Persistent Ascites Research Articles

Preoperative setting of functional liver volume enhanced by portal/hepatic vein embolization is key in preventing serious morbidity after hepatectomy with bile duct resection for biliary tract cancer

BackgroundThe risk of mortality due to serious complications associated with hepatectomy for biliary tract cancer remains high. We aimed to investigate the significance of preoperative functional liver volume in predicting and preventing serious morbidity following hepatectomy with bile duct resection (BDR). MethodsSeventy-one patients who underwent hepatectomy with BDR for biliary tract cancer were included. Functional future remnant liver volume (fFRLV) was calculated using future liver remnant (FLR) volume and functional score measured using EOB-MRI. Patients with unsatisfactory fFRLV values underwent portal or sequential portal/hepatic vein embolization (PVE/HVE). We assessed relationship between variables for liver-related morbidity (LRM), including posthepatectomy liver failure, bile leakage, and persistent ascites. Additionally, we assessed Clavien-Dindo grade IV complications (CD ≥ IV) as indicators of serious morbidity. ResultsLRM and CD ≥ IV occurred in 20 (28.2 %) and 6 (8.5 %) cases, respectively. Preoperative FLR volume (p = 0.021), FLR ratio (p = 0.004), fFRLV (p = 0.008), and ICGK-F (p = 0.023) were associated with LRM. fFRLV (p = 0.017) was predictive for LRM but not independent (AUC:0.704). Preoperative FLR volume (p = 0.005), FLR ratio (p = 0.008), and fFRLV (p < 0.001) were associated with CD ≥ IV. fFRLV (p = 0.017) was an independent predictive factor for CD ≥ IV(AUC:0.914), showing greater predictive power compared to other factors. ConclusionfFRLV predicts CD ≥ IV in patients undergoing hepatectomy with BDR. A sufficient fFRLV, enhanced by PVE/HVE if necessary, may prevent serious morbidity and mortality.

#503 The influence of the degree of liver cell failure on the functional state of the kidneys in patients with liver cirrhosis

Abstract Background and Aims Studying the influence of the severity of liver cirrhosis on the functional ability of the kidneys in patients without concomitant diseases (without diabetes mellitus and hypertension). Method The study included 38 patients with liver cirrhosis who were treated in the gastroenterology department of the Republican Scientific and Practical Center for Therapy and Medical Rehabilitation in Tashkent. The average age of patients was 54 ± 3.4 (from 33 to 65). The examined patients were divided into two groups, depending on the degree of hepatic cellular failure (according to the Child-Pugh classification) and the development of ascitic syndrome. In group 1 Liver cirrhosis without ascites (P-P class A) the number of patients was 20. In group 2 Liver cirrhosis with ascites (P-P class B) the number of patients was 18. When examining patients, we used: Clinical blood test; blood chemistry; determination of electrolytes, creatinine; general urine analysis; glomerular filtration level; Functional renal reserve (defined as the increase in glomerular filtration expressed as a percentage after the administration of Dopamine at a dose of 2-3 μg/kg/min. To assess portal hypertension, all patients underwent ultrasound examination of the organs abdominal cavity and duplex scanning of portal system vessels. Results The examined patients were analyzed for the functional state of the kidneys and its relationship with the main parameters of portal hypertension and hepatic cell failure. Comparative characteristics of the main indicators of renal function significant differences in functional parameters were revealed depending on degree of hepatic cell failure. In the group of patients with cirrhosis with ascites, there was a significant decrease in renal GFR to 77.5 ± 1.4 ml/min, in contrast to the unchanged level of GFR in the group of patients with cirrhosis without ascites—99.3 ml/min. In patients with cirrhosis without ascites, the glomerular filtration rate increases by against the background of dopamine administration was 13.5 ± 4.7% (which corresponds to the norm), in contrast to patients in the second group, where the average Renal Functional Reserve was 8.4 ± 2.8%. Changes in renal function were also characterized by a decrease in Fractional Excretion of Sodium (FENa). The reduction in FENa in the group of patients with persistent ascites. During a detailed assessment of the RFR in patients of the first group, the RFR was below normal only in 2.6 ± 2.5%, while in the second group the number of patients with the decrease in the RFR was 69.7 ± 8.1%. Study of functional renal reserve in a group of patients with cirrhosis with ascites revealed unchanged this indicator in only 10 (30.3 ± 8%). U 19 (57.5 ± 8.6%) of patients in this group, the RFR was less than 10%, and in 12.2 ± 5.7% cases of RFR was below 5%, which indicated pronounced intraglomerular hypertension and the risk of developing resistant ascites. Conclusion The present study indicates that Renal Functional Reserve (RFR) in patients with liver cirrhosis reflects the speed of effective renal plasma flow. A decrease in FPR in Child-Pugh class A liver cirrhosis was detected in 2.6% of cases, with hepatic cell failure, Child-Pugh class B in 69.7%.

