New therapeutic strategy with extracorporeal membrane oxygenation for refractory hepatopulmonary syndrome after liver transplant: A case report

BACKGROUND

Due to the lack of published literature about treatment of refractory hepatopulmonary syndrome (HPS) after liver transplant (LT), this case adds information and experience on this issue along with a treatment with positive outcomes. HPS is a complication of end-stage liver disease, with a 10%-30% incidence in cirrhotic patients. LT can reverse the physiopathology of this process and restore normal oxygenation. However, in some cases, refractory hypoxemia persists, and extracorporeal membrane oxygenation (ECMO) can be used as a rescue therapy with good results.

CASE SUMMARY

A 59-year-old patient with alcohol-related liver cirrhosis and portal hypertension was included in the LT waiting list for HPS. He had good liver function (Model for End-Stage Liver Disease score 12, Child-Pugh class B7). He had pulmonary fibrosis and a mild restrictive respiratory pattern with a basal oxygen saturation of 82%. The macroaggregated albumin test result was > 30. Spirometry demon strated a forced expiratory volume in one second (FEV1) of 78%, forced vital capacity (FVC) of 74%, FEV1/FVC ratio of 81%, diffusion capacity for carbon monoxide of 42%, and carbon monoxide transfer coefficient of 57%. He required domiciliary oxygen at 2 L/min (16 h/d). The patient was admitted to the intensive care unit (ICU) and extubated in the first 24 h, needing high-flow therapy and non-invasive ventilation and inhaled nitric oxide afterwards. Reintubation was needed after 72 h. Due to the non-response to supportive therapies, installation of ECMO was decided with progressive recovery after 9 d. Extubation was possible on the tenth day, maintaining a high-flow nasal cannula and de-escalating to conventional oxygen therapy after 48 h. He was discharged from ICU on postoperative day (POD) 20 with a 90%-92% oxygen saturation. Steroid recycling was needed twice for acute rejection. The patient was discharged from hospital on POD 27 with no symptoms, with an 89%-90% oxygen saturation.

CONCLUSION

Due to the favorable results observed, ECMO could become the central axis of treatment of HPS and refractory hypoxemia after LT.

Implementation of an ERAS protocol on cirrhotic patients in liver resection: a cohort study

The development of laparoscopic liver surgery, the improvement in the perioperative care programs, and the surgical innovation have allowed liver resections on selected cirrhotic patients. However, the great majority of ERAS studies for liver surgery have been conducted on patients with normal liver parenchyma, while its application on cirrhotic patients is limited. The purpose of this study was to evaluate the implementation of an ERAS protocol in cirrhotic patients who underwent liver surgery. We present an analytical observational prospective cohort study, which included all adult patients who underwent a liver resection between December 2017 and December 2019 with an ERAS program. We compare the outcomes in patients cirrhotic (CG)/non-cirrhotic (NCG). A total of 101 patients were included. Thirty of these (29.7%) were patients ≥ 70 cirrhotic. 87% of the both groups had performed > 70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were similar in both groups. The hospital stay was similar in both groups (2.9 days/2.99 days). Morbidity and mortality were similar; Clavien I-II (CG: 44% vs NCG: 30%) and Clavien ≥ III (CG: 3% vs NCG: 8%). Hospital re-entry was higher in the NCG. Overall mortality of the study was 1%. ERAS protocol compliance was associated with a decrease in complications (ERAS < 70%: 80% vs ERAS > 90%: 20%; p: 0.02) and decrease in severity of complications in both study groups. The application of the ERAS program in cirrhotic patients who undergo liver surgery is feasible, safe, and reproducible. It allows postoperative complications, mortality, hospital stay, and readmission rates comparable to those in standard patients.

Liver Transplant With Double Portal Anastomose: A Case Report

BACKGROUND

Reno-portal reconstruction is a surgical alternative to achieve enough portal flow in liver transplant when there is a complete portal thrombosis, provided there are collaterals or portosystemic shunt, with or without spleno-renal shunt.

