Preservation of renal perfusion and postoperative renal function by side-to-side cavo-caval anastomosis in liver transplant recipients

Postoperative renal failure is common after liver transplantation (LT). The aim of this study was to investigate peroperative renal perfusion and postoperative renal function in 12 patients who underwent LT with side-to-side cavocaval anastomosis (SSCCA). Three phases were considered during the procedure: hepatectomy, the anhepatic phase, and the postreperfusion phase (phases 1, 2, and 3, respectively). Mean arterial pressure, IVC pressure, and renal perfusion pressure were significantly higher during phase 2 than during phases 1 and 3. Cardiac index and pulmonary capillary wedge pressure did not differ significantly during the three phases. Creatinine clearance did not significantly decrease postoperatively. We conclude that SSCCA is associated with both the preservation of renal perfusion pressure during the entire procedure and the preservation of postoperative creatinine clearance. It is, moreover, a technique that results in a low rate of postoperative renal failure after LT.     

再次肝移植治疗移植肝失功能22例报告

目的 总结再次肝移植治疗移植肝失功能的临床经验。方法 回顾分析2004年1月至2006年6月期间中山大学附属第三医院施行22例再次肝移植受者的临床资料，结合文献加以讨论。再次肝移植的原因分别为移植术后胆道并发症（12例）、移植术后肝癌复发（4例）、肝动脉栓塞（2例）、肝动脉狭窄（2例）以及乙肝复发（2例）。再次移植率为3．62％，供肝植入均采用改良背驮式肝移植技术。结果 全组无手术死亡，8例随访至今分别存活21、14、8、3个月各1例，12、1个月各2例；14例存活2周到28个月不等。首次肝移植术后8～30d行再次肝移植病人围手术期病死率最高，为66．7％；1年内死亡10例，主要死亡原因为感染（60％）。结论 再次肝移植是移植肝失功能的惟一有效的治疗方法，正确掌握手术时机及适应证，钻研手术技巧，合理的个体化免疫抑制方案以及围手术期有效的抗感染治疗是提高再次肝移植病人存活率的关键。     

Results after liver retransplantation in a group of 50 regrafted patients: two different concepts of elective versus emergency retransplantation

Liver retransplantation remains the only alternative therapy for irreversible graft failure. Previous studies have demonstrated lower survival rates for liver retransplantation than for primary grafts. After reviewing our clinical experience with 55 retransplantations out of 365 liver transplants, we found that the risk and results depend on the surrounding circumstances. Elective retransplantation was shown to be as safe as the first liver transplantation, while emergency retransplantation yielded significantly higher morbidity and mortality rates.     

Results after liver retransplantation in a group of 50 regrafted patients: two different concepts of elective versus emergency retransplantation

Abstract. Liver retransplantation remains the only alternative therapy for irreversible graft failure. Previous studies have demonstrated lower survival rates for liver retransplantation than for primary grafts. After reviewing our clinical experience with 55 retransplantations out of 365 liver transplants, we found that the risk and results depend on the surrounding circumstances. Elective retransplantation was shown to be as safe as the first liver transplantation, while emergency retransplantation yielded significantly higher morbidity and mortality rates.     

Reversibility of Acquired Amyloid Polyneuropathy After Liver Retransplantation

Domino liver transplantation (DLT) has become an accepted procedure designed to address problems with organ limited supply. However, cases of acquired amyloid neuropathy are increasingly being recognized following this procedure. Until now, only one patient had undergone liver retransplantation and follow‐up findings were not reported. We describe the case of a 72‐year‐old patient with partial recovery from acquired amyloid neuropathy following retransplantation with a deceased donor 7 years after DLT performed for end‐stage liver disease. His clinical and paraclinical improvement is described, and the impact of this case on the indication for a domino procedure and the challenges linked to retransplantation are discussed.     