The Lifesaving Impact of Transcatheter Interventions in the Early Post-Fontan Palliation Period.

Despite advancements in postoperative outcomes after Fontan surgery, there remains a risk of suboptimal outcomes and significant morbidity in the early postoperative period. Anatomical obstructions in the Fontan pathway can lead to prolonged pleural effusion or ascites, cyanosis, and low cardiac output syndrome (LCOS). Transcatheter interventions offer an alternative to early re-surgery for treating these complications. Over a 13-year period, early catheter angiography, performed within 30days post-index procedure, was administered to 41 patients, identifying anatomical issues that necessitated re-intervention in 39 cases. This led to transcatheter interventions in 37 (10.4%) of the 344 Fontan surgery patients. The median age was 4.8years (IQR: 4-9.4), and the median weight was 16.5kg (IQR: 15-25.2), with females comprising 51.4% (19/37) of this group. The primary indications for the procedures were persistent pleural effusion or ascites in 27 patients (66%), LCOS in 8 patients (20%), and cyanosis in 6 patients (14%). Among the 37 undergoing transcatheter intervention, 30 were treated solely with this method and discharged, three died in ICU follow-up, and four required early re-surgery. No procedural mortality was observed. Our findings demonstrate that transcatheter interventions, including stent implantation, balloon angioplasty, and fenestration dilation, are safe and effective in the early post-Fontan period. Therefore, they should be considered an integral part of the management strategy for this patient group.

Case Report: Unmasking Meigs’ Syndrome and the resolution of persistent Ascites after Oophorectomy in an 18-year-old Female at Cleveland Specialized Clinic Wampewo

Case Report: Unmasking Meigs’ Syndrome and the resolution of persistent Ascites after Oophorectomy in an 18-year-old Female at Cleveland Specialized Clinic Wampewo

Ultrasound microvascular flow imaging: evaluating fetal mesenteric blood flow and predicting postnatal surgery in meconium peritonitis

