Coccidioidal meningitis after liver transplantation in a nonendemic region: a case report.
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Adult↗
Biomedical subjects
Martin Hertl
Publications and source records attributed to Martin Hertl.
Mirizzi syndrome secondary to an adenoma of the cystic duct.
Bile duct adenomas are uncommon lesions that can cause obstructive jaundice. We report the unusual case of a 54-year-old man who developed Mirizzi syndrome secondary to a bile duct papillary adenoma located in the cystic duct remnant. A case report is presented, together with a review of extrahepatic bile duct adenomas published in the English-language literature, with special attention directed toward the clinical manifestations, locations, and prognosis of these tumors. Bile duct adenomas are very rare tumors. Although cholangiography can detect many of these lesions, few cases were correctly diagnosed preoperatively. Most lesions were located in the distal common bile duct or at the ampulla of Vater. Pathologic examination often revealed foci of carcinoma in situ, dysplasia, or atypia. Local resection was performed in most cases. There were no previous case reports of extrinsic common bile duct obstruction caused by tumors within the cystic duct. We describe here a very rare, acalculous variant of Mirizzi syndrome secondary to a solitary papillary adenoma of the cystic duct. In general, bile duct adenomas are uncommon lesions that are difficult to diagnoses preoperatively. These tumors usually present with jaundice secondary to intraluminal biliary obstruction. These lesions are premalignant and should be managed by complete surgical resection.
Adenoma↗
Liver transplantation for malignancy.
Liver transplantation for hepatic malignancies has emerged from an exotic and desperate approach to a well-documented and proven treatment modality for these unfortunate patients. However, early unsatisfactory results emphasized that only a highly selected patient population would benefit from transplantation. Currently, <10% of all liver transplants performed are for hepatocellular cancer (HCC). There is no controversy that hepatoblastoma is an excellent indication in pediatric patients with unresectable tumors. Similarly, liver transplantation for HCC in the adult population yields good results for patients whose tumor masses do not exceed the Milan criteria. It remains to be determined whether patients with more extensive tumors can be reliably selected to benefit from the procedure. Adjunctive procedures like radiofrequency ablation, chemoembolization, or cryotherapy might be indicated to limit tumor progression for patients on waiting lists. Epitheloid hemangioendothelioma is also an appropriate indication for liver transplantation, unlike angiosarcoma. Metastatic liver disease is not an indication for liver transplantation, with the exception of cases in which the primary is a neuroendocrine tumor, for which liver transplantation can result in long-term survival and even cure in a number of patients. And finally, while gallbladder cancers are never an indication for liver transplantation, rare cases of cholangiocellular cancer might qualify if aggressive combination therapies, including chemotherapy and radiotherapy followed by OLT, are carried through. Survival in these selected patients can approach that for patients with cholestatic liver disease.
Bile Duct Neoplasms↗
Liver transplantation outcomes for early-stage hepatocellular carcinoma: results of a multicenter study.
The incidence of hepatocellular carcinoma (HCC), a frequent and incurable complication of cirrhosis, continues to rise. Orthotopic liver transplantation (OLT) has been proposed as a treatment for unresectable, intrahepatic HCC limited in extent to the Milan criteria adopted by the United Network of Organ Sharing (UNOS) in 1998. More recently, somewhat less restrictive University of California, San Francisco (UCSF)10, criteria were proposed. To examine the long-term outcomes of OLT for HCC patients and to assess the UNOS policy of assigning weighted allocation points to patients with HCC, we retrospectively analyzed 144 patients (113 after 1998) with HCC who underwent OLT over an 11-year period at 3 institutions from UNOS Region 1. We compared their outcomes with 525 patients (272 after 1998) who underwent OLT for nonmalignant liver disease. The 1- and 5-year survival rates were 80.3% and 46.7%, respectively, for patients with HCC and 81.5% and 70.6%, respectively, for patients without HCC (P = .020). However, there was no difference in survival between HCC and non-HCC patients after implementation of disease-specific allocation for HCC in 1998. A higher proportion of the HCC cohort was older and male and had chronic HCV infection and alcoholic liver disease. In univariate analysis, having alpha-fetoprotein (AFP) levels of 10 ng/mL or less and meeting clinical and pathologic UCSF criteria were each significant predictors of improved survival (P = .005, P = .02, and P = .03, respectively). AFP greater than 10 ng/mL and exceeding pathologic UCSF criteria were also significant predictors of recurrence (P = .003 and P = .02, respectively). In conclusion, taken together, our data suggest that OLT is an acceptable option for patients with early HCC and that UCSF criteria predict outcome better than Milan or UNOS criteria. Regardless of which criteria are adopted to define eligibility, strict adherence to the criteria is important to achieve acceptable outcomes.
Adolescent↗
Liver donation: donor safety comes first.
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Hepatectomy↗
Biliary reconstruction following right adult living donor liver transplantation end-to-end or end-to-side duct-to-duct anastomosis.
BACKGROUND AND AIMS: Bile duct complications are the modern Achilles' heel of adult-to-adult living donor liver transplantation. A duct-to-duct anastomosis is currently performed in the presence of single graft ducts, while cholangiojejunostomy is used to drain multiple ducts. Our aim is to describe the feasibility of duct-to-duct anastomoses independent of the presence of one or multiple graft bile ducts. METHODS: The probe technique for right bile duct dissection in donors and a proximal hilar bile duct division in recipients are illustrated. The BARIGA LDLT (biliary anastomosis in right graft for adult living donor liver transplantation recipients) with end-to-side or end-to-end hepatico-hepaticostomy was used in five recipients of right grafts (segments 5-8). RESULTS: All donors and recipients are doing well; all grafts are functional at 13 months. Duct-to-duct anastomoses to single, double, or triple graft ducts have been performed. Two early anastomotic stenoses at 5 and 10 weeks were successfully treated endoscopically. CONCLUSION: The duct-to-duct anastomosis represents a valid alternative to the standard hepaticojejunostomy for right living donor liver grafts. Using this method, biliary complications can be treated endoscopically. End-to-side or end-to-end BARIGA LDLT has the potential to become a standard method in segmental transplantation, including split liver.
