BACKGROUND Liver transplantation(LT)is the preferred treatment for end-stage liver diseases.Early allograft failure(EAF)can result in death or retransplantation.One of the key factors predicting EAF is the degree of g...BACKGROUND Liver transplantation(LT)is the preferred treatment for end-stage liver diseases.Early allograft failure(EAF)can result in death or retransplantation.One of the key factors predicting EAF is the degree of graft injury,which is typically assessed by elevated alanine aminotransferase(ALT)and aspartate aminotransferase(AST)levels.Aminotransferase levels exceeding 5000 U/L within 48 hours of LT are indicative of poor short-term graft survival.AIM To investigate outcomes in liver transplant recipients with peak aminotransferase levels exceeding 5000 U/L and to identify predictors of EAF.METHODS Adult patients who underwent LT from a deceased(brain-dead)donor between 2011 and 2024 at Hospital de Clínicas de Porto Alegre were screened.Patients with peak AST or ALT levels>5000 U/L post-LT were included,excluding those with vascular thrombosis.EAF was defined as death or retransplantation within 90 days.A receiver operating characteristic curve were generated for each EAF predictor to determine the area under the curve(AUC).Sensitivity,specificity,negative predictive value,and positive predictive value were calculated for each predictor’s best cutoff,as defined by the Youden Index.Survival curves were plotted using the Kaplan-Meier method.RESULTS Between 2011 and 2024,341 patients underwent LT.Of these,29(8.5%)patients had AST and/or ALT levels exceeding 5000 U/L within the first 48 hours post-LT.Four patients were excluded due to vascular thrombosis,resulting in a study cohort of 25 patients.EAF were also observed in 11 patients.One-year and five-year graft survival rates were 51.7%and 42.6%,respectively.For patients without EAF,one-year and five-year graft survivals were 92.3%and 76.2%,respectively.The key predictors of EAF included serum factor V and arterial lactate levels on postoperative day(POD)1,with AUCs of 0.936 and 0.919,respectively.The optimal cutoff for EAF prediction were 26.2%for serum factor V and 9 mmol/L for arterial lactate.CONCLUSION Aminotransferase levels>5000 U/L were associated with high EAF risk.However,favorable graft function indicators on POD 1 were associated with long-term survival comparable to that of general LT recipients.Serum factor V and arterial lactate levels emerged as valuable prognostic markers.展开更多
Non-tumoral portal vein thrombosis(PVT)is a frequent and challenging complication in liver transplant candidates.The prevalence reaches up to 26%in patients with cirrhosis on a transplant waiting list.Its severity inc...Non-tumoral portal vein thrombosis(PVT)is a frequent and challenging complication in liver transplant candidates.The prevalence reaches up to 26%in patients with cirrhosis on a transplant waiting list.Its severity increases with liver disease progression and significantly impacts post-transplant outcomes.Advanced PVT increases postoperative mortality to 30%.Effective management requires a multidisciplinary approach,especially in advanced cases.Preoperative strategies emphasize anticoagulation with low molecular weight heparin,while interventional radiology,including transjugular intrahepatic portosystemic shunts,offers alternatives in some cases.Intraoperatively,management is guided by PVT classification systems,ranging from thrombectomy and portal vein reconstruction to non-physiological reconstructions in complex cases.This manuscript explores the management of PVT in liver transplantation candidates,discusses strategies to optimize outcomes,and presents our institutional protocol for addressing this high-risk condition.展开更多
BACKGROUND Primary extra-gastrointestinal stromal tumors(E-GIST)of the liver are rare.The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect.Oncologic surgery followed by ad...BACKGROUND Primary extra-gastrointestinal stromal tumors(E-GIST)of the liver are rare.The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect.Oncologic surgery followed by adjuvant therapy with imatinib is the standard of care.However,under specific circumstances,a cytoreductive approach may represent a therapeutic option.We describe herein the case of an 84-year-old woman who presented with a tender,protruding epigastric mass.Abdominal computed tomography scan revealed a large,heterogeneous mass located across segments III,IV,V,and VIII of the liver.The initial approach was transarterial embolization of the tumor,which elicited no appreciable response.Considering the large size and central location of the tumor and the advanced age of the patient,non-anatomic complete resection was indicated.Due to substantial intraoperative bleeding and hemodynamic instability,only a near-complete resection could be achieved.Histopathology and immunohistochemical staining confirmed the diagnosis of primary E-GIST of the liver.Considering the risk/benefit ratio for therapeutic options,debulking surgery may represent a strategy to control pain and prolong survival.CASE SUMMARY Here,we present a case report of a patient diagnosed with E-GIST primary of the liver,which was indicated a cytoreductive surgery and adjuvant therapy with imatinib.CONCLUSION E-GIST primary of the liver is a rare conditional,the treatment is with systemic therapy and total resection surgery.However,a cytoreductive surgery will be necessary when a complete resection is no possible.展开更多
