Portal Vein Thrombosis after Liver Transplantation: Prevention and Treatment

( Zhaksylyk Doskaliyev ),( Marlen Doskali ),( Abay Baigenzhin ),( Nurbek Ilyassov ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Among complications after liver transplantation the vascular causes of graft dysfunction remains as a devastating complication and its challenging clinical condition requires a multidisciplinary approach for management. Methods: From January 2013 to January 2017, 38 LDLTs were performed in our center. Operation procedures were performed by standard methods in donor and recipients. In all donors right hepatectomies were performed. Risk factors and variables associated with the transplant and the post-transplant period were analyzed. Results: At a median follow up of 3 years, both the patient and graft survival were 82%. The main causes of transplantation were primary biliary cirrhosis (50%), viral hepatitis (30%) and other liver diseases. The median age of the recipients at the time of LDLT was 43.9±17.2 (19-65 years). Recipients average hospital stay was 30±5 days (23-38 days, median 30 days) found. Vascular and biliary complications were the leading cause of reoperation, graft loss and retransplantation. Conclusions: Portal vein thrombosis is an awkward problem to treat after liver transplantation because a different portal inflow is difficult to establish. We successfully applied the heparin-based treatment in 3 patients, but graft loss were found in 2 patients. It is reliable to use a local delivery of thrombolytic therapy compare to systemic therapy because of a high risk of systemic bleeding in post-liver transplant patients. Survival rate depends on presence of PVT in cirrhotic liver before surgery.

Management of Large Hepatic Hemangiomas: The Single Center Experience of Treatment

( Marlen Doskali ),( Zhaksylyk Doskaliyev ),( Yerlan Nurgaliyev ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Hepatic hemangiomas are benign tumors, and they are usually asymptomatic with normal liver function. Surgical resection and surgical enucleation are the treatments of choice in the management of hepatic hemangiomas. In recent period transcatheter arterial embolization (TAE) has become as routine method to manage tumor growth. However, we use definition as large hemangiomas when hepatic tumors reach 4 cm. The aim of this study was to find applicable solutions for patients with large hepatic hemangiomas due to detailed observation of tumor diameter and liver function. Methods: In our study we retrospectively reviewed the patient charts of 21 patients with large hepatic hemangiomas treated with several methods at National Scientific Medical Research Center, Astana. Results: The median age was 41 years (37-51) and 85% were female. The median hemangioma size was 6.5 cm (6-12.1). Abdominal ultrasound was conclusive in 66.7% (13/21) and four-phase computed tomography (CT) in 82.6% (17/21) of patients. The indication for treatment was progressive abdominal pain in 78.6% (18/21). All patients were observed and showed no complications related to the liver hemangioma during follow-up. Conclusions: A large hemangioma resection can be safely performed at highly specialized institutions. The main indication for surgical procedures remains abdominal pain symptoms. Both surgical resection, enucleation and TAE are safe and are well admitted by patients.

Risk Predictors of Infectious Complications after Liver Surgery

( Nurbek Ilyassov ),( Zhaksylyk Doskaliyev ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Introduction: Serious infectious complications such as bloodstream infection pose a life-threatening condition in patients after liver surgery. Despite the development of modern medicine, infection remains one of the main problems in hepatic surgery that affects survival of patients. In recent studies researchers focused on immunological changes in patients with liver diseases which could be the important factors influencing the mortality associated with liver surgery. Materials and methods: Twenty-six patients who had undergone the liver surgery and had severe infectious complications at National Scientific Medical Research Center between January 2011 and December 2017 were enrolled in this study. We included cases in which the infections had developed within 30 days after surgery where the immunostatus and blood culture tests were observed. All patients who underwent a segmental resection, left hepatectomy or trisectionectomy were included. Results: Rates of infectious complications varied significantly across primary procedures and ranged from 6.5% in segmental resection patients to 23% in trisectionectomy patients. No statistically significant differences in any preoperative characteristics between patients with or without infectious complications were observed. There was no correlation between intraoperative factors and infection episodes. The association between the changes in immunological components and infectious complications were found in this study. Conclusion: These results can help identify the patients at risk of developing infectious complications and advance strategies to reduce the incidence of infections.

