Liver retransplantation in adults: a single-centre, 25-year experience

Background:

Retransplantation is the only form of treatment for patients with irreversible graft failure. The aim of this study was to analyse a single centre''s experience of the indications for and outcomes of retransplantation.

Methods:

A total of 196 patients who underwent liver retransplantation using 225 grafts, between January 1982 and July 2007, were included in the study. The following parameters were analysed: patient demographics; primary diagnosis; distribution of retransplantation over different time periods; indications for retransplantation; time interval to retransplantation, and overall patient and graft survival.

Results:

Of the 2437 primary orthotopic liver transplantations, 196 patients (8%) required a first regraft, 23 patients (1%) a second regraft and six patients (0.25%) a third regraft. Autoimmune hepatitis was the most common primary diagnosis for which retransplantation was required (12.7% of primary transplantations). The retransplantation rate declined from 12% at the beginning of our programme to 7.6% at the end of the study period. The most common indication for retransplantation was hepatic artery thrombosis (31.6%). Nearly two-thirds of the retransplantations were performed within 6 months of the primary transplantation. The 1-, 3-, 5- and 10-year patient survival rates following first retransplantation were 66%, 61%, 57% and 47%, respectively. Five-year survival after second retransplantation was 40%. None of the patients have yet survived 3 years after a third regraft. Donor age of ≤55 years and a MELD (Model for End-stage Liver Disease) score of ≤23 were associated with better outcome following retransplantation.

Conclusions:

First retransplantation was associated with good longterm survival. There was no survival benefit following second and third retransplantations. A MELD score of ≤23 and donor age of ≤55 years correlated with better outcome following retransplantation.     

Report of 8 cases of liver retransplantation

BACKGROUND: Retransplantation of the liver is required for several complications of primary grafting, such as primary allograft non-function, hepatic artery thrombosis, biliary problems, or chronic ductopenic rejection. Surgeons usually take regrafting as the only pathway to treat those patients who are considered to have a poor outcome after the first operation. Whether the retransplantation is early or late, further attempts at rescue with a second or more grafts are associated with higher mortality and morbidity. However, retransplantation plays a role in improving survival of the patients. Therefore, it is necessary to summarize the experiences in liver retransplantation, as well as the factors influencing operative effects. METHOD: The clinical data of 8 patients who received liver retransplantation in our center were analyzed retrospectively. RESULTS: Complications of the biliary tract occurred in 5 of the 8 patients, chronic rejection in 2, and embolism in the hepatic artery in 1. Infections occurred in 7 patients before engraftment. Patient 1 had developed renal failure before the surgery, and he died of severe infection and multi-organ failure after transplantation. Patient 4 had a massive hemorrhage during the operation and also died of multi-organ failure after transplantation. Patient 7 developed intracranial hemorrhage and abdominal infection and died soon after transplantation. The other 5 patients recovered and discharged from the hospital. CONCLUSIONS: Liver retransplantation is the only measure that can be taken to save the lives of patients whose liver allograft fails to function. It is very important that the indications and time of retransplantation are carefully selected. Factors leading to harmful effects on retransplantation include the preoperative condition of the recipient, a difficult and prolonged operation, massive hemorrhage during the operation, and severe complications after the surgery.     

Preliminary clinical experience in liver retransplantation

BACKGROUND: The past several decades have witnessed increasingly successful rates of liver transplantation. However, retransplantation remains the only choice for patients with irreversible graft failure after primary transplantation. This article aimed to summarize our clinical experience in liver retransplantation. METHODS: From June 2002 to December 2005, a total of 185 cases of liver transplantation including 8 cases of retransplantation were performed in our hospital. The clinical data were analyzed retrospectively. RESULTS: The rate of liver retransplantation was 4.32%. Retransplantation was indicated for the following reasons: biliary complication (3 cases), chronic rejection (2), hepatic artery thrombosis (1), uncontrollable acute rejection (1) and hepatitis B recurrence (1). The mean model of end-stage liver disease (MELD) scores before primary transplantation and retransplantation were 15.6 and 23.9, respectively (P<0.05). The MELD score reflected the severity of liver disease more precisely than the Child classification. The mean interval between the first and second transplantation was 316 days (78-725 days). The first three patients, with mean interval of 101 days, died of severe infection combined with multiple organ failure after retransplantation. The patients who underwent retransplantation more than six months after the first transplant had better outcomes. The one-year survival rate for retransplantation in our group was 62.5%. CONCLUSIONS: Liver retransplantation is the only means of saving the patient with hepatic allograft failure. Understanding of the indications for retransplantation,careful selection of operation timing, excellent surgical skills and meticulous postoperative management all contribute to the success of each case of retransplantation.     

Liver abscess in inflammatory bowel disease: report of two cases and review of the literature

Hepatic abscesses are a rare complication of inflammatory bowel disease (IBD). Despite the fact that certain hepatobiliary complications of IBD, including cholelithiasis, primary sclerosing cholangitis (PSC) and cholangiocarcinoma predispose patients with IBD to ascending cholangitis, previously published data does not demonstrate that biliary infection is an important mechanism underlying liver abscess development in these patients. We describe two patients with inflammatory bowel disease, both with PSC, who developed multiple liver abscesses, and review the literature on liver abscesses in association with inflammatory bowel disease.     

