Liver transplantation is marked by the ongoing discrepancy between the need of organs and the relatively scarce donor pool. Therefore, surgeons tend to accept livers from marginal donors or livers with borderline pathology, including traumatic lesions or benign tumors. We hereby describe a case of liver transplantation using a donor liver with a giant cavernous hemangioma. A 65-year-old otherwise healthy patient was admitted to a local hospital following a motorcycle crash with severe head injury that ultimately resulted in brain death. Computerized tomography scan of the abdomen showed an inhomogeneous lesion in the right lobe of the liver measuring 10 cm in diameter. In the context of trauma the lesion was initially thought to be an intraparenchymal hematoma of the liver. Surgery for organ donation was performed using a standard midline thoraco-laparotomy. At exploration of the abdomen, the lesion shown seen at imaging was discovered to be a 9-cm tumor in the right lobe of the liver (Figs. 1-2). A second 3-cm whitish lesion was found on the anterior surface of the left lobe of the liver. Biopsies performed from both lesions showed hemangioma. There was no evidence of trauma at exploration. We proceeded with the retrieval of lungs, liver, and kidneys. Abdominal procurement was performed using standard aortic and portal flush with the University of Wisconsin solution (UW) and topical cooling. The liver was then flushed separately with 1 L of UW through the portal vein on a backtable at the donor hospital. The normal liver parenchyma flushed well. However, the large hemangioma partially retained its original color. The donor liver was then taken to the recipient hospital, where it was prepared for transplantation on a sterile backtable. The large hemangioma was resected (Fig. 3) and the donor liver was transplanted in a 59-year-old patient with alcoholic cirrhosis. Liver reperfusion resulted in moderate bleeding from the resection site, which was controlled using argon beam coagulation, hemostatic sutures, and fibrin glue. The resected specimen from the donor liver was confirmed to be a cavernous hemangioma by final pathological examination at the recipient hospital. The postoperative course was characterized by good liver allograft function. The patient made a smooth recovery after surgery. Hemangiomata of the liver are common,1 described in up to 7% of autopsies. Most of the hemangiomatas are asymptomatic and have a benign course,2-6 and they rarely necessitate interventions for hemobilia7,8 spontaneous rupture,9,10 or mechanical symptoms related to their size.4,5,11 Enucleation of the hemangioma is safe12,13 and is the preferred technique used for resection.6,13-17 In the liver transplant setting, small hemangiomatas in donor livers are relatively common lesions, and these livers can be used for transplantation without complications. However, little is known about the fate of large hemangiomatas in transplanted livers. A thorough search of the published literature yielded only one similar case published by one of the current authors.18 The diagnosis of hemangioma can be made based on intraoperative inspection alone. However, in the multiorgan donation setting, with involvement of other potential organ recipients, we feel that a confirmatory frozen section biopsy would be reassuring. In conclusion, donor livers with large hemangio-

Mor, E1; Tillery, W3; Solomon, H1; Netto, G3; Watemberg, I1; Klintmalm, G B1 Author Information

BACKGROUND:The purpose of this study was to determine the effects of early postoperative tube feeding on outcomes of liver transplant recipients.METHODS:Fifty transplant patients were randomized prospectively to receive enteral formula via nasointestinal feeding tubes (tube-feeding [TF] group) or maintenance i.v. fluid until oral diets were initiated (control group). Thirty-one patients completed the study. Resting energy expenditure, nitrogen balance, and grip strength were measured on days 2, 4, 7, and 12 after liver transplantation. Calorie and protein intakes were calculated for 12 days posttransplant.RESULTS:Tube feeding was tolerated in the TF group (n = 14). The TF patients had greater cumulative 12-day nutrient intakes (22,464 +/- 3554 kcal, 927 +/- 122 g protein) than did the control patients (15,474 +/- 5265 kcal, 637 +/- 248 g protein) (p < .002). Nitrogen balance was better in the TF group on posttransplant day 4 than in the control group (p < .03). There was a rise in the overall mean resting energy expenditure in the first two posttransplant weeks from 1487 +/- 338 to 1990 +/- 367 kcal (p = .0002). Viral infections occurred in 17.7% of control patients compared with 0% of TF patients (p = .05). Although other infections tended to occur more frequently in the control group vs the TF group (bacterial, 29.4% vs 14.3%; overall infections, 47.1% vs 21.4%), these differences were not statistically significant. Early posttransplant tube feeding did not influence hospitalization costs, hours on the ventilator, lengths of stay in the intensive care unit and hospital, rehospitalizations, or rejection during the first 21 posttransplant days.CONCLUSIONS:Early posttransplant tube feeding was tolerated and promoted improvements in some outcomes and should be considered for all liver transplant patients.

