Short- and long-term overall results of liver retransplantation: "Doce de Octubre" hospital experience.

INTRODUCTION: The liver retransplantation rate in Spain is about 6%. The main causes are primary nonfunction, vascular complications, chronic rejection, and recurrent liver disease. The results of this procedure are worse than those of first transplantations. PATIENTS AND METHODS: This retrospective study evaluated our experience with 54 retransplantations performed between January 1992 and December 2006, which were 5.6% of the 960 orthotopic liver transplantations (OLT) during this period. RESULTS: In this study, 34.7% of the retransplantations were performed between 4 and 30 days after the first transplantation; another 34.7% were within 1 year. Also, 48.9% of the retransplantations were performed in urgent situations. The main causes for retransplantation during the first month were primary hepatic failure (n = 14) and vascular complications (n = 4). After the first month the main causes were chronic rejection (n = 9), recurrence of hepatic disease (n = 3), and biliary complications (n = 4). Postoperative mortality was 23.9% and morbidity was 76.3%. However, 21.2% of the patients needed a third transplant. The overall rate of patient survival was 60.4% (n = 32) and of graft survival was 56.6% (n = 30). The 5-year actuarial graft survival rate was 65.4% with a mean survival time of 89.84 +/- 8.72 months; the 5-year patient survival rate was 64% with a mean survival time of 114.7 +/- 12.53 months. Worse survival was observed in chronic rejection and in retransplantations performed between 31 and 360 days. CONCLUSIONS: Liver retransplantation presents greater surgical complexity than the first transplantation, but is a good option for patients with failure of the first graft with a 5-year patient and graft survival rate greater than 65%.

Disseminated nocardiosis: a rare infectious complication following non-heart-beating donor liver transplantation.

Nocardiosis is an infrequent disease that affects patients who display a cellular immunodeficiency, such as transplant recipients on immunosuppressive treatment, but uncommonly associated with high morbidity and mortality rates. Disseminated Nocardiosis affecting the central nervous system (CNS), abdomen, skin, and lungs has been described in bone marrow, lung, and kidney transplant recipients. However, to our knowledge, no cases involving all of these structures have been reported in liver transplant recipients. Herein, we have reported a case of CNS, pulmonary, and cutaneous nocardiosis in a liver transplant recipient who experienced hepatitis C virus-related cirrhosis and hepatocellular carcinoma and received the organ from a non-heart-beating donor. At posttransplantation month 7 the patient was admitted to the emergency department with poor general health status, fever, edema, and subcutaneous nodules in the legs. A computed tomography scan revealed multiple nodules disseminated through both lungs, abdomen, brain, and subcutaneous tissue. A needle biopsy was performed into one of the subcutaneous nodules. Cultures of the material tested positive for Nocardia farcinica. Thus, we started treatment with intravenous sulfamethoxazole-trimethoprim (SMZ-TMP), shifting after 1 month to oral therapy. Radiological examination performed after 2 weeks of treatment showed a 70% reduction in subcutaneous, pulmonary, and cerebral lesions. After 6 months of SMZ-TMP treatment, the patient remained free of the symptoms with involution of the subcutaneous nodules and significant radiological improvement. Among opportunistic infections appearing in liver transplant recipients, Nocardia species should have special consideration according to the success of early treatment and the bad prognosis in cases of delayed diagnosis.

Starting a new program of split liver transplantation after a low learning curve: a reality in centers with large experience in liver surgery and whole liver transplantation.

BACKGROUND/AIMS: Split liver transplantation (SLT) is nowadays, considered an adequate surgical solution to expand the grafts from the existing pool of cadaveric donors. METHODOLOGY: A total of 897 liver transplantations were performed between 1986 and 2002; 20 were SLTs (2.3%). A 30% were children. RESULTS: Mean follow up of 15.15 months +/- 13.85. Median age was 42.27 +/- 25.65 yrs. Median recipient weight was 52.29 +/- 20.87 Kg. Mean donor weight was 76.1 +/- 13.11. The majority was "in situ" SLT (65%). There was no primary graft dysfunction. Two patients developed biliary complications (none in situ SLT). Early HAT occurred in 2 patients and delayed HAT in one. Four patients were retransplanted but none were performed because of primary graft dysfunction. Five patients died in the hospital. Fifteen patients (75%) survived the postoperative period and 3 patients died during follow-up. Mean patient survival time was 42 months (95% CI: 31-52). Actuarial patient survival was 93.3%, 84.4%, 84.4% at 6 months, 1 year and 3 years. Mean graft survival was 36 months (95% CI: 25-48). Actuarial graft survival was 87%, 72%, 72% at 6, 12, 36 months. Univariate analysis of risk factors for graft loss showed that the type of splitting technique (p=0.019), and the UNOS (1 and 2a) status of the recipient (p=0.001) were significantly associated with graft loss. CONCLUSIONS: In the context of large volume full cadaveric liver transplantation, split liver can provide adequate results (even after a short learning curve) mainly in elective cases and with the in situ technique.

