Renal pelvis squamous cell carcinoma with inferior vena cava infiltration: Case report and review of the literature

INTRODUCTION

Renal squamous cell carcinoma (RSCC) is a rare tumor that is usually diagnosed late as a locally advanced malignancy with adjacent structure involvement. Radical surgical resection with negative margins is the mainstay of treatment, as it is correlated with improved survival, while other modalities of treatment have been shown to have limited efficacy.

PRESENTATION OF CASE

We report a case of a 56 year old gentleman with right RSCC with tumor encasing the inferior vena cava (IVC), treated successfully with surgical resection.

DISCUSSION

The surgical management of vascular involvement of similar tumors has not been discussed in-depth in the literature. Surgical resection of the IVC without reconstruction can be done successfully in the circumstance of good collateral circulation; otherwise IVC resection with reconstruction will be necessary.

CONCLUSION

Radical resection with clear margins of RSCC tumors with vascular involvement is feasible in selected circumstances.     

Liver transplantation in a patient with complex anomaly of the inferior vena cava

Background

After the introduction of noninvasive imaging exams, congenital anomalies of the inferior vena cava (IVC) have become more commonly recognized. We report the first successful orthotopic liver transplantation (OLT) performed in an asymptomatic adult with complex IVC anomaly: duplication of the infrarenal IVC, azygos continuation of the IVC, agenesia of the hepatic portion of the IVC and presence of several anomalous veins communicating the common iliac vein and the IVC of one side with the contralateral side.

Methods

This complex anomaly was diagnosed with a venous abdominal angio CT.

Results

At liver transplantation, the short suprahepatic portion of the IVC was identified and clamped. The right, middle, and left hepatic veins were sectioned and joined in a single, wide cuff, using venoplasty. This single orifice was anastomosed to the suprahepatic IVC of the new liver. No venovenous bypass was employed. The patient had an uneventful postoperative course. A post transplantation venous abdominal angio CT showed normal blood flow at the anastomosis of the hepatic veins of the receptor and the IVC of the new liver.

Conclusions

This report is important to alert liver transplant teams of the possibility of complex IVC in asymptomatic adult individuals. Identification of these anatomical anomalies is vital to reduce the risk of serious hemorrhage and other operative complications during OLT.     

Graft harvest of right posterior segment for living-donor liver transplantation

INTRODUCTION

Right posterior segmental graft (RPSG) is an alternative procedure for living-donor liver transplantation (LDLT). Although the first case of RPSG was reported in 2001, it has not been disseminated because of the lack of popularity, technical concerns, and surgical difficulties.

PRESENTATION OF CASE

A 37-year-old man with primary sclerosing cholangitis. His spouse was the only transplantation candidate, although she was ABO incompatible. Preoperative investigations revealed that left-lobe graft was insufficient for the recipient and that right-lobe graft was accompanied by donor risk. In RPSG, estimated graft-to-recipient weight ratio (GRWR) and estimated ratio of liver remnant were reasonable. In the donor operation, the right hepatic vein (RHV) and demarcation line were confirmed, and intraoperative cholangiography was performed. The cut line was carefully considered based on the demarcation line and RHV. The RPSG was harvested. Actual GRWR was 0.54. Unfortunately, this recipient showed a poor course and outcome after LDLT.

DISCUSSION

Segmental branches of vessels and biliary duct may be not suitable for reconstruction, and surgeons must exercise some ingenuity in the recipient operation. Segmental territory based on inflow and that based on outflow never overlap completely, even in the same segment. The selection of RPSG based only on liver volume may be unfeasible. Liver resection should be carefully considered based on preoperative imaging, and demarcation line and RHV during surgery.

CONCLUSION

RPSG is a useful tool for LDLT. However, detailed studies before surgery and careful consideration during surgery are important for RPSG harvest.     

Renal vein extension using an autologous renal vein in a living donor with double inferior vena cava: a case report

Background

When the kidney from a living donor with a double inferior vena cava (IVC) is harvested for renal transplantation, the short length of the renal vein may eventually create a technical problem for graft implantation. Herein, we have reported a rare case of renal vein extension using an autologous renal vein in a living donor with a double IVC.

Case Report

A 70-year-old man with end-stage renal disease owing to autosomal-dominant polycystic kidney disease underwent a living donor kidney graft from his wife who had a double IVC. Because of the enlarged kidneys, the patient underwent a bilateral native nephrectomy with concomitant renal transplantation to create space in the pelvis. At nephrectomy, the recipient's renal vein was used to extend the donor renal vein. On the back table, the vein graft was sutured to the donor renal vein, permitting a 3.0-cm extension.

Results

The transplantation was performed safely without any complications; the recipient's renal function and blood flow were excellent after the operation.

Conclusion

This case illustrated that an autologous renal vein graft is a preferable option to extend of short donor renal vein for recipients who require a simultaneous native nephrectomy.     