Objective This study explored the characteristics of fetal mesenteric blood flow perfusion across various gestational weeks and evaluated the efficacy of Microvascular Flow (MV-Flow) imaging technology in assessing intestinal wall blood flow in fetuses with meconium peritonitis (MP). Method In this retrospective study, we analyzed 35 fetuses with MP and 160 healthy fetuses. We examined the correlation between the Vascular Index (VI) of mesenteric perfusion and gestational age, conducted an analysis comparing MP operative and non-operative groups, and developed a predictive model for surgical intervention. Results The VI value demonstrated no significant change with increasing gestational age (correlation coefficient = 0.005, p = 0.946). For healthy fetuses, VI ranged approximately from 34.66% to 67.26% using the automatic ellipse method. The MP operative group exhibited significantly more cesarean deliveries (100% vs. 52.9%, p = 0.003), shorter gestational periods (34.76 ± 2.16 weeks vs. 37.48 ± 1.55 weeks, p < 0.001), lower birth weights (2762.14 ± 452.76 g vs. 3225.88 ± 339.98 g, p = 0.003), more persistent ascites (92.9% vs. 52.9%, p = 0.021), more frequent intestinal wall echo reductions (57.1% vs. 5.9%, p = 0.004), and lower VI (18.57 ± 5.51% vs. 39.41 ± 7.02%, p < 0.001). A predictive model was established: Logit (P)=8.86 - (0.37* VI) + (1.49* ascites), yielding an area under the curve of 0.857, with 78.6% sensitivity and 88.2% specificity. The VI value was significantly associated with the need for postnatal surgery (OR = 0.689, 95% confidence interval: 0.511 − 0.929, p = 0.015). A Receiver Operating Characteristic curve analysis for VI in predicting postnatal surgery showed an area under the curve of 0.971, with an optimal cutoff value of 35%, achieving 91% sensitivity and 94.4% specificity. Conclusion MV-Flow imaging effectively quantified fetal bowel wall blood flow perfusion. There was no significant change in VI across different gestational weeks. Significantly lower VI values in MP fetuses indicated an increased risk of intestinal wall necrosis and the potential need for postnatal surgical intervention.

A rare presentation of mesenteric cyst as persistent ascites: A case report

BackgroundMesenteric cysts have been typically described as cystic lesions of mesentery or omentum occurring either intra-abdominally or in the retroperitoneum. With no typical symptoms, the preoperative diagnosis of mesenteric cyst becomes challenging to establish. Patient and methodsIn this case report, we describe the case of a 29-year-old female who presented with abdominal distension for seven years associated with intermittent constipation. Following complete history, a meticulous physical examination was performed. Laboratory investigations and radiological imaging techniques were used to facilitate the diagnosis which was confirmed on laparotomy. ResultsPhysical examination revealed abdominal ascites. Laboratory investigations were unremarkable. Abdominal ultrasound revealed multiloculated massive ascites. A well-defined cystic area 27 × 18cm displacing abdominal viscera was observed on computed tomography (abdomen and pelvis) with contrast medium. Exploratory laparotomy revealed a massive cyst involving almost the entire peritoneal cavity. On histopathology, no signs of malignancy were reported. The post-operative course was excellent, and the patient was discharged following surgery. ConclusionAs this lesion is rarely considered preoperatively, and the clinical manifestations can be non-specific, we report this case of mesenteric cyst mimicking ascites in order to inform improved decision making among healthcare professionals regarding the timely diagnosis and appropriate management.

Congenital lower urinary tract obstruction with spontaneous fetal bladder rupture due to posterior urethral valves: a case report

BackgroundCongenital lower urinary tract obstruction (LUTO) is a rare but significant condition affecting fetal urinary tract development. LUTO has a range of etiologies, with posterior urethral valves (PUV) being the most common cause. The prenatal diagnosis of LUTO plays a crucial role in recognizing the condition and guiding management decisions. Prenatal ultrasound serves as the primary tool for identifying LUTO, with key findings including megacystis, bladder wall thickening, oligohydramnios, hydronephrosis, and the 'keyhole sign' indicating dilatation of the posterior urethra. We present a case of congenital LUTO with a rare complication of spontaneous fetal bladder rupture and urinary ascites, treated by peritoneo-amniotic shunt placement.Case presentationA 27-year-old pregnant Caucasian women was referred at 28 weeks of pregnancy due to the presence of megacystis and bilateral hydronephrosis on routine ultrasound and suspicion of LUTO. Repeat ultrasound at 29 weeks showed significant fetal ascites, oligohydramnios and resolution of megacystis and hydronephrosis, after which diagnosis of spontaneous bladder rupture was made. Despite ascites aspiration and amnio-infusion, there was persistent ascites and oligohydramnios. A peritoneo-amniotic shunt was placed with resolution of ascites and normalization of the amniotic fluid volume. At 35 weeks, relapse of the megacystis was observed with bilateral pyelectasis and oligohydramnios, possibly due to healing of the bladder rupture, after which elective cesarean section was planned. Cystography confirmed spontaneous healing of the bladder rupture and the presence of posterior urethral valves, which were resected in the neonatal period with cold knife incision. Total follow-up of 8 years continued to show positive ultrasonographic results and good renal function, but the child suffers from bladder dysfunction, manifesting as overactive bladder disease.ConclusionsLUTO might lead to important renal dysfunction and pulmonary hypoplasia in case of increasing disease severity. Spontaneous bladder rupture might improve renal prognosis, acting as a pop-off mechanism by decompression of the urinary tract. However, fetal bladder rupture is rare and only few cases have been reported. Prenatal intervention can be considered for moderate or severe LUTO, but the benefit for long-term outcome remains uncertain and further studies are needed.

