Defining the role of transjugular intrahepatic portosystemic shunts in the management of portal hypertension.
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Animals↗
Biomedical subjects
R L Jenkins
Publications and source records attributed to R L Jenkins.
Percutaneous venovenous bypass in orthotopic liver transplantation.
Since January 1994, we have used percutaneous placement of both the subclavian and femoral cannulae to establish access for venovenous bypass during orthotopic liver transplantation. Percutaneous subclavian and femoral cannulae were used in 36 patients of which 5 had portal decompression by placement of a cannula in inferior mesenteric vein percutaneously through the abdominal wall. Intraoperative placement of the subclavian cannula is facilitated by placing a subclavian central venous line before the abdominal incision. One patient underwent exploration for femoral vein bleeding early in our experience. Another patient sustained hypotension as a result of a kinked subclavian cannula. In 4 patients, early in this experience, we had difficulty placing the subclavian cannula and resorted to axillary vein cut-down. There were no episodes of deep venous thrombosis detected by routine postoperative duplex ultrasonography. Minimum and maximum flow rates were significantly better (P < .01), with percutaneously placed cannulae in comparison to a control group of patients who underwent transplantation in whom we used the standard venous cut-down approach with a #7 Gott shunt (2.14 and 3.17 L/min v 1.65 and 2.41 L/min, respectively). Percutaneous placement of cannulae for venovenous bypass during liver transplantation is quick, safe, and effective. We would advocate this technique as an alternative approach for patients in whom bypass is deemed necessary.
Blood Flow Velocity↗
Biliary intervention by means of percutaneous puncture of the antecolic jejunal loop.
PURPOSE: To evaluate the safety and efficacy of biliary intervention performed by means of percutaneous transjejunal access. MATERIALS AND METHODS: In 28 patients with conventional antecolic Roux-en-Y choledochojejunostomy or hepaticojejunostomy loops, 41 attempts were made at direct percutaneous entry into the jejunal loop. Indications for previous surgery included sclerosing cholangitis, orthotopic liver transplantation, cholangiocarcinoma, bypass of benign iatrogenic strictures, and bypass of choledochal cyst. Roux-en-Y loops were directly accessed with single-wall, 19-gauge needles after localization by review of previous cholangiograms or computed tomographic (CT) scans and localization of surgical clips with fluoroscopy. RESULTS: The transjejunal approach was successful in 36 of 41 attempts. In 30 cases, transhepatic puncture was entirely avoided. There were four minor complications and one major complication of biliary sepsis. No procedure-related deaths occurred. CONCLUSION: This transjejunal approach is an effective and safe route for a variety of percutaneous biliary procedures in patients with biliary-enteric anastomoses.
Anastomosis, Roux-en-Y↗
Fungal infections complicating orthotopic liver transplantation.
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Adolescent↗
Leadership externs: interactions, involvement, interpersonal rewards.
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Humans↗
Hepatitis C infection: a rare cause of fulminant hepatic failure.
Fulminant hepatic failure is caused by a variety of viruses, toxins, and metabolic derangements. The hepatitis C virus (HCV) causes indolent development of cirrhosis and has not been associated with fulminant hepatic failure. We report the first documented case of fulminant hepatitis C in the United States. The patient developed jaundice and stage IV encephalopathy. Initial laboratory evaluation did not reveal the etiology. The patient survived without liver transplantation. Three wk later he was found to have a positive HCV RNA and anti-HCV antibody seroconversion. He continued to improve with alpha-interferon treatment and has normal liver function and a negative HCV RNA 15 months later.
Adult↗
Role of staging laparoscopy in the treatment of hepatic malignancy.
