LETTERS
REFERENCES
Liver Transplantation for Polycystic Liver Disease Daniel Zamora-Valde´s, MD, Alan G Contreras, MD, Miguel A Mercado, Mexico, DF, Mexico
MD
Reoperation is a great challenge for surgeons, and their efforts should include, among other things, strategies aimed at planning this possibility and its safety. The idea of putting a lock in a patient’s abdomen after major surgery is wishful thinking. Liver transplantation (LT) has become a good example of a challenging reoperation, for instance, among children with biliary atresia after a Kasai procedure; LT for bile duct injury after surgical repair; or even retransplantation for disease recurrence. The outstanding team at UCLA has an enormous experience in LT. Baber and colleagues1 recently presented their experience with patients suffering from polycystic liver disease (PLD) managed with LT. The evidence is solid; previous major open procedures are associated with greater morbidity and mortality after LT. Does this mean we should offer LT as a first choice therapy for these patients? We think not. As the authors state, many patients with PLD are candidates for minimally invasive procedures, such as percutaneous cyst ablation and/or selective hepatic artery embolization. Also, a group of patients treated with surgical palliation will not need LT. In the setting of scarcity of donor organs, our efforts should be aimed at safer therapeutic procedures and reoperations in patients with PLD. Abdominal adhesions are the main reason for increased morbidity and mortality in this patient group, particularly liver adhesions to the diaphragm and gastrointestinal structures. Perhaps there is a role for adhesion barriers such as hyaluronate carboxymethylcellulose or oxidized regenerated cellulose in this particular patient group.2 If there is a chance that the symptoms of a patient with PLD can be managed with other strategies, allowing for patients with no other therapeutic option to undergo LT, then symptomatic treatment of these patients should be maximized. If recurrence of symptoms is likely to occur in 9 years3 or so, and the potential graft can be used for a patient with an expected survival of months, there is a weak ethical argument to favor the use of graft livers for these patients as first choice of therapy. The authors deserve to be congratulated on their magnificent paper and the ongoing effort to improve the field.
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
1. Baber JT, Hiatt JR, Busuttil RW, Agopian VG. A 20-year experience with liver transplantation for polycystic liver disease: does prior palliative surgical intervention affect outcomes? J Am Coll Surg 2014;219:695e703. 2. ten Broek RP, Stommel MW, Strik C, et al. Benefits and harms of adhesion barriers for abdominal surgery: a systematic review and meta-analysis. Lancet 2014;383:48e59. 3. Schnelldorfer T, Torres VE, Zakaria S, et al. Polycystic liver disease: a critical appraisal of hepatic resection, cyst fenestration, and liver transplantation. Ann Surg 2009;250:112e118.
Disclosure Information: Nothing to disclose.
Evaluating the Effects of Earlier Palliative Surgical Interventions on Post-Liver Transplant In Reply to Zamora-Valde´s and colleagues John T Baber, MD, Jonathan R Hiatt, Ronald W Busuttil, MD, PhD, FACS, Vatche G Agopian, MD Los Angeles, CA
MD, FACS,
We very much appreciate the comments of Drs ZamoraValde´s, Contreras, and Mercado regarding our manuscript1 evaluating the effects of previous palliative surgical interventions on post-liver transplantation (LT) outcomes in patients with polycystic liver disease (PLD). The main purpose of our study was to raise awareness that open palliative surgical interventions for symptomatic PLD do not come without the price of greater perioperative morbidity and mortality for the patients who ultimately require LT. Given that LT itself is a palliative procedure in symptomatic PLD patients, we certainly agree that it should not be the first choice of therapy. To the extent that we cannot realistically “put a lock in a patient’s abdomen after major surgery,” we agree that strategies to minimize intra-abdominal adhesions with barriers such as hyaluronate carboxymethylcellulose or oxidized regenerated cellulose should be pursued. However, an increasing body of literature supports the relative safety and effectiveness of medical and minimally invasive surgical approaches such as somatostatin analogues, percutaneous aspiration-sclerotherapy, and laparoscopic cyst fenestration.2 Given the considerable perioperative morbidity after major open hepatic fenestration and/or
1192
http://dx.doi.org/10.1016/j.jamcollsurg.2014.09.008 ISSN 1072-7515/14
