Do patients with acute liver failure have a better chance to receive liver grafting?

OBJECTIVE: Patients with acute hepatic failure (AHF) were always given first priority on the transplant waiting list. We investigated whether AHF patients will deprive other patients on the waiting list of the chance of liver transplantation (LTx). METHODS AND RESULTS: From January 1999 to March 2003, a total of 423 patients were on the transplant waiting list at the National Taiwan University Hospital. Sixty-five of the patients had AHF caused by hepatitis-B-related disease (HBV, n = 52, 80%), Wilson disease (n = 3, 4.6%), drug-induced AHF (n = 3, 4.6%), and other causes (n = 7, 10.8%).Thirty-three patients died and 16 survived by medical treatment. Two received LTx abroad and 14 underwent LTx at our hospital (7 living-related; 7 cadaver). A total of 140 patients died while waiting for a transplant during the period studied. Of them, 107 were among 358 non-AHF patients (30%), and time-to-death interval was 133 +/- 175 days (median: 62); 33 were among 65 AHF patients (51%); time to death was 19 +/- 28 days (median: 8). There were 35 cadaver donor livers available during the period; 28 of 358 non-AHF patients (7.8%), and 7 of 65 AHF patients (10.7%) received cadaveric LTx. Their waiting time totaled 342 +/- 316 and 12 +/- 9 days, respectively (P < .0001). CONCLUSION: Most AHF patients died unless they received liver grafts. Even with a higher priority assigned to them, AHF patients still have little chance to get a cadaver donor liver in Taiwan, and non-AHF patients have an even slimmer chance. Therefore, we need to encourage liver donation from living-related donors.     

Transient elastography--an alternative to liver biopsy in patients with chronic hepatitis C?

Liver fibrosis is the main determinant of clinical outcomes of chronic hepatitis C. Liver biopsy is still considered the gold-standard for assessing liver fibrosis. However, liver biopsy is an invasive procedure associated with morbidity and mortality and has several limitations. Moreover, liver biopsy is not well accepted by the patients, especially when repeated examinations are needed, and its accuracy in assessing fibrosis is questionable due to sampling errors, intraobserver and interobserver discrepancies. Therefore, over the last years there has been an increasing interest and desire for non-invasive tests to assess the stage of liver fibrosis in patients with chronic hepatitis C. There are three main groups of non-invasive methodologies for the assessment of liver fibrosis: serum markers, imaging techniques, and transient elastrography. This review summarizes current information on transient elastography used for non-invasive diagnosis of liver fibrosis in patients with chronic hepatitis C.     

Laparoscopic blood-saving liver resection using a new radiofrequency-assisted device: preliminary report of an in vivo study with pig liver

Background

The aim of any device designed for liver resection is to allow blood saving and quick resections. This may be optimized using a minimally invasive approach. A radiofrequency-assisted device is described that combines a cooled blunt-tip electrode with a sharp blade on one side in an in vivo preliminary study using hand-assisted laparoscopy to perform partial hepatectomies.

Methods

Eight partial hepatectomies were performed on pigs with hand-assisted laparoscopy using the radiofrequency-assisted device as the only method for transection and hemostasis. The main outcome measures were transection time, blood loss, transection area, transection speed, blood loss per transection area, and tissue coagulation depth. The risk for biliary leak also was assessed using the methylene blue test.

Results

The transection time was 13 ± 7 min for a mean transected area of 34 ± 11 cm². The mean total blood loss was 26 ± 34 ml. The mean transection speed was 3 ± 1 cm²/min, and the blood loss per transection area was 1 ± 1 ml/cm². Abdominal examination showed no complications in nearby organs. One biliary leak was identified in one case using the methylene blue test. The transection surface was 34 ± 11 cm², and the mean tissue coagulation depth was 9 ± 2 mm. The inviability of the coagulated surface was assessed by adenine dinucleotide (NADH) staining.