Despite current radiologic imaging capabilities, 40% to 70% of patients with primary or metastatic hepatic malignancies are found to have unresectable disease at the time of laparotomy. The present study evaluates the use of laparoscopy in the staging of hepatic malignancy. Twenty-nine patients underwent staging laparoscopy prior to a planned laparotomy for resection of a hepatic malignancy that was deemed resectable by computed axial tomographic scan and ultrasonography. Twelve patients had primary hepatic malignancies, and 17 had metastatic malignancies. Laparoscopy demonstrated evidence of unresectability in 48% (14 of 29) of patients studied. Four patients had unsuspected cirrhosis, and 10 had unresectable or extrahepatic metastatic disease. Patients who underwent laparoscopy alone had shorter mean hospital lengths of stay than historical controls who underwent laparotomy alone. We conclude that diagnostic laparoscopy should precede laparotomy for planned resection of hepatic malignancies.
Carcinoma, Hepatocellular↗
Coronary artery bypass grafting in patients with transplanted livers.
Coronary artery bypass grafting was performed on 3 patients for refractory angina pectoris 48, 5, and 40 months after orthotopic liver transplantation. At the time of the cardiac operation, all 3 patients had drug-induced moderate renal dysfunction, and 1 of the 3 exhibited mild chronic rejection of the graft. Maintenance immunosuppressive therapy was continued during the cardiac operation and the perioperative period. Stress-dose steroids and standard prophylactic antibiotics were also employed. All 3 patients tolerated the cardiac surgical procedure without hepatic decompensation, excessive bleeding, infection, impaired wound healing, and other complications related to the transplanted organ or to the immunosuppressive therapy. Early postoperative liver function test results showed mild transient deterioration. One patient experienced a brief psychotic episode and massive upper gastrointestinal bleeding. Both complications were attributed to the steroids used in immunosuppressive therapy. Follow-up ranging from 2 to 24 months after coronary artery bypass grafting revealed that the patients were active and had no cardiac symptoms or manifestations of hepatic decompensation. It appears from this limited experience that cardiac operations can be performed safely in patients who have previously undergone liver transplantation.
Aged↗
Surgical approach to benign liver tumors.
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Adenoma↗
Liver transplantation with incidental gallbladder carcinoma in the recipient hepatectomy.
Gallbladder carcinoma (GBCA) is the most common malignancy of the biliary tract and is often found seredipitiously after cholecystectomy. We report the first two cases of incidental GBCA in the native gallbladder of two liver transplant recipients. Both patients are 2.5 years following uneventful orthotopiic liver transplantation (OLTx) with no evidence of recurrent disease. Pathology of both recipients was early and favorable. Neither patient received any further therapy. Given the incidence of GBCA and the evolution of OLTx we would anticipate this finding to be more prevalent.
Aged↗
The impact of intraoperative ultrasonography on surgery for liver neoplasms.
To analyze the effect of IOUS on surgical decision making, we performed a retrospective study of 45 patients who had exploratory laparotomy and IOUS for liver neoplasms. Preoperative lesion detection was compared with intraoperative findings. The effect of IOUS on the choice of surgical procedure was analyzed. Preoperative imaging detected 67% of lesions, 78% when combined with surgical inspection and palpation, and 97% were recognized by IOUS. Surgery was modified in 23 of 45 cases (51%); 19 of those 23 cases (83%) were based on IOUS findings alone. IOUS demonstrated superior lesion detection over noninvasive preoperative liver imaging, and IOUS significantly affected surgical decision making.
Adult↗
Assessment of the cytokine response in liver donors at the time of organ procurement and association with allograft function after orthotopic transplantation.
