A technique for safe, frequent biopsy of the liver after hepatic transplantation

Valuable information can be obtained from the hepatic biopsy in patients undergoing hepatic transplantation. Biopsy of the liver can be repeatedly performed safely even in patients with severely deranged clotting function by using the technique described herein. This simple technique provides the window through which the immunologic and metabolic causes of hepatic dysfunction may be more clearly viewed and intelligently studied.     

Fulminant herpes simplex virus hepatic failure in pregnancy requiring liver transplantation

Herpes simplex virus hepatitis is a rare but potentially fatal condition that usually affects the immunocompromised, including pregnant women. This case report details the course of fulminant hepatic failure in a woman at 31 weeks gestation resulting in emergent delivery of the fetus and liver transplant in the mother.     

A simplified technique for revascularization of homografts of the liver with a variant right hepatic artery from the superior mesenteric artery

A simplified technique for conversion of a complex hepatic arterial supply into a common channel is described. This technique permits single vessel anastomosis in the recipient of a liver transplant.     

The use of TDMAC-heparin-impregnated shunt for managing aneurysm of the descending thoracic aorta

From April 1981 to December 1988, a total of 23 patients were operated upon for the repair of an aneurysm of the descending thoracic aorta with a tridodecylmethylammonium chloride (TDMAC)-heparin-impregnated shunt. There were 20 men and 3 women. The ages ranged from 29 to 72 years with a mean of 52.3 years. The major pathological change of the aortic wall was medial cystic necrosis in 19 patients and atherosclerosis in 4. Among them, only 6 patients underwent elective surgery, while 17 patients underwent emergency operations with the surgical indication being shock in 4, oliguria in 3, persistence of chest pain in 2, massive hemoptysis in 1, rapid size progression of the aneurysm in 3, and impending rupture of the aneurysm in 4. During surgery, the aortic cross-clamping time ranged from 40 to 76 minutes with a mean of 54 minutes. Hospital death was limited to 2 patients with a mortality rate of 8.7%. Postoperative complications were noted in 5 patients, cerebrovascular accidents in 4 and transient paraparesis in 1. However, the clinical conditions recovered before those patients were discharged. The follow-up period ranged from 4 to 84 months with a mean of 32.3 months. Except for 1 patient who died of anaphylactic shock due to drug allergy, the other 20 survivors had an apparent improvement of their clinical status and life quality.     

Renal revascularization in patients with severe atherosclerosis of the abdominal aorta or a previous operation on the abdominal aorta.

Renal revascularization has been performed in six patients in whom severe atherosclerosis or previous operative procedures on the abdominal aorta precluded the performance of a standard aortorenal bypass graft. Splenorenal anastomoses were performed in three patients, superior mesenterorenal anastomosis in one patient, long saphenous vein iliorenal anastomosis in one patient, and renal autotransplantation in one patient. Successful renal revascularization with preservation of renal function was accomplished in all patients. The natural history of severe atherosclerotic renovascular disease has demonstrated the relatively frequent occurrence of arterial thrombosis and renal failure in patients with solitary kidneys. Occasionally, the presence of severe aortic disease precludes the use of standard aortorenal bypass grafting. Fortunately, as reported herein, alternate methods of revascularization are available whereby renovascular hypertension can be corrected and renal function preserved, with minimal operative risk.     

Distribution of fluorodeoxyuridine uptake in the liver and colorectal hepatic metastases of human beings after arterial infusion

Little is known about drug distribution in tumor metastases or in the liver after hepatic arterial infusion. This information is important for planning strategies to enhance tumor drug uptake and to improve tumor response to therapy. Dye injection studies have demonstrated hepatic tumor vascular supplies in an anatomic manner, but offer no physiologic data. To evaluate hepatic drug distribution in patients with metastases to the liver and colon and rectum (6-3H) 5-fluorodeoxyuridine (FUdR) and 99m-technetium (TC) macroaggregated albumin (MAA) were infused through the hepatic artery prior to lobectomy of the right hepatic lobe in three patients and before wedge resection of a metastasis in one patient. Forty to 100 specimens of the tumor and liver taken at biopsy were assayed in order to map drug and albumin distribution. Nuclide scanning of the specimen was performed upon two patients. A linear relationship between levels of 3H (representing fluoropyrimidine metabolites) and 99mTc (representing blood flow) was demonstrated in both the tumor (correlation coefficients 0.69 to 0.87, p less than 0.01) and liver (correlation coefficients 0.76 to 0.90, p less than 0.001). The liver immediately adjacent to the tumor retained substantially more 99mTc-MAA than either the tumor itself or liver remote from the tumor, as demonstrated by both nuclide scanning and tissue biopsies. The rim of the liver adjacent to the tumor with enhanced 99mTc uptake had a different histologic appearance from a "normal" liver at a distance from the tumor in all instances. A radionuclide hepatic scan showing increased tumor uptake of 99mTc-MAA after arterial injection predicts an increased likelihood of tumor response to treatment. The results of this study demonstrate for the first time, in human beings, that increased 3H-FUdR uptake occurs in portions of the tumor which retain more 99mTc-MAA and explains the capacity of the arterial 99mTc-MAA perfusion scan to predict tumor response in the treatment of metastases to the liver and colon and rectum.     

Acute fatty liver of pregnancy associated with preeclampsia: management of hepatic failure with postpartum liver transplantation.