Excessive operative blood transfusion has been correlated with an increased rate of infectious complications and lower survival rate after transplantation of the liver. Two hundred and five consecutive transplants of the liver, performed between January 1988 and December 1989, were studied retrospectively to determine preoperative risk factors associated with an increased operative blood loss and to evaluate the impact of operative transfusion on the outcome of transplantation. Preoperative clinical and laboratory parameters in patients who required 10 units or more of banked erythrocytes were compared with those in patients who received less than ten units of erythrocytes. In evaluating the outcome, the two groups were compared for infection, rejection and graft and patient survival rates. The median operative blood loss for 205 patients was 5 units of banked erythrocytes (range of zero to 52, mean of 6.9 units). Only 41 patients (20 percent) required 10 units or more of erythrocytes. The significant factors on univariate analysis that were associated with an increased operative blood loss were hospitalized patients (United Network for Organ Sharing Status > or = 3), fulminant hepatic failure, previous portosystemic shunt and complete ABO mismatch. Patients who required more blood had higher incidence of coagulation abnormalities, renal dysfunction and high bilirubin levels. A stepwise logistic regression analysis model using all these parameters identified an elevated serum creatinine, decreased platelets and a prolonged partial thromboplastin time as being the strongest risk factors. Using these variables, operative bleeding of more than 10 units could be predicted accurately only 60 percent of the time (sensitivity 60.0 percent with a specificity of 69.1 percent). Septic episodes occurred more frequently in patients with an excessive operative blood loss (p < 0.05), and these patients also tended to have a higher rate of severe cytomegalovirus infections and a lower incidence of acute rejection. Patients who required more blood also had significantly prolonged stays in the intensive care units postoperatively (18.3 versus 6.3 days, p < 0.002) and lower graft and patient survival rates (p < 0.001 and p < 0.05, respectively). We conclude that intraoperative bleeding has remained a significant problem affecting the immediate outcome after transplantation of the liver. Preoperative parameters cannot predict operative bleeding accurately and the mainstay to prevent bleeding is a meticulous surgical technique during the hepatectomy and correction of coagulation abnormalities throughout the procedure.

Although prolonged survival of liver allografts has been achieved in animal models with a short course of im-munosuppre~sion,'~~ no such phenomenon has been described in human liver allografting. The use of cyclosporine in clinical organ transplantation since the early 1980s has significantly improved the results of liver transplantation.~owever, rejection occurs in almost two thirds of recipients and remains a significant cause of graft loss in the cyclosporine era.%erein, we will review the current concepts regarding immunology, diagnosis, and management of acute rejection in liver transplantation. We will denote specific issues, including the approach to differentiate early rejection from other causes of graft dysfunction, current management of refractory persistent rejection, and preliminary results us-ing new immunosuppressive drugs.

A total of 365 donor hepatectomies performed between May 1985 and March 1990 were reviewed and analyzed retrospectively to identify risk factors associated with poor graft function and to study the outcome of grafts retrieved from "marginal" donors. The donor mean age was 27.1 years (8-69 years). Mean ICU donor stay was 2.7 days (range 0 to 18 days), and the mean ischemic time was 8.6 hr (range 3 to 22 hr). The pancreas was retrieved in 39 donors. Donor's weight above 100 kg was the only variable found to be associated with both significantly increased 3-month graft loss (P less than 0.01) and early hepatocellular damage--AST or ALT greater than 2000 U/ml, 1st day posttransplant (P less than 0.02). Prolonged stay in the ICU (greater than 3 days), although associated with a significantly increased rate of hepatocellular damage (P less than 0.05), did not affect early graft survival. A systolic blood pressure less than 90 mmHg despite the use of high-dose dopamine (greater than 15 micrograms/mg/min), but not each of these variables itself, was also associated with a significantly increase rate of hepatocellular damage (P less than 0.001). All other variables, including age greater than 50, ischemic time greater than 12 hr, combined liver-pancreas procurement, and liver function test abnormalities, did not affect the outcome. We conclude that extending our limits to accept donors of the higher age group and those who have moderately abnormal liver function tests or a prolonged ischemic time will not jeopardize our results. It is suggested to perform liver biopsy in overweight donors during the retrieval to prevent using grafts with severe fatty infiltration. It is hypothesized that hormonal changes, starvation, and increased risk to develop infection might jeopardize the outcome of grafts from donors with a prolonged ICU stay. Although 70% of the early hepatocellular injuries are reversible, the remaining 30% result in graft failure.

A retrospective review of 375 consecutive orthotopic liver transplants was performed to determine the incidence and outcome of late rejection episodes ([LR] rejection occurring more than 6 months following transplant). A total of 31 episodes in 26 patients were identified. Eighteen of these episodes were associated with subtherapeutic levels of cyclosporine. Of these, 7 were due to noncompliance, 2 were due to biliary strictures, and 1 was due to malabsorption in a cystic fibrosis patient. All 31 episodes were treated initially with steroids, and 22 had a complete response, although one progressed to chronic rejection over a year later. Of the remaining 9, 1 received FK506 with a complete response, and 8 received OKT3. Of the 8 patients who received OKT3, 5 had a complete response, 1 received RS61443 following OKT3 and progressed to chronic rejection, and the remaining 2 received further steroids. Of these 2, 1 had a complete response following the steroids while the second was converted to FK506 with a complete response. Compared with 315 acute rejection episodes ([AR] occurring less than 6 months posttransplant), patients with late rejection episodes had an equivalent response to steroids (63.2% AR reversed vs. 71% LR reversed) but a lower response rate to OKT3 (91.5% AR reversed vs. 62.5% LR reversed). There was, therefore, a higher rate of persistent rejection (61% AR episodes vs. 15.4% LR episodes) but no increase in the incidence of chronic rejection (7% AR episodes vs. 7.7% LR episodes). We conclude that LR is a relatively common occurrence following liver transplant, which is most often associated with low cyclosporine levels. Many of these episodes are due to noncompliance, but biliary problems must also be investigated. The incidence of resistant rejection is higher in this group of patients but is not associated with a concurrent increase in chronic rejection.

A retrospective analysis was undertaken on patients undergoing liver transplantation between April 1985 and May 1980 at Baylor University Medical Center, Dallas, Texas. A total of 358 patients were evaluated, 416 of whom received liver transplants, including 15 simultaneous liver/kidney transplants. The overall patient survival in this group was 82% at 1 year and 75% at 3 years, using Kaplan-Meier life tables.