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P Muiesan

Publications and source records attributed to P Muiesan.

At least 37 records · Page 2Linked to original sources
PubMed2000

Quality of life after liver transplantation for alcoholic liver disease.

There are few data on predictive factors for alcohol relapse or long-term functional outcome after liver transplantation for alcoholic liver disease (ALD). In all 56 surviving UK patients (47 men, 9 women; mean age: 51 years; range: 33 to 69 years) who underwent transplantation for ALD at King's College Hospital over a 10-year period, alcohol relapse and outcome were assessed by outpatient and case-note review and by postal questionnaire containing (1) the Nottingham Health Profile (NHP), (2) the Short-Form-36 (SF-36) Health Survey, and (3) a drug and alcohol questionnaire. At a median of 2.5 years (range: 0.5 to 10 years), 13 of the 47 respondents (28%) and 2 of the 9 nonrespondents (22%) had evidence of potentially harmful drinking (>3 units daily) at some time posttransplantation. An additional 13 patients admitted to drinking some alcohol at least once, corresponding to an overall relapse rate of 50%. The patients with harmful drinking (1) had started drinking regularly at a younger age (18 v 25 years; P =.01), (2) began drinking heavily at a younger age (30 v 40 years; P =.01), (3) had shorter pretransplantation abstinence periods (10 v 23 months; P =.02), and (4) had a longer time since transplantation (median, 5.7 v 1.5 years; P =.0004) than those with no or mild alcohol relapse. They were also more likely to report sleep disturbance (NHP sleep problem score, 45 v 16; P =.01) and use benzodiazepines regularly (7 of 13 v 3 of 34 patients; P =.002). Despite these differences, health dimension scores in the SF-36 and NHP posttransplantation were similar between the groups and to those of UK community controls. In the long term, at least 50% of the patients will drink again at some time posttransplantation, although at lower levels of alcohol intake than previously. Those patients with multiple predictive factors for alcohol relapse may be at greatest risk for harmful drinking and be the group that would benefit most from professional counseling. Overall, the quality of life after liver transplantation for ALD is high and broadly similar to the levels expected in the normal population.

Adult↗
PubMed1999

Oral absorption of tacrolimus in children with intestinal failure due to short or absent small bowel.

We describe two children with intestinal failure due to short or absent small bowel who underwent isolated liver transplantation for liver disease related to parenteral nutrition. Both received reduced-size liver grafts whilst awaiting a suitable small bowel donor. Immunosuppressive therapy was based on oral tacrolimus and intravenous steroids. Therapeutic levels of tacrolimus were achieved at low dosage of 0.14-0.28 mg/kg per day. Median and mean blood tacrolimus levels were 9.9 and 13.7 ng/ml (range 4.9-42.3 ng/ml) in case 1 and 5.8 and 7.2 ng/ml (range 1-30 ng/ml) in case 2 before small bowel transplantation, respectively. Following small bowel transplantation, levels were 17.1 and 20.1 ng/ml (range 9.2-30 ng/ml), with oral doses of 0.54-1.35 mg/kg per day. Both children died of adenovirus pneumonia, with functioning grafts. Our experience demonstrates that effective levels of immunosuppression can be achieved by oral administration of tacrolimus in children with short or absent small bowel.

Adenoviridae Infections↗
PubMed1999

Liver transplantation with monosegments.

BACKGROUND: Shortage of size-matched pediatric donors led to the development of surgical techniques to reduce or split livers and thus increase the potential pool of donors. Despite this, neonatal transplantation remains a problem because of the small size of the recipients. Further reduction of the left lateral segment is possible to provide a single segment graft (segment III). We report our experience of transplanting 6 babies using this technique. METHODS: Of 310 children transplanted in our center between October 1989 and March 1998, 6 patients, 2 male and 4 female, median age 37.5 days (range 5 to 92 days), median weight 3.45 kg (range 2.45 to 5.46 kg) were transplanted with a monosegment. The cause of liver failure was neonatal hemochromatosis in 4, retransplantation for hepatic artery thrombosis in 1, and hepatitis B in one. The donor liver was reduced or split to a left lateral segment. Segment II was then resected and discarded before transplantation. RESULTS: Overall, graft and patient survival is 83.3%. Five patients are alive with good graft function at a mean follow-up of 30.4 months (range 8 to 82 months). One child who was transplanted for hepatic artery thrombosis died from sepsis and multiorgan failure 48 hrs after transplant. None of the survivors had vascular or biliary complications. CONCLUSIONS: Monosegment liver transplantation with segment III appears to be a satisfactory option for treating small babies with liver failure.

