Living donor liver transplantation indicated for compensated liver cirrhosis with symptomatic gallstone diseases: report of two cases
© The Author(s). 2016
Received: 29 March 2016
Accepted: 18 May 2016
Published: 23 May 2016
Surgical interventions for symptomatic gallstone disease could be dangerous in patients with severe comorbid conditions including liver cirrhosis. Here, we report our experience of living donor liver transplantation (LDLT) indicated for two patients with liver cirrhosis complicated with gallstone diseases.
A 70-year-old woman with a history of hepatitis C virus infection was diagnosed as symptomatic choledocholithiasis. She had open cholecystectomy and choledochotomy with choledocholithotomy, which complicated with postoperative liver failure. Her Child-Pugh score increased from 7 to 12 points and Model for End-Stage Liver Disease (MELD) score from 11 to 36. She underwent LDLT, using the right lobe graft donated by her 47-year-old daughter. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 27.
A 46-year-old man with a history of hepatitis B virus infection was diagnosed as cholecystitis. He had cholecystostomy without any complications and his Child-Pugh score remained to be 9 and MELD score 17, followed by LDLT using the right lobe graft donated by his 45-year-old wife. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 44.
LDLT is one of treatment options when patients with Child-Pugh B cirrhosis accompanied with gallstone diseases, likely to be deteriorating their liver functions in the near future.
Gallstones are common and detected as high as 4.11 % in general population , and the rate would be 1.2 to 3 times higher in patients with chronic liver disease (CLD) [2, 3]. Acute cholecystitis and cholangitis results from obstruction of the cystic duct or common bile duct, respectively, usually by gallstones, followed by inflammation of the gallbladder, or bile duct. Laparoscopic cholecystectomy (LC) is the standard treatment for acute cholecystitis in general population . Cholangitis, on the other hand, requires biliary decompression by endoscopic or percutaneous transhepatic approaches and antibiotic therapy . Patients with symptoms caused by gallstone (GS) disease can be difficult to manage if they have severe comorbid conditions, including end-stage liver disease . Morbidity and mortality after cholecystectomy get greater in accords with Child-Pugh class , and Machado reported that mortality after cholecystectomy of patients with Child-Pugh A, B, and C liver cirrhosis was 0.12, 0.97, and 17.1 %, respectively .
Because a poor outcome was observed, some study recommends that percutaneous gall bladder aspiration [8, 9] and endoscopic gallbladder stent placement [2, 10] rather than operation may be a potential treatment or temporizing measure for symptomatic gallbladder disease in patients with liver cirrhosis awaiting liver transplantation (LT) [9, 11]. It is difficult, however, to await LT with temporizing measure in Japan, considering the severe shortage of cadaveric donor grafts . Here, we report our experience of living donor liver transplantation (LDLT) for two patients with liver cirrhosis complicated with GS diseases.
Gallbladder disease of patients with liver cirrhosis is difficult to manage . Open or laparoscopic cholecystectomy has been reported to be performed safely in cirrhotic patients with well-compensated liver function , but in our case 1 the patient with Child-Pugh B cirrhosis suffered postoperative liver failure. Postoperative liver failure without improvement with plasma exchanges is indicated for liver transplantation; and considering the scarcity of cadaveric liver grafts in Japan , LDLT was indicated. Endoscopic treatment would be the first-choice treatment , but cirrhotic patients are at high risk of accompanying with esophageal varices as the patient in our case 1, which interrupt endoscopic treatment.
The best management of cirrhotic patients with symptomatic GS might require a multidisciplinary team of surgeons, endoscopists, and radiologists, to allow the most efficient treatment including LT . For example in our case 2, we performed percutaneous cholecystostomy which controlled symptoms considering the risks of liver failure following surgery like case 1. Definitive treatment was mandate in this case with multiple stones stuck in the gallbladder neck and anticipated relapsing cholecystitis. We did not treat by cholecystectomy, with preparing LDLT just in case, because the results of emergency LDLT have been considered inferior to those of elective transplants . Rather, we preceded percutaneous cholecystostomy followed by LDLT.
Cirrhotic patients with Child-Pugh class B and C with symptomatic GS disease are life-threatening conditions with significant mortality. Multidisciplinary management in a tertiary care center considering LDLT as an option may offer the optimal treatment.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
AST, aspartate aminotransferase; CLD, chronic liver disease; CT, computed tomography; EVL, endoscopic variceal ligation; GS, gallstone; GV/SLV, graft volume to recipient standard liver volume ratio; HBIG, hepatitis B immune globulin; HBV, hepatitis B virus; HCV, hepatitis C virus; INT, international normalized ratio; LC, laparoscopic cholecystectomy; LDLT, living donor liver transplantation; LT, liver transplantation; MELD, Model for End-Stage Liver Disease
This case report is realized without any funding.
YB collected and interpreted the data and wrote the manuscript. TI contributed to the initial draft, review of the final manuscript, and final submission of the paper. YY helped with the data collection. TM, NHarada, and HU contributed to the data collection and interpretation. SI and NHarimoto were involved with the patients during admission. TY contributed to the study concept/design. YM contributed to the review of the final manuscript and its final submission. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Ethical approval is not required.
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