Solid Organ Transplantation After Retrieval From Deceased Donors With Abdominal Aortic Grafts.

INTRODUCTION: Organ procurement from deceased donors has been steadily augmented over the last 20 years. With a more aged donor population, a higher incidence of intraabdominal pathologies, including abdominal aortic aneurysms and atherosclerotic aortic disease, is commonly being encountered. The objective of our study was to report our institutional experience with abdominal aortic grafts during solid organ harvesting. PATIENTS AND METHODS: Data concerning the presence of aortic grafts in deceased solid organ donors during a 36-month period were retrospectively reviewed. RESULTS: During the study period, the organ retrieval team of our institution performed 246 multiorgan retrievals from deceased donors. More specifically, we harvested 6 livers and 12 kidneys from 6 donors with abdominal aortic grafts, which were not known/diagnosed to the organ retrieving team prior to the harvesting procedure. Severe atherosclerosis was present in all these donors. All 18 harvested organs were successfully transplanted. Apart of the absence of the aortic patch in 5 kidney grafts, no further special technical difficulties have been reported by the transplant teams. Data analysis of the recipient and graft outcome was performed through the Eurotransplant database. CONCLUSION: There are so far no literature data on the outcome of recipients and grafts from deceased donors with abdominal aortic grafts. Although retrieval of such organs is very challenging and requires a very experienced team, the transplantation of the corresponding organs can be performed without special technical problems.

Prediction of Microvascular Tumor Invasion in Liver Transplant Candidates With Hepatocellular Carcinoma: A Feasible Concept or a Misleading Illusion?

INTRODUCTION: Hepatocellular carcinoma (HCC) in cirrhosis is a widely accepted indication for liver transplantation (LT). Many scoring systems have been proposed intending to an extension of the established Milan criteria. Bridging treatments are systematically applied in order to maintain or to downstage such patients to the listing criteria. The objective of our study was to estimate the feasibility of the prediction of microvascular tumor invasion in transplant candidates. PATIENTS AND METHODS: Data corresponding to transplanted HCC patients were reviewed for the purposes of this study. All tumor slices were blindly re-evaluated by a single pathologist in order to score for tumor necrosis and microvascular invasion. Recipients of pediatric or split LT were excluded. RESULTS: Eighty patients (30 women and 50 men) were included in the study. Tumor necrosis was absent in 29 of 80 liver explants (36.25%). In the majority of instances (63.75%) tumor necrosis was evident in proportions between 5% and 100%. In 58 liver explants showing 0%-60% tumor necrosis and 22 liver explants showing > 60% tumor necrosis, microvascular tumor invasion was detectable in 11 and 0 cases, respectively (P = .0385). CONCLUSION: In about one-fourth of the cases (27.5%) microvascular tumor invasion could not be detected due to extended areas of tumor necrosis. Preoperative detection of microvascular invasion is misleading.

Renal paratransplant hernia revealed: a review of the literature.

BACKGROUND: Renal paratransplant hernia (RPH) is an uncommon variant of internal hernias developed in renal transplant recipients. The aim of this review is to meticulously present and analyze all data coming mainly from case reports or short-case studies on this very uncommon surgical entity. MATERIALS AND METHODS: The MEDLINE/PubMed database was searched for publications with the medical subject heading ''renal paratransplant hernia''. All the references from the identified articles were searched for relevant information. The end date of the literature search was set to March 2016. RESULTS: Our search revealed five publications, three short clinical series (three cases each) and two case reports. The total number of cases retrieved was 11. RPH should be considered as an iatrogenic surgical complication. The incidence is around 0.45%. CONCLUSIONS: RPH is a relatively uncommon but potentially fatal complication after renal transplantation, and its non-specific symptoms may lead to misdiagnosis. Physician awareness, prompt diagnosis, and early surgical intervention are critical. In addition, meticulous surgical technique during transplantation may help avoid this complication.

A Heartbreaking Renal Transplantation: Is Norepinephrine the Culprit to Blame?