Conclusions

The radiofrequency-assisted device has shown with a laparoscopic approach that it can perform liver resections faster and with less blood loss using a single device in a minimally invasive manner without vascular control than other commercial devices. The results show no significant differences with the same device used in an open procedure.     

Biliary atresia: 20–40-year follow-up with native liver in an Italian centre

IntroductionBiliary atresia (BA) represents the leading indication for liver transplantation in childhood. Only few studies reported the outcome of patients who survived more than 20 years on their native liver, and up to date there are no Italian data available. We reported our 40-year single centre experience with long-term follow-up of BA patients.Materials and methodsAll consecutive patients who underwent Kasai portoenterostomy (KPE) for BA managed at our Institution between 1975 and 1996 were retrospectively reviewed. Native liver (NLS) and overall survival (OS) were analyzed with Kaplan-Meyer curves and LogRank test. A p value of < .05 was regarded as significant. Quality of life of patients currently surviving with their native liver was assessed through a quality of life questionnaire.ResultsDuring the 22-year period of the study 174 patients underwent surgery (median age 60 days). Clearance of jaundice at 6 months from surgery was achieved in 90 patients (51.7%). NLS was 41% at 5 years, 32% at 10 years, 17.8% at 20 years and 14.9% at 40 years. Cholangitis was recorded in 32%, hepatocellular carcinoma in 0.5%. Twenty-six patients (14.9%) survived with their liver more than 20 years; 84.6% had normal serum bilirubin level and 23% had esophageal varices. Quality of life was comparable with the healthy Italian population in all but one patient.ConclusionsOur Italian experience confirms KPE represents the cornerstone of treatment for children with BA. Multidisciplinary and meticulous lifelong post-operative follow-up should be guaranteed for these patients because of the possibility of late-onset cholangitis, portal hypertension, hepatic deterioration and liver malignant tumors.Type of the studyretrospective case series.Level of evidenceIV.     

Does general anesthesia with inhalation anesthetics worsen hypoxemia in patients with end-stage liver disease and an intrapulmonary shunt?

Hepatopulmonary syndrome (HPS) is common among patients with end-stage liver disease (ESLD); however, the effects of general anesthesia on oxygenation capacity have not been studied in these patients. The aim of this study was to evaluate the effects of general anesthesia with inhalation anesthetics on oxygenation parameters according to intrapulmonary shunt grade in patients undergoing liver transplantation. Fifty-eight liver transplant recipients were divided into 2 groups according to the intrapulmonary shunt grade as determined using preoperative echocardiography using the microbubble-syringe technique. Patients in the ‘no shunt’ group (n = 44) had either no detectable or a mild shunt, whereas those in the “shunt” group (n = 14) displayed moderate to severe changes. Arterial blood gas analysis was performed twice for each patient: preoperatively and 30 minutes after induction of general anesthesia. We calculated arterial oxygen partial pressure-to-FiO₂ ratio (PaO₂/FiO₂), alveolar-arterial oxygen difference (A-aDO₂), age-corrected A-aDO₂, A-aDO₂-to-inspiratory oxygen fraction ratio (AaDO₂/FiO₂), and alveolar oxygen partial pressure-to-PaO₂ ratio (PAO₂/PaO₂). In the preoperative period, the PaO₂ was lower in the shunt compared with the no shunt group (77.8 ± 24.3 vs 92.9 ± 14.5, respectively; P = .016), as was the PaO₂/FiO₂. A-aDO₂, age-corrected A-aDO₂, A-aDO₂/FiO₂, and PAO₂/PaO₂ were all greater in the shunt group preoperatively. After induction of general anesthesia, all parameters increased in both groups, but the differences between the 2 groups were no longer significant. Patients with ESLD who underwent liver transplantation with a moderate to severe intrapulmonary shunt showed lower preoperative oxygenation capacities than those without a shunt or with a mild shunt. General anesthesia decreased oxygenation capacity in all patients, but the differences between the 2 groups were no longer significant after induction.     

Is it safe to perform esophagectomy in esophageal cancer patients combined with liver cirrhosis?