Female↗
PubMed1999

Auxiliary partial orthotopic liver transplantation for Crigler-Najjar syndrome type I.

OBJECTIVE: To determine if auxiliary partial orthotopic liver transplantation (APOLT) has the long-term potential to correct the underlying abnormality in Crigler-Najjar syndrome type 1 (CNS1) without the need for total liver replacement. BACKGROUND: Orthotopic liver transplantation has been used successfully to replace the defective enzyme in CNS1. Experimental studies have shown that only 1% to 2% of the normal hepatocyte mass is needed for bilirubin conjugation. If APOLT corrects the underlying metabolic abnormality, it has the advantage of preserving the native liver, which would serve as a "safety net" should the graft fail, and there is the potential for gene therapy in the future with possible withdrawal of immunosuppression. METHODS: Seven APOLT procedures were performed in six recipients with CNS1. Median age at transplantation was 10.5 years. Six transplants were performed as a left auxiliary liver transplant, and one was performed as a right auxiliary liver transplant. Median serum bilirubin level at transplantation was 320 micromol/L. All patients required 12 to 16 hours of phototherapy daily before the transplant to maintain serum bilirubin levels between 250 and 350 micromol/L. RESULTS: Median serum bilirubin level was 50 micromol/L at day 5 after the transplant and 23 micromol/L at a median follow-up of 32 months. In four children, early severe acute rejection developed, requiring conversion to tacrolimus; one underwent a second transplant for chronic rejection and graft atrophy but died from lymphoproliferative disease 6 months after the second transplant. CONCLUSIONS: This report shows that APOLT is technically feasible and provides adequate hepatocyte mass to correct the underlying metabolic abnormality in CNS1.

Adolescent↗
PubMed1998

Hemophagocytosis: a potential complication in small bowel transplantation.

BACKGROUND: Acquired hemophagocytosis is a histiocytic proliferation associated with phagocytosis of the hemopoietic elements resulting in fever, profound pancytopenia, hepatosplenomegaly, lymphadenopathy, and coagulopathy. Acquired hemophagocytic syndrome is a specific entity that can be differentiated from malignant histiocytosis and familial hemophagocytosis. It has been associated with a variety of disorders, including immunodeficiency, infection, hemopathies, cancer, and autoimmune diseases, as well as with the period following solid organ and bone marrow transplantation. METHODS: We describe a case of a fatal outcome, due to hemophagocytosis, after small bowel transplantation in a patient with systemic lupus erythematosus. RESULTS: Hemophagocytosis secondary to systemic lupus erythematosus has been reported to have a better response to steroid therapy than that associated with infection. In this case, the association of an autoimmune disease, high levels of immunosuppression, and posttransplant sepsis may have triggered the onset of hemophagocytosis. CONCLUSION: It is suggested that patients with systemic lupus erythematosus may represent a high-risk group for developing hemophagocytosis after small bowel transplantation.

Fatal Outcome↗
PubMed1998

Use of infrarenal conduits for arterial revascularization in orthotopic liver transplantation.

Arterial conduits that use donor iliac arteries represent a reliable technique for graft revascularization in orthotopic liver transplantation. We reviewed 757 consecutive liver transplantations performed between 1989 and 1995 for acute or chronic liver disease in adults and children. Of these, 218 patients received arterial conduits that used donor iliac arteries. The incidence of hepatic artery thrombosis (HAT) for conduits was 4.1% (9 of 218 patients) compared with 4% (22 of 539 patients) for direct arterial anastomosis. Patients in the arterial conduit group included 66% (99 of 159) of the children younger than 5 years of age, 75% (67 of 89) of all patients who underwent retransplantation, and, in particular, 25 patients regrafted for HAT. Arterial conduits provide an effective and reliable method of revascularization in patients at higher risk of arterial thrombosis. The actuarial 3-year patency rate for conduits is 95% and the incidence of HAT is similar to that in standard arterial anastomoses.

