Başkent Üniversitesi Yayınları
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Item Doppler Ultrasonography Findings of Splenic Arterial Steal Syndrome After Liver Transplant(Başkent Üniversitesi, 2012-08) Uslu, Nihal; Haberal, Mehmet; Arslan, Gulnaz; Boyvat, Fatih; Karakayali, Hamdi; Moray, Gokhan; Tore, Huseyin Gurkan; Aslan, HulyaObjectives: Splenic arterial steal syndrome is an important cause of morbidity and mortality after orthotopic liver transplant. Splenic arterial steal syndrome is characterized by arterial hypoperfusion of the graft; and if left untreated, causes ischemic biliary tract injury. Selective arterial embolization is important when treating splenic arterial steal syndrome. Doppler ultrasound has been used to follow-up liver transplant patients. This study sought to analyze alterations in portal vein velocity, peak systolic velocity, and resistivity index of the hepatic artery before diagnosis and after treatment of splenic arterial steal syndrome. Materials and Methods: We analyzed the Duplex Doppler ultrasonography results of 20 liver transplant recipients who developed angiographically proven splenic arterial steal syndrome between January 2005 and March 2009. Peak systolic velocity and resistivity index of the hepatic artery were noted during transplant surgery, before selective arterial embolization, and after embolization procedures. Results: A statistically significant decrease was found in peak systolic velocity and resistivity index of the hepatic artery between the intraoperative and pre-embolization values. In contrast to the statistically significant increase in peak systolic velocity of the hepatic artery, there were no significant changes in resistivity index after the selective arterial embolization. Portal vein velocity did not show a statistically significant change between intraoperative and preprocedure values. Portal vein velocity did show a tendency to decrease after coil embolization, but this was not significant. Conclusions: Doppler ultrasound surveillance is a valuable tool in early detection of hepatic arterial complications. A decrease in peak systolic velocity and resistivity index compared to the corresponding intraoperative data should raise suspicion of splenic arterial steal syndrome. Also Doppler ultrasound can be effectively used to examine the hepatic arterial inflow after selective arterial embolization.Item Incidence and Risk Factors of Intraoperative Adverse Events During Donor Lobectomy for Living-Donor Liver Transplantation: A Retrospective Analysis(Başkent Üniversitesi, 2012-04) Araz, Coskun; Haberal, Mehmet; Arslan, Gulnaz; Moray, Gokhan; Karakayali, Hamdi; Torgay, Adnan; Unlukaplan, Aytekin; Pirat, ArashObjectives: To evaluate the frequency, type, and predictors of intraoperative adverse events during donor hepatectomy for living-donor liver transplant. Materials and Methods: Retrospective analyses of the data from 182 consecutive living-donor liver transplant donors between May 2002 and September 2008. Results: Ninety-one patients (50%) had at least 1 intraoperative adverse event including hypothermia (39%), hypotension (26%), need for transfusions (17%), and hypertension (7%). Patients with an adverse event were older (P = .001), had a larger graft weight (P = .023), more frequently underwent a right hepatectomy (P = .019), and were more frequently classified as American Society of Anesthesiologists physical status class II (P = .027) than those who did not have these adverse events. Logistic regression analysis revealed that only age (95% confidence interval 1.018-1.099; P = .001) was a risk factor for intraoperative adverse events. Patients with these adverse events more frequently required admission to the intensive care unit and were hospitalized longer postoperatively. A before and after analysis showed that after introduction of in-line fluid warmers and more frequent use of acute normovolemic hemodilution, the frequency of intraoperative adverse events was significantly lower (80% vs 29%; P < .001). Conclusions: Intraoperative adverse events such as hypothermia and hypotension were common in living-donor liver transplant donors, and older age was associated with an increased risk of these adverse events. However, the effect of these adverse events on postoperative recovery is not clear.Item Long-term Results of Incidental