Human hepatocyte transplantation for acute liver failure: state of the art and analysis of cell sources

Liver transplantation is the only treatment available for acute liver failure. However, mortality rates remain high because of the shortage of donor organs. Indeed up to 20% of patients with acute liver failure may survive without transplantation. In the last two decades, research has focused on the development of alternative or supportive measures to deal with acute liver failure; one of the most studied is hepatocyte transplantation, because it is thought that the function of the liver can only be replaced with a biological substrate characterized by functioning liver cells. Hepatocyte transplantation has been successful in many animal models of acute liver failure, although only several clinical attempts have been made in humans with encouraging but not yet convincing results, mainly because of the lack of a reliable source of live liver cells. Allogenic and xenogenic fresh or cryopreserved hepatocytes have been tested. Recent research has focused on fetal hepatocytes and progenitor liver cells of both hepatic and bone marrow origin. The ability to preserve and bank human hepatocytes would allow pooling of cells from multiple donors to increase the numbers for transplantation. The development of a reliable and large-scale available source of live liver cells would probably have a major impact on the introduction of hepatocyte transplantation in clinical practice.

Cryopreserved human hepatocytes from cell bank: in vitro function and clinical application

We Aimed to analyze the in vitro function of isolated and cryopreserved human hepatocytes (CHH) from a cell bank and to define their potential clinical application in a bioartificial liver (BAL) device.

METHODS

Over 24 months, 103 not transplantable livers were utilized for human hepatocytes isolation and cryopreservation. Hepatocytes isolated by collagenase were analyzed for yield, viability, diazepam metabolism, and production of human albumin after isolation and cryopreservation in LN(2).

RESULTS

The causes for refusal for transplantation were macrosteatosis >60%, ischemic damage due to donor hypotension, and nonviral cirrhosis in 60%, 11%, and 8%, respectively. Cell yields averaged 7 million hepatocytes per gram of liver of mean viability of 80% +/- 13%. The viability of CHH after thawing averaged 50%. Thawed hepatocytes showed diazepam metabolism, and human albumin synthesis comparable to fresh cells. CHH were utilized as the biological component of a BAL for temporary support as three applications of two patients affected by fulminant hepatic failure awaiting urgent transplant. Ten to 13 billion viable CHH were loaded into each BAL. Liver function showed bilirubin and ammonia reduction at the end of each treatment. One patient was successfully bridged to emergency OLTx after one BAL; in the second case there was spontaneous recovery of liver function after two BAL.

CONCLUSIONS

Recovery of donor human livers unwanted for transplantation allowed isolation and cryopreservation of viable and functionally active human hepatocytes, which have been banked and successfully used for clinical applications of a BAL device.

One-stage resection without colonic lavage in emergency surgery of the left colon

OBJECTIVE

Intra-operative colonic lavage is a widespread procedure introduced to decompress and clean the colon of its faecal load during emergency surgery of the left colon in order to perform a safe anastomosis. This type of lavage is never performed at our institution. The aim of this study was to evaluate the safety and acceptability of emergency left-sided colectomy without colonic lavage in a consecutive series of patients admitted at our department for perforation and obstruction of the left colon.

PATIENTS AND METHODS

All 44 patients (29 with obstruction and 15 with perforation) on whom a one-stage left-sided colon resection was performed without colonic lavage between January 1998 and June 2004 were evaluated in a retrospective review. During this period all patients with acute disease of the left colon underwent a one stage resection without colonic lavage. The only exclusion criteria for anastomosis were: haemodynamic instability, ASA > 3, unresectable tumour. Death, anastomotic leakage and wound infection were main outcome measures.

RESULT

The leak rate was 4.5% and mortality 2.3% due to one case of postoperative myocardial infarction. A 16% morbidity rate was recorded due to 4 wound infections and 3 minor complications.

CONCLUSION

The procedure is safe. The low morbidity and mortality of one stage resection without colonic lavage can justify future prospective studies enrolling a large number of patients to compare its results with those obtained by one stage resection with colonic lavage.

Octreotide in the treatment of lymphorrhea after axillary node dissection: a prospective randomized controlled trial

BACKGROUND

Axillary lymph node dissection for staging and local control of nodal disease is an integral part of breast cancer therapy. Lymphorrea is a serious and disabling complication of axillary lymphadenectomy, but no effective therapy is currently available. Octreotide is a hormone with general antisecretory effects that has been used to control lymphorrhea in thoracic duct injury and after radical neck dissection. The aim of the study we describe in this article was to determine whether octreotide has a role in the treatment of post axillary lymphadenectomy lymphorrhea.

