RESUMEN
BACKGROUND: Adhesions are abnormal fibrous bands of scar tissue between internal organs and tissues. With respect to recipient hepatectomy in living donor liver transplantation (LDLT), we defined extensive adhesions as adhesions in at least two separate locations that required more than 5 % of the total surgical time to lyse. We aimed to identify the etiology and consequences of this preventable burden. METHODS: A simple retrospective case-control study of all cases with extensive adhesions from August 2011 to September 2014 matched by age, sex, and diagnosis at surgery. RESULTS: A total of 380 cases were studied. Thirty-eight and five patients had extensive adhesions from surgical and non-surgical causes, respectively. The incidence and complications in pediatric patients were far less than in adults. In the adult group, the mean operative time was increased by 75 min (12.3 %) and blood loss by 2.5 L.The incidence of bowel perforation and biliary infections were increased in adults, while there was no significant difference in the rate of ascitic or wound infections. The 1-year survival was slightly less (92 %) than the control group (100 %). CONCLUSIONS: The most common cause of extensive adhesions at LDLT was prior liver resection. Extensive adhesions caused increased morbidity by increased blood loss, transfusion requirements, and increased cold ischemia time. There is also a higher risk of bowel perforation during enterolysis. The use of commercially available barrier techniques is advisable in adults at high risk of developing adhesions with a possibility of liver transplantation, such as liver resection for HCC.
Asunto(s)
Hepatectomía/efectos adversos , Perforación Intestinal/etiología , Trasplante de Hígado , Adherencias Tisulares/cirugía , Adulto , Factores de Edad , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea , Estudios de Casos y Controles , Niño , Isquemia Fría , Humanos , Donadores Vivos , Tempo Operativo , Estudios Retrospectivos , Tasa de Supervivencia , Adherencias Tisulares/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: The methods of differentiation and management of incidental small pulmonary nodules (ISN) in candidates for living donor liver transplantation (LDLT) are not well clarified. We aimed to share our experience and investigate the role of nodular size in application of ISN. MATERIAL AND METHODS: From October 2009 to December 2012, 360 primary adult LDLTs were performed. Thirty-seven candidates with ISN and follow-up of over 2 years were collected. Subjects with pathologic reports of malignancy or infection composed group A, and those with pathologic reports of benign disease or stable lesions on CT image within 3~6 months composed group B. RESULTS: Nodular size was significantly different between group A and B (7.68±3.77 mm versus 4.10±1.37 mm, respectively, p<0.001). Receiver-operating characteristic analysis showed area under the cure values (0.839 (95% confidence interval, 0.701~0.977); sensitivity, 81.3%; and specificity, 76.2%). Recurrent infection was not seen in 13 candidates with infectious ISN up to the median post-transplant follow-up of 40.70 months (range=24.4-61.7 months). Excluding 3 malignancy, 100% of the 34 candidates survived for over 2 years. CONCLUSIONS: With 5 mm as the optimal cutoff, nodular size is a good predictor to differentiate malignant and infectious from benign ISN. For sizes less than 5 mm, follow-up of 3 months is recommended. For over 5 mm of ISN, it is recommended to obtain pathologic diagnosis and treat as diagnosis of infectious ISN.
Asunto(s)
Hallazgos Incidentales , Trasplante de Hígado/métodos , Donadores Vivos , Nódulo Pulmonar Solitario/patología , Obtención de Tejidos y Órganos/métodos , Anciano , Área Bajo la Curva , Distribución de Chi-Cuadrado , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Trasplante de Hígado/efectos adversos , Masculino , Persona de Mediana Edad , Selección de Paciente , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Nódulo Pulmonar Solitario/diagnóstico , Nódulo Pulmonar Solitario/cirugía , Taiwán , Cirugía Torácica Asistida por Video/métodos , Obtención de Tejidos y Órganos/tendencias , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Primary hepatic sarcoma (PHS) is a rare primary liver malignancy. The histological types of PHS are diverse, and the clinical outcomes and management mainly depend on the histopathology. This study aims to evaluate the results of surgical intervention. METHODS: Between January 2003 and June 2009, 13 adult patients with pathologically proven PHS were identified by record review. The patients' demographic profile, tumor characteristics, treatment modalities, and outcomes were reviewed and analyzed. The end of follow-up was December 2014. RESULTS: Nine (69%) underwent curative liver resection and two underwent liver transplantation; the others received non-operative treatments. The pathologic findings were six (46%) angiosarcomas, four (30.7%) undifferentiated sarcomas, one (7.6%) leiomyosarcoma, one (7.6%) malignant mesenchymoma, and one (7.6%) hepatic epithelioid hemangioendothelioma. The median follow-up was 31.4 (2.8 ~ 142.5) months. The 1-, 2-, and 5-year survival of surgical patients were 72.7%, 63.6%, and 36.4%, respectively. Importantly, the 1-, 2-, and 5-year survival rates of non-angiosarcoma patients were superior to those of angiosarcoma (85.7% vs. 33.3%, 71.4% vs. 16.7%, and 57.1% vs. 0%, respectively, P = 0.023). CONCLUSIONS: Surgical intervention provides the possibility of long-term survival from PHS. Angiosarcoma is associated with a more dismal outcome than non-angiosarcoma.