Tumor recurrence after liver transplantation for hepatocellular carcinoma: recurrence pathway and prognostic factors.

INTRODUCTION: Liver transplantation (OLT) has been advocated as a good management option for patients with carcinoma hepatocellular (HCC). More recurrences are extrahepatic due to many pathological factors. PATIENTS AND METHODS: From April 1986 to December 2003, we performed 95. OLTs for HCC including 73% men of mean age of 54.7 years and 25.3% not filling Mazzaferro's criteria. RESULTS: The recurrence incidence was 15.8% (n = 15), including only extrahepatic lesions in 11 (mainly lung recurrence, seven) and hepatic plus extrahepatic in four. Main late mortality was due to tumor recurrence (n = 12, 33.3%). No differences were observed among sex, preoperative chemoembolization, age, Child, Okuda, etiology, or satellite nodules. A greater incidence of tumor recurrence was observed with a preoperative biopsy (45.5% vs 5.9%, P = .0001); and alpha fetoprotein (AFP) > 200 ng/mL (37.5% vs 13.3%, P = .08); known HCC (25.5% vs 3.1%, P = .008); vascular invasion (42.1% vs 10.3%, P = .001); > 5 cm single nodule (50% vs 13%, P = .004); more than three nodules (50% vs 13.9%, P = .01); moderately to poorly differentiated tumors (37.5% vs 12.7%, P = .01); pTNM IV (50% vs 8.7%, P = .0001); and not meeting Milan criteria (40.9% vs 9.2%, P = .001). These are the same factors for extrahepatic recurrence. For hepatic recurrence the prognostic factors were: vascular invasion (15.8% vs 1.5%, P = .008), more than three nodules (25% vs 2.5%, P = .004), moderately to poorly differentiated tumors (18.8% vs 1.4%, P = .003), pTNM IV (16.7% vs 1.4%, P = .006), and not meeting Milan criteria (13.6% vs 1.5%, P = .01). CONCLUSIONS: Recurrence incidence with Milan criteria was less than 10%, mainly extrahepatic (lung). Prognostic factors for tumor recurrence were pathological features, namely vascular invasion, more than three nodules, size larger than 5 cm, moderately to poorly differentiated tumors, pTNM IV stage. The use of preoperative chemoembolization did not decrease the recurrence rate. A preoperative biopsy increased the incidence of extrahepatic recurrence.

Second case of neurocysticercosis in a patient with liver transplantation (first case in Spain): a case report.

BACKGROUND: Neurocysticercosis (NCC) is a disorder caused by the Taenia solium larva. It is the most common parasitosis of the central nervous system (CNS). Its distribution is universal, but it is endemic in many developing countries and in the third world. In Spain most patients come from countries where the condition is endemic. However, sporadic cases occur among the population of rural regions. NCC in transplant recipients is uncommon. One renal transplant recipient developed NCC but responded to treatment with praziquantel. Recently, it has been reported to complicate a liver transplantation. CASE REPORT: The patient was a 49-year-old Ecuatorian man who received a cadaveric donor liver graft in June 2001 due to acute liver failure induced by toadstool and was under treatment with FK506. In January 2006, the patient presented with a generalized onset of a tonic-clonic seizure for 1 minute without sphincter incontinence, headache, fever, or previous brain trauma. Neurological evaluation did not show evidence of organic brain dysfunction. The neuroimaging findings (brain) computed tomography scan, magnetic resonance imaging were compatible with NCC: many cystic lesions intra- and extraparenchymatous with a scolex visible in three of them. Serology for cysticercosis in plasma was initially indeterminate but positive afterward. The patient was treated with anticonvulsivants (valproic acid) and albendazole. Systemic steroids were added in order to reduce the edema produced upon death of the cyst. Treatment lasted 3 weeks and it was completed without complications or neurological symptoms. Liver function was not affected. One year later the patient remained asymptomatic. CONCLUSION: NCC is a condition that must be included in the differential diagnosis of patients with CNS involvement and cystic lesions on neuroimaging investigations in transplant recipients, especially patients originating from or traveling to endemic areas. First-line therapy for active cysts includes antiparasitic drugs (albendazole or praziquantel) as well as steroids and anticonvulsivants. In our patient, this therapy was effective.

