0000000000010597
AUTHOR
Ioannis Fouzas
Hepatic Hilar and Sectorial Vascular and Biliary Anatomy in Right Graft Adult Live Liver Donor Transplantation
Abstract Introduction The aim of this study was to analyze vascular and biliary variants at the hilar and sectorial level in right graft adult living donor liver transplantation. Methods From January 2003 to June 2007, 139 consecutive live liver donors underwent three-dimensional computed tomography (3-D CT) reconstructions and virtual 3-D liver partitioning. We evaluated the portal (PV), arterial (HA), and biliary (BD) anatomy. Results The hilar and sectorial biliary/vascular anatomy was predominantly normal (70%–85% and 67%–78%, respectively). BD and HA showed an equal incidence (30%) of hilar anomalies. BD and PV had a nearly identical incidence of sectorial abnormalities (64.7% and 66.2…
Orthotopic Liver Transplantation: T-Tube or Not T-Tube? Systematic Review and Meta-Analysis of Results
Background The purpose of this study was to compare outcomes after duct-to-duct anastomoses with or without biliary T-tube in orthotopic liver transplantation. Methods We pooled the outcomes of 1027 patients undergoing choledocho-choledochostomy with or without T-tube in 9 of 46 screened trials by means of fixed or random effects models. Results The "without T-tube" and "with T-tube" groups had equivalent outcomes for: anastomotic bile leaks or fistulas, choledocho-jejunostomy revisions, dilatation and stenting, hepatic artery thromboses, retransplantation, and mortality due to biliary complications. The "without T-tube" group had better outcomes when considering "fewer episodes of cholangi…
Intrahepatic biliary anatomy derived from right graft adult live donor liver transplantation
Abstract Objective The successful management of the bile duct in right graft adult live donor liver transplantation requires knowledge of both its central (hilar) and distal (sectorial) anatomy. The purpose of this study was to provide a systematic classification of its branching patterns to enhance clinical decision-making. Patients and Methods We analyzed three-dimensional computed tomography (3-D CT) imaging reconstructions of 139 potential live liver donors evaluated at our institution between January 2003 and June 2007. Results Fifty-four (n = 54 or 38.8%) donor candidates had a normal (classic) hilar and sectorial right bile duct anatomy (type I). Seventy-eight (n = 78 or 56.1%) cases…
A New Systematic Classification of Peripheral Anatomy of the Right Hepatic Duct: Experience From Adult Live Liver Donor Transplantation
Abstract Objective The peripheral intrahepatic biliary anatomy, especially at the sectorial level on the right side, has not been adequately described. The purpose of our study was to systematically describe this complex anatomy in clinically applicable fashion. Patients and Methods We analyzed three-dimensional computed tomography (CT) imaging reconstructions of 139 potential living liver donors evaluated at our institution between January 2003 and June 2007. Results Eighty-nine (64%) donors had a normal right bile duct sectorial anatomy. In the other 50/139 (36%) cases, we observed abnormal sectorial branching patterns, with 45/50 abnormalities as trifurcations, whereas the remaining ones…
Living Donor Liver Transplantation for Hepatocellular Carcinoma in Patients Exceeding the UCSF Criteria
Abstract Background Living donor liver transplantation (LDLT) represents an alternative to expand the organ pool for adult patients with hepatocellular carcinoma (HCC) and end-stage liver disease. The purpose of this study was to demonstrate our institutional experience using criteria exceeding those of the University of California San Francisco (UCSF). Patients and Methods Between September 1998 and December 2006, 22 LDLTs were performed for HCC among patients exceeding the UCSF criteria. Results There were 17 men and 5 women of median age 55 years. Multifocal tumors were present in 19 of 22 patients. Tumor grading was: grade I (n = 8), grade II (n = 10), and grade III (n = 4). Microvascul…
Anatomical Classification of the Peripheral Right Hepatic Duct: Early Identification of a Preventable Source of Morbidity and Mortality in Adult Live Donor Liver Transplantation