Asunto(s)
Hemangiosarcoma/cirugía , Leiomiosarcoma/cirugía , Neoplasias Hepáticas/cirugía , Mesenquimoma/cirugía , Recurrencia Local de Neoplasia/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Hemangiosarcoma/mortalidad , Hemangiosarcoma/patología , Humanos , Leiomiosarcoma/mortalidad , Leiomiosarcoma/patología , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Masculino , Mesenquimoma/mortalidad , Mesenquimoma/patología , Persona de Mediana Edad , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia , Adulto JovenRESUMEN
Small size and multiple ducts, particularly in right lobe liver grafts, are major factors that contribute to biliary complications in living donor liver transplantation. To improve the outcome of biliary reconstruction, further investigation and refinement of reconstruction techniques and management strategies are necessary. From March 2006 to June 2012, routine MBR was performed in 584 grafts in 581 consecutive LDLT (including 3 dual graft transplants). All biliary reconstructions were performed using microsurgical technique by a single microsurgeon. The classification of biliary reconstruction was based according to the number of ducts in the graft, the manner in which these ducts were reconstructed (with or without ductoplasty), and the conduit used (recipient duct or jejunum) to reconstruct the biliary tree. In duct-to-duct reconstruction, posterior wall first technique by using interrupted suture and continuous running and interrupted tie technique (combined method) for the anterior wall were performed. Recipient reduction ductoplasty was done, if necessary. In duct-to-jejunum reconstruction, enterotomy was performed first under microscope; then, the serosal and mucosal layers were sutured together using 8-0 prolene to facilitate the anastomosis. Posterior wall first by using interrupted suture technique and combined method for the anterior wall were also performed. Overall, there were 397 right and 184 left lobe grafts. Single duct opening was noted in 440 (75.34%), two duct openings in 135(23.12%), and three duct openings in 9 (1.54%) grafts. Duct-to-duct anastomosis was performed in 473 (81%) and duct-to-jejunum Roux limb in 111 (19%) biliary reconstructions. Size discrepancy in the graft and recipient ducts was noted in 394 (83.3%) reconstructions. The overall biliary complication was 7.9%. These included 19 (3.3%) bile leaks and 27 (4.6%) biliary strictures. The routine use of MBR capably surmounts the difficulties brought about by the anatomic variations and the size discrepancies between the graft and recipient hepatic ducts with excellent outcome.
Asunto(s)
Conductos Biliares/cirugía , Procedimientos Quirúrgicos del Sistema Biliar , Trasplante de Hígado/métodos , Donadores Vivos , Microcirugia , Procedimientos de Cirugía Plástica , Anastomosis Quirúrgica , Fuga Anastomótica/etiología , Procedimientos Quirúrgicos del Sistema Biliar/efectos adversos , Colestasis/etiología , Humanos , Trasplante de Hígado/efectos adversos , Microcirugia/efectos adversos , Procedimientos de Cirugía Plástica/efectos adversos , Técnicas de Sutura , Resultado del TratamientoRESUMEN
The outflow reconstruction of the right anterior sector in a right liver graft (RLG) with cryopreserved vascular grafts (CVGs) is crucial for preventing graft congestion in living donor liver transplantation (LDLT). The impact of the duration of cryopreservation has not been evaluated so far. From 2006 to 2009, 250 LDLT were performed: 47 of these patients (group 1) received CVGs stored for â¦1 year, and 33 patients (group 2) received CVGs stored for >1 year. Single or multiple segment 8 hepatic veins were reconstructed. The number of anastomoses did not affect vascular graft patency (P = 0.21). The length of the cryopreservation time did not affect the histological findings for CVGs. The preoperative and postoperative liver graft volumes were 783.8 ± 129.7 and 1102 ± 194.7 cc, respectively, for group 1 and 753.7 ± 158.5 and 1097.2 ± 178.7 cc, respectively, for group 2. The regeneration indices for liver grafts in the whole patient group, group 1, and group 2 were 48.9%, 47.4%, and 51.05%, respectively. In conclusion, the storage duration has no impact on the patency of CVGs in outflow reconstruction or on the regeneration of RLGs in LDLT. CVGs stored for >1 year can be safely used for the outflow reconstruction of RLGs in LDLT.
