Right renal vein extension with recipient left renal vein after laparoscopic donor nephrectomy.
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Humans↗
Biomedical subjects
Stephen C Rayhill
Publications and source records attributed to Stephen C Rayhill.
Liver transplantation for hepatocellular carcinoma: a survey of practices.
GOAL: To survey physician practices regarding liver transplantation for patients with hepatocellular carcinoma (HCC). BACKGROUND: Many issues surrounding liver transplantation for HCC are controversial and physician practices have not been well characterized. METHODS: Transplant physicians and surgeons were electronically surveyed regarding surveillance, diagnosis, selection criteria for deceased and living donor transplantation, and use of adjunctive therapy for HCC. RESULTS: Eighty-nine of 174 (51%) physicians completed the survey (39 hepatologists, 41 transplant surgeons, and 9 others). Most respondents were from large US transplant centers. All reported screening for HCC during transplant evaluation, and 98% surveyed patients awaiting transplant. Sixty percent of respondents would biopsy lesions under selective conditions, whereas 32% never biopsy lesions, and 8% biopsy all lesions. Eighty two percent of respondents claimed to adhere to the Milan criteria (single lesion </=5 cm or no more than 3 lesions each </=3 cm without vascular invasion) for patient selection, however, 36% would transplant patients with tumors that invade a small portal branch. Forty one percent of respondents would consider living donor transplantation for patients with tumors exceeding the Milan criteria. Ninety-six percent of respondents treat HCC before transplantation, and 87% would transplant patients down-staged to meet the Milan criteria. CONCLUSIONS: There is consistency related to HCC surveillance and treatment in liver transplant candidates. Variations of responses regarding biopsy of lesions, patient selection for deceased donor and living donor transplantation highlight a need for evidence-based guidelines.
Biopsy↗
Positive serum cryoglobulin is associated with worse outcome after liver transplantation for chronic hepatitis C.
BACKGROUND: Recurrent hepatitis C virus (HCV) infection in patients after liver transplantation is an important clinical problem. Because serum cryoglobulins (CG) are known to be associated with an increased incidence of cirrhosis in nontransplant patients, the authors tested the hypothesis that CG would also predict aggressive recurrent HCV in patients after liver transplantation. METHODS: Using a longitudinal database, the outcomes of 105 allografts transplanted into 97 HCV-positive patients from 1991 through 2002 were analyzed on the basis of CG status using a retrospective cohort design. Fifty-nine CG-negative and 38 CG-positive patients were identified. Histologic outcomes and graft survival were analyzed using Kaplan-Meier estimates and Cox univariate and multivariate analyses. Both overall survival and HCV-specific survival (non-HVC-related deaths and graft losses censored) were analyzed. RESULTS: By Kaplan-Meier estimates, CG-positive patients showed earlier graft failure with decreased time to severe histologic activity and fibrosis as compared with CG-negative patients (P<0.05 for all outcomes). By univariate analysis, CG-positive patients had significantly higher risk ratios for shortened HCV-specific graft survival, severe activity-free survival, and severe fibrosis-free survival as compared with CG-negative patients (P<0.05 for all outcomes). In the multivariate model, CG was an independent predictor for severe activity-free, severe fibrosis-free, and HCV-specific graft survival (P<0.05 for all outcomes). CONCLUSIONS: CG-positivity is associated with severe recurrent HCV disease in liver transplant recipients.
Adult↗
Early postnephrectomy donor renal function: laparoscopic versus open procedure.
Laparoscopic donor nephrectomy (LDN) is becoming the method of choice to procure kidneys from living donors. Despite the benefits to the donor, there have been concerns over the transient deterioration of renal function in the recipient of LDN compared with standard nephrectomy. We carried out a retrospective review of all living donors at our institution between January 2000 and December 2002. On the first postoperative day, the fall in renal function in laparoscopic donors is significantly greater than the fall seen in open donors. This difference could not be explained by relative hypotension, excessive blood loss, or inadequate fluid replacement in the laparoscopic group. Importantly, this difference is no longer evident by the third postoperative day. We speculate that this may be secondary to the pneumoperitoneum or the prolonged anesthesia on glomerular filtration rate. Furthermore, this finding could explain the slower recovery of graft function in recipients of laparoscopically procured kidney transplants.
Adult↗
Correlation of preoperative three-dimensional magnetic resonance angiography with intraoperative findings in laparoscopic renal surgery.