Hepatocellular Carcinoma After Liver Transplant(Başkent Üniversitesi, 2011-06) Aktas, Sema; Haberal, Mehmet; Bilezikci, Banu; Haberal, Nihan; Moray, Gokhan; Karakayali, HamdiObjectives: The incidence of detecting hepatocellular carcinoma in a removed recipient liver after a liver transplant is not rare. Here, we sought to evaluate incidental hepatocellular carcinoma at our center. Materials and Methods: Among 296 patients who had undergone a liver transplant between September 2001 and November 2010, we retrospectively analyzed the outcomes of 6 patients with incidental hepatocellular carcinoma. The proportion of incidental hepatocellular carcinoma was 2%. The rate of incidental hepatocellular carcinoma among all hepatocellular carcinoma patients is 11.5%. There were 3 children and 3 adults (mean age, 28.3 ± 26 years; age range, 1-57 years). Two of the 6 patients were 1 year old. Alpha-fetoprotein levels were mildly elevated in 3 patients. Results: The results of preoperative imaging studies in all patients were normal, except for those that demonstrated regenerative or dysplastic nodules. One of the grafts was from a deceased donor, the remaining 5 were from living-related donors. We encountered no complications after the transplants. Pathology findings showed a mean tumor size of 0.8 ± 0.3 cm (range, 0.5-1.2 cm) and multiplicity in 1 patient. One patient with multiple tumors had microvascular invasion. According to the Tumor Node Metastasis staging system, 5 patients had Stage I, and the remaining patient had Stage II carcinoma. There were no recurrences of hepatocellular carcinoma, and no deaths occurred during a mean follow-up of 63 ± 16.5 months (range, 33-79 months). Conclusions: The incidence of hepatocellular carcinoma in patients with cirrhosis who have undergone a liver transplant at our hospital is similar to those reported in other studies. Incidentally found hepatocellular carcinomas showed less-invasive pathologic features and better prognoses than did preoperatively found hepatocellular carcinomas.Item Liver Transplant and Chronic Hepatitis B Virus Infection(Başkent Üniversitesi, 2011-04) Selcuk, Haldun; Haberal, Mehmet; Karakayali, HamdiHepatitis B immune globulin use for preventing hepatitis B virus recurrence after liver transplant has changed our behavior radically, and it now seems that hepatitis B immune globulin has a vital role in preventing recurrence. New nucleotide or nucleoside analogues have promising results in treating chronic hepatitis and in posttransplant hepatitis B virus-infected patients. Hepatitis B immune globulin and other antivirals act on different pathways, so it is logical to combine these drugs to achieve maximum response in suppressing hepatitis B virus (HBV)-replication.Item Acute Appendicitis After Diaphragmatic Hernia After Pediatric Liver Transplant(Başkent Üniversitesi, 2011-02) Aktas, Sema; Haberal, Mehmet; Bilezikci, Banu; Coskun, Mehmet; Ozcay, Figen; Karakayali, Hamdi; Sevmis, SinasiMultiple complications in liver transplant have been described in the literature. However, appendicitis and diaphragmatic hernia have rarely been reported after solid-organ transplant. The clinical presentation of appendicitis is similar to that of nontransplant patients, but complications are more frequent, because the majority of the patients did not have leukocytosis. Diaphragmatic hernia can present with a variety of atypical clinical symptoms. In this report, 1 patient who developed a diaphragmatic hernia and appendicitis after liver transplant is presented. A 2-year-old boy with end-stage liver cirrhosis owing to progressive familial intrahepatic cholestasis type-2 received a living-donor liver transplant. The posttransplant course was complicated. The diagnosis of diaphragmatic hernia was confirmed by thoracoabdominal computed tomography, and we decided to proceed with surgical repair. The patient had evidence of perforation, and the appendix was removed. After repositioning the intestine in the abdomen, a chest tube was placed, and the defect repaired with interrupted polypropylene sutures. The patient recovered after surgery without untoward sequelae.Item Steroid-Resistant Acute Rejections After Liver Transplant(Başkent Üniversitesi, 2010-06) Aydogan, Cem; Haberal, Mehmet; Demirhan, Beyhan; Karakayali, Hamdi; Aktas, Sema; Sevmis, SinasiObjectives: Liver