METHODS

We present the case of a 58-year-old man with enolic cirrhosis and a history of gastrointestinal hemorrhage due to esophageal varices and portal thrombosis. The clinical case was discussed in the Transplant Committee, and the patient was included in the surgical waiting list with a Model for End-Stage Liver Disease score of 17 and Child-Pugh score of A6. The preoperative computer tomography scan showed significant collateral circulation with esophageal varices, varices dependent on the inferior mesenteric vein (IMV) and hypoplasic portal vein. During the operation, a large shunt from the IMV to the iliac territory and type II portal thrombosis were observed, which was managed with eversion thrombectomy. A temporary portocaval shunt was performed, showing minimal flow in the portal vein, which did not improve after ligation of the systemic shunt. It was decided to perform a reno-portal anastomosis, after which the portal flow measurement was 600 cc per minute; because of this, it was decided to supplement portal flow with an end-to-side portoportal anastomosis, obtaining a flow of 1300 cc per minute with low resistance (R0.5).

RESULTS

The postoperative period was favorable, with good evolution of liver analytical parameters, with permeability of the porto-portal venous anastomoses, reno-portal, arterial, and suprahepatic anastomoses in the imaging tests.

CONCLUSION

If the portal flow is insufficient with a hypoplasic portal vein, a double anastomosis, portoportal, and reno-portal would be a technical resource.

Recipient With Influenza A Infection: Contraindication to Transplant? A Case Report

Active infections in recipients are considered an absolute contraindication to liver transplantation due to the risk of severe disease caused by the required immunosuppression. Even though viral infections, such as Influenza A, have been treated in liver transplant patients both in the immediate and late postoperative period with favorable outcomes, no cases of prediagnosed Influenza A have been described in which the decision to proceed with the indication had to be made. In certain viral infections, like Influenza A, the paucisymptomatic state and the availability of appropriate treatment could open the door to performing liver transplants with positive results.

Implementation of an ERAS protocol on elderly patients in liver resection

BACKGROUND

The increase of quality of life, the improvement in the perioperative care programs, the use of the frailty index, and the surgical innovation has allowed to access of complex abdominal surgery for elderly patients like liver resection. Despite of this, in patients aged 70 or older there is a limitation for the implementation ERAS protocolos. The aim of this study is to evaluate the implementation ERAS protocol on elderly patients (≥70 years) undergoing liver resection.

METHODS

A prospective cohort study of patients who underwent liver resection from December 2017 to December 2019 with an ERAS program. We compare the outcomes in patients ≥70 years (G ≥ 70) versus <70 years (G < 70). The frailty was measured with the Physical Frailty Phenotype score.

RESULTS

A total of 101 patients were included. 32 of these (31.6%) were patients ≥70 years. 90% of the both groups had performed >70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were quicker in <70 years group. The hospital stay was similar in both groups (3.07days/2.7days). Morbidity and mortality were similar; Clavien I-II(G ≥ 70:41% vs G < 70:30,5%) and Clavien ≥ III (G ≥ 70:6% vs G < 70:8.5%), like hospital readmissions. Mortality was <1%. ERAS protocol compliance was associated with a decrease in complications (ERAS < 70%:80% vs ERAS > 90%:20%; p = 0.02) and decrease in severity of complications in both study groups. Frailty was found in 6% of the elderly group; the only patient who died had a frailty index of 4.

CONCLUSION

Implementation of ERAS protocol for elderly patients is possible, with major improvements in perioperative outcomes, without an increase in morbidity, mortality neither readmissions.

A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

PURPOSE

A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort.

METHODS

An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included.

RESULTS

A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%.

CONCLUSION

Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.