肝癌复发与未复发患者再次肝移植的预后分析

目的 探讨肝癌复发与未复发患者再次肝移植的效果.方法 初次肝移植时原发疾病为肝癌(病理诊断)、移植后因各种原因需行再次肝移植者65例(肝癌组),分析其进行再次肝移植的原因以及再次肝移植后的并发症发生情况和预后,并于同期因肝脏良性疾病施行肝移植、移植后因各种原因需行再次肝移植者66例(非肝癌组)进行比较.结果 肝癌组初次肝移植后有11例(16.9％,11/65)因肝癌复发而行再次肝移植,非肝癌组无因肝癌而行再次移植者,两组比较,差异有统计学意义(P＜0.01);非肝癌组初次肝移植后有11例(16.7％0,11/66)因血管并发症而进行再次肝移植,高于肝癌组(4.6％,3/65),差异有统计学意义(P＜0.05).肝癌组初次肝移植后肝癌复发者11例,其中10例(90.9％,10/11)在再次肝移植后因肝癌复发而死亡;肝癌组初次肝移植后肝癌未复发者54例,其中7例(13.0％,7/54)在再次肝移植后肝癌复发,明显低于复发者(P＜0.01),其移植肝5年累积存活率为51.0％,与非肝癌组(51.8％)差异很小(P＞0.05).结论 原发病为肝癌者初次肝移植后因肿瘤复发而行再次肝移植,其预后不佳;而因非肿瘤复发因素而行再次肝移植时,其再次肝移植的效果与因良性疾病而行肝移植者相近,不应受其原发疾病为肝癌的影响.     

Extracorporeal suture technique for suprahepatic caval anastomosis in liver transplantation

BACKGROUND: During liver transplantation, an oversized graft or active bleeding in the hepatic area can make performance of the suprahepatic caval anastomosis extremely difficult or even impossible. In other instances, a brief as possible warm ischemia is desired to provide a marginal graft with maximum chances of good functioning. METHODS: In order to manage those conditions, a suture technique was devised that allows the construction of a substantial part of the suprahepatic caval anastomosis keeping the graft outside the abdomen of the recipient. RESULTS: Over a 12-month period, the technique was applied in 7 out of 148 transplants (5%). The 7 cases presented one or more of the following conditions: significant oversize mismatch (n = 6), active bleeding in the hepatic area (n = 1), and marginal graft (n = 4). Warm ischemia time averaged 27 minutes, a value not significantly different from the mean warm ischemia time of 25 minutes recorded in the easier transplants in which the conventional technique was used (P = 0.2467). CONCLUSIONS: This extracorporeal suture technique allows construction of the suprahepatic caval anastomosis in critical situations arising during liver transplantation and avoidance of the prolonged warm ischemia that could be expected in such cases.     

Successful Renal Retransplantation after Post-Transplant Lymphoproliferative Disease

Post-transplant lymphoproliferative disease (PTLD) is a rare but severe complication of renal transplantation. Reduction of immunosuppression is essential for controlling PTLD but may induce graft loss. Retransplantation after PTLD is considered dangerous, because immunosuppressive treatment resumption may trigger hematological relapse. We retrospectively report six patients (five adults, one child) who underwent a second renal transplantation after successfully treated PTLD. Epstein-Barr virus (EBV) serology was positive before the first transplantation in all patients except the child. Post-transplant lymphoproliferative disease was detected 6.6 months (range 4.5-9.4) after transplantation. Lymphoproliferation was always monomorphic, B-cell, and EBV-related. Post-transplant lymphoproliferative disease was confined to the renal allograft (n = 4), multilocular (n = 1) or cerebral (n = 1). Immunosuppression tapering (6/6) and transplantectomy (5/6) led to hematological remission in all patients. Retransplantation was performed 77 months (range 50-128) after PTLD diagnosis. Immunosuppression included steroids (n = 6), ATG (n = 2), anti-CD25 (n = 2), cyclosporine (n = 4), tacrolimus (n = 2), mycophenolate mofetil (n = 4) and azathioprine (n = 1). After a median follow up of 30 months (range 24-47) patient survival was 100%, with no recurrence of PTLD. In conclusion, renal retransplantation can be considered in patients with monomorphic PTLD history, without major risk of hematological recurrence.     

