Posters
Tuesday May 23, 2006 8:00AM Hepatitis C
Liver
Transplantation
A. Sanchez; H. Bonatti; R.
C. Dickson ; J. H. Nguyen; W. C. Hellinger; R. A.
Hinder; H. K. Chua; J. Aranda-Michel
BACKGROUND:
Liver transplantation (LT) is the
treatment of choice for end-stage liver disease. Liver diseases can be
associated with diseases of the intestinal tract and post LT immunosuppressive
agents might predispose to colonic complications. AIM: We retrospectively
analyzed the incidence and spectrum of colonic complications in a cohort of 402
LT patients.
PATIENTS
AND METHODS:
A total of 467 consecutive LTs in 402 individuals were performed between 1998 and 2001
at the Mayo Clinic,
RESULTS:
During a mean follow up period of
three years 81 colonic complications developed in the 467 LT events. 4/19
patients transplanted for PSC and inflammatory bowel disease (ulcerative
colitis n=16, Crohns disease n=3) had persistent
colitis; 8/19 patients had colectomy prior to LT and
7/19 had no colonic symptoms during the follow up period. Combined colonic
intervention and LT were performed simultaneously in 3 patients; one with
colonic resection due to multiple colonic perforations during re-LT; one with resection
for ischemic colitis associated with acute liver failure and the last case a preexisting transverse colostomy that had to be reinforced.
Colonic polyps were endoscopically removed in seven
patients and three patients were diagnosed with colorectal cancer (one cecal, two rectal cancers), which all were surgically
treated. One patient developed a hemorrhage of the
terminal ileum/cecal region in the course of
intra-abdominal sepsis, and was treated by endovascular embolization
of the ileocolic artery. Two patients developed hemorrhoids requiring surgical interventions, and two
patients had perianal fistulas. Two patients
developed sigmoid diverticulitis and one appendicitis
requiring surgical intervention. There were 32 cases of Clostridium difficile associated enterocolitis.
Nine patients developed CMV gastrointestinal complications with three cases of
colitis, one leading to perforation, intra-abdominal sepsis and death. One
patient developed a herpetic rectal ulcer and two perianal
HSV associated lesions. Chronic diarrhea was seen in
fifteen patients who had a negative evaluation that required withdrawal of mycophenolic acid.
CONCLUSION:
The frequency of colonic disorders in
our series was higher than expected. Infection complications account for the
majority of colonic complications seen in LT patients. The high incidence of
clostridium colitis warrants improvement in screening and preventive
measurements. Screening for polyps pre-transplant and post-transplant is highly
recommended.
Abstract T1218 Incidence, endoscopic
findings and treatment of biliary tract complications after orthotopic liver
transplantation - a single centre experience.
N. Hoepffner; Y. Shastri; B. Akoglu; C. Zapletal; W. O. Bechstein; W. Caspary; D. Faust
Background:
Despite standardization for biliary
reconstruction biliary complications after orthotopic
liver transplantation (OLTx) occur in 7 to 51% of
cases and are an important cause of early and late postoperative morbidity and
mortality. The most common biliary complications are
bile leaks and bile duct strictures. Early diagnosis and prompt treatment of biliary complications are necessary to reduce morbidity and
mortality related to LTx. Here we have evaluated the
role of endoscopic retrograde Cholangio Pancreatography (ERCP) in the diagnosis, treatment and
outcome of post OLTx biliary
complications.
Patients and
methods:
This retrospective study included 162 patients (109
male, age 52 ± 10 yrs; 53 female, age 49 ± 14 yrs) who underwent OLTx between 1984 and 2004 and were regularly followed up
at
Results:
40 (24.6%) patients underwent ERCP for diagnosis and
treatment of biliary complications. The median time
between OLTx and first suspicion of biliary complications was 12 month (range 1 to 94 months).
Overall 70 different biliary tract complications were
identified. The most frequently diagnosed complication was isolated anastomotic strictures in 28 (40%), followed by bile leakage
in 17 (24%) and non anastomotic strictures in 6 (9%),
whereas 19 patients (27%) experienced miscellaneous complications like choledocholithiasis 7 (10%), abscess 5 (7%) or secondary cholangitis in 4 (6%). 50% of the patients developed only 1
type of biliary complication after OLTx. Number of ERCPs performed
per patient ranged from 2 to 52. Sustained success was achieved in 26 (81%),
while endoscopic treatment failed in 6 (19%). Out of this, 3 patients were
re-operated. Till date, none of these were considered for re-transplantation.
