Background & Aims HBV reactivation after liver transplantation may be related to persistence of covalently closed circular (ccc) DNA. We investigated the safety of HBV prophylaxis withdrawal in ...selected HBV transplanted patients. Methods Thirty patients transplanted 64–195 months earlier (23 males, median age 56 yrs), HBsAg-positive, HBeAg, and HBV-DNA negative at transplant (43% HCV/HDV co-infected), with undetectable intrahepatic total and ccc-DNA were enrolled. All patients underwent HBIg withdrawal and continued lamivudine with monthly HBsAg and HBV-DNA monitoring and sequential liver biopsies. Those with confirmed intrahepatic total and ccc-DNA undetectability 24 weeks after stopping HBIg, also underwent lamivudine withdrawal and were followed-up without prophylaxis. Results Twenty-five patients did not exhibit signs of HBV recurrence after prophylaxis withdrawal (median follow-up 28.7 months, range 22–42). Five patients became HBsAg-positive: one early after HBIg withdrawal, the other four after HBIG and lamivudine withdrawal. None of these patients experienced clinically relevant events. In the first patient, HBIg were reinstituted with prompt HBsAg negativization. Of the other four, one remained HBsAg-positive with detectable HBV-DNA and mild ALT elevation and was successfully treated with tenofovir. In the remaining three, HBsAg positivity was transient and followed by anti-HBs seroconversion, thus no antiviral treatment was needed. Conclusions Patients with undetectable HBV viremia at transplant and no evidence of intrahepatic total and cccDNA may safely undergo cautious weaning of prophylaxis, showing low rate of HBV recurrence after a 2 year follow-up. Undetectability of intrahepatic ccc-DNA may help to identify patients at low-risk of recurrence, yet studies with longer follow-up are needed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Native nephrectomies in patients scheduled for a kidney transplant may represent a major challenge. The timing of the procedures as well as the magnitude of both surgical procedures require a risk ...mitigation strategy that may be restricted by the specific condition of the patients. We report a case of a simultaneous laparoscopic hand-assisted native nephrectomy contralateral to the site of the living donor kidney transplant.
Background There is no consensus on the optimal perioperative antibiotic prophylaxis regimen for renal transplant recipients. Some studies have reported that irrigation of the wound at the time of ...closure without systemic antibiotics may suffice to minimize the risk for surgical site infection (SSI), but many centers still use long-term, multidose regimens in which antibiotics are administered until removal of foreign bodies occur, such as the urethral catheter, drain and central line. Methods We designed a prospective, randomized, multicenter, controlled trial to compare a single dose versus a multidose regimen of systemic antibiotic prophylaxis in adult, nondiabetic, non-morbidly obese patients undergoing renal transplantation. The primary endpoint was the incidence of SSI; the assessment of other infection in the first postoperative month was the secondary endpoint. Results Two hundred five patients were enrolled and randomized to receive either a single ( n = 103) or multidose antibiotic regimen ( n = 102) for prophylaxis. The incidences of SSI and urinary tract infection were similar in both groups. Conclusion As the dramatic increase in antibiotic resistance has mandated the implementation of global programs to optimize the use of antibiotic agents in humans, we believe that the single dose regimen is preferred, at least in nondiabetic, non-morbidly obese, adult renal transplant recipients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background and objective: Liver hemangioma (LH) is the most common benign tumour of the liver, but its origin is still not clear and not much is known about a possible familiarity. Caudate lobectomy ...is the most effective surgical treatment for benign tumors arisen in segment I. The occurrence of giant LH within the same liver segments in different members of the same family has never been described in literature. Herein we report the first two consecutive laparoscopic caudate lobectomy for familiar giant LH in a father and his daughter. Methods: The father showed a lesion in the caudate lobe (CL) suggestive of LH steadily grown, asymptomatic for 24 years until it has caused abdominal discomfort and pain (Dmax 89 mm). The daughter showed multiple hepatic hemangiomas with the biggest one located in the CL compressing the inferior vena cava (Dmax 88 mm). Results: Despite the size of the masses, we opted for a pure laparoscopic approach and a caudate lobectomy was performed in both cases. Operation time was 140 and 180 min. Patients had an uneventful recovery and a good outcome after the scheduled follow up exams 6 months after the procedure. Conclusions: A chance of familiarity transmission for hemangiomas exists and therefore should be further investigated. Laparoscopic isolated caudate lobectomy for symptomatic GLH is feasible and safely performed on selected patients by experienced hepatobiliary surgeons. Prospective randomized studies on larger populations are needed to assess if this minimally invasive approach can be proposed as a standard of care for S-I LH.