First Spanish series of intestinal transplantation in adult recipients.

BACKGROUND: short-bowel transplantation has experienced a substantial growth worldwide following improved results from the late 1990's on, and its coverage by Medicare. According to the International Registry (1985-2005), a total of 1,292 intestinal transplants for 1,210 patients in 65 hospitals across 20 countries have been carried out thus far. OBJECTIVE: to know short-term (6 months) results regarding patient and graft survival from the first Spanish series of intestinal transplants in adult recipients. MATERIAL AND METHODS: we present our experience in the assessment of 20 potential candidates to short-bowel transplantation between June 2004 and October 2005. Of these, 10 patients were rejected and 4 were transplanted, which makes up the sample of our study. RESULTS: to this date 5 transplants have been carried out in 4 patients (2 retransplants, 2 desmoid tumors, 1 short bowel syndrome after excision as a result of mesenteric ischemia). Upon study completion and after a mean follow-up of 180 days (range 90-190 days) all recipients are alive, and all grafts but one (75%) are fully operational, with complete digestive autonomy. All patients received induction with alemtuzumab except one, who received thymoglobulin; in all induction was initiated with no steroids. CONCLUSIONS: intestinal transplantation represents a therapeutic option that is applicable in our setting and valid for recipients with an indication who have no other feasible alternative to keep their intestinal failure under control.

Incidence of de novo nonmelanoma skin tumors after liver transplantation for alcoholic and nonalcoholic liver diseases.

INTRODUCTION: Skin tumors are the most common malignancies after orthotopic liver transplantation (OLT). They have been related to sunlight exposure, tobacco consumption, and immunosuppression. The aim of this study was to compare the incidence of de novo skin tumors (nonmelanoma) in patients who underwent liver transplantation for alcoholic cirrhosis versus nonalcoholic diseases. PATIENTS AND METHODS: Between April 1986 and July 2004, we performed 1000 OLT in a population of 888 recipients. This study was performed in a sample of 701 adult recipients who survived >2 months after transplantation: 276 patients (39.4%) underwent OLT for alcoholic cirrhosis (AC-group), and 425 (60.6%) for nonalcoholic disease (N-AC). The overall incidence of de novo skin tumors was 3.5% (25 tumors): 5.4% (15 tumors) in the AC-group and 2.4% (10 tumors) in the N-AC group (P = .027). Two patients developed two tumors. There were 19 men and 4 women, mean age at OLT of 54.4 +/- 6.8 years (range, 40 to 66 years). The mean time from OLT to tumor diagnosis was 66.1 +/- 51.4 months (range, 3 to 165 months): 56.4 +/- 44.4 months in the AC-group versus 80.6 +/- 59.8 months in the N-AC group (P = NS). Histologically, 17 tumors (68%) were basal cell carcinomas and eight tumors (32%) were squamous cell carcinomas (P = .128). Fourteen patients (60.8%) were smokers: 11 patients (84.6%) in the AC-group versus 3 patients (30%) in the N-AC group (P = .012). All the patients underwent tumor resection, with only one patient dying, because of lymph node invasion of the neck. CONCLUSION: There was a higher incidence of de novo skin tumors among patients who smoked who underwent OLT for alcoholic cirrhosis.