BACKGROUND Hepatocellular carcinoma(HCC)is an aggressive malignant neoplasm that requires liver transplantation(LT).Despite patients with HCC being prioritized by most organ allocation systems worldwide,they still hav...BACKGROUND Hepatocellular carcinoma(HCC)is an aggressive malignant neoplasm that requires liver transplantation(LT).Despite patients with HCC being prioritized by most organ allocation systems worldwide,they still have to wait for long periods.Locoregional therapies(LRTs)are employed as bridging therapies in patients with HCC awaiting LT.Although largely used in the past,transarterial embolization(TAE)has been replaced by transarterial chemoembolization(TACE).However,the superiority of TACE over TAE has not been consistently shown in the literature.AIM To compare the outcomes of TACE and TAE in patients with HCC awaiting LT.METHODS All consecutive patients with HCC awaiting LT between 2011 and 2020 at a single center were included.All patients underwent LRT with either TACE or TAE.Some patients also underwent percutaneous ethanol injection(PEI),concom-itantly or in different treatment sessions.The choice of LRT for each HCC nodule was determined by a multidisciplinary consensus.The primary outcome was waitlist dropout due to tumor progression,and the secondary outcome was the occurrence of adverse events.In the subset of patients who underwent LT,complete pathological response and post-transplant recurrence-free survival were also assessed.RESULTS Twelve(18.5%)patients in the TACE group(only TACE and TACE+PEI;n=65)and 3(7.9%)patients in the TAE group(only TAE and TAE+PEI;n=38)dropped out of the waitlist due to tumor progression(P log-rank test=0.29).Adverse events occurred in 8(12.3%)and 2(5.3%)patients in the TACE and TAE groups,respectively(P=0.316).Forty-eight(73.8%)of the 65 patients in the TACE group and 29(76.3%)of the 38 patients in the TAE group underwent LT(P=0.818).Among these patients,complete pathological response was detected in 7(14.6%)and 9(31%)patients in the TACE and TAE groups,respectively(P=0.145).Post-LT,HCC recurred in 9(18.8%)and 4(13.8%)patients in the TACE and TAE groups,respectively(P=0.756).Posttransplant recurrence-free survival was similar between the groups(P log-rank test=0.71).CONCLUSION Dropout rates and posttransplant recurrence-free survival of TAE were similar to those of TACE in patients with HCC.Our study reinforces the hypothesis that TACE is not superior to TAE as a bridging therapy to LT in patients with HCC.展开更多
基金Supported by Financiamento e IncentivoàPesquisa of Hospital de Clínicas de Porto Alegre,No.170271.
文摘BACKGROUND Liver transplantation(LT)is the preferred treatment for end-stage liver diseases.Early allograft failure(EAF)can result in death or retransplantation.One of the key factors predicting EAF is the degree of graft injury,which is typically assessed by elevated alanine aminotransferase(ALT)and aspartate aminotransferase(AST)levels.Aminotransferase levels exceeding 5000 U/L within 48 hours of LT are indicative of poor short-term graft survival.AIM To investigate outcomes in liver transplant recipients with peak aminotransferase levels exceeding 5000 U/L and to identify predictors of EAF.METHODS Adult patients who underwent LT from a deceased(brain-dead)donor between 2011 and 2024 at Hospital de Clínicas de Porto Alegre were screened.Patients with peak AST or ALT levels>5000 U/L post-LT were included,excluding those with vascular thrombosis.EAF was defined as death or retransplantation within 90 days.A receiver operating characteristic curve were generated for each EAF predictor to determine the area under the curve(AUC).Sensitivity,specificity,negative predictive value,and positive predictive value were calculated for each predictor’s best cutoff,as defined by the Youden Index.Survival curves were plotted using the Kaplan-Meier method.RESULTS Between 2011 and 2024,341 patients underwent LT.Of these,29(8.5%)patients had AST and/or ALT levels exceeding 5000 U/L within the first 48 hours post-LT.Four patients were excluded due to vascular thrombosis,resulting in a study cohort of 25 patients.EAF were also observed in 11 patients.One-year and five-year graft survival rates were 51.7%and 42.6%,respectively.For patients without EAF,one-year and five-year graft survivals were 92.3%and 76.2%,respectively.The key predictors of EAF included serum factor V and arterial lactate levels on postoperative day(POD)1,with AUCs of 0.936 and 0.919,respectively.The optimal cutoff for EAF prediction were 26.2%for serum factor V and 9 mmol/L for arterial lactate.CONCLUSION Aminotransferase levels>5000 U/L were associated with high EAF risk.However,favorable graft function indicators on POD 1 were associated with long-term survival comparable to that of general LT recipients.Serum factor V and arterial lactate levels emerged as valuable prognostic markers.