Acute fatty liver of pregnancy is a potentially fatal disorder. We report a patient complicated by preeclampsia, coagulopathy, encephalopathy, and hepatorenal syndrome successfully managed by postpartum hepatic transplantation.     

Combined hepatic and pancreaticoduodenal procurement for transplantation

We have used a procurement method whereby both the liver and whole pancreas grafts are procured from the same donor and successfully transplanted. During the combined procurement, the hepatic artery is completely mobilized; the splenic artery is transected from the hepatic artery and the gastroduodenal artery is ligated from the hepatic artery. The portal vein is mobilized 2 centimeters from the head of the pancreas. The whole pancreas graft includes the splenic artery and the superior mesenteric artery, which are reconstructed. The hepatic graft includes the entire length of the hepatic artery with the celiac axis, and no further reconstruction is required. Using this technique, we have performed nine combined hepatic and whole pancreas procurements; only one liver was not transplanted because of technical complications. When a replaced right hepatic artery is identified from the superior mesenteric artery, we have abandoned the pancreatic retrieval. All combined retrievals have included successful renal retrieval, and the majority have been associated with cardiac retrieval also. Combined hepatic and whole pancreas procurement is feasible with minimal technical complications with the liver or the pancreatic graft and should be standard in most procurements.     

Chemoinfusion of the hepatic artery for metastases to the liver

During a five year period, 69 patients were treated for carcinoma of the liver (seven primary tumors and 62 metastatic tumors) with 5-fluorodeoxyuridine (5-FUDR) administered through a hepatic artery (n = 62) or portal vein (n = 3) implantable infusion pump. Ten patients proved to have previously unsuspected extrahepatic nodal metastases at laparotomy for pump insertion. 5-FUDR was given in 14 day cycles for three months. At the end of that period and at three month intervals thereafter (mean follow-up time of 18 months, a range of one to 60 months), patients were evaluated with roentgenograms of the chest, liver function tests, carcinoembryonic antigen levels, radionuclide scans and computed tomography. Thirty-five patients had a partial response, nine had stabilization of the disease and 25 had progression of the disease (five during therapy, who were given mitomycin C). Median regression was 6.8 months (a range of three to 18 months). Six of the 35 partial responders, three of the nine patients with stabilization and ten of the 25 patients with progression had extrahepatic visceral disease. Survival time averaged 18.4 months (a range of five to 60 months) for the partial responders, 12.6 months (a range of two to 40 months) for patients with stabilization and seven months (a range of one to 17 months) for those with progression of the disease.     

Proximal abdominal graft for arterialization during hepatic transplantation

A new method of arterial grafting during orthotopic hepatic transplantations is described herein. The advantages compared with other techniques include better exposure, less extensive dissection, reduced blood loss and, with correct anatomic orientation, a reduced risk of kinking the graft in a blind tunnel.     

Evolution and future perspectives for reduced-size hepatic transplantation

Reduced-size hepatic transplantation has evolved into a clinically useful procedure, particularly at institutions specializing in treating pediatric patients. It is being adopted by many of the hepatic transplantation institutions in the United States as a result of its effectiveness in providing a greater number of donors for small recipients and an outcome equal to full-size hepatic transplantation. It has led to the development of "split-liver" transplantation, which is at present not universally applicable because of its complexity, but could double the supply of donors available to small patients. It is also the precursor of orthotopic auxiliary transplantation, which could become the preferred method for treating children with metabolic diseases, but no structural changes, such as cirrhosis. Finally, the knowledge gained in reduced-size hepatic transplantation will inevitably lead to transplantation using living donors, which could completely alleviate the shortage of donors for small patients.     

Complete myocardial revascularization using only pedicled arterial conduits in Kawasaki disease.

A 16-year-old boy with Kawasaki disease suffered from progressive angina and exercise intolerance for 1 year. Coronary angiography showed 60% stenosis of the left main coronary artery, a calcified aneurysm with total occlusion at the proximal left anterior descending artery (LAD), and another aneurysm with total occlusion at the middle portion of the right coronary artery. Aortocoronary bypass was done with the left internal mammary artery (IMA) anastomosed to the first obtuse marginal branch, the right IMA to the distal LAD, and the right gastroepiploic artery to the posterior descending artery. Graft patency was documented by follow-up coronary angiography 1 month after surgery. During follow-up, his rapid improvement led to an upgrade from New York Heart Association functional class III to class I. The results of the present case suggest that complete myocardial revascularization using arterial conduits in patients with Kawasaki disease with coronary artery occlusion is safe and effective.     

Cyclosporine in transplantation of the liver in the dog

Orthotopic hepatic transplantation was performed upon 29 dogs. Four dogs received no immunosuppressant, 12 received cyclosporine and 13 received azathioprine. Dogs treated with cyclosporine at a dose of 20 milligrams per kilogram yielded histologic and functional data indistinguishable from those of the dogs in the sham transplant group. Histologic evidence of rejection consistently appeared when the dose was decreased to 10 milligrams per kilogram but was reversed upon resuming the administration of the higher dosage. Serum levels of bilirubin and hepatic enzymes, serum glutamic-oxalacetic transaminase, serum glutamic-pyruvic transaminase and alkaline phosphatase did not correlate with the development or resolution of histologic evidence of rejection in dogs receiving cyclosporine. Dogs receiving cyclosporine for 60 days had a prolonged survival when the drug was stopped, whereas the dogs receiving such therapy for less than 60 days did not have a prolonged survival period.