Adult↗
Right-liver living donor transplantation for decompensated end-stage liver disease.
Adult-to-adult living donor liver transplantation (LDLT) for patients with decompensated end-stage liver disease (DELD) is controversial. Nevertheless, these patients are most in need of a timely liver transplant. We present the results of 7 patients who underwent transplantation with this procedure and discuss the rationale for its possible broader application. Seven of 51 patients who underwent right LDLT (segments 5 to 8) between August 1998 and April 2001 had DELD, defined as Child-Pugh-Turcotte score greater than 13 or Model for End-Stage Liver Disease score greater than 30. All patients also were listed for cadaveric liver transplantation. Mean age of the 7 transplant recipients was 54 years (range, 44 to 63 years). Three patients had ethyltoxic cirrhosis; 2 patients, hepatitis C; 1 patient, hepatitis B; and 1 patient, autoimmune hepatitis cirrhosis. The average intensive care unit stay was 23 days (range, 3 to 88 days), and average hospital stay was 77 days (range, 27 to 132 days). Three patients are alive 31, 21, and 17 months after LDLT. At a mean follow-up of 15.1 +/- 10 months, patient and graft survival rates are 43%. Four transplant recipients died day 30, 60, 117, and 180 after transplantation. Three of the seven donors (43%) experienced a complication. At present, all donors are well and have returned to their normal activities. No donors had regrets about the procedure, and all donors stated that they would donate again if presented with the same decision. In conclusion, with the lack of other therapeutic options, LDLT represents a timely and effective alternative to cadaveric liver transplantation. Better outcome is foreseeable with a decrease in posttransplantation complications and more experience in predicting survival of these critical patients.
Adult↗
Split-liver transplantation: future use of scarce donor organs.
The main obstacle to a expansion of human liver transplantation is the lack of donor organs. At present mortality reported for pediatric and adult patients on the waiting list is 10%to 20%. This article focuses on several techniques to alleviate this problem. Several years ago, application of reduced-size liver transplantation overcame the donor shortage among small infants through the use of grafts shaped to almost any size needed. Today reduced-size grafts are only rarely used, most commonly with traumatized donor livers or particularly small pediatric donor livers. Split liver transplantation also yields a net gain of organs, in that it uses one organ to save either an adult and a child or, recently, two adults. The technique of ex situ splitting is progressively being replaced by the in situ splitting technique, which yields better preserved grafts,optimization of graft/donor matching by pretransplant manipulation(preconditioning), avoidance of early rejection in the recipient,portal decompression, temporary liver support, if necessary, and induction of fast regeneration. In acute hepatic failure, auxiliary heterotopic liver transplantation might be sufficient to support liver function until regeneration of the native liver has begun. Domino transplantation in some patients with inborn errors of metabolism or storage disease should be considered. This article focuses on increasing the organ supply by using split liver transplantation techniques and living-donor liver transplantation.
Forecasting↗
Structural requirements and interactions of transplant centers.
Transplantation of solid organs such as the heart, lung, liver, pancreas, small intestine, and kidney is the only way by which a potentially life-threatening condition can be treated permanently. Transplantation comprises not only the equipment needed to perform the transplantation itself and to offer pre- and postoperative care for the patient but also the know-how of an experienced team of surgeons and all other specialties involved in the care of a transplant candidate (cardiologists, nephrologists, and hepatologists, to name a few). Organ transplantation is a team effort that requires many "wheels to turn" to obtain the successful results we have today. Frequently, enthusiastic individuals try to setup a transplant center "single-handedly." None has succeeded without institutional, financial, and continuous support and in particular without an effectively structured organizational backbone to support the effort. This article summarizes the requirement for a liver transplantation center to perform these procedures and focuses also on ethical considerations.
Health Workforce↗
Evaluation of living liver transplant donors: method for precise anatomic definition by using a dedicated contrast-enhanced MR imaging protocol.
Liver transplantation from a living donor involves removal of part of the donor liver in a fashion that does not endanger its vascular supply or metabolic function. The radiologist plays an important role in evaluation of the living donor to define the conditions under which graft donation is contraindicated and to identify anatomic variations that may alter the surgical approach. In the past, diagnostic work-up of the donor involved costly and invasive tests. Currently, dynamic contrast material-enhanced computed tomography and magnetic resonance (MR) imaging are the imaging tests performed, each of which has advantages and limitations. MR imaging performed with liver-specific and extravascular contrast agents may be used as a single imaging test for comprehensive noninvasive evaluation of living liver transplant donors. MR imaging provides valuable information about variations in the vascular and biliary anatomy and allows evaluation of the hepatic parenchyma for diffuse or focal abnormalities.
Biliary Tract↗
Live organ donation: social context, clinical encounter, and the psychology of communication.
Organ transplantation is increasingly available to the thousands of patients who suffer from end-organ failure. There has been an attendant increase in demand for living donor participation. This combined with a bioethical focus on autonomy increases the burden of decision on donor candidates. The authors review the history of living donor participation in organ transplantation and explore the psychological dynamics of the clinical encounter between donor and transplant surgeon. The field of communication psychology lends to the understanding of coercion and to the importance of donors possessing a status of patient-hood in the classical Hippocratic condition.
Coercion↗