INTRODUCTION: Takotsubo cardiomyopathy (TCM), also known as "broken heart syndrome," "apical ballooning syndrome," and "stress-induced cardiomyopathy," was first described in Japanese patients in 1990 by Sato et al. TCM is an increasingly recognized syndrome characterized by transient and reversible systolic dysfunction of the apical and middle segments of the left ventricle. This syndrome resembles acute myocardial infarction in the absence of evident coronary artery occlusion. Herein, we present a case of a 51-year-old male who underwent his second deceased-donor renal transplantation for end-stage-renal-disease due to a work-related accident. Perioperatively, initiation of continuous infusion of noradrenaline was decided to achieve adequate graft perfusion due to persistently low blood pressure. On the second postoperative day, the patient experienced tachycardia and atypical angina-like chest pain. Electrocardiogram (ECG) showed signs of myocardial infarction and elevated troponin levels were observed. Urgent coronary angiography was normal and transthoracic echocardiography (TEE) was indicative for Takotsubo cardiomyopathy. DISCUSSION: Although, the precise pathophysiology of Takotsubo cardiomyopathy is still unknown, it seems that it is associated with excessive sympathetic stimulation, microvascular dysfunction, coronary artery vasospasm, and abnormal myocardial tissue metabolism. The development of patient's symptoms after the initiation of norepinephrine along with their immediate resolution after the discontinuation of the drug might suggest a causal relationship. This is the first time that TCM after renal transplantation is thought to be linked with the administration of exogenous catecholamines.

Surgical Dead End in a Renal Transplant Recipient Associated With a Rare Thrombohemorrhagic Syndrome.

BACKGROUND: Primary breast angiosarcoma is an extremely rare malignancy. Association of this type of tumor with Kasabach-Merritt syndrome has only been reported in 3 cases in the past. To our knowledge, this is the first reported case of a solid-organ recipient. METHODS: A 53-year-old woman who underwent a deceased-donor renal transplantation 5 years previously presented with a 12-month history of a giant ulcerated lesion on her left breast. Biopsy of the overlying skin suggested primary angiosarcoma. Concurrently, the patient's bleeding from the site of the biopsy and hematology investigations indicated the presence of Kasabach-Merritt syndrome. RESULTS: The case was discussed in a multidisciplinary setting. The decision was to use anthracycline-based chemotherapy as up-front treatment to assess tumor response and gain a local benefit for a subsequent resection. After the completion of 1 cycle of chemotherapy, the patient died of cardiovascular insufficiency. Primary angiosarcoma of the breast occurs in the third to fourth decade and has been reported only in women. CONCLUSIONS: A high clinical suspicion and referral to a specialized center are necessary. Total mastectomy appears to be the only treatment conferring benefit; chemotherapy and radiation therapy are of little value.

Amyand's hernia: a case series with critics of role of appendectomy.

Amyand's hernia is an inguinal hernia that contains vermiform appendix in its sac. It consists 1% of all inguinal hernias while appendicitis in an Amyand's hernia accounts for 0.1% of all appendicitis cases. Its clinical image is identical to that of an incarcerated or perforated inguinal hernia. Diagnosis is usually established intraoperatively. Hernioplasty (with or without mesh repair and with or without appendectomy) is the treatment of choice. According to Losannof and Basson's criteria, performance of appendectomy shall depend on vermiform appendix's inflammation status. In this case series, authors present three patients who had to undergo prophylactic appendectomy because of medical conditions, unrelated to appendix's inflammation status thus escaping from therapeutic frame set by Losanoff and Basson's criteria.

Incidence and management of Kaposi sarcoma in renal transplant recipients: the Greek experience.

