C-reactive protein but not procalcitonin may predict antibiotic response and outcome in infections following major abdominal surgery

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann–Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann–Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.

The role of minimally invasive surgery in the treatment of cholangiocarcinoma

Cholangiocarcinoma (CC) is the second most common type of primary liver cancer after hepatocellular carcinoma. Surgical resection is considered the only curative treatment for CC. In general, laparoscopic liver surgery (LLS) is associated with improved short-term outcomes without compromising the long-term oncological outcome. However, the role of LLS in the treatment of CC is not yet well established. In addition, CC may arise in any tract of the biliary tree, thus requiring different types of treatment, including pancreatectomies and extrahepatic bile duct resections. This review presents and discusses the state of the art in the laparoscopic and robotic surgical treatment of all types of CC. An electronic search was performed to identify all studies dealing with laparoscopic or robotic surgery and cholangiocarcinoma. Laparoscopic resection in patients with intrahepatic CC (ICC) is feasible and safe. Regarding oncologic adequacy, as R0 resections, depth of margins, and long-term overall and disease-free survival, laparoscopy is comparable to open procedures for ICC. An adequate patient selection is required to obtain optimal results. Use of laparoscopy in perihilar CC (PHC) has not gained popularity. Further studies are still needed to confirm the benefit of this approach over conventional surgery for PHC. Laparoscopic pancreaticoduodenectomy for distal CC (DCC) represents one of the most advanced abdominal operations owing to the necessity of a complex dissection and reconstruction and has also had small widespread so far. Minimally invasive surgery seems feasible and safe especially for ICC. Laparoscopy for PHC is technically challenging notably for the caudate lobectomy. Not least as for the LLR, the robotic approach for DCC appears technically achievable in selected patients.

The ALPPS procedure for hepatocellular carcinoma

BACKGROUND

The main limiting factor to major hepatic resections is the amount of the future liver remnant (FLR). Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a procedure which induces a rapid hypertrophy of the FLR in patients with non-resectable liver tumours.

METHODS

ALPPS is a surgical technique of in-situ splitting of the liver along the main portal scissura or the right side of the falciform ligament, in association with portal vein ligation in order to induce a rapid hypertrophy of the left FLR.

RESULTS

The median FLR volume increase was 18.7% within one week after the first step and 38.6% after the second step. At the first step the median operating time was 300 min, blood transfusions were not required in any case, median blood loss was 150 cc. At the second step median operating time was 180 min, median blood loss was 50 cc, none of the patients required intra-operative blood. All patients are alive at a median follow up of 9 months.

CONCLUSIONS

This novel strategy seems to be feasible even in the context of a cirrhotic liver, and demonstrates the capacity to reach a sufficient FLR within a shorter interval of time.

The ALPPS procedure for hepatocellular carcinoma

BACKGROUND

The main limiting factor to major hepatic resections is the amount of the future liver remnant (FLR). Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a procedure which induces a rapid hypertrophy of the FLR in patients with non-resectable liver tumours.

METHODS

ALPPS is a surgical technique of in-situ splitting of the liver along the main portal scissura or the right side of the falciform ligament, in association with portal vein ligation in order to induce a rapid hypertrophy of the left FLR.

RESULTS

The median FLR volume increase was 18.7% within one week after the first step and 38.6% after the second step. At the first step the median operating time was 300 min, blood transfusions were not required in any case, median blood loss was 150 cc. At the second step median operating time was 180 min, median blood loss was 50 cc, none of the patients required intra-operative blood. All patients are alive at a median follow up of 9 months.

CONCLUSIONS

This novel strategy seems to be feasible even in the context of a cirrhotic liver, and demonstrates the capacity to reach a sufficient FLR within a shorter interval of time.

A Bayesian methodology to improve prediction of early graft loss after liver transplantation derived from the liver match study

BACKGROUND

To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry.

METHODS

Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis.

RESULTS

A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76).

CONCLUSION

Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.

Hanging of the hepatic veins septa: a safe control prior and during outflow anastomosis in liver transplantation

Inferior vena cava (IVC) preservation during orthotopic liver transplantation (OLT) is known as the "piggyback" technique. The end-to-side anastomosis is constructed between the graft's IVC and recipient's hepatic veins using a Satinsky side clamp applied in a transverse position. To stabilize the large Satinsky clamp and preserve a sufficient vascular stump after hepatectomy and before graft implantation, we propose a technical innovation consisting of hanging the septa between the left and middle hepatic vein and between the middle and right hepatic vein using 2 tapes. This technique showed some advantages when performing the caval outflow anastomosis, representing a further technical refinement of the piggyback end-to-side technique for the implantation on the 3 hepatic veins. From November 2001 to September 2012, we performed 272 consecutive OLT at our institution with the piggyback technique using the hanging of the hepatic veins septa in all cases. In conclusion, the hanging of the 3 hepatic veins septa presented in this study represents a simple, safe and reproducible technique for the outflow anastomosis using the piggyback technique.