Adult↗
PubMed1998

Diaphragmatic nerve palsy in young children following liver transplantation. Successful treatment by plication of the diaphragm.

Diaphragmatic paralysis was identified in four children after liver transplantation. All presented with persistent right upper lobe atelectasis, pleural effusion and recurrent respiratory infections and could not be weaned from mechanical ventilatory support. Fluoroscopy and real-time ultrasound confirmed paradoxical right diaphragmatic movements. Diaphragmatic plication was undertaken and enabled rapid and sustained weaning from respiratory support in all four cases. Vascular clamping of the suprahepatic vena cava seems to be the cause. Diaphragmatic plication allows optimal recruitment of the respiratory muscles with a favourable impact on lung mechanics and gas exchange.

Child, Preschool↗
PubMed1998

Bowel perforation after paediatric orthotopic liver transplantation.

Bowel perforation is a well-recognized complication following orthotopic liver transplantation. Of 194 paediatric liver transplantations performed in our hospital, 13 patients (6.7%) developed bowel perforation post-transplantation. Contributory factors included previous operation, steroid therapy and viral infection. The incidence was higher in children who underwent transplantation for biliary atresia after a previous Kasai portoenterostomy. Seven patients (53% of this group) reperforated. Diagnosis may be difficult and a high index of suspicion is needed.

Child↗
PubMed1998

Split liver transplantation: King's College Hospital experience.

BACKGROUND: The purpose of split liver transplantation is to increase the source of pediatric grafts without compromising the adult donor pool. Early results have been discouraging because of technical complications and selection of poor risk patients. METHODS: The results of a single center experience of 41 split liver transplantations were analyzed. Patient and graft survival and complications related to the technique were analyzed. RESULTS: Patient and graft survival for the whole group was 90% and 88% respectively at a median follow up of 12 months (range 6-70 months). Patient and graft survival for the right lobe graft was 95% and the left lateral segment 86% and 82% respectively. Four patients died, of which two of the patients were first two splits following technical complications. Two others died, one from cerebral lymphoma and the other of multiorgan failure secondary to sepsis. One patient has been retransplanted for chronic biliary sepsis. CONCLUSION: Split liver transplantation has now become an acceptable treatment option for both adult and pediatric recipients with end stage liver disease. Right lobe recipients are not disadvantaged by the procedure. Good results can be achieved with better patient selection and by the use of good quality organs.

Adolescent↗
PubMed1998

Pediatric liver transplantation.

Liver transplantation in children has become a treatment of choice for end-stage liver disease. Both graft and patient survival has significantly improved over the last two decades. The major factor contributing towards improved survival is availability of cyclosporin. Surgical innovations like living related donation has not only increased the donor pool, but has also helped patients in countries where cadaveric donation is not available. Auxiliary liver transplantation has made a significant change to the management of children with liver-based metabolic disorders and, in selected cases of acute liver failure, immunosuppression can be safely withdrawn once the native liver recovers. However, the complications associated with immunosuppression, such as nephrotoxicity, lymphoproliferative disease and viral infections, continue to be a matter of great concern. Most children with good graft function enjoy near normal quality of life.

Child↗
PubMed1997

Hepatic transplantation in children under 3 months of age: a single centre's experience.