Primera serie nacional de trasplante de intestino en receptores adultos / First Spanish series of intestinal transplantation in adult recipients

Introducción: el trasplante de intestino, con la mejoría en los resultadosdesde finales de los años 90 y desde su cobertura por el Medicare,ha experimentado un crecimiento sustancial a nivel internacional.En la actualidad, según el Registro Internacional (1985-2005),se han realizado un total de 1.292 trasplantes de intestino en 1.210pacientes en 65 hospitales distribuidos por 20 países.Objetivo: conocer los resultados a corto plazo (6 meses) entérminos de supervivencia del paciente y del injerto de la primeraserie nacional de trasplante de intestino en receptores adultos.Material y métodos: presentamos nuestra experiencia en laevaluación de 20 potenciales candidatos a trasplante intestinal entrejunio de 2004 y octubre de 2005. De ellos, fueron desestimadosun total 10 pacientes y fueron trasplantados 4, lo que constituyela muestra de nuestro estudio.Resultados: hasta la fecha se han realizado 5 trasplantes en 4pacientes (2 retrasplantes, 2 tumores desmoides, y 1 síndrome deintestino corto tras exéresis por isquemia mesentérica). Al final delestudio y tras un seguimiento medio de 180 días (rango, 90-190días), todos los receptores están vivos, y todos los injertos, a excepciónde uno (75%), están funcionando plenamente, con autonomíadigestiva completa. Todos los pacientes recibieron induccióncon alemtuzumab excepto uno que recibió timoglobulina y entodos se inició la inducción sin esteroides.Conclusiones: el trasplante intestinal constituye una opciónterapéutica aplicable en nuestro medio y válida en receptores enquienes está indicado y que no tienen otra alternativa válida paracontrolar su insuficiencia intestinal

Background: short-bowel transplantation has experienced asubstantial growth worldwide following improved results from thelate 1990s on, and its coverage by Medicare. According to the InternationalRegistry (1985-2005), a total of 1,292 intestinal trasplantsfor 1,210 patients in 65 hospitals across 20 countries have been carriedout thus far.Objective: to know short-term (6 months) results regardingpatient and graft survival from the first Spanish series of intestinaltransplants in adult recipients.Material and methods: we present our experience in the assessmentof 20 potential candidates to short-bowel transplantationbetween June 2004 and October 2005. Of these, 10 patientswere rejected and 4 were transplanted, which makes up thesample of our study.Results: to this date 5 transplants have been carried out in4 patients (2 retransplants, 2 desmoid tumors, 1 short bowelsyndrome after excision as a result of mesenteric ischemia).Upon study completion and after a mean follow-up of 180days (range 90-190 days) all recipients are alive, and all graftsbut one (75%) are fully operational, with complete digestiveautonomy. All patients received induction with alemtuzumabexcept one, who received thymoglobulin; in all induction wasinitiated with no steroids.Conclusions: intestinal transplantation represents a therapeuticoption that is applicable in our setting and valid for recipientswith an indication who have no other feasible alternative tokeep their intestinal failure under control

Simultaneous liver-kidney transplantation for adult recipients with irreversible end-stage renal disease.

HYPOTHESIS: Combined liver-kidney transplantation is safe (low morbidity and acceptable mortality) and effective in patients with end-stage liver disease. Although refinements in surgical technique have resulted in better patient and allograft outcomes, the negative impact of renal insufficiency on survival in patients undergoing liver transplantation has been widely reported, although some aspects are controversial. DESIGN: Analysis of the clinical characteristics and outcome in the management of patients undergoing combined liver-kidney transplantation. The end points were operative mortality, morbidity, and long-term survival. SETTING: University Hospital 12 de Octubre. PATIENTS: Between May 1986 and December 2001, 820 liver transplantations were performed. There were 16 cases (1.96%) of combined liver-kidney transplantations, which represent the sample of this study. RESULTS: Mean +/- SD follow-up of 42.2 +/- 29 months: 6 patients died (37.5% mortality rate). There were 4 (25%) hospital deaths within 6 months following surgery and 2 after 6 months (4 sepsis, 1 refractory heart failure, and 1 recurrent hepatitis C virus disease). Univariate analysis related to mortality included age, sex, etiology, preoperative creatinine level, United Network for Organ Sharing status, Child-Pugh score, type of hepatectomy (piggyback), intraoperative blood product administration, and the presence of postoperative complications. The only 2 significant factors were the presence of postoperative complications (P = .01) and the United Network for Organ Sharing status (P = .02). Crude survival rate was 62.5%. Actuarial survival rates were 80%, 71%, and 60% at 1, 3, and 5 years, respectively. CONCLUSION: Because end-stage renal disease is not a formal contraindication for liver transplantation, a combined liver-kidney transplantation for adults with end-stage renal disease can be done safely and effectively.