Conclusion:
Biliary complications still
remain an important problem in liver transplant patients. Endoscopic management
is usually effective in majority of them but may require multiple procedures
especially to treat strictures. Surgical intervention is required only in a few
selected cases.
Abstract T1219 Endoscopic Treatment for Biliary Complications in Donors after Living-donor
Liver Transplantation
S. Shio; S. Yazumi; K. Hasegawa; M. Kida; J. Yamauchi; S. Tada; H. Egawa; S. Uemoto; T. Chiba
Background
and Aims.
With the increased number of
living-donor liver transplantation (LDLT), post-operative biliary
complications of the donors have become one of the most significant problems of
the LDLT. The aims of this study were to characterize the features of the biliary complications of the donors occurred after LDLT and
to evaluate the feasibility of treating biliary
complication endoscopically.
Patients
and Methods.
A database of 613 consecutive donors
(360 right lobes and 253 left robes) of LDLT from July 1999 through April 2005
in
Results.
The overall incidence of biliary complications was 4.1% (25/613); the incidence in
right-lobe donors [6.1% (22/360)] was significantly higher than that in
left-lobe donors [1.2% (3/253)] (p>0.001). The complications were 23 biliary leakages and 7 biliary
strictures;5 of 7 biliary strictures occured after closure of biliary
leakage. Out of 25 patients with biliary
complications, 5 could not be treated endoscopically
due to difficulty of cannulation (n=2), and large
sized biliary leakage (n=3). They were all converted
to surgical treatment. Biliary leakage (n=18) and
stricture (n=7) were treated by ENBD and EBD, respectively. Finally, 20 of 25
patients (80.0%) could be treated endoscopically.
There were no significant ERCP-related complications.
Conclusion.
The right-lobe donors for LDLT have a
significantly higher incidence of biliary
complications than the left-lobe donors. The endoscopic treatment is useful for
biliary complications of donors for LDLT and should
be attempted before surgical conversion.
Abstract T1220 Evaluation of
transabdominal ultrasonography for biliary
complications after liver transplantation in recipients with choledochocholedochostomy without T-tube
C. J. Long; S. Biggins; R. B. Goldstein; E. Yen; K. Bagatelos;
S. Feng; J. W. Ostroff
BACKGROUND:
Biliary complications after liver
transplantation (LT) are common, account for significant morbidity, and can be
difficult to distinguish from graft rejection or disease recurrence. Transabdominal ultrasonography
(TAUS) is a non-invasive initial diagnostic test for biliary
complications after LT. Prior studies have predominantly evaluated TAUS in LT
recipients with Roux-en Y biliary reconstruction or choledochocholedochostomy (CDCD) with a T-tube. AIM: To
evaluate the diagnostic characteristics of TAUS for biliary
complications after LT in patients with CDCD without T-tube.
METHODS:
Records of patients who had LT with CDCD anastomosis without T-tube at our institution between
4/30/1998 and 5/30/2003 were reviewed for evidence of post-transplant
endoscopic retrograde cholangiopancreatography
(ERCP), percutaneous transhepatic cholangiography
(PTC), or biliary surgery performed for the
evaluation of a suspected biliary complication.
Patients within this group having TAUS within 4 weeks prior to ERCP, PTC, or
surgery were included in this study. TAUS reports were compared to ERCP, PTC,
or surgical reports as the gold-standard. Biliary
dilation, perihepatic fluid collections, or intraductal stones were considered positive sonographic findings.
RESULTS:
Of 459 LT recipients, 82 patients met inclusion
criteria for this study. Mean age was 51 years (range 18-72) and 58% were male.
The most common reason for transplantation was hepatitis C. 5/82 patients
received living donor transplants. The mean (range) time from TAUS to the
gold-standard exam was 4.5 (0-28) days. A biliary
complication was confirmed in 71/82 (87%) patients based on gold standard
evaluation. The sensitivity of TAUS for detecting a biliary
complication was 60/66 (91%) with a specificity of 5/16 (31%). The sensitivity
for detecting anastomotic stricture, non-anastomotic stricture, and biliary
leaks was 95%, 100%, and 100% respectively. The positive predictive value and
negative predictive value of TAUS in detecting any biliary
complication in this study was 60/71 (85%) and 5/11 (45%), respectively.