Coexistent End-stage Nonalcoholic Steatohepatitis and Colon Cancer: Should We Do Liver Transplantation?

Background

Colon cancer accompanying decompensated liver cirrhosis is a rare clinical condition. Usually, treatment of colon cancer is prioritized, with cirrhosis dealt with later.

Commercial renal transplantation: A risky venture? A single Canadian centre experience

Background:

Canada, akin to other developed nations, faces the growing challenges of end-stage renal disease (ESRD). Even with expanded donor criteria for renal transplantation (the treatment of choice for ESRD), the supply of kidneys is outpaced by the escalating demand. Remuneration for kidney donation is proscribed in Canada. Without an option of living-related transplantation (biological or emotional donors), patients often struggle with long waiting lists for deceased donor transplantation. Accordingly, many patients are now opting for more expedient avenues to obtaining a renal transplant. Through commercial organ retrieval programs, from living and deceased donors, patients are travelling outside Canada to have the procedure performed.

Methods:

Between September 2001 and July 2007, 10 patients (7 males, 3 females) underwent commercial renal transplantation outside Canada. We describe the clinical outcomes of these patients managed postoperatively at our single Canadian transplant centre.

Results:

Six living unrelated and 4 deceased donor renal transplantations were performed on these 10 patients (mean age 49.5 years). All procedures were performed in developing countries and the postoperative complications were subsequently treated at our centre. The mean post-transplant serum creatinine was 142 μmol/L. The average follow-up time was 29.8 months (range: 3 to 73 months). One patient required a transplant nephrectomy secondary to fungemia and subsequently died. One patient had a failed transplant and has currently resumed hemodialysis. Acute rejection was seen in 5 patients with 3 of these patients requiring re-initiation of hemodialysis. Only 1 patient had an uncomplicated course after surgery.

Discussion:

Despite the kidney trade being a milieu of corruption and commercialization, and the high risk of unconventional complications, patients returning to Canada after commercial renal transplantation are the new reality. Patients are often arriving without any documentation; therefore, timely, goal-directed therapy for surgical and infectious complications is frequently delayed because of the time taken to establish an accurate diagnosis. Refuting the existence of commercial renal transplantation may not be a practical solution; more consistent communication and documentation with transplant teams may be more pragmatic. In the current climate, patients considering the option of overseas commercial renal transplantation should be advised of the potential increased risks.     

Role of Hand-Assisted Laparoscopic Surgery in Living-Donor Right Liver Harvest

Objective

The cosmetic aspects of abdominal skin incisions are a matter of concern for both live liver donors and surgeons. We performed a prospective comparative study on the use of minilaparotomy to perform right liver graft harvests with and without hand-assisted laparoscopic surgery (HALS).

Methods

Young donors were indicated for surgery using minilaparotomy with or without HALS. In the non-HALS group (n = 20), a 10–12-cm-long right subcostal incision was used for right liver graft harvest. In the HALS group (n = 20), an 8-cm-sized right subcostal incision was used for hand assistance and 3 laparoscopic holes made for manipulation. The retrohepatic inferior vena cava (IVC) was initially laparoscopically dissected while using air inflation. The skin incision was extended to 10–12 cm, and then hilar dissection and hepatic transection were performed through the skin incision.

Results

In all 40 donors in the study cohort, safe uneventful harvesting of the right liver grafts was successfully achieved through the minilaparotomy incisions. The HALS group required an additional 30 minutes for laparoscopic preparation and dissection compared with the non-HALS group. HALS facilitated retrohepatic IVC dissection, and the remaining part of the surgery was the same as that for minimal-incision surgery. The minimal skin incision for the delivery of the liver from the abdomen was an average 10 cm for grafts <500 g and 12 cm for grafts ≥700 g. Compared with the patient profiles, there were no differences regarding donor age, body mass index, graft weight, intraoperative blood loss, postoperative increase in peak liver enzymes, total hospital stay, and incidence of postoperative complications.

Conclusions

HALS facilitates the performance of donor hepatectomy with the use of a minimal incision, which probably allows for a wider selection of living donors.     

20-Year Analysis of Kidney Transplantation: A Single Center in Japan

Background

Patient and graft survival after successful kidney transplantation (KT) have improved despite an increase in the number of challenging cases. Various factors have evolved during the long history of kidney transplantation.

Methods

Between 1988 and 2012, a total of 292 living donor and 56 deceased donor KTs were performed at Niigata University Hospital. Long-term patient and graft survival and changes in background during a 20-year period in a single center were retrospectively analyzed.