BACKGROUND: The cause of allograft liver dysfunction after transplantation is unresolved. We tested the hypothesis that human donor liver may be predisposed to ischemia reperfusion injury, and graft dysfunction subsequent to ongoing inflammatory processes during donor hospitalization. STUDY DESIGN: A prospective study of organ donors and transplant recipients of allograft livers from these donors was conducted. Portal venous, inferior vena caval, and superior vena caval blood samples were obtained from 16 clinical organ donors at the time of organ procurement (one to 12 days post-trauma) to characterize the hepatic cytokine and acute phase protein response, to determine whether or not this response resulted from bacterial or endotoxin translocation to the portal circulation, and to assess whether or not transplant outcome was associated with plasma levels of cytokines in the donor. RESULTS: In comparison with systemic blood samples from ten healthy persons, all 16 donors exhibited significantly (p < 0.05) elevated plasma concentrations of interleukin-6, interleukin-8, soluble p55 tumor necrosis factor receptor type I (sTNFr-I), and C-reactive protein. No concentration differences existed among portal venous, inferior vena caval, and superior vena caval blood samples for any cytokine or acute phase protein measured. Donor levels of endotoxin, TNF-alpha, soluble intercellular adhesion molecule-1 (sICAM-1), alpha 1-acid glycoprotein, alpha 1-antitrypsin, and haptoglobin were comparable with those in the healthy persons. Bacterial cultures of portal blood were negative. There was no association between the causation of donor trauma and either donor cytokine response or function and quality of the allograft liver after transplantation. Nor could an association between donor cytokine response and either early allograft function (less than 96 hours) or eventual transplant outcome in the recipients be detected. CONCLUSIONS: These results indicate that, although an ongoing inflammatory response to injury was evident in these donors at the time of organ procurement, there were no apparent adverse effects arising from these inflammatory processes on the function and quality of the donor liver after transplantation. Bacterial translocation does not seem to be a component of the pathogenesis of inflammation. Whether or not the presence of inflammation in the donor alters the metabolic responses of the allograft liver and recipient to transplant operation is unknown.
Acute-Phase Proteins↗
Orthotopic liver transplantation for familial amyloidotic polyneuropathy.
Orthotopic liver transplantation for inborn errors of metabolism has become a standard indication for transplantation in pediatric and adult patients with alpha-1 antitrypsin deficiency, Wilson's disease and tyrosinemia, amongst several less common diseases. Familial amyloidotic polyneuropathy (FAP) is a rare autosomal dominant disease whose metabolic origin lies in an abnormal protein synthesized primarily in the liver. FAP, also discussed as the autosomal dominant form of amyloidosis, is characterized as a hereditary form of amyloidosis. It is the rarest form of amyloidosis affecting kindreds of specific ethnic backgrounds. The true incidence of this disease in the United States is not known. The mutant protein, called transthyretin or prealbumin, forms amyloid fibrils which accumulate in vital tissues ultimately leading to the patient's death. Liver transplantation for this inherited disease leads to the production of normal transthyretin protein. This theoretically should arrest the disease process. The first 5 patients in the United States with FAP who have undergone transplantation are presented.
Adult↗
A comparison of operation, endoscopic retrograde cholangiopancreatography, and percutaneous transhepatic cholangiography in biliary complications after hepatic transplantation.
BACKGROUND: Biliary complications (BC) remain a significant cause of morbidity and mortality after orthotopic liver transplantation (OLT). STUDY DESIGN: In an effort to determine the incidence of BC after OLT and the success of management options, 157 hepatic transplants performed from January 1987 to July 1991 were reviewed. RESULTS: The incidence of BC was 25 percent, with a one year mortality rate of 43.5 percent compared with 23.4 percent for patients in a control group (p < 0.05). Most BC occurring before postoperative day 30 presented as leaks, with a one year mortality rate of 50 percent (p < 0.03 versus control group). Biliary complications presenting after postoperative day 30 presented as strictures, with a one year mortality rate of 36.8 percent (p = NS versus control group). Endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTHC), and operative treatment were analyzed to determine relative patency rates after intervention for BC. The analysis showed that ERCP and PTHC were equivalent, with a one year patency rate of 45 percent. Operative treatment had a patency rate of 89 percent (p < 0.05 compared to ERCP and PTHC). CONCLUSIONS: The results from ERCP and PTHC may be useful for delineation of rejection versus BC after OLT. However, operative treatment is significantly more effective for definitive treatment of BC after OLT.
Adult↗
Biliary strictures after liver transplantation.
Biliary strictures in the liver transplant population remain significant potential sources of patient morbidity in both early and late postoperative periods. Continuous monitoring of the patient through periodic laboratory testing, ultrasonography, and pre-emptive cholangiography permits early detection and safer management of the patient. A multimodality approach emphasizing both non-surgical and surgical treatment options contributes to continued excellent function of the graft and maximal quality of life for the patient.
