Physical Condition, Glycemia, Liver Function, and Quality of Life in Liver Transplant Recipients After a 12-Month Supervised Exercise Program.

BACKGROUND AND AIMS: Despite the excellent long-term outcomes in liver transplant (LT) recipients, several medical complications related to lifestyle still represent an issue. This study examined the effects of a 12-month supervised aerobic and strength training program on the aerobic capacity, muscle strength, metabolic profile, liver function, and quality of life of a cohort of LT recipients. METHODS: LT recipients with stable liver function were assigned to interventional exercise (group A) or usual care (group B). Aerobic capacity, muscle strength, metabolic profile, liver and kidney function, and health-related quality of life were assessed at baseline and after 6 and 12 months. Group A attended supervised training sessions 3 times per week for 12 months. Group B received general recommendations about home-based exercise. RESULTS: Forty patients from 6 Italian LT centers were randomized. Twenty-nine (72.5%, men-to-women ratio 23:6, mean age, 52 ± 8 years) LT recipients completed the study. Baseline characteristics were similar between groups except for body mass index and time from LT. No episode of acute rejection nor increase of transaminases occurred. Maximum workload and body mass index increased in both groups over time, but fasting glucose significantly decreased in group A (94.0 ± 15.0 mg/dL vs 90.0 ± 17.0 mg/dL; P = .037) and increased in controls (95.0 ± 24.0 mg/dL vs 102.0 ± 34.0 mg/dL, P = .04). Upper limb muscle strength increased only in supervised LT recipients. Vitality and general and mental health domains significantly improved after physical exercise. CONCLUSIONS: Supervised combined training was safe and effective in increasing aerobic capacity, muscle strength, and quality of life and in improving glucose metabolism in stable LT recipients.

Safety and efficacy of endoscopic retrograde cholangiopancreatography in patients with post-liver transplant biliary complications: results of a cohort study with long-term follow-up.

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach for the management of biliary complications in liver transplant patients; however, its safety and efficacy have not been established in this setting. This study was performed to evaluate the safety and long-term efficacy of ERCP in transplant patients. METHODS: The case reports of 1,500 liver transplant patients were reviewed. Orthotopic liver transplantation (OLT) patients were matched 1:2 with non-OLT patients and followed-up for long-term outcome (median, 7.4 years). RESULTS: Of the 1,500 liver transplant patients, 94 (6.3%) underwent 150 ERCPs after OLT. Anastomotic strictures were present in 45 patients, biliary stones in 24, biliary leaks in 7, papillary stenosis in 2, and primary sclerosing cholangitis in 1. An ERCP success rate of 90.7% was achieved; biliary stenting led to resolution of the bile leak in 7/7 (100%) patients, and biliary stones were removed in 21/24 (87.5%) patients. In addition, 34 of 45 patients with anastomotic stricture underwent endoscopic dilation. We obtained complete resolution in 22/34 (64.7%) patients. OLT patients did not show a higher probability of complications (odds ratio [OR], 1.04), of pancreatitis (OR, 0.80) or of bleeding (OR, 1.34). CONCLUSIONS: ERCP is safe and effective for the treatment of post-OLT biliary complications, has a low rate of pancreatitis and results in a durable effect.

Safety and efficacy of the percutaneous treatment of bile leaks in hepaticojejunostomy or split-liver transplantation without dilatation of the biliary tree.

Biliary leaks complicating hepaticojejunostomy (HJA) or fistulas from cut surface are severe complications after liver transplantation (LT) and split-liver transplantation (SLT). The aim of the study was to describe our experience about the safety and efficacy of radiological percutaneous treatment without dilatation of intrahepatic biliary ducts. From 1990 to 2006, 1595 LTs in 1463 patients were performed in our center. In 1199 LTs (75.2%), a duct-to-duct anastomosis was performed, and in 396 (24.8%), an HJA was performed. One hundred twenty-nine anastomotic or cut-surface bile leakages occurred in 115 patients. Sixty-two biliary leaks occurred in 54 patients with HJA; in 48 cases, an anastomotic fistula was found. Cut-surface fistulas occurred in 14 cases: 5 in right SLTs and 5 in left SLTs. Twenty-two patients were treated with 23 percutaneous approaches for 17 HJA fistulas and 6 cut-surface leaks without intrahepatic bile duct dilatation. Two percutaneous therapeutic approaches were used: percutaneous transhepatic biliary drainage (PTBD) for fistula alone and PTBD with percutaneous drainage of biliary collection in patients with both complications. PTBD was successful in 21 cases (91.3%); the median delay from catheter insertion and leak resolution was 10.3 days (range: 7-41). The median maintenance of drainage was 14.8 days. In 1 patient, fistula recurrence after PTBD needed a surgical approach; after that, an anastomotic fistula was still found, and a new PTBD was successfully performed. In another patient, PTBD was immediately followed by retransplantation for portal vein thrombosis. There were no complications related to the interventional procedure. In conclusion, biliary fistulas after HJA in LT or after SLT can be successfully treated by PTBD. The absence of enlarged intrahepatic biliary ducts should not be a contraindication for percutaneous treatment.

The first one thousand liver transplants in Turin: a single-center experience in Italy.

The first Italian liver transplant center to reach the goal of 1000 procedures was Turin. The paper reports this single-center experience, highlighting the main changes that have occurred over time. From 1990 to 2002, 1000 consecutive liver transplants were performed in 910 patients, mainly cirrhotics. Surgical technique was based on the preservation of the retrohepatic vena cava of the recipient. The veno-venous bypass was used in 30 cases only and abandoned since 1997. Operating time, warm ischemia time and length of hospital stay significantly decreased over the years, while operating room extubation became routine. Immunosuppression pivoted on cyclosporine A. Management of retransplantations, marginal grafts, and of HCV-positive, HBV-positive and hepatocellular carcinoma recipients were optimized. Median follow-up of the patients was 41 months. Overall survival rates at 1, 5 and 10 years were 87%, 78% and 72% respectively. Survival rates obtained in the second half of the cases (1999-2002 period) were significantly better than those obtained in the first half (1990-1998 period) (90% vs. 83% at 1 year and 81% vs. 76% at 5 years respectively). Increasing experience in liver transplant surgery and postoperative care allowed standardization of the procedure and expansion of the activity, with parallel improvement of the results.

Marginal grafts: finding the correct treatment for fatty livers.

The influence of steatosis on the outcome of orthotopic liver transplantation (OLT) was evaluated in 860 liver transplantations carried out in 784 patients from October 1990 to August 2001. Donor variables considered were: age, hepatic enzymes, bilirubin, total and warm ischemia times, macrovesicular and microvesicular steatosis. Recipient variables considered were: age, UNOS status, Child-Pugh score and indication for OLT. Patient and graft survival were the main outcome indicators. Macrovesicular steatosis affecting 15% or more of the hepatocytes was the only variable independently associated with shorter patient and graft survival ( P=0.0012 and 0.0028). A significantly worse prognosis was to be expected if >15% macrovesicular steatosis was associated with a total ischemia time >10 h ( P=0.048), or donor age >65 years ( P=0.016) or with HCV-positive recipients ( P=0.0014). From our study we can conclude that macrovesicular steatosis involving 15% or more of the hepatocytes identifies marginal livers. The risk of graft non-function or patient loss after OLT rises if macrovesicular steatosis >15% is associated with long ischemia time, high donor age, or HCV positivity in recipients.