The incidence and natural history of ascites after liver transplantation.

Ascites is common in cirrhosis but uncommon after liver transplant. We aimed to characterize the incidence, natural history, and current management strategies of post-transplant ascites. We performed a retrospective cohort study of patients who underwent liver transplantation at 2 centers. We included patients who underwent deceased donor whole graft liver transplants between 2002 and 2019. Chart review identified patients with post-transplant ascites, requiring a paracentesis between 1 and 6-month post-transplants. Detailed chart review identified clinical and transplant characteristics, evaluation of ascites etiology, and treatments. Of 1591 patients who successfully underwent a first-time orthotopic liver transplant for chronic liver disease, 101 (6.3%) developed post-transplant ascites. Only 62% of these patients required large volume paracentesis for ascites before transplant. 36% of patients with post-transplant ascites had early allograft dysfunction. Most patients with post-transplant ascites (73%) required a paracentesis within 2 months of transplant, but 27% had delayed ascites onset. From 2002 to 2019, ascites studies were obtained less often, and hepatic vein pressure measurement was performed more often. Diuretics were the mainstay of treatment (58%). The use of albumin infusion and splenic artery embolization to treat post-transplant ascites increased over time. Larger pre-transplant spleen size was associated with a greater number of post-transplant paracenteses (r=0.32 and p=0.003). For patients who underwent splenic intervention, paracentesis frequency was significantly reduced (1.6-0.4 paracenteses/month, p=0.0001). The majority (72%) of patients had clinical resolution of their ascites at 6-month post-transplant. Persistent or recurrent ascites continues to be a clinical issue in the modern era of liver transplantation. Most had clinical resolution within 6 months, some requiring intervention.

Efficacy of Pigtails for the Management of Refractory Malignant Ascites or Effusion: A Systematic Retrospective Chart Review of an Institution

Introduction: Malignant ascites and effusions have been observed in various diseases and persistent ascites or effusion from any of causes prompts the need for urgent first-line therapies. Refractory forms of ascites and effusion can cause noteworthy symptoms and can severely affect the quality of life (QoL). We therefore assessed the viability, efficacy, and patient-reported results of pigtails in the administration of refractory ascites or effusion due to malignancy.&#x0D; Aims &amp; Objectives: We aimed to assess the viability, efficacy and patient-reported results of pigtails in the administration of refractory ascites or effusion by malignancy.&#x0D; Place and duration of study: It was conducted in Vascular Interventional Radiology Department, Dow Institute of Radiology, Dow University of Health Sciences, Ojha Campus for a period of 18 months between January 2021 and June 2022.&#x0D; Material &amp; Methods: A retrospective chart review from a single center was done. All available data of the Interventional Radiology Department was utilized to identify patients(n=65) with refractory malignant ascites or effusion who underwent pigtail placement. Data analysis was performed using SPSS version 21, p?0.05 was taken as significant. Results: Procedural success rate was 100% for placement and similarly no mortality was observed. Duodenal, liver and ovarian cancer was the primary source of malignancy. The catheters, 8Fr (n=45, 69.20%) and10Fr (n=20, 30.80%) were implanted. Leakage was the highest experienced complication followed by dislodgement. Overall catheter mean survival time was [23.37days, 95%:21.63- 25.10]. The estimated mean [(24.46, 95%21.98-26.94 Vs 22.53, 95%20.08-24.97)]&#x0D; duration of catheter dwelling time for pleural effusion was greater than that of ascites (p&gt;0.05). Overall, estimated mean time for 8Fr catheter was greater than that of 10 Fr (p=0.048). Infection and leakage had an estimated mean catheter survival time lower than that of dislodgment and occlusion [log rank-chi square 13.64,p=0.003].&#x0D; Conclusion: Procedural success rate achieved was 100% and acceptable outcomes in terms of complications and catheter time. These minimally invasive treatment options should be utilized to soothe symptoms and improve the QoL.Furthermore, experimental studies with bigger sample size assessing the adverse outcome and ascertaining the possible cost savings should be performed.

