Reconstructing single hepatic artery with two arterial stumps: biliary complications in pediatric living donor liver transplantation.

INTRODUCTION: Liver grafts can at times have two hepatic arterial stumps. This can result in a dilemma whether to reconstruct single or both the arteries. Hepatic artery (HA) thrombosis is the most dreaded complication in pediatric living donor liver transplantation (LDLT) as it can result in biliary complications and subsequent graft loss. We herein report the feasibility of reconstructing single hepatic artery in pediatric living donor liver transplantation having two arterial stumps in the liver graft. MATERIALS AND METHODS: From 2008 to 2010, 87 pediatric patients undergoing LDLT were divided into three groups. Group 1 (n = 20): two HA stumps with two HA reconstruction, Group 2 (n = 22): two HA stumps with one HA reconstruction and Group 3 (n = 45): one HA stump with one HA reconstruction. The decision regarding the reconstruction of single or multiple HAs was made depending on the pre-operative radiological and intraoperative assessments. RESULTS: The incidence of HA thrombosis (p = 0.126) and biliary complications (p = 0.617), was similar in the three groups. CONCLUSION: Single HA reconstruction does not increase the risk of biliary strictures in pediatric LDLT recipients having dual hepatic arterial stumps in the liver graft.

Health-behavior induced disease: return of the milk-alkali syndrome.

The milk-alkali syndrome is a well-documented consequence of excessive calcium and alkali intake first recognized in association with early 20th century antacid regimens. The syndrome became rare after widespread implementation of modern peptic ulcer disease therapies. With recent trends in osteoporosis therapy coupled with widely available calcium-containing supplements, the milk-alkali syndrome has reemerged as an important clinical entity. Our case illustrates a patient who self-medicated his peptic ulcer disease with a regimen resembling a common early 20th century dyspepsia regimen. When superimposed upon chronic high calcium supplementation, the patient became acutely ill from the milk-alkali syndrome. When taken to excess, or used inappropriately, medications and supplements ordinarily considered beneficial, can have harmful effects. Our case underscores the importance of obtaining a thorough medication history including use of over-the-counter supplementation.

Liver lobe graft side and outcomes in living-donor liver transplant with small-for-size grafts.

OBJECTIVES: Living-donor liver transplant with small-for-size grafts (graft-to-recipient weight ratio < 0.8) may provide satisfactory results. We compared outcomes between right and left donor lobe in living-donor liver transplant. MATERIALS AND METHODS: Patients who had living-donor liver transplant from 2006 to 2008 with graft-to-recipient weight ratio < 0.8 (graft: right lobe, 24 patients; left lobe, 26 patients) were reviewed retrospectively. RESULTS: There were no significant differences in demographic and preoperative clinical data between patients who received a right or left lobe liver graft. Duration of surgery was longer, cold ischemia time was shorter, and mean baseline portal vein flow was greater in transplants performed with left than right donor lobes. Portal vein flow modulation with splenectomy was performed when portal flow was > 250 mL/min/100 g graft. Small-for-size syndrome was observed in 6 recipients (14%), but no patient who developed small-for-size syndrome developed liver failure or required revision transplant. The frequency of small-for-size syndrome was significantly greater in patients who had left lobe (4 patients [15%]) than right lobe transplant (2 patients [8%]; P ≤ .05). Graft dysfunction-free survival was significantly greater with right than left lobe grafts. In multivariate analysis, graft side was the only significant risk factor for small-for-size syndrome. CONCLUSIONS: In patients having living-donor liver transplant with small-for-size grafts, outcome was better with right than left lobe grafts.

Fungal colonization of a pneumonectomy stump.

A 59-year-old woman developed mild recurring hemoptysis once a week for several months after a fall with trauma to the chest. Sixteen years earlier she had undergone a right pneumonectomy at a hospital elsewhere for sequelae of pulmonary tuberculosis. Bronchoscopy, performed because of the recent hemoptysis, showed material in the pneumonectomy stump. The material had a gelatinous appearance, green color with a pale margin, and oblique striations. The material was removed by grasping with forceps and withdrawing the bronchoscope. Grocott methanamine silver stain was positive for septate, nonpigmented fungal organisms. Anatomic pathology microscopy also showed mucous, acute inflammatory cells, and necrotic tissue. Cytopathology of washings from the bronchial stump showed rare degenerated benign bronchial epithelial cells and fungal hyphae. Acid fast bacilli smears and cultures were negative. Bacterial cultures showed 3+ Pseudomonas aeruginosa. The patient had no further hemoptysis.