Malignant insulinoma presenting as metastatic liver tumor. Case report and review of the literature

Insulin-secreting tumors are the commonest hormone-producing neoplasm of the gastrointestinal tract. They occur with an incidence of 4 cases per million per year. About 10% of them are metastatic and malignant insulinomas very rarely observed in children and in elderly. We report a rare case of very large malignant insulinoma in a 71-year-old woman admitted in our Oncological Institute on October 2005. She presented with fasting hypoglicemia (blood glucose 35 mg/dl) and high serum insulin levels (insulin 115.9 microU/ml). A computerized tomographic scan showed a pancreatic tail lesion of about 6 cm in max diameter and multiple liver metastases. A whole body scintiscan using 111In-DTPA-D-Phe1-octreotide was made and an increased uptake in the tail of the pancreas has been found. The patient was submitted to liver biopsy and the diagnosis of a metastatic insulin-secreting tumor was immunoistochemically confirmed. Due to the presence of some hypoglicemic episodes uncontrolled by medical treatment, on December 2005 the patient was admitted to surgical intervention with a body and tail pancreatic resection. Post-operatively the patient experienced again syncope with hypoglycemia and hyperinsulinemia. It was then decided to start a schedule of treatment with somatostatin analog (octreotide subcutaneously 500 microg three times a day) with a good control of blood glucose levels (101 mg/dl). A trans-arterial chemioembolization was planned but the patient died for pancreatic and cardiovascular complications before this treatment started.

First-line liver resection and salvage liver transplantation are increasing therapeutic strategies for patients with hepatocellular carcinoma and child a cirrhosis

AIM

The present study focused on nine patients with hepatocellular carcinoma (HCC) associated with Child A liver cirrhosis undergoing first-line liver resection and salvage liver transplantation (SLT) for liver tumor recurrence.

PATIENTS AND METHODS

Forty-six patients with HCC underwent liver transplantation (OLT); 37 (80.5%) were primary liver transplantations (PLTs) and 9 (19.5%) were SLTs. All patients who underwent SLT received minor transabdominal liver resections.

RESULTS

The posttransplant 1-, 3-, and 5-year overall survival rates for SLT (88.9%, 88.9%, and 88.9%) were similar to those for PLT (78%, 62.7%, and 62.7%). Four (10.8%) patients in the PLT group had HCC recurrence, while there was zero recurrence in the SLT group. The 1-, 3-, 5-year disease-free survival rates for PLT (89%, 74%, and 74%) were similar to those for SLT (100%, 100%, and 100%). The 1-, 3-, 5-year disease-free survival rates after PLT were 89%, 74%, and 74%, and after SLT were 100%, 100%, and 100%, respectively. The operative mortality, intraperioperative bleeding, operative time, intensive care unit stay, in-hospital stay, and overall incidence of postoperative complications were similar in the two groups.

CONCLUSIONS

In our experience, SLT for HCC is a feasible procedure with similar results in terms of overall survival, disease-free survival, and postoperative complications to those reported for patients who underwent PLT at our institute. An important role exists for SLT as shown by the fact that such a strategy has been used in the 20% of the patients undergoing OLT for HCC.

Modified liver hanging maneuver during orthotopic liver transplantation with inferior vena cava preservation: results after 120 consecutive applications

The outflow venovenous anastomosis represent a crucial aspect during orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation. The modified Belghiti liver hanging maneuver applied to the last phase of hepatectomy, lifting the liver, provides a better exposure of the suprahepatic region and allows easier orthogonal clamping of the three suprahepatic veins with a minimal portion of IVC occlusion. The outflow anastomosis constructed with a common cloacae of the three native suprahepatic veins is associated with a lower incidence of graft related venous outflow complications. The procedure planned in 120 consecutive OLT was achieved in 118 (99%). The outflow anastomosis was constructed on the common cloaca of the three hepatic veins in 111/120 cases (92.5%). No major complications were observed (bleeding during tunnel creation, graft outflow dysfunction, etc) except in one patient with acute Budd-Chiari, who successfully underwent retransplantation.

Liver transplantation in HIV-positive patients

AIMS

The aim of this study was to evaluate the feasibility of liver transplantation (OLT) in human immunodeficiency virus (HIV), hepatitis C virus (HCV) coinfected patients in Italy.