A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Abstract Background Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant. Purpose The primary aim of our study is to report a case of NALF with successful liver transplant. Method We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation. Result(s) This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29. Conclusion(s) Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared MICROBIOME &amp; MICROBIAL THERAPY

P-089 SPONTAONEUS BOWEL EVISCERATION IN UMBILICAL HERNIA: CASE REPORT

Abstract Aim Spontaneous rupture of sac of hernia is a less common complication and mainly associated to persistent ascites or congenital wall defects. In literature we have few cases of spontaneous bowel eviscerations in umbilical hernias. Case Report a 53-year-old male years old man addicted to heroin, cocaine and alcohol, presented to the Emergency Department with evisceration of small bowel through an existing umbilical hernia. The patient was conscious and not complaining pain. He stated a protrusion of small bowel through his umbilical skin caused to sudden coughing after assumption of a dose of heroin.In emergency room showed an ileal loop with sub ischemic features. Blood test revealed an hepatitis C infection. During the urgent laparotomy there wasn't evidence of ascites and was necessary to performed an ileal resection and latero-lateral anastomosis with mechanical suturing machine. The placement of a prosthesis was performed; therefore, direct plastic surgery of the abdominal wall. After surgery with a short stay in ICU of 24 hours, the patient was discharged in POD 5. The postoperative course was regular without wound complications. After four months he was free from recurrence and VAS was 0. Conclusions Spontaneous bowel eviscerations in umbilical hernias is associated with refractory ascites in cirrhotic patients or congenital defect. This case is one of few case depicted in literature as spontaneous evisceration of bowel in non cirrhotic patient with umbilical hernia.

Low viscoelastic clot strength, platelet transfusions, and graft dysfunction are associated with persistent postoperative ascites following liver transplantation

IntroductionHigh output, persistent ascites (PA) is a common complication following liver transplant (LT). Recent work has identified that platelets help maintain endothelial integrity and can decrease leakage in pathological states. We sought to assess the association of PA following LT with platelet count and platelet function. MethodsClot strength (MA) is a measure of platelet function and was quantified using thrombelastography (TEG). Total drain output following surgery was recorded in 24-h intervals during the same time frame as TEG. PA was considered >1 L on POD7, as that much output prohibits drain removal. Results105 LT recipients with moderate or high volume preoperative ascites were prospectively enrolled. PA occurred in 28%. Platelet transfusions before and after surgery were associated with PA, in addition to POD5 TEG MA and POD5 MELD score. Patients with PA had a longer hospital length of stay and an increased rate of intraabdominal infections. ConclusionPersistent ascites following liver transplant is relatively common and associated with platelet transfusions, low clot strength, and graft dysfunction.