食管癌患者食管-管状胃环形吻合器端侧吻合与半器械侧侧吻合近期治疗效果观察

目的观察食管癌患者食管-管状胃环形吻合器端侧吻合与半器械侧侧吻合术后近期治疗效果。方法回顾性分析66例手术治疗食管癌患者的临床资料。30例采用食管-管状胃颈部半器械侧侧吻合术,36例采用食管-管状胃胸内环形吻合器端侧吻合术,比较两种吻合术后近期吻合口瘘、吻合口狭窄、反流性食管炎的发生率。结果半器械侧侧吻合术食管狭窄和反流性食管炎的发生率分别为3.3%(1/30例)和20.0%(6/30例),均低于环形吻合器吻合术的25.0%(9/36例)和61.1%(22/36例),两组比较差异有统计学意义(P0.05);半器械侧侧吻合和环形吻合器吻合术后吻合口狭窄发生率分别为3.3%(1/30例)和5.6%(2/36例),两组比较差异无统计学意义(P0.05)。结论食管一管状胃半器械侧侧吻合与形吻合器端侧吻合比较,术后近期吻合口狭窄及反流性食管炎发生率较低。     

再次肝移植

在首次移植失败后,再次肝脏移植是挽救移植肝失功受体病人生命的唯一手段。随着肝移植受体数量的积累,再次肝移植的数量也必将越来越多,再次肝移植越来越成为一个令人关注的问题。近年来随着供体紧缺和新型免疫抑制剂的研发,再次肝移植的适应证发生了明显变化,而总的再移植发生率逐步下降。严格评估再次肝移植术前受体的状况,充分考虑再次肝移植的危险因素对提高再次肝移植术后的生存率尤为重要。手术时机和适应证的正确把握、手术技巧的提高是再次肝移植手术成功和提高术后生存率的关键。     

Comparison of short- and long-term outcomes after early versus late liver retransplantation: a single-center experience

Background

As the survival of patients after liver transplantation (LT) improves, the requirement of liver retransplantation (reLT) for late graft failure has grown. Although some have reported that the short-term outcome of late reLT was comparable with that of early reLT, it remains unknown whether long-term survival of late reLT is inferior to that of early reLT patients.

Materials and methods

We reviewed early (<6 mo after primary LT) and late (≥6 mo after primary LT) reLT cases performed between January 2000 and December 2010.

Results

Sixteen early and 32 late reLT cases were analyzed. There was no significant difference regarding the number of units of red blood cells transfused during the transplantation between the groups, whereas operative time was significantly longer in the late reLT cases. Graft loss within 3 mo after early and late reLT was 18.6% and 15.6%, respectively. Patient and graft survival rates after 1, 3, 5, and 10 y in the late reLT group were 80.6%, 73.3%, 73.3%, and 67.7% and 80.7%, 69.1%, 63.3%, and 54.3%, respectively, whereas those in the early reLT group were 75.0%, 75.0%, 64.3%, and 64.3% and 81.3%, 75.0%, 64.3%, and 32.1%, respectively. There was no significant difference in patient or graft survival rates between the groups (P = 0.91 and 0.91, respectively).

Conclusions

Acceptable short- and long-term survival were provided in early and late reLT. The time between the primary LT and reLT does not seem to play significant role in the prognosis of reLT in the long term.     

End-to-side caval anastomosis in adult piggyback liver transplantation

No consensus exists regarding the optimal reconstruction of the cavo-caval anastomosis in piggyback orthotopic liver transplantation (PB-LT). The aim of this study was to analyze our experience with end-to-side (ES) cavo-cavostomy. Outcome parameters were patient and graft survival and surgical complications. During the period 1995-2002 146 full-size PB-LT in 137 adult patients were performed with ES cavo-cavostomy without the routine use of temporary portocaval shunt (TPCS). In 12 patients (8%) this technique was used for implantation of second or third grafts. Veno-venous bypass was not used in any case and TPCS was performed only in eight patients (6%). One-, three- and five-yr patient and graft survival were 84%, 79% and 75%, and 81%, 74% and 69%, respectively. The median number of intraoperative transfusion of packed red blood cells (RBC) was 2.0 (range 0-33) and 30% of the patients (n = 43) did not require any RBC transfusion. Surgical complications of various types were observed after 49 LT (34%) and none of the complications was specifically related to the technique of ES cavo-cavostomy. Our experience indicates that PB-LT with ES cavo-cavostomy is a safe procedure, can safely be performed without the routine use of a TPCS, has a very low risk of venous outflow obstruction and can also be used effectively during retransplantations.     