METHODS

Between September 2002 and April 2006, 12 HIV(+) coinfected patients (11 men, mean age 42 years) underwent OLT at our Institute. Eleven (91%) patients were HCV-positive and one was hepatitis B virus-positive. Pre-OLT plasma HIV 1-RNA level was undetectable and CD4(+) T-cell count >200 cells/microL for 3 months in all patients. Six patients had to stop highly active antiretroviral therapy (HAART) before OLT because of liver disease severity (n = 2) and for hepato cellular carcinoma (n = 4).

RESULTS

The actuarial 1-, 2-, and 3-year survival rates were 83.3%, 58.3%, and 58.3%, respectively, which were significantly lower than those observed among HIV-negative patients transplanted in our center. Six patients are alive with a mean follow-up of 26 months (range: 5 to 46 months). We recorded a low rate of opportunistic infections and rejection. All alive patients have low levels of HIV RNA, and the CD4(+) T-cell counts increased after OLT. Nine patients developed early recurrence of hepatitis C requiring combination therapy with peg-interferon plus ribavirin. Significant improvement in the quality of life was observed in 7/11 patients.

CONCLUSIONS

OLT in HIV-positive patients was feasible with good results in the short and medium term. Early severe HCV recurrence may be observed. Key challenges for the management of HIV(+) patients after transplantation included treatment of severe HCV recurrence and attention to the pharmacological interactions of HAART with immunosuppressive drugs.

Incidence and Timing of Infections After Liver Transplant in Italy

BACKGROUND

Infections are one of the main complications that cause high morbidity and mortality in transplant recipients. This study sought to estimate the incidence of infections and their main determinants in liver transplant recipients in the first year after transplantation.

PATIENTS AND METHODS

A prospective study was conducted on 103 consecutive patients (72% men) who underwent transplantation in three centers in Northern (Bologna) and Central (Rome) Italy in 2005. Person-years (PY) at risk, incidence rates (IR), IR ratios and 95% confidence intervals were computed for viral, fungal, and bacterial infections.

RESULTS

The 103 patients (median age 55 years) contributed a total of 78.2 PYs, with a median follow-up of 286 days (interquartile range: 194 to 365 days). Fifty-eight patients (56.3%) experienced one or more infections, namely, 151 events (IR = 193.2 infections/100 PYs). IR for bacterial, fungal, and viral infections were 110.0, 56.3, and 26.9 infections/100 Pys, respectively. Within the first 30 days after transplantation, 37.9% patients (39/103) developed one or more events. Bacterial infections represented the most frequent event (86/151, 57.0%). Risk factors significantly associated with increased IR were gender (female), age (>50 years), prolonged intensive care stay volume of blood transfused during surgery and posttransplant, and need for retransplantation.

CONCLUSIONS

These preliminary results showed the relevance of infectious events after liver transplantation especially those of bacterial etiology, and identified factors mainly associated with their occurrence.

[Isolated resection of the caudate lobe in metastasis of colorectal cancer]

The presence of metastatic lesions confined to the caudate lobe (CL or segment I) is quite a rare event. Even more rare is the decision to perform an isolate CL resection. Segmental resection in the liver is justified by the evidence that primary and secondary lesions, in early stage, are confined to the originating segment, and therefore a segmentectomy can be considered for the CL as well. Anatomy of the CL was deeply studied through the years since the surgical approach to this liver segment requires a detailed knowledge of its surgical anatomy and only after 1985 the surgical technique for CL isolate resection was established. We report our experience with 1 case of isolate colo-rectal metastasis confined to the caudate lobe and describe the surgical technique employed.

Resection and transplantation: evaluation of surgical perspectives in HIV positive patients affected by end-stage liver disease

PURPOSE

The aim of this study was to evaluate the opportunity of surgical treatment in terms of liver resection or liver transplantation in HIV positive patients affected by an end stage liver disease that referred to our liver unit.

METHODS

Among 1350 outpatients who referred to our liver unit from January 2002 to September 2003, thirty-two (2,4%) were HIV positive. The routes of transmission of the viral infection, the related co-infections and the underlying liver disease were recorded. The therapeutic pathway was analysed. The kind and the duration of the surgical procedures were assessed.

RESULTS

Fourteen (44%) of these thirty-two patients were not suitable for surgical treatment. Surgery was planned in 9 of 32 HIV positive patients (28%). Four patients (12%) were submitted to liver resection and OLT was performed in five patients (15%). Hepatocellular Carcinoma was present in 4 (44%) of the HIV positive patients considered for surgery.

CONCLUSIONS

In conclusion in our centre the 28% of HIV positive out patients had the opportunity to receive a surgical treatment. The candidate to this surgery is mostly young, HCV and/or HBV coinfected and affected by HCC in 44% of cases.

