Tumor recurrence after liver transplantation for hepatocellular carcinoma is associated with a poor prognosis. Because immunosuppression is a well-known risk factor for tumor growth, it is surprising that its possible role in the outcome of liver transplantation has been poorly evaluated. We performed a case-control review of prospectively collected data and compared 2 groups of patients according to the type of immunosuppression after liver transplantation for hepatocellular carcinoma at a single center. One hundred six patients received tacrolimus and mycophenolate mofetil, and 121 received sirolimus. Patients in the sirolimus group had significantly higher recurrence-free survival rates than patients in the tacrolimus group (P ϭ 0.0003). The sirolimus group also had significantly higher patient survival rates than the tacrolimus group at 1 year (94% versus 79%), 3 years (85% versus 66%), and 5 years (80% versus 59%; P ϭ 0.001). Sirolimus was well tolerated, and the patients in this study did not have the increase in surgical complications noted by other investigators. Leukopenia was the most common side effect, but it typically resolved with dose reduction. Dyslipidemia and mouth ulcers were common but were easily controlled. In summary, the data suggest a beneficial effect of sirolimus immunosuppression on recurrence-free survival, which translates into patient survival benefits.
Portal vein problems remain a formidable challenge in liver transplantation. In select situations, a portal vein conduit can provide a solution. No long-term results have been reported. This study was designed to assess the impact of portal vein conduits on graft survival after liver transplantation and the safety of portal vein conduits and to establish the long-term results (up to 20 years) of portal vein conduits. Data from 2370 adult liver transplants were prospectively collected into a computerized research database and analyzed. All portal vein conduits were constructed from the donor iliac vein obtained at the liver retrieval. Portal vein conduits were required in 35 (1.5%) first transplants. The long-term (up to 20 years of follow-up) graft survival after liver transplantation using portal vein conduits was excellent and comparable to that of the control group. The graft survival was 65% with the conduit versus 66% without the conduit at 5 years of follow-up, 58% versus 51% at 10 years, and 48% versus 35% at 15 years. There was a higher rate (8.6% versus 1.4%) of portal vein thrombosis after the portal vein conduit, and the majority occurred in the first 3 months after transplantation. For the same time period, there was no statistically significant difference in graft survival or patient survival for the retransplants with and without portal vein conduits. There was no statistically significant difference in graft survival or patient survival for the transplants with portal vein conduits and with portal vein thrombendvenectomy. In conclusion, portal vein conduits can be used safely for liver transplantation with no negative impact on long-term graft survival or patient survival. Despite the higher rate of portal vein thrombosis in the immediate postoperative period, excellent long-term results can be obtained. The portal vein conduit is an important tool in the armamentarium of the liver transplant surgeon. There is considerable controversy concerning the assessment of the safety and indications of portal vein conduits. No long-term results (over 5 years) have been reported.In our institution, we create a portal vein conduit only if restoration of the flow in the recipient portal vein is either unsuccessful or not feasible.The goal of this study was to assess the impact of portal vein conduits on graft survival after liver transplantation and the safety of portal vein conduits in liver transplantation and to establish the long-term results (up to 20 years) of portal vein conduits. Also, a direct comparison was made between transplants with portal vein conduits and with portal vein thrombendvenectomy. PATIENTS AND METHODSData from 2370 adult liver transplants performed at the Baylor Regional Transplant Institute were prospectively collected into a computerized research database and analyzed. Portal vein conduits placed at the time of the initial transplant were analyzed separately from retransplants. This study was approved by the institutional review board of the Baylor University Medical Center.The tec...
Cholecystocutaneous fistulas (CCFs) are an increasingly rare consequence of chronic gallbladder inflammation and disease. Historically, they were commonly noted in the literature by Courvoisier, Naunyn, and Bonnet in the late 1800s. Due to improvements in diagnostic imaging and treatment options in the last century, there has been a marked decrease in the incidence of the CCF cases in the literature. From the late 1890s to 1949, there were only 37 cases presented in the literature; only 28 cases have been reported since 2007. This case is only the second noted CCF in the literature that followed percutaneous cholecystostomy drain placement and removal. General surgery was consulted on a 60-year-old morbidly obese female, who presented to the emergency department after one week of fever, right upper quadrant (RUQ) pain, nausea, emesis, and shortness of breath. She had a history of acute cholecystitis treated with a cholecystostomy tube the year prior, but after the removal of the tube, she was lost to follow up. She was found to have a 14cm x 5cm fluctuant abdominal wall abscess in her RUQ that was treated with incision and drainage (I&D) along with ertapenem. She continued to improve until day 7 post-I&D when yellowish-green discharge was noted draining from the wound. After a negative hepatobiliary iminodiacetic acid scan, a follow-up abdominal computed tomography (CT) showed a contracted gallbladder with fistula formation underlying the abscess location, near the site of her prior cholecystostomy tube. A robotic-assisted cholecystectomy was performed, which improved the wound drainage, and the patient was discharged home 5 days later. This case is the only noted CCF presenting as a RUQ abscess after cholecystostomy drain placement. The patient lacks follow up after the removal of her percutaneous drain and continued inflammation in the gallbladder provided perfect nidus for the fistula formation. As seen in other CCF patients, cholecystectomy is the treatment of choice, and this case was successfully treated via robotic-assisted cholecystectomy with adhesiolysis.
Vascular thrombosis is a cause of allograft loss after pancreas transplantation. We present the use of intraoperative fluorescence imaging with the SPY imaging device (Novadaq Technologies Inc, Toronto, Canada) in two pancreas transplants as a means to assess potency of the vascular anastomoses. Intravenous indocyanine green 2.5 mg/mL was fluoresced with the device to create the intraoperative video sequences, which were recorded. After 60-day follow-up, real-time SPY imaging on these two pancreas transplants did not demonstrate adverse effects on patients or the transplanted allografts. This method of vascular imaging could prove useful in improving short-term graft survival and possibly lowering the thrombosis rates seen with pancreas transplantation. Long-term correlation studies between intraoperative findings and graft survival must be performed to confirm the utility of this imaging method.
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