Julio Wiederkehr

By Julio Cesar Wiederkehr, Barbara de Aguiar Wiederkehr and Henrique de Aguiar Wiederkehr

Liver transplantation (LT) has become standard management of pediatric liver diseases that lead to acute liver failure or can progress to end-stage liver disease (ESLD). Indications for LT in pediatric patients can be classified into cholestatic disorders, metabolic liver diseases causing liver cirrhosis, metabolic liver diseases without liver cirrhosis, acute liver failure, acute and chronic hepatitis, and liver tumors. The most common indication of PLT is biliary atresia. Generally, the patient is a child with biliary atresia with several prior surgical procedures, extremely malnourished, with stigmata of fat-soluble vitamin deficiency, bleeding diathesis, uncontrolled portal hypertension and massive ascites. Before the technique of liver splitting, pediatric patients were dependent on donors with similar age or size. Partial liver grafts can be obtained either by splitting a cadaveric donor organ or by living-donor liver donation. Living donor liver recipients have a shorter waiting time. The majority of centers employ a regime of' triple therapy with prednisolone, mycophenolate and tacrolimus. LT in the pediatric setting is technically challenging due to the reduced size of the vasculature and biliary tree. Strategies for identification and mitigation of risk factors, prevention of technical complications, and protocols for early detection of vascular complications may reduce mortality, morbidity.

Part of the book: Frontiers in Transplantology

By Julio Wiederkehr, Barbara Wiederkehr and Henrique Wiederkehr

The adenocarcinoma of the colon and rectum (CRC) affects more than 1.3 million patients each year, being the third most common malignancy in the world. Approximately, 30–50% of these patients will present with liver metastasis at the time of diagnosis or will develop metastasis later. The incidence of metastatic CRC (mCRC) is approximately 4.3% at 1 year, 8.7% at 2 years, 12% at 3 years, and 16.5% at 5 years after resection. Recently, the clinical outcome for patients with mCRC has improved, with a median overall survival (OS) for patients with mCRC is approximately 30 months, more than twice of that observed 20 years ago. The treatment approach for patients with colorectal liver metastases should be focused toward complete resection whenever possible, with both oncological and technical criteria being considered. Considering the fact that nearly 80% of patients with mCRC are not candidates for resection at diagnosis, initial treatment options include chemotherapy and locoregional therapies. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has emerged as modification on classic two-staged hepatectomy (TSH) with portal vein embolization. In experienced hepatobiliary centers and in well-selected patients, ALPPS can be performed with low morbidity and minimal mortality, resulting in good intermediate-term survival and excellent quality of life. Multidisciplinary tumor boards should critically scrutinize the best treatment options.

Part of the book: Surgical Challenges in the Management of Liver Disease

By Henrique A. Wiederkehr, Julio Wiederkehr, Barbara A. Wiederkehr, Lucas M. Sarquis, Oona T. Daronch, Lucas Scopel and João V. Zeni

Liver trauma is responsible for the majority of penetrating abdominal trauma and is the third most common injury caused by firearms. Presenting a 20% mortality rate, it is an organ with wide and complex vascularization, receiving blood from the hepatic veins and portal vein, as well as from the hepatic arteries. The diagnosis is not always simple in polytrauma patients and contains a wide range of exams such as computerized tomography and diagnostic peritoneal lavage. Treatment depends mostly on a few factors such as the patient’s hemodynamic stability, the degree of injury according to the AAST classification, the resources available, and the surgeon’s expertise. Considering these factors, minor lesions can be treated mostly with a conservative approach in hemodynamically stable patients. Embolization by arteriography has shown good results in major lesions in clinically stable patients as well. On the other hand, more complex lesions associated with hemodynamically unstable patients may indicate damage control surgery applying techniques such as temporary liver packing and clamping the pedicle to restore the hemodynamic status. This chapter aims to describe those techniques and their indications in liver trauma.

Part of the book: Trauma and Emergency Surgery