Personal experience on treatment of colorectal liver metastases: a multidisciplinary approach

Diagnosed colorectal cancer patients presents liver metastases at presentation in 25% of cases, an another 25% of patients will develop hepatic recurrence during follow-up period. Natural history of disease in untreated patients is sad without long term survivors. The only chance of curative treatment is surgical resection. Aim of this study was to evaluate recurrence and survival in the multimodal approach of colorectal liver metastases patients.

MATERIALS

From 1990 to 2003, 212 colorectal cancer liver metastases patients were observed at the "Regina Elena" cancer institute of Rome, the 48.8% of cases were synchronous. Of 185 patients with minimum follow-up of 12 months, 80 were surgically resected, while 105 were not. Major resection was possible in 45.3% of cases and 66.1% of them were radicals. Tweny were treated by surgery alone, 65% were resected after i.v. chemotherapy, in the last 10% resection followed HAI chemotherapy. Of non resected patients, in the 36.2% i.v. chemotherapy was administered, 26.1% were submitted to HAI chemotherapy, in 18.9% others treatments were carried out and 18.8 were untreated.

RESULTS

Operative mortality was contained to 2.5%. The hepatic recurrence was observed in 50.5% of cases while extrahepatic was in the 13.6%. In the resected cases the 5-yr. Overall survival was 38.8%, the disease-free survival decreased to 14.7% with a median time to progression of 15 months. The liver recurrence-free survival was 31.3%. Really bad prognopsis was observed in the non resected patients with none survived at 5 years and 3-yr overall survival of 18.7%.

CONCLUSION

In selected patients the multimodality approach to treatment of hepatic metastases showed satisfactory results in terms of local and distal control of disease. Long term survivors were observed in the our experience.

[Trauma of the liver and hepatic pedicle]

Traumatic injuries of the liver and hepatic pedicle secondary to blunt abdominal trauma are unusual and often associated with injuries of other abdominal and/or thoracic organs. These lead the patient to an emergency operation for hemorrhagic shock. The diagnosis of trauma severity and hepatic pedicle involvement is made intraoperatively. Often only one anatomical structure of the hepatic pedicle is involved, whereas involvement of two or all three anatomical structures is rare and associated with a bad prognosis. The management of these injuries still remain one of the most challenging scenario in trauma surgery. The overall experience is not significant. Clear treatment guidelines or management algorithms have not yet been established, in part due to the complexity, severity and variability of these injuries and to the lack of large series with these rare events. Three cases of associated liver and hepatic pedicle injuries treated in our unit are reported.

[Acute liver toxicity of antiretroviral therapy (HAART) after liver transplantation in a patient with HIV-HCV coinfection and associated hepatocarcinoma (HCC)]

OLT in HIV infected patients still remains a challenging option requiring a careful monitoring of patients for HCV reinfection, drug interactions and antiretroviral toxicity. Severe adverse events due to HAART have been already reported for post exposure prophylaxis in HIV infected patients. Here we report a case of liver graft toxicity related to HAART in a HIV-HCV co-infected patient (46 yrs-male) with associated a small HCC transplanted with a marginal liver graft. The patient had pre-OLT plasma HIV 1-RNA levels undetectable and CD4+ T-cell count of > 200 cells/microL for 6 months. At day 2 a severe graft dysfunction was observed (AST 1570 U/L, ALT 2180 U/L, BIL tot 8.3 mg/dL, BIL Dir 6.6 mg/dL and PT 35%--INR 2.5). Doppler scan showed hepatic artery always patient. Later the postoperative in-hospital course was complicated by tense ascites and severe cholestasis. Serum bilirubin reached 42 mg/dL in day 12. Hypertransaminasemia ended at day 15 while cholestasis ended after 46 days. Tacrolimus was reintroduced at day 7. A liver biopsy 10 after OLT showed severe intrahepatic cholestasis, centrolobular necrosis and macrovesicular steatosis (30%). The patient was discharged 48 days after OLT with good liver function. After seven months HIV-RNA is still undetectable and HAART has not been restarted. We believe that the early complications we observed may be attributed to a sudden increase in plasma concentration of antiretroviral drugs secondary to drug redistribution from peripheral tissues and hepatic clearance deficiency after OLT. Although a pre-OLT withdrawal of HAART seems unjustified a delayed re-introduction of HAART or the use of less hepatotoxic drugs may be advisable.