OBJECTIVE: One of the most common malignancies in kidney transplant recipients is Kaposi sarcoma. The incidence of Kaposi sarcoma, which develops after renal transplantation, is 400-500 times higher than that in the general population. The aims of this study were to review the experience with Kaposi sarcoma in the highest-volume transplantation Unit in Greece and to analyze clinical characteristics and response to treatment, with respect to both the patients' survival and the renal graft function. MATERIALS AND METHODS: The records of 2008 renal graft recipients between March 1983 and December 2012 were retrospectively reviewed. Kaposi sarcoma was diagnosed based on clinical, laboratory, radiological, endoscopic, and histopathologic examinations. The disease was staged according to the classification of Al-Khader et al. RESULTS: The prevalence of Kaposi sarcoma was 1.2% in our renal transplant population. Of these, 1006 recipients underwent living-donor renal transplantation, whereas 1002 received their graft from deceased donors. Post-transplantation malignancy developed in 153 patients, among which, Kaposi sarcoma has been found in 24 cases. Of the 24 cases of Kaposi sarcoma, lesions were mainly cutaneous in 14 cases, visceral and cutaneous in 8, and concomitant visceral and lymph node involvement was observed in 2 patients. With regard to the final outcome, 20 patients (83.3%) showed remission of the disease, whereas 4 patients with visceral involvement (16.6%) did not respond to chemotherapy and discontinuation of immunosuppression and died. Moreover, 8 deaths occurred due to apparently unrelated causes. CONCLUSIONS: Kaposi sarcoma is an important part (15.7%) of all post-transplantation neoplasias in our series. Furthermore, our findings confirmed the previously described close association between human herpesvirus-8 and post-transplantation Kaposi sarcoma. Reduction of immunosuppression or discontinuation of calcineurin inhibitors results in remission of the disease in most of the cases. Prognosis in patients with Kaposi sarcoma limited to the skin is favorable, whereas visceral involvement is associated with high mortality.

Lithiasis of the renal allograft, a rare urological complication following renal transplantation: a single-center experience of 2,045 renal transplantations.

BACKGROUND AND PURPOSE: Urinary lithiasis represents an unusual urologic complication in renal transplantation, with an incidence of 0.17%-1.8%.We present our experience with renal graft lithiasis in our series of renal transplantations. MATERIAL AND METHODS: We reviewed the medical records for 2045 patients who underwent kidney transplantation from January 1983 to July 2013. Among the grafts, 9 patients were found to have allograft lithiasis. In 6 cases, the calculi were localized within the renal unit, and in 3 cases in the ureter. Two of the patients had relapsed after a few years from the first treatment. In both of them the stones were localized again in the ureter. RESULTS: In our series, incidence of graft lithiasis was 0.44% (n = 9). Three of the 9 patients (33.3%) were treated via percutaneous nephrolithotripsy (PCNL), 3 (33.3%) underwent extracorporeal shockwave lithotripsy (ESWL), 2 (22.2%) passed their stones spontaneously, and 1 (11.1%) underwent PCNL after 2 failed ESWL interventions. All patients are currently stone free but still remain under close urologic surveillance. CONCLUSIONS: Urinary stone formation can lead to significant morbidity and graft loss. The treatment options should be similar to those for patients in the general population. Long-term follow-up is substantial to determine the outcome and to prevent the recurrence.

Single-center experience of transplantation for polycystic liver disease.

BACKGROUND: Polycystic liver disease (PLD) may lead to massive hepatomegaly, abdominal distension, pain, and various degrees of dyspnea. The surgical treatment of this entity remains controversial. METHODS: We report our experience from a retrospective analysis of 23 patients suffering from PLD who were treated with liver transplantation (LT) in our institution. RESULTS: Liver transplantation for PLD patients with extensive hepatic involvement offers excellent symptoms relief. The actuarial 1-, 3-, and 5-year survival rate after transplantation was 86%. CONCLUSIONS: Our experience demonstrates that PLD patients with extensive hepatic involvement and who are treated with LT have good long-term prognosis and excellent symptoms relief. LT might be considered in severe PLD cases where conventional surgery is not a curative option, and it must be balanced against the risks of LT and lifelong commitment to immunosuppression.

Ovarian carcinosarcoma in a renal transplant recipient. A unique case of a rare tumor.

INTRODUCTION: De novo malignancies have become one of the leading causes of late mortality after renal transplantation, with their incidence being 2-15 fold higher than in general population. We present herein a unique case of ovarian carcinosarcoma in a renal transplant recipient. CASE REPORT: A 69-year-old female renal transplant recipient presented with progressive distension and vague abdominal pain. Clinical examination revealed a large abdominal mass. Magnetic resonance imaging scan verified the presence of the mass. An exploratory laparotomy was performed, identifying a giant tumor measuring 33 x 22 x 10 cm. Optimal debulking surgery was performed, the postoperative course was uneventful and she was discharged on the 8(th) postoperative day. The final diagnosis was ovarian carcinosarcoma. The patient received adjuvant chemotherapy and at 6-month follow-up, she was disease-free. CONCLUSION: Ovarian Carcinosarcoma is a rare and aggressive neoplasia, comprising 1-2 % of all ovarian tumors. Radical surgical approach, as well as appropriate chemotherapy are the cornerstone of treatment. In the presented case, where immunosuppression is involved, further evaluation should be made as far as immunosuppression dose reduction or switch is concerned.