Abstract Background Life-long prophylaxis against HBV recurrence is recommended in patients transplanted for HBV-related disease. The risk of HBV reactivation is due to persistence of covalently ...closed circular (ccc) DNA in hepatocytes. Whether cccDNA persists in livers of long-term transplant survivors who received conventional prophylaxis is unknown. Aim To investigate the presence of intrahepatic total and cccDNA in transplanted patients with no evidence of biochemical markers of HBV recurrence. Methods Intrahepatic total and cccDNA were assessed using sensitive nested and real-time PCR from 44 HBsAg-positive patients (75% male; mean age 55.2 ± 8.9 years) who had undetectable serum HBV-DNA at transplant. The mean follow-up after transplant was 88.3 months (range, 18–159). Results One patient underwent HBV recurrence after transplant and was the only who tested positive for both intrahepatic total HBV-DNA and cccDNA. Of the 43 patients negative for all serological markers of HBV infection, only 2 tested positive for intrahepatic total HBV-DNA, but none for cccDNA. Conclusions Most patients with undetectable HBV-DNA at transplant, who received conventional HBV prophylaxis, have no evidence of intrahepatic total HBV-DNA and cccDNA. cccDNA should be considered a new additional diagnostic tool, also to identify patients at low risk of HBV recurrence after liver transplantation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
We assessed the incidence and outcome of pancreaticoduodenectomy for patients with a pre-operative benign diagnosis and in patients who had an unexpected diagnosis of benign disease following ...resection. We have also compared how the introduction of endoscopic ultrasound fine needle aspiration (EUS-FNA) has altered our pre-operative assessment.
Between January 1997 and April 2006, 499 patients underwent pancreaticoduodenectomy at the Queen Elizabeth Hospital. Data were collected prospectively. A further 85 patients between 2006 and 2008 had a different diagnostic approach (after imaging these patients have been also studied by EUS-FNA).
Overall, 78 (15.6%) patients had no malignant disease on final histology. Out of 459 patients who underwent pancreaticoduodenectomy for presumed malignancy, 49 (10.6%) had benign disease (sensitivity, 97%; positive predictive value, 89%). In a further 40 patients with a pre-operative benign diagnosis, we found 11 cases (27%) of malignancy (sensitivity, 37%; negative predictive value, 72%). Following the introduction of EUS-FNA, the sensitivity and specificity of the diagnostic work were 92% and 75%, respectively (positive predictive value, 93%; negative predictive value, 63%). The median follow-up was 35 months (range, 1-116 months).
Prior to the introduction of EUS-FNA, a significant number of patients, in whom pancreaticoduodenectomy is carried out for suspected benign disease, turn out to have an underlying malignancy. The use of EUS-FNA has improved the specificity of diagnostic work-up.
Background
Indefinite, long‐term administration of hepatitis B immunoglobulins (HBIg), together with a third generation nucleos(t)ide analog (NA), is the currently recommended prophylactic strategy ...to prevent viral recurrence after liver transplantation (LT) for Hepatitis Delta virus (HDV)/Hepatitis B virus (HBV)‐related disease.
Methods
We retrospectively analyzed the safety and long‐term clinical and virological outcomes of a consecutive cohort of 16 patients (10 males, median age 64.5, range 41–75) transplanted for HDV/HBV‐related cirrhosis at our Institution, who discontinued HBIg after a median of 24.5 months (range 15–116) after transplant. All patients continued prophylaxis with same NA used before LT. Recurrence of HDV/HBV infection was defined as reappearance of serum HDV‐RNA with detectable serum HBsAg and/or HBV‐DNA.