Liver transplantation in neonates represents a major medical and technical challenge particularly in babies weighing less than 5 kg. The authors report the experience of 10 liver transplants in 9 babies (6 boys and 3 girls), mean age, 6 weeks (range, 2 to 11); median weight, 3.7 kg (range, 2.4 to 5). All had fulminant hepatic failure caused by neonatal haemochromatosis (n = 3), non-A non-B hepatitis (n = 3), total parenteral nutrition induced (n = 1), hepatitis B (n = 1), and hepatic haemangio-endothelioma (n = 1). One child underwent retransplantation for hepatic artery thrombosis. Immunosuppression was by Cyclosporine A-based triple therapy in all cases. All received a reduced size graft consisting of left lobe (n = 1), left lateral segment (n = 6) and monosegment III (n = 3). In nine cases the donor hepatic artery was anastomosed to an iliac artery conduit from the infrarenal aorta, and a Roux loop was used for bile duct reconstruction. Primary abdominal wound closure was possible in six patients, skin closure alone in one, and a silastic patch was used in three. Complications included infection (n = 5), bowel perforation (n = 2), diaphragmatic perforation (n = 2), bile leak (n = 1), hepatic artery thrombosis (n = 1), and portal vein thrombosis (n = 1). None of the babies experienced acute rejection. Currently five of the nine recipients are alive with good graft function at a mean follow-up of 22 months (range, 5 to 58). Of the four deaths, two were related to infection (one in combination with portal vein thrombosis), one to multiorgan failure and fluid overload, and one to early graft dysfunction and sepsis after undergoing retransplantation for hepatic artery thrombosis. From our experience liver transplantation offers a promising option for the treatment of severe liver disease in children less than 3 months old.

Age Factors↗
PubMed1997

Liver transplantation for extra hepatic biliary atresia.

Kasai portoenterostomy has transformed the prognosis for children with Extra Hepatic Biliary Atresia (EHBA). However, for children developing end stage liver disease following portoenterostomy, liver transplantation (OLT) is the treatment of choice. Between February 1989 and March 1996, 64 children with EHBA underwent 79 transplants (26 males, 38 females; median age 2.2 years, range 5 months-17 years; median weight 11.4 kg, range 5-65 kg). Of these, 58 (85%) had undergone previous portoenterostomy. Nineteen patients (30%) had gastrointestinal bleeding prior to OLT assessment. Mean serum bilirubin was 229 mumol/liter (range 11-801 muml/liter). Four children had associated polysplenia syndrome. Of the 79 transplants, 30 received whole and 41 reduced-size cadaveric grafts and 9 living related grafts. Eleven patients (17%) died, nine within one month of surgery. Thirteen patients were retransplanted once and one twice. There were 16 vascular complications (10 hepatic artery thrombosis, 3 portal vein thrombosis, 3 venous outflow obstruction) and 10 biliary complications (4 anastomotic leaks, 6 strictures). Ten patients (16%) had bowel perforation following the transplant. The 5 year actuarial patient and graft survival for this group is 84% and 69% respectively with normal physical and mental development in the majority. OLT provides satisfactory treatment for children with EHBA with end stage liver disease with long term survival in the majority.

Adolescent↗
PubMed1996

Hepatic artery thrombosis after liver transplantation in children under 5 years of age.

The incidence of hepatic artery thrombosis (HAT) following orthotopic liver transplantation in children varies from 4% to 26% and represents a significant cause of graft loss. The purpose of this study was to analyze the risk factors for HAT following liver transplantation in children less than 5 years old. Seventy-three transplants were performed in 62 children under 5 years of age, including 16 for acute hepatic failure, 46 for chronic liver disease, and 11 retransplants. Twenty-four whole liver grafts (WLG) and 49 reduced size grafts (3 right lobes, 16 left lobes, and 30 left lateral segments) were transplanted. The recipient common hepatic artery was used to provide arterial inflow in 22 transplants and an infrarenal iliac conduit in 51 transplants. The overall incidence of HAT was 8 out of 73 transplants (11%). The cold ischemia time (14.3 +/- 3.03 hr) in this group was significantly longer than the cold ischemia time for those without HAT (11.7 +/- 3.94 hr) (P = 0.049). The incidence of HAT for whole and reduced grafts was 25% (6/24) and 4% (2/49), respectively (P = 0.01). HAT occurred in 6 of 22 grafts (27.3%) revascularized from the recipient common hepatic artery, compared with 2 of 51 grafts (3.9%) using an infrarenal arterial conduit (P = 0.008). The combination of recipient hepatic arterial inflow to a WLG resulted in HAT in 50% (6/12), whereas there were no cases of HAT with an iliac conduit to a WLG (P = 0.01). Of the eight patients with HAT, five are alive (median follow-up, 20 months; range, 7-27 months). Five patients were retransplanted, three within the first 2 weeks and two at 4 and 5 months for abnormal liver function in association with clinical and histological features of chronic rejection. Prolonged cold ischemia time and use of a whole graft with recipient hepatic arterial inflow are risk factors for developing HAT. The use of reduced size grafts and infrarenal iliac arterial conduits are associated with a low incidence of HAT.