Treatment of acute intraoperative Budd-Chiari syndrome by placement of silicone prosthesis

Complete liver mobilization for major resections sometimes causes liver tilting due to the release of the suspensory elements of the liver. Rarely this may take to a liver abnormal position with acute obstruction to venous flow at the suprahepatic level (Budd-Chiari syndrome). To avoid this complication, techniques such as post-operative stent implantation have been described. The case of a patient who underwent a complete mobilization of the liver for resection of the inferior venous cava and a right renal tumor, was reported. After that, an acute Budd-Chiari Syndrome was observed caused of the liver malposition, which was solved with the placement of two silicone prostheses in the liver cell.

Recommendations on intervention for hepatobiliary oncological surgery during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic requires an analysis in the field of oncological surgery, both on the risk of infection, with very relevant clinical consequences, and on the need to generate plans to minimize the impact on possible restrictions on health resources.

The AEC is making a proposal for the management of patients with hepatopancreatobiliary (HPB) malignancies in the different pandemic scenarios in order to offer the maximum benefit to patients, minimising the risks of COVID-19 infection, and optimising the healthcare resources available at any time. This requires the coordination of the different treatment options between the departments involved in the management of these patients: medical oncology, radiotherapy oncology, surgery, anaesthesia, radiology, endoscopy department and intensive care.

The goal is offer effective treatments, adapted to the available resources, without compromising patients and healthcare professionals’ safety.

Recommendations on intervention for hepatobiliary oncological surgery during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic requires an analysis in the field of oncological surgery, both on the risk of infection, with very relevant clinical consequences, and on the need to generate plans to minimize the impact on possible restrictions on health resources. The AEC is making a proposal for the management of patients with hepatopancreatobiliary (HPB) malignancies in the different pandemic scenarios in order to offer the maximum benefit to patients, minimising the risks of COVID-19 infection, and optimising the healthcare resources available at any time. This requires the coordination of the different treatment options between the departments involved in the management of these patients: medical oncology, radiotherapy oncology, surgery, anaesthesia, radiology, endoscopy department and intensive care. The goal is offer effective treatments, adapted to the available resources, without compromising patients and healthcare professionals safety.

Predictive Models of Hepatocellular Carcinoma Recurrence After Liver Transplantation

BACKGROUND

Liver transplantation (LT) is a curative treatment for patients with hepatocellular carcinoma who are not candidates for resection. Despite the generalized use of the Milan criteria and up-to-seven criteria, new markers have been proposed to predict recurrence after LT. Biomarkers such as neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), and scores such as the Model of Recurrence After Liver transplantation (MORAL) are used as predictors of post-LT recurrence.

OBJECTIVE

We aim to compare NLR, PLR, and MORAL score with Milan criteria and up-to-seven criteria.

METHODS

A descriptive study of 99 patients who underwent LT for hepatocellular carcinoma in our hospital between April 2010 and April 2016. The 5 prognostic models were applied to the patients to stratify them into risk groups. We used a Kaplan-Meier survival plot to measure recurrence-free survival in each model. Receiver operative curves were used to compare the models.

RESULTS

Three-year recurrence-free survival in MORAL was 91.1% for the low-risk group, 89.8% for the moderate-risk group, 60% for the high-risk group, and 75% for the very high-risk group (P = .003). The combined MORAL score was superior in predicting 1- and 3-year recurrence with the area under the curve 0.684 (95% confidence interval [CI]: 0.52-0.85) compared with Milan (0.536 [95% CI: 0.37-0.70]), up-to-seven (0.601 [95% CI: 0.43-0.77]), PLR (0.452 [95% CI: 0.30-0.61]), and NLR (0.542 [95% CI: 0.37-0.71]).

CONCLUSIONS

A model based only on pre-LT radiological signs leads to underdiagnosis of tumor load; therefore, the risk of recurrence must be recalculated after LT. The combined MORAL score was the best prognostic model of 1- and 3-year recurrence after LT in our study.