STUDY DESIGN

This is a prospective randomized controlled trial. Two hundred sixty-one consecutive patients with various stages of breast cancer who underwent axillary lymph node dissection were randomized and followed for 7 years. The treatment group received 0.1 mg octreotide subcutaneously three times a day for 5 days, starting on the first postoperative day, while the control group received no treatment. Of the 261 patients undergoing axillary node dissection, 136 were assigned to the control group and 125 composed the treatment group. The control group and the treatment group were evaluated for amount and duration of lymphorrhea as well as inflammatory and infectious complications.

RESULTS

In the control group, the mean quantity (+/- standard deviation) of lymphorrhea was 94.6 +/- 19 cc per day and the average duration was 16.7 +/- 3.0 days. In comparison, the mean quantity of lymphorrhea in the treatment group was 65.4 +/- 21.1 cc (p < 0.0001) per day and the average duration was 7.1 +/- 2.9 days (p < 0.0001). We did not find an important difference in the number of infectious complication or hematomas formation between the study groups.

CONCLUSIONS

Octreotide can be used successfully for the treatment of post-axillary dissection lymphorrea, and potentially, in the prevention of post-axillary lymph node dissection lymphosarcoma, since the amount and duration of lymphorrhea in this setting are known to be important risk factors for its development. Potentially, octreotide might be used in similar situations where lymphorrhea is detrimental, such as peripheral vascular surgery and regional lymph node dissection for melanoma.

The role of laparoscopy in patients with suspected peritonitis: experience of a single institution

PURPOSE

In this report, we retrospectively evaluate the effect of a laparoscopic approach in the diagnosis and treatment of acute abdominal pain in patients with suspected peritonitis.

PATIENTS AND METHODS

We evaluated the clinical records of patients admitted to our institution between January 1995 and July 2001 with a diagnosis of acute abdomen and suspected peritonitis.

RESULTS

Ninety four of 229 patients underwent diagnostic laparoscopy. In this series, 83 (88.3%) of the cases were successfully treated by emergent laparoscopy for an acute abdomen. Eleven (11.7%) required conversion to an open laparotomy procedure. Overall, the preoperative diagnosis was confirmed by laparoscopy in 67 (71.27%) of the cases. It was not confirmed in 27 (28.73%). Postoperative mortality was 4.25%. Morbidity was 8.5%.

DISCUSSION

Data reported in the literature establish that laparoscopy offers adequate visualization of the entire abdomen and pelvic cavity in the diagnosis of an abdomen acute secondary to peritonitis. In this series, laparoscopy confirmed the diagnosis in 97.8% of the patients, and minimally invasive treatment was achieved in 88.3% of the cases. Female patients with gynecologic disease particularly benefitted from a laparoscopic approach, which permitted the correct evaluation of this condition and may have prevented unnecessary laparotomy. We believe that laparoscopy is an accurate modality for the diagnosis and treatment of patients with an acute abdomen and suspected peritonitis when the diagnosis cannot be clearly made by physical examination and noninvasive methods.

A new method of preemptive analgesia in laparoscopic cholecystectomy

BACKGROUND

Although laparoscopic cholecystectomy (LC) results in less pain then open cholecystectomy, it is not a pain-free procedure. The aim of this study was to test a new method of preemptive analgesia.

METHODS

By simple randomization 60 patients were assigned to two groups (30 in each group). Group A, the placebo group, received 200 ml of 0.9% saline, and group B received 5 mg/kg of a local anesthetic solution (ropivacaine) in 200 ml of 0.9% saline. Local anesthetic or placebo solution were administer before creation of the pneumoperitoneum.

RESULTS

Pain intensity, as rated by visual analog and verbal rating scales, and stress response data were significantly less in the group receiving ropivacaine than in the placebo group. No patients in treatment group received an additional dose of analgesic, whereas two patients in placebo group needed an additional analgesic.

CONCLUSIONS

Our results support the clinical validity of preemptive analgesia, but the timing of intraperitoneal administration of local anesthetic is very important. Only application before creation of the pneumoperitoneum may preempt every neuronal central sensitization.

