Orthotopic liver transplantation for incurable alveolar echinococcosis of the liver: Report of 17 cases

Abstract

Between 1986 and 1989, orthotopic liver transplantations were performed in our unit for 17 patients with incurable alveolar echinococcosis. Ten patients had hilar involvement (group I), and seven patients had posterior localization (five of them had chronic Budd-Chiari syndrome) (group II). The delay between diagnosis and the orthotopic liver transplantation was more than 48 mo in group Ia (six patients), less than 24 mo in group Ib (four patients) and less than 48 mo in group II. Previous operations were more common in group Ia than in group Ib and II. Five patients have died-four in group I and one in group II. The actuarial survival rate at 15 mo was 75%. Early reoperations were frequent (69%), mainly caused by rebleeding. Bacterial and fungal infections occurred only in group Ia (four cases) and group II (three cases). In eight patients (palliative group), residual foci of infected nonhepatic tissue occurred after surgery. The titer of specific antibodies decreased during the first 3 mo in all the patients but one. In patients with radical liver transplantation, the complete disappearance of specific antibodies occurred within 2 yr in four cases. In the remaining five patients, specific antibodies remained detectable, but no evidence of recurrence has been obtained up to now. In the palliative group, a peak of specific IgM occurred at 3 mo; an increase of specific IgG was observed later. The growth of residual parasitic foci was relatively slow, and all these patients remained asymptomatic with a mean follow-up of 19 mo. We conclude that orthotopic liver transplantation is feasible in incurable alveolar echinococcosis and could be proposed without delay to patients with parasitic Budd-Chiari syndrome or complicated secondary biliary cirrhosis. In the other cases, the best time to perform an orthotopic liver transplantation is more difficult to determine. Nevertheless, in the perspective of an orthotopic liver transplantation, the management of these patients has to change, and repetitive laparotomies for palliative surgical procedures have to be replaced by interventional radiology.

Liver Transplantation in Alveolar Hydatid Disease

“…As stated before, the same loop can be used if the patient has had previous hepaticojejunostomy. If the portal vein of the recipient is occluded, the superior mesenteric vein, the splenic vein or the splenomesenteric confluence can be used for venous reconstruction [2,4,18]. If length is a problem, a bypass between the superior mesenteric vein and the donor portal vein using a segment of donor iliac vein is an alternative.…”

“…A venovenous cavocaval shunt [16] should be placed early in order to reduce the venous pressure in the territory of the inferi or vena cava, and to limit blood losses during dissection. In addition, placing of the shunt allows prompt total exclusion of the liver if required (severe hemorrhage, dif ficult dissection) [2,4], One must open the diaphragm or even the pericardium to control the supradiaphragmatic, respectively the intrapericardial inferior vena cava (I VC), should fibrosis or extension of the parasitic lesions pre vent access to the suprahepatic I VC [2,4,13,17], Partial excision of the diaphragm or pericardium is not unusual. In our series, partial excision of the diaphragm was neces sary in 10 cases, and intrapericardial control of the I VC in 7.…”

“…In contrast, AHD behaves like a malignant tumor of the liver [4], The natural reservoir for the parasite is the fox where it lives in the small bowel. The eggs are excreted in the feces, contaminating the ground, grass, and small berries.…”

“…De spite the numerous similarities between the two parasites, AE and cystic hydatid disease are completely different [4]. Cystic echinococcosis behaves like a benign tumor of the liver.…”

“…At this stage, medical treatment often needs to be complemented by palliative measures to relieve jaundice or portal hyperten sion. On account of the poor results associated with pallia tive therapy, which does not prevent a fatal evolution in the vast majority of the patients, some authors, in the mid-1980s, suggested that orthotopic liver transplanta tion (OLT) might represent an optimal and definitive treatment for alveolar hydatid disease (AHD) [2][3][4], The aim of this article is to review the current place of OLT in the management of AE.…”