Asunto(s)
Criopreservación , Venas Hepáticas/patología , Venas Hepáticas/cirugía , Trasplante de Hígado , Venas/cirugía , Adolescente , Adulto , Anciano , Anastomosis Quirúrgica , Femenino , Venas Hepáticas/trasplante , Humanos , Regeneración Hepática , Donadores Vivos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Recolección de Tejidos y Órganos , Venas/trasplante , Adulto JovenRESUMEN
The success of liver transplantation worldwide has brought increased demand for the liver graft. Western and Asian countries have coped differently with the problems of the shortages in organ donation. In the West, efforts have focused on promoting deceased donor organ donation, whereas in Asia the focus has been on living donor liver transplantation (LDLT), as this procedure is more acceptable in most Asian cultures. LDLT, which was initially devised for paediatric liver transplant patients, has evolved from using a left lobe graft to a right lobe graft for an adult recipient. To widen the donor pool, dual grafts for a single recipient have been used in LDLT, and donors with hepatitis B core antibody positivity have been accepted, as well as ABO incompatible donors and recipients. The great advances in the field of LDLT have been dictated by the needs and the norms of Asian society. In this Perspectives article, we outline the reasons why LDLT flourishes in Asia.
Asunto(s)
Trasplante de Hígado , Donadores Vivos , Asia , Humanos , Hígado , Obtención de Tejidos y ÓrganosRESUMEN
OBJECTIVE: Microsurgical techniques, initially used for hepatic artery reconstruction, have been extended to biliary reconstruction to decrease biliary complications. The routine use of microsurgical biliary reconstruction in pediatric living donor liver transplantation (LDLT) has not been elucidated. METHODS: Sixty-seven pediatric patients underwent primary LDLT. All biliary reconstructions were performed by a single microsurgeon using microsurgical techniques. A biliary stent was not used. The minimum follow-up was 12 months. Thirty-four patients had a minimum follow-up of 36 months. The outcomes of those who underwent microsurgical biliary reconstruction were compared with the outcomes of a cohort of 67 patients who underwent conventional biliary reconstruction. RESULTS: The demographical and clinical profiles of the two groups were not significantly different. There were 5 anastomotic complications in the conventional and 2 anastomotic complications in the microsurgical reconstruction groups. All complications developed within 90 days after transplant. There were no late biliary complications. Further analysis showed that conventional reconstruction increased the risk of biliary complications by 2.4 times (relative risk: 2.42; attributable risk: 4.5). CONCLUSION: The routine use of microsurgical biliary reconstruction in pediatric LDLT is a technical innovation that led to decreased anastomotic biliary complications.
Asunto(s)
Trasplante de Hígado , Donadores Vivos , Microcirugia/métodos , Procedimientos de Cirugía Plástica/métodos , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Complicaciones Posoperatorias , Taiwán , Resultado del TratamientoRESUMEN
We describe our early and long-term experience with routine biliary reconstruction via a microsurgical technique in living donor liver transplantation (LDLT). One hundred seventy-seven grafts (including 3 dual grafts) were primarily transplanted into 174 recipients. The minimum follow-up was 44 months. Biliary reconstructions were based on biliary anatomical variations in graft and recipient ducts. The recipient demographics, graft characteristics, types of biliary reconstruction, biliary complications (BCs), and outcomes were evaluated. There were 130 right lobe grafts and 47 left lobe grafts. There were single ducts in 71.8%, 2 ducts in 26.0%, and 3 ducts in 2.3% of the grafts. The complications were not significantly related to the size and number of ducts, the discrepancy between recipient and donor ducts, the recipient age, the ischemia time, or the type of graft. The overall BC rate was 9.6%. The majority of the complications occurred within the first year, and only 1 patient developed a stricture at 20 months. No new complications were noted after 2 years. When the learning-curve phase of the first 15 cases was excluded, the overall BC rate was 6.79%, and the rate of complications requiring interventions was 2.5%. In conclusion, the routine use of microsurgical biliary reconstruction decreases the number of early and long-term anastomotic BCs in LDLT.