[The modified "hanging maneuver" during orthotopic liver transplantation using a technique for conserving the inferior vena cava]

We describe a modification of Belghiti's "liver hanging maneuver" applied to the last phase of hepatectomy during OLT with IVC preservation. The proposed maneuver provides a better exposition of the suprahepatic veins allowing an ortogonal clamping of the suprahepatic confluence and avoiding caval clamping. It allows, moreover, an increase of venous surface available for the anastomosis that results wider and easier to perform. This provides a large outflow anastomotic cloaca and prevents outflow problems of the graft.

[Intestinal transplantation in the rat. Surgical technique]

Small bowel transplant (SBT) is a still open challenge in the field of transplantation. Immunological problems make it a technique not yet completely reliable for patients with irreversible chronic intestinal failure and, thus, accepted at the moment only for those who present potentially life threatening complications of total parenteral nutrition (TPN). Recently, new immunosuppression protocols have greatly improved the results, however research for new regimens to prevent rejection is still going on. The rat represents an invaluable model for studying small bowel transplant. The simplicity of the technique and the use of inbred species allow to study both rejection and graft versus host disease. The technique of rat small bowel transplant in the rat is presented and illustrated by a very didactic and explicable series of images.

Apoptosis and rejection in rat intestinal transplantation: correlation with FK506 doses and donor specific bone marrow infusions

BACKGROUND

Our purpose was to investigate the occurrence and the evolution of apoptosis of enterocytes during acute and chronic rejection in an experimental model of allogeneic heterotopic small bowel transplantation (SBTx).

METHODS

Forty-five rats were divided in 10 experimental groups according to the dose of FK506 administration and donor bone marrow infusions (DBMI). Groups 1 and 2 did not received BMI. Groups 3 and 4 received 150x106 cells at day 0, groups 5 and 6 received 75x106 cells at days 0-4, groups 7 and 8 received 75x106 cells at days 4 and 10, and groups 9 and 10 received 30x106 cells at days 4, 10, 15, 20, and 25. Animals of groups 1, 3, 5, 7, and 9 were immunosuppressed with 0.5 mg/kg FK 506, although the remaining groups with 1 mg/kg FK 506, from day 0 to 4 after transplant. Fragment end labeling of DNA was used to detect apoptosis.

RESULTS

The number of apoptotic cells detected was highest at day 15 (184+/-154) and then progressively decreased thereafter (day 30=159+/-197; day 45=80+/-167; day 60=0). The number of apoptotic enterocytes was found increased during mild (151+/-108) and moderate (281+/-161) allograft rejection, although a low apoptotic rate was observed in cases without rejection (59+/-13) and during severe (53+/-131) and chronic rejection (46+/-136). Furthermore the number of labeled cells was found inversely correlated with fibrosis (P<0.0001). There was no correlation between apoptosis and the presence or absence of DBMI; however, at day 15 rats receiving 1 mg/day of FK 506 had a significantly lower number of apoptotic cells detected (127+/-103 vs. 233+/-174; P<0.02).

CONCLUSIONS

In this study the number of apoptotic cells correlated positively with mild and moderate rejection episodes. In case of severe and chronic rejection a low apoptotic rate was found due probably to extensive necrosis and fibrosis of the mucosa. These data suggest an important role of apoptosis in acute and chronic intestinal rejection in a rat model of intestinal transplantation. Determination of apoptosis in allografts might represent an early sign of small bowel rejection and a useful marker in defining the degree of rejection and its outcome/prognosis.

Intestinal transplantation for short gut syndrome attributable to necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is a life-threatening condition of the neonatal age, which frequently requires surgical intervention. After extensive bowel resection, a small proportion of these patients may develop chronic short gut syndrome (SGS) and require chronic total parenteral nutrition (TPN) use. Intestinal transplantation has been performed in these patients as a life-saving option. This study reviews our experience with intestinal transplantation for SGS attributable to NEC emphasizing the mode of presentation, natural history, timing, and outcome.

METHODS

A retrospective chart review was performed for all pediatric patients who underwent small bowel transplantation for NEC at the University of Miami between August 1994 and March 1999.

RESULTS

Eleven transplants were performed for 10 patients with NEC (8 male and 2 female; median age: 1.75 years [range: 10 months to 10. 1 years]). Procedures performed were isolated intestinal transplants (n = 2), combined liver-intestinal transplants (n = 6), and multivisceral transplants (n = 3). All patients were born prematurely with median birth weight of 1.640 kg (range: 810 g to 2. 730 kg). They developed NEC in the first few days of life and subsequently underwent an average of 5 surgeries per patient before transplant. Transplant was indicated for liver failure in 8 patients and recurrent central line sepsis in 2 others. At present, 6 patients are alive with an overall 1-year and 3-year actuarial survival of 60% and a median follow-up of 29 months (range: 9-46 months). Six children have been weaned off TPN after a median time of 71 days (range: 19-131) from transplantation. All survivors are at home with functional grafts.

