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Ernesto P Molmenti

Publications and source records attributed to Ernesto P Molmenti.

At least 19 recordsLinked to original sources
PubMed2006

Liver transplantation with "rescue organ offers" within the eurotransplant area: a 2-year report from the University Hospital Essen.

Liver transplantation (LTx) is the only treatment for patients with end-stage liver failure. This report focuses on 45 deceased donor liver allografts allocated through Eurotransplant as "rescue offers," which were accepted and subsequently transplanted at our center over a two-year period. These organs had been officially offered to and rejected by other transplant centers a total of 162 times prior to our acceptance. Primary nonfunction was observed in six patients. Two of them died and four were retransplanted. Overall patient survival was 84.4%. LTx with such "rescue organs" constitutes an additional transplant option and a safe mechanism to "rescue" organs within Eurotransplant.

Adult↗
PubMed2006

Left hepatic trisectionectomy for hepatobiliary malignancies.

BACKGROUND: Left hepatic trisectionectomy is the most extended hepatic resection. To date, few data are available on longterm outcomes after this operation. STUDY DESIGN: Between June 1998 and July 2004, a total of 52 patients underwent left trisectionectomy for primary or secondary hepatobiliary tumors at our institution. Data were analyzed with regard to patient characteristics, intraoperative details, pathologic findings, perioperative morbidity and mortality, and outcomes as determined by survival. RESULTS: Left trisectionectomy was combined with caudate lobectomy and hilar lymph node dissection in 29 and 35 patients, respectively. In addition, 43 procedures were performed in 31 patients: resection of hilar bifurcation (n = 15), bile-duct revision (n = 5), wedge resection of segment VI/VII (n = 10), gastrectomy (n = 1), and resection or reconstruction of hepatic vessels or the inferior vena cava (n = 12). Operative morbidity and mortality were 50% and 11.9%, respectively. By multivariate analysis, additional operative procedures constituted the only positive predictor of postoperative morbidity. One-, 3-, and 5-year survival rates were 65%, 52%, and 33%, respectively. After R0 resection (n = 37), 1-, 3-, and 5-year survival rates were 78%, 68%, and 44% compared with 38%, 15%, and 7% after R1 resection (p = 0.0004). Survival corresponding to the four most frequent tumor types (hepatocellular carcinoma, cholangiocellular carcinoma, hilar cholangiocarcinoma, and colorectal metastases) was comparable with survival data reported in the literature after less-extensive resections. CONCLUSIONS: Left trisectionectomy provides acceptable survival rates in both locally advanced primary hepatobiliary malignancies and large metastatic liver tumors. Despite major progress in surgical technique and perioperative management, left trisectionectomy is still associated with higher operative mortality and morbidity than less-extensive resections. Because selection criteria for this type of procedure are not clearly defined, particular attention should be focused on the oncologic benefits when considering this operation.

Adult↗
PubMed2006

Surgery for hepatocellular carcinoma arising in hereditary hemochromatosis.

BACKGROUND: Hepatocellular carcinoma (HCC) is a well-known complication of hereditary hemochromatosis. The benefit of surgical therapy in this clinical entity is not well documented. The purpose of this study was to evaluate the outcome of such patients both in our own experience as well as in the published literature. METHODS: 320 patients with a diagnosis of HCC were evaluated at our institution to undergo either surgical resection (n = 262) or liver transplantation (n = 58) during the 4- year period from January 2001 to December 2004. We identified 5 patients with HCC arising in the setting of hemochromatosis. A literature search was performed to estimate resectability rates as well as outcomes after liver transplantation for HCC arising in hemochromatosis. RESULTS: HCC was multifocal in 4 instances and solitary in 1 case. The liver was cirrhotic in all but 1 case. Three patients underwent an exploratory laparotomy, 1 an exploratory laparoscopy, and 1 underwent transplantation. HCC was unresectable in all cases. The patient with a solitary tumor and cirrhosis underwent 5 sessions of transarterial chemoembolization and is alive 37 months after surgical exploration. The 3 patients with multifocal tumors who underwent exploratory laparotomies died within 6 months after the intervention. The fifth patient who underwent a deceased donor split liver transplantation for multifocal tumor is alive without recurrence 3 years after transplantation. These results are similar to those in the literature that concur with the low resectability rate and the favorable outcome after liver transplantation. CONCLUSION: Resectability rates of HCCs arising in hemochromatosis are extremely low, given that tumors are usually multifocal and the livers cirrhotic in the majority of the instances. Early detection of hemochromatosis as well as intensive tumor screening of cirrhotic patients with hemochromatosis could possibly optimize the role of surgery or accelerate the decision to proceed with liver transplantation.

