20130512 移植相關 issue

Ann of Surg- PAP

A Retrospective Study on Risk Factors Associated With Failed Endoscopic Treatment of Biliary Anastomotic Stricture After Right-Lobe Living Donor Liver Transplantation With Duct-to-Duct Anastomosis

A retrospective study was performed on 287 patients who received right-lobe living donor liver transplantation with duct-to-duct anastomosis. 

The morphology of BAS was categorized into 3 types: pouched, intermediately pouched, and triangular. 

Results: 

Fifty-nine patients (20.6%) had BAS and received ERC and balloon dilatation with or without stenting. 

The success rate was 73.2%. 

The median number of sessions needed for successful ERC was 3. 

In the 15 patients with failed ERC,
4 : percutaneous transhepatic biliary drainage and balloon dilatation, 11: hepaticojejunostomy 

Risk factors for failed ERC:
Recipient age [odds ratio (OR): 0.922; 95% confidence interval (CI): 0.85-1.00; P = 0.049], Operation time (OR: 1.007; 95% CI: 1.001-1.013; P = 0.025),
Morphology of stricture (OR: 6.722; 95% CI: 1.31-34.48; P = 0.022)

The success rates for the 3 types of BAS-pouched, intermediately pouched, and triangular-were 42.9%, 63.6%, and 88.9%, respectively (P = 0.021). Association was found between bile leak and pouched BAS (P = 0.008).

Transplantation 15 May 2013 - Volume 95 - Issue 9

Once-Daily Extended-Release Versus Twice-Daily Standard-Release Tacrolimus in Kidney Transplant Recipients: A Systematic Review

Six randomized controlled trials (n=2499) and 15 observational studies (n=2886) were included in the review. 

Results:

No significant differences in
biopsy-proven acute rejection (two trials, n=1093; risk ratio [RR; confidence interval (CI)], 1.24 [0.93–1.65]; P=0.15; I2=0%),
patient survival (three trials, n=1156; RR [CI], 0.99 [0.97–1.02]; P=0.55; I2=32%), and
graft survival (three trials, n=1156; RR [CI], 0.99 [0.97–1.02]; P=0.67; I2=0%) between the two formulations at 12 months. 

Similar results for
acute rejection (five studies, n=391; RR [CI], 0.99 [0.93–1.06]; P=0.84; I2=0%) and
overall patient survival (two studies, n=218; RR [CI], 1.02 [0.94–1.10]; P=0.62; I2=0%) were observed in observational studies. 

Conclusions: Once-daily tacrolimus appears to be as effective as twice-daily tacrolimus up to 12 months after kidney transplantation.

De Novo Malignancies After Adult-to-Adult Living-Donor Liver Transplantation With a Malignancy Surveillance Program: Comparison With a Japanese Population-Based Study

360 adult LDLT recipients who survived more than 1 year after transplantation. 

Results: Mean follow-up period was 7.5±3.4 years.
During the follow-up period, 27 de novo malignancies were diagnosed in 26 recipients. Colorectal cancer was the most commonly detected malignancy. 

The overall mortality of the recipients with de novo malignancies was similar to the findings of the Japanese general population-based study (standardized mortality ratio=0.9). 

Overall, the incidence of cancer was significantly higher in transplant recipients than in the Japanese general population (standardized incidence ratio=1.8). 

The 5-year estimated survival rate of recipients with de novo malignancies was 81% and those of recipients without malignancies was 93% (P<0 .0001="" font="" nbsp="">

Conclusions: Colorectal malignancies predominated in Japanese liver transplant recipients. Although de novo malignancies correlated with a poor prognosis, the standardized mortality ratio was 0.9 compared with that of subjects of a Japanese population-based study.

Hepatic Hydrothorax and Treatment

Cause: 因為已經被問到兩次了,而且有人說可以把Diaphragm補起來...所以來查查！！ 

Definition: recurrent pleural effusion in patients with end-stage liver disease and portal hypertension in the absence of comorbid cardiac or pulmonary disease

Theories:

1955: hydrothorax develop frequently have defects in the diaphragm that permit egress of ascites into the negative-pressure space of the pleural cavity 

=> Intra-abdominal pressure elevated -> Diaphragm herniation -> rupture to pleural space

=> Can be seen under following the passage of various tracers—air, dyes, and radiolabeled substances—from the peritoneal to pleural compartments and by direct thorascopic visualization of the defects （1992～2005）

2007: Development of hydrothorax include transdiaphragmatic leakage of fluid from lymphatic channels and azygos vein hypertension 

Icidence: 5~12%

More right side(85%), 仍有Left side(13%) or bilateral side(2%)!!

Diagnosis:

Thoracocentesis: transudative by traditional criteria of Light and colleagues

(From Aliment Pharmacol Ther 2004; 20: 271–279.)

Treatment:

For relieve dyspnea 

=> Therapeutic thoracentesis , 

=> No need of chest tube:
      induced infection, acute renal failure, and reflecting large volume loss , even poor outcomes

Medical Management: Similar to ascites 

          => diet salt restriction(low sodium diet of 70–90 mmol/day) and 

               diuretics(BEST: furosemide 40 mg/day and spironolactone 100 mg/day.)