肝移植术后肝动脉并发症的再次肝移植治疗

目的 探讨再次肝移植治疗肝移植术后肝动脉并发症的可行性及手术时机.方法 回顾性分析2003年12月至2006年12月收治的13例肝动脉并发症患者再次肝移植的临床资料.结果 再次肝移植的无肝期、手术时间和首次移植比较差异无统计学意义(P=0.291,P=0.312),术中出血量、ICU停留时间和首次移植比较差异有统计学意义[(3.1±1.1)L比(1.5±0.9)L(P=0.005),(4.3±1.8)d比(3.2±2.5)d(P=0.015)].围手术期病死率为38.5%(5/13),其中移植间隔1个月内死亡1例(1/4),超过1个月死亡4例(4/9).死亡原因分别为急性肾功能衰竭2例、严重感染2例、心肌梗死1例.8例存活,随访6～51个月,中位生存时间22.5个月.结论 再次肝移植是治疗肝移植术后肝动脉并发症导致不可逆性肝功能损害时的惟一有效手段.选择适宜的手术时机和手术方式、调整免疫抑制方案、加强围手术期管理是提高再次肝移植疗效的关键.     

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目的总结再次肝移植病人围手术期临床特点和管理经验。方法回顾分析中山大学附属第三医院肝移植中心2004年1月至2006年12月期间施行的34例再次肝移植受者临床资料。结果再次肝移植的原因分别为移植术后胆道并发症(18例)、移植术后肝癌复发(6例)、肝炎复发(6例)以及肝动脉并发症(4例)。34例均采用附加腔静脉整形的改良背驮式肝移植技术。全组无手术死亡。院内死亡9例(26.5%),明显高于首次肝移植的病死率(6.9%,46/671)(P<0.05)。死亡原因中感染占55.6%(5/9)。再次肝移植组术前感染率为32.4%(11/34),首次肝移植组为10.7%(72/671),两组间差异有显著性意义(P<0.05)。再次肝移植组术后感染率为61.8%(21/34),首次肝移植组为46.3%(311/671),两组相比差异无显著性意义(P>0.05)。结论感染是再移植的主要死亡原因,围手术期有效的抗感染治疗和针对再次肝移植特点的个体化免疫抑制方案可以提高再次肝移植的成功率。     

再次肝移植10例临床分析

目的总结再次肝移植的临床经验。方法回顾性分析我中心自2003年5月至2006年12月间实施的10例再次肝移植患者的临床资料并进行随访,对再次移植的指征、手术时机、手术方式及预后进行讨论。结果在连续实施的315例同种异体原位肝移植中共有10例接受了再次移植．再次移植率为3．17％。再次移植指征分别为胆道并发症4例（40％）,原发病复发4例（40％）,其中包括肝癌复发2例（20％）,乙肝复发1例（10％）,肝硬化复发1例（10％）,移植肝原发性无功能1例（10％）．肝动脉血栓形成1例（10％）。10例患者中有3例死亡,其中2例死于全身严重的感染伴多器官功能衰竭,1例死于肝癌复发转移。其余7例患者均痊愈出院．随访至今已存活10～28月．肝功能及一般状况良好。结论合理选择再次移植的指征,把握合适的手术时机,建立完善的预后评估模型是提高再次肝移植患者存活率的关键。     

Successful regrafting of a transplanted liver

We report on the successful regrafting of a transplanted liver. The donor liver was first grafted into a patient suffering from cryptogenic cirrhosis; the patient died 1 day after the elective transplantation of cerebral bleeding. The well-functioning graft was harvested again and transferred to our institution. After another 12 h of cold ischemia, the liver was reperfused in an urgently registered patient with recurrence of hepatitis B in his first graft. The transplantation was successfully performed and the patient is now doing well, more than 5 months after regrafting with the reused liver. Received: 21 October 1996 Received after revision: 9 January 1997 Accepted: 27 January 1997     

When Living Donor Liver Allografts Fail: Exploring the Outcomes of Retransplantation Using Deceased Donors