Liver transplantation for hepatocellular carcinoma using extended criteria donor grafts.

BACKGROUND: Liver transplantation (OLT) represents the treatment of choice for small hepatocellular carcinomas (HCC) in patients with end-stage liver disease. However, because of organ scarcity, alternative options must be explored, such as the use of extended criteria donor (ECD) grafts. PATIENTS AND METHODS: We reviewed data of transplanted HCC patients using ECD grafts. Statistical analysis included uni- and multivariate Cox proportional hazards regression and survival analysis using the Kaplan-Meier method with the log-rank test. RESULTS: Over a 6-year period, we transplanted 53 HCC patients with ECD grafts. The 38 men and 15 women showed a mean age of 56.3 ± 8.26 years. Thirty-four patients underwent a bridging treatment before OLT. Thirty-eight patients (72%) were outside the Milan criteria. The median value for alpha fetoprotein (AFP) level was 30.7 ng/dL. Pathologic tumor grade was G1 (n = 4), G2 (n = 32), G3 (n = 6), or Gx (n = 11). Median follow-up time was 23 months (range, 9-75). Overall 3- and 5- year patient survivals were 79% and 74%, respectively. The 5-year survivals for patients within or outside the Milan criteria were 87% versus 69%, respectively (P = .3728). Donor transaminases and post-OLT hemodialysis were prognostic factors for patient survival upon mutivariate regression analysis (P = .0043 and P = .0003, respectively). CONCLUSION: OLT with ECD grafts constitutes an additional option for patients with HCC and cirrhosis, particularly subjects outside the Milan criteria. The risk- benefit ratio in these instances should be evaluated on a case-by-case basis.

Orthotopic liver transplantation in patients with portal vein thrombosis in the absence of hepatocellular carcinoma.

BACKGROUND: Liver transplantation (OLT) in the setting of portal vein thrombosis (PVT) has been a matter of controversy in the past. We herein report our experience with OLT for PVT in the absence of hepatocellular carcinoma. PATIENTS AND METHODS: Data from patients undergoing OLT for end-stage liver disease, having a documented PVT before OLT, were reviewed. RESULTS: Twenty-five patients were included for the period July, 2003 to December, 2009. There were 20 men and 5 women of median age 57 years. Median values for waiting time and Model for End-Stage Liver Disease score were 150 days and 18, respectively. PVT was classified as grade II (n = 6), IIIa (n = 7), IIIb (n = 9), or IVa (n = 3). Partial portal vein resection/reconstruction, operative thrombectomy, and eversion thromboendovenectomy were performed in 2, 16, and 7 instances, respectively. After a median follow-up of 18 months, 14 patients are alive. Survival rates at 3, 6, 9, and 12, months and 3 years post-OLT were 68%, 64%, 61%, 61%, and 61%, respectively. PVT grade was a negative predictor of survival by Cox proportional hazard analysis (P = .0253). CONCLUSION: Despite the technical innovations in recent years, PVT grade correlated with poor patient survival irrespective of the surgical technique.

Sorafenib treatment for recurrent hepatocellular carcinoma after liver transplantation.

BACKGROUND: With an increasing number of patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (OLT), HCC recurrence remains the main limiting factor for long-term survival. We herein report our experience with sorafenib treatment for HCC recurrence post-OLT. PATIENTS AND METHODS: We reviewed data on transplanted HCC patients receiving sorafenib for HCC recurrence. RESULTS: Fourteen patients were included for the period November 2006 to February 2011. There were 9 men and 5 women of median age of 57 years. Twelve patients (86%) received rescue grafts through Eurotransplant allocation. Median values for alpha fetoprotein levels, Model for End-Stage Liver Disease score, sorafenib daily dose, and length of treatment were 97 ng/mL, 10, 400 mg, and 6.5 months, respectively. Sorafenib side effects led to discontinuation (n = 4) or reduction (n = 2) of the daily dose. Four patients experienced tumor progression during treatment. Seven patients are currently alive, 3 patients died of tumor progression, and 4 patients of non-tumor-related causes of death. Median survival was 25 months. CONCLUSION: Sorafenib treatment for HCC recurrence in transplant recipients represents a challenging oncologic approach that requires further validation in prospective, multicenter studies.