Radiation-induced angiosarcoma of the breast: case report and self-criticism of therapeutic approach

Angiosarcoma (AS) of the breast is a rare and highly aggressive vascular cancer. It presents as a primitive or radioinduced form. The case of a 46-year-old woman who underwent quadrantectomy of the breast plus axillary lymph node dissection and radiotherapy postoperatively (QUART) for ductal infiltrant carcinoma is reported in the following. Ten years later, the patient underwent mastectomy with immediate reconstruction, for local recurrence that was diagnosed as an AS of the breast at final pathological examination. She did not receive any adjuvant treatment due to local post-operative complications related to breast reconstruction. We criticize our therapeutic approach and we recommend more attention about local recurrence suggesting that tru-cut needle biopsy of local recurrence of the breast after QUART, should be the correct diagnostic approach.

[Role of surgery in the treatment of primary gastric lymphoma and assessment of new therapeutic approaches]

Controversy remains regarding the best treatment for primary gastric lymphoma (PGL). Recent developments in diagnosis and chemotherapy have changed strategies for this disease. Fourteen patients with primary gastric non-Hodgkin's lymphoma underwent surgery. Before surgery 9/14 patients underwent Helicobacter pylori eradication, and 4/14 were treated with chemotherapy. In two patients chemotherapy was not possible because of risk of perforation recurred. Total gastrectomy with N2 lymphadenectomy, splenectomy, biopsy of mesenteric lymph nodes, and hepatic biopsy were done. Then patients underwent post-operative chemotherapy. Involved-field radiation therapy was made in four patients. The overall survival was 64.2 percent. Surgery was the treatment of choice in cases of gastric lymphoma non-responsive to medical therapy and to control complications or when gastroscopy did not supply correct diagnosis.

Subcutaneous right leg metastasis from rectal adenocarcinoma without visceral involvement

The occurrence of cutaneous metastasis from colorectal cancer is rare, with a reported frequency of less than 4 to 5 percent. Typically signifies widespread disease and a poor prognosis. Metastases from adenocarcinoma of the colon-rectum usually occur within two years of resection of the primary tumour, and the average survival of a patient with cutaneous metastasis has been reported as ranging from 3 to 18 months. The case reported here concerns a patient who developed a skin metastasis without evidence of visceral involvement after treatment of rectal carcinoma. It is advisable to implement cutaneous biopsy in patients with a history of carcinoma; this may establish the diagnosis of metastatic disease and change the methods of therapeutic intervention and prognosis.

Crustacean cardioactive peptide is a modulator of oviduct contractions in Locusta migratoria

Crustacean cardioactive peptide (CCAP) stimulates the contractions of locust oviducts. CCAP increased the basal tonus and increased the frequency and amplitude of phasic contractions, as well as the amplitude of neurally-evoked oviduct contractions in a dose-dependent manner. Oviducts from Vth instar larvae and adult locusts aged 10 days or less, were more sensitive to CCAP than oviducts from adult locusts aged 12 days or more. This may be indicative of a differential expression of number or subtypes of CCAP receptors on the oviducts at different ages, and may be related to reproductive functions or to functions of CCAP on the oviducts during ecdysis. The oviducts appear more sensitive to CCAP when compared with previously published reports of CCAP actions on the hindgut. CCAP actions on the amplitude of neurally-evoked contractions of the oviducts are similar to those of proctolin, however, the oviducts are more sensitive to CCAP. No CCAP-like immunoreactive structures were discovered in the nerves innervating the oviducts, or on the oviducts themselves, confirming the previously published suggestion (Dircksen et al., 1991) that CCAP acts as a neurohormone at the oviducts. Cells showing CCAP-like immunoreactivity were discovered in the fat body associated with the oviducts and represent a potential source of CCAP, along with CCAP released from the transverse nerve and perivisceral organs.