Asunto(s)
Procedimientos Quirúrgicos del Sistema Biliar , Trasplante de Hígado/métodos , Donadores Vivos , Microcirugia , Procedimientos de Cirugía Plástica , Adolescente , Adulto , Anciano , Procedimientos Quirúrgicos del Sistema Biliar/efectos adversos , Niño , Preescolar , Competencia Clínica , Femenino , Humanos , Lactante , Curva de Aprendizaje , Trasplante de Hígado/efectos adversos , Masculino , Microcirugia/efectos adversos , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Procedimientos de Cirugía Plástica/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: This paper presents an innovative technique to address complex multiple hepatic vein (HV) reconstruction in right lobe graft living donor liver transplantation (RL-LDLT). METHODS: A patient with hepatitis C virus-related cirrhosis underwent RL-LDLT. The graft had seven HVs, including: the right HV (17 mm); one segment VII HV (11 mm); two segment VI HVs (6 mm and 16 mm), and three segment V HVs. The graft weighed 663 g (53% of standard liver volume; ratio of graft weight to recipient body weight: 0.96). Each HV had significant drainage territory requiring reconstruction. A cryopreserved iliac vein graft was used to create a sleeve patch to incorporate the HV openings. The holes were anastomosed to their corresponding HV tributaries using continuous 6-0 polydioxanone (PDS) sutures. Two of the three segment V HVs were combined using a smaller iliac vein patch, which was anastomosed in an end-to-side fashion to a previously harvested recipient umbilical vein interposition graft. The other end of the umbilical vein graft was anastomosed to the larger iliac vein sleeve patch. RESULTS: Overall, six HV openings were incorporated in one sleeve patch to allow a single wide anastomosis with the recipient inferior vena cava. Doppler ultrasound after reconstruction showed adequate flow patterns in all the HVs. CONCLUSIONS: All-in-one sleeve patch graft venoplasty simplifies the reconstruction of multiple HVs and reduces warm ischaemia time in RL-LDLT with excellent outcomes.
Asunto(s)
Venas Hepáticas/cirugía , Vena Ilíaca/trasplante , Cirrosis Hepática/cirugía , Trasplante de Hígado/métodos , Donadores Vivos , Procedimientos de Cirugía Plástica , Injerto Vascular , Adulto , Anastomosis Quirúrgica , Criopreservación , Femenino , Venas Hepáticas/diagnóstico por imagen , Hepatitis C/complicaciones , Humanos , Cirrosis Hepática/virología , Persona de Mediana Edad , Técnicas de Sutura , Resultado del Tratamiento , Ultrasonografía Doppler , Venas Umbilicales/trasplanteRESUMEN
For pediatric living donor liver transplantation, portal vein complications cause significant morbidity and graft failure. Routine intra-operative Doppler ultrasound is performed after graft reperfusion to evaluate the flow of portal vein. This retrospective study reviewed 65 children who had undergone living donor liver transplantation. Seven patients were detected with suboptimal portal vein flow velocity following vascular reconstruction and abdominal closure. They underwent immediate on-table interventions to improve the portal vein flow. Both surgical and endovascular modalities were employed, namely, graft re-positioning, collateral shunt ligation, thrombectomy, revision of anastomosis, inferior mesenteric vein cannulation, and endovascular stenting. The ultrasonographic follow-up assessment for all seven patients demonstrated patent portal vein and satisfactory flow. We reviewed our experience on the different modalities and proposed an approach for our future intra-operative management to improve portal vein flow at the time of liver transplantation.