BACKGROUND AND PURPOSE: Contrast-enhanced three-dimensional magnetic resonance angiography (3D-MRA) with image reconstruction has important applications in laparoscopic urologic surgery. We now use 3D-MRA as part of our preoperative evaluation in selected patients undergoing laparoscopic donor nephrectomy, pyeloplasty, radical nephrectomy, and partial nephrectomy. PATIENTS AND METHODS: From June 2001 to December 2002, 50 patients underwent preoperative 3D-MRA at 1.5 T prior to laparoscopic renal surgery. In general, preoperative 3D-MRA was obtained for donor nephrectomies and pyeloplasties and for cases where prior imaging suggested a possible vascular anomaly. Patients who underwent preoperative imaging included those having donor nephrectomy (N = 28), pyeloplasty (N = 12), radical nephrectomy (N = 5), partial nephrectomy (N = 3), and other laparoscopic renal procedures (N = 2). The 3D-MRA studies were interpreted by one radiologist, and all laparoscopic cases were performed by one of two surgeons. The findings of 3D-MRA were correlated with the intraoperative findings with special attention to aberrant vasculature, including duplicated renal arteries or veins, accessory vessels, or crossing vessels. RESULTS: Among patients undergoing laparoscopic donor nephrectomy, 3D-MRA correctly predicted the number of renal vessels in 27 of 28 cases (96%), including all 3 cases of left retroaortic renal vein. Also, 3DMRA correctly predicted the presence or absence of a crossing vessel in 10 of 12 cases (83%) of laparoscopic pyeloplasty. The imaging study also correctly predicted the number of hilar vessels in all five cases of radical nephrectomy, all three cases of partial nephrectomy, and both cases of other renal operations. Overall, 3D-MRA correctly defined the renal hilar anatomy in 48 of 50 patients, for an overall accuracy of 96%. CONCLUSIONS: Three-dimensional MRA findings correlate well (96%) with intraoperative findings in laparoscopic renal surgery. The imaging study provides exquisite vascular detail and is highly accurate, making it sufficient imaging prior to laparoscopic donor nephrectomy and useful for pyeloplasty and other complex renal operations.
Chelating Agents↗
Hemosiderosis is associated with accelerated decompensation and decreased survival in patients with cirrhosis.
AIM: Although hepatic iron deposition unrelated to hereditary hemochromatosis is commonly observed in cirrhosis, its clinical significance is unclear. The aim of this study was to examine the outcomes of cirrhotic patients with and without hemosiderosis. METHODS: Patients with an initial liver biopsy demonstrating cirrhosis between January 1993 and December 1997 were identified using the Department of Pathology database. Based on iron staining, patients were characterized as siderotic or nonsiderotic. Charts were reviewed to determine outcomes. RESULTS: Siderotic patients had significantly higher Child-Pugh (CP) and model for end-stage liver disease (MELD) scores. Their median survival without transplant was 23 months vs. 85 months in the nonsiderotics (P<0.0001, confidence interval: 95%). On univariate analysis, siderosis was associated with a hazard ratio of 2.74 (P<0.0001). On multivariate analysis, the effect of siderosis was reduced but remained significant after correction for the CP or MELD score (hazard ratios 1.82 and 2.06, P=0.05 and 0.02, respectively). Child's A cirrhotics with hemosiderosis decompensated more rapidly and had shorter median survival than those without siderosis (P=0.007 and P=0.01, respectively). CONCLUSIONS: The presence of siderosis is associated with more advanced liver dysfunction. Even when the effects of baseline liver function are taken into account, siderosis is associated with decreased survival and more rapid decompensation in cirrhosis.
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Long-term outcome of deceased donor renal transplants correlates with the 30-day creatinine reduction ratio.
A simplified model to correlate early allograft function with long-term allograft survival in recipients of deceased donor renal transplants (DDRT) remains challenging. We propose here a novel approach, using the change from the pretransplant creatinine to the 30-day posttransplant creatinine. The outcomes of 153 consecutive DDRT performed at our center between January 1998 and March 2001 were reviewed. The percentage change in creatinine from the pretransplant to 1 month posttransplant, termed here, the creatinine reduction ratio (CRR), was calculated as follows: (pretransplant creatinine-creatinine at 1 month)/pretransplant creatinine *100%. Patients were divided as follows: group 1 CRR>or=67% and group 2<67%. Group 1 had a graft survival at 1 and 5 years of 100% and 89.1% versus 88% and 69.1% for group 2 (log-rank p=0.0008). The risk ratio for graft loss during the follow-up period was four times lower for the patients on group 1. Using the Cox hazards model to compare CRR>or=67% with determinants of long-term outcome, the risk ratio of graft loss during the observational period was 0.26 (p=0.001). The creatinine reduction ratio, when stratified by a level of >or=67% has a strong correlation with superior long-term allograft survival in recipients of DDRT.
Adult↗
New national liver transplant allocation policy: is the regional review board process fair?
Experienced transplant professionals may predict mortality better, in highly selected cirrhotic patients referred for accelerated listing to regional review boards, than the (Pediatric) Model for End-Stage Liver Disease score. However, these requests are often denied. We wished to establish if (1) such denials increase mortality and (2) referring physicians predict mortality better than the score. We analyzed 1,965 non-status 1 requests made between February and November 2002 from the United Network for Organ Sharing (UNOS) national scientific registry. Kaplan-Meier survival and time to transplant were compared between denied and approved patients. Cox proportional hazards analysis was used to establish if referring physicians predicted mortality better than the score. More requests were denied for patients with nonsanctioned conditions (45.7%) than for those with sanctioned conditions (13.3%); P less than.0001). Fewer patients denied accelerated listing had a transplant (46.6% vs. 63.8%; P <.0001); time to transplant was similar (P =.2). However, nonsanctioned cirrhotic cases denied accelerated listing had lower mortality than approved cases (P <.04). Referring physicians predict mortality poorly (P =.23), whereas the Model for End-Stage Liver Disease (MELD)-Pediatric Model for End-Stage Liver Disease (PELD) score was highly predictive (P =.0003). In conclusion, regional review boards are fair and can accurately distinguish high- from low-risk patients. Denying requests does not increase mortality. The MELD-PELD score remains the best predictor of mortality, but the review board process adds additional information. Referring physicians predict patient mortality poorly.
