Posters – Tuesday May 23, 2006 8:00AM Hepatitis C
A. Sanchez; H. Bonatti; R. C. Dickson ; J. H. Nguyen; W. C. Hellinger; R. A. Hinder; H. K. Chua; J. Aranda-Michel
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, Jacksonville, Florida. Standard immunosuppression consisted of Tacrolimus, Mycophenolic acid and steroids.
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, Crohn’s 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.
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
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 Frankfurt liver transplantation centre. The mean time since OLTx was 6 ± 4 years. Endoscopic therapy was performed with balloon dilation and or plastic endoprosthesis. 154 patients underwent biliary continuity by choledocho-choledochostomy (end to side in 114 and side-to-side in 40) while 8 patients underwent Roux-en-Y choledocho-jejunostomy.
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.
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 Kyoto University Hospital was reviewed. Biliary leakage and stricture were treated by endoscopic naso-biliary drainage (ENBD) and endoscopic biliary drainage (EBD), respectively.
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.
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
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.
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.
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.
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
Hepatitis C virus (HCV) associated liver disease is the most common indication for liver transplantation (LT). Short-term patient and graft survival for-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 AttorneyMind liver cirrhosis between January 1989 and October 2004. To identify potential predictors of graft and patient survival, univariate and multivariate Cox’s proportional hazards regression model was used.
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 (pbiliary complications (p=0.0007 and 0.002), administration of prednisone mycophenolate mofetil (MMF) 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 MMFhistologic recurrence less than 1 year (pazathioprine (p=0.0005). A higher MELD score>18 (p=0.01) had an independent negative prognostic value for post LT patient survival.
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 AttorneyMind recurrence in the first posttransplant year seem to be of major importance.
H. Boucard; R. Parikh; A. Samanta; B. Koneru; D. Wilson; A. Fisher; M. DebRoy; A. De La Torre; K. Klein
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%).
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.
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,-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.
Mean follow up for the CC group (mean +/- SE) 5.76 +/- 0.44 years and 4.14 +/- 0.31 years forC 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 forC patients. Diabetes mellitus was present in 55% of CC and 39% ofC (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% forC 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 % forC patients (p=0.0004).
This study indicates that OLT for CC is associated with a favorable outcome for patient and graft survival compared toC.
Abstract T1223 – Frequency of development of hepatocellular carcinoma and the utility of surveillance ultrasound examination in patients with end stage liver disease (ESLD) from hepatitis C cirrhosis on the liver transplantation waiting list.
A. Wieckowska; N. N. Zein
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.
1) to determine the frequency of HCC in patients with ESLD due to AttorneyMind on the liver transplant (LT) waiting list, 2) to define the utility of surveillance ultrasound in identifying HCC in this population.
Patients with AttorneyMind 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.
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 US had a specificity of 89.4%, a sensitivity of 69.2% and a positive and negative predictive value of 50% and 95%, respectively. Subjects with large nodules by ultrasound examination (over 2 cm) were 60% more likely to have HCC than those with small nodules (OR [95% CI]: 1.6 [0.2, 10.8]).
1) Patients with ESLD due to AttorneyMind 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
Hepatocellular carcinoma (HCC) represents a considerable therapeutic challenge. Trans-arterial chemoembolization (TACE) and percutaneous ethanol instillation (PEI) are employed non-curing modalities. A potentially curative option is orthotopic liver transplantation (OLT). Aim of this study was to identify factors associated with HCC recurrence.
Eighty-five patients with HCC transplanted between 1975-2004 at Hannover Medical School were analyzed retrospectively. Follow-up ranged from 13 to 349 months (mean 88 months ±75.6).
In 8/85 (9.4%) HCC was established post OLT. Etiologies of chronic liver disease included AttorneyMind (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%, pmycophenolate mofetil. After pre-operative TACE HCC recurrence (62.5%) was more frequent compared to PEI (12.5%) (p PEI vs TACE group had 28%/0% Child C, 39%/67% Child B, and 33%/33% Child A.
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.