Asunto(s)
Complicaciones Intraoperatorias/cirugía , Complicaciones Intraoperatorias/terapia , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/métodos , Vena Porta/fisiopatología , Velocidad del Flujo Sanguíneo , Procedimientos Endovasculares , Femenino , Humanos , Lactante , Complicaciones Intraoperatorias/fisiopatología , Donadores Vivos , Masculino , Vena Porta/diagnóstico por imagen , Vena Porta/cirugía , Estudios Retrospectivos , Ultrasonografía DopplerRESUMEN
Our aim is to evaluate the relationship and impact of right-lobe (RL) liver grafts procured with or without the middle hepatic vein (MHV) trunk and MHV tributary reconstruction on segmental regeneration of these grafts in adult living donor liver transplantation (ALDLT). Patients underwent primary ALDLT using a RL liver graft were divided into three groups according to graft type: with MHV tributary reconstruction (group I), without MHV tributary reconstruction (group II), and with inclusion of the MHV trunk (group III). The overall graft volume and the volumes of the anterior and posterior segments of the grafts six months post-transplant, evaluated using computed tomography, were calculated as the regeneration indices. Optimal regeneration of the RL liver graft was achieved in the three groups of patients. There was no significant difference in the regeneration indices between groups I (149.4%) and III (143.6%). However, in group II (112.4%) without MHV or tributary reconstruction, the anterior regenerative index was lower than the other two groups and exhibited transient prolonged hyperbilirubinemia. Segmental graft regeneration is maximized by adequate venous drainage. Inclusion of the MHV trunk or MHV tributary reconstruction influences segmental liver regeneration and preclude transient hyperbilirubinemia in the early post-liver transplant phase.
Asunto(s)
Hepatectomía , Venas Hepáticas/cirugía , Regeneración Hepática , Trasplante de Hígado/efectos adversos , Hígado/cirugía , Donadores Vivos , Adulto , Femenino , Estudios de Seguimiento , Humanos , Hígado/irrigación sanguínea , Masculino , Persona de Mediana Edad , Pronóstico , Procedimientos de Cirugía Plástica , Tasa de Supervivencia , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Exact knowledge of biliary anatomy is essential in living donor liver transplantation. The purpose of this study was to evaluate the accuracy of pretransplant magnetic resonance cholangiography (MRC) in depicting the biliary anatomy in comparison with intraoperative cholangiography (IOC). MATERIALS AND METHODS: From May 2006 to July 2009, 451 potential living liver donors underwent pretransplant evaluation at the Chang Gung Memorial Hospital-Kaohsiung Medical Center. Two hundred thirty-three donors underwent donor hepatectomy. Of these, only 203 donors with both preoperative MRC and IOC were included in this study. RESULTS: Of the 451 potential donors, 218 (48.3%) were considered unsuitable for liver donation, hence was immediately disqualified after the initial evaluation for various reasons. Six of the 218 unsuitable donors (2.8%) were excluded due to complicated biliary anatomy. The overall accuracy rate of MRC for defining the biliary anatomy was 91.6%, with 84.9% sensitivity, 96% specificity, 88.2% positive predictive value, and 94.7% negative predictive value. There were 14 misidentified cases. The errors in MRC reading was largely attributed to the poor contrast between the biliary ducts and the surrounding tissues and organs. The concurrence between MRC and IOC were commendable (κ=0.9). No significant biliary complications were noted in the mismatch group. CONCLUSION: MRC is essential for all pretransplantation evaluation with 91.6% accuracy rate.
Asunto(s)
Sistema Biliar/anatomía & histología , Colangiografía , Pancreatocolangiografía por Resonancia Magnética , Trasplante de Hígado , Donadores Vivos , Adolescente , Adulto , Selección de Donante/métodos , Femenino , Hepatectomía/métodos , Humanos , Periodo Intraoperatorio , Trasplante de Hígado/métodos , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios , Recolección de Tejidos y Órganos/métodos , Adulto JovenRESUMEN
Two adult patients who underwent living donor liver transplantation with acute accumulation of right-side pleural effusion are reported. The chest X-ray of patient 1 showed no specific finding 3 days before the operation, and patient 2 was known to have pleural effusion and underwent pigtail drainage before transplant. After anesthesia induction and insertion of central venous catheters, a portable chest radiograph was taken to confirm the positions of the central venous catheters and endotracheal tube. A massive right-side pleural effusion was noted unexpectedly in both patients. Approximately 2,000 ml transudative fluid was surgically drained through the right diaphragm in patient 1 upon opening of the abdominal cavity. The acute accumulation of massive pleural fluid in patient 2 was caused by clamping of the pigtail drainage tube during patient transfer to the operating room; upon unclamping of the tube, 2,000 ml fluid was drained. The intraoperative and postoperative transplant courses of both patients were uneventful. Both were discharged from the hospital in stable condition. Our cases suggest that chest X-ray after induction of the anesthesia and before liver transplantation surgery is recommended. In addition to documenting the positions of the central venous catheters and endotracheal tube, a potential life-threatening pleural effusion requiring appropriate management may be detected.