Results
The median follow‐up after LT was 138 months (range 73–316) and 110 months (range 52–200) after HBIg withdrawal. All patients were HBsAg‐positive, HBV‐DNA negative, and anti‐HDV positive at the time of LT and without coinfections with HCV or HIV. Patients were followed with biochemical and virological tests every 3–6 months after HBIg withdrawal. No recurrences of HDV/HBV infection or disease were observed during monoprophylaxis with NA. In addition, eight patients (50%) spontaneously developed anti‐HBs titers above 10 IU/L at a median of 74 months (range 58–140) following HBIG discontinuation.
Conclusions
HBIg withdrawal after LT is a safe and efficacious strategy in patients transplanted for HDV/HBV disease and is frequently associated with the spontaneous development of serological immunity against HBV. These data call for a revision of current prophylactic recommendations in this setting.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Tailored approaches have been attempted to prevent hepatitis B virus (HBV) reinfection in antibodies against hepatitis B surface antigen (HBsAg)–positive liver transplantation (LT) recipients in ...order to minimize the use of hepatitis B immune globulin (HBIG) and nucleoside analogues (NAs). We report the results of complete HBV prophylaxis withdrawal after a follow‐up of at least 6 years in LT recipients with undetectable serum HBV DNA and intrahepatic total HBV DNA and covalently closed circular DNA at LT. We included 30 HBsAg positive, hepatitis B e antigen–negative recipients, 6 with hepatitis C virus and 7 with hepatitis D virus coinfection, who had received HBIG plus NA for at least 5 years after LT. Stepwise HBIG and NA withdrawal was performed in two 6‐month periods under strict monitoring of HBV virology. All patients underwent a clinical, biochemical, and virological follow‐up at 3‐6 month intervals. HBV recurrence (HBsAg seroreversion ± detectable HBV DNA) occurred in 6 patients: in 1 patient after HBIG interruption and in 5 after both HBIG and NA cessation. Only 3 patients required reinstitution of HBV prophylaxis because of persistent HBV replication, and all achieved optimal control of HBV infection and did not experience clinical events. The other who recurred showed only short‐lasting HBsAg positivity, with undetectable HBV DNA, followed by spontaneous anti‐HBs seroconversion. An additional 15 patients mounted an anti‐HBs titer, without previous serum HBsAg detectability. At the end of follow‐up, 90% of patients were still prophylaxis‐free, 93.3% were HBsAg negative, and 100% were HBV DNA negative; 60% had anti‐HBs titers >10 IU/L (median, 143; range, 13‐1000). This small series shows that complete prophylaxis withdrawal is safe in patients transplanted for HBV‐related disease at low risk of recurrence and is often followed by spontaneous anti‐HBs seroconversion. Further studies are needed to confirm this finding. Liver Transplantation 22 1205–1213 2016 AASLD
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
AIMWe designed a retrospective case-control study to determine the efficacy and feasibility of everolimus (EVR) combined with low-dose tacrolimus (Tac) ab initio vs. standard-dose Tac after liver ...transplantation (LT). MethodsBetween September 2009 and June 2015 seventy-one adult LT patients, receiving EVR and low-dose Tac without corticosteroids or induction therapy from post-operative day 1 (EVR group), were compared with a well-matched control group of 61 recipients treated with standard-dose Tac in association with antimetabolite.
RESULTSBaseline characteristics for the two groups were comparable. The median study follow-up was 27 months (range0-82). The overall patient and graft survival were similar (p=0.908). Liver function was stable during the follow-up. In the EVR group, biopsy-proven acute rejection occurred in 2 cases (2.8%), while chronic rejection in one (1.4%). The EVR group experienced a better renal function already after 2 weeks eGFR89.85 (36.46-115.3) ml/min/1.73m2 vs. 68.77 (16.11-115.42)ml/min/1.73m2, (p=0.013), which was also observed after a median time of 27 (range 0-82) months from LT eGFR80 (45-118.3)ml/min/1.73m2 vs. 70.9(45-88.4)ml/min/1.73m2, (p=0.04)). After a median time of 27 months, the EVR-group showed lower incidence of arterial hypertension and insulin-dependent diabetes mellitus.
CONCLUSIONAb initio EVR-based immunosuppression could be a valid option immediately after surgery in recipients at high-risk of post-LT renal impairment.
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