S1828 Recurrent Pancreatitis Secondary to Adderall Use With Pancreatic Ascites: A Sight Typically Unseen

Introduction: Pancreatic ascites is a rare disease with a prevalence of 3.5% resulting from pancreatic duct injury. While small ascites resolves spontaneously, large volume, persistent ascites can cause significant morbidity and mortality. We present a case of pancreatic ascites in a patient with recurrent pancreatitis from Adderall use. Case Description/Methods: 38-year-old female with attention deficit hyperactive disorder (ADHD), remote alcohol use, and recurrent pancreatitis complicated by pseudocyst and ascites presented with acute on chronic epigastric pain. Her last reported alcohol use was 2 years ago. Home medications included Adderall (amphetamine and dextroamphetamine) and benzodiazepines. Physical examination revealed normal vital signs, severe cachexia and peripheral edema. Abdomen was distended with epigastric tenderness. Pertinent labs included hemoglobin of 10.8g/dl, calcium 7.6mg/dl, albumin 1.7g/dl and a lipase of 462U/l. Bilirubin, transaminases, alkaline phosphatase and INR were normal. Quantitative immunoglobulins, IgG4, triglycerides and thyroid stimulating hormone were within normal limits. Blood alcohol and phosphatidylethanol (PETH) levels were negative. Previous CT scan demonstrated pancreatic head cyst (4.6cm), stable pseudocysts in the head and body, peripancreatic inflammation and large abdominal ascites. MRCP this admission revealed pancreatic head fluid collection decreased in size (2.3cm), consistent with walled off necrosis (Figure). Diagnostic paracentesis was significant for: WBC 93 cells/mm3, PMN 25%, RBC 2050 cells/mm3, protein 1.9g/dl, lactate dehydrogenase 102U/L, amylase 1496U/L and a serum ascites-albumin gradient (SAAG) < 1.1. An endoscopic retrograde cholangiopancreatography (ERCP) was pursued due to suspicion for pancreatic ascites which showed abrupt cut off of the pancreatic duct in the head, without filling of the pancreatic duct in the body or tail likely due to stricture. A pancreatic stent was placed into the ventral pancreatic duct to maintain patency with plan for endoscopic ultrasound examination (EUS) to exclude obstructive pathology. Discussion: Pancreatic ascites is often seen with recurrent pancreatitis commonly of alcoholic etiology. Our patient had recurrent pancreatitis and ascites due to chronic adderall use. While pancreatitis from adderall use is rare, presentation with ascites can pose a diagnostic challenge. Hence, clinicians should familiarize themselves with early diagnosis and endoscopic management which improves prognosis in this rare disease.Figure 1.: MRCP images revealing large volume ascites (red arrow), walled off necrosis in the pancreatic head (yellow arrow) and peripancreatic inflammation (blue arrow).

Approach to persistent ascites after liver transplantation.

Persistent ascites (PA) after liver transplantation (LT), commonly defined as ascites lasting more than 4 wk after LT, can be expected in up to 7% of patients. Despite being relatively rare, it is associated with worse clinical outcomes, including higher 1-year mortality. The cause of PA can be divided into vascular, hepatic, or extrahepatic. Vascular causes of PA include hepatic outflow and inflow obstructions, which are usually successfully treated. Regarding modifiable hepatic causes, recurrent hepatitis C and acute cellular rejection are the leading ones. Considering predictors for PA, the presence of ascites, refractory ascites, hepato-renal syndrome type 1, spontaneous bacterial peritonitis, hepatic encephalopathy, and prolonged ischemic time significantly influence the development of PA after LT. The initial approach to patients with PA should be to diagnose the treatable cause of PA. The stepwise approach in evaluating PA includes diagnostic paracentesis, ultrasound with Doppler, and an echocardiogram when a cardiac cause is suspected. Finally, a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear. PA of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.

Management of Ascites Following Deceased Donor Liver Transplantation: A Case Series.