Hepatic allograft arterialization by means of the gastroduodenal bifurcation (branch patch) as a prognostic factor.

INTRODUCTION: Because of the current shortage of cadaveric organs, it is important to determine preoperatively those variables that are readily available, inexpensive, and noninvasive that can predict a higher incidence of hepatic artery thrombosis (HAT). MATERIAL AND METHODS: From April 1986 to October 2001, 717 patients underwent 804 liver transplants. All the arterial reconstructions were performed with fine (7-0) monofilament sutures in an interrupted fashion. Two methods were used: group I, end-to-end arterial anastomosis, and group II, the gastroduodenal branch patch. RESULTS: After a mean follow-up of 72 (range 3-174) months, HAT was observed in 19 patients (overall incidence 2.4%). End-to-end anastomosis (group I) was performed in 39.50% (316) of cases, and HAT developed in 14 (4.4%) cases. Branch-patch anastomoses (group II) were carried out in 60.5% (488) of the patients; the presence of HAT was detected in five cases (1.03%) (P = 0.03, P < 0.05). A total of 21 variables were selected in the univariate analysis; however, after the multivariate analysis, all but two of the factors lost statistical significance, and these corresponded to the type of arterial reconstruction (gastroduodenal branch patch vs. end-to-end) and the ABO compatibility. CONCLUSIONS: Liver transplantation with compatible grafts using branch-patch anastomosis for the arterialization (both manipulative by the transplant team) reduces HAT-derived loss of grafts, with the consequent increase in graft availability and reduced mortality rate on the waiting list.

Exceptional bilateral adrenalectomy after secondaries from colorectal cancer.

We report a very uncommon case of bilateral adrenal metastasis treated at our institution. The patient was 65 years old, with a history of low anterior resection for colorectal cancer in 2001. One year later, he was diagnosed with bilateral adrenal metastasis, based on the results of abdominal computed tomography-scan. A bilateral adrenalectomy extended to distal pancreatectomy and splenectomy was performed. Postoperative course was uneventful. He is alive and free of disease 12 months after adrenalectomy. We conclude adrenal metastasis from colorectal cancer should be managed surgically, even if they are bilateral.

Liver recipients undergoing hepatic transplantation and subsequent retransplantation: a comparison between clinical characteristics.

BACKGROUND/AIMS: In order to establish a rational strategy for organ distribution and optimal patient management, we postulate it is mandatory not only to understand the pathophysiology of failing grafts but also to better recognize the baseline clinical characteristics of the recipients shortly before receiving a second liver allograft. METHODOLOGY: Between March 1986 and December 1997, 1061 patients underwent 1087 orthotopic liver transplantation at three Hospitals in Madrid (122 retransplants). RESULTS: Mean follow-up was 36 months (range, 1-90), 40.6% of the recipients were alive and survival at 1, 3 and 5 years was 62%, 53%, and 46%. Almost 50% of the recipients were UNOS 1 before retransplantation. In comparison to p-OLT (15% UNOS 1), it is clearly shown that the retransplants have been performed in the sickest patients with more adverse prognostic indicators (higher AST, bilirubin, creatinine serum levels, higher Child-Pugh score, higher rate of ascites and lower serum levels of albumin and prothrombin activity). CONCLUSIONS: Liver retransplantation is acceptable and significant differences in recipients' baseline characteristics suggest an impact on lower survival.

Live liver donation: a prospective analysis of exclusion criteria for healthy and potential donors.

