Letters to the EditorAn Overview of Orthotopic Liver Transplantation Abdul-Wahed Nasir MeshikhesMBChB(Dublin), FRCSI Abdul-Wahed Nasir Meshikhes Search for more papers by this author Published Online:1 Nov 1995https://doi.org/10.5144/0256-4947.1995.669SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo the Editor: I read with interest the review article by Schutz et al. entitled “An Overview of Orthotopic Liver Transplantation” in the January 1995 issue of Annals of Saudi Medicine. However, there are a few points which need further discussion and elaboration. First, the authors mentioned that many liver institutions consider the presence of hepatitis B surface antigen (HBsAg) to be a contraindication to liver transplantation. This is not entirely true, as improvements in graft and patient survival and the widespread application of orthotopic liver transplantation (OLT) in treating a greater variety of liver diseases in countries where HBV infection is prevalent have led major liver units throughout the world to consider patients with HBV end-stage liver disease for OLT. Nevertheless, the presence of active viral replication, indicated by positive hepatitis B e antigen (HBeAg) and hepatitis B DNA (HBV DNA) serology prior to transplantation is now considered an absolute contraindication.1 Lower reinfection rates have been reported in patients presenting with fulminant hepatic failure, patients with an inactive replicative state and patients with hepatitis delta virus coinfection.1 The one- and three-year recurrence rates have been greatly reduced by administering long-term immunoprophylaxis using anti-HBs immunoglobulin.2 As anti-HBs immunoglobulin is quite expensive and may be associated with some side effects, e.g., anaphylactic reaction,3 clinical trials involving a safer drug called lamivudine (3'-thiacytidine) are underway in Europe and North America. It is hoped that this drug will reduce the incidence of liver allograft reinfection and thereby improve patient and graft survival.Patients with HBV reinfection after liver transplantation run a variable course with as many as 50% having a prolonged period of rehabilitation with reasonable liver function despite reinfection.4 This, and the fact that reinfection can be greatly reduced by long-term immunoprophylaxis,2 argues strongly against denying these patients the benefits of liver transplantation.Based on the reported experience of major transplant centers and the fact that HBV infection is quite prevalent in Saudi Arabia, I personally feel that HBV-related end-stage liver disease should be a major indication for liver transplantation and any liver transplant program in Saudi Arabia will defeat its objective if such patients are excluded. Offering these patients OLT locally will save them from the long and painful wait in countries where the gap between donors and recipients is widening at an alarming rate and the first priority is justifiably given to their own citizens on the waiting list.Secondly, on describing the transplant technique, the authors indicate that an intraoperative cholangiogram is obtained if duct-to-duct reconstruction was performed. This is not routinely performed. Although duct-to-duct reconstruction is traditionally performed over a t-tube to allow easy radiological access to the biliary tree whenever the need arises, it is now considered safe to perform biliary reconstruction without a t-tube,5 saving the patient from an admission three months later for t-tube removal with its associated risk of biliary leakage.The Annals of Saudi Medicine welcomes Letters to the Editor from its readers. They may be on any topic, though the Editor especially encourages discussion of papers published in the Annals. Letters should be no more than 100 typewritten lines in length, typed double-space, and submitted in triplicate. Letters may include one figure or brief table and up to five references. Submission of a letter constitutes permission for the Annals to use it for publication. Letters should not duplicate similar material being submitted or published elsewhere, and the Annals reserves the right to edit letters submitted. Letters referring to a recent Annals article should be received within six weeks of the article's publication.ARTICLE REFERENCES:1. Samuel D, Bismuth A, Mathieu D, et al. "Passive immunoprophylaxis after liver transplantation in HBsAg-positive patients" . Lancet. 1991; 337:813-5. Google Scholar2. Samuel D, Muller R, Alexander G, et al. "Liver transplantation in European patients with hepatitis B surface antigen" . N Engl J Med. 1993; 329:1842-7. Google Scholar3. Meshikhes AN, Ferraz-Neto B-H, Ahmed M, et al. "Hepatitis B virus and hepatitis C virus infection following liver transplantation" . (in preparation). Google Scholar4. Iwatsuki S, Starzl TE, Todo S, et al. "Experience in 1000 liver transplants under cyclosporin-steroid therapy: a survival report" . Trans Proc. 1988; 20:498-504. Google Scholar5. Rolles K, Dawson K, Noull R, Hayter B, Davidson B, Burroughs A. "Biliary anastomosis after liver transplantation does not benefit from t-tube splintage" . Transplantation. 1994; 57:402-4. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 15, Issue 6November-December 1995 Metrics History Published online1 November 1995 InformationCopyright © 1995, Annals of Saudi MedicineThis work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.PDF download