Portoumbilical anastomosis as a simple method of transient portosystemic shunt during liver transplantation.

BACKGROUND: This article describes a new method of transient intraoperative portosystemic shunting, Splachnic edema after portal cross-clamping can be a dangerous complication during the anhepatic phase of the liver transplant operation. The current method seeks to avoid this problem, without the use of external venovenous bypass pump, by a temporary portocaval shunt, with retrohepatic cava preservation as first described experimentally in dogs by Fonkalsrud et al in 1966. METHODS AND RESULTS: Among 227 liver transplant operations, we utilized a transient portosystemic shunt in 29 cases. The indication to perform a temporary shunt in all cases was the development of splachnic edema. In 3 instances, we performed a portoumbilical anastomosis using a prominent umbilical vein. The other 26 procedures employed the usual portocaval shunts. In these cases, splachnic congestion and onset of edema developed after cross-clamping of the round ligament and the portal vein, which resolved after the portoumbilical anastomosis. DISCUSSION: The flow in the shunt was in all cases greater than 1 L/min. The most important risk factor for the development of splachnic edema was the presence of a patent umbilical vein, which occurred in 34.5% of shunted patients. CONCLUSION: The use of a patent umbilical vein to perform a portoumbilical shunt was an effective, easy method to decompress the splachnic area, avoiding dangerous congestion and edema.

Liver transplantation complications in the intensive care unit and at 6 months.

OBJECTIVE: This study sought to determine the factors that influence the 6-month outcomes of liver transplants. PATIENTS AND METHODS: One hundred ninety-six variables (donor, recipient, operation, intensive care unit [ICU], evolution at 3 and 6 months) were collected from the first 74 consecutive liver transplantation performed from 2002 to 2004. The primary endpoint was patient survival at 6 months. The statistical analysis included a screening univariate analysis followed by a stepwise logistic regression with forward inclusion to test independent associations and finally generation of receiver-operator characteristic (ROC) curves to evaluate predictive factors. RESULTS: Patient survival at 6 months was 86%, namely 10 deaths, including 4 intraoperatively and 6 postoperatively due to sepsis. Complications in the ICU were classified as reoperations due to biliary problems, vascular complications, and peritonitis. Late complications included 51% rejection episodes, 24% infections, 11% pleural effusions, and 16% diabetes mellitus. Logistic regression analysis showed independent negative predictors of survival were the number of packed red cells during transplantation, the number of fresh frozen plasma units administered in the ICU, blood urea nitrogen (BUN) concentration in the ICU, and graft complications. The odds ratios of these variables were 10.2, 5.2, 42.1, and 36.9, respectively. The area under the curve (AUC) of the ROC was 0.99; the sensitivity was 94%; and the specificity was 100%. The independent predictors of surgical complications were the length of the operation, the need for pressor support, and the number of fresh frozen plasma units administered in the operating room, with odds ratios of 1.0, 7.7, and 1.1, respectively. CONCLUSION: This study revealed specific operative and ICU variables that correlated with the evolution of our patients.

Renoportal anastomosis as a rescue technique in postoperative portal thrombosis in liver transplantation.

Renoportal anastomosis has been used as the primary portal revascularization technique in grade 4 portal thrombosis, but never after posttransplant portal thrombosis. A cirrhotic patient with hepatocellular carcinoma and partial portal thrombosis of two-thirds of the lumen was transplanted. The thrombus was removed and good portal flow obtained upon reperfusion (2.8 L/min). On the ninth postoperative day Doppler ultrasound revealed complete portal thrombosis extending from the splenomesenteric confluence. At emergency reoperation, we removed the newly formed thrombus. Portal vein branches were flushed with heparin and urokinase. After reconstruction of the anastomosis, we achieved a flow of 1.1 L/min. Rethrombosis occurred again on day 13. At reoperation, thrombus was removed again. However, this time portal flow was not recovered, due to hepatofugal flow associated with both the presence of collaterals and pancreatic edema. A left renoportal anastomosis was performed using an interposed iliac vein graft. A catheter was placed into the portal vein through a recanalization of the umbilical vein of the graft. After urokinase perfusion, portal inflow was 1.7 L/min. The postoperative course was satisfactory, with progressive normalization of liver tests and no further thrombosis. Persistent ascites improved with treatment. Angiography on day 41 showed good portal flow from the renal vein, with uniform distribution within the liver. A renoportal anastomosis can be useful for recovery of liver failure after posttransplant portal thrombosis, in the absence of portal flow.

Colangitis esclerosante primaria como causa de un pseudotumor de la confluencia de la vía biliar / Primary sclerosing cholangitis as a cause of bile duct confluence pseudotumor

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Pattern of recurrence after esophageal resection for cancer.

BACKGROUND/AIMS: Surgery is still the main treatment option for esophageal cancer; however, long-term survival has remained poor, even when a curative operation is performed. The present study was undertaken to analyze the pattern and time of recurrence after a curative esophagectomy. METHODOLOGY: We studied 53 patients who underwent curative esophageal resection for cancer between 1985 and 1994. We examined number and pattern of recurrences, time after surgery, and any factor with contribution to carcinoma recurrence. RESULTS: During the follow-up period, 34 patients had tumor recurrence. The disease-free interval was 12.7 months (SD = 9.8). Twenty patients (58.9%) developed extrathoracic tumor recurrence and 23 patients (67.6%) intrathoracic. In 3 cases an esophageal stump recurrence was presented. Thirteen patients were considered for palliative treatment after recurrence. The 5-year survival rate was 13%, with median survival time between recurrence and death, 4.1 months. The recurrence of disease was always before 40 months after surgery. Any significant difference related with recurrence was observed between the analyzed factors. CONCLUSIONS: The majority of recurrences are developed before 2 years. Neoplastic recurrence is most common at the mediastinum. Palliative treatments after recurrence do not modify the progression of tumor.