Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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Comparative Study
Harvesting the middle hepatic vein with a right hepatectomy does not increase the risk for the donor.
The harvesting of the middle hepatic vein (MHV) with a right hepatectomy for living-donor liver transplantation allows an optimal venous drainage for the recipient but can also have adverse effects for the donor. This study compares morbidity, early liver function, and volume regeneration in 2 groups of donors who underwent right hepatectomy with (MHV+, n = 21) or without (MHV-, n = 20) MHV harvesting during 2 successive periods. The operative time was 401 +/- 60 minutes in the MHV+ group compared with 392 +/- 63 minutes in the MHV- group, and the transection time was 152 +/- 53 minutes in the MHV+ group compared with 131 +/- 30 minutes in the MHV- group (not significant). ⋯ The overall morbidity was lower in the MHV+ group compared with the MHV- group (36% vs. 55%; P >.05, not significant). The donor's remnant liver volume regeneration, evaluated by computed tomography (CT) volumetric study on day 7, was similar in the 2 groups (97% +/- 29% in the MHV+ group and 103% +/- 39% in the MHV- group, P >.05). The results of this comparative study show that right hepatectomy with the MHV neither affects morbidity nor impairs early liver function and regeneration in donors.
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The new allocation policy of the United Network of Organ Sharing (UNOS) based on the model for end-stage liver disease (MELD) gives candidates with stage T1 or stage T2 hepatocellular carcinoma (HCC) a priority MELD score beyond their degree of hepatic decompensation. The aim of this study was to determine the impact of the new allocation policy on HCC candidates before and after the institution of MELD. The UNOS database was reviewed for all HCC candidates listed between July 1999 and July 2002. ⋯ Furthermore, the 5-month dropout rate has decreased significantly. In addition, 5-month survival while waiting has increased in the post-MELD period. Thus, the new MELD-based allocation policy has benefited HCC candidates.
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Patients with small-for-size syndrome (SFSS) and acute liver failure share some important clinical features that are paralleled by common approaches to their intensive care unit management. Both are characterized by a period of acute hepatic insufficiency, with clinical features reflecting the impairment of metabolic and immunologic function that results. The basic principles of management of the two conditions remain essentially the same: to support hepatic regeneration, to anticipate and prevent the development of complications, and to identify patients unlikely to survive early in their clinical course so that retransplantation may be considered. ⋯ Extracorporeal liver support has several theoretical attractions in the critically ill patient with SFSS, through its ability by removal of hepatotoxins to provide an environment more conducive to hepatic regeneration and recovery, or to support and bridge the patient to transplantation. The molecular adsorbent recycling system has been proposed to remove both water-soluble and protein-bound toxins. This system is particularly attractive in the treatment of SFSS, however, despite its current clinical application, there are presently limited published data to support its use.
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We investigated the clinical significance of time of onset, duration, and type of pulmonary edema after orthotopic liver transplantation by retrospectively reviewing 93 consecutive recipients. Pulmonary edema was diagnosed by means of radiographic criteria and Pao(2)/Fio(2) ratio <300. Type was identified by pulmonary artery wedge pressure (hydrostatic, >18 mm Hg; permeability, < or =18 mm Hg). ⋯ Patients with persistent hydrostatic-type edema did not differ from those without edema in mean arterial pressure (84 versus 87 mm Hg, P >.05) or pulmonary vascular resistance (67 versus 53 dyn. second. m(-5), P >.05), but had increased mean pulmonary arterial pressure (27 versus 16, P <.01), suggesting a flow volume-dependent mechanism. Duration of mechanical ventilation, intensive care, and hospital stay were prolonged in patients with late or persistent permeability-type edema but not in patients with immediate pulmonary edema of any type. In conclusion, immediate pulmonary edema resolving within 24 hours after liver transplantation had little clinical consequence; persistent permeability-type pulmonary edema portended a worse outcome.