RESUMO
BACKGROUND: Donor hepatectomy with maximal safety while preserving graft viability is of principal concern in living donor liver transplantation. There are compelling reasons for avoiding blood transfusion, even with autologous blood, to avoid the potential risks it imposes on healthy donors. This study aims to describe the surgical technique and clinical outcomes of living donor hepatectomy with minimal blood loss requiring no blood transfusion. METHODS: Donor hepatectomy was performed in 30 living donors according to a detailed preoperative imaging study of the vascular and biliary anatomy. Liver parenchymal transection was carried out with strict adherence to a meticulous surgical technique without vascular inflow occlusion to either side of the liver. Pre-, intra-, and postoperative data were gathered, and factors related to blood loss were analyzed retrospectively. RESULTS: The intraoperative blood loss ranged from 20 to 300 ml with a mean of 72.0+/-58.9 ml (median, 55 ml), and neither homologous nor autologous blood transfusion was required in any of the donors intra- and postoperatively. All 30 donors were discharged with minimal complications, and remain well at a mean follow-up of 24 months after donation. Excellent graft viability was verified by the fact that all 30 recipients are alive and well with a few manageable complications. The actual graft and patient survival are both 100% at the time of writing. CONCLUSIONS: Regardless of the extent of donor hepatectomy, blood loss can and should be kept to a minimum, and living donor hepatectomy without blood transfusion is a realistic objective.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Hepatectomia/métodos , Transplante de Fígado , Adolescente , Adulto , Pressão Venosa Central , Criança , Pré-Escolar , Feminino , Humanos , Lactente , MasculinoRESUMO
BACKGROUND: Hepatic venous reconstruction is critical in living donor liver transplantation because outflow obstruction may lead to graft dysfunction or loss. We describe our experience and analyze outcomes with a technique of creating a single outflow tract using venoplasties of the graft and recipient hepatic veins. PATIENTS AND METHODS: A retrospective study was done on 38 consecutive living donor liver transplants performed from June 1994 to March 2000. The grafts included 36 left-side grafts and 2 right-side grafts. Nine grafts had multiple hepatic veins and required a venoplasty of two or three hepatic veins to create a single outflow orifice. Triple recipient hepatic venoplasty was performed in 32 patients, double venoplasty in 5 and none in 1. RESULTS: There were four cases of outflow obstruction, three occurring in patients with a double recipient venoplasty. Two of the problems were remedied intraoperatively by adjusting the position of the graft although two were structural in nature and required the insertion of expandable metallic vascular stents. All donors and recipients with their original grafts are alive at a mean follow-up period of 27 months. CONCLUSION: A triple recipient venoplasty with a matching venoplasty of multiple graft hepatic veins to create a single wide outflow orifice is recommended in living donor liver transplantation using left side grafts.
Assuntos
Veias Hepáticas/cirurgia , Transplante de Fígado , Doadores Vivos , Adolescente , Adulto , Anastomose Cirúrgica , Criança , Pré-Escolar , Feminino , Seguimentos , Doença de Depósito de Glicogênio/cirurgia , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: The chronic course and non-specific clinical manifestations of tuberculous (TB) wrist often cause failure to make a timely diagnosis. OBJECTIVE: To better understand the rarely encountered TB wrist. PATIENTS AND METHODS: Retrospective review and analysis of cases of TB wrist between 1986 and 1997 in a medical centre in southern Taiwan. RESULTS: Thirty-seven cases (16 definitive, 13 probable and eight possible) of TB wrist (25 men, 12 women; mean age, 56.3 +/- 13.0 years) were found among a total of 4970 cases of tuberculosis. The most common presenting sign and symptom (mean duration 9.4 months) were local swelling and pain over the affected wrist. The mean white blood cell (WBC) count in peripheral blood was 7.04 x 10(9)/l, and the erythrocyte sediment rates (ESR) in seven of 31 patients who had ESR assayed were normal. Forty-six per cent of the patients had abnormal chest X-ray, and 35% had had previous manipulation of the affected wrist. CONCLUSION: Physicians should have a high index of suspicion for TB wrist among patients with chronic arthritis, even when their peripheral WBC count and ESR are normal. An abnormal chest X-ray and/or a history of previous manipulation of the affected wrist could be important clues for possible TB wrist.
