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Use of liver graft infested with clonorchis sinensis for living related liver transplantation: a case report
Use of Liver Graft Infested With Clonorchis Sinensis for Living Related Liver Transplantation: A Case Report Y.J. Hwang, Y.I. Kim, Y.K. Yun, and J.W. Kim
C
LONORCHIS sinensis, the liver fluke, has been well known as a parasite of major public health importance in Southeast Asian countries. In the era of severe shortage of liver grafts, it may be an important issue whether the infested liver is suitable for graft or not. We report on the use of such infested liver from living-related donor for orthotopic liver transplantation. CASE REPORT
A 22-month old, 13.5 kg boy with biliary atresia who underwent Kasai portoenterostomy was listed as a candidate for liver transplantation for his deteriorating condition. Because of extreme shortage of cadaveric donors, his 29-year-old father was evaluated for living-related donor
which revealed the mild peripheral intrahepatic ductal dilatation (Fig 1) and positivity of stool ova of Clonorchis sinensis. After treating with praziquantel, we proceeded to liver transplantation using donor’s left lateral segment with standard techniques. The operative cholangiogram disFrom the Department of Transplant Surgery Biomolecular Engineering Center, and Liver Research Institute, Kyungpook National University, School of Medicine, Taegu, Korea. This work was supported by the Korea Science and Engineering Foundation (KOSEF) through the Biomolecular Engineering Center at Kyungpook National University. Address reprint requests to Yang-II Kim, Department of Transplant Surgery and Biomolecular Engineering Centre, Kyungpook National University, School of Medicine, Taegu, 700-721, Korea.
Fig 1. The preoperative (“1”) scanning shows mild peripheral intrahepatic dilatation of bile duct.
0041-1345/00/$–see front matter PII S0041-1345(00)01625-0
© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2182
Transplantation Proceedings, 32, 2182–2183 (2000)
LIVER GRAFT INFECTED WITH CLONORCHIS SINENSIS
2183
Fig 2. The operative cholangiogram shows disproportional dilatation of peripheral intrahepatic bile duct.
closed mild intrahepatic ductal dilatation (Fig 2) and the dead parasites were observed during organ procurement but the postoperative course was uneventful. Upon follow-up for 10 months, no other ill effect has been observed and repeated examination of stool ova for Clonorchis sinensis in this patient revealed negative, indicating that all the parasites probably had been killed by the praziquantel and the cold perfusion. DISCUSSION
Clonorchiasis is the most prevalent helminthic infection and endemic in the river basins in Southeast Asian countries. C. sinensis is mechanically stimulatory and destructive on the bile duct epithelium in contact. The fluke provokes the pathologic changes in the biliary trees such as the inflammation of the bile ducts, the hyperplasia and desquamation of endothelial cells, the glandular dilatation and thickening of bile ducts, the periductal and periportal fibrosis, and the increase of mucin-secreting cells and goblet cells.1 Although the majority remain asymptomatic and are generally undetected or unsuspected by conventional clinical evaluation, preoperative evaluation of stool ova of C. sinensis may be needed to avoid possible sequellae especially in the endemic area. Also the transplant team of Western countries, where the number of Asian immigrants are increasing, will need to be aware of the likelihood of
using such infested graft which is uncovered only during harvesting or bench working. Yeung et al reported 2 cases of successful liver transplantation using the grafts infested with C. sinensis without preoperative antihelminthic chemotherapy.2 They assumed that the parasites might have been killed by the cold preservation procedures. However, one of them experienced the early cessation of bile flow from the biliary splintage tube due to blockage by the dead parasites. We believe that preoperative antihelminthic chemotherapy may be of help to reduce the likelihood of this complication and avoid the forceful flushing which may have harmful effect on biliary epithelium provided the infestation to detected preoperatively, especially in livingrelated liver donors. With the extreme shortage of cadaveric liver donors and lack of serious morbidity associated with use of these infested grafts. It is reasonable to include these mild infected livers as acceptable donors. As the C. sinensis is known to be associated with mucin-secreting type of cholangiocarcinoma,3 however, special caution is required on long-term follow-up. REFERENCES 1. Gibson JB, Sun T: Clonorchiasis. In pathology and helminthic disease. Marcial-Rolas ed. Baltimore: Williams & Wilkins Co; 1971, p 546 2. Yeung CK, Ho JK, Lau WY, et al: Postgrad Med J 72:427 3. Hon PC: J Pathol Bacteriol 72:219, 1956