Abstract Introduction The purpose of this study was to determine the impact of our classification on right graft adult live donor liver transplantation (ALDLT) outcomes. Methods Three-dimensional computed tomography (CT) reconstructions were used to classify the hilar and sectorial biliary anatomy of 71 consecutive live liver donors. Four possible clinical types were defined, based on the normal (N) or abnormal (A) features of the corresponding hilar/sectorial ducts: type I, N/N; type II, N/A; type III, A/N; and type IV, A/A. We subsequently performed an analysis of the operative outcomes based on the donor anatomy. Results Type I was encountered in 47.9% of cases, type II in 29.6%, type II…
Long-Term Results After Liver Transplantation With “Livers That Nobody Wants” Within Eurotransplant: A Center's Experience
Abstract Background Orthotopic liver transplantation (OLT) represents the only curative treatment for end-stage liver disease, but its application is limited because of organ shortages. The purpose of this study was to review the long-term outcomes after OLT during a 2-year period of 45 rescue offers organs within Eurotransplant. Patients and Methods Forty-five deceased donor liver allografts had been officially offered to and rejected by other transplantation centers 162 times prior to our acceptance. Data analysis addressed recurrence of primary disease, ischemic-type biliary lesions (ITBL), re-evaluation or relisting for OLT, re-OLT, as well as overall patient and graft survivals. Result…
Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes
Abstract Background The objective of this study was to examine the outcomes of comparisons between laparoscopic and open mesh repairs in the setting of recurrent inguinal hernia. Methods The electronic databases MEDLINE, Embase, Pubmed, and the Cochrane Library were used to search for articles from 1990 to 2008. The present meta-analysis pooled the effects of outcomes of a total of 1,542 patients enrolled into 5 randomized controlled trials and 7 comparative studies, using classic and modern meta-analytic methods. Results Significantly fewer cases of hematoma/seroma formation were observed in the laparoscopic group in comparison with the Lichtenstein group (odds ratio, .38; .15–.96; P = .04…
Corticosteroid-free immunosuppression in liver transplantation: a meta-analysis and meta-regression of outcomes.
To examine the impact of steroid withdrawal from the immunosuppression protocols in liver transplantation. The electronic databases Medline, Embase, Pubmed and the Cochrane Library were searched. Meta-analysis pooled the effects of outcomes of a total of 2590 patients enrolled into 21 randomized controlled trials (RCTs), using classic and modern meta-analytic methods. Meta-analysis of RCTs addressing patients transplanted for any indication showed no differences between corticosteroid-free immunosuppression and steroid-based protocols in most of the analyzed outcomes. More importantly, steroid-free cohorts appeared to benefit in terms of de novo diabetes mellitus development [R.R = 1.86 (1.…
Liver transplantation with grafts from septuagenarians.
Abstract Background The purpose of this study was to evaluate our experience with orthotopic liver transplantation (OLT) using grafts from septuagenarians. Patients and Methods Seventeen adult patients underwent transplantation with grafts from donors 70 years of age or older during an 8-year period. Results The median donor age was 73 years (range, 70–83). Eleven (64.7%) donors had experienced at least 1 hypotensive period and received vasoactive drugs. Median cold and warm ischemia times were 7.25 hours and 35 minutes, respectively. Two recipients underwent retransplantation because of dysfunction or primary nonfunction. Morbidity rate was 47% and hospital mortality rate was 23.5%. After …
Liver transplantation for hepatocellular carcinoma with intrahepatic lymphatic invasion: case reports.
Multiple studies addressing liver transplantation (OLT) for hepatocellular carcinoma (HCC) have identified various prognostic determinants of tumor recurrence and decreased patient survival. However, little information is available on the impact of intrahepatic lymphatic invasion on tumor recurrence and survival after OLT for HCC. Intrahepatic lymphatic invasion was observed in 1.4% (n = 2) of liver explants with HCC in our series. Both recipients are alive without tumor recurrence at 16 and 39 months post-OLT, respectively. Intrahepatic lymphatic invasion may not be an absolute adverse prognostic factor in cases of HCC with no hilar lymph node involvement at the time of OLT.