transplant is the definitive treatment for the end-stage liver disease. Although effective immunosuppressants are available, steroid-resistant acute rejection can be encountered. Materials and Methods: Between September 2001 and April 2010, 285 adult and pediatric liver transplant were done on 279 patients from deceased donors and living-related donors at our center. All patients received tacrolimus-based immunosuppressive therapy. Steroids were tapered in 3 months. Liver biopsy was done to confirm acute rejection after vascular or biliary complications had been excluded. High-dose steroids were administered for acute rejections. If there was no response to steroids, acute rejection was defined as steroid-resistant acute rejection. After confirming steroid-resistant acute rejection by a second biopsy, antithymocyte globulin was given to patients until liver functions return to normal level with ganciclovir prophylaxis. Results: Acute rejection was detected in 87 liver transplants (30.5%). Steroid-resistant acute rejections were detected in 12 of 87 patients (7 male, 5 female; 8 pediatric, 4 adult patients; mean age, 16.08 ± 12.1 years) (13.7%). Mean time from transplant to steroid-resistant acute rejection was 73.58 ± 59.24 days (range, 20-181 days). The predominant cause of liver disease before liver transplant in patients who had steroid-resistant acute rejection was fulminant hepatic failure. Steroid-resistant acute rejection therapy was successful in 10 of 12 patients (83.3%). Two patients did not respond to therapy; therefore, they advanced to chronic rejection. Adverse effects due to cytokine release were the most frequently encountered reactions in the early period of antithymocyte globulin treatment. The mean follow-ups after steroid-resistant acute rejection treatment were 38.2 ± 26 months (range, 2-85 months). We did not encounter any serious reaction, serious infection, or long-term adverse effect after antithymocyte globulin treatment. Conclusions: According to our experience, antithymocyte globulin can be considered as a good therapeutic option in steroid-resistant acute rejection with acceptable adverse effects.Item Pulmonary Complications and Mortality After Liver Transplant(Başkent Üniversitesi, 2008-12) Bozbas, Serife Savas; Haberal, Mehmet; Karakayali, Hamdi; Sevmis, Sinasi; Arslan, Nevra Gullu; Ergur, Figen Ozturk; Eyuboglu, Fusun OnerObjectives: Pulmonary complications after liver transplant significantly affect mortality and morbidity; however, their relation has not been clearly established. We sought to determine pulmonary complications during the early and late term after liver transplant and identify risk factors for mortality. Materials and Methods: At our institution, 130 liver transplant patients (mean age, 40.1 ± 14.6 years; 71.1% male) were retrospectively evaluated, and 114 adult orthotopic liver transplant patients were included. Cause of liver disease, pulmonary function test results, arterial blood gas analyses, surgery duration, length of stay in the intensive care unit and the hospital, pulmonary complications, and mortality causes were noted. Results: Pulmonary complications were detected in 48 patients (42.1%), pneumonia in 24 patients (21.1%), and pleural effusion in 21 patients (18.4%). Development of pulmonary complications was found to be significantly related to survival (P = .001). Fifty-two patients (45.6%) were smokers, a significant predictor of pulmonary complications (P = .03). There was no relation between pulmonary function test results and orthodeoxia and pulmonary complications and mortality. Early and late survival rates were significantly lower in patients in whom a microorganism was isolated on deep tracheal aspirate culture, while early survival was significantly reduced in the presence of a pleural effusion (P < .005). Conclusions: Pulmonary complications after liver transplant are common. Care must be taken to determine preoperative risk factors, and patients should be observed closely for development of respiratory complications after liver transplant.Item Interventional Radiology in Liver Transplant(Başkent Üniversitesi, 2008-06) Boyvat, Fatih; Haberal, Mehmet; Karakayali, Hamdi; Aytekin, CuneytAn increased number of transplant centers now actively perform deceased-donor as well as living-related liver transplants. Although postoperative