CONCLUSION

Intestinal transplantation provided a reasonable outcome in patients with NEC-associated SGS who had already developed life-threatening complications related to TPN. Intestinal transplantation replaced the diseased intestine and liver, enfranchised patients from TPN, and conferred improved quality of life. These patients should be actively considered for intestinal transplantation and referred to a transplant center as soon as possible.

Metabolic and ultrastructural effects of cyclosporin A on pancreatic islets

We investigated the effect of different doses of cyclosporin A (CyA) on glucose and insulin levels, as well as its residual effects on pancreatic islets ultrastructure after discontinuation of the drug. We studied four groups of Wistar rats. One control- (n = 5) and three experimental groups, n = 10 each, were treated with different doses of CyA i.m. for 14 days: group I, 5 mg/Kg; group II, 15 mg/Kg; and group III, 25 mg/Kg. Five animals of each group were sacrificed after 14 days, and the remaining five after 21 days to assess residual CyA effects. On the day of sacrifice, the rats underwent maltose absorption test, and glucose and insulin levels were measured. Pancreatic biopsies were obtained on day 21 to evaluate islets ultrastructure by electron microscopy. As a result, statistically significant, dose dependent (P < 0.05) increases in glucose and insulin levels were observed in CyA-treated groups. Groups II and III showed insulin levels significantly higher after fasting (P < 0.05) on day 14 comparing to the controls, while in groups I and II values returned to normal after CyA discontinuation. Group III showed persistently increased insulin levels on day 21. Pancreatic ultrastructural changes were observed only in group III. We can conclude that CyA effects on glucose and insulin levels were temporary and reversible at low doses. Ultrastructural changes in the pancreatic islets may occur with high doses of CyA.

One-year pilot study on tauroursodeoxycholic acid as an adjuvant treatment after liver transplantation

BACKGROUND

The usefulness of ursodeoxycholic acid after liver transplantation is controversial. Tauroursodeoxycholic acid, the natural taurine-amidate, is a highly hydrophilic and cytoprotective bile salt currently under investigation.

AIMS

To investigate the clinical usefulness of tauroursodeoxycholic acid after liver transplantation.

PATIENTS

Thirty-three patients undergoing liver transplantation entered the study.

METHODS

Sixteen patients were randomized to receive tauroursodeoxycholic acid (250 b.i.d. for 12 months) and 17 served as controls. Tauroursodeoxycholic acid was given from day 5 after transplantation for one year.

RESULTS

Tauroursodeoxycholic acid treatment was safe and well tolerated. No drop outs occurred. Among the 29 patients undergoing long-term follow-up, five deaths occurred (3 of whom in the tauroursodeoxycholic acid group), none of which was related to treatment. The one-year actuarial survival was 78.6% in patients treated with tauroursodeoxycholic acid and 86.7% in controls (n.s.). No differences were observed with respect to early or late graft function and survival, nor to acute cellular rejection. Tauroursodeoxycholic acid therapy was associated with lower serum cholesterol levels (p < 0.02) during the early postoperative months; with milder cholestasis; with a drop in biliary cholates but no changes in endogenous hydrophobic bile salts.

CONCLUSIONS

Long-term treatment with low dose tauroursodeoxycholic acid after liver transplantation is safe but does not affect graft function and survival.

A pilot study on the safety and effectiveness of immunosuppression without prednisone after liver transplantation

BACKGROUND

Corticosteroids are commonly used in the immunosuppression therapy after liver transplantation, yet are associated with considerable side effects. Retrospective studies have shown that corticosteroids can be safely withdrawn from months to years after transplant. We prospectively investigated the effects of early immunosuppression without the use of corticosteroids on graft outcome and transplant complications.

METHODS

Forty-five patients undergoing liver transplantation were randomized to receive immunosuppression composed of cyclosporine microemulsion and azathioprine with (n=22) or without prednisone (n=23), in conventional doses. In those patients who received prednisone, this was withdrawn within 3 months after transplant. The median follow-up of survivors was 14 months (range: 6-24). The study end points were to determine graft survival and function, infectious complications, including hepatitis C virus (HCV)-RNA levels in HCV-infected recipients, acute rejection, kidney function, and metabolic complications.

