RESUMO
BACKGROUND: Pediatric liver transplantations generally represent advanced surgery for selected patients. In case of acute or chronic graft failure, biliary or vessel complications, a retransplantation (reLT) can be necessary. In these situations massive adhesions, critical patient condition or lack of good vessels for anastomosis often are problematic. METHODS: Between 2008 and 2021, 208 pediatric patients received a liver transplantation at our center. Retrospectively, all cases with at least one retransplantation were identified and stored in a database. Indication, intra- and postoperative course and overall survival (OS) were analyzed. RESULTS: Altogether 31 patients (14.9%) received a reLT. In 22 cases only one reLT was done, 8 patients received 2 reLTs and 1 patient needed a fourth graft. Median age for primary transplantation, first, second and third reLT was 14 (range: 1-192 months), 60.5 (range: 1-215 months), 58.5 (range: 14-131 months) and 67 months, respectively. Although biliary atresia (42%) and acute liver failure (23%) represented the main indications for the primary liver transplantation, acute and chronic graft failure (1st reLT: 36%, 2nd reLT: 38%), hepatic artery thrombosis (1st reLT: 29%, 2nd reLT: 25%, 3rd reLT: 100%) and biliary complications (1st reLT: 26%, 2nd reLT: 37%) were the most frequent indications for reLT. OS was 81.8% for patients with 1 reLT, 87.5% with 2 reLTs and 100% with 3 reLTs. CONCLUSION: Pediatric liver retransplantation is possible with a good outcome even after multiple retransplantations in specialized centers. Nevertheless, careful patient and graft selection, as well as good preoperative conditioning, are essential.
Assuntos
Transplante de Fígado , Obtenção de Tecidos e Órgãos , Humanos , Criança , Reoperação , Estudos Retrospectivos , FígadoRESUMO
BACKGROUND: Early patient and allograft survival after liver transplantation (LT) depend primarily on parenchymal function, but long-term allograft success relies often on biliary-tree function. We examined parameters related to cholangiocyte damage that predict poor long-term LT outcomes after donation after brain death (DBD). METHODS: Sixty bile ducts (BD) were assessed by a BD damage-score and divided into groups with "major" BD-damage (n = 33) and "no relevant" damage (n = 27) during static cold storage. Patients with "major" BD damage were further investigated by measuring biliary excretion parameters in the first 14 days post-LT (followed-up for 60-months). RESULTS: Patients who received LT showing "major" BD damage had significantly worse long-term patient survival, versus grafts with "no relevant" damage (p = .03). When "major" BD damage developed, low bilirubin levels (p = .012) and high gamma-glutamyl transferase (GGT)/bilirubin ratio (p = .0003) were evident in the early post-LT phase (7-14 days) in patients who survived (> 60 months), compared to those who did not. "High risk" patients with bile duct damage and low GGT/bilirubin ratio had significantly shorter overall survival (p < .0001). CONCLUSIONS: Once "major" BD damage occurs, a high GGT/bilirubin ratio in the early post-operative phase is likely indicator of liver and cholangiocyte regeneration, and thus a harbinger of good overall outcomes. "Major" BD damage without markers of regeneration identifies LT patients that could benefit from future repair therapies.
Assuntos
Transplante de Fígado , Humanos , Ductos Biliares , Bilirrubina , Biomarcadores , Fígado , Transplante de Fígado/efeitos adversosRESUMO
BACKGROUND: After pediatric split liver transplantation, intra-abdominal loss of domain due to large-for-size left lateral grafts is a frequent problem for fascial closure and potentially leads to reduced liver perfusion and abdominal compartment syndrome. Therefore, delayed fascial closure with the use of temporary silastic meshes and reoperation or alternative fascial bridging procedures are necessary. METHODS: Between March 2019 and October 2021, biologic meshes were used for abdominal wall expansion in 6 cases of pediatric split liver transplantation. These cases were analyzed retrospectively. RESULTS: One male and 5 female children with median age of 6 months (range: 0-57 months) and weight of 6 kg (range: 3.5-22 kg) received a large-for-size left lateral graft. Graft-to-recipient weight ratio (GRWR) was 4.8% (range: 1.5%-8.5%) in median. Biologic mesh implantation for abdominal wall expansion was done in median 7 days (range: 3-11 days) after transplantation when signs of abdominal compartment syndrome with portal vein thrombosis in 3 and of the liver artery in 1 case occurred. In 2 cases, bovine acellular collagen matrix and 4 cases ovine reinforced tissue matrix was used. Median follow-up was 12.5 months (range: 4-28 months) and showed good liver perfusion by sonography and normal corporal development without signs of ventral hernia. One patient died because of fulminant graft rejection and emergency re-transplantation 11 months after the initial transplantation. CONCLUSIONS: Biologic meshes can be used as safe method for abdominal wall expansion to achieve fascial closure in large-for-size liver transplant recipients. Usage for primary fascial closure can be considered in selected patients.