Outcomes of retransplantation after initial living donor liver transplantation (LDLT) are poorly understood. The aim of this study is to better understand the indications, timing, and outcomes of retransplantation after initial LDLT when compared to after initial deceased donor transplantation (DDLT). From 2002 to 2013, 209 retransplant recipients after initial LDLT and 2893 after initial DDLT were identified in Organ Procurement and Transplantation Network/United Network for Organ Sharing. Multivariable logistic models evaluated the association between initial transplant type and 1‐year mortality. The most frequent reason for early graft failure (≤14 days) in LDLT recipients was vascular thrombosis (63.6%) versus primary graft failure in initial DDLT recipients (59.1%). LDLT recipients were more often acutely and/or critically ill with a greater proportion of Status 1 (42.6% vs. 27.3%; p < 0.001) and intensive care unit (52.2% vs. 39.9%; p = 0.001) recipients at the time of retransplantation. There was no difference in adjusted 1‐year mortality between retransplant recipients after initial LDLT versus DDLT (odds ratio 0.74; 95% confidence interval 0.51–1.08). The proportion of recipients who ultimately required retransplantation for a third time was not different between the two groups (4.8%). Retransplantation outcomes after LDLT are not different from other retransplant procedures, despite recipients having greater acuity of illness and different indications.     

The Liver Retransplantation Risk Score: a prognostic model for survival after adult liver retransplantation

High-risk combinations of recipient and graft characteristics are poorly defined for liver retransplantation (reLT) in the current era. We aimed to develop a risk model for survival after reLT using data from the European Liver Transplantation Registry, followed by internal and external validation. From 2006 to 2016, 85 067 liver transplants were recorded, including 5581 reLTs (6.6%). The final model included seven predictors of graft survival: recipient age, model for end-stage liver disease score, indication for reLT, recipient hospitalization, time between primary liver transplantation and reLT, donor age, and cold ischemia time. By assigning points to each variable in proportion to their hazard ratio, a simplified risk score was created ranging 0–10. Low-risk (0–3), medium-risk (4–5), and high-risk (6–10) groups were identified with significantly different 5-year survival rates ranging 56.9% (95% CI 52.8–60.7%), 46.3% (95% CI 41.1–51.4%), and 32.1% (95% CI 23.5–41.0%), respectively (P < 0.001). External validation showed that the expected survival rates were closely aligned with the observed mortality probabilities. The Retransplantation Risk Score identifies high-risk combinations of recipient- and graft-related factors prognostic for long-term graft survival after reLT. This tool may serve as a guidance for clinical decision-making on liver acceptance for reLT.     

Renal-splenic shunt for infrahepatic caval occlusion after piggy-back liver transplantation

Inferior vena cava thrombosis after liver transplantation is uncommon. We describe a case of this unusual complication occurring after piggy-back (end-to-side) graft implantation. Renal failure, lower limb edema, and hemodynamic instability were the presenting symptoms requiring immediate surgical correction with a left renal-to-splenic vein shunt over a ringed 2.5-cm prosthesis. The decision to go ahead with the shunt was preceded by an intraoperative confirmation of a 10-cm H₂O pressure gradient between the caval and portal circulations. This gradient, unlike that observed in liver cirrhosis, ultimately turned a splenorenal shunt into a renal-splenic one. Six months after the procedure, the patient is alive and well with normal liver and renal function. The technique described may be useful in the management of other clinical conditions of acute infrahepatic caval hypertension. Received: 17 January 1997 Received after revision: 2 May 1997 Accepted: 13 May 1997     

再次肝移植--挽救肝移植失败受体生命唯一的手段(附774例报告)

目的 评估肝移植，尤其是再次肝移植的长期随访结果及影响结果的因素。方法 对1981年2月至1998年4月期间进行的、存活时间大于2年的4000例肝移植进行随访，其中再次肝移植774例。根据首次肝移植的时间，分为A、B、C三期。结果 774例（19．4％）接受第2次肝移植，148例（3．7％）接受第3次肝移植，20例（0．5％）接受第4次肝移植，5例（0．13％）接受第5次及5次以上肝移植。第1次再移植原因主要为移植肝原发性无功能、肝动脉栓塞和排斥反应。C期再次肝移植率（13．4％）明显低于A期（33．4％）和B期（23．7％），P＝0．001。结论 掌握适当的再移植指征、再次手术时机、受体的选择和手术技巧，再次肝移植的长期生存率明显改善。