vascular and nonvascular complications after liver transplant have been well documented, early diagnosis and intervention are important to increase graft and recipient survival. With improvements in interventional radiologic techniques and a multidisciplinary approach to liver transplant, management of complications by percutaneous and endovascular techniques is possible with less morbidity and mortality. This article outlines the recent developments in, and applications of, interventional radiologic techniques in liver transplant patients.Item Pediatric Liver Transplant: Results of a Single Center(Başkent Üniversitesi, 2008-03) Haberal, Mehmet; Arslan, Gulnaz; Demirhan, Beyhan; Torgay, Adnan; Yilmaz, Ugur; Moray, Gokhan; Ozcay, Figen; Karakayali, Hamdi; Sevmis, SinasiObjectives: Liver transplant in the pediatric population has become an accepted treatment modality for children with end-stage liver disease. In this study, we analyze our experiences with pediatric liver transplant at our center. Materials and Methods: Since September 2001, 8 deceased-donor and 96 living-donor liver transplants have been done in 101 children (mean age, 6.7 ± 5.5 years; range, 2 months to 17 years). The children’s charts were reviewed retrospectively. Results: Indications for liver transplant were cholestatic liver disease (n=17), biliary atresia (n=24), Wilson’s disease (n=16), fulminant liver failure (n=18), hepatic tumor (n=13), and other (n=13). The median pediatric end-stage liver disease score was 23.1 ± 11.1 (range, –8 to 48). The median follow-up was 24.2 ± 19.4 months (range, 1-77 months). Three children underwent retransplant. The main complications were infections (25.9%) and surgical complications (39.5%) (including biliary complications and vascular problems). The incidence of acute cellular rejection was 42.3%. Sixteen children died during follow-up, and, at the time of this writing, the remaining 85 children (85%) were alive with good graft functioning, showing patient survival rates of 90%, 85%, and 83% at 6, 12, and 36 months, respectively. Conclusions: In conclusion, the overall outcomes of pediatric liver transplantation at our center are quite promising.Item Perioperative Anesthetic Management for Recipients of Orthotopic Liver Transplant Undergoing Nontransplant Surgery(Başkent Üniversitesi, 2007-12) Zeyneloglu, Pinar; Arslan, Gulnaz; Karakayali, Hamdi; Torgay, Adnan; Sulemanji, Demet; Pirat, ArashObjectives: The number of organ transplant recipients who present for nontransplant surgery has increased annually. The aim of this study was to evaluate the perioperative anesthetic management of recipients of an orthotopic liver transplant who have undergone nontransplant surgery at Baskent University Hospital. Patients and Methods: The medical records of 22 recipients of an orthotopic liver transplant who had undergone a total of 32 nontransplant elective surgeries between December 1988 and February 2006 were retrospectively reviewed. Demographic information, including the anesthetic management and the results of perioperative liver and renal function tests, was recorded. Results: The mean age of the patients at the time of transplant was 20.2 ± 17.9 years. The mean interval from liver transplant to the first surgery was 739.1 ± 502.2 days. The most frequent type of surgery was abdominal (28.1%). The types of anesthetic techniques used were general (75%), regional (9.4%), local (9.4%), and sedoanalgesia (6.3%). General anesthesia was induced with thiopental, propofol, or ketamine, and was maintained with isoflurane and nitrous oxide. Endotracheal intubation was performed in 43.8% of the patients. Spinal anesthesia was induced in 3 patients, and peripheral neural blockage was used in 2 patients. Prothrombin time, activated partial thromboplastin time, international normalized ratio, and levels of serum alanine transaminase, aspartate transaminase, total bilirubin, blood urea nitrogen, and creatinine were similar preoperatively and on the first day after surgery (P > .05). Conclusions: In this study, neither regional nor general anesthesia was associated with a deterioration of liver function. We suggest that recipients of orthotopic liver transplant can undergo nontransplant surgery without postoperative graft dysfunction if hepatic perfusion is maintained with appropriate anesthetic management.