CONCLUSION:
In LT recipients with CDCD biliary
anastomosis, transabdominal
ultrasonography is a sensitive screening modality for
the evaluation of biliary tract complications. Transabdominal ultrasonography
should be included in the initial evaluation of suspected post-tranplant biliary complications.
S. Iacob; S. Beckebaum; R. Iacob; V. Cicinnati; C. Klein; L. Gheorghe; C. Gheorghe; I. Popescu; A. Frilling; M. Malago;
G. Gerken; C. Broelsch
INTRODUCTION:
Hepatitis C virus (HCV) associated liver disease is the
most common indication for liver transplantation (LT). Short-term patient and
graft survival for HCV-infected recipients have been reported to be similar to
that of most other indications, but long-term survival rates are shorter.
AIM &
METHODS:
To assess the impact of different pre and post LT
factors on graft survival. For this purpose we reviewed the records of 168
patients who underwent LT for HCV liver cirrhosis between January 1989 and
October 2004. To identify potential predictors of graft and patient survival, univariate and multivariate Coxs proportional hazards
regression model was used.
RESULTS:
One year overall graft and patient survival rates were
72% and 85% respectively and 5 year survival rates were 51% and 73%. Median
survival was 6.1 years for graft and 12 years for patient. In the univariate survival analysis the following parameters were
identified as predictors of both graft failure and patient death: diagnosis of
histologically proven recurrent hepatitis before 1 year after LT (p<0.0001
and 0.001), presence of early (within the first 6 months) biliary
complications (p=0.0007 and 0.002), administration of prednisone <180 days
(p<0.0001 and 0.01) and mycophenolate mofetil (MMF) <180 days (p=0.0009 and 0.02), induction
without azathioprine (p=0.0002 and 0.003). Absence of
post LT antiviral therapy was associated with a poorer graft survival (p=0.003)
and severity of pre LT liver disease illustrated by Child-Pugh classification C
(p=0.009), MELD score > 18 (p=0.01), presence of hepato-renal
syndrome (p=0.03) with patient mortality. Independent predictors of both graft
failure and patient death in the multivariate survival analysis were: presence
of early biliary complications (p=0.0001 and
p=0.004), administration of MMF<180 days (p<0.0001 and p=0.02) and time
to histologic recurrence less than 1 year
(p<0.0001 and p=0.001). Graft loss was independently influenced also by the
recent year of LT after 2000 (p=0.0009), administration of prednisone <180
days (p=0.0004) and induction without azathioprine
(p=0.0005). A higher MELD score>18 (p=0.01) had an independent negative
prognostic value for post LT patient survival.
CONCLUSIONS:
There are factors affecting both graft and patient
survival, among which certain immunosuppressive strategies, the presence of
early bile duct complications and the identification of the histologic
HCV recurrence in the first posttransplant year seem
to be of major importance.
Abstract T1222 Long-Term Outcome of
Orthotopic Liver Transplantation in Cryptogenic Cirrhosis.
H. Boucard; R. Parikh; A. Samanta; B. Koneru; D. Wilson; A.
Fisher; M. DebRoy; A. De La Torre;
K. Klein
Introduction:
Cryptogenic cirrhosis (CC) is one of
the common indications for liver transplantation. Long term outcome in CC is
not clearly defined with previous studies revealing conflicting results. It is
being increasingly recognized that hepatitis following transplantation occurs
in such patients with varying frequency (0-50%).
Aim:
The present study compared the
outcome of liver transplantation in CC with that in hepatitis C virus related
cirrhosis (HCVC) by studying patient and graft survival.
Method:
This is a retrospective study
involving 41 patients who underwent transplantation for CC between December
1994 and October 2003 at our transplant center. The diagnosis of CC was made by
negative serology for auto-immune liver diseases (ANA, Anti-smooth muscle Ab, AMA), negative viral hepatitis serology (anti-HCV,
HCV-RNA by PCR, HBsAg, HBsAb,
HBcAb), normal ceruloplasmin,
α-1 antitrypsin, transferrin
saturation and confirmed by liver histology that was negative for viral or
known metabolic liver diseases.