Assuntos
Tuberculose Osteoarticular/diagnóstico , Punho , Adulto , Idoso , Idoso de 80 Anos ou mais , Artrite Infecciosa/diagnóstico , Sedimentação Sanguínea , Feminino , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Radiografia Torácica , Estudos RetrospectivosRESUMO
Hepatopulmonary syndrome (HPS) is characterized by hypoxemia in patients with severe chronic liver disease and pulmonary vasodilatation in the absence of primary cardiac or pulmonary disease. Severe hypoxemia resulting from HPS is generally considered a contraindication to liver transplantation. We describe the case of a 6-year-old girl with biliary atresia complicated with HPS who was successfully treated with liver transplantation. Cyanosis and dyspnea had initially developed at the age of 5 years. Arterial blood gas showed a PaO2 of 46.6 mm Hg on room air. The diagnosis of HPS was confirmed by contrast echocardiography, lung perfusion scan with 99mTc macroaggregate albumin, and pulmonary angiography. The lung scan revealed an intrapulmonary shunt of 24%. She underwent living donor liver transplantation and received a left lateral segment graft from her mother. One year after successful liver transplantation, she had normal arterial oxygen saturation and a normal lung scan without intrapulmonary shunting. This case demonstrates that HPS associated with end-stage liver disease is potentially curable by liver transplantation.
Assuntos
Atresia Biliar/cirurgia , Síndrome Hepatopulmonar/etiologia , Transplante de Fígado , Atresia Biliar/complicações , Criança , Contraindicações , Feminino , Síndrome Hepatopulmonar/sangue , Síndrome Hepatopulmonar/diagnóstico por imagem , Humanos , Pulmão/diagnóstico por imagem , Oxigênio/sangue , Radiografia , Cintilografia , Compostos Radiofarmacêuticos , Agregado de Albumina Marcado com Tecnécio Tc 99mRESUMO
Malignant fibrous histiocytoma (MFH), a frequent sarcoma in retroperitoneal mesenchimal tissues, has also been reported, although in a few cases, in digestive viscera. We present a case of a primary MFH of the pancreas in a 37-year-old male, treated with a 90% distal pancreatectomy, plus external and intraoperative radiotherapy over the tumoral bed, and polychemotherapy. Response to treatment was poor, with early local recurrence, liver and bone metastases and a survival of 7 months. Only 4 other cases of MFH of the pancreas have been reported. We analyze these 5 cases: they have been usually diagnosed in young adults, with vague symptoms and large tumoral masses without jaundice. Local recurrence seems to be frequent; they develop liver metastases rather than lung metastases. Even when they are resectable, the anatomical relations of the pancreas with vital vascular structures make broad resection difficult, and local recurrences frequent. Analysis of these five reported cases of MFH of the pancreas, allows to expect a local recurrence rate higher than 50% and a 5-year-survival rate lower than 30% due to distant metastases. Only radiotherapy seems to play a role as an adjuvant treatment after surgery for pancreas and other retroperitoneal sarcoma as it significantly increases survival.
Assuntos
Histiocitoma Fibroso Benigno/patologia , Neoplasias Pancreáticas/patologia , Adulto , Humanos , MasculinoAssuntos
Bile/diagnóstico por imagem , Doenças da Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/diagnóstico por imagem , Cateterismo Periférico , Colecistite/complicações , Colecistografia , Drenagem/métodos , Doenças da Vesícula Biliar/etiologia , Doenças da Vesícula Biliar/terapia , Humanos , Masculino , Pessoa de Meia-Idade , UltrassonografiaAssuntos
Antígenos Heterófilos/administração & dosagem , Diabetes Mellitus Experimental/imunologia , Sobrevivência de Enxerto/efeitos da radiação , Transplante das Ilhotas Pancreáticas/imunologia , Isoantígenos/administração & dosagem , Doadores de Tecidos , Transplante Heterotópico/imunologia , Animais , Antígenos Heterófilos/imunologia , Rejeição de Enxerto/imunologia , Sobrevivência de Enxerto/imunologia , Isoantígenos/imunologia , Ratos , Ratos Wistar , Suínos , Timo , Transplante HeterólogoAssuntos
Glicemia/metabolismo , Diabetes Mellitus Experimental/sangue , Sobrevivência de Enxerto/imunologia , Transplante das Ilhotas Pancreáticas/imunologia , Transplante Heterotópico/imunologia , Animais , Terapia de Imunossupressão , Masculino , Ratos , Ratos Wistar , Suínos , Timo , Transplante HeterólogoAssuntos
Ciclosporina/uso terapêutico , Transplante de Fígado/imunologia , Doadores Vivos , Adolescente , Corticosteroides/uso terapêutico , Adulto , Azatioprina/uso terapêutico , Criança , Pré-Escolar , Ciclosporina/farmacocinética , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Terapia de Imunossupressão/métodos , Hepatopatias/classificação , Hepatopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de TempoAssuntos