Aged↗
PubMed2006

Liver transplantation and incidentally found hepatocellular carcinoma in liver explants: need for a new definition?

BACKGROUND: "Incidentally" identified hepatocellular carcinoma (iHCC) in liver explants after liver transplantation (LTx) is a frequently reported finding, which is characterized with a good prognosis. The purpose of this study was to evaluate the outcome of patients with these tumors in our series and in literature reports, and to compare their prognosis to that of HCC diagnosed preoperatively. METHODS: From April 1998 to December 2003, 432 patients underwent deceased-donor LTx at our center for nonmalignant indications. An additional 31 patients with a preoperative known HCC (pkHCC) received deceased-donor grafts. A literature search was performed intending to estimate the incidence of iHCC in liver explants and the outcome after LTx. RESULTS: iHCC was found in 5 of the 432 patients. All five patients are currently alive without evidence of tumor recurrence after a median follow-up of 43 months. On the other hand, in the group of the 31 patients with pkHCC, 22 of them are at the moment alive in a median follow-up of 28 months. When comparing the two groups, no difference in survival could be found (P=0.1419 in log-rank test). Literature reports of 705 instances with iHCC over the past 20 years showed a statistical "better survival" in only 24 cases. CONCLUSION: Literature reports showed a remarkable "deviation" of the expected tumor characteristics for the iHCC. Obviously, this is because of a widely characterization of iHCC, including also tumors which are rather undetected HCC during the waiting time to LTx. A more precise definition for the iHCC is needed.

Carcinoma, Hepatocellular↗
PubMed2005

Hepatic venous outflow reconstruction in right live donor liver transplantation.

The increasing experience with live donor liver transplantation has allowed for the identification of potential morbidities associated with technical considerations. Technical graft failure can be associated with both inflow and outflow vascular compromise. Although the latter has not always been given the relevance of the former, evidence pointing to its pivotal role continues to mount. We believe that impaired venous outflow was a cause of previously unexplained graft failures during our initial experience. Based on this observation, we developed a technique to prevent the "choking" of the graft at the outflow anastomosis with the inferior vena cava (IVC). The enhanced outflow via a cloaca maximum is achieved by reconstructing the graft vessels with preserved veins or arteries (usually iliac vessels are used) from a blood-group-identical or blood-group-compatible deceased organ donor. Alternatively, hepatic vein or portal vein obtained from the resected native liver can be used. The reconstructed common outflow is anastomosed to a triangular opening of the IVC. Such enhanced outflow provides optimal venous drainage, especially during the early phase of growth of the graft.

Anastomosis, Surgical↗
PubMed2005

Inflammatory pseudotumor of the liver.

Inflammatory pseudotumor of the liver (IPL) is a rare benign neoplasm. It often masquerades as a malignancy, either primary or metastatic. We describe the case of a 71-year-old man who presented with fever and malaise. Workup revealed a cecal mass, as well as a lesion in the left lobe of the liver. Pathologic examination showed a cecal neoplasm and a hepatic inflammatory pseudotumor. The patient recovered uneventfully. This case highlights the ability of IPL to masquerade as a malignant hepatic neoplasm, and emphasizes the difficulties in diagnosis.

Aged↗
PubMed2005

Transplantation and palliative care: the convergence of two seemingly opposite realities.

One of the authors once asked a great transplant surgeon what came to his mind when asked about palliative care. He had two answers: the first,was somewhat simplistic; the second was profound. He said that this type of service was helpful in the ICU when there was not much more to be done surgically for a patient who was dying; the second, was a story about an individual whom he had transplanted three times (who survived!) because he and his team did not want the patient and family to give up hope. The second answer is fundamentally more in keeping with the philosophy of palliative care, despite the extraordinary specific circumstances. The surgeon demonstrated ongoing presence and non abandonment. This patient was palliated, although few surgeons could have accomplished this by doing two retransplantations! Fortunately, for the less gifted and lucky, there are many ways in which to continue a meaningful presence to an ailing or dying patient on a transplant service that do not require a transplantation procedure. One wonders why palliative care and transplantation have not been more formally acquainted in the past given the extensive overlap of the populations served, the nature of the day-to-day problems, and the intensity of the commitment to the patient. The time is ripe for a formal mutual acquaintance between palliative care specialists and transplant teams,perhaps in the format of a work group that is similar to the work groups that promoted excellence in palliative care, such as the End Stage Renal Disease Workgroup, that were grant funded by the Robert Wood Johnson Foundation. The fields of transplantation and palliative care have a treasure trove of experience that is lacking in the other that could be exchanged profitably with a great sense of satisfaction for all.

Attitude to Health↗
PubMed2005

The utility of TIPS in the management of Budd-Chiari syndrome.