Results:
Mean follow up for the CC group (mean
+/- SE) 5.76 +/- 0.44 years and 4.14 +/- 0.31 years for HCVC patients. For
patients with CC the age, BMI and MELD score were 55.2 +/- 1.93 years, 30.9 +/-
3.82 m2/kg, and 19.45 +/- 1.06 respectively compared to 52.04 +/- 1.15 years,
27.58 +/- 0.68 m2/kg, 19.87 +/- 0.97 for HCVC patients. Diabetes mellitus was
present in 55% of CC and 39% of HCVC (p=0.17). Actuarial patient survival by
Kaplan Meier analysis for CC was significantly better at 1 and 3 years being 90
+/- 7.5 % and 77.5 +/- 6.6 % compared to 84 +/- 4.6% and 62 +/- 6% for HCVC
patients (p=0.0026). Actuarial graft survival for CC was also significantly
better at 1 and 3 years being 87.8 +/- 5.1 %, and 78 +/- 6.5% compared to 77
+/- 4.96 % and 54 +/- 5.9 % for HCVC patients (p=0.0004).
Conclusions:
This study indicates that OLT for CC
is associated with a favorable outcome for patient
and graft survival compared to HCVC.
A. Wieckowska;
N. N. Zein
Background:
Patients with hepatitis C virus (HCV)
cirrhosis are at increased risk for the development of hepatocellular carcinoma
(HCC). Periodic surveillance ultrasound examination for early detection for HCC
has been recommended.
Aims:
1) to determine the frequency of HCC
in patients with ESLD due to HCV on the liver transplant (LT) waiting list, 2)
to define the utility of surveillance ultrasound in identifying HCC in this
population.
Methods:
Patients with HCV cirrhosis in the
absence of HCC that were listed for LT at our institution between 1997 and 2004
were identified. Histologically proven HCC (by biopsy, explanted liver or on
autopsy) was used to define HCC in this population. Patients who died prior to
LT and had no autopsy examination were excluded. Patients who were still on the
waiting list at the time of the analysis were excluded since histological
examination was not available. All patients had at least one ultrasound
examination while waiting for LT. A total of 211 ultrasound examinations were
performed in 98 patients during the waiting time (1 to 8 ultrasounds per
patients). The mean time from listing to transplantation was 10.7 months.
Results:
In total, 13 patients were found to
have histologically proven HCC (13%). Of 98 patients, 18 (18.4 %) had at least
one positive ultrasound examination identifying a liver nodule during the
waiting time on the list. Of these 18 patients, 9 were confirmed to have HCC by
histology, while 9 appeared to have a false positive ultrasounds for HCC. Of
the remaining 80 patients who had a negative ultrasound, 4 (5%) were found to
have HCC on histologic examination of explanted liver
(2 of 4 HCC were greater than 2 cm). Overall, surveillance
Conclusion:
1) Patients with ESLD due to HCV
cirrhosis on the LT waiting list had a high frequency of HCC, supporting the
need for surveillance measures with high sensitivity for early detection. 2)
The sensitivity of surveillance ultrasound for early detection of HCC appears
to be suboptimal, particularly in the current era where patients with HCC may
receive a higher priority score for LT.
Abstract T1224 Hepatitis B, tumor treatment and immunosuppression influence recurrence of hepatocellular
carcinoma after liver transplantation
S. Ciesek; T. Becker; T. Greten;
J. Klempnauer; M. P. Manns; C. P. Strassburg
Introduction
Hepatocellular carcinoma (HCC)
represents a considerable therapeutic challenge. Trans-arterial chemoembolization (TACE) and percutaneous ethanol
instillation (
Methods
Eighty-five patients with HCC
transplanted between 1975-2004 at
Results
In 8/85 (9.4%) HCC was established
post OLT. Etiologies of chronic liver disease
included HCV (39%) and HBV (24%) infection, and alcoholic cirrhosis (15%).
Cirrhosis was absent in 6/85 (7%). Recurrent HCC occurred in 18.8% after a mean
of 3.3 years following OLT. HCC stages at OLT were T1 (18%), T2 (37%), T3 (13%)
and T4 (12%). Recurrence was associated with T4 (31% vs
7%, p=0.018, OR 5.82) but not with T1-3, with HBV (60% vs
40%, p=0.02 OR 3.85), and with patients receiving tacrolimus
(62.5% vs 37.5%, p<0.0001, OR 10) and/or steroids
(69% vs. 31%, p=0.0006, OR 7.69) compared to cyclosporine or mycophenolate mofetil. After
pre-operative TACE HCC recurrence (62.5%) was more frequent compared to
Conclusions
Recurrence-free survival was achieved
in 80% of patients undergoing OLT. Tumor stage, TACE
before OLT, HBV infection and immunosuppression with tacrolimus and steroids were identified as risk factors for
HCC recurrence. Pre- and post-operative management of HCC therefore influences
the outcome in OLT in HCC.