Liver Transplantation for Hepatocellular Carcinoma After Yttrium Therapy: A Case Report
Yttrium-90 microspheres constitute one of the most recent treatment options for hepatocellular carcinoma (HCC) in the setting of cirrhosis. As such, their spectrum of indication is not yet fully established. Herein, we have reported the case of a patient with HCC beyond the listing criteria for liver transplantation (OLT) who was treated preoperatively with selective transarterial chemoembolization and yttrium-90 microspheres. He was subsequently transplanted with a liver from an 81-year-old donor allocated through Eurotransplant as a "rescue offer." The posttransplant course was uneventful. Pathologic examination revealed a multifocal, well-differentiated pT2 tumor with no vascular invasio…
Liver "Compliance": A previously unrecognized preoperative predictor of small-for-size syndrome in adult living donor liver transplantation
The purpose of this study was to investigate the effect of liver compliance on computed tomography (CT) volumetry and to determine its association with postoperative small-for-size syndrome (SFSS).Unenhanced, arterial, and venous phase CT images of 83 consecutive living liver donors who underwent graft hepatectomy for adult-to-adult living donor liver transplantation (ALDLT) were prospectively subjected to three-dimensional (3-D) CT liver volume calculations and virtual 3-D liver partitioning. Graft volume estimates based on 3-D volumetry, which subtracted intrahepatic vascular volume from the "smallest" (native) unenhanced and the "largest" (venous) CT phases, were subsequently compared wi…
Liver transplantation for hepatic metastases of neuroendocrine pancreatic tumors: a survival-based analysis.
Background. Liver transplantation (LT) has been accepted as a treatment in selected cases of neuroendocrine tumors (NETs) with hepatic metastases. Patients and Methods. A systematic review of the literature was conducted to evaluate long-term patient survival in the instances of LT for pancreatic NET. Univariate and multivariate regression analyses and survival analysis were performed. Results. Fifty-three clinical studies were screened. Data from 20 studies encompassing 89 transplanted patients were included in the study. Most primary tumors were endocrine pancreatic tumors (n = 69), with gastrinomas representing the most frequent diagnosis (n = 21). There were 61 functioning pancreatic NE…
Five-Year Survival After Monotherapy for Hepatocellular Carcinoma in the Setting of Cirrhosis
The purpose of this study was to evaluate the long-term results with monotherapy for hepatocellular carcinoma (HCC) in the setting of cirrhosis. We reviewed data of 14 patients who survived for at least 5 years after performance of liver resection (n = 1), transarterial chemoembolization (TACE, n = 3), or liver transplantation (OLT, n = 19). Eight patients were within the Milan criteria, whereas the remaining 6 were beyond the criteria. Tumor stages according to the UICC were I (n = 8), II (n = 5), and IIIA (n = 1). Vascular invasion was not detected in any patient. The HCCs recurred in 2 patients, at 81 and 48 months' posttransplant. Sites of recurrence were the intrathoracic lymph nodes i…
Incidence of liver retransplantation and its effect on patient survival.
Purpose. The purpose of this study was to review our institutional experience with re-liver transplantation (OLT) after split and full-size OLT. Patients and methods. We evaluated data corresponding to retransplanted patients over an 8-year period who underwent deceased donor OLT at our institution. Variables analyzed included indications for primary OLT, and re-OLT, the type of graft used during the initial versus re-OLT, the time from initial to re-OLT, and patient survival after re-OLT. Results. Sixty-four of 697 first OLT (9.2%) required re-OLT. Forty-nine cases were among 637 (7.6%) full-size OLT, while 15 were among 60 (25%) split OLT (P <.001). Median time to re-OLT was 8 days (range…
Eurotransplant special request for high-urgency status after liver transplantation for hepatocellular carcinoma: a case report.
Hepatic artery thrombosis after liver transplantation remains a major indication for retransplantation. We report the case of a 49-year-old man with a hepatocellular carcinoma in the setting of cirrhosis associated with chronic hepatitis B and C infections who underwent split liver transplantation. The patient experienced a complicated postoperative course, characterized by 2 relaparotomies for necrosis of segment IV, and a late hepatic artery thrombosis, first discovered on postoperative day 20. His subsequent course was characterized by relapsing cholangitis and liver abscesses requiring antibiotics and percutaneous drainage. Transient control of the septic complications allowed for the f…
Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience.
Abstract Background Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC). Patients and Methods Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration. Results Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Tho…
“Preemptive” Live Donor Liver Transplantation for Fibrolamellar Hepatocellular Carcinoma: A Case Report
Fibrolamellar (FL) hepatocellular carcinoma (HCC) is a distinctive form of primary HCC that occurs principally in children and young adults. Although liver transplantation is not contraindicated for FL-HCC, noncirrhotic patients with large HCC tumors (including FL-HCCs) are not prioritized. Although hepatic resection is considered to be the primary treatment for FL-HCC, living donor liver transplantation is evolving into a potentially better alternative. Herein we have reported successful "preemptive" living donor liver transplantation for presumed recurrence of FL-HCC after an extended right hepatectomy with resection and synthetic graft replacement of the inferior vena cava.