文摘Non-tumoral portal vein thrombosis(PVT)is a frequent and challenging complication in liver transplant candidates.The prevalence reaches up to 26%in patients with cirrhosis on a transplant waiting list.Its severity increases with liver disease progression and significantly impacts post-transplant outcomes.Advanced PVT increases postoperative mortality to 30%.Effective management requires a multidisciplinary approach,especially in advanced cases.Preoperative strategies emphasize anticoagulation with low molecular weight heparin,while interventional radiology,including transjugular intrahepatic portosystemic shunts,offers alternatives in some cases.Intraoperatively,management is guided by PVT classification systems,ranging from thrombectomy and portal vein reconstruction to non-physiological reconstructions in complex cases.This manuscript explores the management of PVT in liver transplantation candidates,discusses strategies to optimize outcomes,and presents our institutional protocol for addressing this high-risk condition.
基金Supported by Fundo de IncentivoàPesquisa(FIPE)/Hospital de Clínicas de Porto Alegre and Universidade Federal do Rio Grande do Sul.
文摘BACKGROUND Primary extra-gastrointestinal stromal tumors(E-GIST)of the liver are rare.The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect.Oncologic surgery followed by adjuvant therapy with imatinib is the standard of care.However,under specific circumstances,a cytoreductive approach may represent a therapeutic option.We describe herein the case of an 84-year-old woman who presented with a tender,protruding epigastric mass.Abdominal computed tomography scan revealed a large,heterogeneous mass located across segments III,IV,V,and VIII of the liver.The initial approach was transarterial embolization of the tumor,which elicited no appreciable response.Considering the large size and central location of the tumor and the advanced age of the patient,non-anatomic complete resection was indicated.Due to substantial intraoperative bleeding and hemodynamic instability,only a near-complete resection could be achieved.Histopathology and immunohistochemical staining confirmed the diagnosis of primary E-GIST of the liver.Considering the risk/benefit ratio for therapeutic options,debulking surgery may represent a strategy to control pain and prolong survival.CASE SUMMARY Here,we present a case report of a patient diagnosed with E-GIST primary of the liver,which was indicated a cytoreductive surgery and adjuvant therapy with imatinib.CONCLUSION E-GIST primary of the liver is a rare conditional,the treatment is with systemic therapy and total resection surgery.However,a cytoreductive surgery will be necessary when a complete resection is no possible.
基金Supported by Financiamento e IncentivoàPesquisa(FIPE/HCPA)of Hospital de Clínicas de Porto Alegre,No.2020-0473.
文摘BACKGROUND Hepatocellular carcinoma(HCC)is an aggressive malignant neoplasm that requires liver transplantation(LT).Despite patients with HCC being prioritized by most organ allocation systems worldwide,they still have to wait for long periods.Locoregional therapies(LRTs)are employed as bridging therapies in patients with HCC awaiting LT.Although largely used in the past,transarterial embolization(TAE)has been replaced by transarterial chemoembolization(TACE).However,the superiority of TACE over TAE has not been consistently shown in the literature.AIM To compare the outcomes of TACE and TAE in patients with HCC awaiting LT.METHODS All consecutive patients with HCC awaiting LT between 2011 and 2020 at a single center were included.All patients underwent LRT with either TACE or TAE.Some patients also underwent percutaneous ethanol injection(PEI),concom-itantly or in different treatment sessions.The choice of LRT for each HCC nodule was determined by a multidisciplinary consensus.The primary outcome was waitlist dropout due to tumor progression,and the secondary outcome was the occurrence of adverse events.In the subset of patients who underwent LT,complete pathological response and post-transplant recurrence-free survival were also assessed.RESULTS Twelve(18.5%)patients in the TACE group(only TACE and TACE+PEI;n=65)and 3(7.9%)patients in the TAE group(only TAE and TAE+PEI;n=38)dropped out of the waitlist due to tumor progression(P log-rank test=0.29).Adverse events occurred in 8(12.3%)and 2(5.3%)patients in the TACE and TAE groups,respectively(P=0.316).Forty-eight(73.8%)of the 65 patients in the TACE group and 29(76.3%)of the 38 patients in the TAE group underwent LT(P=0.818).Among these patients,complete pathological response was detected in 7(14.6%)and 9(31%)patients in the TACE and TAE groups,respectively(P=0.145).Post-LT,HCC recurred in 9(18.8%)and 4(13.8%)patients in the TACE and TAE groups,respectively(P=0.756).Posttransplant recurrence-free survival was similar between the groups(P log-rank test=0.71).CONCLUSION Dropout rates and posttransplant recurrence-free survival of TAE were similar to those of TACE in patients with HCC.Our study reinforces the hypothesis that TACE is not superior to TAE as a bridging therapy to LT in patients with HCC.
