Localized fluid collections after liver transplantation

The role of CEUS in the management of biloma

BACKGROUND

A biloma refers to an abnormal, well-defined accumulation of bile outside the biliary tree within the abdomen, which can be either intra- or extra-hepatic in nature. It can result from traumatic or iatrogenic causes, leading to a disruption in the biliary system. Without prompt diagnosis and appropriate management, it can result in significant morbidity and mortality. While magnetic resonance cholangiopancreatography (MRCP) is the typical diagnostic method, there are instances where it may not provide conclusive results.

CASE PRESENTATION

We present the case of a 72-year-old woman who underwent an hepatic resection of the seventh segment after recurrence of hepatocellular carcinoma (HCC). During the ultrasound (US) follow-up, she developed a peri-hepatic collection which proved to be a biloma continuously refurnished by the biliary tree. Neither the MRCP nor the percutaneous transhepatic cholangiography (PTC) were able to clearly detect the exact site of the bile leak. While awaiting the Endoscopic Retrograde Cholangio-Pancreatography (ERCP), a Contrast-Enhanced Ultrasound (CEUS) was conducted administering the contrast agent directly through the percutaneous drainage catheter placed in the biloma. This revealed the presence of contrast flow from the collection to a peripheral right bile duct, confirming the intra-hepatic leak communication.

CONCLUSIONS

This case demonstrates that Contrast-Enhanced Ultrasound (CEUS) presents a straightforward, secure, and precise approach to detect biliary leakage responsible for the formation of a biloma. Additionally, the adoption of CEUS offers the dual benefit of minimizing radiation exposure for the patient and obviating the requirement for anesthesia. In summary, CEUS emerges as a compelling alternative to conventional diagnostic methods for effectively managing a biloma.

Early Intra-Abdominal Bacterial Infections after Orthotopic Liver Transplantation: A Narrative Review for Clinicians

Despite recent advances in the transplant field, infectious complications after orthotopic liver transplantation (OLT) are major causes of morbidity and mortality. Bacterial intra-abdominal infections (IAIs) are predominant during the first month post-transplantation and affect patient and graft survival. Recently, the emergence of multidrug resistant bacteria has generated great concern in OLT patients. We performed this narrative review of the literature in order to propose a "ready-to-use" flowchart for reasoned empirical antibiotic therapy in the case of suspected post-OLT IAIs. The review was ultimately organized into four sections: "Epidemiology and predisposing factors for IAI"; "Surgical-site infections and perioperative prophylaxis"; "MDRO colonization and infections"; and "Reasoned-empirical antibiotic therapy in early intra-abdominal infections post OLT and source control". Multidisciplinary teamwork is warranted to individualize strategies for the prevention and treatment of IAIs in OLT recipients, taking into account each patient's risk factors, the surgical characteristics, and the local bacterial epidemiology.

Early removal of drains and lines after liver transplantation to reduce the length of hospital stay and enhance recovery - A systematic review of the literature and expert panel recommendations

BACKGROUND

The timing of removing abdominal drains, central venous catheters (CVC), and urinary catheters (UC) on post liver transplantation (LT) outcomes is not well elucidated.

OBJECTIVES

To provide international expert panel recommendations and guidelines on time of drain and catheter removal as a part of an ERAS protocol to reduce the length of hospital stay and enhance recovery.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Papers considered were those reporting one or more outcomes of interest related to drainage and line removal in the setting of LT. POSPERO Protocol ID: CRD42021238349 RESULTS: On analyzing five relevant studies pertaining to drains in patients undergoing LT (four retrospectives and one prospective), the length of hospital and/or ICU stay was similar or shorter, and postoperative morbidity and mortality were lower in those without drains. No studies pertaining specifically to the time of removal of drains, CVC's, or UC's in LT were found. Studies in patients undergoing major abdominal surgery or hepatectomies recommend early removal of CVC and UC to reduce catheter-associated infections.

CONCLUSIONS

Based more on expert recommendation, we propose that abdominal drains, if placed during LT, should be removed by postoperative day 5 after LT, based on quantity and fluid characteristics (Quality of Evidence; Low to Moderate | Grade of Recommendation; Strong). Larger studies are needed to more reliably determine indications for early drain and line removal in an ERAS protocol setting.