Assuntos
Parede Abdominal , Produtos Biológicos , Hipertensão Intra-Abdominal , Humanos , Criança , Masculino , Animais , Feminino , Bovinos , Ovinos , Recém-Nascido , Lactente , Pré-Escolar , Parede Abdominal/cirurgia , Estudos Retrospectivos , Fígado/cirurgiaRESUMO
Development of subcutaneous abdominal wound healing impairment (SAWHI) can greatly affect patient care. Complications from SAWHI include delayed healing, increased risk of infection, and fascial dehiscence resulting in increased patient care and associated costs. Treatment options include conventional wound treatment or negative pressure wound therapy, both of which can be used in the out-of-hospital setting. However, limited published evidence on cost-effectiveness exists. A conservative health economic model was created to assess the cost-benefit of negative pressure wound therapy in the out-of-hospital setting for the management of SAWHI. Study data from a published multicentre randomised controlled trial were used and represented 221 patients that received care in the out-of-hospital setting. The mean per-patient total cost within 42 days was slightly higher in the negative pressure wound therapy group (2034.98 versus 1918.91 ); however, when wound closure rates were considered, a cost savings of 4155.98 per closed wound was observed with the use of negative pressure wound therapy (4324.34 versus 8480.32 ). A cost-effectiveness analysis was constructed, and negative pressure wound therapy was observed to have a lower cost of care and a higher incremental closure rate.
Assuntos
Traumatismos Abdominais , Tratamento de Ferimentos com Pressão Negativa , Humanos , Análise Custo-Benefício , Tratamento de Ferimentos com Pressão Negativa/métodos , Cicatrização , HospitaisRESUMO
BACKGROUND: Risks for living-liver donors are lower in case of a left liver donation, however, due to lower graft volume, the risk for small-for-size situations in the recipients increases. This study aims to prevent small-for-size situations in recipients using an auxiliary two-staged partial resection liver transplantation (LTX) of living-donated left liver lobes. CASE PRESENTATION: Two patients received a two-stage auxiliary LTX using living-donated left liver lobes after left lateral liver resection. The native extended right liver was removed in a second operation after sufficient hypertrophy of the left liver graft had occurred. Neither donor developed postoperative complications. In both recipients, the graft volume increased by an average of 105% (329 ml to 641 ml), from a graft-to-body-weight ratio of 0.54 to 1.08 within 11 days after LTX, so that the remnant native right liver could be removed. No recipient developed small-for-size syndrome; graft function and overall condition is good in both recipients after a follow-up time of 25 months. CONCLUSIONS: Auxiliary two-staged partial resection LTX using living-donor left lobes is technically feasible and can prevent small-for-size situation. This new technique can expand the potential living-donor pool and contributes to increase donor safety.