C
LONORCHIS sinensis, the liver fluke, has been well known as a parasite of major public health importance in Southeast Asian countries. In the era of severe shortage of liver grafts, it may be an important issue whether the infested liver is suitable for graft or not. We report on the use of such infested liver from living-related donor for orthotopic liver transplantation. CASE REPORT
A 22-month old, 13.5 kg boy with biliary atresia who underwent Kasai portoenterostomy was listed as a candidate for liver transplantation for his deteriorating condition. Because of extreme shortage of cadaveric donors, his 29-year-old father was evaluated for living-related donor
which revealed the mild peripheral intrahepatic ductal dilatation (Fig 1) and positivity of stool ova of Clonorchis sinensis. After treating with praziquantel, we proceeded to liver transplantation using donor’s left lateral segment with standard techniques. The operative cholangiogram disFrom the Department of Transplant Surgery Biomolecular Engineering Center, and Liver Research Institute, Kyungpook National University, School of Medicine, Taegu, Korea. This work was supported by the Korea Science and Engineering Foundation (KOSEF) through the Biomolecular Engineering Center at Kyungpook National University. Address reprint requests to Yang-II Kim, Department of Transplant Surgery and Biomolecular Engineering Centre, Kyungpook National University, School of Medicine, Taegu, 700-721, Korea.
Fig 1. The preoperative (“1”) scanning shows mild peripheral intrahepatic dilatation of bile duct.
0041-1345/00/$–see front matter PII S0041-1345(00)01625-0
© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2182
Transplantation Proceedings, 32, 2182–2183 (2000)
LIVER GRAFT INFECTED WITH CLONORCHIS SINENSIS
2183
Fig 2. The operative cholangiogram shows disproportional dilatation of peripheral intrahepatic bile duct.
closed mild intrahepatic ductal dilatation (Fig 2) and the dead parasites were observed during organ procurement but the postoperative course was uneventful. Upon follow-up for 10 months, no other ill effect has been observed and repeated examination of stool ova for Clonorchis sinensis in this patient revealed negative, indicating that all the parasites probably had been killed by the praziquantel and the cold perfusion. DISCUSSION
Clonorchiasis is the most prevalent helminthic infection and endemic in the river basins in Southeast Asian countries. C. sinensis is mechanically stimulatory and destructive on the bile duct epithelium in contact. The fluke provokes the pathologic changes in the biliary trees such as the inflammation of the bile ducts, the hyperplasia and desquamation of endothelial cells, the glandular dilatation and thickening of bile ducts, the periductal and periportal fibrosis, and the increase of mucin-secreting cells and goblet cells.1 Although the majority remain asymptomatic and are generally undetected or unsuspected by conventional clinical evaluation, preoperative evaluation of stool ova of C. sinensis may be needed to avoid possible sequellae especially in the endemic area. Also the transplant team of Western countries, where the number of Asian immigrants are increasing, will need to be aware of the likelihood of
using such infested graft which is uncovered only during harvesting or bench working. Yeung et al reported 2 cases of successful liver transplantation using the grafts infested with C. sinensis without preoperative antihelminthic chemotherapy.2 They assumed that the parasites might have been killed by the cold preservation procedures. However, one of them experienced the early cessation of bile flow from the biliary splintage tube due to blockage by the dead parasites. We believe that preoperative antihelminthic chemotherapy may be of help to reduce the likelihood of this complication and avoid the forceful flushing which may have harmful effect on biliary epithelium provided the infestation to detected preoperatively, especially in livingrelated liver donors. With the extreme shortage of cadaveric liver donors and lack of serious morbidity associated with use of these infested grafts. It is reasonable to include these mild infected livers as acceptable donors. As the C. sinensis is known to be associated with mucin-secreting type of cholangiocarcinoma,3 however, special caution is required on long-term follow-up. REFERENCES 1. Gibson JB, Sun T: Clonorchiasis. In pathology and helminthic disease. Marcial-Rolas ed. Baltimore: Williams & Wilkins Co; 1971, p 546 2. Yeung CK, Ho JK, Lau WY, et al: Postgrad Med J 72:427 3. Hon PC: J Pathol Bacteriol 72:219, 1956