A new method of segmental orthotopic liver transplantation in children

Orthotopic liver transplantation requires matching of the donor and recipient for size. The rarity of suitable pediatric and infant donors in many countries has resulted in the acceptance of the principle of a reduced-sized adult liver graft for children. A new method of segmental orthotopic liver transplant is described. This method involves resecting the recipient liver off the inferior vena cava, which is left in situ, and the donor hepatic vein is anastomosed end to side to the inferior vena cava. The technique allows orthotopic liver transplantation with widely mismatched sizes from adults to infants.     

Infections following orthotopic liver transplantation.

The epidemiology of infections associated with orthotopic liver transplantation is summarized herein, and approaches to prophylaxis are outlined. Infection is a major complication following orthotopic liver transplantation, and more than half of transplant recipients develop at least one infection. The risk of infection is highest in the first month after transplantation, and the most common pathogens are bacteria and cytomegalovirus (CMV). Bacterial infections usually occur in the first month, arise in the abdomen, and are caused by aerobes. The peak incidence of CMV infection is late in the first month and early in the second month after transplantation. CMV syndromes include fever and neutropenia, hepatitis, pneumonitis, gut ulceration, and disseminated infection. Other significant problems are Candida intraabdominal infection, Herpes simplex mucocutaneous infection or hepatitis, adenovirus hepatitis, and Pneumocystis carinii pneumonia. Prophylaxis of infection in liver transplant recipients has not been well-studied. Several different regimens of parenteral, oral absorbable, and/or oral non-absorbable antibiotics active against bacteria and yeast have been used at various centers, but no randomized controlled trials have been conducted. Selective bowel decontamination appears to be a promising approach to the prevention of bacterial and Candida infections, while oral acyclovir may be a relatively convenient and effective agent for CMV prophylaxis.     

一例成功的肝移植

对１例乙型肝炎肝硬变患者实施原位肝移植术，使用ＵＷ液保存共体肝脏６小时，术中采用静脉－静脉转流。术后应用大剂量中基强的松龙和标准剂量的环孢素Ａ（ＣｓＡ）进行免疫抑制治疗，对术后迟发性急性排斥反应使用甲基强的松龙冲击治疗，根据血中ＣｓＡ浓度调整ＣｓＡ用量，术后第６个月时ＨＢｓＡｇ再度转为阳性，但目前患者一般情况良好，生活片理，肝脏功能正常。认为乙型肝炎患者施行肝移植时必须配合相应的治疗，以预防肝炎复     

Late mortality after orthotopic liver transplantation.

BACKGROUND: Mortality within the first year after orthotopic liver transplantation (OLTx) is usually due to infection or allograft failure. Late complications leading to death after OLTx have not been extensively evaluated. The aim of this study was to determine the incidence of late mortality and to identify the most common causes and risk factors associated with late mortality after OLTx. METHODS: A total of 479 OLTx were performed in 459 patients (320 males, 139 females; mean age 47 years, range 13 to 69) between September 1991 and April 2000. All patient deaths among liver transplant recipients who survived more than 1 year after transplantation (follow-up mean 3.4 years, median 3, range 1 to 8.6) were reviewed. RESULTS: In all, 122 allografts (24%) were lost in 109 patients during the study period (24%). Seventy-five allografts were lost in 69 patients by 1 year (15%). Forty-seven allografts were lost in 40 patients who survived at least 1 year (9.6%). Actuarial survivals at 2 years, 5 years, and 9 years were 95%, 85%, and 80%, respectively (based on 100% survival at 1 year). The causes of the late mortality were malignancy (9 patients), disease recurrence (8), late infection (6), renal failure complications (5), cardiovascular complications (4), chronic rejection (3), gastrointestinal hemorrhage (2), medication noncompliance (1), and unknown (2). CONCLUSIONS: Malignancy and disease recurrence are the major causes of late mortality among adult OLTx recipients. Pharmacologic immunosuppression is associated with many of the causes of late mortality. Advances in immunosuppression with less toxicity may improve long-term survival after OLTx.     

Caroli's disease and orthotopic liver transplantation.