                              => Doubling dose 3-5 days, 

                              => up to spironolactone up to 400 mg/day and furosemide up to 160 mg/day.

          => Early TIPS -> But not so sure as ascites-> 79% and 75 % response at POM1 and POM6 

                (Dhanasekaran et al, 2009). 

                      但如果不能作TIPS, 那就不好處理了～～～

(From Aliment Pharmacol Ther 2004; 20: 271–279.)

Surgical treatment:

Definite: Liver transplantation!!

Other surgical tx: 

# Timing: TIPS or VATS  repair of the diaphragmatic defects (with or without pleurodesis) are effective strategies in those who are not transplant candidates or those awaiting organ availability.

(from Ann Hepatol. 2008 Oct-Dec;7(4):313-20.)

=> Surgical repair of the diaphragmatic defects => 問題還是Child C 的Morbidity and Mortality!

=> Traditional thoracoscope + talc

     Chest 2000; 118: 13–7.

     thoracentesis followed by talc poudrage under thoracoscopy        and repair of diaphragmatic defects if seen

     18 patients with 21 procedures

     => Diaphragm defect was only in 5 pts. (27.8%)

     => High morbidity (57.1%) and mortality (38.9%)

     => Only 10/21 (47.6%) effective

     => 43.7% recurred and with complication 

     

=> VATS + talc Pleurodesis + repair

      Chest. 1996 Apr;109(4):1093-6.

     8 patients underwent VATS to localize and close of diaphragmatic defects!

     2 no defects, Drainage placed for 15 and 18 days, Volume: 3 and 4L

     6 with defects(75%), Drainage placement for 7.6 +/- 1.75 days, Volume:  0.408 +/- 0.157 mL

               No of these 6 pts got recurrence....

      Am J Gastroenterol 2002; 97: 3172–5.

        15 pts with VATS + talc pleurodesis

      11/15 (73%) resolution at 1st month, 

          8/11: asymptomatic after median 5.5 m/o f/u

          3/11:recurr between 45~60 days after VATS

     Complications: Pain, Low grade fever, fistula and empyema!

=> VATS + talc Pleurodesis , no repair

      Ann Thorac Surg. 2003 Mar;75(3):986-9. 

     => Conclusion: Even with tunnel, Talc pleurodesis still effect! 

                               -> In poor clinical status, repeat injection may be useful!

                            VATS+pleurodesis: a choice!

      13 pts underwent VATS + Pleuraodesis, 

          => 2 of them with defects(15.4%), 1 of them with fluid leakage

          => 10 of them no recurrence, 2 of them got late recurr before dying from cirrhosis

                1 of them ear;y recurrence -> following Talc pleurodesis 

      8 pt cannot tolerate GA-> Chest tube insertion

          => 3: Septic shock-> die! 

          => 3: early recurrence -> Cured after Talc pleurodesis

               1: mid-term

               1: early recurr -> Tx with TIPS -> Partial improvement!! 

      Ann Thorac Surg. 2006 Aug;82(2):457-9. 

     => VATSsurgery with talc is safe and successful in about 3/4 of patients, 

           but repeat talc slurry through the chest tube or repeat VATS is often needed.

     => An alternative effective Tx to TIPS

     41 pts underwent VATS + talc pleurodesis, followed 6 m/o

     => Only 2 patient with defect (<5 font="">

     => 1/40 (2.5%) Mortality -> Intra-operative, Due to coagulopathy!

     => 7/41 (17%) need repeat beside talc injection

     => Overall success rate: 80% (33 / 41)

     => 4 experienced symptomatic fluid collection, and Tx by repeat VATS -> 2/4 success!!

=> VATS + other pleurodesis

     Surg Endosc. 2004 Jan;18(1):140-3. Epub 2003 Nov 21.

     9 pts with VATS ->argon plasma ->   bioabsorbable prostheses
                    -> 3ml fibrin glue and sprinkled 5 KE of OK-432 + 100mg minocyclin

     All clinical improvement, 7/9 successful (77.8%), 

     2 recur at POM1 and POM4, 1/2: success after repet pleurodesis!!

=> Tunnel pleral catheters!!

=> Catheter placement -> as useful in palliative care...

Take home message:

1. 遇到Hepatic Hydrothorax 的病人, 重點還是在Ascites control!!

2. Definite Defect 其實不常見( <5 b="">

3. 治療, 能換肝就換肝, 不能換肝或等換肝太嚴重的, TIPS可以是選擇

   VATS +/- pleurodesis +/- defect repair 也是有效的 (recently可到70~80% 成功率！)

   => This is CS field 

4. 重點還是在這種病人能不能忍受General anethesia, 千萬不要輕易開進去！！！

Reference:

Blumgart’s Surgery of the Liver, Biliary Tract, and Pancreas, 5th edition

Aliment Pharmacol Ther. 2004 Aug 1;20(3):271-9. 

Ann Thorac Surg. 2006 Aug;82(2):457-9. 

Ann Thorac Surg. 2003 Mar;75(3):986-9. 

Chest. 1996 Apr;109(4):1093-6.

Ann Hepatol. 2008 Oct-Dec;7(4):313-20.