there were no statistical differences between groups or among treatments. Deferred therapy was used in 30 patients, with 20% readmitted for recurrence of biliary pancreatitis. Length of intensive care unit and total hospital stay were similar for all groups and treatments. CONCLUSIONS: Older patients with biliary pancreatitis may be safely treated with a combined laparoendoscopic approach. Management of common bile duct stones depends on age, with laparoscopic transcystic duct exploration or open common bile duct exploration preferred for younger patients and laparoscopic transcystic duct exploration or postoperative endoscopic sphincterotomy for older ones. Deferred therapy has a substantial relapse rate.

Nonoperative management of major blunt liver injury with hemoperitoneum.

We evaluated the role of nonoperative therapy in 16 patients with blunt multisystem trauma, hemodynamic stability following resuscitation, and major lobar liver injury; the patients were treated with a protocol of intensive care unit observation and computed tomographic scanning to identify and follow up the hepatic lesion. Computed tomographic scans showed right-lobe or bilobar liver lacerations and/or subcapsular hematomas in all patients and associated hemoperitoneum in 8 patients. Exploration was required in 2 patients; both were found to have a hemoperitoneum and a nonbleeding liver laceration. There were no deaths. Patients with hemoperitoneum requiring transfusion had significantly greater injury severity scores and longer intensive care unit and hospital stays. The major advantage of a nonoperative approach is the opportunity to stabilize major extra-abdominal (particularly head) injuries as the first priority. Unstable hemodynamics, abdominal distension, and falling hematocrit are indications for prompt exploration. Nonoperative care of these injuries requires a strict treatment protocol.

Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?

OBJECTIVE: To evaluate treatments for common bile duct stones (CBDS). DESIGN: Retrospective review of authors' case series. SETTING: Large private metropolitan teaching hospital. PATIENTS: All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography. INTERVENTIONS: Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10). MAIN OUTCOME MEASURES: Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization. RESULTS: Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death. CONCLUSIONS: For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.

Orthotopic liver transplantation for biliary atresia. Evolution of management.

Forty-five patients with biliary atresia were accepted for orthotopic liver transplantation. Nine patients died awaiting transplantation, and 36 underwent transplantation. A portoenterostomy had been performed in 28 of these 36 patients, and its presence did not significantly affect the intraoperative blood loss (5.6 vs 4.1 blood volumes), the need for retransplantation (21% vs 12%), biliary complications (21% vs 12%), postoperative infections (36% vs 25%), or survival (82% vs 63%). These results indicate that early portoenterostomy is appropriate early therapy for biliary atresia; however, prompt referral to a liver transplant center for evaluation at the first sign of cholestasis is needed to attain optimal results for transplantation. Revisions of the portoenterostomy prior to transplantation did not improve the longevity of the procedure but did substantially increase complications and death after orthotopic liver transplantation.

Variables influencing the outcome following orthotopic liver transplantation.

Seventy-two patients who underwent orthotopic liver transplantation (OLT) were studied to identify perioperative variables that would predict survival and intraoperative blood loss. Survival and intraoperative blood loss were not affected by encephalopathy, length of donor liver ischemia, or any of the preoperative laboratory values studied. Survival was significantly decreased in patients requiring postoperative dialysis (41%) and in patients who had severe rejection requiring retransplantation (33%). Intraoperative blood loss was significantly greater in patients over 50 years of age (11.6 blood volumes) and patients with biliary atresia (8.7 blood volumes). These results may aid in choosing future recipients for orthotopic liver transplantation and in anticipating the postoperative support needed.

A prospective study on the use of monoclonal anti-T3-cell antibody (OKT3) to treat steroid-resistant liver transplant rejection.

Conventional treatment of acute liver allograft rejection has included high doses of corticosteroids and antithymocyte globulin. Urgent retransplantation was the only option for patients who failed to respond. We report our initial experience with the use of monoclonal anti-T3-cell antibody (OKT3) in 25 patients with acute hepatic allograft rejection that was resistant to steroid and/or antithymocyte globulin therapy. Twenty-four of 25 patients had a response to OKT3, which was complete in 14 and partial in ten. With a mean follow-up of 8.2 months, allograft salvage has been 80% and patient survival 88%; two patients underwent successful retransplantation. Side effects have been mild and well tolerated. Repeated rejection has occurred in 40% of patients, but these episodes have responded to steroid therapy. We conclude that OKT3 is well tolerated and highly effective in reversing severe episodes of acute hepatic allograft rejection that is resistant to high-dose steroid therapy.