Caroli's disease is a rare congenital hepatic disease, characterized by segmental dilatation of the biliary tree. Patients who have recurrent bouts of biliary infection, particularly those with complications related to portal hypertension, may require orthotopic liver transplantation (OLT). Few case reports have described the outcome of OLT in patients with Caroli's disease and to date there is no large series reported in the literature. We retrospectively analyzed the outcome of OLT in patients with Caroli's disease who underwent OLT between 1982 and 2002 at Starzl Transplantation Institute, University of Pittsburgh. Patients were identified and data was collected by computerized search of the electronic database system. All patients had confirmation of diagnosis by histopathology of explanted liver. A total of 33 patients with Caroli's disease were listed for liver transplantation, 3 of whom were excluded, as they were not transplanted. A total of 90% had signs of hepatic decompensation at the time of OLT. Median posttransplantation follow-up was 7.7 yr. Short-term graft and patient survival at 1 month was 83% and 86%, whereas overall long-term graft survival rates at 1, 5, and 10 yr were 73%, 62%, and 53%, respectively, and patient survival rates were 76%, 65%, and 56%, respectively. Long-term outcome in patients who survived the first year after transplantation was significantly better. Their survival rate at 5 and 10 yr was 90% and 78%. On univariable analysis, recipient age, donor male gender, coexistent congenital hepatic fibrosis, and re-OLT were associated with poor patient survival. Eight patients were retransplanted, 3 of whom had primary nonfunction. A total of 13 patients died; the most common cause of death being sepsis and cardiovascular complications. Patients who died of sepsis had cholangitis pre-OLT. In conclusion, OLT is a form of curative and life-saving therapy in patients with Caroli's disease, especially in those with decompensated liver disease. Overall survival is better with liver transplantation and is comparable with the survival of recipients who undergo OLT for other etiologies of chronic liver disease. Survival was poor in patients with congenital hepatic fibrosis (Caroli's syndrome) and in those who had cholangitis at the time OLT.     

Canine orthotopic liver transplantation

For the purpose of increasing long-term survival in canine orthotopic hepatic allotransplantation, immunosuppression by mizoribine and/or cyclosporin was instituted with the following results: 1) The survival of control dogs without treatment (n = 5) was 10.0 +/- 2.9 days (Mean +/- S.E.), and the survival of dogs treated with mizoribine (n = 15) was 44.6 +/- 31.8 days. There was no statistical difference between the two groups. On the other hand, the mean survival of dogs that were initially treated with cyclosporin and were then switched to mizoribine at one to three months after transplantation reached 145.4 +/- 70.8 days. The survival rate of dogs in the cyclosporin-mizoribine group was significantly greater than that of control group (p less than 0.02); and the survival rate of the former group proved also significantly better than that of the mizoribine group at 20 days after transplantation (X2, p less than 0.05); 2) in cases of acute rejection of the allograft, a gradual increase of the serum bilirubin level with a concomitant rise of S-GPT and alkaline phosphatase was generally observed. For an accurate diagnosis, however, an assessment of the biopsy findings of the allograft is important; 3) in chronic rejection, one animal developed the selective disappearance of interlobular bile ducts, often referred to as the "vanishing bile duct syndrome"; and 4) for differential diagnosis of vascular and/or biliary tract complications, specific morphological diagnostic procedures such as vascular and/or biliary tract angiographies are needed.     

Sexual health after orthotopic liver transplantation.

Many studies have reported improved health-related quality of life outcomes after orthotopic liver transplantation; however, specific research regarding sexual health in liver transplant recipients is limited. We surveyed liver transplant recipients to determine the prevalence of sexual dysfunction. Of the 320 adult liver transplant recipients surveyed by mailed questionnaire, 150 responded (42%). The median age was 54 years. A total of 62% of respondents were male, and 93% were at least 1 year after transplantation. Thirty-six respondents (24%) reported sexual dysfunction before transplantation; this persisted in 22 patients (15%) after transplantation. A total of 48 respondents (32%) reported de novo sexual dysfunction after transplantation. After transplantation, 23% of male and 26% of female respondents reported decreased libido, and 33% of men and 26% of women reported having difficulty reaching orgasm with intercourse. A total of 42% of respondents felt that immunosuppressive medication was the main contributing factor to their sexual problems: 33% and 35% of respondents receiving tacrolimus or cyclosporine monotherapy, respectively, experienced some degree of sexual problems after transplantation. Despite the reported sexual problems, 59% of respondents were "moderately" to "very satisfied" with their sexual relationships after transplantation. Nineteen percent of the respondents used sildenafil to improve their sexual function, and 65% of these reported benefit. In conclusion, sexual problem after orthotopic liver transplantation is a common but poorly studied problem. Although this single-center study has shed some light on the relationship between liver transplantation and sexual health, further prospective studies, involving larger study population and validated instruments, will be needed to better evaluate the influence of liver transplantation on recipients' sexual health.     

A new bioabsorbable material for rat orthotopic liver transplantation.

Rat orthotopic liver transplantation was performed using a newly synthesized bioabsorbable material (LA-GA copolymer) cuffs and the ordinary polyethylene cuffs. The LA-GA copolymer cuff which anastomosed the portal vein was patent and developed no collateral veins even after 6 months, keeping the transplanted liver normal. By contrast, the polyethylene cuff-anastomosed portal vein was completely occluded and the collateral veins were highly developed, with the transplanted liver showing the fatty degeneration of hepatocytes and numerous regenerative nodules. It is concluded that the LA-GA copolymer cuff is a suitable material for the short- and long-term study of rat orthotopic liver transplantation.