Liver cell adenoma: A case report and a review of 30 cases reported in Japan

A 38 year old man with a huge liver cell adenoma extending to the pelvis was treated by left lateral lobectomy. The tumour, which was well-encapsulated by fibrous membrane, was 18 × 19 × 6 cm in size and weighed 1500g. Histopathologically, this tumour was composed of well-differentiated liver cell trabeculae and a small number of pseudobiliary ducts, but no Glisson sheaths. For the past 4 years 8 months he has remained asymptomatic. Thirty cases of liver cell adenoma found in Japanese literature are reviewed here and possible pathogenic implications are discussed.     

Isolated hepatic tuberculosis: report of five cases and review of the literature

Tuberculosis is one of the most common and well-described infectious diseases, with a worldwide distribution and a vast spectrum of clinical manifestations. Involvement of the liver alone by tuberculosis is, however, uncommon. It usually presents as a protracted illness frequently associated with jaundice and hepatomegaly. It can, therefore, mimic primary or metastatic liver malignancies. We report five cases of isolated hepatic tuberculosis, emphasizing the importance of obtaining a tissue diagnosis in all subjects with suspicious liver lesions to avoid missing the uncommon but curable hepatic tuberculosis.     

Liver haemorrhage in haemophilia – a case report and review of the literature

We present two patients with severe haemophilia A, who presented with haemorrhagic shock, secondary to a liver haematoma in the neonatal period. Both required emergency treatment and diagnosis of the hereditary coagulation defect. Major organ bleeding in severe haemophilia A in the newborn period is rare, and this unusual complication is not well recognized. Failure to recognize that the bleeding is due to a bleeding disorder, particularly in the absence of a family history, may lead to delay in appropriate management.     

肝血色病1例报道并文献复习

肝血色病又称肝血色素沉着症或肝铁过度沉积症,是一种罕见的因铁代谢紊乱,肠道铁被过度吸收导致体内铁过量的疾病。现将我院收治的1例肝血色病及相关文献复习报道如下。     

Liver transplantation with an uncommon full right hemiliver graft after hydatid cysts resection: Case report and review of the literature

Because of widespread organ shortage, the transplant community has been exploiting more and more so‐called “extended criteria” donors. In this scenario, liver grafts harboring benign tumors or large cysts represent an infrequent but potentially valuable source of viable grafts. We depict a challenging case of liver transplantation performed using a graft harboring two large Echinococcus granulosus hydatid cysts in close proximity with the hilar plate and complicated by cystobiliary communication. Although liver transplantation using grafts with hydatid cyst has been rarely reported (three published cases), our case was peculiar as one of the cysts was located close to the hilum and was ruptured into the left hepatic duct. The graft was finally accepted taking into account the low risk profile of the recipient, the good quality and size of the remnant liver parenchyma, and only after complete resection of the cysts was achieved. Although the recipient had a complication due to biliary confluence necrosis, at 10‐months follow‐up he is in good health with normal hepatic function, and a graft that could have been otherwise discarded was successfully used. The decision process along with technical and management issues are discussed.     

Liver resection in cases of isolated hepatic actinomycosis: case report and review of the literature

Hepatic actinomycosis is an uncommon entity that forms communicating abscesses and fistulae. We report a 53-y-old immunocompetent male patient with hepatic actinomycosis. Symptoms included intermittent fever, abdominal pain, right upper quadrant tenderness and jaundice. A hepatic tumour mass was found on abdominal sonography and computerized tomography. Two preoperative percutaneous core biopsies of the mass were not diagnostic. The above findings were highly suggestive for liver abscess or purulent primary liver neoplasm. Treatment with intravenous antibiotics was continued for 20 d, but both symptoms and liver ultrasound findings remained unchanged. The patient underwent exploratory laparotomy and right posterior segmentectomy of the liver. Pathological examination of the surgically removed specimen disclosed hepatic actinomycosis. Following operation the patient remains in excellent condition without evidence of recurrence.     

Different modalities of arterial reconstruction in hepatic retransplantation using right partial graft

Though split-liver and living-related transplantation are routinely performed, they are done almost exclusively for primary liver transplantation because of potential surgical difficulties. These difficulties are generally related to arterial revascularization, particularly if there is hepatic artery thrombosis. According to UNOS data, of the hepatic retransplantations performed between 1996 and 2007, only 8.7% were done using right or extended right grafts from deceased donors, and 14.3% using right grafts from live donors. Here we report our experience with 5 hepatic retransplantations in which right partial grafts resulting from conventional in situ splits, and one right lobe resulting from an adult-to- adult living-related transplant, were successfully used with different modalities of graft arterialization.     