Patients with liver cirrhosis undergoing gastrointestinal surgery still suffer from high operative morbid-mortality despite advancements in surgical critical care. The objective of this study is to see if this same relationship applies to patients undergoing esophagectomy for cancer. From 1993 to 2003, sixteen esophageal cancer patients with liver cirrhosis were operated on. They were all male with a mean age of 51.5 years. According to the Child-Pugh classification, 10 patients were Child 'A', 4 patients Child 'B' and Child 'C' in 2 patients. The surgical procedure was through an Ivor-Lewis esophagogastrectomy with intra-thoracic anastomosis. Major morbidity included: 4 respiratory failure, 2 acute renal failure, 3 pneumonia, and one in each of the patients with gastrointestinal bleeding and hepatic failure. The mean follow up among the survivors was 19.1 months. The hospital mortality was 25% (4/16). Using the rate according to Child classification, the mortality rates were: A: 1/10 (10%), B: 2/4 (50%) and C: 2/2 (100%). We conclude that patients with liver cirrhosis in Child-Pugh A could tolerate esophagectomy with an acceptable risk. However, patients with a more advanced state of liver dysfunction are at higher risk for esophagogastrectomy. Careful patient selection and meticulous peri-operative care is warranted in those embarking on surgical resection.     

T cell–mediated response to SARS-CoV-2 in liver transplant recipients with prior COVID-19

Whether immunosuppression impairs severe acute respiratory syndrome coronavirus 2-specific T cell–mediated immunity (SARS-CoV-2-CMI) after liver transplantation (LT) remains unknown. We included 31 LT recipients in whom SARS-CoV-2-CMI was assessed by intracellular cytokine staining (ICS) and interferon (IFN)-γ FluoroSpot assay after a median of 103 days from COVID-19 diagnosis. Serum SARS-CoV-2 IgG antibodies were measured by ELISA. A control group of nontransplant immunocompetent patients were matched (1:1 ratio) by age and time from diagnosis. Post-transplant SARS-CoV-2-CMI was detected by ICS in 90.3% (28/31) of recipients, with higher proportions for IFN-γ-producing CD4⁺ than CD8⁺ responses (93.5% versus 83.9%). Positive spike-specific and nucleoprotein-specific responses were found by FluoroSpot in 86.7% (26/30) of recipients each, whereas membrane protein-specific response was present in 83.3% (25/30). An inverse correlation was observed between the number of spike-specific IFN-γ-producing SFUs and time from diagnosis (Spearman's rho: −0.418; p value = .024). Two recipients (6.5%) failed to mount either T cell–mediated or IgG responses. There were no significant differences between LT recipients and nontransplant patients in the magnitude of responses by FluoroSpot to any of the antigens. Most LT recipients mount detectable—but declining over time—SARS-CoV-2-CMI after a median of 3 months from COVID-19, with no meaningful differences with immunocompetent patients.     

Is computed tomography necessary to determine liver injury in pediatric trauma patients with negative ultrasonography?

Purpose

Abdominal trauma is the third most common cause of all trauma-related deaths in children. Liver injury is the second most common, but the most fatal injury associated with abdomen trauma. Because the liver enzymes have high sensitivity and specificity, the use of tomography has been discussed for accurate diagnosis of liver injury.

Methods

Our study was based on retrospective analyses of hemodynamically stabil patients under the age of 18 who were admitted to the emergency department with blunt abdominal trauma.

Results

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were significantly higher as a result of liver injury. In the patients whose AST and ALT levels were lower than 40 IU/L, no liver injury was observed in the contrast-enhanced computed tomography (CT). No liver injury was detected in the patients with AST levels lower than 100 IU/L. Liver injury was detected with contrast-enhanced CT in only one patient whose ALT level was lower than 100 IU/L, but ultrasonography initially detected liver injury in this patient.

Conclusions

According to our findings, abdominal CT may not be necessary to detect liver injury if the patient has ALT and AST levels below 100 IU/L with a negative abdominal USG at admission and during follow-up.