Background.Persistent ascites after orthotropic liver transplantation has numerous causes and can be challenging to manage. This study aimed to determine the outcomes associated with conservative and endovascular intervention of posttransplant ascites after deceased donor liver transplantation.Methods.Adult (≥18 y) liver transplant recipients (between 2006 and 2019) who underwent hepatic venous pressure studies to investigate posttransplant ascites were included in this retrospective study. Comparisons were made between those who were managed with conservative therapy versus endovascular intervention and were also based on hepatic venous wedge pressure gradient (normal [≤10 mm Hg] versus elevated [>10 mm Hg]).Results.A total of 30 patients underwent hepatic venography to investigate ascites during the study period. The median time from transplant to venography was 70 d. At least 1 endovascular intervention was performed in 18 of 30 patients (62%), and 12 of 30 patients (38%) were managed conservatively. Endovascular interventions included angioplasty (n = 4), hepatic vein stenting (n = 9), or a transjugular intrahepatic portosystemic shunt (n = 7). The mean (range) hepatic venous wedge pressure gradient for the conservative and endovascular intervention groups was 12 mm Hg (3–23) and14 mm Hg (2–35), respectively. At a 6-mo follow-up, ascites resolved in 6 of 12 patients (50%) and 11 of 18 patients (61%) in the medical management and endovascular groups, respectively. The graft survival rates at 6 and 12 mo were (7/12 [58%] versus 17/18 [94%], P = 0.02) and (7/12 [58%] versus 14/18 [78%], P = 0.25), respectively.Conclusions.Despite medical or endovascular intervention, resolution of ascites is achieved in <60% of patients with persistent ascites. Biopsy findings and venographic pressure studies should be carefully integrated into the management of posttransplant ascites.

Spleen transient elastography predicts actuarial survival after liver transplantation.

Splenic transient elastography (TE) correlates with increased portal pressure. Little data are available in the post liver transplantation (LTx) setting. Three months after LTx, we performed splenic TE in 125 LTx recipients. Mean splenic TE values were 29.4 (±6.3; range, 21.6-49.2) kPa. Splenic TE correlated with reduced time to development until persistent ascites (30 events, OR =1.082, 95% CI: 1.034-1.133; P=0.001), hepatorenal syndrome (8 events, OR =1.109, 95% CI: 1.015-1.211; P=0.022) and hepatic encephalopathy (16 events, OR =1.136, 95% CI: 1.066-1.211; P=0.000). In Cox univariate analysis, splenic TE served as a predictor of actuarial survival free of liver (OR =1.114, 95% CI: 1.050-1.182; P<0.001) and remained an independent risk factor associated with reduced actuarial survival free of LTx in multivariate analysis (OR =1.103, 95% CI: 1.026-1.186; P=0.008). Splenic TE measurement at 3 months after LTx serves as a robust predictor of survival in LTx recipients.

Lymphatic leakage after pelvic lymphadenectomy for cervical cancer: a retrospective case-control study

BackgroundThe study aims to evaluate the clinical features and management of postoperative lymphatic leakage (PLL) in patients with cervical cancer who received pelvic lymphadenectomy.MethodsThis retrospective study screened consecutive patients with cervical cancer (stage Ia2-IIb).ResultsAmong 3427 cases screened, 63 patients (1.8%) were diagnosed with PLL, which manifested as persistent abdominal drainage (42/63, 66.7%), chylous ascites (12/63, 19.0%) or vaginal drainage (9/63, 14.3%). Median time from surgery to onset of PLL was 6 days (range, 4–21 days). All cases resolved in a median 10 days (range, 3–56 days) after conservative treatment; although one case experienced recurrence of vaginal drainage after 26 days, this also resolved after conservative therapy. Multivariate analysis showed that two cycles of neoadjuvant chemotherapy (odds ratio [OR], 3.283; 95% confidence interval [95%CI], 1.289–8.360; P = 0.013), a decrease in hemoglobin level of ≥20 and < 30 g/L (OR, 6.175; 95%CI, 1.033–10.919; P = 0.046) or ≥ 30 g/L (OR, 8.467; 95%CI, 1.248–17.426; P = 0.029), and postoperative albumin level ≥ 30 and < 35 g/L (OR, 2.552; 95%CI, 1.112–5.857; P = 0.027) or < 30 g/L (OR, 5.517; 95%CI, 2.047–18.148; P = 0.012) were associated with PLL.ConclusionNeoadjuvant chemotherapy, postoperative anemia and postoperative hypoproteinemia are risk factors for PLL.

