Portal vein thrombosis and liver transplantation: long term

Obstruction of the portal vein may be related to constriction by malignant tumors or thrombosis associated with liver disease. We herein have reported our experience with patients undergoing liver transplantation with portal vein thrombosis (PVT) whose diagnosis was made intraoperatively. From September 1991 to May 2009, we studied 27/419 (6.4%) patients with PVT who were evaluated according to the presence of esophagogastric varices, underlying disease, malignancy, and if there was previous surgery, review of medical records on data collected prospectively. We observed 24 (88.9%) patients with PVT grade 1, 2 (7.4%) with grade 2, and 1 (3.7%) with grade 3. The average age of the PVT patients was 47.5 years; the average model for End-Stage Liver Discase score was 18.3, and the predominant diagnosis, hepatitis C cirrhosis. Eighteen underwent a sclerotherapy/ligature. The sensitivity of ultrasound for grade 1 thrombosis was 39.1%; for grade 2, 50%; and for grade 3, 100%. Portal vein thrombectomy was performed in 24 patients. In other patients (grade 2), we performed an anastomosis of the donor portal vein to the recipient gastric vein or to a greater splanchnic collateral vein. In only 1 patient was the graft performed using the donor portal vein-donor iliac vein-recipient superior mesenteric vein. None of the patients displayed PVT in the immediate postoperative period. Actuarial survivals at the years 1, 3, and 5 were 85%, 74%, and 63%, respectively. We concluded that PVT cannot be considered to be a contraindication for liver transplantation.

Intraoperative massive transfusion decreases survival after liver transplantation

Patients undergoing liver transplantation often experience coagulopathy and massive intraoperative blood loss that can lead to morbidity and reduced survival. The aim of this study was to verify the survival rate and discover predictive factors for death among liver transplant patients who received massive intraoperative blood transfusions. This cohort study was based on prospective data collected retrospectively from January 2004 to July 2006. The 232 patients were distributed according to their blood requirements, (namely, more or less than 6 units), including red blood cell saver. The statistical analyses were performed using Student t test, Cox hazard regression, and the Kaplan-Meier method (log-rank test). The massively transfused cohort displayed higher Child-Pugh classifications (10.2 vs 9.6; P = .03); model for end-stage liver disease (MELD) scores (19 vs 17; P = .02); recipient weights (75.4 vs 71 kg; P = .03); as well as warm ischemia times (70.7 vs 56.4 minutes; P < .001) and surgery times (584.6 vs 503.4 minutes; P < .05). The proportional hazard (Cox) regression analysis showed that the risk of death increased 2.1% for each unit of donor sodium and 1.6% for each additional year of donors age over 50. The survival rates at 6, 12, 60, and 120 months for > or = 6 vs <6 U of blood transfusion of 63.8% vs 83.3%; 53.9% vs 76.3%; 40% vs 60%; 34.5% vs 49.2%. In conclusion, we observed that patients receiving over 6 red blood cell units intraoperatively displayed reduced survival. Predictive factors for this risk factor were high donor level of sodium and of age.

Gastrointestinal bleeding during liver transplantation--report of two cases

A few authors have reported, especially as intraoperative complications, gastrointestinal hemorrhage related to liver transplantation. The aim of this study was to show two cases of gastrointestinal hemorrhage, which occurred during surgery. The first patient was male, 46 years old, with viral hepatic cirrhosis. He had previously presented two episodes of digestive bleeding. Upper digestive endoscopy showed esophageal gastric varices. During the hepatectomy there was bleeding inside the nasogastric tube associated with severe hemodynamics instability without other sources of bleeding. Intraoperative endoscopy evidenced bleeding gastric varices. Gastrectomy was carried out and the varices were tied. The piggyback technique was used in the liver transplantation. The surgery was concluded without problems and in the following four and a half years his condition has evolved well. In the second case, the patient was aged 17, female, with autoimmune hepatic cirrhosis. She had previously presented one episode of digestive bleeding. Intraoperative endoscopy showed median esophageal varices. During the anesthetic induction she presented an episode of hematemesis. A Sengstaken-Blakemore balloon was introduced. The transplant was performed without further problems. Her case has been followed for 14 months in the outpatients' clinic with a good postoperative course. To sum up, gastrointestinal hemorrhage can be due to portal hypertension during the liver transplantation and must be treated quickly. In these cases the surgery must be ongoing.