Cholecystectomy due to symptomatic gallbladder disease after orthotopic liver transplantation: report of three cases.

Although biliary stones and sludge are relatively common after liver transplantation (OLT), symptomatic cholecystolithiasis or acute cholecystitis have rarely been reported. Until the early 1990s few transplant centers preserved the donor's gallbladder for transplantation with the liver graft. This technique allows one to perform procedures, such as cholecystojejunostomy or a donor gallbladder conduit for biliary tract reconstruction, to treat posttransplant biliary complications. Herein we have reported three cases of successful either laparoscopic or open cholecystectomy for symptomatic cholecystolithiasis or acute cholecystitis between 14 and 19 years after OLT, as well as a systematic literature review.

Successful salvage delivery and liver transplantation for fulminant hepatic failure in a 34-week pregnant woman: a case report.

We report the case of a 40-year-old multiparous woman with fulminant hepatic failure due to acute hepatitis B virus infection who underwent a successful cesarean delivery of a healthy male fetus at 34 weeks, gestation and a few hours thereafter successful salvage orthotopic liver transplantation (OLT). There were no obstetric complications; the neonatal outcome was excellent. At 27 months, follow-up, the patient is doing well, and the newborn exhibits normal development. OLT for acute liver failure during pregnancy is an uncommon occurrence with variable outcomes. This case illustrates the challenge of treating this rare condition and demonstrates that a salvage double surgical approach-emergency delivery and OLT-is a feasible therapeutic option for treatment of these patients.

Incarcerated diaphragmatic hernia after right hepatectomy for living donor liver transplantation: case report of an extremely rare late donor complication.

Living donor liver transplantation has evolved to an indispensable surgical strategy to minimize the mortality of adult and pediatric patients awaiting transplantation. The crucial prerequisite to performing this procedure is a minimal risk of donor morbidity and mortality. A 46-year-old woman underwent right hepatectomy for living donor liver transplantation. Two and a half years after liver donation, she presented with upper abdominal pain and fullness. Radiographic evaluation revealed an incarcerated diaphragmatic hernia of the right hemithorax. After emergency laparotomy and evaluation of the right hemithorax, a partial jejunal resection was performed due to ischemic findings. The diaphragmatic hernia was repaired. Diaphragmatic hernia is a rarely reported complication of right donor hepatectomy for transplantation and should be considered to be a potential late complication.

Long-term outcomes of liver transplant patients with human immunodeficiency virus infection and end-stage-liver-disease: single center experience.

OBJECTIVE: Orthotopic-liver-transplantation (OLT) in patients with Human-Immunodeficiency-Virus infection (HIV) and end-stage-liver-disease (ESDL) is rarely reported. The purpose of this study is to describe our institutional experience on OLT for HIV positive patients. MATERIAL AND METHODS: This is a retrospective study of all HIV-infected patients who underwent OLT at the University Hospital of Essen, from January 1996 to December 2009. Age, sex, HIV transmission-way, CDC-stage, etiology of ESDL, concomitant liver disease, last CD4cell count and HIV-viral load prior to OLT were collected and analysed. Standard calcineurin-inhibitors-based immunosuppression was applied. All patients received anti-fungal and anti-pneumocystis carinii pneumonia prophylaxis post-OLT. RESULTS: Eight transplanted HIV-infected patients with a median age of 46 years (range 35-61years) were included. OLT indications were HCV (n = 5), HBV (n = 2), HCV/HBV/HDV-related cirrhosis (n = 1) and acute liver-failure (n = 1). At OLT, CD4 cell-counts ranged from 113-621 cells/µl, and HIV viral-loads from <50-175,000 copies/ml. Seven of eight patients were exposed to HAART before OLT. Patients were followed-up between 1-145 months. Five died 1, 3, 10, 31 and 34 months after OLT due to sepsis and graft-failure respectively. Graft-failure causes were recurrent hepatic-artery thrombosis, HCV-associated hepatitis and chemotherapy-induced liver damage due to Hodgkin-disease. One survivor is relisted for OLT due to recurrent chronic HCV-disease but non-progredient HIV-infection 145 months post-OLT. Two other survivors show stable liver function and non-progredient HIV-disease under HAART 21 and 58 months post-OLT. CONCLUSIONS: OLT in HIV-infected patients and ESLD is an acceptable therapeutic option in selected patients. Long-term survival can be achieved without HIV disease-progression under antiretroviral therapy and management of the viral hepatitis co-infection.