Partial major hepatectomy with cyst fenestration for polycystic liver disease: Indications, short and long-term outcomes

Background and objectiveSymptomatic polycystic liver disease (PLD) with massive hepatomegaly represents a challenging surgical issue. In this work, we focused on early and long term outcomes after partial hepatectomy with cyst fenestration (PHCF) in selected patients. MethodsAll patients who had PHCF for treatment of PLD between January 2003 and December 2019 in our center were included in this study. PHCF was undertaken if at least one hepatic section was relatively spared from PLD, afferent and efferent hepatic vasculature was patent, and liver function was maintained. ResultsTwenty nine patients (25 women) with a mean age of 54.6 ± 9 years underwent PHCF. Major hepatectomy was performed in all cases with 4.3 ± 0.8 resected segments. Overall perioperative morbidity (Clavien ≥ II) and mortality rates were 41.4.6% and 13.8% respectively. Significant postoperative liver volume reduction was 52.8% within the first year and 55.5% thereafter. From preoperative evaluation, performance status (PS) normalized or improved in 84% of patients. After a mean follow-up time of 70.8 ± 65 months, overall patient survival was 82.7%. In univariate analysis, PS, initial liver volume, operative time and transfusion were associated with post-operative complications and PS, preoperative cyst infection, portal hypertension, transfusion, postoperative sepsis and persistent ascites were associated with mortality. ConclusionsOur study confirms that in spite of significant morbidity rate, PHCF allows a massive reduction of liver volume in selected patients with symptomatic PLD and is highly and durably effective for the reduction of liver volume and improvement of quality of life.

Carnitine status before and after paracentesis in patients with ascites and liver cirrhosis and improvement of subjective symptoms by intravenous administration of carnitine ― Initial study

Carnitine status before and after paracentesis in patients with ascites and liver cirrhosis and improvement of subjective symptoms by intravenous administration of carnitine ― Initial study

End-stage liver disease in persons with hemophilia and transfusion-associated infections

Many persons with hemophilia were infected with hepatitis C and B viruses (HCV, HBV) and HIV, but the consequences of these transfusion-acquired infections are poorly defined. We estimated the risk of HCV-related end-stage liver disease (ESLD) and the associations of age, HBV, and HIV with that risk. All 1816 HCV-seropositive hemophilic patients at 16 centers were followed for up to 16 years. Of these, 624 were HIV(-) and 1192 were HIV-coinfected; 135 had persistent HBV surface antigenemia, 1374 had resolved HBV infection, and 287 were HBV-uninfected. ESLD was defined as bleeding esophageal varices, hepatic encephalopathy, persistent ascites, or death excluding nonhepatic causes of these conditions. Competing risk models were used to estimate the annual hazard rate and cumulative incidence of ESLD. Proportional hazards models were used to estimate relative hazards of ESLD with covariates. ESLD developed in 127 of the HCV/HIV-coinfected participants, with an estimated 16-year cumulative incidence of 14.0% (95% confidence interval [CI], 11.6%-16.4%). Without HIV, 10 HCV-infected participants developed ESLD, for a significantly lower cumulative incidence of 2.6% (95% CI, 1.0%-4.3%, P <.0001). ESLD risk increased steeply with age in both groups. With HIV, ESLD risk was increased 8.1-fold (95% CI, 1.9-35.2) with HBV surface antigenemia, 2.1-fold (95% CI, 1.3-3.3) with fewer than 0.2 x 10(9)/L (200/microL) CD4(+) lymphocytes, and 1.04-fold (95% CI, 1.03-1.06) per year of age. Thus, HIV is associated with a markedly increased risk of HCV-related ESLD for persons with hemophilia, particularly with HBV infection, low CD4(+) lymphocytes, or older age.