No Benefit of Prophylactic Surgical Drainage in Combined Liver and Kidney Transplantation: Our Experience and Review of the Literature

Background: Contrasting results have emerged from limited studies investigating the role of prophylactic surgical drainage in preventing wound morbidity after liver and kidney transplantation. This retrospective study analyzes the use of surgical drain and the incidence of wound complications in combined liver and kidney transplantation (CLKTx).

Methods: A total of 55 patients aged ≥18 years were divided into two groups: the drain group (D) (n = 35) and the drain-free group (DF) (n = 20). Discretion to place a drain was based exclusively on surgeon preference. All deceased donor kidneys were connected to the LifePort Renal Preservation Machine® prior to transplantation, in both simultaneous and delayed technique of implantation of the renal allograft. The primary outcome was the development of superficial/deep wound complications during the study follow-up. Secondary outcomes included the development of delayed graft function (DGF) of the transplanted kidney, primary non-function (PNF) and early allograft dysfunction (EAD) of the transplanted liver, graft failure, graft and patient survival, overall post-operative morbidity rate and length of hospital stay.

Results: With a median follow-up of 14.4 months after transplant, no difference in the incidence of superficial/deep wound complications, except for hematomas, in collections size, intervention rate, PNF, EAD, graft failure and patient survival, was observed between the 2 groups. Significantly lower level of platelets, higher INR values, DGF, morbidity rates and length of hospital stay were reported post-operatively in the D group. Pre-operative hypoalbuminemia and longer CIT were included in the propensity score for receiving a drain and were associated with a significantly higher rate of developing a hematoma post-transplant.

Conclusions: Absence of the surgical drain did not appear to adversely affect wound morbidity compared to the prophylactic use of drains in renal transplant patients during CLKTx.

Imaging complications of liver transplantation: a multimodality pictorial review

Liver transplantation is one of the most commonly performed surgical procedures for the treatment of end-stage liver disease and hepatocellular carcinoma. Post-transplantation complications include vascular, nonvascular, and biliary. Common imaging techniques used to evaluate the hepatic graft are ultrasonography (US), CT, MR imaging, cholangiography, angiography, and scintigraphy. The purposes of this pictorial review are to review imaging findings of complications of liver transplantation and provide a framework for early detection of post-surgical complications.

Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions

Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.

Impact of localized ascites after pediatric living donor liver transplantation: report of three cases

Fluid collection is common after living donor liver transplantation (LDLT), and can include hematomas, bilomas, abscesses, and seromas. Although accumulated fluid rarely becomes infected and usually remains localized, localized ascites can sometimes be sufficiently extensive to induce vascular complications. This report presents three such cases in pediatric patients that underwent LDLT. A 33-month-old patient showed an increase in the volume of localized ascites around the hepatic vein anastomoses together with low hepatic vein flow on postoperative day (POD) 47. An 82-month-old patient showed an increase in the volume of localized ascites around the portal vein anastomoses together with low portal vein flow on POD 71. A 63-month-old patient showed an increase in the size of a localized abscess around the hepaticojejunostomy with dilatation of all of the intrahepatic bile ducts on POD 20. These cases illustrate the need for awareness of possible vascular or biliary complications due to compressive localized ascites after LDLT.

Infections in liver transplant recipients

Liver transplantation is a standard life-saving procedure for the treatment of many end-stage liver diseases. The success of this procedure may be limited by infectious complications. In this article, we review the contemporary state of infectious complications during the post-operative period, with particular emphasis on those that occur most commonly during the first 6 mo after liver transplantation. Bacteria, and less commonly Candida infections, remain the predominant pathogens during the immediate post-operative period, especially during the first month, and infections caused by drug-resistant strains are emerging. Infections caused by cytomegalovirus and Aspergillus sp. present clinically during the "opportunistic" period characterized by intense immunosuppression. As newer potent immunosuppressive therapies with the major aim of reducing allograft rejection are developed, one potential adverse effect is an increase in certain infections. Hence, it is essential for liver transplant centers to have an effective approach to prevention that is based on predicted infection risk, local antimicrobial resistance patterns, and surveillance. A better understanding of the common and most important infectious complications is anticipated to lead to improvements in quality of life and survival of liver transplant recipients.

Spectrum of normal or near-normal sonographic findings after orthotopic liver transplantation

The initial imaging immediately after orthotopic liver transplantation is generally performed with ultrasound. Although significant posttransplant complications do occur, many abnormal findings including minor vascular waveform abnormalities, anastomotic mismatches, and fluid collections can be seen in asymptomatic patients. It is important to differentiate these benign findings from more serious complications to avoid unnecessary intervention.