Increased blood volume and CD34(+)CD38(-) progenitor cell recovery using a novel umbilical cord blood collection system

A major problem with the use of umbilical cord/placental blood (UCB) is the limited blood volume that can be collected from a single donor. In this study, we evaluated a novel system for the collection of UCB and analyzed the kinetics of output of hematopoietic stem cells in the collected blood. Sequential UCB fractions were collected from 48 placentas by gravity following common procedures. When UCB flow was ended, collection was continued using the device. Nucleated cell (NC) density in each fraction was evaluated and the expression of CD34, CD38 and other hematopoietic markers was assessed by flow cytometry. The total collected volume was 60.9 +/- 26.2 ml (mean +/- SD, range 17-141.5). The device yield (volume collected using the device/total volume) was 26.5 +/- 15.1%. No significant difference was observed in NC count in sequential fractions. A significant increase in CD34(+) cell content in sequential fractions and a 2.07 +/- 1.18-fold increase in the percentage of CD34(+) cells in the last versus first fraction were observed. Furthermore, within the CD34(+) population, the percentage of CD38(-) pluripotent stem cells in the first fraction was 3.24 +/- 1.39, while in the last fraction it raised to 34.43 +/- 22.62. Thus, at the end of a collection performed following current procedures, further blood rich in the most primitive progenitor cells can be recovered. Therefore, the optimization and standardization of collection procedures are required to obtain maximal recovery from each placenta and increase the percentage of UCB units suitable for clinical use.

Malignant lymphoma complicating ulcerative colitis

Carcinoma of the colon as a complication of chronic ulcerative colitis is relatively common, whereas malignant lymphoma is apparently rare. We report two cases of patients with malignant lymphoma complicating ulcerative colitis, a CD 30 + T-cell lymphoma of the intestine and a low grade B-cell non-Hodgkin's lymphoma of MALT type. It is important to be aware of the possibility of malignant lymphoma in ulcerative colitis in order to evaluate correctly any lymphoid infiltrate seen in a biopsy, especially when anti-inflammatory treatment seems to be ineffective or when symptoms change.

Efficiency of doxorubicin handling by isolated hepatocytes is a valuable indicator for restored cell function

Pig liver is a possible source of hepatocytes for extracorporeal bio-artificial liver devices. In order to evaluate recovered hepatocyte function following enzymatic isolation, we developed a cytochemical method that is based on the capacity of hepatocytes to sequester the anthracycline antitumour drug doxorubicin within intracellular acidic compartments. Doxorubicin is a naturally fluorescent molecule. Thus, the process of drug concentration within hepatocytes can be visualized in living conditions by fluorescence microscopy. Porcine hepatocytes harvested from heart-beating donors were grown either as isolated cell suspensions or as tissue monolayers. Immediately after isolation and at fixed culture times, cells were incubated with 0.1 mM doxorubicin in Hanks' balanced salt solution for 10 min at 37 degrees C in 5% CO2-humidified atmosphere and observed by fluorescence microscopy. Parallel electron microscopy was performed to compare fluorescence data with general cell morphology. To monitor lysosomal acidification capacity, the fluorescent pH-sensitive vital dye LysoSensor-Blue was used. Doxorubicin fluorescence showed different patterns of nuclear and cytoplasmic staining, according to the time allowed for cell recovery and the culture method. In particular, cytoplasmic fluorescence changed from a diffuse staining, that could be observed after cell isolation and in hepatocyte suspensions, to a punctate perinuclear and pericanalicular fluorescence detectable in fully recovered hepatocyte monolayers. This study indicates that the 'doxorubicin-fluorescence test' may be considered a simple and rapid procedure for assessing hepatocyte functional condition. It may provide valuable and 'real time' guidelines for judging the correct way these cells are to be collected, preserved and utilized for clinical purposes.

Application of a clinical score for the diagnosis of acute appendicitis in childhood: a retrospective analysis of 197 patients

PURPOSE

The aim of this study was to validate a clinical scoring system for the diagnosis of acute appendicitis in childhood.

METHODS

The authors retrospectively applied a clinical scoring system on 197 consecutive pediatric patients operated on for acute appendicitis. They therefore looked for a correlation between the management suggested by the scoring system and pathologic diagnosis on surgical specimens.

RESULTS

Based on final pathologic specimen, surgery has been performed unnecessarily in 23% of cases. The proposed scoring system could have reduced unnecessary surgery to 2%. Only 8% of patients with acute appendicitis would have been discharged home. Sensitivity and specificity of the scoring system used in this study was 87% and 86%, respectively.

CONCLUSION

The clinical scoring system proposed in this study could be of help in early clinical diagnosis of appendicitis to reduce the rate of unnecessary emergency surgery.