RESULTS

Eleven deaths occurred, 6 of which were in the prednisone group. Two-year survival did not differ between patients treated with or without prednisone (70.2% vs. 78.3%, P=0.83), nor did the causes of death. No differences were observed with regard to graft function, renal function, and infectious complications. In the subset of patients who received transplants for HCV-related cirrhosis, the dynamics of virus replication HCV-RNA was faster among those treated with prednisone. The incidence and severity of acute rejection was similar in the two groups. More than 80% of acute rejections in both groups were classified as mild or moderate and underwent spontaneous resolution. Only two patients in each group had severe acute rejection requiring additional treatment with high-dose steroids. Patients receiving prednisone tended to have greater biochemical signs of cholestasis, higher serum cholesterol and glucose levels, and more frequent insulin requirement than those treated without corticosteroids.

CONCLUSIONS

Liver transplantation can be performed safely without using corticosteroids in the early postoperative course, and there is no need for routine aggressive steroid treatment of established acute rejections.

Immunosuppression without prednisone after liver transplantion is safe and associated with normal early graft function: preliminary results of a randomized study

Prednisone has been commonly considered the mainstay of immunosuppressive therapy after liver transplantation. Recent data suggest that prednisone withdrawal late after transplant reduces complications without affecting graft function. We report here the preliminary results of an open-label, randomized study aimed at investigating whether prednisone therapy can be completely avoided during the first 3 months after transplantation. Twenty-seven consecutive patients were randomized to receive double (group A: cyclosporine and azathioprine) or triple (group B: prednisone, cyclosporine, and azathioprine) immunosuppressive therapy after liver transplantation. Six patients died within the first 3 weeks in each group and were excluded from the calculations. The present results refer to 10 patients in group A and 11 in group B. The actuarial 1-year survival did not differ between the two groups (90.9% vs 88.8%). There were no differences with respect to infectious complications or episodes of histological acute graft rejections. Only one severe acute rejection occurred in group A and two in group B. During the first month after transplant, liver and kidney functions tended to be better in the group of patients treated without prednisone, although there were no differences in the mean cyclosporine blood levels. These data, though preliminary, indicate that early immunosuppression without the use of prednisone is safe and tends to be associated with improved liver and renal functions compared to conventional triple therapy.

Advantages of Neoral conversion in renal transplant patients

BACKGROUND

Sandimmun Neoral is a microemulsion formulation of Sandimmun cyclosporin (Cya) with predictable pharmacokinetics, superior absorption and less dependent upon bile production. Recently Neoral replaced the old Cya in the clinical ground.

METHODS

The aim of this study was to assess the effectiveness, safety and advantages of this conversion in 90 adult renal transplant patients with stable renal function transplanted at least 24 months earlier. There were 48 males and 42 females with a mean age of 39 years (range: 18-56). Mean interval from transplant to conversion was 3.6 years (range: 2.7-5.4). Conversion rate was 1:1. Mean Neoral dose at conversion was 3.8 mg/kg/day (range: 2.1-5.7).

RESULTS

One month after conversion mean Neoral dose was 3.4 mg/kg/day (range: 2.2-3.9) and at six months was 3.2 mg/kg/day (range: 2.1-4). Serum creatinine and CyA trough levels remained stable. We did not observe rejection episodes or infections. The incidence of side effects due to CyA was slightly increased and there were not differences in terms of arterial pressure values and number of antihypertensive drugs given.

CONCLUSIONS

The conclusion is drown that conversion to Neoral is safe and results in rapid attainment of therapeutic trough levels. Six months after conversion the mean Neoral dose was decreased of 0.6 mg/kg/die per patient.

[Primary angiosarcoma of the liver]

Hepatic angiosarcoma (AS) is a rare tumor with a fatal course. It represents 1-2% of all primary hepatic tumors and it is the most frequent primary mesenchymal tumor of the liver. Recently its incidence is dramatically increased because of its epidemiological association with exposure to thorotrast, vinyl chloride and other carcinogens. We present the epidemiological, clinical, diagnostic and therapeutic features of 6 patients with primary hepatic AS. No apparent predisposing factors were present. At presentation symptoms, signs and liver function tests were not specific. Four patients presented with metastatic disease: lung (2), peritoneum (1), bone and spleen (1). At time of diagnosis tumor was bilobar in 4 cases and in 2 of whom was multifocal. Median tumor size was 10.5 cm (range: 4-20 cm). Four patients with extrahepatic disease were conservatively treated with chemotherapy (VAC) and the longest survival was 8 months and 2 with tumor confined to the liver were transplanted but both had an early recurrence at 3 and 5 months post-tx respectively and the longest survival was 10 months. These disappointing results confirm the aggressive nature of hepatic AS. An early diagnosis is needed and the radical resection of the tumor is still the best form of treatment.