Hepatopatias/cirurgia , Transplante de Fígado/métodos , Coleta de Tecidos e Órgãos/métodos , Adolescente , Adulto , Fatores Etários , Idoso , Cadáver , Feminino , Humanos , Transplante de Fígado/estatística & dados numéricos , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/classificação , Resultado do TratamentoAssuntos
Artéria Hepática/cirurgia , Transplante de Fígado/métodos , Doadores Vivos , Veia Porta/cirurgia , Adolescente , Adulto , Anastomose Cirúrgica/métodos , Criança , Pré-Escolar , Artéria Hepática/diagnóstico por imagem , Humanos , Lactente , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Veia Porta/diagnóstico por imagem , Estudos Retrospectivos , Ultrassonografia Doppler/métodosAssuntos
Veias Hepáticas/fisiologia , Circulação Hepática/fisiologia , Transplante de Fígado/métodos , Doadores Vivos , Adulto , Velocidade do Fluxo Sanguíneo/fisiologia , Feminino , Hepatectomia/métodos , Veias Hepáticas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Ultrassonografia/métodosAssuntos
Transplante de Fígado/diagnóstico por imagem , Fígado/diagnóstico por imagem , Listas de Espera , Ascite/diagnóstico por imagem , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Fígado/irrigação sanguínea , Transplante de Fígado/mortalidade , Modelos Logísticos , Masculino , Prognóstico , Fatores de Risco , Ultrassonografia DopplerRESUMO
Intestinal hemorrhage due to arteriodigestive fistula is described to be a rare and serious complication of radiotherapy. Three cases of this type of fistula in gastric cancer patients treated with gastrectomy, intraoperative electron boost (15 Gy), and fractionated external beam irradiation (46 Gy) are reported. Selective angiography is most helpful in the diagnosis and immediate surgery could be lifesaving. An attempt to explain the etiopathogenesis is made.
Assuntos
Artéria Celíaca , Fístula/etiologia , Fístula Intestinal/etiologia , Artérias Mesentéricas , Lesões por Radiação , Neoplasias Gástricas/radioterapia , Estômago/irrigação sanguínea , Adulto , Duodenopatias/etiologia , Feminino , Fístula/diagnóstico por imagem , Fístula/cirurgia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/cirurgia , Humanos , Fístula Intestinal/diagnóstico por imagem , Fístula Intestinal/cirurgia , Doenças do Jejuno/etiologia , Masculino , Pessoa de Meia-Idade , Lesões por Radiação/cirurgia , Radiografia , Neoplasias Gástricas/cirurgiaRESUMO
The donor shortage problem is particularly serious in Asia and has markedly limited progress in liver transplantation. The increasing demand has, in fact, made it necessary to resort to living donor liver transplantation in both pediatric and adult recipients. Nevertheless, expanding the use of split liver allografts is yet another option to increase the supply. This has a wide potential application on a regional level because most liver transplant programs are still small and may have limited resources in terms of being able to do two transplants in one sitting. The first experience of overseas sharing of split liver grafts in Asia took place in January 1999. The graft was from a 35-yr-old donor from Kaohsiung, Taiwan, who sustained irreversible brain damage in a vehicular accident and had optimal conditions for multiorgan donation. The liver was split ex vivo and the left lateral segment was given to a 3-yr-old girl with biliary atresia at the Chang Gung Memorial Hospital. The extended right lobe split graft was transported to Hong Kong and transplanted into a 51-yr-old male patient with end-stage hepatitis C cirrhosis who was then in a state of acute failure with hepatorenal syndrome. Graft function was excellent in both recipients and the patient from Taiwan was discharged without any complications. Unfortunately, the Hong Kong recipient developed a cerebrovascular accident and required a reoperation for bile leakage from the cut surface of the liver in the early postoperative period. He has made a steady recovery since then; graft function has remained good and his kidneys have recovered. Both patients are currently alive and well 11 months post-transplant. This initial experience of overseas sharing of split liver grafts in Asia demonstrates its feasibility. It has a potentially wide applicability and could lead to the establishment of a formal organ-sharing network in the region. Established competence and mutual trust among the participating liver transplant teams would be essential in perpetuating such a graft-multiplying strategy on an organized basis.