Tumor markers as a diagnostic key for hilar cholangiocarcinoma.

OBJECTIVE: Hilar cholangiocarcinoma is the fourth most common gastrointestinal malignancy. CA19-9 and CEA are helpful devices in the management of gastrointestinal malignancies and belong to clinical routine in surgical oncology. But the validity of these parameters in terms of tumor extension and prognosis of bile duct malignancies still remains unclear. METHODS: From 1998 to 2008, we obtained preoperative CA19-9 and CEA serum levels in 136 patients with hilar cholangiocarcinoma. We correlated tumor stage, resectability rate and survival with preoperative CA 19-9 and CEA serum levels. RESULTS: CA19-9 (UICC I: 253 ± 561U/ml; UICC II: 742 ± 1572 U/ml; UICC III: 906 ± 1708 U/ml; UICC IV: 1707 ± 3053U/ml) and CEA levels (UICC I: 2.9 ± 3.8U/ml; UICC II: 4.6 ± 6.5 U/ml; UICC III: 18.1 ± 29.6 U/ml; UICC IV: 22.7 ± 53.9 U/ml) increase significantly with rising tumor stage. Patients with pre?operative serum levels of CA19-9 (>1000U/ml) and CEA (>14.4ng/ml) showed a significant poorer resectability rate and survival than patients with lower CA19-9 and CEA serum levels respectively. CONCLUSION: CA19-9 and CEA serum levels are associated with the tumor stage. If preoperatively obtained CA19-9 and CEA serum levels are highly elevated patients have an even worse survival and the frequency of irresectability is significantly higher.

Transplantation after blunt trauma to the liver: a valuable option or just a "waste of organs"?

OBJECTIVE: Liver injury due to trauma is a rare indication for transplantation. The main indications in such cases were uncontrollable bleeding and insufficient hepatic function. Because of poor results, liver transplantation in these patients is occasionally described as "waste of organs", however based on insufficient data. This study aims to report our experience and to critically question the indication of transplantation in these patients. METHODS: All liver transplantations at our institution were reviewed retrospectively. This covered 1,529 liver transplants between September 1987 and December 2008. Of them, 6 transplants were performed due to motor-vehicle accidents which caused uncontrollable acute liver trauma in 4 patients. The patients' peri-operative course, short- and long-term outcomes were analyzed. RESULTS: Five deceased-donor liver transplantations (4 full size, 1 split) and 1 living donor (right) transplantation were performed. The median GCS score was 9/15; the median MELD score was 15. Postoperative complications were observed in 3 patients, requiring re-operation in 2. After a median (range) follow-up of 32.95 (10.3-55.6) months, 2 patients are alive and remain well on immunosuppression. CONCLUSION: Liver transplantation in patients with otherwise surgically uncontrollable acute liver injury can be indicated as a life saving procedure and can be performed successfully in highly selected cases.

[Hemicolectomy for ischemic colitis : A case report of a (H1N1) virus-associated death]. / Hemikolektomie bei Kolonischämie : Fallbericht von Schweinegrippe mit letalem Verlauf.

Pandemic influenza A (H1N1) virus infection is rapidly spreading and has also become a common problem in Germany. Many cases with severe clinical presentation and death have been documented, especially in persons with underlying medical conditions. As of December 15, 2009, Germany has reported 119 H1N1-associated deaths. We report here the first H1N1-associated death in Germany, a 36-year-old woman with morbid obesity. The patient underwent a laparotomy with colon resection due to colon ischemia, a rare visceral complication in such cases. In this article an attempt has been made to reflect the state of requirements in terms of safety, occupational health, hygiene and working conditions with respect to activities involving logistics in the diagnostics, treatment (also surgical) and handling of such patients. Given the rapidly evolving nature the outbreak of human infection with the novel influenza A (H1N1) virus, influenza vaccination is recommended as the only way to prevent the infection of health care workers and patients with underlying medical conditions.