Liver Transplantation for Patient with Emergency Indication

( Aidos Kulmagambetov,),( Marlen Doskali,),( Zhaksylyk Doskaliyev ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Decompensate liver cirrhosis is often accompanied by hepatorenal syndrome (HRS) with mortality up to 80%. The aim is improving the results of critical cases of decompensate liver cirrhosis in terminal phase. Methods: Patient S., 32 years old, female, enrolled with decompensated Primary Liver Cirrhosis, Child-Pugh class C, portal hypertension, esophageal varices II degree, ascites and hydrothorax, secondary coagulopathy and hepatic encephalopathy - III. MELD was 38. In inpatient ward his condition become worse as marked dyspnea, itching, ascites, oliguria. The total bilirubin increasedto critical levels (571 mcmol/L), hepatocellular, kidney (Cre 220mcmol/L) and respiratory failure progression and growing of ascites tense. MARS-therapy was ineffective. Despite significant coagulopathy, the continuous renal replacement procedure was performed safely and without incident. Cadaveric donor liver transplantation was indicated and performed by standard method. Results: In postoperative period intensive care and triple immunosuppression therapy (calcineurin inhibitor started on the 4th day, because of HRS) were done. In our patient, our treatment strategy resulted in resolution of ascites and edema, and improvement of renal function and hemodynamics. Patient discharged after 42 days after transplantation operation. Conclusions: Thus, in this emergency case just organized and undertaken by highly qualified emergency medical care to a patient in a terminal state would save lives.

Self-Experience of Surgical Management of Bile Duct Strictures after Liver Transplantation

( Yerkin Turdiyev ),( Marlen Doskali ),( Abai Baigenzhin ),( Zhaksylyk Doskaliyev ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Bile duct (BD) stricture is one of the most common complication following liver transplant surgery and its challenging clinical condition requires a multidisciplinary approach for management. Methods: We analyzed the outcome of 6 patients who hospitalized in our center with BD strictures and underwent traditional surgery. In all patients biliary strictures are associated with a broad spectrum of signs and symptoms, ranging from subclinical disease with mild elevation of liver enzymes to complete obstruction with jaundice, itching and cholangitis. Results: Traditional reconstructive surgery on bile duct remains as the mainstay of treatment, even it is associated with significant morbidity and variable long-term outcome. In our center an outcome of surgical management depended on both the etiology and location of stricture. Our data shows successful long-term results in patients with conventional surgery on BD. Conclusions: In conclusion, bile duct strictures often due to surgical inexperience, failure to recognize abnormal biliary anatomy and congenital anomalies, misplacement of clips, excessive use of cautery, and excessive dissection around the major bile ducts. Surgeons should be confident to avoid these causes and minimize an ischemic injury of BD.