Child, Preschool↗
PubMed1996

A prospective randomised trial of bile duct reconstruction at liver transplantation: T tube or no T tube?

A prospective randomised study of end-to-end bile duct reconstruction with or without T-tube drainage during orthotopic liver transplantation (OLT) was undertaken in 60 patients well matched for age, sex, aetiology of liver disease, operative blood loss, cold ischaemic time, preoperative serum bilirubin level and Child-Pugh score. Significant biliary complications in the T tube group occurred in five patients and included bile duct stricture (n = 2), bile leak/peritonitis (n = 1) and cholangitis (n = 2). Bile duct strictures occurred in six patients in the no T tube group (P > 0.05, NS). Hepatic artery stenosis was identified in one patient from each group in association with a biliary stricture. Biliary complications in both groups were associated with a prolonged graft cold ischaemic time (P < 0.01). As no significant difference was noted in the number of early and late biliary complications between the two groups, the routine use of a T tube has been discontinued.

Adolescent↗
PubMed1996

Vascular hypertrophy and remodeling in secondary hypertension.

It has been proposed that several neurohumoral factors may be involved in the genesis of vascular structural changes (remodeling or hypertrophy) frequently observed in essential hypertension. Therefore, in this study we investigated vascular structural alterations of subcutaneous small resistance arteries in patients with secondary forms of hypertension. The study included 70 participants: 11 with pheochromocytoma, 13 with primary aldosteronism, and 17 with renovascular hypertension; 13 normotensive subjects and 16 patients with essential hypertension served as controls. All subjects were submitted to a biopsy of subcutaneous fat. Small resistance arteries were dissected and mounted on a micromyograph, and media-lumen ratio, media thickness, remodeling index, and growth index were evaluated. Endothelial function was evaluated according to the dose-response curve to acetylcholine. In patients with either primary aldosteronism or renovascular hypertension, a marked increase in media-lumen ratio was observed, whereas in patients with pheochromocytoma, the extent of vascular structural alterations was similar to that observed in patients with essential hypertension. The increase in media-lumen ratio in patients with essential hypertension and with pheochromocytoma was mainly due to vascular remodeling (remodeling index, 93% to 94%), whereas in patients with renovascular hypertension, there was vascular growth (remodeling index, 70%; growth index, 53%). Patients with primary aldosteronism had an intermediate pattern compared with the other two forms of secondary hypertension. An evident impairment of endothelial function was observed in all four hypertensive groups. In conclusion, the renin-angiotensin-aldosterone system seems to be more powerful than the adrenergic system in inducing vascular growth.

Acetylcholine↗
PubMed1995

A technique for hepatic artery anastomosis during orthotopic liver transplantation.

Hepatic artery thrombosis remains the most common technical complication that causes graft failure following orthotopic liver transplantation. The Hepatic artery anastomosis should be performed using meticulous technique and adequate magnification. We report a very low incidence of Hepatic artery thrombosis (1.3%) utilising a modified microvascular 120 degrees triangulating technique in 150 adult liver transplants.

Adult↗
PubMed1995

The incidence and management of biliary complications following liver transplantation in children.

Biliary complications following liver transplantation are a cause of significant morbidity and mortality. During the period 1988-1993 ten cases of biliary complications occurred after 98 transplantations in 78 children. The complications were four bile leaks, three intrahepatic biliary strictures (one with recurrent cholangitis), two anastomotic biliary strictures (one with recurrent cholangitis) and one recurrent cholangitis. All leaks occurred within 6 weeks of transplantation whereas all strictures and cholangitic episodes occurred after 3 months. Two biliary complications (20%) - one intrahepatic and one anastomotic stricture - developed secondary to hepatic artery thrombosis. The incidence of biliary complications was 13.2% with whole liver grafts as compared to 6.7% with partial liver grafts and it was 4.3% with duct-to-duct anastomosis as compared to 12.0% with Roux-en-Y hepatico-jejunostomy. Seven children required intervention for management of biliary complications and three were managed conservatively. There were no deaths related to the biliary complications.

Adolescent↗