REFERENCES
Liver Transplantation for Polycystic Liver Disease Daniel Zamora-Valde´s, MD, Alan G Contreras, MD, Miguel A Mercado, Mexico, DF, Mexico
MD
Reoperation is a great challenge for surgeons, and their efforts should include, among other things, strategies aimed at planning this possibility and its safety. The idea of putting a lock in a patient’s abdomen after major surgery is wishful thinking. Liver transplantation (LT) has become a good example of a challenging reoperation, for instance, among children with biliary atresia after a Kasai procedure; LT for bile duct injury after surgical repair; or even retransplantation for disease recurrence. The outstanding team at UCLA has an enormous experience in LT. Baber and colleagues1 recently presented their experience with patients suffering from polycystic liver disease (PLD) managed with LT. The evidence is solid; previous major open procedures are associated with greater morbidity and mortality after LT. Does this mean we should offer LT as a first choice therapy for these patients? We think not. As the authors state, many patients with PLD are candidates for minimally invasive procedures, such as percutaneous cyst ablation and/or selective hepatic artery embolization. Also, a group of patients treated with surgical palliation will not need LT. In the setting of scarcity of donor organs, our efforts should be aimed at safer therapeutic procedures and reoperations in patients with PLD. Abdominal adhesions are the main reason for increased morbidity and mortality in this patient group, particularly liver adhesions to the diaphragm and gastrointestinal structures. Perhaps there is a role for adhesion barriers such as hyaluronate carboxymethylcellulose or oxidized regenerated cellulose in this particular patient group.2 If there is a chance that the symptoms of a patient with PLD can be managed with other strategies, allowing for patients with no other therapeutic option to undergo LT, then symptomatic treatment of these patients should be maximized. If recurrence of symptoms is likely to occur in 9 years3 or so, and the potential graft can be used for a patient with an expected survival of months, there is a weak ethical argument to favor the use of graft livers for these patients as first choice of therapy. The authors deserve to be congratulated on their magnificent paper and the ongoing effort to improve the field.
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
1. Baber JT, Hiatt JR, Busuttil RW, Agopian VG. A 20-year experience with liver transplantation for polycystic liver disease: does prior palliative surgical intervention affect outcomes? J Am Coll Surg 2014;219:695e703. 2. ten Broek RP, Stommel MW, Strik C, et al. Benefits and harms of adhesion barriers for abdominal surgery: a systematic review and meta-analysis. Lancet 2014;383:48e59. 3. Schnelldorfer T, Torres VE, Zakaria S, et al. Polycystic liver disease: a critical appraisal of hepatic resection, cyst fenestration, and liver transplantation. Ann Surg 2009;250:112e118.
Disclosure Information: Nothing to disclose.
Evaluating the Effects of Earlier Palliative Surgical Interventions on Post-Liver Transplant In Reply to Zamora-Valde´s and colleagues John T Baber, MD, Jonathan R Hiatt, Ronald W Busuttil, MD, PhD, FACS, Vatche G Agopian, MD Los Angeles, CA
MD, FACS,
We very much appreciate the comments of Drs ZamoraValde´s, Contreras, and Mercado regarding our manuscript1 evaluating the effects of previous palliative surgical interventions on post-liver transplantation (LT) outcomes in patients with polycystic liver disease (PLD). The main purpose of our study was to raise awareness that open palliative surgical interventions for symptomatic PLD do not come without the price of greater perioperative morbidity and mortality for the patients who ultimately require LT. Given that LT itself is a palliative procedure in symptomatic PLD patients, we certainly agree that it should not be the first choice of therapy. To the extent that we cannot realistically “put a lock in a patient’s abdomen after major surgery,” we agree that strategies to minimize intra-abdominal adhesions with barriers such as hyaluronate carboxymethylcellulose or oxidized regenerated cellulose should be pursued. However, an increasing body of literature supports the relative safety and effectiveness of medical and minimally invasive surgical approaches such as somatostatin analogues, percutaneous aspiration-sclerotherapy, and laparoscopic cyst fenestration.2 Given the considerable perioperative morbidity after major open hepatic fenestration and/or
1192
http://dx.doi.org/10.1016/j.jamcollsurg.2014.09.008 ISSN 1072-7515/14