Splenic Artery Embolization after Adult-to-adult Liver Transplantation

( Rysmakhanov M. 1,doskalim. ),( Baygenzhina. ),( Doskaliyev Zh ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Hypersplenism (thrombocytopenia, leukocytopenia, anemia) syndrome and ascites after orthotopic liver transplantation (OLT) are not rare complications. Commonly, such conditions treated by open splenectomy. But open splenectomy have many negative sides. As alternative surgical measure, splenic artery embolization (SAE) has been reported in literature. Our report presents the outcomes of SAE in 3 patients after liver transplantation with hypersplenism and/or ascites. Methods: Between January 2013 and January 2016 in our Center we performed 32 OLT: 24 from living donor (1 - left lobe, 23 - right), 8 - from cadaver. Three patients after OLT received partial splenic artery embolization. Before OLT 2 recipients (both - female) with primary biliary cirrhosis, 1 - Hepatitis B Virus-related liver cirrhosis (male). Two patients after right lobe living OLT, one - cadaveric OLT. SAE in 3 cases were performed after 12, 8 and 6 month respectively. The indications for SAE was based on clinical examination, ultrasonography and CT (ascites, splenomegaly) and laboratory criteria (thrombocytopenia, when PLT<60x109/l, leukocytopenia, when WBC<2x109/l). Two recipient has leuko-thrombocytopenia and refractory ascites, 1 - only thrombocytopenia. SAE was performed via a percutaneous femoral artery approach under local anesthesia. All patients has preoperative antibiotic prophylaxis and desensitize medication. After selective celiac and splenic arterial angiographies were obtained to determine the target splenic artery branches. Transcatheter splenic artery branches occlusion was performed by the deployment of embolic device. Results: The size of spleens were between 8.5-12.5 cm to 17.5-22.0 cm. Patients ascites were more than 1000 ml. Total spleen embolization volume was approximately 70%. Ascites decreased after SAE in all patients. After SAE the platelets levels increased in all patients too. In one patient (who has leukocytopenia), WBS level normalized for 3 days. After SAE: 2 patients had analgesia none-needed abdominal pain, 2 - had fever (max To was 38.5oC) during 3 days. The patients was discharged 6, 8, 9 days after SAE. One patient had perisplenic abscess without fever 1 month later after discharge. Abscess was draned under ultrasound control. Than that patients discharged. One patient is died - after hepatic artery stenosis. Two patients after 1 year have normal leukocytes and thrombocytes levels. Conclusions: Hereby, SAE, although limited by the minimal cases, is a safety minimally invasive methods for treatment hypersplenism and ascites of recipients after liver transplantations. Also, this method justified in patients under immunosuppression as alternatives to open total splenectomy.

Management of Pregnant Patients to Prevent the Graft Loss after Liver Transplantation: First Experience in National Scientific Medical Research Center

( Sabit Dossanbayev ),( Alya Taganova ),( Zhaksylyk Doskaliyev ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: There were many studies showed the successful pregnancy and delivery in patients after liver transplantation. From 2012 more than 100 living donor liver transplantations has carried out in Kazakhstan and our report represents the first successful pregnancy and delivery in recipient after liver transplantation. Methods: Orthotopic transplantation of right liver lobe from a living related donor was performed to our patient from her elder brother. The main cause of liver cirrhosis was autoimmune hepatitis. After one year of LDLT the patient informed us about unplanned pregnancy. Results: Among complications in early postoperative period the portal vein thrombosis was detected and successfully treated by heparin monotherapy. No other complications found in late period after transplantation. The standard third-component immunosuppressive therapy (CNI + MMF + GCS) was applied during the first year after transplantation. After the sudden information of 2 weeks pregnancy the MMF application was canceled. In first three months no significant alterations were found during the childbearing. On 18-20 weeks the first signs of liver rejection was appeared where sensitization of HLA class 1 was 0% and HLA class 2 consisted 91%. As a main treatment the pulse therapy with GCS and plasmapheresis were performed. On 40 weeks delivery was successfully done by Cesarean section. The child was male with weight - 2830 g, and height - 54.3 cm and without no visible any defects. Conclusions: In our case, it was an acceptable outcome for both mother and baby, although considered a high risk pregnancy.

Experience of Managment of Large Liver Hemangiomas

( Aidos Kulmagambetov ),( Marlen Doskali ),( Zhaksylyk Doskaliyev ),( Abai Baigenzhin ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Hepatic hemangiomas are benign tumors, and they are usually asymptomatic with normal liver function. The aim of this study was to find applicable solutions for patients with large hepatic hemangiomas due to detailed observation of tumor diameter and liver function. Methods: In our study we retrospectively reviewed the patient charts of 21 patients with large hepatic hemangiomas treated with several methods at National Scientific Medical Research Center, Astana. Clinical Features: - The commonest liver tumor - 5% of autopsies - Usually single small - Well demarcated capsule - Usually asymptomatic Results: The median age was 41 years (37-51) and 85% were female. The median hemangioma size was 6.5 cm (6-12.1). Abdominal ultrasound was conclusive in 66.7% (13/21) and four-phase computed tomography (CT) in 82.6% (17/21) of patients. The indication for treatment was progressive abdominal pain in 78.6% (18/21). All patients were observed and showed no complications related to the liver hemangioma during follow-up. A large hemangioma resection - 3 cases - safely performed at highly specialized surgeon. The main indication for surgical procedures remains abdominal pain symptoms. Both surgical resection, enucleation and TAE are safe and are well admitted by patients. Conclusions: Surgical resection and surgical enucleating are the treatments of choice in the management of hepatic hemangiomas. In recent period transcatheter arterial embolization (TAE) has become as routine method to manage tumor growth. However, we use definition as large hemangiomas when hepatic tumors reach 4 cm.