Adult↗
Successful non-heart-beating donor organ retrieval in a patient with a left ventricular assist device.
Non-heart-beating donors (NHBD) represent an option to expand the organ supply with good results. We report a donor patient with a left ventricular assist device (LVAD) due to dilated cardiomyopathy in which controlled NHBD was performed. Due to the LVAD, a modified procurement technique was utilized. The liver and kidneys were procured and successfully transplanted. Patients and grafts are alive and well. Successful organ retrieval can be achieved on selected cases of NHBD with LVADs in which modifications of the procurement technique are implemented without jeopardizing the procurement and not increasing preservation injury.
Adult↗
Vasopressor agents without volume expansion as a safe alternative to venovenous bypass during cavaplasty liver transplantation.
BACKGROUND: Cavaplasty orthotopic liver transplantation (OLT) offers advantages for hepatectomy and implantation and eliminates the risk of outflow obstruction. However, it does require clamping of the cava. This study describes the use of a vasopressor without fluid expansion or venovenous bypass (VB) for hemodynamic control during the anhepatic phase. METHODS: The cavaplasty OLT technique was used routinely. A vasopressor was administered if the mean arterial blood pressure (MAP) was less than 60 mm Hg after clamping of the cava. If the MAP did not reach 60 mm Hg after adjusting the dosage of the vasopressor, femoro-axillary VB would be used. VB was also indicated for preexisting cardiac disease or for massive hemorrhage from severe portal hypertension and extensive adhesions. RESULTS: Among all the 121 adult cavaplasty OLTs, 33 were supported with VB and 50 received a vasopressor. The remaining 38 were excluded. However, baseline variables were well matched, except that preexisting cardiac disease was more frequent in the VB group. The median dosage of epinephrine was 0.07 microg/kg/min (range 0.01-0.6). The VB and vasopressor groups were similar in the reduction in mean MAP and the accumulation in arterial lactate upon clamping as well as in the central venous pressure upon unclamping. Postreperfusion hypotension was more frequent in the VB than in the vasopressor group (27.3% vs. 4.0%, P=0.006). There was no primary graft nonfunction or intraoperative right heart failure. One patient in the vasopressor group required postoperative temporary dialysis. Ninety-day patient and graft survival for the VB and vasopressor groups were 97.0% vs. 98.0% and 97.0% vs. 94.0%, respectively. CONCLUSION: Modest doses of vasopressor without volume expansion or VB can maintain hemodynamic stability during the anhepatic phase of cavaplasty OLT.
Adult↗
Small bowel obstruction caused by metastatic squamous cell carcinoma of the skin without lymphadenopathy in a renal transplant recipient.
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Aged↗
Diagnostic value of gadolinium-enhanced 3D magnetic resonance angiography in patients with suspected hepatic arterial complications after liver transplantation.
PURPOSE: To evaluate the accuracy and clinical role of gadolinium-enhanced 3D magnetic resonance angiography (MRA) in patients with suspected hepatic arterial complications after liver transplantation. MATERIALS AND METHODS: Thirty-six consecutive MRA studies were performed in 33 liver transplant recipients after transplantation. MRA image quality was assessed subjectively. Thirty-two MRA studies were retrospectively reviewed and correlated with surgery (n = 2), conventional angiography (n = 18), or clinical follow-up (n = 12). MRA findings were also correlated with those of Doppler sonography in 30 of the cases. In 20 cases, concordance between MRA and surgery or conventional angiography was evaluated for each grade of hepatic artery stenosis (normal, mild [<50%], moderate [50-75%], severe [>75%], or occluded). RESULTS: MRA image quality was degraded 13 of 36 cases (36.1%) studies. The sensitivity, specificity, and accuracy of MRA by consensus reading for more than 50% of hepatic artery stenosis or occlusion were 67%, 90%, and 81.3%, respectively. Of the 19 cases in which Doppler sonography was abnormal, MRA correctly characterized hepatic artery stenosis in 16 (84.2%). MRA also correctly identified all 5 occurrences of celiac artery stenosis. However, MRA overestimated the severity of hepatic arterial stenosis in 3 (15%) of 20 cases and underestimated 5 (25%) of 20 cases. CONCLUSION: MRA complements Doppler ultrasound to exclude significant hepatic artery stenosis. However, a substantial number of MRA studies were technically inadequate, and MRA demonstrated limited efficacy for correctly grading the severity of hepatic artery stenosis.
Adult↗