Liver transplantation represents the best therapeutic modality in end-stage chronic liver disease, severe acute hepatitis, and selected cases of liver tumors.
To describe a double retransplant in a male patient diagnosed with Crohn's disease and complicated with primary sclerosing cholangitis, severe portal hypertension, and cholangiocarcinoma diagnosed in the transplanted liver.
A 48-year-old male patient diagnosed with Crohn's disease 25 years ago, complicated with primary sclerosing cholangitis and severe portal hypertension. He underwent a liver transplantation in 2018 due to secondary biliary cirrhosis. In 2021, a primary sclerosing cholangitis recurrence was diagnosed and a liver retransplantation was indicated. Recipient's hepatectomy was very difficult by reason of complex portal vein thrombosis requiring extensive thromboendovenectomy. Intraoperative ultrasound with liver doppler evaluation was performed. Two suspicious nodules were incidentally diagnosed in the donor's liver and immediately removed for anatomopathological evaluation.
After pathological confirmation of carcinoma, probable cholangiocarcinoma, at frozen section, the patient was re-listed as national priority and a new liver transplantation was performed within 24 hours. The patient was discharged after 2 weeks.
The screening for neoplasms in donated organs should be part of our strict daily diagnostic arsenal. Moreover, we argue that, for the benefit of an adequate diagnosis and the feasibility of a safer procedure, the adoption of imaging tests routine for the liver donor is essential, allowing a reduction of the costs and some potential risks of liver transplant procedure.
The outcome of the patients after liver transplant is complex and to characterize the risk for complications is not always easy. In this context, the hepatic post-reperfusion biopsy is capable of portraying alterations of prognostic importance.
To compare the results of liver transplantation, correlating the different histologic features of the hepatic post-reperfusion biopsy with graft dysfunction, primary non-function and patient survival in the first year after transplantation.
From the 377 transplants performed from 1996 to 2008, 164 patients were selected. Medical records were reviewed and the following clinical outcomes were registered: mortality in 1, 3, 6 and 12 months, graft dysfunction in varied degrees and primary graft non-function. The post-reperfusion biopsies had been examined by a blinded pathologist for the outcomes. The following histological variables had been evaluated: ischemic alterations, congestion, steatosis, neutrophilic exudate, monomorphonuclear infiltrate and necrosis.
The variables associated with increased mortality were: steatosis (p=0.02209), monomorphonuclear infiltrate (p=0.03935) and necrosis (p<0.00001). The neutrophilic exudate reduced mortality in this study (p=0.00659). The primary non-function showed significant association (p<0.05) with the necrosis, steatosis and the monomorphonuclear infiltrate.
Post-reperfusion biopsy is useful tool to foresee complications after liver transplant.
Appendicitis is a common cause of emergency surgery that in the population undergoing organ transplantation presents a rare incidence due to late diagnosis and treatment.
To report the occurrence of acute appendicitis in a cohort of liver transplant recipients.
Retrospective analysis in a period of 12 years among 925 liver transplants, in witch five cases of acute appendicitis were encountered.
Appendicitis occurred between three and 46 months after liver transplantation. The age ranged between 15 and 58 years. There were three men and two women. The clinical presentations varied, but not discordant from those found in non-transplanted patients. Pain was a symptom found in all patients, in two cases well located in the right iliac fossa (40%). Two patients had symptoms characteristic of peritoneal irritation (40%) and one patient had abdominal distention (20%). All patients were submitted to laparotomies. In 20% there were no complications. In 80% was performed appendectomy complicated by suppuration (40%) or perforation (40%). Superficial infection of the surgical site occurred in two patients, requiring clinical management. The hospital stay ranged from 48 h to 45 days.
Acute appendicitis after liver transplantation is a rare event being associated with a high rate of drilling, due to delays in diagnosis and therapy, and an increase in hospital stay.
Liver transplant (LT) is the only effective and long-lasting option for patients with end-stage liver disease. Innovations and refinements in surgical techniques occurred with the advent of transplants with partial grafts and laparoscopy. Despite these modifications, the abdominal incision remains with only few changes.
Demonstrate the experience with the upper midline incision in LT recipients with whole liver grafts from deceased donors.
Retrospective study with patients submitted to LT. Data were collected from the recipients who performed the surgical procedure through the upper midline incision.
The upper midline incision was used in 20 LT, 19 of which were performed in adult recipients. The main cause was liver disease secondary to alcohol. Male, BMI>25 kg/m² and MELD greater than 20 were prevalent in the study. Biliary complications occurred in two patients. Hemoperitoneum was an indication for reoperation at one of the receptors. Complication of the surgical wound occurred in two patients, who presented superficial surgical site infection and evisceration (omental). Two re-transplant occurred in the first postoperative week due to severe graft dysfunction and hepatic artery thrombosis, which were performed with the same incision, without the need to increase surgical access. There were two deaths due to severe graft dysfunction after re-transplant in 72 h and respiratory sepsis with multiple organ dysfunction in the third week.
The upper midline incision can be safely used in LT recipients with whole grafts from deceased donors. However, receptor characteristics and hepatic graft size should be considered in the option of abdominal surgical access.
Colorectal adenocarcinoma is a common malignancy around the world and synchronous or metachronous liver metastases will be observed in about 50% of these patients. Hepatic resection is a potentially curative treatment for metastases from colorectal cancer1,2. However, only about 20% of the patients are suitable for resection, and recurrence occur in the majority of these patients and they are candidates for palliative chemotherapy. Liver transplant has been performed for liver tumors in well selected patients, mainly hepatocellular carcinoma, liver metastases from neuroendocrine tumors and peri-hilar cholangiocarcinoma emerging the concept of transplant oncology. Complete surgical resection is the treatment of choice for patients with liver metastases, but in a large proportion it is not possible to obtain a complete R0 resection. In 2006 the Oslo group started the first trial on liver transplant for patients with colorectal liver metastases (SECA I study). The inclusion criteria were R0 primary colorectal resection, unresectable liver metastases, no extrahepatic disease, at least six weeks of chemotherapy and an Eastern Cooperative Oncology Group (ECOG) performance status 0-12,3. Twenty-one patients with unresectable colorectal liver metastases (u-CRLM) were included. The overall survival rate at five years was 60% with a median survival time of 27 months. Notwithstanding the disease free survival rate was 35% at one year and all patients got relapse if observed up to three years, mainly in the form of lung metastases which were slow growing and most often resectable. Some factors were identified as related to worse prognosis (the Oslo Criteria) and include: 1) time from primary cancer surgery <2 years; 2) progressive disease on chemotherapy; 3) maximum tumor diameter >5.5 cm; and 4) CEA levels >80 μg/l. Beside Norway, liver transplant for colorectal liver metastasis have been performed in Japan, France, Canada, Portugal, Turkey, and Germany2,4,5. Very recently the Oslo group reported the preliminary results of SECA II trial, indicating that a five year overall survival of about 80% may be obtained if stricter selection criteria for liver transplant in this patient cohort are used6. Nowadays, the majority of liver transplant reported for u-CRLM utilize deceased donor liver transplant (DDLT). In Brazil DDLT is not possible due to organ shortage problem and living donor liver transplant (LDLT) seems to be the only available alternative.
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