BACKGROUND AND AIM: Budd-Chiari syndrome (BCS) is a rare condition associated with hepatic venous outflow obstruction classically treated with portosystemic shunts or liver transplantation. Recent reports indicate promising results with the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of these patients. PATIENTS AND METHODS: We reviewed a 10-year single-institution experience with TIPS in patients diagnosed with BCS. RESULTS: Eleven patients with BCS underwent TIPS procedures, 3 of whom carried a diagnosis of paroxysmal nocturnal hemoglobinuria, a relative contraindication for liver transplantation. One TIPS procedure was unsuccessful for technical reasons. No patient suffered mortality or major morbidity related to the TIPS procedure. The mean reduction of portal venous pressures was 43.7%, with a mean decrease of 73% in the pressure gradient. Of the 7 patients where long-term follow-up was available, 57% had shunts which remained patent but required several nonsurgical revisions for occlusion, with an average assisted patency of 37.5 months. CONCLUSIONS: TIPS is an effective modality in the treatment of patients with BCS, especially for those who are not candidates for liver transplantation. TIPS can be successfully used as a bridge to surgical portosystemic shunting, as well as liver transplantation, but may cause technical difficulties when performing transplantation.

Budd-Chiari Syndrome↗
PubMed2005

Primary liver carcinoma arising in people younger than 30 years.

Primary liver carcinomas in children and young adults are uncommon and poorly described. We examined primary liver carcinomas in people younger than 30 years and performed immunostains for markers of biliary (cytokeratin [CK] 7, CK19, CD56) and hepatocellular (HepPar) differentiation. We found 23 primary liver carcinomas were found: 13 hepatocellular carcinomas (HCCs), 9 fibrolamellar carcinomas (FLCs), and 1 cholangiocarcinoma. Most HCCs showed compact (n = 7) or trabecular (n = 4) growth patterns. The Edmondson grades were as follows: 1, 3 tumors; 2, 8 tumors; and 3, 2 tumors). All HCCs and FLCs were HepPar(+). All FLCs and 7 of 9 HCCs were CK7(+). In contrast, a control group of 65 adult HCCs showed less CK7 positivity (24 [37%]; P = .03). CK19 was positive in 2 HCCs and CD56 in 1 HCC. No chronic background liver disease was seen, although 3 cases showed foci of altered hepatocytes. HCCs are the most common primary liver carcinoma in children and young adults followed by FLCs. They are morphologically similar to adult HCC, but more likely to be CK7(+).

Adolescent↗
PubMed2004

Procurement of liver and pancreas allografts in donors with replaced/accessory right hepatic arteries.

Anatomic variants in the origin of the right hepatic artery have led to various approaches at the time of organ procurement for transplantation. Of special relevance is the presence of a replaced or accessory right hepatic artery arising independently from the superior mesenteric artery. On the basis of an estimated combined experience of almost 2,000 organ procurements and implantations, we propose a technique in which dissection is kept to a minimum, with the goal of preventing procurement-associated injuries.

Hepatectomy↗
PubMed2004

Laparoscopic-assisted renal autotransplantation.

OBJECTIVES: To report our experience with laparoscopic nephrectomy and autotransplantation for the management of a variety of conditions with significant loss of healthy ureteral tissue or ureteral length. Renal autotransplantation has been described as an effective method for addressing this problem, avoiding the need for nephrectomy or complex ureteral replacement. In an effort to decrease the morbidity associated with traditional autotransplantation we elected to perform laparoscopic procurement of the kidney. METHODS: Four patients underwent laparoscopic nephrectomy using a transperitoneal four-port technique and subsequent autotransplantation into the iliac fossa for the treatment of proximal ureteral avulsion (2 patients), ureteral malignancy, and ureteral stricture. All patients had less than 5 cm of viable ureter. RESULTS: All procedures were performed without intraoperative complications. All renal scans on postoperative day 1 demonstrated good perfusion. None of the patients had a postoperative rise in serum creatinine. On postoperative day 1, the mean creatinine value was 0.95 mg/dL. Three patients had an uneventful postoperative course. One patient, however, had loss of the graft because of renal vein thrombosis on postoperative day 7. She was later found to have an undiagnosed thrombophilic disorder (decreased levels of antithrombin III) and to have a recent history of oral contraceptive use. CONCLUSIONS: Laparoscopic nephrectomy with renal autotransplantation is a feasible minimally invasive alternative to treat patients who have significant ureteral loss. This approach avoids the need for an upper abdominal or flank incision, resulting in decreased morbidity. The initial follow-up studies indicated stable renal function. Additional long-term observation is currently under way.

Adult↗