Results

Excellent patient survival rates of 95.1% at 20 years for living donor KT and 96.2% at 15 years for deceased donor KT were observed. Graft survival rates at 1, 5, 10, 15, and 20 years were 96.8%, 95.4%, 83.1%, 61.8%, and 56.2% in living donor KT, respectively. In contrast, graft survival rates at 1, 5, 10, and 15 years in deceased donor KT were 89.0%, 80.3%, 77.3%, and 33.8%, respectively. These survival rates have dramatically improved since 2002 (91.7% for living and 80.9% for deceased donor KT at 10 years post-transplantation). The number of elderly recipients (older than 60 years) and the percentage of grafts donated from spouses have increased. The rejection rate decreased and the cytomegalovirus antigenemia–positive rate increased during the 20-year period assessed. The percentage of pre-emptive KTs progressively increased, with graft survival in this group tending to be better than non-preemptive KTs. The causes of graft loss were chronic allograft dysfunction (54.7%), acute rejection (11.1%), and malignancies (9.4%). After living donor KT, the principal predictors of graft loss were if the recipient was younger than 30 years, if the donor was older than 50 years, and if the rejection episodes occurred after living donor KT. In contrast, the only risk factor in the case of deceased donor KT occurred after transplantation from donors who were older than 50 years.

Conclusions

A summary of the long-term outcome of KT over 20 years in a single center has been reported. Along with the changes in patient backgrounds, immunosuppressive drugs, and our knowledge of transplantation, patient and graft survival outcomes have also changed. Investigation into such outcomes during a different transplantation era is required to fully appreciate advances in KT.     

Higher Renal Allograft Function in Deceased-Donor Kidney Transplantation Rather Than in Living-Related Kidney Transplantation

Objectives

To compare the clinical outcome of kidney transplantation from living-related and deceased donors.

Simplified technique for auxiliary orthotopic liver transplantation using a whole graft

Background

Acute liver failure is associated with a high mortality rate and the main purposes of treatment are to prevent cerebral edema and infections, which often are responsible for patient death. The orthotopic liver transplantation is the gold standard treatment and improves the 1-year survival.

Aim

To describe an alternative technique to auxiliary liver transplant on acute liver failure.

Method

Was performed whole auxiliary liver transplantation as an alternative technique for a partial auxiliary liver transplantation using a whole liver graft from a child removing the native right liver performed a right hepatectomy. The patient met the O´Grady´s criteria and the rational to indicate an auxiliary orthotopic liver transplantation was the acute classification without hemodynamic instability or renal failure in a patient with deterioration in consciousness.

Results

The procedure improved liver function and decreased intracranial hypertension in the postoperative period.

Conclusion

This technique can overcome some postoperative complications that are associated with partial grafts. As far as is known, this is the first case of auxiliary orthotopic liver transplantation in Brazil.     

Prediction of delayed graft function after renal transplantation

Introduction:

Delayed graft function (DGF), defined as the need for dialysis during the first week after renal transplantation, is an important adverse clinical outcome. A previous model relied on 16 variables to quantify the risk of DGF, thereby undermining its clinical usefulness. We explored the possibility of developing a simpler, equally accurate and more user-friendly paradigm for renal transplant recipients from deceased donors.

Methods:

Logistic regression analyses addressed the occurrence of DGF in 532 renal transplant recipients from deceased donors. Predictors consisted of recipient age, gender, race, weight, number of HLA-A, HLA-B and HLA-DR mismatches, maximum and last titre of panel reactive antibodies, donor age and cold ischemia time. Accuracy was quantified with the area under the curve. Two hundred bootstrap resamples were used for internal validation.

Results:

Delayed graft function occurred in 103 patients (19.4%). Recipient weight (p < 0.001), panel of reactive antibodies (p < 0.001), donor age (p < 0.001), cold ischemia time (p = 0.005) and HLA-DR mismatches (p = 0.05) represented independent predictors. The multivariable nomogram relying on 6 predictors was 74.3% accurate in predicting the probability of DGF.

Conclusion:

Our simple and user-friendly model requires 6 variables and is at least equally accurate (74%) to the previous nomogram (71%). We demonstrate that DGF can be accurately predicted in different populations with this new model.     

Solid-organ Transplants From Living Donors: Cumulative United States Experience on 140,156 Living Donor Transplants Over 28 Years

Background

Transplantation of organs from living donors helps to decrease the organ shortage and shortens waiting times. Living donor (LD) transplantation is also generally associated with better outcomes. Unfortunately, there has been no comprehensive analysis and comparison of all types of solid-organ transplantation from living donors since the inception of the United Network for Organ Sharing (UNOS).

COMBINED LIVER-KIDNEY TRANSPLANTATION: EXPERIENCE AT A BRAZILIAN UNIVERSITY HOSPITAL

Background

Combined liver-kidney transplant is a routine procedure in many transplant centers. The increase in its number coincided with the introduction in 2002 of the MELD (Model for End-stage Liver Disease) score for allocation of livers, prioritizing patients with renal dysfunction.