Comparison of laparoscopic and open staging in Hodgkin disease.

BACKGROUND: Staging laparotomy provides useful information for management of Hodgkin disease but has fallen into disfavor because procedure-related morbidity exceeds that of new chemotherapeutic regimens. OBJECTIVE: To determine the feasibility, effectiveness, and safety of laparoscopic staging for Hodgkin disease compared with those of open staging. PATIENTS: Fifty-five patients with Hodgkin disease of cell types including nodular sclerosis in 43 (78%), mixed cellularity in 9 (16%), and lymphocyte predominance in 3 (5%). STUDY DESIGN: Concurrent evaluation of laparoscopic staging (n = 15) and retrospective review of open staging (n = 40). INTERVENTIONS: Laparoscopic and open techniques of surgical staging for Hodgkin disease, including splenectomy, liver biopsies, and lymph node sampling. MAIN OUTCOME MEASURES: Operative time, duration of postoperative ileus and of postoperative hospitalization, morbidity, number of lymph nodes retrieved, alteration in pathologic stage, recurrence, and survival. RESULTS: For laparoscopic staging vs open staging groups, mean operative time was 202 vs 144 minutes (P=.001); mean postoperative ileus was 1.9 vs 3.2 days (P<.001); mean postoperative hospitalization was 4.4 vs 6.7 days (P<.001); complications occurred in 3 patients (20%) vs 11 patients (28%) (P=.57); and mean number of lymph nodes retrieved was 8.5 vs 4.6 (P=.05). In the laparoscopic staging group, 2 cases (13%) were upstaged and 2 cases (13%) were downstaged. In the open staging group, 6 cases (15%) were upstaged and 3 cases (7.5%) were downstaged. Follow-up data were available for all patients in the laparoscopic staging group, at a mean of 23.5 months postoperatively. All were alive, none had recurrent disease below the diaphragm, and 2 (13%) had residual mediastinal disease. Follow-up data were available for 31 patients (78%) in the open staging group at a mean of 52.5 months postoperatively. All were alive, 27 (87%) were disease free, 3 (10%) had had relapses above the diaphragm, and 1 (3%) had residual mediastinal disease. CONCLUSIONS: Compared with open staging, laparoscopic staging of Hodgkin disease is oncologically equivalent and functionally superior. These data should encourage reappraisal of the role of operative staging in the management of Hodgkin disease.

Indolent presentation of pancreatic abscess. Experience with 100 cases.

One hundred cases of pancreatic abscess were identified at five hospitals affiliated with UCLA between 1973 and 1985. Patients were included if a pancreatic mass or phlegmon followed an episode of pancreatitis, if the clinical impression was pancreatic abscess, and if drainage cultures were positive. Less than three Ranson's signs were present on admission in 72% of patients. The admission temperature was less than 38.3 degrees C in 71% of patients, and 27% of patients never had a fever. Abdominal tenderness was absent in 40% of patients. The admission amylase concentrations and white blood cell counts were normal in 36% and 23% of patients, respectively. Extensive débridement, external drainage, and a low threshold for reoperation were the mainstays of surgical therapy. Twenty patients (20%) died, but Ranson's signs did not predict outcome. pancreatic abscess may have an insidious presentation. A high index of suspicion, early computed tomographic scanning, and diagnostic needle aspiration may be necessary to establish this diagnosis.

Infectious complications in liver transplantation.

Thirty-five patients received 42 liver homografts between February 1984 and August 1985. One or more infections developed in 23 patients (66%) some time after transplantation. An average of 2.5 infections per infected patient occurred. Of 37 bacterial infections, two thirds were either bacteremias or localized intra-abdominal infections. The median onset was 29 days after operation. Thirteen viral infections were identified, with a median onset of 18 days after operation. Nine fungal infections, six disseminated and three localized, were identified, with a median onset of nine days after operation. Infection was the primary cause of death in five (14%) of 35 patients. Fatal infections were evenly distributed among bacterial (two), fungal (three), and viral (two) pathogens. Despite advances in surgical techniques and the use of cyclosporine, infection after orthotopic liver transplantation is a serious problem. Certain patients can be identified as high risks for infection and require an aggressive diagnostic workup followed by early institution of antimicrobial therapy.