Influence of Preoperative Muscle Mass Assessed by Computed Tomography on Prognosis After Liver Transplantation

BACKGROUND

Sarcopenia (SP) and preoperative muscle mass are independent predictive factors for short- and long-term outcome of liver transplantation.

OBJECTIVE

To assess the influence of muscle mass index (MMI) and preoperative SP on the prognosis of patients who underwent liver transplantation in our hospital.

METHODS

Ninety-seven patients who underwent liver transplantation in the Regional University Hospital of Málaga from September 2013 to March 2016 were analyzed. SP was determined based on the MMI, as assessed by psoas muscle area at the L4 level measured by computed tomography (CT), with adjustment for patient sex. Two cohorts were differentiated: 54 patients without SP and 42 patients with SP. Postoperative complications, graft survival, and patient survival were assessed. A 3-year follow-up was carried out.

RESULTS

Recipient characteristics were similar in both cohorts, except for MMI ± SD (group without SP: 94.03 ± 15.43 cm2/m2 vs group with SP: 56.99 ± 13.59 cm2/m2; P = .001). The incidence of postoperative complications (Clavien ≥ 3) in patients with and without SP was 39.5% and 24.1%, respectively (P = .08). SP was not associated with poorer long-term graft or patient survival.

CONCLUSIONS

SP, determined by preoperative measurement of MMI, was identified as a predictive factor associated with a higher incidence of postoperative complications. Since MMI can be easily determined by CT, it should be assessed in all candidates for liver transplantation.

Results of liver transplantation with donors older than 80 years: a case control study

AIM

The inclusion of elderly donors can increase the pool of organs available for transplant.

BACKGROUND

To compare clinical outcomes and survival rates in patients who received livers from donors aged ≥ 80 years vs. younger donors.

METHODS

We considered all liver transplantations performed in our unit between January 2006 and January 2015. Twelve patients received liver from a cadaveric donor aged ≥ 80 years (study group) and their outcomes were compared with those of patients who received liver from a younger donor (control group). This study was carried out to analyze the characteristics of donors and recipients, as well as the clinical course and survival of recipients.

RESULTS

Statistically significant differences were observed in donors' age (55.6 ± 14.4 vs. 82.7 ± 2.7 years, p < 0.001), donors' ICU stay (p = 0.008), donors' ALT levels (p = 0.009) and donors' AST levels (p = 0.01). Statistically significant differences were found in ischemia time (p < 0.05). In total, 8.3% of the recipients of liver from a donor aged < 80 required retransplantation vs. 25% of recipients of donor's ≥ 80 years. Patient survival at one, three and five years was 89%, 78.6% and 74.5%, respectively vs. 83.4%, 79.4% and 59.6% for the study group.

CONCLUSION

Livers from older donors can be safely used for transplantation with acceptable patient survival rates. However, graft survival rates are lower for recipients of livers from older donors as compared to younger donors, and survival only increased with retransplantation.

[Negative pressure therapy in wounds with enteric fistulas]

OBJECTIVE

Negative pressure therapy (VAC, vacuum assisted closure) is a method used still in our country. It consists of a system of aspirating a wound by means of a piece of foam and a few adhesive films. It allows the treatment of complex wounds, included (although this is still controversial) those with intestinal fistulas. We present 3 cases of treatment with VAC in this situation and a review of the published literature.

PATIENTS AND METHOD

We have treated 10 patients, since VAC therapy was introduced into our centre of which 3 of whom had a fistula in the bed of the surgical wound. We describe the clinical information of the patients and the therapy that followed in each of the cases.

RESULTS

Significant local clinical improvement of the disease, with control of the symptoms, was achieved in all 3 cases. We were able to re-operate to close the fistula in one of the patients, with subsequent good progression of the wound. In the other two cases it gave them a better quality of life although both died due to the overall complexity of their situation.

CONCLUSIONS

VAC therapy, although controversial in the treatment of intestinal fistulas, can help to improve the local situation of the wounds, the comfort of the patients and their general situation.