Aim

To analyze the experience with combined liver-kidney transplantation in a liver transplant center in Brazil.

Method

A retrospective review was conducted. All transplants were performed using grafts from deceased donors.

Results

Sixteen combined liver-kidney transplantations were performed in the same period, which corresponds to 2.7% and 2.5% of the kidney and liver transplants, respectively. Fourteen patients were male (87.5 %) and two were female (12.5%). The average patients and donors age was 57.3±9.1 and 32.7±13.1, respectively. The MELD score mean was 23.6±3.67. The main cause of liver dysfunction were chronic hepatitis C virus (n=9). As for renal dysfunction, diabetic nephropathy (n=4) was the most frequent. There were six deaths, two of them by severe dysfunction of the liver graft and four by infectious causes. The 1, 3 and 5 years survival rate in patients undergoing liver-kidney transplantations was 68.8%, 57.3% and 57.3%, respectively.

Conclusion

The survival rates achieved in this series are considered satisfactory and show that this procedure has an acceptable morbidity and survival.     

Outcomes of Expanded-Criteria Deceased Donor Kidney Transplantation in a Single Center

Background

In an effort to expand the deceased donor pool, transplant centers have accepted expanded-criteria donors as appropriate for many of the patients in the deceased donor pool. We investigated expanded-criteria deceased donor kidney transplantation and compared the outcomes of kidney transplantation according to donor types.

Methods

We retrospectively analyzed 88 kidney transplantations performed between June 2006 and December 2012. We divided the patient into 4 groups: SCDD, standard-criteria deceased donor; ECDD, expanded-criteria deceased donor; ECMO, donor under extracorporeal membrane oxygenation support; living donor.

Results

Deceased and living donor kidney transplantations were performed in 52 (59.1%) and 36 (40.9%) cases, respectively. Among deceased donors, 31 (35.2%) were standard-criteria donors and 14 cases (15.9%) were expanded-criteria donors. Seven (8.0%) donors were under extracorporeal membrane oxygenation support. Mean follow-up was 26.1 ± 20 months. Average number of HLA mismatches among the donor types was 3.39, 3.07, 3.0, and 2.94 in SCDD, ECDD, ECMO, and living donor groups, respectively (P = .708). Delayed graft function occurred in 2 (6.9%), 3 (21.4%), 3 (42.9%), and 3 (8.3%) patients in the SCDD, ECDD, ECMO, and living donor groups, respectively (P = .043). Episodes of acute rejection within a year occurred in 14 (45.2%), 2 (14.3%), 1 (14.3%), and 6 (16.7%) patients in the SCDD, ECDD, ECMO, and living donor groups, respectively (P = .029). Renal functions after kidney transplantation at 3 months, 6 months, 9 months, and 1 year were not significantly different according to donor types. Graft survival was not different among the different donor types (87.1%, 92.8%, 85.7%, 91.7% in SCDD, ECDD, ECMO, and living donor groups, respectively; P = .67). Patient survival was not different among the different donor types (87.1%, 92.9%, 100%, 97.2% in SCDD, ECDD, ECMO, and living donor group, respectively; P = .36).

Conclusion

The use of expanded-criteria deceased donor had no impact on graft or patient survival after kidney transplantation.     

Higher Incidence of Renal Allograft Glomerulonephritis in Living-Related Donor Kidney Transplantation

Glomerulonephritis recurrence has emerged as one of the leading causes of allograft loss. We aimed to investigate the effect of living-related and deceased donation on the incidence of renal allograft glomerulonephritis and its effect on renal allograft survival.

Systematic review on the treatment of deceased organ donors

Background

Currently, there is no consensus on which treatments should be a part of standard deceased-donor management to improve graft quality and transplantation outcomes. The objective of this systematic review was to evaluate the effects of treatments of the deceased, solid-organ donor on graft function and survival after transplantation.

Postoperative Doppler Ultrasonography in Liver Transplantation

Background

Doppler ultrasonography plays an important role in the postoperative management of liver transplantation. We present our initial experiences evaluating liver transplants with the use of postoperative Doppler sonography.

Better Selection Criteria With Prognostic Factors for Liver Transplantation

Background

Liver transplantation has evolved significantly in recent years, with each advancement part of the effort toward increasing patient and graft survival as well as quality of life. The objective of this study was to evaluate the prognostic factors and selection criteria for liver transplantation.

How to Reconstruct Middle Hepatic Vein Branches With Explanted Portal Vein and Inferior Mesenteric Vein Graft: A Case Report

Objective

The middle hepatic vein reconstruction is one of the crucial parts in adult living donor liver transplantation. Numerous techniques had been reported by using cadaveric iliac vessel or synthetic graft. The limitations of reported techniques are availability of the vessel and complication of synthetic graft. We report the technique of using explanted portal vein and inferior mesenteric vein graft in sequential fashion.