Asunto(s)
Anestesia , Complicaciones Intraoperatorias/terapia , Trasplante de Hígado/efectos adversos , Donadores Vivos , Derrame Pleural/etiología , Líquidos Corporales/fisiología , Cateterismo Venoso Central , Constricción , Drenaje , Enfermedad Hepática en Estado Terminal/cirugía , Humanos , Cirrosis Hepática Alcohólica/cirugía , Masculino , Persona de Mediana Edad , Derrame Pleural/diagnóstico por imagen , Derrame Pleural/terapia , Neumotórax/diagnóstico por imagen , Neumotórax/etiología , RadiografíaRESUMEN
BACKGROUND: In liver transplantation, blood loss can be massive, requiring timely and rapid fluid resuscitation. Maintaining proper documentation of fluids during such situations can be difficult and may often lead to counting errors. We report our method of documentation of fluid management during liver transplantation. MATERIAL/METHODS: Each unit of red blood cells (125 cc) that comes from the blood bank had a serial number of 10 Arabic numbers which were verified and double-checked. Each unit was then numbered and labeled as encircled absolute numbers (e.g., 1, 2, 3). Both the encircled number and the serial number of the bag were recorded in the anesthesia chart. Each liter of crystalloids and colloids were similarly numbered and labeled in sequence for ease of calculation. At the end of the operation, the nurse anesthetist ascertains that the number of units of blood products used matched with the number of units supplied by the blood bank. The total amounts of crystalloids and colloids given during the operation was also calculated, rechecked and written in a tabulated form. RESULTS: Since the introduction of this method, we have detected and readily corrected 3 incidences of counting discrepancy in the total units of blood products transfused and the products supplied by the blood bank. Moreover, our records have now become transparent data that are easily retrievable for future scientific research. CONCLUSIONS: Our method of documentation of fluid management during liver transplantation is easy, accurate and effective.
Asunto(s)
Documentación/métodos , Cuidados Intraoperatorios/métodos , Trasplante de Hígado/métodos , Adulto , Bancos de Sangre , Transfusión Sanguínea/estadística & datos numéricos , Niño , Documentación/estadística & datos numéricos , Fluidoterapia/métodos , Fluidoterapia/estadística & datos numéricos , Humanos , Cuidados Intraoperatorios/estadística & datos numéricos , Donadores Vivos , Estudios Retrospectivos , TaiwánRESUMEN
BACKGROUND: The Pringle maneuver (hepatic inflow occlusion), applied intermittently or continuously, carries the risk of inducing ischemic and reperfusion injury. The risk of damage is higher in the latter procedure. Studies have shown that continuous Pringle maneuver coupled with in situ hypothermic perfusion (CPM-HP) circumvents such adversity. However, reports comparing this technique with the intermittent Pringle maneuver (IPM) are lacking. We therefore report our experience with the use of CPM-HP and compare its outcome with that of IPM. METHODS: We evaluated the outcome of similar sets of patients who had major hepatic resections performed under IPM and CPM-HP. Variables including short-term survival rate (>90 days), complications, operative time, transection time, intraoperative blood loss, postoperative liver functions, and postoperative hospital stay were used to compare the two groups. RESULTS: Eighteen major hepatectomies were performed with CPM-HP and 16 with IPM. CPM-HP was safely performed in patients with chronic liver disease. Lowering the liver's temperature extends the clamping period to 140 min. Perioperative outcomes including operative time (383.9 ± 89.4 vs. 351.9 ± 70.3 min, p = 0.252), blood loss (225.6 ± 48.4 vs. 351.9 ± 70.3 ml, p = 0.057), postoperative hospital stay, morbidity rate, and the rate of liver functions following resections were comparable for the CPM-HP and IPM groups. There was no mortality. Parenchymal transection time was significantly longer in the CPM-HP group (104.1 ± 20.2 vs. 85.0 ± 15.4 min, p = 0.004) CONCLUSION: Our findings did not show there to be a significant advantage of CPM-HP over IPM.