Transplantation for end stage liver disease related to alpha 1 antitrypsin

Alpha 1 antitrypsin deficiency (AT) is an autosomal recessive disease associated with chronic liver disease in adults and children and emphysema in adults. The disease is one of the most common inherited disorders of the Caucasian population of North Europe and North America and is the most common genetic reason for pediatric orthotopic liver transplantation (OLTx), although it is a rare indication in adults. The natural history of the disease is unpredictable and the pathogenesis of the liver injury unclear. Thirty-five patients with histologically apparent alpha 1 AT accumulation in the liver (22 adults, 13 children) have been transplanted in this center. Clinical features were correlated with the pretransplant phenotype, serum alpha 1 antitrypsin levels and potential precipitating factors. All children were PiZZ homozygotes, most of whom had presented with neonatal hepatitis. The majority of adult patients were heterozygotes presenting with portal hypertension and liver cirrhosis. Current one-year posttransplant survival figures are 73% for adults and 87.5% for children. Replacement of the cirrhotic liver results in acquisition of the donor phenotype, a rise in serum levels of alpha 1 antitrypsin, and apparent prevention of associated disease.

Therapeutic drug monitoring of tacrolimus in clinical transplantation

Initial clinical trials of FK did not incorporate available FK levels, and difficulties were quickly experienced particularly with neurotoxicity and nephrotoxicity. The introduction of routine assay allowed broad parameters to be identified, which assisted in evaluating effective therapeutic parameters. Levels approximately 20 ng/ml were frequently associated with toxicity and the initial therapeutic range between 10-25 ng/ml was probably excessive. Reliable effective assay > 5 ng/ml using the Abbott IMx is not available, and many patients will have excellent hepatic or renal function with what are currently undetectable levels of FK. However, IncStar have an ELISA assay with a sensitivity of 0.5 mg/ml. Clinical practice does not, at this time, dictate elevation of FK, although careful monitoring continues. Education of oral administration from 0.15 mg/kg to 0.1 mg/kg in combination therapy with steroids and 0.05 mg/kg with azathioprine and steroids has led to revision of therapeutic parameters, e.g., 5-15 ng/ml is now widely used. Therapeutic drug monitoring is important to avoid unnecessary toxicity, but the lower limit has not been fully defined. Clearly, many patients with < 5 ng/ml have excellent hepatic function.

[Ureteral obstruction in the kidney transplant patient]

Ureteric obstruction is a common complication following kidney transplantation ranging from 2% to 5% after one year and till 9% after five years post-transplantation. It hinders the return to good renal function and in certain cases leads to the organ loss or patient mortality. Technical factors and ureteric ischemia are the most important causes. The authors report their experience with kidney transplantation and 6 cases of ureter obstruction with a global incidence of 5.5%. We discuss the aetiology, the management and the treatment for this complication emphasizing the importance of either color Doppler ultrasound for the diagnosis or percutaneous nephrostomy for the radiological establishment of the blocked level as well as the first choice of treatment. In order to reduce the morbidity and mortality for this complication early and aggressive treatment is advocated.

[The Urovac bladder evacuator: comparison with traditionally used devices]

Bladder evacuation device "Urovac": comparison with the conventional most used devices. We evaluated a new technique for bladder evacuation primarily during Turp using a disposable device called Urovac. This device proved to be better for evacuation of prostatic chips than both the Ellik evacuation and Toomey syringe.

[Synergism between cyclosporin and gangliosides in anti-rejection therapy. Experimental in vivo model]

In vivo gangliosides (GS) bring about inhibitory effects on the immune response which is attributable to a weakening of the interaction between interleukin-2 (IL-2) and its receptor. In a previous paper we showed that the GS are capable of bringing about in vitro the immunosuppressive power of cyclosporin A CyA2 in this paper we have tried to associate gangliosides (GS) and low dose of CyA in the grafting of rat allogen cutis in order to have in this way in vivo a confirmation of the results previously obtained in vitro. Cutaneous strips taken from Lewis rats were grafted into Sprague Dawley rats and treated for 21 days with intraperitoneal administration of GS, of Cya, and a mixture of the two. The rats were not treated and the rats treated with GS and with CyA separately rejected the graft of the cutis. On the other hand, the use of an association of Gs and CyA brought about a successful graft in 8 rats out of 10. Splenic cells extracted 21 days after the graft from rats treated with GS and with CyA separately were stimulated in vitro with Packweed mitogen (PWM); on the contrary the cells extracted from rats treated with a combination of the two drugs did not react to the stimulation with PWM. Our results show that the GS brings about in vivo the immunosuppressive effects of low doses of CyA.

[The current role of microsurgery in the therapy of idiopathic varicocele]

The authors report a case of recidivant varicocele. After having considered the epidemiological and clinical features of varicocele, traditional and microsurgical technics are analyzed and discussed.