Inflammatory pseudotumor of the liver: report of eight cases, including three unusual cases, and a literature review

BACKGROUND: Inflammatory pseudotumor (IPT) of the liver is a rare but increasingly recognized tumor-like lesion. This condition is becoming an important differential diagnosis in patients with hepatic space-occupying lesions. This study reports the clinical features of eight cases of IPT of the liver, including the first report of three cases with an unusual associated disease or clinical course. METHODS: The study sample included cases of IPT diagnosed based on the histopathology in our institution from 1995 to 2004. Clinical events were reported and compared with reports in the literature. RESULTS: The age of the patients ranged from 28 to 78 years. The most common symptoms were abdominal pain, fever and bodyweight loss. Three patients were diagnosed incidentally. The initial clinical diagnoses were hepatocellular carcinoma in three cases, liver abscess in two cases, metastasis in one case and uncertain nature in two cases. Two cases were associated with preceding endophthalmitis and cholangiocarcinoma, respectively. Two patients had spontaneous lesion regression, but one of these had possible recurrence 10 months later. The other two patients experienced resolution of their lesions following antibiotic treatment. Four patients underwent surgical resection with subsequent recovery. CONCLUSIONS: The clinical and imaging features of IPT in this small series were found to sometimes mimic those of malignant liver tumors or abscess. Surgical resection was performed in half of the cases. However, IPT of the liver could resolve spontaneously or following antibiotics treatment.     

Liver transplantation for metastatic gut autonomic nerve (GAN) tumor: Case report and review of the literature

A 24-year-old woman underwent gastrectomy because of a gut autonomic nerve (GAN) tumor originating from the gastric antrum; three synchronous liver metastases were also resected. Liver resection was repeated twice, due to recurring liver metastases. After a disease-free period of 2 years, liver transplantation was felt to be indicated because of the presence of non-resectable, recrudescent liver metastases. Nearly 5 years after orthotopic liver transplantation, there are no signs of clinical or biological tumor recurrence. In view of the literature, liver transplantation may very well be indicated in the presence of liver metastases stemming from GAN tumors which originate from the proximal gastrointestine.     

Intrathoracic caudate lobe of the liver:A case report and literature review

Heterotopic supradiaphragmatic livers are rare.A total of 23 cases of primary supradiaphragmatic livers have been reported in the literature.The clinical presentations of heterotopic supradiaphragmatic liver are variable.The simultaneous detection of intrathoracic accessory liver and pulmonary sequestration is extremely rare,and only one case has previously been reported.It is difficult to make a correct diagnosis preoperatively.We presented a 53-year-old woman with complaints of an intermittent,productive cough and dyspnea for two months that was refractory to medical treatment.She had no previous history of trauma or surgery.A chest radiograph only showed a widening of the mediastinum.Contrast-enhanced computed tomography of the chest revealed a well-circumscribed homogenous soft-tissue mass,approximately 4.35 cm×2.5 cm×6.14 cm in size,protruding through the right diaphragmatic crura to the right pleural cavity,attached to the inferior vena cava,esophagus and liver.There was no conclusive diagnosis before surgery.After the operation,we discovered that this patient was the first case of a supradiaphragmatic heterotopic liver,which passed through the inferior vena cava foramen and was coincidentally combined with an intralobar pulmonary sequestration that was found intraoperatively.We discussed its successful management with surgical resection via a thoracic approach and reviewed the published literature.     

Eosinophilic cystitis: eight cases report and literature review

Historically, eosinophilic cystitis is a rare disorder of bladder inflammation with eosinophils infiltration diagnosed by pathologic examination. The etiology is unclear despite the past identification of many factors contributing to this disease. Eight patients with eosinophilic cystitis were reported. The intact history, clinical manifestation, radiological examination and response to therapy were all evaluated. The results showed that 7 patients developed hematuria, 6 patients were with dysuria, 4 patients with frequency and 4 patients with urine retention. Seven patients had abnormal urinalysis but no positive finding in culture. Radiological findings revealed that one patient had bladder mass lesions and upper urinary tract dilation. Cystoscopic examination was performed in every patient and showed mass-like, edematous, ulcerative or hyperemic mucosa lesions. Cold-cup biopsy or transurethral resection of bladder lesions were all performed and could be the first priority to be considered. However, partial or total cystectomy should be taken into consideration when simple treatment failed to resolve this problem. Additionally, antihistamines, steroids or antibiotics are given to control the clinical symptoms. The results of these treatments were good except for one case who suffered from recurrence but recovered after simple operation and oral therapy. Although good results were found concerning treatment, long-term follow-up is necessary.     

Kartagener综合征3例分析并文献复习

目的 供临床医师提高对Kartagener综合征早期诊断和治疗.方法 通过3例病史、临床表现、影像学、彩超、心电图等检查明确诊断进行分析和文献复习.结果 Kartagener综合征是一种少见的常染色体隐性遗传性疾病.症状为:副鼻窦炎一支气管扩张一内脏转位三联征,其临床表现为反复咳嗽、咯脓痰、咯血等肺部表现,同时伴副鼻窦炎.结论 在内脏转位的患者中若出现支气管扩张症状及影像学表现,应想到Kartagener综合征的可能.