Asunto(s)
Hepatectomía/métodos , Hipotermia Inducida/métodos , Cuidados Intraoperatorios/métodos , Neoplasias Hepáticas/cirugía , Daño por Reperfusión/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Hepatectomía/efectos adversos , Mortalidad Hospitalaria/tendencias , Humanos , Circulación Hepática/fisiología , Pruebas de Función Hepática , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Perfusión/métodos , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Cuidados Preoperatorios/métodos , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Parenchymal pseudoaneurysm of the hepatic arteries with massive intraperitoneal bleeding is rare but a serious life-threatening complication when it occurs following liver transplantation. We report a case of an adult postliving donor liver transplant recipient who developed massive subcapsular bleeding combined with massive right pleural effusion from ruptured multiple small intrahepatic arteries, which developed from a pseudoaneurysm that was treated by hepatic arterial embolization. Successful embolization was performed via a percutaneous trans-catheter approach by depositing 20-25%N-butyl-2-cyanoacrylate (NBCA) through the multiple small intrahepatic arteries into the pseudoaneurysm. Complete occlusion of the feeding arteries and pseudoaneurysm cavity resulted to immediate cessation of bleeding. There was no re-bleeding; and normal liver graft function was noted postembolization. Hepatic arterial embolization with NBCA can be used as treatment for postliver transplant peripheral intrahepatic artery pseudoaneurysm bleeding.
Asunto(s)
Aneurisma Falso/terapia , Embolización Terapéutica/métodos , Enbucrilato/uso terapéutico , Hemorragia/terapia , Trasplante de Hígado/efectos adversos , Anciano , Aneurisma Falso/etiología , Embolización Terapéutica/efectos adversos , Femenino , Arteria Hepática/cirugía , Humanos , Donadores VivosRESUMEN
Liver transplantation has been an accepted treatment for end-stage liver disease since the 1980s. The development of living donor liver transplantation (LDLT) was driven by limited deceased donor organ donation and a response to the growing demand for the option of liver replacement. LDLT is now performed with high rates of success due to judicious donor and recipient selection, careful preoperative planning, excellent anesthesia management, and prompt detection and treatment of complications. The first successful liver transplantation in Asia was performed in 1984, in Chang Gung Memorial Hospital in a Taiwanese adolescent with Wilson's disease, complicated by end-stage liver cirrhosis. The longest Asian liver transplant survivor has now been living for 26 years and that patient's transplant was also performed in Chang Gung Memorial Hospital. Through December 31, 2011, a total of 924 (783 living donor, 141 deceased donor) liver transplants have been performed at the Kaohsiung Chang Gung Memorial Hospital, where both graft and patient survivals are excellent. For biliary atresia, hepatitis B virus cirrhosis, and hepatocellular carcinoma recipients, our 5-year LDLT survival rates are 98%, 94%, and 90%, respectively. Our overall (deceased and living donor) actuarial 3-year survival rate is 91%. Innovative techniques in LDLT represent technical refinements in hepatic vein, portal vein, hepatic artery, and biliary reconstruction approaches. Hepatic vein reconstruction is highlighted by venoplasty reconstructions in both graft hepatic vein orifices and recipient hepatic veins, to ensure adequate outflow and decrease ischemia times during implantation. Vascular interposition to reconstruct middle hepatic vein tributaries with either fresh or cryopreserved vessels is used when the middle hepatic vein is not routinely harvested with the graft. We have extended the routine use of microsurgical techniques, initially for hepatic artery reconstruction, to biliary reconstruction where the possibility of duct-to-duct reconstruction is performed with accuracy and precision in pediatric non-biliary atresia and in multiple, small bile ducts. Long-term survival has always been related to the immunosuppression regimen, which influences outcome. Newer drugs do not equate to lesser complications. Rather, improvement in how we can find new uses for old drugs is now the norm. Less immunosuppression, as long as hepatic function is maintained at an acceptable level, decreases the chances of long-term complications related to immunosuppression use.