Immunosuppression after Liver Transplantaton

( Kulmaganbetov A. 1,doskalim. ),( Baigenzhina. ),( Doskaliyev Zh ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Immunosuppressive medications have many negative effects. one way of solving this is to minimize immunosuppression. Methods: 30 liver transplantations performed in our Medical Center between January 2013 and January 2016: 22 - from living donor, 8 - from cadaver. Most liver transplants were performed in collaboration with SNUH (Seoul, Korea). The indications for liver transplantation (LT) were as follows: primary biliary cirrhosis - 6, hepatitis C virus (HCV) cirrhosis - 3, hepatitis B virus (HBV) cirrhosis - 20, autoimmune hepatitis - 1. Results: In 28 recipients at the beginning immunosuppression was based on 3 components: Tacrolimus - MMF - Corticosteroids. All patients discontinuous steroid after 6-12 month after transplantations, depending on the etiology of liver cirrhosis. One patient finished receiving MMF 2 years after transplantation. Two patients (after living donor transplantation) received (and receive now) only Tacrolimus and had no rejection episodes. But they were appointed hormones for a week after transplantations. One patient had a conversion from Tacrolimus to Cyclosporine. She had hyperglycemia. After conversion glucose levels returned to normal. Conclusions: Minimization of immunosuppression is a necessary goal for the transplant patients. Many immunosuppressive drugs have side effects, which lead to undesirable consequences or death. Immunosuppression minimization regimes should be safe for rejection and infectious complications in liver transplant patients.

The Severity of Condition and Mortality of Patients with the Hepatorenal Syndrome to Prevent the Organ Failure by the Treatment with Cell Mediators

( Saule Kushenova,),( Marlen Doskali,),( Zhaksylyk Doskaliyev ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Hepatorenal Syndrome (HRS) plays an important role in patients with liver cirrhosis. To determine the dynamics of the severity of the condition and prediction of the estimated risk of mortality (ERM) patients with HRS using cellular mediators. Methods: The study included a group of 11 patients with HRS in ages from 18 to 70 years. 6 patients of the main group received cell mediators. The severity of the condition and prognosis of hospital mortality was evaluated on a scale APACHE III. Inside the main group investigated patients were divided into 3 groups (moderate, severe and very severe) depending on the number of points. Assessment of the dynamics of flow multiple organ failure (MOF) performed before treatment, 3-5 days and 7-10 days of treatment. Results: According to the results of intragroup analysis revealed statistically significant dynamic changes in the main group for the subgroup of moderate severity. Decrease in the average scores in the subgroup indicates positive patient outcomes. Comparison between subgroups and control group showed no statistical differences in the dynamics of APACHE III. The exception were two subgroups moderate groups where there was a statistically significant difference in the initial state - prior to treatment. This is due to the small sample of patients, where the average score was higher APACHE III in the study group than in the control. At subsequent stages of observation for 3-5 and 7-10 day these differences offset due to the patients. The dynamics of the estimated risk of death in 1 and 2 subgroup of the main group shows a statistically significant decrease of this indicator. Conclusions: The use of cell mediators may be considered appropriate in someone the complex therapy of patients to prevent the MOF. The positive trend in the state of patients with of severity for inclusion in the comprehensive treatment by cellular mediators. The appropriate use of cell mediators in patients with HRS remains controversial and requires further evidence by the researchs.