Bile Ducts↗
Risk factors for invasive fungal infections complicating orthotopic liver transplantation.
Risk factors for invasive fungal infection in patients undergoing orthotopic liver transplantation were examined. Thirty-four of 168 transplants were complicated within 100 days after transplantation by documented invasive fungal infection (Candida species, 28 patients; mycelial fungi, 5; both Candida and Aspergillus species, 1). In the multivariate Cox proportional hazards model, three baseline and two posttransplant variables were independently significant risk factors for infection: level of creatinine (hazard ratio = 1.4), length of transplant operation (HR = 1.2), retransplantation (HR = 3.2), abdominal or intrathoracic reoperations (HR = 2.5), and cytomegalovirus infection (HR = 8.5). Four predictors (creatinine of > 3.0 mg/dL, operative time of > or = 11 h, retransplantation, and early colonization) assessable at the time of transplantation or shortly thereafter were incorporated into a simple predictive model for risk stratification. The risk of invasive fungal infection ranged from 1% in patients with no predictors to 67% in patients with two or more predictors. Strategies to prevent invasive fungal infections after liver transplantation should be targeted to these high-risk groups.
Adrenal Cortex Hormones↗
Treatment of giant hemangiomas of the liver by enucleation.
Cavernous hemangiomas are the most common benign tumors of the liver. The results of natural history studies have demonstrated that asymptomatic hemangiomas can be observed without deleterious results. The appropriate treatment for symptomatic cavernous hemangiomas remains unclear. Since 1987, ten patients with symptomatic giant cavernous hemangiomas have undergone simple enucleation at the New England Deaconess Hospital, Boston, Massachusetts. Ten patients who underwent both anatomic and nonanatomic resections for benign hepatic tumors were chosen as a control group. We analyzed patient demographics and characteristics of the hospital course. Both groups had similar periods of hospitalization (9.5 +/- 1.2 versus 9.1 +/- 1.8 days; p = NS), operative time (2.2 +/- 0.3 versus 2.4 +/- 0.2 hours; p = NS) and lesion size (7.6 +/- 1.3 versus 8.4 +/- 1.2 centimeters; p = NS). The enucleation group had 49 percent less intraoperative blood loss when compared with the resection group (400 +/- 129 versus 742 +/- 116 milliliters; p < 0.05). Two units of blood were transfused in the enucleation group while 6 units were transfused in the resection group. Postoperatively, two patients in the resection group required computed tomographic guided drainage of extrahepatic bile collections. There were none in the enucleation group. Because enucleation is performed in the fibrous capsule composed of compressed hepatic parenchyma, injury to major bile ducts and blood vessels may be avoided. Enucleation is a safe alternative to resection for treatment of symptomatic giant hemangiomas.
Adult↗
Dependence of the plasma triacylglycerol-lowering effect of fish oil on insulin replacement in streptozotocin diabetic rats.
Streptozotocin diabetic rats, with and without insulin replacement, and sham-injected controls were fed a high-fat (30% of energy) menhaden oil (MO) or corn oil (CO) diet for 2 weeks. After an overnight fast, plasma and livers were collected for analysis of insulin, glucose, triacylglycerol, cholesterol and glucose-6-phosphate dehydrogenase activity. Streptozotocin treatment resulted in decreased plasma insulin and elevated glucose. MO-feeding to insulin-replaced diabetic rats resulted in higher insulin and lower glucose levels compared to the respective CO-fed rats, suggesting decreased hepatic insulin extraction and greater peripheral utilization of glucose with MO. Plasma triacylglycerol and cholesterol, and hepatic glucose-6-phosphate dehydrogenase activity were reduced in MO-fed vs. CO-fed control rats. These effects of MO were prevented in the diabetic rats but were restored by insulin replacement. We conclude from our data that the presence of insulin is required to observe at least some of the effects of fish oil (FO). To explain our observations we propose that many of the effects of FO on hepatic metabolism are mediated by an inhibition of insulin action in the liver, thus providing a possible central mechanism for the regulation of hepatic lipid metabolism by dietary FO.
Animals↗