Assuntos
Doença Hepática Terminal , Hepatectomia , Transplante de Fígado , Adolescente , Adulto , Doença Hepática Terminal/cirurgia , Feminino , Hepatectomia/métodos , Humanos , Transplante de Fígado/métodos , Doadores Vivos , Masculino , Resultado do TratamentoAssuntos
Trombose , Vacinas , ChAdOx1 nCoV-19 , Terapia Combinada , Humanos , Vacinação/efeitos adversosAssuntos
Carbamatos/administração & dosagem , Hepacivirus , Hepatectomia/métodos , Hepatite C , Compostos Heterocíclicos de 4 ou mais Anéis/administração & dosagem , Neoplasias Hepáticas/cirurgia , Transplante de Fígado/métodos , Sofosbuvir/administração & dosagem , Adulto , Antivirais/administração & dosagem , Criança , Fígado Gorduroso/diagnóstico , Feminino , Hepacivirus/efeitos dos fármacos , Hepacivirus/isolamento & purificação , Hepatite C/sangue , Hepatite C/diagnóstico , Hepatite C/tratamento farmacológico , Humanos , Testes de Função Hepática/métodos , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/secundário , Doadores Vivos , Monitorização Fisiológica/métodos , Transplantados , Resultado do Tratamento , Carga Viral/métodosRESUMO
In case of potential contamination, implantation of synthetic meshes in hernia and abdominal wall surgery is problematic due to a higher risk of mesh infection. As an alternative, a variety of different biologic meshes have been used. However, relevant data comparing outcome after implantation of these meshes are lacking. Between January 2012 and October 2021, biologic meshes were used for reconstruction of the abdominal wall in 71 patients with preoperative or intraoperative abdominal contamination. In this retrospective study, semiresorbable biologic hybrid meshes (BHM) and completely resorbable meshes (CRM) were compared and analyzed using a Castor EDC database. In 28 patients, semiresorbable biologic hybrid meshes were used; in 43 patients, completely resorbable meshes were used. Both groups showed no difference in age, gender, BMI, operation duration, hernia size and Charlson comorbidity index. The risk degree of surgical-site occurrences was graded according to the Ventral Hernia Working Group (VHWG) classification, and the median value was 3 (range 2-4) in the BHM group and 3 (range 2-4) in the CRM group. Hernia recurrence within 24 months after hernia repair was significantly lower in the BHM group (3.6% vs. 28.9%; p = 0.03), while postoperative complication rate, with respect to seromas in need of therapy (61.4% vs. 55.5%, p = 0.43) and operative revision (28.6% vs. 16.3%, p = 0.22) was not different in either group. Biologic hybrid meshes can be used safely in case of possible contamination. BHM seems to reduce the risk of hernia recurrence compared to completely resorbable biologic meshes, but this has to be investigated further.
Assuntos
Produtos Biológicos , Hérnia Ventral , Humanos , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Telas Cirúrgicas , Estudos Retrospectivos , Resultado do Tratamento , Hérnia Ventral/cirurgiaRESUMO
BACKGROUND: Incisional surgical site infections (iSSI) in hepatopancreatobiliary (HPB) surgery usually lead to prolonged hospital stays, consume valuable resources, and impact on patients' outcome. Prophylactic closed incision negative pressure wound therapy (ciNPWT) to decrease wound complications has become available. Owing to an increasing number of studies, evidence for superiority in many indication areas has accumulated; however, in general surgery, there are a few data and those have shown contradictory results. METHODS: In this monocentric, prospective, randomized, controlled, two-armed study, the influence of ciNPWT on incisional surgical site infection rates after HPB operations will be investigated. A total of 222 patients will be randomized 1:1 to an interventional group (7-day treatment with ciNPWT) or a control group (treated with gauze dressing). The primary parameter to evaluate efficacy is the rate of incisional SSIs within 30 days after surgery. Additionally, several clinically relevant secondary outcomes will be assessed. DISCUSSION: A reduction in the rate of incisional SSIs would not only lead to a significant cost reduction and shorter postoperative length of stay, but may also improve postoperative quality of life for patients. While earlier publications have shown advantages for ciNPWT, recent studies did not confirm a positive effect regarding iSSI rate. Even if iSSI rate is not reduced, findings obtained from the secondary endpoints may be of clinical relevance, such as reduction of wound complication rates. TRIAL REGISTRATION: This trial has been registered in the German Clinical Trials Register, DRKS 00015136 . Registered on 19 February 2019 and has been approved by the local ethics committee of the University of Regensburg: 18-1225-101.