INTRODUCTION: Living donor liver transplantation represents a controversial option to increase the donor pool. DESIGN: Prospective and descriptive clinical study. OBJECTIVE: (1) To identify risk factors (exclusion criteria) for live donation; (2) to determine the rate of recipients that benefit from a living donor. METHODS: Between May 1995 (first adult-to-adult living donor liver transplantation in Spain) and November 2002, we evaluated 74 healthy volunteers and performed 12 living donor liver transplants (no donor mortality). RESULTS: All actual donors and volunteers are alive and healthy. After a mean time of 3.2+/-0.5 weeks, 72% of potential donors were considered unsuitable for live donation. Exclusion criteria were grouped in three categories: (primary) donor safety reasons (68%); (secondary): ABO mismatch (17%) and (tertiary): cadaveric graft transplantation (15%). Consequently, just 43.7% of the recipients presenting to us with a potential living donor, did finally benefit from these organs. The mortality rate was 8.3% for 43 recipients presenting with a living donor in comparison to 15% for those who did not (321 recipients between May 1995 and November 2001). CONCLUSIONS: ALDLT can benefit a significant number of recipients on the waiting list (43.7% of those presenting with a donor). The most frequent exclusion criteria concern donor safety, namely, unsuspected chronic liver diseases and unsuspected thrombophilic disorders.

Liver transplantation for hepatocellular carcinoma: our experience from 1986.

UNLABELLED: Currently liver transplantation is the treatment of choice for early hepatocellular carcinoma and end-stage liver disease. We analyzed our experience to identify factors that could be used to select patients who will benefit from liver transplantation. PATIENTS AND METHODS: From April 1986 to December 2001, 71 (8.7%) of 816 LT performed in our institution, were for patients with hepatocellular carcinoma. In 25 patients the tumor was observed incidental by (35.2%). All patients had liver cirrhosis, most due to hepatitis C related (35) or alcoholic (14) diseases. Before liver transplantation, chemoembolization was performed in 18 patients (25.4%). RESULTS: Bilateral involvement was present in seven patients. Eight patients showed macroscopic vascular invasion, and eight others showed satellite nodules. Most patients were stage TNM II (29) and IVa (16). Overall 1-, 3-, and 5-year survival were 79.3%, 61%, and 50.3% with recurrence-free survivals of 74.6%, 57.5%, and 49%, respectively. With a mean follow-up of 42 months, 12 patients (19%) developed recurrence and 29 patients died (only 11 due to recurrence). Stage TNM IVa, macroscopic vascular invasion, and the presence of satellite nodules significantly affected overall survival and recurrence-free survival rates and histologic differentiation and bilateral involvement only recurrence-free survival. Patients with solitary tumors less than 5 cm or no more than three nodules smaller than 3 cm showed better recurrence-free survival and lower recurrence rates. DISCUSSION: In our experience, liver transplantation proffers good recurrence-free survival and low recurrence rates among patients with limited tumor extension. The most important prognostic factor was macroscopic vascular invasion.

Simultaneous liver-kidney transplant for combined renal and hepatic end-stage disease.

INTRODUCTION: After the first combined liver-kidney transplantation (CLKT) reported by Margreiter in 1984, it became clear that renal failure was no longer an absolute contraindication. OBJECTIVE: Our goal was to assess our results with combined liver-kidney transplant. Among 875 liver transplants performed between May 1986 and October 2002, there were 17 cases (1.96%) of combined liver-kidney transplant. RESULTS: With a mean follow-up of 42.2+/-29 months (range, 1-90), six patients had died (mortality: 37.5%). There were four (25%) operative in-hospital deaths, and two late mortality cases (beyond the month 6 after hospital discharge). The causes were sepsis (four cases, three postoperative and one in later follow-up), refractory heart failure (one postoperative), and recurrent liver disease (HCV-induced severe recurrence) during follow-up one). Actuarial survival (calculated for those who survived the postoperative period) was 80%, 71%, and 60% at 12, 36, and 60 months. Actuarial mean survival time was 60 months (95%IC:47-78). Neither the sex, the UNOS status, the etiology of liver disease, the etiology of renal failure, the type of hepatectomy (piggy back vs others) or the type of immunosuppression (P=.83) were related to long-term survival according to the log-rank test. A control group of 48 patients was constructed with subjects who underwent liver transplantation immediately before or after the combined transplant. A total (two cases after the CLKT and one case prior to). There were no differences in survival. CONCLUSION: Combined liver-kidney transplant represents a proper therapeutic option for patients with simultaneously failing organs based on long- and short-term outcomes.

Trasplante pancreático heterotópico con injerto total vascularizado (órgano completo) / Heterotopic pancreatic transplantation with whole vascularized graft (whole organ)

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